hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|IL,"To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Rehabilitation Institute of Chicago d/b/a Shirley Ryan Abilitylab,2024-12-23,2.0.0,Shirley Ryan Ability Lab,"355 E. Erie Street, Chicago, IL 60611",143026,true ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
description,Code|1,code|1|type,Code|2,code|2|type,modifiers,Setting,drug_unit_of_measurement,drug_type_of_measurement,standard_charge|gross,standard_charge|discounted_cash,standard_charge|Blue Cross of IL|PPO|negotiated_dollar,standard_charge|Blue Cross of IL|PPO|negotiated_percentage,standard_charge |Blue Cross of IL|PPO|negotiated_algorithm,estimated_amount|Blue Cross of IL|PPO,standard_charge|Blue Cross of IL|PPO|methodology,additional_payer_notes|Blue Cross of IL|PPO,standard_charge|Blue Choice|PPO|negotiated_dollar,standard_charge|Blue Choice|PPO|negotiated_percentage,standard_charge |Blue Choice|PPO|negotiated_algorithm,estimated_amount|Blue Choice|PPO,standard_charge|Blue Choice|PPO|methodology,additional_payer_notes|Blue Choice|PPO,standard_charge|Aetna|PPO|negotiated_dollar,standard_charge|Aetna|PPO|negotiated_percentage,standard_charge |Aetna|PPO|negotiated_algorithm,estimated_amount|Aetna|PPO,standard_charge|Aetna|PPO|methodology,additional_payer_notes|Aetna|PPO,standard_charge|Advocate Physician Partners|negotiated_dollar,standard_charge|Advocate Physician Partners|negotiated_percentage,standard_charge |Advocate Physician Partners| negotiated_algorithm,estimated_amount|Advocate Physician Partners|,standard_charge|Advocate Physician Partners|methodology,additional_payer_notes|Advocate Physician Partners|,standard_charge|BC HMO|negotiated_dollar,standard_charge|BC HMO|negotiated_percentage,standard_charge |BC HMO| negotiated_algorithm,estimated_amount|BC HMO|,standard_charge|BC HMO|methodology,additional_payer_notes|BC HMO|,standard_charge|Cigna|negotiated_dollar,standard_charge|Cigna|negotiated_percentage,standard_charge |Cigna| negotiated_algorithm,estimated_amount|Cigna|,standard_charge|Cigna|methodology,additional_payer_notes|Cigna|,standard_charge|Cigna Local Plus|negotiated_dollar,standard_charge|Cigna Local Plus|negotiated_percentage,standard_charge |Cigna Local Plus| negotiated_algorithm,estimated_amount|Cigna Local Plus|,standard_charge|Cigna Local Plus|methodology,additional_payer_notes|Cigna Local PLus|,standard_charge|Humana|negotiated_dollar,standard_charge|Humana|negotiated_percentage,standard_charge |Humana| negotiated_algorithm,estimated_amount|Humana|,standard_charge|Humana|methodology,additional_payer_notes|Humana|,standard_charge|Aetna IL Preferred|negotiated_dollar,standard_charge|Aetna IL Preferred|negotiated_percentage,standard_charge |Aetna IL Preferred| negotiated_algorithm,estimated_amount|Aetna IL Preferred|,standard_charge|Aetna IL Preferred|methodology,additional_payer_notes|Aetna IL Preferred|,standard_charge|United|negotiated_dollar,standard_charge|United|negotiated_percentage,standard_charge |United| negotiated_algorithm,estimated_amount|United|,standard_charge|United|methodology,additional_payer_notes|United|,standard_charge|Community Health Alliance |negotiated_dollar,standard_charge|Community Health Alliance|negotiated_percentage,standard_charge |Community Health Alliance| negotiated_algorithm,estimated_amount|Community Health Alliance|,standard_charge|Community Health Alliance|methodology,additional_payer_notes|Community Health Alliance|,standard_charge|First Health |negotiated_dollar,standard_charge|First Health|negotiated_percentage,standard_charge |First Health| negotiated_algorithm,estimated_amount|First Health |,standard_charge|First Health|methodology,additional_payer_notes|First Health|,standard_charge|Health Alliance |negotiated_dollar,standard_charge|Health Alliance|negotiated_percentage,standard_charge |Health Alliance| negotiated_algorithm,estimated_amount|Health Alliance|,standard_charge|Health Alliance|methodology,additional_payer_notes|Health Alliance|,standard_charge|HFN|negotiated_dollar,standard_charge|HFN|negotiated_percentage,standard_charge |HFN| negotiated_algorithm,estimated_amount|HFN|,standard_charge|HFN|methodology,additional_payer_notes|HFN|,standard_charge|LUPF |negotiated_dollar,standard_charge|LUPF|negotiated_percentage,standard_charge |LUPF| negotiated_algorithm,estimated_amount|LUPF|,standard_charge|LUPF|methodology,additional_payer_notes|LUPF|,standard_charge|PHCS |negotiated_dollar,standard_charge|PHCS|negotiated_percentage,standard_charge |PHCS| negotiated_algorithm,estimated_amount|PHCS|,standard_charge|PHCS|methodology,additional_payer_notes|PHCS|,standard_charge|UIC Physician Group |negotiated_dollar,standard_charge|UIC Physician Group|negotiated_percentage,standard_charge |UIC Physician Group| negotiated_algorithm,estimated_amount|UIC Physician Group|,standard_charge|UIC Physician Group|methodology,additional_payer_notes |UIC Physician Group|,standard_charge|UIC Campus Care |negotiated_dollar,standard_charge|UIC Campus Care|negotiated_percentage,standard_charge |UIC Campus Care| negotiated_algorithm,estimated_amount|UIC Campus Care|,standard_charge|UIC Campus Care|methodology,additional_payer_notes |UIC Campus Care|,standard_charge|University of Chicago Practice Plan|negotiated_dollar,standard_charge|University of Chicago Practice Plan|negotiated_percentage,standard_charge |University of Chicago Practice Plan| negotiated_algorithm,estimated_amount|University of Chicago Practice Plan|,standard_charge|University of Chicago Practice Plan|methodology,additional_payer_notes |University of Chicago Practice Plan|,standard_charge|Healthlink|negotiated_dollar,standard_charge|Healthlink|negotiated_percentage,standard_charge |Healthlink| negotiated_algorithm,estimated_amount|Healthlink|,standard_charge|Healthlink| methodology,additional_payer_notes |Healthlink|,standard_charge|Ingalls|negotiated_dollar,standard_charge|Ingalls|negotiated_percentage,standard_charge |Ingalls| negotiated_algorithm,estimated_amount|Ingalls|,standard_charge|Ingalls| methodology,additional_payer_notes |Ingalls|,standard_charge|Advocate Medicare|negotiated_dollar,standard_charge|Advocate Medicare|negotiated_percentage,standard_charge |Advocate Medicare| negotiated_algorithm,estimated_amount|Advocate Medicare|,standard_charge|Advocate Medicare| methodology,additional_payer_notes |Advocate Medicare|,standard_charge|Aetna Medicare|negotiated_dollar,standard_charge|Aetna Medicare|negotiated_percentage,standard_charge |Aetna Medicare| negotiated_algorithm,estimated_amount|Aetna Medicare|,standard_charge|Aetna Medicare| methodology,additional_payer_notes |Aetna Medicare|,standard_charge|BC Medicare|negotiated_dollar,standard_charge|BC Medicare|negotiated_percentage,standard_charge |BC  Medicare| negotiated_algorithm,estimated_amount|BC Medicare|,standard_charge|BC Medicare| methodology,additional_payer_notes |BC Medicare|,standard_charge|Health Alliance Medicare|negotiated_dollar,standard_charge|Health Alliance Medicare|negotiated_percentage,standard_charge |Health Alliance  Medicare| negotiated_algorithm,estimated_amount|Health Alliance Medicare|,standard_charge|Health Alliance Medicare| methodology,additional_payer_notes |Health Alliance Medicare|,standard_charge|United Medicare|negotiated_dollar,standard_charge|United Medicare|negotiated_percentage,standard_charge |United  Medicare| negotiated_algorithm,estimated_amount|United Medicare|,standard_charge|United Medicare| methodology,additional_payer_notes |United Medicare|,standard_charge|BC MMAI|negotiated_dollar,standard_charge|BC MMAI|negotiated_percentage,standard_charge |BC MMAI| negotiated_algorithm,estimated_amount|BC MMAI|,standard_charge|BC MMAI| methodology,additional_payer_notes |BC MMAI|,standard_charge|Humana MMAI|negotiated_dollar,standard_charge|Humana MMAI|negotiated_percentage,standard_charge |Humana MMAI| negotiated_algorithm,estimated_amount|Humana MMAI|,standard_charge|Humana MMAI| methodology,additional_payer_notes |Humana MMAI|,standard_charge|Meridian MMAI|negotiated_dollar,standard_charge|Meridian MMAI|negotiated_percentage,standard_charge |Meridian MMAI| negotiated_algorithm,estimated_amount|Meridian MMAI|,standard_charge|Meridian MMAI| methodology,additional_payer_notes |Meridian MMAI|,standard_charge|ChoiceCare Medicare|negotiated_dollar,standard_charge|ChoiceCare Medicare|negotiated_percentage,standard_charge |ChoiceCare Medicare| negotiated_algorithm,estimated_amount|ChoiceCare Medicare|,standard_charge|Choice Care Medicare| methodology,additional_payer_notes |Choice Care Medicare|,standard_charge|Tricare|negotiated_dollar,standard_charge|Tricare|negotiated_percentage,standard_charge |Tricare| negotiated_algorithm,estimated_amount|Tricare|,standard_charge|Tricare| methodology,additional_payer_notes |Tricare|,standard_charge|Meridian Complete|negotiated_dollar,standard_charge|Meridian Complete|negotiated_percentage,standard_charge |Meridian Complete| negotiated_algorithm,estimated_amount|Meridian Complete|,standard_charge|Meridian Complete| methodology,additional_payer_notes |Meridian Complete|,standard_charge|Humana Gold|negotiated_dollar,standard_charge|Humana Gold|negotiated_percentage,standard_charge |Humana Gold| negotiated_algorithm,estimated_amount|Humana Gold|,standard_charge|Humana Gold| methodology,additional_payer_notes |Humana Gold|,standard_charge|Aetna MMAI|negotiated_dollar,standard_charge|Aetna MMAI|negotiated_percentage,standard_charge |Aetna MMAI| negotiated_algorithm,estimated_amount|Aetna MMAI|,standard_charge|Aetna MMAI| methodology,additional_payer_notes |Aetna MMAI|,standard_charge|United MMAI|negotiated_dollar,standard_charge|United MMAI|negotiated_percentage,standard_charge |United MMAI| negotiated_algorithm,estimated_amount|United MMAI|,standard_charge|UnitedMMAI| methodology,additional_payer_notes |United MMAI|,standard_charge|County Care|negotiated_dollar,standard_charge|County Care|negotiated_percentage,standard_charge |County Care| negotiated_algorithm,estimated_amount|County Care|,standard_charge|County Care| methodology,additional_payer_notes |County Care|,standard_charge|Meridian ICP|negotiated_dollar,standard_charge|Meridian ICP|negotiated_percentage,standard_charge |Meridian ICP| negotiated_algorithm,estimated_amount|Meridian ICP|,standard_charge|Meridian ICP| methodology,additional_payer_notes |Meridian ICP|,standard_charge|Blue Community ICP|negotiated_dollar,standard_charge|Blue Community ICP|negotiated_percentage,standard_charge |Blue Community ICP| negotiated_algorithm,estimated_amount|Blue Community ICP|,standard_charge|Blue Community ICP| methodology,additional_payer_notes |Blue Community ICP|,standard_charge|Aetna Better Health ICP|negotiated_dollar,standard_charge|Aetna Better Health ICP|negotiated_percentage,standard_charge |Aetna Better Health ICP| negotiated_algorithm,estimated_amount|Aetna Better Health ICP|,standard_charge|Aetna Better Health ICP| methodology,additional_payer_notes |Aetna Better Health ICP|,standard_charge | min,standard_charge | max,additional_generic_notes
PT Gait Training Units,97116,CPT,,,GP,both,,,227,136.2,,45.5,,103.29,percent of total billed charges,,,45.3,,102.83,percent of total billed charges,,84.05,,,,fee schedule,353% of fee schedule,,,,,,,,80,,181.6,percent of total billed charges,,,61.4,,139.38,percent of total billed charges,,,57.4,,130.3,percent of total billed charges,,,81,,183.87,percent of total billed charges,,80.72,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,192.95,percent of total billed charges,,,85,,192.95,percent of total billed charges,,,49,,111.23,percent of total billed charges,,,90,,204.3,percent of total billed charges,,,65,,147.55,percent of total billed charges,,,80,,181.6,percent of total billed charges,,,55,,124.85,percent of total billed charges,,,55,,124.85,percent of total billed charges,,,65,,147.55,percent of total billed charges,,,78,,177.06,percent of total billed charges,,,70,,158.9,percent of total billed charges,,,,,,,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,,29.54,,,,100% of Medicare,61.4,,,,EAPG Rate,100% of IL Medicaid,61.4,,,,EAPG Rate,100% of IL Medicaid,61.4,,,,EAPG Rate,100% of IL Medicaid,61.4,,,,EAPG Rate,100% of IL Medicaid,29.54,204.3,
OT Self Care/Home Management Units,97535,CPT,,,GO,both,,,224,134.4,,45.5,,101.92,percent of total billed charges,,,45.3,,101.47,percent of total billed charges,,93.72,,,,fee schedule,353% of fee schedule,,,,,,,,80,,179.2,percent of total billed charges,,,61.4,,137.54,percent of total billed charges,,,57.4,,128.58,percent of total billed charges,,,81,,181.44,percent of total billed charges,,90,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,190.4,percent of total billed charges,,,85,,190.4,percent of total billed charges,,,49,,109.76,percent of total billed charges,,,90,,201.6,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,80,,179.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,78,,174.72,percent of total billed charges,,,70,,156.8,percent of total billed charges,,,,,,,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,,32.85,,,,100% of Medicare,61.4,,,,EAPG Rate,100% of IL Medicaid,61.4,,,,EAPG Rate,100% of IL Medicaid,61.4,,,,EAPG Rate,100% of IL Medicaid,61.4,,,,EAPG Rate,100% of IL Medicaid,32.85,201.6,
Chiro Patient Self/Home Care Charge,97535,CPT,,,GP,outpatient,,,224,134.4,,45.5,,101.92,percent of total billed charges,,,45.3,,101.47,percent of total billed charges,,93.72,,,,fee schedule,353% of fee schedule,,,,,,,,80,,179.2,percent of total billed charges,,,61.4,,137.54,percent of total billed charges,,,57.4,,128.58,percent of total billed charges,,,81,,181.44,percent of total billed charges,,90,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,190.4,percent of total billed charges,,,85,,190.4,percent of total billed charges,,,49,,109.76,percent of total billed charges,,,90,,201.6,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,80,,179.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,78,,174.72,percent of total billed charges,,,70,,156.8,percent of total billed charges,,,,,,,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,,32.85,,,,100% of Medicare,61.4,,,,EAPG Rate,100% of IL Medicaid,61.4,,,,EAPG Rate,100% of IL Medicaid,61.4,,,,EAPG Rate,100% of IL Medicaid,61.4,,,,EAPG Rate,100% of IL Medicaid,32.85,201.6,
PT Self Care/Home Management Units,97535,CPT,,,GP,both,,,224,134.4,,45.5,,101.92,percent of total billed charges,,,45.3,,101.47,percent of total billed charges,,93.72,,,,fee schedule,353% of fee schedule,,,,,,,,80,,179.2,percent of total billed charges,,,61.4,,137.54,percent of total billed charges,,,57.4,,128.58,percent of total billed charges,,,81,,181.44,percent of total billed charges,,90,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,190.4,percent of total billed charges,,,85,,190.4,percent of total billed charges,,,49,,109.76,percent of total billed charges,,,90,,201.6,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,80,,179.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,78,,174.72,percent of total billed charges,,,70,,156.8,percent of total billed charges,,,,,,,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,,32.85,,,,100% of Medicare,61.4,,,,EAPG Rate,100% of IL Medicaid,61.4,,,,EAPG Rate,100% of IL Medicaid,61.4,,,,EAPG Rate,100% of IL Medicaid,61.4,,,,EAPG Rate,100% of IL Medicaid,32.85,201.6,
PT Treatment Self Care Home Management,97535,CPT,,,GP,both,,,224,134.4,,45.5,,101.92,percent of total billed charges,,,45.3,,101.47,percent of total billed charges,,93.72,,,,fee schedule,353% of fee schedule,,,,,,,,80,,179.2,percent of total billed charges,,,61.4,,137.54,percent of total billed charges,,,57.4,,128.58,percent of total billed charges,,,81,,181.44,percent of total billed charges,,90,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,190.4,percent of total billed charges,,,85,,190.4,percent of total billed charges,,,49,,109.76,percent of total billed charges,,,90,,201.6,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,80,,179.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,78,,174.72,percent of total billed charges,,,70,,156.8,percent of total billed charges,,,,,,,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,32.85,,,,100% of Medicare,,,32.85,,,,100% of Medicare,61.4,,,,EAPG Rate,100% of IL Medicaid,61.4,,,,EAPG Rate,100% of IL Medicaid,61.4,,,,EAPG Rate,100% of IL Medicaid,61.4,,,,EAPG Rate,100% of IL Medicaid,32.85,201.6,
OT Hot/Cold Pack Units,97010,CPT,,,GO,both,,,120,72,,45.5,,54.6,percent of total billed charges,,,45.3,,54.36,percent of total billed charges,,17.93,,,,fee schedule,353% of fee schedule,,,,,,,,80,,96,percent of total billed charges,,,61.4,,73.68,percent of total billed charges,,,57.4,,68.88,percent of total billed charges,,,81,,97.2,percent of total billed charges,,17.22,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,102,percent of total billed charges,,,85,,102,percent of total billed charges,,,49,,58.8,percent of total billed charges,,,90,,108,percent of total billed charges,,,65,,78,percent of total billed charges,,,80,,96,percent of total billed charges,,,55,,66,percent of total billed charges,,,55,,66,percent of total billed charges,,,65,,78,percent of total billed charges,,,78,,93.6,percent of total billed charges,,,70,,84,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,17.22,124.8,
PT Hot/Cold Pack Units,97010,CPT,,,GP,both,,,120,72,,45.5,,54.6,percent of total billed charges,,,45.3,,54.36,percent of total billed charges,,17.93,,,,fee schedule,353% of fee schedule,,,,,,,,80,,96,percent of total billed charges,,,61.4,,73.68,percent of total billed charges,,,57.4,,68.88,percent of total billed charges,,,81,,97.2,percent of total billed charges,,17.22,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,102,percent of total billed charges,,,85,,102,percent of total billed charges,,,49,,58.8,percent of total billed charges,,,90,,108,percent of total billed charges,,,65,,78,percent of total billed charges,,,80,,96,percent of total billed charges,,,55,,66,percent of total billed charges,,,55,,66,percent of total billed charges,,,65,,78,percent of total billed charges,,,78,,93.6,percent of total billed charges,,,70,,84,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,17.22,124.8,
PT Modality 1+ area/ Hot Cold Pack Application,97010,CPT,,,GP,both,,,120,72,,45.5,,54.6,percent of total billed charges,,,45.3,,54.36,percent of total billed charges,,17.93,,,,fee schedule,353% of fee schedule,,,,,,,,80,,96,percent of total billed charges,,,61.4,,73.68,percent of total billed charges,,,57.4,,68.88,percent of total billed charges,,,81,,97.2,percent of total billed charges,,17.22,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,102,percent of total billed charges,,,85,,102,percent of total billed charges,,,49,,58.8,percent of total billed charges,,,90,,108,percent of total billed charges,,,65,,78,percent of total billed charges,,,80,,96,percent of total billed charges,,,55,,66,percent of total billed charges,,,55,,66,percent of total billed charges,,,65,,78,percent of total billed charges,,,78,,93.6,percent of total billed charges,,,70,,84,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,17.22,124.8,
OT Mechanical Traction Units,97012,CPT,,,GO,both,,,168,100.8,,45.5,,76.44,percent of total billed charges,,,45.3,,76.1,percent of total billed charges,,41.48,,,,fee schedule,353% of fee schedule,,,,,,,,80,,134.4,percent of total billed charges,,,61.4,,103.15,percent of total billed charges,,,57.4,,96.43,percent of total billed charges,,,81,,136.08,percent of total billed charges,,39.83,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,142.8,percent of total billed charges,,,85,,142.8,percent of total billed charges,,,49,,82.32,percent of total billed charges,,,90,,151.2,percent of total billed charges,,,65,,109.2,percent of total billed charges,,,80,,134.4,percent of total billed charges,,,55,,92.4,percent of total billed charges,,,55,,92.4,percent of total billed charges,,,65,,109.2,percent of total billed charges,,,78,,131.04,percent of total billed charges,,,70,,117.6,percent of total billed charges,,,,,,,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,,14.75,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,14.75,151.2,
PT Mechanical Traction Units,97012,CPT,,,GP,both,,,168,100.8,,45.5,,76.44,percent of total billed charges,,,45.3,,76.1,percent of total billed charges,,41.48,,,,fee schedule,353% of fee schedule,,,,,,,,80,,134.4,percent of total billed charges,,,61.4,,103.15,percent of total billed charges,,,57.4,,96.43,percent of total billed charges,,,81,,136.08,percent of total billed charges,,39.83,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,142.8,percent of total billed charges,,,85,,142.8,percent of total billed charges,,,49,,82.32,percent of total billed charges,,,90,,151.2,percent of total billed charges,,,65,,109.2,percent of total billed charges,,,80,,134.4,percent of total billed charges,,,55,,92.4,percent of total billed charges,,,55,,92.4,percent of total billed charges,,,65,,109.2,percent of total billed charges,,,78,,131.04,percent of total billed charges,,,70,,117.6,percent of total billed charges,,,,,,,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,,14.75,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,14.75,151.2,
OT Unattended E-Stim Units,97014,CPT,G0283,HCPCS,GO,both,,,194,116.4,,45.5,,88.27,percent of total billed charges,,,45.3,,87.88,percent of total billed charges,,37.84,,,,fee schedule,353% of fee schedule,,,,,,,,80,,155.2,percent of total billed charges,,,61.4,,119.12,percent of total billed charges,,,57.4,,111.36,percent of total billed charges,,,81,,157.14,percent of total billed charges,,36.34,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,164.9,percent of total billed charges,,,85,,164.9,percent of total billed charges,,,49,,95.06,percent of total billed charges,,,90,,174.6,percent of total billed charges,,,65,,126.1,percent of total billed charges,,,80,,155.2,percent of total billed charges,,,55,,106.7,percent of total billed charges,,,55,,106.7,percent of total billed charges,,,65,,126.1,percent of total billed charges,,,78,,151.32,percent of total billed charges,,,70,,135.8,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,36.34,174.6,
PT Unattended E-Stim Units,97014,CPT,G0283,HCPCS,GP,both,,,194,116.4,,45.5,,88.27,percent of total billed charges,,,45.3,,87.88,percent of total billed charges,,37.84,,,,fee schedule,353% of fee schedule,,,,,,,,80,,155.2,percent of total billed charges,,,61.4,,119.12,percent of total billed charges,,,57.4,,111.36,percent of total billed charges,,,81,,157.14,percent of total billed charges,,36.34,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,164.9,percent of total billed charges,,,85,,164.9,percent of total billed charges,,,49,,95.06,percent of total billed charges,,,90,,174.6,percent of total billed charges,,,65,,126.1,percent of total billed charges,,,80,,155.2,percent of total billed charges,,,55,,106.7,percent of total billed charges,,,55,,106.7,percent of total billed charges,,,65,,126.1,percent of total billed charges,,,78,,151.32,percent of total billed charges,,,70,,135.8,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,36.34,174.6,
OT Vasopneumatic Devices Units,97016,CPT,,,GO,both,,,235,141,,45.5,,106.93,percent of total billed charges,,,45.3,,106.46,percent of total billed charges,,33.96,,,,fee schedule,353% of fee schedule,,,,,,,,80,,188,percent of total billed charges,,,61.4,,144.29,percent of total billed charges,,,57.4,,134.89,percent of total billed charges,,,81,,190.35,percent of total billed charges,,32.61,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,199.75,percent of total billed charges,,,85,,199.75,percent of total billed charges,,,49,,115.15,percent of total billed charges,,,90,,211.5,percent of total billed charges,,,65,,152.75,percent of total billed charges,,,80,,188,percent of total billed charges,,,55,,129.25,percent of total billed charges,,,55,,129.25,percent of total billed charges,,,65,,152.75,percent of total billed charges,,,78,,183.3,percent of total billed charges,,,70,,164.5,percent of total billed charges,,,,,,,,12.14,,,,100% of Medicare,,12.14,,,,100% of Medicare,,12.14,,,,100% of Medicare,,12.14,,,,100% of Medicare,,12.14,,,,100% of Medicare,,12.14,,,,100% of Medicare,,12.14,,,,100% of Medicare,,12.14,,,,100% of Medicare,,12.14,,,,100% of Medicare,,12.14,,,,100% of Medicare,,12.14,,,,100% of Medicare,,12.14,,,,100% of Medicare,,,12.14,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,12.14,211.5,
PT Vasopeumatic Devices Units,97016,CPT,,,GP,both,,,235,141,,45.5,,106.93,percent of total billed charges,,,45.3,,106.46,percent of total billed charges,,33.96,,,,fee schedule,353% of fee schedule,,,,,,,,80,,188,percent of total billed charges,,,61.4,,144.29,percent of total billed charges,,,57.4,,134.89,percent of total billed charges,,,81,,190.35,percent of total billed charges,,32.61,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,199.75,percent of total billed charges,,,85,,199.75,percent of total billed charges,,,49,,115.15,percent of total billed charges,,,90,,211.5,percent of total billed charges,,,65,,152.75,percent of total billed charges,,,80,,188,percent of total billed charges,,,55,,129.25,percent of total billed charges,,,55,,129.25,percent of total billed charges,,,65,,152.75,percent of total billed charges,,,78,,183.3,percent of total billed charges,,,70,,164.5,percent of total billed charges,,,,,,,,12.14,,,,100% of Medicare,,12.14,,,,100% of Medicare,,12.14,,,,100% of Medicare,,12.14,,,,100% of Medicare,,12.14,,,,100% of Medicare,,12.14,,,,100% of Medicare,,12.14,,,,100% of Medicare,,12.14,,,,100% of Medicare,,12.14,,,,100% of Medicare,,12.14,,,,100% of Medicare,,12.14,,,,100% of Medicare,,12.14,,,,100% of Medicare,,,12.14,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,12.14,211.5,
OT Paraffin Bath Units,97018,CPT,,,GO,both,,,215,129,,45.5,,97.83,percent of total billed charges,,,45.3,,97.4,percent of total billed charges,,16.98,,,,fee schedule,353% of fee schedule,,,,,,,,80,,172,percent of total billed charges,,,61.4,,132.01,percent of total billed charges,,,57.4,,123.41,percent of total billed charges,,,81,,174.15,percent of total billed charges,,16.31,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,182.75,percent of total billed charges,,,85,,182.75,percent of total billed charges,,,49,,105.35,percent of total billed charges,,,90,,193.5,percent of total billed charges,,,65,,139.75,percent of total billed charges,,,80,,172,percent of total billed charges,,,55,,118.25,percent of total billed charges,,,55,,118.25,percent of total billed charges,,,65,,139.75,percent of total billed charges,,,78,,167.7,percent of total billed charges,,,70,,150.5,percent of total billed charges,,,,,,,,6.58,,,,100% of Medicare,,6.58,,,,100% of Medicare,,6.58,,,,100% of Medicare,,6.58,,,,100% of Medicare,,6.58,,,,100% of Medicare,,6.58,,,,100% of Medicare,,6.58,,,,100% of Medicare,,6.58,,,,100% of Medicare,,6.58,,,,100% of Medicare,,6.58,,,,100% of Medicare,,6.58,,,,100% of Medicare,,6.58,,,,100% of Medicare,,,6.58,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,6.58,193.5,
PT Paraffin Units,97018,CPT,,,GP,both,,,215,129,,45.5,,97.83,percent of total billed charges,,,45.3,,97.4,percent of total billed charges,,16.98,,,,fee schedule,353% of fee schedule,,,,,,,,80,,172,percent of total billed charges,,,61.4,,132.01,percent of total billed charges,,,57.4,,123.41,percent of total billed charges,,,81,,174.15,percent of total billed charges,,16.31,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,182.75,percent of total billed charges,,,85,,182.75,percent of total billed charges,,,49,,105.35,percent of total billed charges,,,90,,193.5,percent of total billed charges,,,65,,139.75,percent of total billed charges,,,80,,172,percent of total billed charges,,,55,,118.25,percent of total billed charges,,,55,,118.25,percent of total billed charges,,,65,,139.75,percent of total billed charges,,,78,,167.7,percent of total billed charges,,,70,,150.5,percent of total billed charges,,,,,,,,6.58,,,,100% of Medicare,,6.58,,,,100% of Medicare,,6.58,,,,100% of Medicare,,6.58,,,,100% of Medicare,,6.58,,,,100% of Medicare,,6.58,,,,100% of Medicare,,6.58,,,,100% of Medicare,,6.58,,,,100% of Medicare,,6.58,,,,100% of Medicare,,6.58,,,,100% of Medicare,,6.58,,,,100% of Medicare,,6.58,,,,100% of Medicare,,,6.58,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,6.58,193.5,
OT Whirpool Units,97022,CPT,,,GO,both,,,312,187.2,,45.5,,141.96,percent of total billed charges,,,45.3,,141.34,percent of total billed charges,,50.41,,,,fee schedule,353% of fee schedule,,,,,,,,80,,249.6,percent of total billed charges,,,61.4,,191.57,percent of total billed charges,,,57.4,,179.09,percent of total billed charges,,,81,,252.72,percent of total billed charges,,48.41,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,265.2,percent of total billed charges,,,85,,265.2,percent of total billed charges,,,49,,152.88,percent of total billed charges,,,90,,280.8,percent of total billed charges,,,65,,202.8,percent of total billed charges,,,80,,249.6,percent of total billed charges,,,55,,171.6,percent of total billed charges,,,55,,171.6,percent of total billed charges,,,65,,202.8,percent of total billed charges,,,78,,243.36,percent of total billed charges,,,70,,218.4,percent of total billed charges,,,,,,,,16.12,,,,100% of Medicare,,16.12,,,,100% of Medicare,,16.12,,,,100% of Medicare,,16.12,,,,100% of Medicare,,16.12,,,,100% of Medicare,,16.12,,,,100% of Medicare,,16.12,,,,100% of Medicare,,16.12,,,,100% of Medicare,,16.12,,,,100% of Medicare,,16.12,,,,100% of Medicare,,16.12,,,,100% of Medicare,,16.12,,,,100% of Medicare,,,16.12,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,16.12,280.8,
PT Whirlpool/Fluidotherapy Units,97022,CPT,,,GP,both,,,312,187.2,,45.5,,141.96,percent of total billed charges,,,45.3,,141.34,percent of total billed charges,,50.41,,,,fee schedule,353% of fee schedule,,,,,,,,80,,249.6,percent of total billed charges,,,61.4,,191.57,percent of total billed charges,,,57.4,,179.09,percent of total billed charges,,,81,,252.72,percent of total billed charges,,48.41,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,265.2,percent of total billed charges,,,85,,265.2,percent of total billed charges,,,49,,152.88,percent of total billed charges,,,90,,280.8,percent of total billed charges,,,65,,202.8,percent of total billed charges,,,80,,249.6,percent of total billed charges,,,55,,171.6,percent of total billed charges,,,55,,171.6,percent of total billed charges,,,65,,202.8,percent of total billed charges,,,78,,243.36,percent of total billed charges,,,70,,218.4,percent of total billed charges,,,,,,,,16.12,,,,100% of Medicare,,16.12,,,,100% of Medicare,,16.12,,,,100% of Medicare,,16.12,,,,100% of Medicare,,16.12,,,,100% of Medicare,,16.12,,,,100% of Medicare,,16.12,,,,100% of Medicare,,16.12,,,,100% of Medicare,,16.12,,,,100% of Medicare,,16.12,,,,100% of Medicare,,16.12,,,,100% of Medicare,,16.12,,,,100% of Medicare,,,16.12,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,16.12,280.8,
OT Infrared Units,97026,CPT,,,GO,both,,,185,111,,45.5,,84.18,percent of total billed charges,,,45.3,,83.81,percent of total billed charges,,18.92,,,,fee schedule,353% of fee schedule,,,,,,,,80,,148,percent of total billed charges,,,61.4,,113.59,percent of total billed charges,,,57.4,,106.19,percent of total billed charges,,,81,,149.85,percent of total billed charges,,18.17,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,157.25,percent of total billed charges,,,85,,157.25,percent of total billed charges,,,49,,90.65,percent of total billed charges,,,90,,166.5,percent of total billed charges,,,65,,120.25,percent of total billed charges,,,80,,148,percent of total billed charges,,,55,,101.75,percent of total billed charges,,,55,,101.75,percent of total billed charges,,,65,,120.25,percent of total billed charges,,,78,,144.3,percent of total billed charges,,,70,,129.5,percent of total billed charges,,,,,,,,7.24,,,,100% of Medicare,,7.24,,,,100% of Medicare,,7.24,,,,100% of Medicare,,7.24,,,,100% of Medicare,,7.24,,,,100% of Medicare,,7.24,,,,100% of Medicare,,7.24,,,,100% of Medicare,,7.24,,,,100% of Medicare,,7.24,,,,100% of Medicare,,7.24,,,,100% of Medicare,,7.24,,,,100% of Medicare,,7.24,,,,100% of Medicare,,,7.24,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,7.24,166.5,
PT Infrared Units,97026,CPT,,,GP,both,,,185,111,,45.5,,84.18,percent of total billed charges,,,45.3,,83.81,percent of total billed charges,,18.92,,,,fee schedule,353% of fee schedule,,,,,,,,80,,148,percent of total billed charges,,,61.4,,113.59,percent of total billed charges,,,57.4,,106.19,percent of total billed charges,,,81,,149.85,percent of total billed charges,,18.17,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,157.25,percent of total billed charges,,,85,,157.25,percent of total billed charges,,,49,,90.65,percent of total billed charges,,,90,,166.5,percent of total billed charges,,,65,,120.25,percent of total billed charges,,,80,,148,percent of total billed charges,,,55,,101.75,percent of total billed charges,,,55,,101.75,percent of total billed charges,,,65,,120.25,percent of total billed charges,,,78,,144.3,percent of total billed charges,,,70,,129.5,percent of total billed charges,,,,,,,,7.24,,,,100% of Medicare,,7.24,,,,100% of Medicare,,7.24,,,,100% of Medicare,,7.24,,,,100% of Medicare,,7.24,,,,100% of Medicare,,7.24,,,,100% of Medicare,,7.24,,,,100% of Medicare,,7.24,,,,100% of Medicare,,7.24,,,,100% of Medicare,,7.24,,,,100% of Medicare,,7.24,,,,100% of Medicare,,7.24,,,,100% of Medicare,,,7.24,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,7.24,166.5,
OT Attended E-Stim Units,97032,CPT,,,GO,both,,,214,128.4,,45.5,,97.37,percent of total billed charges,,,45.3,,96.94,percent of total billed charges,,41.48,,,,fee schedule,353% of fee schedule,,,,,,,,80,,171.2,percent of total billed charges,,,61.4,,131.4,percent of total billed charges,,,57.4,,122.84,percent of total billed charges,,,81,,173.34,percent of total billed charges,,39.83,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,181.9,percent of total billed charges,,,85,,181.9,percent of total billed charges,,,49,,104.86,percent of total billed charges,,,90,,192.6,percent of total billed charges,,,65,,139.1,percent of total billed charges,,,80,,171.2,percent of total billed charges,,,55,,117.7,percent of total billed charges,,,55,,117.7,percent of total billed charges,,,65,,139.1,percent of total billed charges,,,78,,166.92,percent of total billed charges,,,70,,149.8,percent of total billed charges,,,,,,,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,,14.75,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,14.75,192.6,
Chiro E-Stim Attended Charge,97032,CPT,,,GP,outpatient,,,214,128.4,,45.5,,97.37,percent of total billed charges,,,45.3,,96.94,percent of total billed charges,,41.48,,,,fee schedule,353% of fee schedule,,,,,,,,80,,171.2,percent of total billed charges,,,61.4,,131.4,percent of total billed charges,,,57.4,,122.84,percent of total billed charges,,,81,,173.34,percent of total billed charges,,39.83,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,181.9,percent of total billed charges,,,85,,181.9,percent of total billed charges,,,49,,104.86,percent of total billed charges,,,90,,192.6,percent of total billed charges,,,65,,139.1,percent of total billed charges,,,80,,171.2,percent of total billed charges,,,55,,117.7,percent of total billed charges,,,55,,117.7,percent of total billed charges,,,65,,139.1,percent of total billed charges,,,78,,166.92,percent of total billed charges,,,70,,149.8,percent of total billed charges,,,,,,,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,,14.75,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,14.75,192.6,
PT Attended E-Stim Units,97032,CPT,,,GP,both,,,214,128.4,,45.5,,97.37,percent of total billed charges,,,45.3,,96.94,percent of total billed charges,,41.48,,,,fee schedule,353% of fee schedule,,,,,,,,80,,171.2,percent of total billed charges,,,61.4,,131.4,percent of total billed charges,,,57.4,,122.84,percent of total billed charges,,,81,,173.34,percent of total billed charges,,39.83,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,181.9,percent of total billed charges,,,85,,181.9,percent of total billed charges,,,49,,104.86,percent of total billed charges,,,90,,192.6,percent of total billed charges,,,65,,139.1,percent of total billed charges,,,80,,171.2,percent of total billed charges,,,55,,117.7,percent of total billed charges,,,55,,117.7,percent of total billed charges,,,65,,139.1,percent of total billed charges,,,78,,166.92,percent of total billed charges,,,70,,149.8,percent of total billed charges,,,,,,,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,14.75,,,,100% of Medicare,,,14.75,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,14.75,192.6,
OT Iontophoresis Units,97033,CPT,,,GO,both,,,224,134.4,,45.5,,101.92,percent of total billed charges,,,45.3,,101.47,percent of total billed charges,,56.87,,,,fee schedule,353% of fee schedule,,,,,,,,80,,179.2,percent of total billed charges,,,61.4,,137.54,percent of total billed charges,,,57.4,,128.58,percent of total billed charges,,,81,,181.44,percent of total billed charges,,54.61,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,190.4,percent of total billed charges,,,85,,190.4,percent of total billed charges,,,49,,109.76,percent of total billed charges,,,90,,201.6,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,80,,179.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,78,,174.72,percent of total billed charges,,,70,,156.8,percent of total billed charges,,,,,,,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,,19.38,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,19.38,201.6,
PT Iontophoresis Units,97033,CPT,,,GP,both,,,224,134.4,,45.5,,101.92,percent of total billed charges,,,45.3,,101.47,percent of total billed charges,,56.87,,,,fee schedule,353% of fee schedule,,,,,,,,80,,179.2,percent of total billed charges,,,61.4,,137.54,percent of total billed charges,,,57.4,,128.58,percent of total billed charges,,,81,,181.44,percent of total billed charges,,54.61,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,190.4,percent of total billed charges,,,85,,190.4,percent of total billed charges,,,49,,109.76,percent of total billed charges,,,90,,201.6,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,80,,179.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,78,,174.72,percent of total billed charges,,,70,,156.8,percent of total billed charges,,,,,,,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,,19.38,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,19.38,201.6,
PT Modality 1+ area/ Iontophoresis,97033,CPT,,,GP,both,,,224,134.4,,45.5,,101.92,percent of total billed charges,,,45.3,,101.47,percent of total billed charges,,56.87,,,,fee schedule,353% of fee schedule,,,,,,,,80,,179.2,percent of total billed charges,,,61.4,,137.54,percent of total billed charges,,,57.4,,128.58,percent of total billed charges,,,81,,181.44,percent of total billed charges,,54.61,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,190.4,percent of total billed charges,,,85,,190.4,percent of total billed charges,,,49,,109.76,percent of total billed charges,,,90,,201.6,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,80,,179.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,78,,174.72,percent of total billed charges,,,70,,156.8,percent of total billed charges,,,,,,,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,19.38,,,,100% of Medicare,,,19.38,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,19.38,201.6,
OT Contrast Bath Units,97034,CPT,,,GO,both,,,86,51.6,,45.5,,39.13,percent of total billed charges,,,45.3,,38.96,percent of total billed charges,,41.58,,,,fee schedule,353% of fee schedule,,,,,,,,80,,68.8,percent of total billed charges,,,61.4,,52.8,percent of total billed charges,,,57.4,,49.36,percent of total billed charges,,,81,,69.66,percent of total billed charges,,39.93,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,73.1,percent of total billed charges,,,85,,73.1,percent of total billed charges,,,49,,42.14,percent of total billed charges,,,90,,77.4,percent of total billed charges,,,65,,55.9,percent of total billed charges,,,80,,68.8,percent of total billed charges,,,55,,47.3,percent of total billed charges,,,55,,47.3,percent of total billed charges,,,65,,55.9,percent of total billed charges,,,78,,67.08,percent of total billed charges,,,70,,60.2,percent of total billed charges,,,,,,,,14.11,,,,100% of Medicare,,14.11,,,,100% of Medicare,,14.11,,,,100% of Medicare,,14.11,,,,100% of Medicare,,14.11,,,,100% of Medicare,,14.11,,,,100% of Medicare,,14.11,,,,100% of Medicare,,14.11,,,,100% of Medicare,,14.11,,,,100% of Medicare,,14.11,,,,100% of Medicare,,14.11,,,,100% of Medicare,,14.11,,,,100% of Medicare,,,14.11,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,14.11,124.8,
PT Contrast Bath Units,97034,CPT,,,GP,both,,,86,51.6,,45.5,,39.13,percent of total billed charges,,,45.3,,38.96,percent of total billed charges,,41.58,,,,fee schedule,353% of fee schedule,,,,,,,,80,,68.8,percent of total billed charges,,,61.4,,52.8,percent of total billed charges,,,57.4,,49.36,percent of total billed charges,,,81,,69.66,percent of total billed charges,,39.93,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,73.1,percent of total billed charges,,,85,,73.1,percent of total billed charges,,,49,,42.14,percent of total billed charges,,,90,,77.4,percent of total billed charges,,,65,,55.9,percent of total billed charges,,,80,,68.8,percent of total billed charges,,,55,,47.3,percent of total billed charges,,,55,,47.3,percent of total billed charges,,,65,,55.9,percent of total billed charges,,,78,,67.08,percent of total billed charges,,,70,,60.2,percent of total billed charges,,,,,,,,14.11,,,,100% of Medicare,,14.11,,,,100% of Medicare,,14.11,,,,100% of Medicare,,14.11,,,,100% of Medicare,,14.11,,,,100% of Medicare,,14.11,,,,100% of Medicare,,14.11,,,,100% of Medicare,,14.11,,,,100% of Medicare,,14.11,,,,100% of Medicare,,14.11,,,,100% of Medicare,,14.11,,,,100% of Medicare,,14.11,,,,100% of Medicare,,,14.11,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,14.11,124.8,
OT Ultrasound Units,97035,CPT,,,GO,both,,,220,132,,45.5,,100.1,percent of total billed charges,,,45.3,,99.66,percent of total billed charges,,40.63,,,,fee schedule,353% of fee schedule,,,,,,,,80,,176,percent of total billed charges,,,61.4,,135.08,percent of total billed charges,,,57.4,,126.28,percent of total billed charges,,,81,,178.2,percent of total billed charges,,39.02,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,187,percent of total billed charges,,,85,,187,percent of total billed charges,,,49,,107.8,percent of total billed charges,,,90,,198,percent of total billed charges,,,65,,143,percent of total billed charges,,,80,,176,percent of total billed charges,,,55,,121,percent of total billed charges,,,55,,121,percent of total billed charges,,,65,,143,percent of total billed charges,,,78,,171.6,percent of total billed charges,,,70,,154,percent of total billed charges,,,,,,,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,,14.44,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,14.44,198,
Chiro Ultrasound Charge,97035,CPT,,,GP,outpatient,,,220,132,,45.5,,100.1,percent of total billed charges,,,45.3,,99.66,percent of total billed charges,,40.63,,,,fee schedule,353% of fee schedule,,,,,,,,80,,176,percent of total billed charges,,,61.4,,135.08,percent of total billed charges,,,57.4,,126.28,percent of total billed charges,,,81,,178.2,percent of total billed charges,,39.02,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,187,percent of total billed charges,,,85,,187,percent of total billed charges,,,49,,107.8,percent of total billed charges,,,90,,198,percent of total billed charges,,,65,,143,percent of total billed charges,,,80,,176,percent of total billed charges,,,55,,121,percent of total billed charges,,,55,,121,percent of total billed charges,,,65,,143,percent of total billed charges,,,78,,171.6,percent of total billed charges,,,70,,154,percent of total billed charges,,,,,,,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,,14.44,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,14.44,198,
PT Ultrasound Units,97035,CPT,,,GP,both,,,220,132,,45.5,,100.1,percent of total billed charges,,,45.3,,99.66,percent of total billed charges,,40.63,,,,fee schedule,353% of fee schedule,,,,,,,,80,,176,percent of total billed charges,,,61.4,,135.08,percent of total billed charges,,,57.4,,126.28,percent of total billed charges,,,81,,178.2,percent of total billed charges,,39.02,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,187,percent of total billed charges,,,85,,187,percent of total billed charges,,,49,,107.8,percent of total billed charges,,,90,,198,percent of total billed charges,,,65,,143,percent of total billed charges,,,80,,176,percent of total billed charges,,,55,,121,percent of total billed charges,,,55,,121,percent of total billed charges,,,65,,143,percent of total billed charges,,,78,,171.6,percent of total billed charges,,,70,,154,percent of total billed charges,,,,,,,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,14.44,,,,100% of Medicare,,,14.44,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,14.44,198,
OT Therapeutic Exercise Units,97110,CPT,,,GO,both,,,201,120.6,,45.5,,91.46,percent of total billed charges,,,45.3,,91.05,percent of total billed charges,,84.05,,,,fee schedule,353% of fee schedule,,,,,,,,80,,160.8,percent of total billed charges,,,61.4,,123.41,percent of total billed charges,,,57.4,,115.37,percent of total billed charges,,,81,,162.81,percent of total billed charges,,80.72,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,170.85,percent of total billed charges,,,85,,170.85,percent of total billed charges,,,49,,98.49,percent of total billed charges,,,90,,180.9,percent of total billed charges,,,65,,130.65,percent of total billed charges,,,80,,160.8,percent of total billed charges,,,55,,110.55,percent of total billed charges,,,55,,110.55,percent of total billed charges,,,65,,130.65,percent of total billed charges,,,78,,156.78,percent of total billed charges,,,70,,140.7,percent of total billed charges,,,,,,,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,,29.54,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,29.54,180.9,
Chiro Therapeutic Exercise Charge,97110,CPT,,,GP,outpatient,,,201,120.6,,45.5,,91.46,percent of total billed charges,,,45.3,,91.05,percent of total billed charges,,84.05,,,,fee schedule,353% of fee schedule,,,,,,,,80,,160.8,percent of total billed charges,,,61.4,,123.41,percent of total billed charges,,,57.4,,115.37,percent of total billed charges,,,81,,162.81,percent of total billed charges,,80.72,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,170.85,percent of total billed charges,,,85,,170.85,percent of total billed charges,,,49,,98.49,percent of total billed charges,,,90,,180.9,percent of total billed charges,,,65,,130.65,percent of total billed charges,,,80,,160.8,percent of total billed charges,,,55,,110.55,percent of total billed charges,,,55,,110.55,percent of total billed charges,,,65,,130.65,percent of total billed charges,,,78,,156.78,percent of total billed charges,,,70,,140.7,percent of total billed charges,,,,,,,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,,29.54,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,29.54,180.9,
Outpatient Physical Therapy Treatment ABN,97110,CPT,,,GP,both,,,201,120.6,,45.5,,91.46,percent of total billed charges,,,45.3,,91.05,percent of total billed charges,,84.05,,,,fee schedule,353% of fee schedule,,,,,,,,80,,160.8,percent of total billed charges,,,61.4,,123.41,percent of total billed charges,,,57.4,,115.37,percent of total billed charges,,,81,,162.81,percent of total billed charges,,80.72,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,170.85,percent of total billed charges,,,85,,170.85,percent of total billed charges,,,49,,98.49,percent of total billed charges,,,90,,180.9,percent of total billed charges,,,65,,130.65,percent of total billed charges,,,80,,160.8,percent of total billed charges,,,55,,110.55,percent of total billed charges,,,55,,110.55,percent of total billed charges,,,65,,130.65,percent of total billed charges,,,78,,156.78,percent of total billed charges,,,70,,140.7,percent of total billed charges,,,,,,,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,,29.54,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,29.54,180.9,
PT Therapeutic Exercise,97110,CPT,,,GP,both,,,201,120.6,,45.5,,91.46,percent of total billed charges,,,45.3,,91.05,percent of total billed charges,,84.05,,,,fee schedule,353% of fee schedule,,,,,,,,80,,160.8,percent of total billed charges,,,61.4,,123.41,percent of total billed charges,,,57.4,,115.37,percent of total billed charges,,,81,,162.81,percent of total billed charges,,80.72,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,170.85,percent of total billed charges,,,85,,170.85,percent of total billed charges,,,49,,98.49,percent of total billed charges,,,90,,180.9,percent of total billed charges,,,65,,130.65,percent of total billed charges,,,80,,160.8,percent of total billed charges,,,55,,110.55,percent of total billed charges,,,55,,110.55,percent of total billed charges,,,65,,130.65,percent of total billed charges,,,78,,156.78,percent of total billed charges,,,70,,140.7,percent of total billed charges,,,,,,,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,,29.54,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,29.54,180.9,
PT Therapeutic Exercise Strength Endurance ROM Flexibility,97110,CPT,,,GP,both,,,201,120.6,,45.5,,91.46,percent of total billed charges,,,45.3,,91.05,percent of total billed charges,,84.05,,,,fee schedule,353% of fee schedule,,,,,,,,80,,160.8,percent of total billed charges,,,61.4,,123.41,percent of total billed charges,,,57.4,,115.37,percent of total billed charges,,,81,,162.81,percent of total billed charges,,80.72,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,170.85,percent of total billed charges,,,85,,170.85,percent of total billed charges,,,49,,98.49,percent of total billed charges,,,90,,180.9,percent of total billed charges,,,65,,130.65,percent of total billed charges,,,80,,160.8,percent of total billed charges,,,55,,110.55,percent of total billed charges,,,55,,110.55,percent of total billed charges,,,65,,130.65,percent of total billed charges,,,78,,156.78,percent of total billed charges,,,70,,140.7,percent of total billed charges,,,,,,,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,,29.54,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,29.54,180.9,
PT Therapeutic Exercise Units,97110,CPT,,,GP,both,,,201,120.6,,45.5,,91.46,percent of total billed charges,,,45.3,,91.05,percent of total billed charges,,84.05,,,,fee schedule,353% of fee schedule,,,,,,,,80,,160.8,percent of total billed charges,,,61.4,,123.41,percent of total billed charges,,,57.4,,115.37,percent of total billed charges,,,81,,162.81,percent of total billed charges,,80.72,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,170.85,percent of total billed charges,,,85,,170.85,percent of total billed charges,,,49,,98.49,percent of total billed charges,,,90,,180.9,percent of total billed charges,,,65,,130.65,percent of total billed charges,,,80,,160.8,percent of total billed charges,,,55,,110.55,percent of total billed charges,,,55,,110.55,percent of total billed charges,,,65,,130.65,percent of total billed charges,,,78,,156.78,percent of total billed charges,,,70,,140.7,percent of total billed charges,,,,,,,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,29.54,,,,100% of Medicare,,,29.54,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,29.54,180.9,
OT Neuromuscular Reeducation Units,97112,CPT,,,GO,both,,,265,159,,45.5,,120.58,percent of total billed charges,,,45.3,,120.05,percent of total billed charges,,97.43,,,,fee schedule,353% of fee schedule,,,,,,,,80,,212,percent of total billed charges,,,61.4,,162.71,percent of total billed charges,,,57.4,,152.11,percent of total billed charges,,,81,,214.65,percent of total billed charges,,93.56,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,225.25,percent of total billed charges,,,85,,225.25,percent of total billed charges,,,49,,129.85,percent of total billed charges,,,90,,238.5,percent of total billed charges,,,65,,172.25,percent of total billed charges,,,80,,212,percent of total billed charges,,,55,,145.75,percent of total billed charges,,,55,,145.75,percent of total billed charges,,,65,,172.25,percent of total billed charges,,,78,,206.7,percent of total billed charges,,,70,,185.5,percent of total billed charges,,,,,,,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,,32.82,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,32.82,238.5,
Chiro Neuromuscular Re-education Charge,97112,CPT,,,GP,outpatient,,,265,159,,45.5,,120.58,percent of total billed charges,,,45.3,,120.05,percent of total billed charges,,97.43,,,,fee schedule,353% of fee schedule,,,,,,,,80,,212,percent of total billed charges,,,61.4,,162.71,percent of total billed charges,,,57.4,,152.11,percent of total billed charges,,,81,,214.65,percent of total billed charges,,93.56,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,225.25,percent of total billed charges,,,85,,225.25,percent of total billed charges,,,49,,129.85,percent of total billed charges,,,90,,238.5,percent of total billed charges,,,65,,172.25,percent of total billed charges,,,80,,212,percent of total billed charges,,,55,,145.75,percent of total billed charges,,,55,,145.75,percent of total billed charges,,,65,,172.25,percent of total billed charges,,,78,,206.7,percent of total billed charges,,,70,,185.5,percent of total billed charges,,,,,,,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,,32.82,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,32.82,238.5,
PT Neuromuscular Re-Education,97112,CPT,,,GP,both,,,265,159,,45.5,,120.58,percent of total billed charges,,,45.3,,120.05,percent of total billed charges,,97.43,,,,fee schedule,353% of fee schedule,,,,,,,,80,,212,percent of total billed charges,,,61.4,,162.71,percent of total billed charges,,,57.4,,152.11,percent of total billed charges,,,81,,214.65,percent of total billed charges,,93.56,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,225.25,percent of total billed charges,,,85,,225.25,percent of total billed charges,,,49,,129.85,percent of total billed charges,,,90,,238.5,percent of total billed charges,,,65,,172.25,percent of total billed charges,,,80,,212,percent of total billed charges,,,55,,145.75,percent of total billed charges,,,55,,145.75,percent of total billed charges,,,65,,172.25,percent of total billed charges,,,78,,206.7,percent of total billed charges,,,70,,185.5,percent of total billed charges,,,,,,,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,,32.82,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,32.82,238.5,
PT Neuromuscular Reeducation Units,97112,CPT,,,GP,both,,,265,159,,45.5,,120.58,percent of total billed charges,,,45.3,,120.05,percent of total billed charges,,97.43,,,,fee schedule,353% of fee schedule,,,,,,,,80,,212,percent of total billed charges,,,61.4,,162.71,percent of total billed charges,,,57.4,,152.11,percent of total billed charges,,,81,,214.65,percent of total billed charges,,93.56,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,225.25,percent of total billed charges,,,85,,225.25,percent of total billed charges,,,49,,129.85,percent of total billed charges,,,90,,238.5,percent of total billed charges,,,65,,172.25,percent of total billed charges,,,80,,212,percent of total billed charges,,,55,,145.75,percent of total billed charges,,,55,,145.75,percent of total billed charges,,,65,,172.25,percent of total billed charges,,,78,,206.7,percent of total billed charges,,,70,,185.5,percent of total billed charges,,,,,,,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,,32.82,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,32.82,238.5,
PT NM Reed Units,97112,CPT,,,GP,both,,,265,159,,45.5,,120.58,percent of total billed charges,,,45.3,,120.05,percent of total billed charges,,97.43,,,,fee schedule,353% of fee schedule,,,,,,,,80,,212,percent of total billed charges,,,61.4,,162.71,percent of total billed charges,,,57.4,,152.11,percent of total billed charges,,,81,,214.65,percent of total billed charges,,93.56,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,225.25,percent of total billed charges,,,85,,225.25,percent of total billed charges,,,49,,129.85,percent of total billed charges,,,90,,238.5,percent of total billed charges,,,65,,172.25,percent of total billed charges,,,80,,212,percent of total billed charges,,,55,,145.75,percent of total billed charges,,,55,,145.75,percent of total billed charges,,,65,,172.25,percent of total billed charges,,,78,,206.7,percent of total billed charges,,,70,,185.5,percent of total billed charges,,,,,,,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,32.82,,,,100% of Medicare,,,32.82,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,32.82,238.5,
OT Aquatic Units,97113,CPT,,,GO,both,,,182,109.2,,45.5,,82.81,percent of total billed charges,,,45.3,,82.45,percent of total billed charges,,106.15,,,,fee schedule,353% of fee schedule,,,,,,,,80,,145.6,percent of total billed charges,,,61.4,,111.75,percent of total billed charges,,,57.4,,104.47,percent of total billed charges,,,81,,147.42,percent of total billed charges,,101.94,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,154.7,percent of total billed charges,,,85,,154.7,percent of total billed charges,,,49,,89.18,percent of total billed charges,,,90,,163.8,percent of total billed charges,,,65,,118.3,percent of total billed charges,,,80,,145.6,percent of total billed charges,,,55,,100.1,percent of total billed charges,,,55,,100.1,percent of total billed charges,,,65,,118.3,percent of total billed charges,,,78,,141.96,percent of total billed charges,,,70,,127.4,percent of total billed charges,,,,,,,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,,37.47,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,37.47,163.8,
PT Aquatic Therapy Therapeutic Exercise,97113,CPT,,,GP,both,,,182,109.2,,45.5,,82.81,percent of total billed charges,,,45.3,,82.45,percent of total billed charges,,106.15,,,,fee schedule,353% of fee schedule,,,,,,,,80,,145.6,percent of total billed charges,,,61.4,,111.75,percent of total billed charges,,,57.4,,104.47,percent of total billed charges,,,81,,147.42,percent of total billed charges,,101.94,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,154.7,percent of total billed charges,,,85,,154.7,percent of total billed charges,,,49,,89.18,percent of total billed charges,,,90,,163.8,percent of total billed charges,,,65,,118.3,percent of total billed charges,,,80,,145.6,percent of total billed charges,,,55,,100.1,percent of total billed charges,,,55,,100.1,percent of total billed charges,,,65,,118.3,percent of total billed charges,,,78,,141.96,percent of total billed charges,,,70,,127.4,percent of total billed charges,,,,,,,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,,37.47,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,37.47,163.8,
PT Aquatic Units,97113,CPT,,,GP,both,,,182,109.2,,45.5,,82.81,percent of total billed charges,,,45.3,,82.45,percent of total billed charges,,106.15,,,,fee schedule,353% of fee schedule,,,,,,,,80,,145.6,percent of total billed charges,,,61.4,,111.75,percent of total billed charges,,,57.4,,104.47,percent of total billed charges,,,81,,147.42,percent of total billed charges,,101.94,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,154.7,percent of total billed charges,,,85,,154.7,percent of total billed charges,,,49,,89.18,percent of total billed charges,,,90,,163.8,percent of total billed charges,,,65,,118.3,percent of total billed charges,,,80,,145.6,percent of total billed charges,,,55,,100.1,percent of total billed charges,,,55,,100.1,percent of total billed charges,,,65,,118.3,percent of total billed charges,,,78,,141.96,percent of total billed charges,,,70,,127.4,percent of total billed charges,,,,,,,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,37.47,,,,100% of Medicare,,,37.47,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,37.47,163.8,
OT Massage Units,97124,CPT,,,GO,both,,,116,69.6,,45.5,,52.78,percent of total billed charges,,,45.3,,52.55,percent of total billed charges,,81.68,,,,fee schedule,353% of fee schedule,,,,,,,,80,,92.8,percent of total billed charges,,,61.4,,71.22,percent of total billed charges,,,57.4,,66.58,percent of total billed charges,,,81,,93.96,percent of total billed charges,,78.44,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,98.6,percent of total billed charges,,,85,,98.6,percent of total billed charges,,,49,,56.84,percent of total billed charges,,,90,,104.4,percent of total billed charges,,,65,,75.4,percent of total billed charges,,,80,,92.8,percent of total billed charges,,,55,,63.8,percent of total billed charges,,,55,,63.8,percent of total billed charges,,,65,,75.4,percent of total billed charges,,,78,,90.48,percent of total billed charges,,,70,,81.2,percent of total billed charges,,,,,,,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,,30.58,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,30.58,124.8,
Chiro Massage Charge,97124,CPT,,,GP,outpatient,,,116,69.6,,45.5,,52.78,percent of total billed charges,,,45.3,,52.55,percent of total billed charges,,81.68,,,,fee schedule,353% of fee schedule,,,,,,,,80,,92.8,percent of total billed charges,,,61.4,,71.22,percent of total billed charges,,,57.4,,66.58,percent of total billed charges,,,81,,93.96,percent of total billed charges,,78.44,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,98.6,percent of total billed charges,,,85,,98.6,percent of total billed charges,,,49,,56.84,percent of total billed charges,,,90,,104.4,percent of total billed charges,,,65,,75.4,percent of total billed charges,,,80,,92.8,percent of total billed charges,,,55,,63.8,percent of total billed charges,,,55,,63.8,percent of total billed charges,,,65,,75.4,percent of total billed charges,,,78,,90.48,percent of total billed charges,,,70,,81.2,percent of total billed charges,,,,,,,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,,30.58,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,30.58,124.8,
PT Massage Units,97124,CPT,,,GP,both,,,116,69.6,,45.5,,52.78,percent of total billed charges,,,45.3,,52.55,percent of total billed charges,,81.68,,,,fee schedule,353% of fee schedule,,,,,,,,80,,92.8,percent of total billed charges,,,61.4,,71.22,percent of total billed charges,,,57.4,,66.58,percent of total billed charges,,,81,,93.96,percent of total billed charges,,78.44,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,98.6,percent of total billed charges,,,85,,98.6,percent of total billed charges,,,49,,56.84,percent of total billed charges,,,90,,104.4,percent of total billed charges,,,65,,75.4,percent of total billed charges,,,80,,92.8,percent of total billed charges,,,55,,63.8,percent of total billed charges,,,55,,63.8,percent of total billed charges,,,65,,75.4,percent of total billed charges,,,78,,90.48,percent of total billed charges,,,70,,81.2,percent of total billed charges,,,,,,,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,,30.58,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,30.58,124.8,
"PT Therapeutic procedure, massage",97124,CPT,,,GP,both,,,116,69.6,,45.5,,52.78,percent of total billed charges,,,45.3,,52.55,percent of total billed charges,,81.68,,,,fee schedule,353% of fee schedule,,,,,,,,80,,92.8,percent of total billed charges,,,61.4,,71.22,percent of total billed charges,,,57.4,,66.58,percent of total billed charges,,,81,,93.96,percent of total billed charges,,78.44,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,98.6,percent of total billed charges,,,85,,98.6,percent of total billed charges,,,49,,56.84,percent of total billed charges,,,90,,104.4,percent of total billed charges,,,65,,75.4,percent of total billed charges,,,80,,92.8,percent of total billed charges,,,55,,63.8,percent of total billed charges,,,55,,63.8,percent of total billed charges,,,65,,75.4,percent of total billed charges,,,78,,90.48,percent of total billed charges,,,70,,81.2,percent of total billed charges,,,,,,,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,30.58,,,,100% of Medicare,,,30.58,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,30.58,124.8,
SLP Therapeutic Cognitive Function Units,97129,CPT,,,GN,both,,,142,85.2,,45.5,,64.61,percent of total billed charges,,,45.3,,64.33,percent of total billed charges,,64.63,,,,fee schedule,353% of fee schedule,,,,,,,,80,,113.6,percent of total billed charges,,,61.4,,87.19,percent of total billed charges,,,57.4,,81.51,percent of total billed charges,,,81,,115.02,percent of total billed charges,,62.07,,,,fee schedule,339% of fee schedule,427.44,,,,fee schedule,,,85,,120.7,percent of total billed charges,,,85,,120.7,percent of total billed charges,,,49,,69.58,percent of total billed charges,,,90,,127.8,percent of total billed charges,,,65,,92.3,percent of total billed charges,,,80,,113.6,percent of total billed charges,,,55,,78.1,percent of total billed charges,,,55,,78.1,percent of total billed charges,,,65,,92.3,percent of total billed charges,,,78,,110.76,percent of total billed charges,,,70,,99.4,percent of total billed charges,,,,,,,,21.9,,,,100% of Medicare,,21.9,,,,100% of Medicare,,21.9,,,,100% of Medicare,,21.9,,,,100% of Medicare,,21.9,,,,100% of Medicare,,21.9,,,,100% of Medicare,,21.9,,,,100% of Medicare,,21.9,,,,100% of Medicare,,21.9,,,,100% of Medicare,,21.9,,,,100% of Medicare,,21.9,,,,100% of Medicare,,21.9,,,,100% of Medicare,,,21.9,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,21.9,427.44,
OT Therapeutic Cognitive Function Units,97129,CPT,,,GO,both,,,142,85.2,,45.5,,64.61,percent of total billed charges,,,45.3,,64.33,percent of total billed charges,,64.63,,,,fee schedule,353% of fee schedule,,,,,,,,80,,113.6,percent of total billed charges,,,61.4,,87.19,percent of total billed charges,,,57.4,,81.51,percent of total billed charges,,,81,,115.02,percent of total billed charges,,62.07,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,120.7,percent of total billed charges,,,85,,120.7,percent of total billed charges,,,49,,69.58,percent of total billed charges,,,90,,127.8,percent of total billed charges,,,65,,92.3,percent of total billed charges,,,80,,113.6,percent of total billed charges,,,55,,78.1,percent of total billed charges,,,55,,78.1,percent of total billed charges,,,65,,92.3,percent of total billed charges,,,78,,110.76,percent of total billed charges,,,70,,99.4,percent of total billed charges,,,,,,,,21.9,,,,100% of Medicare,,21.9,,,,100% of Medicare,,21.9,,,,100% of Medicare,,21.9,,,,100% of Medicare,,21.9,,,,100% of Medicare,,21.9,,,,100% of Medicare,,21.9,,,,100% of Medicare,,21.9,,,,100% of Medicare,,21.9,,,,100% of Medicare,,21.9,,,,100% of Medicare,,21.9,,,,100% of Medicare,,21.9,,,,100% of Medicare,,,21.9,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,21.9,127.8,
SLP Ther Cognitive Func Addl 15min Units,97130,CPT,,,GN,both,,,132,79.2,,45.5,,60.06,percent of total billed charges,,,45.3,,59.8,percent of total billed charges,,61.78,,,,fee schedule,353% of fee schedule,,,,,,,,80,,105.6,percent of total billed charges,,,61.4,,81.05,percent of total billed charges,,,57.4,,75.77,percent of total billed charges,,,81,,106.92,percent of total billed charges,,59.33,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,112.2,percent of total billed charges,,,85,,112.2,percent of total billed charges,,,49,,64.68,percent of total billed charges,,,90,,118.8,percent of total billed charges,,,65,,85.8,percent of total billed charges,,,80,,105.6,percent of total billed charges,,,55,,72.6,percent of total billed charges,,,55,,72.6,percent of total billed charges,,,65,,85.8,percent of total billed charges,,,78,,102.96,percent of total billed charges,,,70,,92.4,percent of total billed charges,,,,,,,,21.25,,,,100% of Medicare,,21.25,,,,100% of Medicare,,21.25,,,,100% of Medicare,,21.25,,,,100% of Medicare,,21.25,,,,100% of Medicare,,21.25,,,,100% of Medicare,,21.25,,,,100% of Medicare,,21.25,,,,100% of Medicare,,21.25,,,,100% of Medicare,,21.25,,,,100% of Medicare,,21.25,,,,100% of Medicare,,21.25,,,,100% of Medicare,,,21.25,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,21.25,124.8,
OT Ther Cognitive Func Addl 15min Units,97130,CPT,,,GO,both,,,132,79.2,,45.5,,60.06,percent of total billed charges,,,45.3,,59.8,percent of total billed charges,,61.78,,,,fee schedule,353% of fee schedule,,,,,,,,80,,105.6,percent of total billed charges,,,61.4,,81.05,percent of total billed charges,,,57.4,,75.77,percent of total billed charges,,,81,,106.92,percent of total billed charges,,59.33,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,112.2,percent of total billed charges,,,85,,112.2,percent of total billed charges,,,49,,64.68,percent of total billed charges,,,90,,118.8,percent of total billed charges,,,65,,85.8,percent of total billed charges,,,80,,105.6,percent of total billed charges,,,55,,72.6,percent of total billed charges,,,55,,72.6,percent of total billed charges,,,65,,85.8,percent of total billed charges,,,78,,102.96,percent of total billed charges,,,70,,92.4,percent of total billed charges,,,,,,,,21.25,,,,100% of Medicare,,21.25,,,,100% of Medicare,,21.25,,,,100% of Medicare,,21.25,,,,100% of Medicare,,21.25,,,,100% of Medicare,,21.25,,,,100% of Medicare,,21.25,,,,100% of Medicare,,21.25,,,,100% of Medicare,,21.25,,,,100% of Medicare,,21.25,,,,100% of Medicare,,21.25,,,,100% of Medicare,,21.25,,,,100% of Medicare,,,21.25,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,21.25,124.8,
OT Manual Therapy Units,97140,CPT,,,GO,both,,,182,109.2,,45.5,,82.81,percent of total billed charges,,,45.3,,82.45,percent of total billed charges,,77.38,,,,fee schedule,353% of fee schedule,,,,,,,,80,,145.6,percent of total billed charges,,,61.4,,111.75,percent of total billed charges,,,57.4,,104.47,percent of total billed charges,,,81,,147.42,percent of total billed charges,,74.31,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,154.7,percent of total billed charges,,,85,,154.7,percent of total billed charges,,,49,,89.18,percent of total billed charges,,,90,,163.8,percent of total billed charges,,,65,,118.3,percent of total billed charges,,,80,,145.6,percent of total billed charges,,,55,,100.1,percent of total billed charges,,,55,,100.1,percent of total billed charges,,,65,,118.3,percent of total billed charges,,,78,,141.96,percent of total billed charges,,,70,,127.4,percent of total billed charges,,,,,,,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,,27.9,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,27.9,163.8,
Chiro Manual Therapy Techniques Charge,97140,CPT,,,GP,outpatient,,,182,109.2,,45.5,,82.81,percent of total billed charges,,,45.3,,82.45,percent of total billed charges,,77.38,,,,fee schedule,353% of fee schedule,,,,,,,,80,,145.6,percent of total billed charges,,,61.4,,111.75,percent of total billed charges,,,57.4,,104.47,percent of total billed charges,,,81,,147.42,percent of total billed charges,,74.31,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,154.7,percent of total billed charges,,,85,,154.7,percent of total billed charges,,,49,,89.18,percent of total billed charges,,,90,,163.8,percent of total billed charges,,,65,,118.3,percent of total billed charges,,,80,,145.6,percent of total billed charges,,,55,,100.1,percent of total billed charges,,,55,,100.1,percent of total billed charges,,,65,,118.3,percent of total billed charges,,,78,,141.96,percent of total billed charges,,,70,,127.4,percent of total billed charges,,,,,,,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,,27.9,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,27.9,163.8,
PT Manual Therapy 1+ region,97140,CPT,,,GP,both,,,182,109.2,,45.5,,82.81,percent of total billed charges,,,45.3,,82.45,percent of total billed charges,,77.38,,,,fee schedule,353% of fee schedule,,,,,,,,80,,145.6,percent of total billed charges,,,61.4,,111.75,percent of total billed charges,,,57.4,,104.47,percent of total billed charges,,,81,,147.42,percent of total billed charges,,74.31,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,154.7,percent of total billed charges,,,85,,154.7,percent of total billed charges,,,49,,89.18,percent of total billed charges,,,90,,163.8,percent of total billed charges,,,65,,118.3,percent of total billed charges,,,80,,145.6,percent of total billed charges,,,55,,100.1,percent of total billed charges,,,55,,100.1,percent of total billed charges,,,65,,118.3,percent of total billed charges,,,78,,141.96,percent of total billed charges,,,70,,127.4,percent of total billed charges,,,,,,,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,,27.9,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,27.9,163.8,
PT Manual Therapy Units,97140,CPT,,,GP,both,,,182,109.2,,45.5,,82.81,percent of total billed charges,,,45.3,,82.45,percent of total billed charges,,77.38,,,,fee schedule,353% of fee schedule,,,,,,,,80,,145.6,percent of total billed charges,,,61.4,,111.75,percent of total billed charges,,,57.4,,104.47,percent of total billed charges,,,81,,147.42,percent of total billed charges,,74.31,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,154.7,percent of total billed charges,,,85,,154.7,percent of total billed charges,,,49,,89.18,percent of total billed charges,,,90,,163.8,percent of total billed charges,,,65,,118.3,percent of total billed charges,,,80,,145.6,percent of total billed charges,,,55,,100.1,percent of total billed charges,,,55,,100.1,percent of total billed charges,,,65,,118.3,percent of total billed charges,,,78,,141.96,percent of total billed charges,,,70,,127.4,percent of total billed charges,,,,,,,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,27.9,,,,100% of Medicare,,,27.9,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,27.9,163.8,
OT Class Units,97150,CPT,,,GO,both,,,131,78.6,,45.5,,59.61,percent of total billed charges,,,45.3,,59.34,percent of total billed charges,,50.02,,,,fee schedule,353% of fee schedule,,,,,,,,80,,104.8,percent of total billed charges,,,61.4,,80.43,percent of total billed charges,,,57.4,,75.19,percent of total billed charges,,,81,,106.11,percent of total billed charges,,48.04,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,111.35,percent of total billed charges,,,85,,111.35,percent of total billed charges,,,49,,64.19,percent of total billed charges,,,90,,117.9,percent of total billed charges,,,65,,85.15,percent of total billed charges,,,80,,104.8,percent of total billed charges,,,55,,72.05,percent of total billed charges,,,55,,72.05,percent of total billed charges,,,65,,85.15,percent of total billed charges,,,78,,102.18,percent of total billed charges,,,70,,91.7,percent of total billed charges,,,,,,,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,,18.04,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,18.04,124.8,
OT Double Therapy Units,97150,CPT,,,GO,both,,,131,78.6,,45.5,,59.61,percent of total billed charges,,,45.3,,59.34,percent of total billed charges,,50.02,,,,fee schedule,353% of fee schedule,,,,,,,,80,,104.8,percent of total billed charges,,,61.4,,80.43,percent of total billed charges,,,57.4,,75.19,percent of total billed charges,,,81,,106.11,percent of total billed charges,,48.04,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,111.35,percent of total billed charges,,,85,,111.35,percent of total billed charges,,,49,,64.19,percent of total billed charges,,,90,,117.9,percent of total billed charges,,,65,,85.15,percent of total billed charges,,,80,,104.8,percent of total billed charges,,,55,,72.05,percent of total billed charges,,,55,,72.05,percent of total billed charges,,,65,,85.15,percent of total billed charges,,,78,,102.18,percent of total billed charges,,,70,,91.7,percent of total billed charges,,,,,,,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,,18.04,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,18.04,124.8,
OT Group Therapy Units,97150,CPT,,,GO,both,,,131,78.6,,45.5,,59.61,percent of total billed charges,,,45.3,,59.34,percent of total billed charges,,50.02,,,,fee schedule,353% of fee schedule,,,,,,,,80,,104.8,percent of total billed charges,,,61.4,,80.43,percent of total billed charges,,,57.4,,75.19,percent of total billed charges,,,81,,106.11,percent of total billed charges,,48.04,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,111.35,percent of total billed charges,,,85,,111.35,percent of total billed charges,,,49,,64.19,percent of total billed charges,,,90,,117.9,percent of total billed charges,,,65,,85.15,percent of total billed charges,,,80,,104.8,percent of total billed charges,,,55,,72.05,percent of total billed charges,,,55,,72.05,percent of total billed charges,,,65,,85.15,percent of total billed charges,,,78,,102.18,percent of total billed charges,,,70,,91.7,percent of total billed charges,,,,,,,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,,18.04,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,18.04,124.8,
PT Double Therapy Units,97150,CPT,,,GP,both,,,131,78.6,,45.5,,59.61,percent of total billed charges,,,45.3,,59.34,percent of total billed charges,,50.02,,,,fee schedule,353% of fee schedule,,,,,,,,80,,104.8,percent of total billed charges,,,61.4,,80.43,percent of total billed charges,,,57.4,,75.19,percent of total billed charges,,,81,,106.11,percent of total billed charges,,48.04,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,111.35,percent of total billed charges,,,85,,111.35,percent of total billed charges,,,49,,64.19,percent of total billed charges,,,90,,117.9,percent of total billed charges,,,65,,85.15,percent of total billed charges,,,80,,104.8,percent of total billed charges,,,55,,72.05,percent of total billed charges,,,55,,72.05,percent of total billed charges,,,65,,85.15,percent of total billed charges,,,78,,102.18,percent of total billed charges,,,70,,91.7,percent of total billed charges,,,,,,,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,,18.04,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,18.04,124.8,
PT Group Therapy Units,97150,CPT,,,GP,both,,,131,78.6,,45.5,,59.61,percent of total billed charges,,,45.3,,59.34,percent of total billed charges,,50.02,,,,fee schedule,353% of fee schedule,,,,,,,,80,,104.8,percent of total billed charges,,,61.4,,80.43,percent of total billed charges,,,57.4,,75.19,percent of total billed charges,,,81,,106.11,percent of total billed charges,,48.04,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,111.35,percent of total billed charges,,,85,,111.35,percent of total billed charges,,,49,,64.19,percent of total billed charges,,,90,,117.9,percent of total billed charges,,,65,,85.15,percent of total billed charges,,,80,,104.8,percent of total billed charges,,,55,,72.05,percent of total billed charges,,,55,,72.05,percent of total billed charges,,,65,,85.15,percent of total billed charges,,,78,,102.18,percent of total billed charges,,,70,,91.7,percent of total billed charges,,,,,,,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,,18.04,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,18.04,124.8,
PT Treatment Double,97150,CPT,,,GP,both,,,131,78.6,,45.5,,59.61,percent of total billed charges,,,45.3,,59.34,percent of total billed charges,,50.02,,,,fee schedule,353% of fee schedule,,,,,,,,80,,104.8,percent of total billed charges,,,61.4,,80.43,percent of total billed charges,,,57.4,,75.19,percent of total billed charges,,,81,,106.11,percent of total billed charges,,48.04,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,111.35,percent of total billed charges,,,85,,111.35,percent of total billed charges,,,49,,64.19,percent of total billed charges,,,90,,117.9,percent of total billed charges,,,65,,85.15,percent of total billed charges,,,80,,104.8,percent of total billed charges,,,55,,72.05,percent of total billed charges,,,55,,72.05,percent of total billed charges,,,65,,85.15,percent of total billed charges,,,78,,102.18,percent of total billed charges,,,70,,91.7,percent of total billed charges,,,,,,,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,,18.04,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,18.04,124.8,
PT Treatment Group,97150,CPT,,,GP,both,,,131,78.6,,45.5,,59.61,percent of total billed charges,,,45.3,,59.34,percent of total billed charges,,50.02,,,,fee schedule,353% of fee schedule,,,,,,,,80,,104.8,percent of total billed charges,,,61.4,,80.43,percent of total billed charges,,,57.4,,75.19,percent of total billed charges,,,81,,106.11,percent of total billed charges,,48.04,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,111.35,percent of total billed charges,,,85,,111.35,percent of total billed charges,,,49,,64.19,percent of total billed charges,,,90,,117.9,percent of total billed charges,,,65,,85.15,percent of total billed charges,,,80,,104.8,percent of total billed charges,,,55,,72.05,percent of total billed charges,,,55,,72.05,percent of total billed charges,,,65,,85.15,percent of total billed charges,,,78,,102.18,percent of total billed charges,,,70,,91.7,percent of total billed charges,,,,,,,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,18.04,,,,100% of Medicare,,,18.04,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,18.04,124.8,
OT Therapeutic Activities Units,97530,CPT,,,GO,both,,,248,148.8,,45.5,,112.84,percent of total billed charges,,,45.3,,112.34,percent of total billed charges,,109.18,,,,fee schedule,353% of fee schedule,,,,,,,,80,,198.4,percent of total billed charges,,,61.4,,152.27,percent of total billed charges,,,57.4,,142.35,percent of total billed charges,,,81,,200.88,percent of total billed charges,,104.85,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,210.8,percent of total billed charges,,,85,,210.8,percent of total billed charges,,,49,,121.52,percent of total billed charges,,,90,,223.2,percent of total billed charges,,,65,,161.2,percent of total billed charges,,,80,,198.4,percent of total billed charges,,,55,,136.4,percent of total billed charges,,,55,,136.4,percent of total billed charges,,,65,,161.2,percent of total billed charges,,,78,,193.44,percent of total billed charges,,,70,,173.6,percent of total billed charges,,,,,,,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,,35.5,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,35.5,223.2,
Chiro Therapeutic Fuctional Act Charge,97530,CPT,,,GP,outpatient,,,248,148.8,,45.5,,112.84,percent of total billed charges,,,45.3,,112.34,percent of total billed charges,,109.18,,,,fee schedule,353% of fee schedule,,,,,,,,80,,198.4,percent of total billed charges,,,61.4,,152.27,percent of total billed charges,,,57.4,,142.35,percent of total billed charges,,,81,,200.88,percent of total billed charges,,104.85,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,210.8,percent of total billed charges,,,85,,210.8,percent of total billed charges,,,49,,121.52,percent of total billed charges,,,90,,223.2,percent of total billed charges,,,65,,161.2,percent of total billed charges,,,80,,198.4,percent of total billed charges,,,55,,136.4,percent of total billed charges,,,55,,136.4,percent of total billed charges,,,65,,161.2,percent of total billed charges,,,78,,193.44,percent of total billed charges,,,70,,173.6,percent of total billed charges,,,,,,,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,,35.5,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,35.5,223.2,
PT Therapeutic Activity Functional Performance,97530,CPT,,,GP,both,,,248,148.8,,45.5,,112.84,percent of total billed charges,,,45.3,,112.34,percent of total billed charges,,109.18,,,,fee schedule,353% of fee schedule,,,,,,,,80,,198.4,percent of total billed charges,,,61.4,,152.27,percent of total billed charges,,,57.4,,142.35,percent of total billed charges,,,81,,200.88,percent of total billed charges,,104.85,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,210.8,percent of total billed charges,,,85,,210.8,percent of total billed charges,,,49,,121.52,percent of total billed charges,,,90,,223.2,percent of total billed charges,,,65,,161.2,percent of total billed charges,,,80,,198.4,percent of total billed charges,,,55,,136.4,percent of total billed charges,,,55,,136.4,percent of total billed charges,,,65,,161.2,percent of total billed charges,,,78,,193.44,percent of total billed charges,,,70,,173.6,percent of total billed charges,,,,,,,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,,35.5,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,35.5,223.2,
PT Therapeutic Activity Units,97530,CPT,,,GP,both,,,248,148.8,,45.5,,112.84,percent of total billed charges,,,45.3,,112.34,percent of total billed charges,,109.18,,,,fee schedule,353% of fee schedule,,,,,,,,80,,198.4,percent of total billed charges,,,61.4,,152.27,percent of total billed charges,,,57.4,,142.35,percent of total billed charges,,,81,,200.88,percent of total billed charges,,104.85,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,210.8,percent of total billed charges,,,85,,210.8,percent of total billed charges,,,49,,121.52,percent of total billed charges,,,90,,223.2,percent of total billed charges,,,65,,161.2,percent of total billed charges,,,80,,198.4,percent of total billed charges,,,55,,136.4,percent of total billed charges,,,55,,136.4,percent of total billed charges,,,65,,161.2,percent of total billed charges,,,78,,193.44,percent of total billed charges,,,70,,173.6,percent of total billed charges,,,,,,,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,35.5,,,,100% of Medicare,,,35.5,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,35.5,223.2,
SLP Sensory Integrative Techniques,97533,CPT,,,GN,both,,,218,130.8,,45.5,,99.19,percent of total billed charges,,,45.3,,98.75,percent of total billed charges,,167.89,,,,fee schedule,353% of fee schedule,,,,,,,,80,,174.4,percent of total billed charges,,,61.4,,133.85,percent of total billed charges,,,57.4,,125.13,percent of total billed charges,,,81,,176.58,percent of total billed charges,,161.23,,,,fee schedule,339% of fee schedule,427.44,,,,fee schedule,,,85,,185.3,percent of total billed charges,,,85,,185.3,percent of total billed charges,,,49,,106.82,percent of total billed charges,,,90,,196.2,percent of total billed charges,,,65,,141.7,percent of total billed charges,,,80,,174.4,percent of total billed charges,,,55,,119.9,percent of total billed charges,,,55,,119.9,percent of total billed charges,,,65,,141.7,percent of total billed charges,,,78,,170.04,percent of total billed charges,,,70,,152.6,percent of total billed charges,,,,,,,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,,61.95,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,61.95,427.44,
OT Sensory Integrative Techniques Units,97533,CPT,,,GO,both,,,218,130.8,,45.5,,99.19,percent of total billed charges,,,45.3,,98.75,percent of total billed charges,,167.89,,,,fee schedule,353% of fee schedule,,,,,,,,80,,174.4,percent of total billed charges,,,61.4,,133.85,percent of total billed charges,,,57.4,,125.13,percent of total billed charges,,,81,,176.58,percent of total billed charges,,161.23,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,185.3,percent of total billed charges,,,85,,185.3,percent of total billed charges,,,49,,106.82,percent of total billed charges,,,90,,196.2,percent of total billed charges,,,65,,141.7,percent of total billed charges,,,80,,174.4,percent of total billed charges,,,55,,119.9,percent of total billed charges,,,55,,119.9,percent of total billed charges,,,65,,141.7,percent of total billed charges,,,78,,170.04,percent of total billed charges,,,70,,152.6,percent of total billed charges,,,,,,,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,,61.95,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,61.95,196.2,
PT Sensory Integration Units,97533,CPT,,,GP,both,,,218,130.8,,45.5,,99.19,percent of total billed charges,,,45.3,,98.75,percent of total billed charges,,167.89,,,,fee schedule,353% of fee schedule,,,,,,,,80,,174.4,percent of total billed charges,,,61.4,,133.85,percent of total billed charges,,,57.4,,125.13,percent of total billed charges,,,81,,176.58,percent of total billed charges,,161.23,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,185.3,percent of total billed charges,,,85,,185.3,percent of total billed charges,,,49,,106.82,percent of total billed charges,,,90,,196.2,percent of total billed charges,,,65,,141.7,percent of total billed charges,,,80,,174.4,percent of total billed charges,,,55,,119.9,percent of total billed charges,,,55,,119.9,percent of total billed charges,,,65,,141.7,percent of total billed charges,,,78,,170.04,percent of total billed charges,,,70,,152.6,percent of total billed charges,,,,,,,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,61.95,,,,100% of Medicare,,,61.95,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,61.95,196.2,
Job Placement Group Units,97537,CPT,,,,outpatient,,,107,64.2,,45.5,,48.69,percent of total billed charges,,,45.3,,48.47,percent of total billed charges,,89.77,,,,fee schedule,353% of fee schedule,,,,,,,,80,,85.6,percent of total billed charges,,,61.4,,65.7,percent of total billed charges,,,57.4,,61.42,percent of total billed charges,,,81,,86.67,percent of total billed charges,,86.21,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,90.95,percent of total billed charges,,,85,,90.95,percent of total billed charges,,,49,,52.43,percent of total billed charges,,,90,,96.3,percent of total billed charges,,,65,,69.55,percent of total billed charges,,,80,,85.6,percent of total billed charges,,,55,,58.85,percent of total billed charges,,,55,,58.85,percent of total billed charges,,,65,,69.55,percent of total billed charges,,,78,,83.46,percent of total billed charges,,,70,,74.9,percent of total billed charges,,,,,,,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,,32.5,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,32.5,124.8,
Voc Rehab Group Units,97537,CPT,,,,outpatient,,,155,93,,45.5,,70.53,percent of total billed charges,,,45.3,,70.22,percent of total billed charges,,89.77,,,,fee schedule,353% of fee schedule,,,,,,,,80,,124,percent of total billed charges,,,61.4,,95.17,percent of total billed charges,,,57.4,,88.97,percent of total billed charges,,,81,,125.55,percent of total billed charges,,86.21,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,131.75,percent of total billed charges,,,85,,131.75,percent of total billed charges,,,49,,75.95,percent of total billed charges,,,90,,139.5,percent of total billed charges,,,65,,100.75,percent of total billed charges,,,80,,124,percent of total billed charges,,,55,,85.25,percent of total billed charges,,,55,,85.25,percent of total billed charges,,,65,,100.75,percent of total billed charges,,,78,,120.9,percent of total billed charges,,,70,,108.5,percent of total billed charges,,,,,,,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,,32.5,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,32.5,139.5,
Job Placement Individual Units,97537,CPT,,,,outpatient,,,77,46.2,,45.5,,35.04,percent of total billed charges,,,45.3,,34.88,percent of total billed charges,,89.77,,,,fee schedule,353% of fee schedule,,,,,,,,80,,61.6,percent of total billed charges,,,61.4,,47.28,percent of total billed charges,,,57.4,,44.2,percent of total billed charges,,,81,,62.37,percent of total billed charges,,86.21,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,65.45,percent of total billed charges,,,85,,65.45,percent of total billed charges,,,49,,37.73,percent of total billed charges,,,90,,69.3,percent of total billed charges,,,65,,50.05,percent of total billed charges,,,80,,61.6,percent of total billed charges,,,55,,42.35,percent of total billed charges,,,55,,42.35,percent of total billed charges,,,65,,50.05,percent of total billed charges,,,78,,60.06,percent of total billed charges,,,70,,53.9,percent of total billed charges,,,,,,,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,,32.5,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,32.5,124.8,
Job Coaching Units,97537,CPT,,,,outpatient,,,169,101.4,,45.5,,76.9,percent of total billed charges,,,45.3,,76.56,percent of total billed charges,,89.77,,,,fee schedule,353% of fee schedule,,,,,,,,80,,135.2,percent of total billed charges,,,61.4,,103.77,percent of total billed charges,,,57.4,,97.01,percent of total billed charges,,,81,,136.89,percent of total billed charges,,86.21,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,143.65,percent of total billed charges,,,85,,143.65,percent of total billed charges,,,49,,82.81,percent of total billed charges,,,90,,152.1,percent of total billed charges,,,65,,109.85,percent of total billed charges,,,80,,135.2,percent of total billed charges,,,55,,92.95,percent of total billed charges,,,55,,92.95,percent of total billed charges,,,65,,109.85,percent of total billed charges,,,78,,131.82,percent of total billed charges,,,70,,118.3,percent of total billed charges,,,,,,,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,,32.5,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,32.5,152.1,
OT Community/Work Reintegration Units,97537,CPT,,,GO,both,,,197,118.2,,45.5,,89.64,percent of total billed charges,,,45.3,,89.24,percent of total billed charges,,89.77,,,,fee schedule,353% of fee schedule,,,,,,,,80,,157.6,percent of total billed charges,,,61.4,,120.96,percent of total billed charges,,,57.4,,113.08,percent of total billed charges,,,81,,159.57,percent of total billed charges,,86.21,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,167.45,percent of total billed charges,,,85,,167.45,percent of total billed charges,,,49,,96.53,percent of total billed charges,,,90,,177.3,percent of total billed charges,,,65,,128.05,percent of total billed charges,,,80,,157.6,percent of total billed charges,,,55,,108.35,percent of total billed charges,,,55,,108.35,percent of total billed charges,,,65,,128.05,percent of total billed charges,,,78,,153.66,percent of total billed charges,,,70,,137.9,percent of total billed charges,,,,,,,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,,32.5,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,32.5,177.3,
PT Community/Work Reintegration Units,97537,CPT,,,GP,both,,,197,118.2,,45.5,,89.64,percent of total billed charges,,,45.3,,89.24,percent of total billed charges,,89.77,,,,fee schedule,353% of fee schedule,,,,,,,,80,,157.6,percent of total billed charges,,,61.4,,120.96,percent of total billed charges,,,57.4,,113.08,percent of total billed charges,,,81,,159.57,percent of total billed charges,,86.21,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,167.45,percent of total billed charges,,,85,,167.45,percent of total billed charges,,,49,,96.53,percent of total billed charges,,,90,,177.3,percent of total billed charges,,,65,,128.05,percent of total billed charges,,,80,,157.6,percent of total billed charges,,,55,,108.35,percent of total billed charges,,,55,,108.35,percent of total billed charges,,,65,,128.05,percent of total billed charges,,,78,,153.66,percent of total billed charges,,,70,,137.9,percent of total billed charges,,,,,,,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,,32.5,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,32.5,177.3,
Job Placement Case Management Units,97537,CPT,,,,outpatient,,,206,123.6,,45.5,,93.73,percent of total billed charges,,,45.3,,93.32,percent of total billed charges,,89.77,,,,fee schedule,353% of fee schedule,,,,,,,,80,,164.8,percent of total billed charges,,,61.4,,126.48,percent of total billed charges,,,57.4,,118.24,percent of total billed charges,,,81,,166.86,percent of total billed charges,,86.21,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,175.1,percent of total billed charges,,,85,,175.1,percent of total billed charges,,,49,,100.94,percent of total billed charges,,,90,,185.4,percent of total billed charges,,,65,,133.9,percent of total billed charges,,,80,,164.8,percent of total billed charges,,,55,,113.3,percent of total billed charges,,,55,,113.3,percent of total billed charges,,,65,,133.9,percent of total billed charges,,,78,,160.68,percent of total billed charges,,,70,,144.2,percent of total billed charges,,,,,,,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,,32.5,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,32.5,185.4,
Voc Rehab Case Management Units,97537,CPT,,,,outpatient,,,220,132,,45.5,,100.1,percent of total billed charges,,,45.3,,99.66,percent of total billed charges,,89.77,,,,fee schedule,353% of fee schedule,,,,,,,,80,,176,percent of total billed charges,,,61.4,,135.08,percent of total billed charges,,,57.4,,126.28,percent of total billed charges,,,81,,178.2,percent of total billed charges,,86.21,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,187,percent of total billed charges,,,85,,187,percent of total billed charges,,,49,,107.8,percent of total billed charges,,,90,,198,percent of total billed charges,,,65,,143,percent of total billed charges,,,80,,176,percent of total billed charges,,,55,,121,percent of total billed charges,,,55,,121,percent of total billed charges,,,65,,143,percent of total billed charges,,,78,,171.6,percent of total billed charges,,,70,,154,percent of total billed charges,,,,,,,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,,32.5,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,32.5,198,
Inpatient Vocational Rehab Evaluation,97537,CPT,,,,outpatient,,,258,154.8,,45.5,,117.39,percent of total billed charges,,,45.3,,116.87,percent of total billed charges,,89.77,,,,fee schedule,353% of fee schedule,,,,,,,,80,,206.4,percent of total billed charges,,,61.4,,158.41,percent of total billed charges,,,57.4,,148.09,percent of total billed charges,,,81,,208.98,percent of total billed charges,,86.21,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,219.3,percent of total billed charges,,,85,,219.3,percent of total billed charges,,,49,,126.42,percent of total billed charges,,,90,,232.2,percent of total billed charges,,,65,,167.7,percent of total billed charges,,,80,,206.4,percent of total billed charges,,,55,,141.9,percent of total billed charges,,,55,,141.9,percent of total billed charges,,,65,,167.7,percent of total billed charges,,,78,,201.24,percent of total billed charges,,,70,,180.6,percent of total billed charges,,,,,,,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,,32.5,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,32.5,232.2,
Voc Rehab Inpatient Evaluations Units,97537,CPT,,,,outpatient,,,258,154.8,,45.5,,117.39,percent of total billed charges,,,45.3,,116.87,percent of total billed charges,,89.77,,,,fee schedule,353% of fee schedule,,,,,,,,80,,206.4,percent of total billed charges,,,61.4,,158.41,percent of total billed charges,,,57.4,,148.09,percent of total billed charges,,,81,,208.98,percent of total billed charges,,86.21,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,219.3,percent of total billed charges,,,85,,219.3,percent of total billed charges,,,49,,126.42,percent of total billed charges,,,90,,232.2,percent of total billed charges,,,65,,167.7,percent of total billed charges,,,80,,206.4,percent of total billed charges,,,55,,141.9,percent of total billed charges,,,55,,141.9,percent of total billed charges,,,65,,167.7,percent of total billed charges,,,78,,201.24,percent of total billed charges,,,70,,180.6,percent of total billed charges,,,,,,,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,32.5,,,,100% of Medicare,,,32.5,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,32.5,232.2,
OT Wheelchair Management Units,97542,CPT,,,GO,both,,,224,134.4,,45.5,,101.92,percent of total billed charges,,,45.3,,101.47,percent of total billed charges,,90.72,,,,fee schedule,353% of fee schedule,,,,,,,,80,,179.2,percent of total billed charges,,,61.4,,137.54,percent of total billed charges,,,57.4,,128.58,percent of total billed charges,,,81,,181.44,percent of total billed charges,,87.12,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,190.4,percent of total billed charges,,,85,,190.4,percent of total billed charges,,,49,,109.76,percent of total billed charges,,,90,,201.6,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,80,,179.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,78,,174.72,percent of total billed charges,,,70,,156.8,percent of total billed charges,,,,,,,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,,31.51,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,31.51,201.6,
OT Wheelchair Management Units,97542,CPT,,,GO,both,,,224,134.4,,45.5,,101.92,percent of total billed charges,,,45.3,,101.47,percent of total billed charges,,90.72,,,,fee schedule,353% of fee schedule,,,,,,,,80,,179.2,percent of total billed charges,,,61.4,,137.54,percent of total billed charges,,,57.4,,128.58,percent of total billed charges,,,81,,181.44,percent of total billed charges,,87.12,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,190.4,percent of total billed charges,,,85,,190.4,percent of total billed charges,,,49,,109.76,percent of total billed charges,,,90,,201.6,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,80,,179.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,78,,174.72,percent of total billed charges,,,70,,156.8,percent of total billed charges,,,,,,,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,,31.51,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,31.51,201.6,
OT Wheelchair Management Units,97542,CPT,,,GO,both,,,224,134.4,,45.5,,101.92,percent of total billed charges,,,45.3,,101.47,percent of total billed charges,,90.72,,,,fee schedule,353% of fee schedule,,,,,,,,80,,179.2,percent of total billed charges,,,61.4,,137.54,percent of total billed charges,,,57.4,,128.58,percent of total billed charges,,,81,,181.44,percent of total billed charges,,87.12,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,190.4,percent of total billed charges,,,85,,190.4,percent of total billed charges,,,49,,109.76,percent of total billed charges,,,90,,201.6,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,80,,179.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,78,,174.72,percent of total billed charges,,,70,,156.8,percent of total billed charges,,,,,,,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,,31.51,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,31.51,201.6,
OT Wheelchair Management Units,97542,CPT,,,GO,both,,,224,134.4,,45.5,,101.92,percent of total billed charges,,,45.3,,101.47,percent of total billed charges,,90.72,,,,fee schedule,353% of fee schedule,,,,,,,,80,,179.2,percent of total billed charges,,,61.4,,137.54,percent of total billed charges,,,57.4,,128.58,percent of total billed charges,,,81,,181.44,percent of total billed charges,,87.12,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,190.4,percent of total billed charges,,,85,,190.4,percent of total billed charges,,,49,,109.76,percent of total billed charges,,,90,,201.6,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,80,,179.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,78,,174.72,percent of total billed charges,,,70,,156.8,percent of total billed charges,,,,,,,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,,31.51,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,31.51,201.6,
OT Wheelchair Management Units,97542,CPT,,,GO,both,,,224,134.4,,45.5,,101.92,percent of total billed charges,,,45.3,,101.47,percent of total billed charges,,90.72,,,,fee schedule,353% of fee schedule,,,,,,,,80,,179.2,percent of total billed charges,,,61.4,,137.54,percent of total billed charges,,,57.4,,128.58,percent of total billed charges,,,81,,181.44,percent of total billed charges,,87.12,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,190.4,percent of total billed charges,,,85,,190.4,percent of total billed charges,,,49,,109.76,percent of total billed charges,,,90,,201.6,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,80,,179.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,78,,174.72,percent of total billed charges,,,70,,156.8,percent of total billed charges,,,,,,,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,,31.51,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,31.51,201.6,
OT Wheelchair Management Units,97542,CPT,,,GO,both,,,224,134.4,,45.5,,101.92,percent of total billed charges,,,45.3,,101.47,percent of total billed charges,,90.72,,,,fee schedule,353% of fee schedule,,,,,,,,80,,179.2,percent of total billed charges,,,61.4,,137.54,percent of total billed charges,,,57.4,,128.58,percent of total billed charges,,,81,,181.44,percent of total billed charges,,87.12,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,190.4,percent of total billed charges,,,85,,190.4,percent of total billed charges,,,49,,109.76,percent of total billed charges,,,90,,201.6,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,80,,179.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,78,,174.72,percent of total billed charges,,,70,,156.8,percent of total billed charges,,,,,,,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,,31.51,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,31.51,201.6,
OT Wheelchair Management Units,97542,CPT,,,GO,both,,,224,134.4,,45.5,,101.92,percent of total billed charges,,,45.3,,101.47,percent of total billed charges,,90.72,,,,fee schedule,353% of fee schedule,,,,,,,,80,,179.2,percent of total billed charges,,,61.4,,137.54,percent of total billed charges,,,57.4,,128.58,percent of total billed charges,,,81,,181.44,percent of total billed charges,,87.12,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,190.4,percent of total billed charges,,,85,,190.4,percent of total billed charges,,,49,,109.76,percent of total billed charges,,,90,,201.6,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,80,,179.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,78,,174.72,percent of total billed charges,,,70,,156.8,percent of total billed charges,,,,,,,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,,31.51,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,31.51,201.6,
OT Wheelchair Management Units,97542,CPT,,,GO,both,,,224,134.4,,45.5,,101.92,percent of total billed charges,,,45.3,,101.47,percent of total billed charges,,90.72,,,,fee schedule,353% of fee schedule,,,,,,,,80,,179.2,percent of total billed charges,,,61.4,,137.54,percent of total billed charges,,,57.4,,128.58,percent of total billed charges,,,81,,181.44,percent of total billed charges,,87.12,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,190.4,percent of total billed charges,,,85,,190.4,percent of total billed charges,,,49,,109.76,percent of total billed charges,,,90,,201.6,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,80,,179.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,78,,174.72,percent of total billed charges,,,70,,156.8,percent of total billed charges,,,,,,,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,,31.51,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,31.51,201.6,
OT Wheelchair Management Units,97542,CPT,,,GO,both,,,224,134.4,,45.5,,101.92,percent of total billed charges,,,45.3,,101.47,percent of total billed charges,,90.72,,,,fee schedule,353% of fee schedule,,,,,,,,80,,179.2,percent of total billed charges,,,61.4,,137.54,percent of total billed charges,,,57.4,,128.58,percent of total billed charges,,,81,,181.44,percent of total billed charges,,87.12,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,190.4,percent of total billed charges,,,85,,190.4,percent of total billed charges,,,49,,109.76,percent of total billed charges,,,90,,201.6,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,80,,179.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,78,,174.72,percent of total billed charges,,,70,,156.8,percent of total billed charges,,,,,,,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,,31.51,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,31.51,201.6,
OT Wheelchair Management Units,97542,CPT,,,GO,both,,,224,134.4,,45.5,,101.92,percent of total billed charges,,,45.3,,101.47,percent of total billed charges,,90.72,,,,fee schedule,353% of fee schedule,,,,,,,,80,,179.2,percent of total billed charges,,,61.4,,137.54,percent of total billed charges,,,57.4,,128.58,percent of total billed charges,,,81,,181.44,percent of total billed charges,,87.12,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,190.4,percent of total billed charges,,,85,,190.4,percent of total billed charges,,,49,,109.76,percent of total billed charges,,,90,,201.6,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,80,,179.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,78,,174.72,percent of total billed charges,,,70,,156.8,percent of total billed charges,,,,,,,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,,31.51,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,31.51,201.6,
OT Wheelchair Management Units,97542,CPT,,,GO,both,,,224,134.4,,45.5,,101.92,percent of total billed charges,,,45.3,,101.47,percent of total billed charges,,90.72,,,,fee schedule,353% of fee schedule,,,,,,,,80,,179.2,percent of total billed charges,,,61.4,,137.54,percent of total billed charges,,,57.4,,128.58,percent of total billed charges,,,81,,181.44,percent of total billed charges,,87.12,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,190.4,percent of total billed charges,,,85,,190.4,percent of total billed charges,,,49,,109.76,percent of total billed charges,,,90,,201.6,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,80,,179.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,78,,174.72,percent of total billed charges,,,70,,156.8,percent of total billed charges,,,,,,,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,,31.51,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,31.51,201.6,
OT Wheelchair Management Units,97542,CPT,,,GO,both,,,224,134.4,,45.5,,101.92,percent of total billed charges,,,45.3,,101.47,percent of total billed charges,,90.72,,,,fee schedule,353% of fee schedule,,,,,,,,80,,179.2,percent of total billed charges,,,61.4,,137.54,percent of total billed charges,,,57.4,,128.58,percent of total billed charges,,,81,,181.44,percent of total billed charges,,87.12,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,190.4,percent of total billed charges,,,85,,190.4,percent of total billed charges,,,49,,109.76,percent of total billed charges,,,90,,201.6,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,80,,179.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,78,,174.72,percent of total billed charges,,,70,,156.8,percent of total billed charges,,,,,,,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,,31.51,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,31.51,201.6,
OT Wheelchair Management Units,97542,CPT,,,GO,both,,,224,134.4,,45.5,,101.92,percent of total billed charges,,,45.3,,101.47,percent of total billed charges,,90.72,,,,fee schedule,353% of fee schedule,,,,,,,,80,,179.2,percent of total billed charges,,,61.4,,137.54,percent of total billed charges,,,57.4,,128.58,percent of total billed charges,,,81,,181.44,percent of total billed charges,,87.12,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,190.4,percent of total billed charges,,,85,,190.4,percent of total billed charges,,,49,,109.76,percent of total billed charges,,,90,,201.6,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,80,,179.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,78,,174.72,percent of total billed charges,,,70,,156.8,percent of total billed charges,,,,,,,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,,31.51,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,31.51,201.6,
OT Wheelchair Management Units,97542,CPT,,,GO,both,,,224,134.4,,45.5,,101.92,percent of total billed charges,,,45.3,,101.47,percent of total billed charges,,90.72,,,,fee schedule,353% of fee schedule,,,,,,,,80,,179.2,percent of total billed charges,,,61.4,,137.54,percent of total billed charges,,,57.4,,128.58,percent of total billed charges,,,81,,181.44,percent of total billed charges,,87.12,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,190.4,percent of total billed charges,,,85,,190.4,percent of total billed charges,,,49,,109.76,percent of total billed charges,,,90,,201.6,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,80,,179.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,78,,174.72,percent of total billed charges,,,70,,156.8,percent of total billed charges,,,,,,,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,,31.51,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,31.51,201.6,
PT Wheelchair Management Units,97542,CPT,,,GP,both,,,224,134.4,,45.5,,101.92,percent of total billed charges,,,45.3,,101.47,percent of total billed charges,,90.72,,,,fee schedule,353% of fee schedule,,,,,,,,80,,179.2,percent of total billed charges,,,61.4,,137.54,percent of total billed charges,,,57.4,,128.58,percent of total billed charges,,,81,,181.44,percent of total billed charges,,87.12,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,190.4,percent of total billed charges,,,85,,190.4,percent of total billed charges,,,49,,109.76,percent of total billed charges,,,90,,201.6,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,80,,179.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,78,,174.72,percent of total billed charges,,,70,,156.8,percent of total billed charges,,,,,,,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,31.51,,,,100% of Medicare,,,31.51,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,31.51,201.6,
OT Work Hardening-Initial 2 Hours Units,97545,CPT,,,GO,both,,,815,489,,45.5,,370.83,percent of total billed charges,,,45.3,,369.2,percent of total billed charges,,478.84,,,,fee schedule,353% of fee schedule,,,,,,,,80,,652,percent of total billed charges,,,61.4,,500.41,percent of total billed charges,,,57.4,,467.81,percent of total billed charges,,,81,,660.15,percent of total billed charges,,459.85,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,692.75,percent of total billed charges,,,85,,692.75,percent of total billed charges,,,49,,399.35,percent of total billed charges,,,90,,733.5,percent of total billed charges,,,65,,529.75,percent of total billed charges,,,80,,652,percent of total billed charges,,,55,,448.25,percent of total billed charges,,,55,,448.25,percent of total billed charges,,,65,,529.75,percent of total billed charges,,,78,,635.7,percent of total billed charges,,,70,,570.5,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,733.5,
PT Work hardening/conditioning: initial 2 hours,97545,CPT,,,GP,both,,,815,489,,45.5,,370.83,percent of total billed charges,,,45.3,,369.2,percent of total billed charges,,478.84,,,,fee schedule,353% of fee schedule,,,,,,,,80,,652,percent of total billed charges,,,61.4,,500.41,percent of total billed charges,,,57.4,,467.81,percent of total billed charges,,,81,,660.15,percent of total billed charges,,459.85,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,692.75,percent of total billed charges,,,85,,692.75,percent of total billed charges,,,49,,399.35,percent of total billed charges,,,90,,733.5,percent of total billed charges,,,65,,529.75,percent of total billed charges,,,80,,652,percent of total billed charges,,,55,,448.25,percent of total billed charges,,,55,,448.25,percent of total billed charges,,,65,,529.75,percent of total billed charges,,,78,,635.7,percent of total billed charges,,,70,,570.5,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,733.5,
PT Work Hardening-Initial 2 Hours Units,97545,CPT,,,GP,both,,,815,489,,45.5,,370.83,percent of total billed charges,,,45.3,,369.2,percent of total billed charges,,478.84,,,,fee schedule,353% of fee schedule,,,,,,,,80,,652,percent of total billed charges,,,61.4,,500.41,percent of total billed charges,,,57.4,,467.81,percent of total billed charges,,,81,,660.15,percent of total billed charges,,459.85,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,692.75,percent of total billed charges,,,85,,692.75,percent of total billed charges,,,49,,399.35,percent of total billed charges,,,90,,733.5,percent of total billed charges,,,65,,529.75,percent of total billed charges,,,80,,652,percent of total billed charges,,,55,,448.25,percent of total billed charges,,,55,,448.25,percent of total billed charges,,,65,,529.75,percent of total billed charges,,,78,,635.7,percent of total billed charges,,,70,,570.5,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,733.5,
OT Work Hardening-Each Addl Hour Units,97546,CPT,,,GO,both,,,186,111.6,,45.5,,84.63,percent of total billed charges,,,45.3,,84.26,percent of total billed charges,,190.62,,,,fee schedule,353% of fee schedule,,,,,,,,80,,148.8,percent of total billed charges,,,61.4,,114.2,percent of total billed charges,,,57.4,,106.76,percent of total billed charges,,,81,,150.66,percent of total billed charges,,183.06,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,158.1,percent of total billed charges,,,85,,158.1,percent of total billed charges,,,49,,91.14,percent of total billed charges,,,90,,167.4,percent of total billed charges,,,65,,120.9,percent of total billed charges,,,80,,148.8,percent of total billed charges,,,55,,102.3,percent of total billed charges,,,55,,102.3,percent of total billed charges,,,65,,120.9,percent of total billed charges,,,78,,145.08,percent of total billed charges,,,70,,130.2,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,190.62,
PT Work hardening/conditioning: each additional hour,97546,CPT,,,GP,both,,,186,111.6,,45.5,,84.63,percent of total billed charges,,,45.3,,84.26,percent of total billed charges,,190.62,,,,fee schedule,353% of fee schedule,,,,,,,,80,,148.8,percent of total billed charges,,,61.4,,114.2,percent of total billed charges,,,57.4,,106.76,percent of total billed charges,,,81,,150.66,percent of total billed charges,,183.06,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,158.1,percent of total billed charges,,,85,,158.1,percent of total billed charges,,,49,,91.14,percent of total billed charges,,,90,,167.4,percent of total billed charges,,,65,,120.9,percent of total billed charges,,,80,,148.8,percent of total billed charges,,,55,,102.3,percent of total billed charges,,,55,,102.3,percent of total billed charges,,,65,,120.9,percent of total billed charges,,,78,,145.08,percent of total billed charges,,,70,,130.2,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,190.62,
PT Work Hardening-Each Addl Hour Units,97546,CPT,,,GP,both,,,186,111.6,,45.5,,84.63,percent of total billed charges,,,45.3,,84.26,percent of total billed charges,,190.62,,,,fee schedule,353% of fee schedule,,,,,,,,80,,148.8,percent of total billed charges,,,61.4,,114.2,percent of total billed charges,,,57.4,,106.76,percent of total billed charges,,,81,,150.66,percent of total billed charges,,183.06,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,158.1,percent of total billed charges,,,85,,158.1,percent of total billed charges,,,49,,91.14,percent of total billed charges,,,90,,167.4,percent of total billed charges,,,65,,120.9,percent of total billed charges,,,80,,148.8,percent of total billed charges,,,55,,102.3,percent of total billed charges,,,55,,102.3,percent of total billed charges,,,65,,120.9,percent of total billed charges,,,78,,145.08,percent of total billed charges,,,70,,130.2,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,,,,EAPG Rate,100% of IL Medicaid,73.04,190.62,
XR Spine Thoracolumbar In/Out of Brace,72080,CPT,,,59,both,,,751,450.6,,45.5,,341.71,percent of total billed charges,,,45.3,,340.2,percent of total billed charges,,,51,,383.01,percent of total billed charges,,,,,,,,,80,,600.8,percent of total billed charges,,,61.4,,461.11,percent of total billed charges,,,57.4,,431.07,percent of total billed charges,,,81,,608.31,percent of total billed charges,,,51.5,,386.77,percent of total billed charges,,365,,,,fee schedule,,,85,,638.35,percent of total billed charges,,,85,,638.35,percent of total billed charges,,,49,,367.99,percent of total billed charges,,,90,,675.9,percent of total billed charges,,,65,,488.15,percent of total billed charges,,,80,,600.8,percent of total billed charges,,,55,,413.05,percent of total billed charges,,,55,,413.05,percent of total billed charges,,,65,,488.15,percent of total billed charges,,,78,,585.78,percent of total billed charges,,,70,,525.7,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,675.9,
XR Spine Thoracolumbar 2 Views,72080,CPT,,,,both,,,751,450.6,,45.5,,341.71,percent of total billed charges,,,45.3,,340.2,percent of total billed charges,,,51,,383.01,percent of total billed charges,,,,,,,,,80,,600.8,percent of total billed charges,,,61.4,,461.11,percent of total billed charges,,,57.4,,431.07,percent of total billed charges,,,81,,608.31,percent of total billed charges,,,51.5,,386.77,percent of total billed charges,,365,,,,fee schedule,,,85,,638.35,percent of total billed charges,,,85,,638.35,percent of total billed charges,,,49,,367.99,percent of total billed charges,,,90,,675.9,percent of total billed charges,,,65,,488.15,percent of total billed charges,,,80,,600.8,percent of total billed charges,,,55,,413.05,percent of total billed charges,,,55,,413.05,percent of total billed charges,,,65,,488.15,percent of total billed charges,,,78,,585.78,percent of total billed charges,,,70,,525.7,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,675.9,
XR Scoliosis Series 2/3 Views,72082,CPT,,,,both,,,727,436.2,,45.5,,330.79,percent of total billed charges,,,45.3,,329.33,percent of total billed charges,,,51,,370.77,percent of total billed charges,,,,,,,,,80,,581.6,percent of total billed charges,,,61.4,,446.38,percent of total billed charges,,,57.4,,417.3,percent of total billed charges,,,81,,588.87,percent of total billed charges,,,51.5,,374.41,percent of total billed charges,,365,,,,fee schedule,,,85,,617.95,percent of total billed charges,,,85,,617.95,percent of total billed charges,,,49,,356.23,percent of total billed charges,,,90,,654.3,percent of total billed charges,,,65,,472.55,percent of total billed charges,,,80,,581.6,percent of total billed charges,,,55,,399.85,percent of total billed charges,,,55,,399.85,percent of total billed charges,,,65,,472.55,percent of total billed charges,,,78,,567.06,percent of total billed charges,,,70,,508.9,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,110.85,654.3,
XR Spine T-L Spine Upright + Supine,72082,CPT,,,,both,,,727,436.2,,45.5,,330.79,percent of total billed charges,,,45.3,,329.33,percent of total billed charges,,,51,,370.77,percent of total billed charges,,,,,,,,,80,,581.6,percent of total billed charges,,,61.4,,446.38,percent of total billed charges,,,57.4,,417.3,percent of total billed charges,,,81,,588.87,percent of total billed charges,,,51.5,,374.41,percent of total billed charges,,365,,,,fee schedule,,,85,,617.95,percent of total billed charges,,,85,,617.95,percent of total billed charges,,,49,,356.23,percent of total billed charges,,,90,,654.3,percent of total billed charges,,,65,,472.55,percent of total billed charges,,,80,,581.6,percent of total billed charges,,,55,,399.85,percent of total billed charges,,,55,,399.85,percent of total billed charges,,,65,,472.55,percent of total billed charges,,,78,,567.06,percent of total billed charges,,,70,,508.9,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,110.85,654.3,
XR Spine Lumbosacral 2 or 3 Views,72100,CPT,,,,both,,,748,448.8,,45.5,,340.34,percent of total billed charges,,,45.3,,338.84,percent of total billed charges,,,51,,381.48,percent of total billed charges,,,,,,,,,80,,598.4,percent of total billed charges,,,61.4,,459.27,percent of total billed charges,,,57.4,,429.35,percent of total billed charges,,,81,,605.88,percent of total billed charges,,,51.5,,385.22,percent of total billed charges,,365,,,,fee schedule,,,85,,635.8,percent of total billed charges,,,85,,635.8,percent of total billed charges,,,49,,366.52,percent of total billed charges,,,90,,673.2,percent of total billed charges,,,65,,486.2,percent of total billed charges,,,80,,598.4,percent of total billed charges,,,55,,411.4,percent of total billed charges,,,55,,411.4,percent of total billed charges,,,65,,486.2,percent of total billed charges,,,78,,583.44,percent of total billed charges,,,70,,523.6,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,110.85,673.2,
XR Spine Lumbosacral Flex/Ext,72100,CPT,,,,both,,,748,448.8,,45.5,,340.34,percent of total billed charges,,,45.3,,338.84,percent of total billed charges,,,51,,381.48,percent of total billed charges,,,,,,,,,80,,598.4,percent of total billed charges,,,61.4,,459.27,percent of total billed charges,,,57.4,,429.35,percent of total billed charges,,,81,,605.88,percent of total billed charges,,,51.5,,385.22,percent of total billed charges,,365,,,,fee schedule,,,85,,635.8,percent of total billed charges,,,85,,635.8,percent of total billed charges,,,49,,366.52,percent of total billed charges,,,90,,673.2,percent of total billed charges,,,65,,486.2,percent of total billed charges,,,80,,598.4,percent of total billed charges,,,55,,411.4,percent of total billed charges,,,55,,411.4,percent of total billed charges,,,65,,486.2,percent of total billed charges,,,78,,583.44,percent of total billed charges,,,70,,523.6,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,110.85,673.2,
XR Ischium,72170,CPT,,,,both,,,636,381.6,,45.5,,289.38,percent of total billed charges,,,45.3,,288.11,percent of total billed charges,,,51,,324.36,percent of total billed charges,,,,,,,,,80,,508.8,percent of total billed charges,,,61.4,,390.5,percent of total billed charges,,,57.4,,365.06,percent of total billed charges,,,81,,515.16,percent of total billed charges,,,51.5,,327.54,percent of total billed charges,,365,,,,fee schedule,,,85,,540.6,percent of total billed charges,,,85,,540.6,percent of total billed charges,,,49,,311.64,percent of total billed charges,,,90,,572.4,percent of total billed charges,,,65,,413.4,percent of total billed charges,,,80,,508.8,percent of total billed charges,,,55,,349.8,percent of total billed charges,,,55,,349.8,percent of total billed charges,,,65,,413.4,percent of total billed charges,,,78,,496.08,percent of total billed charges,,,70,,445.2,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,110.85,572.4,
XR Pelvis 1 or 2 Views,72170,CPT,,,,both,,,636,381.6,,45.5,,289.38,percent of total billed charges,,,45.3,,288.11,percent of total billed charges,,,51,,324.36,percent of total billed charges,,,,,,,,,80,,508.8,percent of total billed charges,,,61.4,,390.5,percent of total billed charges,,,57.4,,365.06,percent of total billed charges,,,81,,515.16,percent of total billed charges,,,51.5,,327.54,percent of total billed charges,,365,,,,fee schedule,,,85,,540.6,percent of total billed charges,,,85,,540.6,percent of total billed charges,,,49,,311.64,percent of total billed charges,,,90,,572.4,percent of total billed charges,,,65,,413.4,percent of total billed charges,,,80,,508.8,percent of total billed charges,,,55,,349.8,percent of total billed charges,,,55,,349.8,percent of total billed charges,,,65,,413.4,percent of total billed charges,,,78,,496.08,percent of total billed charges,,,70,,445.2,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,110.85,572.4,
XR Pelvis AP/Lat 2 Views,72170,CPT,,,,both,,,636,381.6,,45.5,,289.38,percent of total billed charges,,,45.3,,288.11,percent of total billed charges,,,51,,324.36,percent of total billed charges,,,,,,,,,80,,508.8,percent of total billed charges,,,61.4,,390.5,percent of total billed charges,,,57.4,,365.06,percent of total billed charges,,,81,,515.16,percent of total billed charges,,,51.5,,327.54,percent of total billed charges,,365,,,,fee schedule,,,85,,540.6,percent of total billed charges,,,85,,540.6,percent of total billed charges,,,49,,311.64,percent of total billed charges,,,90,,572.4,percent of total billed charges,,,65,,413.4,percent of total billed charges,,,80,,508.8,percent of total billed charges,,,55,,349.8,percent of total billed charges,,,55,,349.8,percent of total billed charges,,,65,,413.4,percent of total billed charges,,,78,,496.08,percent of total billed charges,,,70,,445.2,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,110.85,572.4,
XR Pelvis Inlet/Outlet Views,72170,CPT,,,,both,,,636,381.6,,45.5,,289.38,percent of total billed charges,,,45.3,,288.11,percent of total billed charges,,,51,,324.36,percent of total billed charges,,,,,,,,,80,,508.8,percent of total billed charges,,,61.4,,390.5,percent of total billed charges,,,57.4,,365.06,percent of total billed charges,,,81,,515.16,percent of total billed charges,,,51.5,,327.54,percent of total billed charges,,365,,,,fee schedule,,,85,,540.6,percent of total billed charges,,,85,,540.6,percent of total billed charges,,,49,,311.64,percent of total billed charges,,,90,,572.4,percent of total billed charges,,,65,,413.4,percent of total billed charges,,,80,,508.8,percent of total billed charges,,,55,,349.8,percent of total billed charges,,,55,,349.8,percent of total billed charges,,,65,,413.4,percent of total billed charges,,,78,,496.08,percent of total billed charges,,,70,,445.2,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,110.85,572.4,
XR Coccyx,72220,CPT,,,,both,,,713,427.8,,45.5,,324.42,percent of total billed charges,,,45.3,,322.99,percent of total billed charges,,,51,,363.63,percent of total billed charges,,,,,,,,,80,,570.4,percent of total billed charges,,,61.4,,437.78,percent of total billed charges,,,57.4,,409.26,percent of total billed charges,,,81,,577.53,percent of total billed charges,,,51.5,,367.2,percent of total billed charges,,365,,,,fee schedule,,,85,,606.05,percent of total billed charges,,,85,,606.05,percent of total billed charges,,,49,,349.37,percent of total billed charges,,,90,,641.7,percent of total billed charges,,,65,,463.45,percent of total billed charges,,,80,,570.4,percent of total billed charges,,,55,,392.15,percent of total billed charges,,,55,,392.15,percent of total billed charges,,,65,,463.45,percent of total billed charges,,,78,,556.14,percent of total billed charges,,,70,,499.1,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,641.7,
XR Sacrum,72220,CPT,,,,both,,,713,427.8,,45.5,,324.42,percent of total billed charges,,,45.3,,322.99,percent of total billed charges,,,51,,363.63,percent of total billed charges,,,,,,,,,80,,570.4,percent of total billed charges,,,61.4,,437.78,percent of total billed charges,,,57.4,,409.26,percent of total billed charges,,,81,,577.53,percent of total billed charges,,,51.5,,367.2,percent of total billed charges,,365,,,,fee schedule,,,85,,606.05,percent of total billed charges,,,85,,606.05,percent of total billed charges,,,49,,349.37,percent of total billed charges,,,90,,641.7,percent of total billed charges,,,65,,463.45,percent of total billed charges,,,80,,570.4,percent of total billed charges,,,55,,392.15,percent of total billed charges,,,55,,392.15,percent of total billed charges,,,65,,463.45,percent of total billed charges,,,78,,556.14,percent of total billed charges,,,70,,499.1,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,641.7,
XR Sacrum/Coccyx Minimum 2 Views,72220,CPT,,,,both,,,713,427.8,,45.5,,324.42,percent of total billed charges,,,45.3,,322.99,percent of total billed charges,,,51,,363.63,percent of total billed charges,,,,,,,,,80,,570.4,percent of total billed charges,,,61.4,,437.78,percent of total billed charges,,,57.4,,409.26,percent of total billed charges,,,81,,577.53,percent of total billed charges,,,51.5,,367.2,percent of total billed charges,,365,,,,fee schedule,,,85,,606.05,percent of total billed charges,,,85,,606.05,percent of total billed charges,,,49,,349.37,percent of total billed charges,,,90,,641.7,percent of total billed charges,,,65,,463.45,percent of total billed charges,,,80,,570.4,percent of total billed charges,,,55,,392.15,percent of total billed charges,,,55,,392.15,percent of total billed charges,,,65,,463.45,percent of total billed charges,,,78,,556.14,percent of total billed charges,,,70,,499.1,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,641.7,
XR Shoulder + Grashey + Axillary View Left,73030,CPT,,,LT,both,,,708,424.8,,45.5,,322.14,percent of total billed charges,,,45.3,,320.72,percent of total billed charges,,,51,,361.08,percent of total billed charges,,,,,,,,,80,,566.4,percent of total billed charges,,,61.4,,434.71,percent of total billed charges,,,57.4,,406.39,percent of total billed charges,,,81,,573.48,percent of total billed charges,,,51.5,,364.62,percent of total billed charges,,365,,,,fee schedule,,,85,,601.8,percent of total billed charges,,,85,,601.8,percent of total billed charges,,,49,,346.92,percent of total billed charges,,,90,,637.2,percent of total billed charges,,,65,,460.2,percent of total billed charges,,,80,,566.4,percent of total billed charges,,,55,,389.4,percent of total billed charges,,,55,,389.4,percent of total billed charges,,,65,,460.2,percent of total billed charges,,,78,,552.24,percent of total billed charges,,,70,,495.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,637.2,
XR Shoulder + Grashey + Y + Axil LT,73030,CPT,,,LT,both,,,708,424.8,,45.5,,322.14,percent of total billed charges,,,45.3,,320.72,percent of total billed charges,,,51,,361.08,percent of total billed charges,,,,,,,,,80,,566.4,percent of total billed charges,,,61.4,,434.71,percent of total billed charges,,,57.4,,406.39,percent of total billed charges,,,81,,573.48,percent of total billed charges,,,51.5,,364.62,percent of total billed charges,,365,,,,fee schedule,,,85,,601.8,percent of total billed charges,,,85,,601.8,percent of total billed charges,,,49,,346.92,percent of total billed charges,,,90,,637.2,percent of total billed charges,,,65,,460.2,percent of total billed charges,,,80,,566.4,percent of total billed charges,,,55,,389.4,percent of total billed charges,,,55,,389.4,percent of total billed charges,,,65,,460.2,percent of total billed charges,,,78,,552.24,percent of total billed charges,,,70,,495.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,637.2,
XR Shoulder + Grashey + Y View Left,73030,CPT,,,LT,both,,,708,424.8,,45.5,,322.14,percent of total billed charges,,,45.3,,320.72,percent of total billed charges,,,51,,361.08,percent of total billed charges,,,,,,,,,80,,566.4,percent of total billed charges,,,61.4,,434.71,percent of total billed charges,,,57.4,,406.39,percent of total billed charges,,,81,,573.48,percent of total billed charges,,,51.5,,364.62,percent of total billed charges,,365,,,,fee schedule,,,85,,601.8,percent of total billed charges,,,85,,601.8,percent of total billed charges,,,49,,346.92,percent of total billed charges,,,90,,637.2,percent of total billed charges,,,65,,460.2,percent of total billed charges,,,80,,566.4,percent of total billed charges,,,55,,389.4,percent of total billed charges,,,55,,389.4,percent of total billed charges,,,65,,460.2,percent of total billed charges,,,78,,552.24,percent of total billed charges,,,70,,495.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,637.2,
XR Shoulder + Grashey Left,73030,CPT,,,LT,both,,,708,424.8,,45.5,,322.14,percent of total billed charges,,,45.3,,320.72,percent of total billed charges,,,51,,361.08,percent of total billed charges,,,,,,,,,80,,566.4,percent of total billed charges,,,61.4,,434.71,percent of total billed charges,,,57.4,,406.39,percent of total billed charges,,,81,,573.48,percent of total billed charges,,,51.5,,364.62,percent of total billed charges,,365,,,,fee schedule,,,85,,601.8,percent of total billed charges,,,85,,601.8,percent of total billed charges,,,49,,346.92,percent of total billed charges,,,90,,637.2,percent of total billed charges,,,65,,460.2,percent of total billed charges,,,80,,566.4,percent of total billed charges,,,55,,389.4,percent of total billed charges,,,55,,389.4,percent of total billed charges,,,65,,460.2,percent of total billed charges,,,78,,552.24,percent of total billed charges,,,70,,495.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,637.2,
XR Shoulder AP True + Outlet + Axil LT,73030,CPT,,,LT,both,,,708,424.8,,45.5,,322.14,percent of total billed charges,,,45.3,,320.72,percent of total billed charges,,,51,,361.08,percent of total billed charges,,,,,,,,,80,,566.4,percent of total billed charges,,,61.4,,434.71,percent of total billed charges,,,57.4,,406.39,percent of total billed charges,,,81,,573.48,percent of total billed charges,,,51.5,,364.62,percent of total billed charges,,365,,,,fee schedule,,,85,,601.8,percent of total billed charges,,,85,,601.8,percent of total billed charges,,,49,,346.92,percent of total billed charges,,,90,,637.2,percent of total billed charges,,,65,,460.2,percent of total billed charges,,,80,,566.4,percent of total billed charges,,,55,,389.4,percent of total billed charges,,,55,,389.4,percent of total billed charges,,,65,,460.2,percent of total billed charges,,,78,,552.24,percent of total billed charges,,,70,,495.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,637.2,
XR Shoulder + Grashey + Axillary View Right,73030,CPT,,,RT,both,,,708,424.8,,45.5,,322.14,percent of total billed charges,,,45.3,,320.72,percent of total billed charges,,,51,,361.08,percent of total billed charges,,,,,,,,,80,,566.4,percent of total billed charges,,,61.4,,434.71,percent of total billed charges,,,57.4,,406.39,percent of total billed charges,,,81,,573.48,percent of total billed charges,,,51.5,,364.62,percent of total billed charges,,365,,,,fee schedule,,,85,,601.8,percent of total billed charges,,,85,,601.8,percent of total billed charges,,,49,,346.92,percent of total billed charges,,,90,,637.2,percent of total billed charges,,,65,,460.2,percent of total billed charges,,,80,,566.4,percent of total billed charges,,,55,,389.4,percent of total billed charges,,,55,,389.4,percent of total billed charges,,,65,,460.2,percent of total billed charges,,,78,,552.24,percent of total billed charges,,,70,,495.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,637.2,
XR Shoulder + Grashey + Y + Axil RT,73030,CPT,,,RT,both,,,708,424.8,,45.5,,322.14,percent of total billed charges,,,45.3,,320.72,percent of total billed charges,,,51,,361.08,percent of total billed charges,,,,,,,,,80,,566.4,percent of total billed charges,,,61.4,,434.71,percent of total billed charges,,,57.4,,406.39,percent of total billed charges,,,81,,573.48,percent of total billed charges,,,51.5,,364.62,percent of total billed charges,,365,,,,fee schedule,,,85,,601.8,percent of total billed charges,,,85,,601.8,percent of total billed charges,,,49,,346.92,percent of total billed charges,,,90,,637.2,percent of total billed charges,,,65,,460.2,percent of total billed charges,,,80,,566.4,percent of total billed charges,,,55,,389.4,percent of total billed charges,,,55,,389.4,percent of total billed charges,,,65,,460.2,percent of total billed charges,,,78,,552.24,percent of total billed charges,,,70,,495.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,637.2,
XR Shoulder + Grashey + Y View Right,73030,CPT,,,RT,both,,,708,424.8,,45.5,,322.14,percent of total billed charges,,,45.3,,320.72,percent of total billed charges,,,51,,361.08,percent of total billed charges,,,,,,,,,80,,566.4,percent of total billed charges,,,61.4,,434.71,percent of total billed charges,,,57.4,,406.39,percent of total billed charges,,,81,,573.48,percent of total billed charges,,,51.5,,364.62,percent of total billed charges,,365,,,,fee schedule,,,85,,601.8,percent of total billed charges,,,85,,601.8,percent of total billed charges,,,49,,346.92,percent of total billed charges,,,90,,637.2,percent of total billed charges,,,65,,460.2,percent of total billed charges,,,80,,566.4,percent of total billed charges,,,55,,389.4,percent of total billed charges,,,55,,389.4,percent of total billed charges,,,65,,460.2,percent of total billed charges,,,78,,552.24,percent of total billed charges,,,70,,495.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,637.2,
XR Shoulder + Grashey Right,73030,CPT,,,RT,both,,,708,424.8,,45.5,,322.14,percent of total billed charges,,,45.3,,320.72,percent of total billed charges,,,51,,361.08,percent of total billed charges,,,,,,,,,80,,566.4,percent of total billed charges,,,61.4,,434.71,percent of total billed charges,,,57.4,,406.39,percent of total billed charges,,,81,,573.48,percent of total billed charges,,,51.5,,364.62,percent of total billed charges,,365,,,,fee schedule,,,85,,601.8,percent of total billed charges,,,85,,601.8,percent of total billed charges,,,49,,346.92,percent of total billed charges,,,90,,637.2,percent of total billed charges,,,65,,460.2,percent of total billed charges,,,80,,566.4,percent of total billed charges,,,55,,389.4,percent of total billed charges,,,55,,389.4,percent of total billed charges,,,65,,460.2,percent of total billed charges,,,78,,552.24,percent of total billed charges,,,70,,495.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,637.2,
XR Shoulder AP True + Outlet + Axil RT,73030,CPT,,,RT,both,,,708,424.8,,45.5,,322.14,percent of total billed charges,,,45.3,,320.72,percent of total billed charges,,,51,,361.08,percent of total billed charges,,,,,,,,,80,,566.4,percent of total billed charges,,,61.4,,434.71,percent of total billed charges,,,57.4,,406.39,percent of total billed charges,,,81,,573.48,percent of total billed charges,,,51.5,,364.62,percent of total billed charges,,365,,,,fee schedule,,,85,,601.8,percent of total billed charges,,,85,,601.8,percent of total billed charges,,,49,,346.92,percent of total billed charges,,,90,,637.2,percent of total billed charges,,,65,,460.2,percent of total billed charges,,,80,,566.4,percent of total billed charges,,,55,,389.4,percent of total billed charges,,,55,,389.4,percent of total billed charges,,,65,,460.2,percent of total billed charges,,,78,,552.24,percent of total billed charges,,,70,,495.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,637.2,
XR Hip Complete Left,73502,CPT,,,LT,both,,,626,375.6,,45.5,,284.83,percent of total billed charges,,,45.3,,283.58,percent of total billed charges,,,51,,319.26,percent of total billed charges,,,,,,,,,80,,500.8,percent of total billed charges,,,61.4,,384.36,percent of total billed charges,,,57.4,,359.32,percent of total billed charges,,,81,,507.06,percent of total billed charges,,,51.5,,322.39,percent of total billed charges,,365,,,,fee schedule,,,85,,532.1,percent of total billed charges,,,85,,532.1,percent of total billed charges,,,49,,306.74,percent of total billed charges,,,90,,563.4,percent of total billed charges,,,65,,406.9,percent of total billed charges,,,80,,500.8,percent of total billed charges,,,55,,344.3,percent of total billed charges,,,55,,344.3,percent of total billed charges,,,65,,406.9,percent of total billed charges,,,78,,488.28,percent of total billed charges,,,70,,438.2,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,563.4,
XR Hip Complete Right,73502,CPT,,,RT,both,,,626,375.6,,45.5,,284.83,percent of total billed charges,,,45.3,,283.58,percent of total billed charges,,,51,,319.26,percent of total billed charges,,,,,,,,,80,,500.8,percent of total billed charges,,,61.4,,384.36,percent of total billed charges,,,57.4,,359.32,percent of total billed charges,,,81,,507.06,percent of total billed charges,,,51.5,,322.39,percent of total billed charges,,365,,,,fee schedule,,,85,,532.1,percent of total billed charges,,,85,,532.1,percent of total billed charges,,,49,,306.74,percent of total billed charges,,,90,,563.4,percent of total billed charges,,,65,,406.9,percent of total billed charges,,,80,,500.8,percent of total billed charges,,,55,,344.3,percent of total billed charges,,,55,,344.3,percent of total billed charges,,,65,,406.9,percent of total billed charges,,,78,,488.28,percent of total billed charges,,,70,,438.2,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,563.4,
XR Hip Bilateral w/Pelvis,73522,CPT,,,,both,,,700,420,,45.5,,318.5,percent of total billed charges,,,45.3,,317.1,percent of total billed charges,,,51,,357,percent of total billed charges,,,,,,,,,80,,560,percent of total billed charges,,,61.4,,429.8,percent of total billed charges,,,57.4,,401.8,percent of total billed charges,,,81,,567,percent of total billed charges,,,51.5,,360.5,percent of total billed charges,,365,,,,fee schedule,,,85,,595,percent of total billed charges,,,85,,595,percent of total billed charges,,,49,,343,percent of total billed charges,,,90,,630,percent of total billed charges,,,65,,455,percent of total billed charges,,,80,,560,percent of total billed charges,,,55,,385,percent of total billed charges,,,55,,385,percent of total billed charges,,,65,,455,percent of total billed charges,,,78,,546,percent of total billed charges,,,70,,490,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,110.85,630,
XR Knee 1 or 2 Views Left,73560,CPT,,,LT,both,,,424,254.4,,45.5,,192.92,percent of total billed charges,,,45.3,,192.07,percent of total billed charges,,,51,,216.24,percent of total billed charges,,,,,,,,,80,,339.2,percent of total billed charges,,,61.4,,260.34,percent of total billed charges,,,57.4,,243.38,percent of total billed charges,,,81,,343.44,percent of total billed charges,,,51.5,,218.36,percent of total billed charges,,365,,,,fee schedule,,,85,,360.4,percent of total billed charges,,,85,,360.4,percent of total billed charges,,,49,,207.76,percent of total billed charges,,,90,,381.6,percent of total billed charges,,,65,,275.6,percent of total billed charges,,,80,,339.2,percent of total billed charges,,,55,,233.2,percent of total billed charges,,,55,,233.2,percent of total billed charges,,,65,,275.6,percent of total billed charges,,,78,,330.72,percent of total billed charges,,,70,,296.8,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,381.6,
XR Knee 1 or 2 Views Right,73560,CPT,,,RT,both,,,424,254.4,,45.5,,192.92,percent of total billed charges,,,45.3,,192.07,percent of total billed charges,,,51,,216.24,percent of total billed charges,,,,,,,,,80,,339.2,percent of total billed charges,,,61.4,,260.34,percent of total billed charges,,,57.4,,243.38,percent of total billed charges,,,81,,343.44,percent of total billed charges,,,51.5,,218.36,percent of total billed charges,,365,,,,fee schedule,,,85,,360.4,percent of total billed charges,,,85,,360.4,percent of total billed charges,,,49,,207.76,percent of total billed charges,,,90,,381.6,percent of total billed charges,,,65,,275.6,percent of total billed charges,,,80,,339.2,percent of total billed charges,,,55,,233.2,percent of total billed charges,,,55,,233.2,percent of total billed charges,,,65,,275.6,percent of total billed charges,,,78,,330.72,percent of total billed charges,,,70,,296.8,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,381.6,
XR Knee 3 Views Left,73562,CPT,,,LT,both,,,701,420.6,,45.5,,318.96,percent of total billed charges,,,45.3,,317.55,percent of total billed charges,,,51,,357.51,percent of total billed charges,,,,,,,,,80,,560.8,percent of total billed charges,,,61.4,,430.41,percent of total billed charges,,,57.4,,402.37,percent of total billed charges,,,81,,567.81,percent of total billed charges,,,51.5,,361.02,percent of total billed charges,,365,,,,fee schedule,,,85,,595.85,percent of total billed charges,,,85,,595.85,percent of total billed charges,,,49,,343.49,percent of total billed charges,,,90,,630.9,percent of total billed charges,,,65,,455.65,percent of total billed charges,,,80,,560.8,percent of total billed charges,,,55,,385.55,percent of total billed charges,,,55,,385.55,percent of total billed charges,,,65,,455.65,percent of total billed charges,,,78,,546.78,percent of total billed charges,,,70,,490.7,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,630.9,
XR Knee 3 Views Right,73562,CPT,,,RT,both,,,701,420.6,,45.5,,318.96,percent of total billed charges,,,45.3,,317.55,percent of total billed charges,,,51,,357.51,percent of total billed charges,,,,,,,,,80,,560.8,percent of total billed charges,,,61.4,,430.41,percent of total billed charges,,,57.4,,402.37,percent of total billed charges,,,81,,567.81,percent of total billed charges,,,51.5,,361.02,percent of total billed charges,,365,,,,fee schedule,,,85,,595.85,percent of total billed charges,,,85,,595.85,percent of total billed charges,,,49,,343.49,percent of total billed charges,,,90,,630.9,percent of total billed charges,,,65,,455.65,percent of total billed charges,,,80,,560.8,percent of total billed charges,,,55,,385.55,percent of total billed charges,,,55,,385.55,percent of total billed charges,,,65,,455.65,percent of total billed charges,,,78,,546.78,percent of total billed charges,,,70,,490.7,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,630.9,
XR Knee + Sunrise Left,73562,CPT,,,LT,both,,,708,424.8,,45.5,,322.14,percent of total billed charges,,,45.3,,320.72,percent of total billed charges,,,51,,361.08,percent of total billed charges,,,,,,,,,80,,566.4,percent of total billed charges,,,61.4,,434.71,percent of total billed charges,,,57.4,,406.39,percent of total billed charges,,,81,,573.48,percent of total billed charges,,,51.5,,364.62,percent of total billed charges,,365,,,,fee schedule,,,85,,601.8,percent of total billed charges,,,85,,601.8,percent of total billed charges,,,49,,346.92,percent of total billed charges,,,90,,637.2,percent of total billed charges,,,65,,460.2,percent of total billed charges,,,80,,566.4,percent of total billed charges,,,55,,389.4,percent of total billed charges,,,55,,389.4,percent of total billed charges,,,65,,460.2,percent of total billed charges,,,78,,552.24,percent of total billed charges,,,70,,495.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,637.2,
XR Knee + Tunnel Left,73562,CPT,,,LT,both,,,708,424.8,,45.5,,322.14,percent of total billed charges,,,45.3,,320.72,percent of total billed charges,,,51,,361.08,percent of total billed charges,,,,,,,,,80,,566.4,percent of total billed charges,,,61.4,,434.71,percent of total billed charges,,,57.4,,406.39,percent of total billed charges,,,81,,573.48,percent of total billed charges,,,51.5,,364.62,percent of total billed charges,,365,,,,fee schedule,,,85,,601.8,percent of total billed charges,,,85,,601.8,percent of total billed charges,,,49,,346.92,percent of total billed charges,,,90,,637.2,percent of total billed charges,,,65,,460.2,percent of total billed charges,,,80,,566.4,percent of total billed charges,,,55,,389.4,percent of total billed charges,,,55,,389.4,percent of total billed charges,,,65,,460.2,percent of total billed charges,,,78,,552.24,percent of total billed charges,,,70,,495.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,637.2,
XR Knee + Sunrise Right,73562,CPT,,,RT,both,,,708,424.8,,45.5,,322.14,percent of total billed charges,,,45.3,,320.72,percent of total billed charges,,,51,,361.08,percent of total billed charges,,,,,,,,,80,,566.4,percent of total billed charges,,,61.4,,434.71,percent of total billed charges,,,57.4,,406.39,percent of total billed charges,,,81,,573.48,percent of total billed charges,,,51.5,,364.62,percent of total billed charges,,365,,,,fee schedule,,,85,,601.8,percent of total billed charges,,,85,,601.8,percent of total billed charges,,,49,,346.92,percent of total billed charges,,,90,,637.2,percent of total billed charges,,,65,,460.2,percent of total billed charges,,,80,,566.4,percent of total billed charges,,,55,,389.4,percent of total billed charges,,,55,,389.4,percent of total billed charges,,,65,,460.2,percent of total billed charges,,,78,,552.24,percent of total billed charges,,,70,,495.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,637.2,
XR Knee + Tunnel Right,73562,CPT,,,RT,both,,,708,424.8,,45.5,,322.14,percent of total billed charges,,,45.3,,320.72,percent of total billed charges,,,51,,361.08,percent of total billed charges,,,,,,,,,80,,566.4,percent of total billed charges,,,61.4,,434.71,percent of total billed charges,,,57.4,,406.39,percent of total billed charges,,,81,,573.48,percent of total billed charges,,,51.5,,364.62,percent of total billed charges,,365,,,,fee schedule,,,85,,601.8,percent of total billed charges,,,85,,601.8,percent of total billed charges,,,49,,346.92,percent of total billed charges,,,90,,637.2,percent of total billed charges,,,65,,460.2,percent of total billed charges,,,80,,566.4,percent of total billed charges,,,55,,389.4,percent of total billed charges,,,55,,389.4,percent of total billed charges,,,65,,460.2,percent of total billed charges,,,78,,552.24,percent of total billed charges,,,70,,495.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,637.2,
XR Knee + Obliques Left,73564,CPT,,,LT,both,,,787,472.2,,45.5,,358.09,percent of total billed charges,,,45.3,,356.51,percent of total billed charges,,,51,,401.37,percent of total billed charges,,,,,,,,,80,,629.6,percent of total billed charges,,,61.4,,483.22,percent of total billed charges,,,57.4,,451.74,percent of total billed charges,,,81,,637.47,percent of total billed charges,,,51.5,,405.31,percent of total billed charges,,365,,,,fee schedule,,,85,,668.95,percent of total billed charges,,,85,,668.95,percent of total billed charges,,,49,,385.63,percent of total billed charges,,,90,,708.3,percent of total billed charges,,,65,,511.55,percent of total billed charges,,,80,,629.6,percent of total billed charges,,,55,,432.85,percent of total billed charges,,,55,,432.85,percent of total billed charges,,,65,,511.55,percent of total billed charges,,,78,,613.86,percent of total billed charges,,,70,,550.9,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,110.85,708.3,
XR Knee + Tunnel + Sunrise Left,73564,CPT,,,LT,both,,,787,472.2,,45.5,,358.09,percent of total billed charges,,,45.3,,356.51,percent of total billed charges,,,51,,401.37,percent of total billed charges,,,,,,,,,80,,629.6,percent of total billed charges,,,61.4,,483.22,percent of total billed charges,,,57.4,,451.74,percent of total billed charges,,,81,,637.47,percent of total billed charges,,,51.5,,405.31,percent of total billed charges,,365,,,,fee schedule,,,85,,668.95,percent of total billed charges,,,85,,668.95,percent of total billed charges,,,49,,385.63,percent of total billed charges,,,90,,708.3,percent of total billed charges,,,65,,511.55,percent of total billed charges,,,80,,629.6,percent of total billed charges,,,55,,432.85,percent of total billed charges,,,55,,432.85,percent of total billed charges,,,65,,511.55,percent of total billed charges,,,78,,613.86,percent of total billed charges,,,70,,550.9,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,110.85,708.3,
XR Knee + Obliques Right,73564,CPT,,,RT,both,,,787,472.2,,45.5,,358.09,percent of total billed charges,,,45.3,,356.51,percent of total billed charges,,,51,,401.37,percent of total billed charges,,,,,,,,,80,,629.6,percent of total billed charges,,,61.4,,483.22,percent of total billed charges,,,57.4,,451.74,percent of total billed charges,,,81,,637.47,percent of total billed charges,,,51.5,,405.31,percent of total billed charges,,365,,,,fee schedule,,,85,,668.95,percent of total billed charges,,,85,,668.95,percent of total billed charges,,,49,,385.63,percent of total billed charges,,,90,,708.3,percent of total billed charges,,,65,,511.55,percent of total billed charges,,,80,,629.6,percent of total billed charges,,,55,,432.85,percent of total billed charges,,,55,,432.85,percent of total billed charges,,,65,,511.55,percent of total billed charges,,,78,,613.86,percent of total billed charges,,,70,,550.9,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,110.85,708.3,
XR Knee + Tunnel + Sunrise Right,73564,CPT,,,RT,both,,,787,472.2,,45.5,,358.09,percent of total billed charges,,,45.3,,356.51,percent of total billed charges,,,51,,401.37,percent of total billed charges,,,,,,,,,80,,629.6,percent of total billed charges,,,61.4,,483.22,percent of total billed charges,,,57.4,,451.74,percent of total billed charges,,,81,,637.47,percent of total billed charges,,,51.5,,405.31,percent of total billed charges,,365,,,,fee schedule,,,85,,668.95,percent of total billed charges,,,85,,668.95,percent of total billed charges,,,49,,385.63,percent of total billed charges,,,90,,708.3,percent of total billed charges,,,65,,511.55,percent of total billed charges,,,80,,629.6,percent of total billed charges,,,55,,432.85,percent of total billed charges,,,55,,432.85,percent of total billed charges,,,65,,511.55,percent of total billed charges,,,78,,613.86,percent of total billed charges,,,70,,550.9,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,110.85,708.3,
XR Knee Standing AP Bilateral,73565,CPT,,,,both,,,438,262.8,,45.5,,199.29,percent of total billed charges,,,45.3,,198.41,percent of total billed charges,,,51,,223.38,percent of total billed charges,,,,,,,,,80,,350.4,percent of total billed charges,,,61.4,,268.93,percent of total billed charges,,,57.4,,251.41,percent of total billed charges,,,81,,354.78,percent of total billed charges,,,51.5,,225.57,percent of total billed charges,,365,,,,fee schedule,,,85,,372.3,percent of total billed charges,,,85,,372.3,percent of total billed charges,,,49,,214.62,percent of total billed charges,,,90,,394.2,percent of total billed charges,,,65,,284.7,percent of total billed charges,,,80,,350.4,percent of total billed charges,,,55,,240.9,percent of total billed charges,,,55,,240.9,percent of total billed charges,,,65,,284.7,percent of total billed charges,,,78,,341.64,percent of total billed charges,,,70,,306.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,394.2,
XR Ankle Complete Left,73610,CPT,,,LT,both,,,638,382.8,,45.5,,290.29,percent of total billed charges,,,45.3,,289.01,percent of total billed charges,,,51,,325.38,percent of total billed charges,,,,,,,,,80,,510.4,percent of total billed charges,,,61.4,,391.73,percent of total billed charges,,,57.4,,366.21,percent of total billed charges,,,81,,516.78,percent of total billed charges,,,51.5,,328.57,percent of total billed charges,,365,,,,fee schedule,,,85,,542.3,percent of total billed charges,,,85,,542.3,percent of total billed charges,,,49,,312.62,percent of total billed charges,,,90,,574.2,percent of total billed charges,,,65,,414.7,percent of total billed charges,,,80,,510.4,percent of total billed charges,,,55,,350.9,percent of total billed charges,,,55,,350.9,percent of total billed charges,,,65,,414.7,percent of total billed charges,,,78,,497.64,percent of total billed charges,,,70,,446.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,574.2,
XR Ankle Complete Right,73610,CPT,,,RT,both,,,638,382.8,,45.5,,290.29,percent of total billed charges,,,45.3,,289.01,percent of total billed charges,,,51,,325.38,percent of total billed charges,,,,,,,,,80,,510.4,percent of total billed charges,,,61.4,,391.73,percent of total billed charges,,,57.4,,366.21,percent of total billed charges,,,81,,516.78,percent of total billed charges,,,51.5,,328.57,percent of total billed charges,,365,,,,fee schedule,,,85,,542.3,percent of total billed charges,,,85,,542.3,percent of total billed charges,,,49,,312.62,percent of total billed charges,,,90,,574.2,percent of total billed charges,,,65,,414.7,percent of total billed charges,,,80,,510.4,percent of total billed charges,,,55,,350.9,percent of total billed charges,,,55,,350.9,percent of total billed charges,,,65,,414.7,percent of total billed charges,,,78,,497.64,percent of total billed charges,,,70,,446.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,574.2,
XR Foot 2 Views Left,73620,CPT,,,LT,both,,,486,291.6,,45.5,,221.13,percent of total billed charges,,,45.3,,220.16,percent of total billed charges,,,51,,247.86,percent of total billed charges,,,,,,,,,80,,388.8,percent of total billed charges,,,61.4,,298.4,percent of total billed charges,,,57.4,,278.96,percent of total billed charges,,,81,,393.66,percent of total billed charges,,,51.5,,250.29,percent of total billed charges,,365,,,,fee schedule,,,85,,413.1,percent of total billed charges,,,85,,413.1,percent of total billed charges,,,49,,238.14,percent of total billed charges,,,90,,437.4,percent of total billed charges,,,65,,315.9,percent of total billed charges,,,80,,388.8,percent of total billed charges,,,55,,267.3,percent of total billed charges,,,55,,267.3,percent of total billed charges,,,65,,315.9,percent of total billed charges,,,78,,379.08,percent of total billed charges,,,70,,340.2,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,437.4,
XR Foot 2 Views Right,73620,CPT,,,RT,both,,,486,291.6,,45.5,,221.13,percent of total billed charges,,,45.3,,220.16,percent of total billed charges,,,51,,247.86,percent of total billed charges,,,,,,,,,80,,388.8,percent of total billed charges,,,61.4,,298.4,percent of total billed charges,,,57.4,,278.96,percent of total billed charges,,,81,,393.66,percent of total billed charges,,,51.5,,250.29,percent of total billed charges,,365,,,,fee schedule,,,85,,413.1,percent of total billed charges,,,85,,413.1,percent of total billed charges,,,49,,238.14,percent of total billed charges,,,90,,437.4,percent of total billed charges,,,65,,315.9,percent of total billed charges,,,80,,388.8,percent of total billed charges,,,55,,267.3,percent of total billed charges,,,55,,267.3,percent of total billed charges,,,65,,315.9,percent of total billed charges,,,78,,379.08,percent of total billed charges,,,70,,340.2,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,437.4,
XR Foot Complete Left,73630,CPT,,,LT,both,,,578,346.8,,45.5,,262.99,percent of total billed charges,,,45.3,,261.83,percent of total billed charges,,,51,,294.78,percent of total billed charges,,,,,,,,,80,,462.4,percent of total billed charges,,,61.4,,354.89,percent of total billed charges,,,57.4,,331.77,percent of total billed charges,,,81,,468.18,percent of total billed charges,,,51.5,,297.67,percent of total billed charges,,365,,,,fee schedule,,,85,,491.3,percent of total billed charges,,,85,,491.3,percent of total billed charges,,,49,,283.22,percent of total billed charges,,,90,,520.2,percent of total billed charges,,,65,,375.7,percent of total billed charges,,,80,,462.4,percent of total billed charges,,,55,,317.9,percent of total billed charges,,,55,,317.9,percent of total billed charges,,,65,,375.7,percent of total billed charges,,,78,,450.84,percent of total billed charges,,,70,,404.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,520.2,
XR Foot Complete Right,73630,CPT,,,RT,both,,,578,346.8,,45.5,,262.99,percent of total billed charges,,,45.3,,261.83,percent of total billed charges,,,51,,294.78,percent of total billed charges,,,,,,,,,80,,462.4,percent of total billed charges,,,61.4,,354.89,percent of total billed charges,,,57.4,,331.77,percent of total billed charges,,,81,,468.18,percent of total billed charges,,,51.5,,297.67,percent of total billed charges,,365,,,,fee schedule,,,85,,491.3,percent of total billed charges,,,85,,491.3,percent of total billed charges,,,49,,283.22,percent of total billed charges,,,90,,520.2,percent of total billed charges,,,65,,375.7,percent of total billed charges,,,80,,462.4,percent of total billed charges,,,55,,317.9,percent of total billed charges,,,55,,317.9,percent of total billed charges,,,65,,375.7,percent of total billed charges,,,78,,450.84,percent of total billed charges,,,70,,404.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,520.2,
50016-0957-21 - sodium hyaluronate 10 mg/mL Soln,J7321,HCPCS,50016-0957-21,NDC,,both,2.5,ML,386.35,231.81,,45.5,,175.79,percent of total billed charges,,,45.3,,175.02,percent of total billed charges,,,51,,197.04,percent of total billed charges,,,,,,,,,80,,309.08,percent of total billed charges,,,61.4,,237.22,percent of total billed charges,,,57.4,,221.76,percent of total billed charges,,,81,,312.94,percent of total billed charges,,,51.5,,198.97,percent of total billed charges,,,57.6,,222.54,percent of total billed charges,,,85,,328.4,percent of total billed charges,,,85,,328.4,percent of total billed charges,,,49,,189.31,percent of total billed charges,,,90,,347.72,percent of total billed charges,,,65,,251.13,percent of total billed charges,,,80,,309.08,percent of total billed charges,,,55,,212.49,percent of total billed charges,,,55,,212.49,percent of total billed charges,,,65,,251.13,percent of total billed charges,,,78,,301.35,percent of total billed charges,,,70,,270.45,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,197.21,,,,EAPG,100% of IL Medicaid,197.21,,,,EAPG,100% of IL Medicaid,197.21,,,,EAPG,100% of IL Medicaid,197.21,,,,EAPG,100% of IL Medicaid,175.02,347.72,
08024-0724-20 - sodium hyaluronate 10 mg/mL Soln,J7321,HCPCS,08024-0724-20,NDC,,both,2,ML,525.4,315.24,,45.5,,239.06,percent of total billed charges,,,45.3,,238.01,percent of total billed charges,,,51,,267.95,percent of total billed charges,,,,,,,,,80,,420.32,percent of total billed charges,,,61.4,,322.6,percent of total billed charges,,,57.4,,301.58,percent of total billed charges,,,81,,425.57,percent of total billed charges,,,51.5,,270.58,percent of total billed charges,,,57.6,,302.63,percent of total billed charges,,,85,,446.59,percent of total billed charges,,,85,,446.59,percent of total billed charges,,,49,,257.45,percent of total billed charges,,,90,,472.86,percent of total billed charges,,,65,,341.51,percent of total billed charges,,,80,,420.32,percent of total billed charges,,,55,,288.97,percent of total billed charges,,,55,,288.97,percent of total billed charges,,,65,,341.51,percent of total billed charges,,,78,,409.81,percent of total billed charges,,,70,,367.78,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,197.21,,,,EAPG,100% of IL Medicaid,197.21,,,,EAPG,100% of IL Medicaid,197.21,,,,EAPG,100% of IL Medicaid,197.21,,,,EAPG,100% of IL Medicaid,197.21,472.86,
89122-0724-20 - sodium hyaluronate 10 mg/mL Soln,J7321,HCPCS,89122-0724-20,NDC,,both,2,ML,763.7,458.22,,45.5,,347.48,percent of total billed charges,,,45.3,,345.96,percent of total billed charges,,,51,,389.49,percent of total billed charges,,,,,,,,,80,,610.96,percent of total billed charges,,,61.4,,468.91,percent of total billed charges,,,57.4,,438.36,percent of total billed charges,,,81,,618.6,percent of total billed charges,,,51.5,,393.31,percent of total billed charges,,,57.6,,439.89,percent of total billed charges,,,85,,649.15,percent of total billed charges,,,85,,649.15,percent of total billed charges,,,49,,374.21,percent of total billed charges,,,90,,687.33,percent of total billed charges,,,65,,496.41,percent of total billed charges,,,80,,610.96,percent of total billed charges,,,55,,420.04,percent of total billed charges,,,55,,420.04,percent of total billed charges,,,65,,496.41,percent of total billed charges,,,78,,595.69,percent of total billed charges,,,70,,534.59,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,197.21,,,,EAPG,100% of IL Medicaid,197.21,,,,EAPG,100% of IL Medicaid,197.21,,,,EAPG,100% of IL Medicaid,197.21,,,,EAPG,100% of IL Medicaid,197.21,687.33,
89130-4444-01 - sodium hyaluronate soln (Supartz) 10 mg/mL Soln,J7321,HCPCS,89130-4444-01,NDC,,both,2.5,ML,951.2,570.72,,45.5,,432.8,percent of total billed charges,,,45.3,,430.89,percent of total billed charges,,,51,,485.11,percent of total billed charges,,,,,,,,,80,,760.96,percent of total billed charges,,,61.4,,584.04,percent of total billed charges,,,57.4,,545.99,percent of total billed charges,,,81,,770.47,percent of total billed charges,,,51.5,,489.87,percent of total billed charges,,,57.6,,547.89,percent of total billed charges,,,85,,808.52,percent of total billed charges,,,85,,808.52,percent of total billed charges,,,49,,466.09,percent of total billed charges,,,90,,856.08,percent of total billed charges,,,65,,618.28,percent of total billed charges,,,80,,760.96,percent of total billed charges,,,55,,523.16,percent of total billed charges,,,55,,523.16,percent of total billed charges,,,65,,618.28,percent of total billed charges,,,78,,741.94,percent of total billed charges,,,70,,665.84,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,197.21,,,,EAPG,100% of IL Medicaid,197.21,,,,EAPG,100% of IL Medicaid,197.21,,,,EAPG,100% of IL Medicaid,197.21,,,,EAPG,100% of IL Medicaid,197.21,856.08,
XR Abdomen 1 View,74018,CPT,,,,both,,,543,325.8,,45.5,,247.07,percent of total billed charges,,,45.3,,245.98,percent of total billed charges,,,51,,276.93,percent of total billed charges,,,,,,,,,80,,434.4,percent of total billed charges,,,61.4,,333.4,percent of total billed charges,,,57.4,,311.68,percent of total billed charges,,,81,,439.83,percent of total billed charges,,,51.5,,279.65,percent of total billed charges,,365,,,,fee schedule,,,85,,461.55,percent of total billed charges,,,85,,461.55,percent of total billed charges,,,49,,266.07,percent of total billed charges,,,90,,488.7,percent of total billed charges,,,65,,352.95,percent of total billed charges,,,80,,434.4,percent of total billed charges,,,55,,298.65,percent of total billed charges,,,55,,298.65,percent of total billed charges,,,65,,352.95,percent of total billed charges,,,78,,423.54,percent of total billed charges,,,70,,380.1,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,113.77,,,,EAPG rate,100% of IL Medicaid,91.79,488.7,
"Needle electromyography, each extremity; limited (95885)",95885,CPT,,,,outpatient,,,370,222,,45.5,,168.35,percent of total billed charges,,,45.3,,167.61,percent of total billed charges,,,51,,188.7,percent of total billed charges,,,,,,,,,80,,296,percent of total billed charges,,,61.4,,227.18,percent of total billed charges,,,57.4,,212.38,percent of total billed charges,,,81,,299.7,percent of total billed charges,,,51.5,,190.55,percent of total billed charges,,,57.6,,213.12,percent of total billed charges,,,85,,314.5,percent of total billed charges,,,85,,314.5,percent of total billed charges,,,49,,181.3,percent of total billed charges,,,90,,333,percent of total billed charges,,,65,,240.5,percent of total billed charges,,,80,,296,percent of total billed charges,,,55,,203.5,percent of total billed charges,,,55,,203.5,percent of total billed charges,,,65,,240.5,percent of total billed charges,,,78,,288.6,percent of total billed charges,,,70,,259,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,134.83,,,,EAPG rate,100% of IL Medicaid,134.83,,,,EAPG rate,100% of IL Medicaid,134.83,,,,EAPG rate,100% of IL Medicaid,134.83,,,,EAPG rate,100% of IL Medicaid,134.83,333,
"Needle electromyography, each extremity; limited Bilateral (95885-50)",95885,CPT,,,50,outpatient,,,554,332.4,,45.5,,252.07,percent of total billed charges,,,45.3,,250.96,percent of total billed charges,,,51,,282.54,percent of total billed charges,,,,,,,,,80,,443.2,percent of total billed charges,,,61.4,,340.16,percent of total billed charges,,,57.4,,318,percent of total billed charges,,,81,,448.74,percent of total billed charges,,,51.5,,285.31,percent of total billed charges,,,57.6,,319.1,percent of total billed charges,,,85,,470.9,percent of total billed charges,,,85,,470.9,percent of total billed charges,,,49,,271.46,percent of total billed charges,,,90,,498.6,percent of total billed charges,,,65,,360.1,percent of total billed charges,,,80,,443.2,percent of total billed charges,,,55,,304.7,percent of total billed charges,,,55,,304.7,percent of total billed charges,,,65,,360.1,percent of total billed charges,,,78,,432.12,percent of total billed charges,,,70,,387.8,percent of total billed charges,,,,,,,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,,150% of Medicare,134.83,,,,EAPG rate,100% of IL Medicaid,134.83,,,,EAPG rate,100% of IL Medicaid,134.83,,,,EAPG rate,100% of IL Medicaid,134.83,,,,EAPG rate,100% of IL Medicaid,134.83,498.6,
"CC ONLY - Needle electromyography, each extremity, with related paraspinal; complete (95886)",95886,CPT,,,,outpatient,,,411,246.6,,45.5,,187.01,percent of total billed charges,,,45.3,,186.18,percent of total billed charges,,,51,,209.61,percent of total billed charges,,,,,,,,,80,,328.8,percent of total billed charges,,,61.4,,252.35,percent of total billed charges,,,57.4,,235.91,percent of total billed charges,,,81,,332.91,percent of total billed charges,,,51.5,,211.67,percent of total billed charges,,,57.6,,236.74,percent of total billed charges,,,85,,349.35,percent of total billed charges,,,85,,349.35,percent of total billed charges,,,49,,201.39,percent of total billed charges,,,90,,369.9,percent of total billed charges,,,65,,267.15,percent of total billed charges,,,80,,328.8,percent of total billed charges,,,55,,226.05,percent of total billed charges,,,55,,226.05,percent of total billed charges,,,65,,267.15,percent of total billed charges,,,78,,320.58,percent of total billed charges,,,70,,287.7,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,134.83,,,,EAPG rate,100% of IL Medicaid,134.83,,,,EAPG rate,100% of IL Medicaid,134.83,,,,EAPG rate,100% of IL Medicaid,134.83,,,,EAPG rate,100% of IL Medicaid,134.83,369.9,
"Needle electromyography, each extremity, with related paraspinal; complete (95886)",95886,CPT,,,,outpatient,,,411,246.6,,45.5,,187.01,percent of total billed charges,,,45.3,,186.18,percent of total billed charges,,,51,,209.61,percent of total billed charges,,,,,,,,,80,,328.8,percent of total billed charges,,,61.4,,252.35,percent of total billed charges,,,57.4,,235.91,percent of total billed charges,,,81,,332.91,percent of total billed charges,,,51.5,,211.67,percent of total billed charges,,,57.6,,236.74,percent of total billed charges,,,85,,349.35,percent of total billed charges,,,85,,349.35,percent of total billed charges,,,49,,201.39,percent of total billed charges,,,90,,369.9,percent of total billed charges,,,65,,267.15,percent of total billed charges,,,80,,328.8,percent of total billed charges,,,55,,226.05,percent of total billed charges,,,55,,226.05,percent of total billed charges,,,65,,267.15,percent of total billed charges,,,78,,320.58,percent of total billed charges,,,70,,287.7,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,134.83,,,,EAPG rate,100% of IL Medicaid,134.83,,,,EAPG rate,100% of IL Medicaid,134.83,,,,EAPG rate,100% of IL Medicaid,134.83,,,,EAPG rate,100% of IL Medicaid,134.83,369.9,
"Needle electromyography, each extremity, with related paraspinal; complete Bilateral (95886-50)",95886,CPT,,,50,outpatient,,,616,369.6,,45.5,,280.28,percent of total billed charges,,,45.3,,279.05,percent of total billed charges,,,51,,314.16,percent of total billed charges,,,,,,,,,80,,492.8,percent of total billed charges,,,61.4,,378.22,percent of total billed charges,,,57.4,,353.58,percent of total billed charges,,,81,,498.96,percent of total billed charges,,,51.5,,317.24,percent of total billed charges,,,57.6,,354.82,percent of total billed charges,,,85,,523.6,percent of total billed charges,,,85,,523.6,percent of total billed charges,,,49,,301.84,percent of total billed charges,,,90,,554.4,percent of total billed charges,,,65,,400.4,percent of total billed charges,,,80,,492.8,percent of total billed charges,,,55,,338.8,percent of total billed charges,,,55,,338.8,percent of total billed charges,,,65,,400.4,percent of total billed charges,,,78,,480.48,percent of total billed charges,,,70,,431.2,percent of total billed charges,,,,,,,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,,150% of Medicare,134.83,,,,EAPG rate,100% of IL Medicaid,134.83,,,,EAPG rate,100% of IL Medicaid,134.83,,,,EAPG rate,100% of IL Medicaid,134.83,,,,EAPG rate,100% of IL Medicaid,134.83,554.4,
BD Bone Density DEXA App Skeleton,77081,CPT,,,,both,,,266,159.6,,45.5,,121.03,percent of total billed charges,,,45.3,,120.5,percent of total billed charges,,,51,,135.66,percent of total billed charges,,,,,,,,,80,,212.8,percent of total billed charges,,,61.4,,163.32,percent of total billed charges,,,57.4,,152.68,percent of total billed charges,,,81,,215.46,percent of total billed charges,,,51.5,,136.99,percent of total billed charges,,,57.6,,153.22,percent of total billed charges,,,85,,226.1,percent of total billed charges,,,85,,226.1,percent of total billed charges,,,49,,130.34,percent of total billed charges,,,90,,239.4,percent of total billed charges,,,65,,172.9,percent of total billed charges,,,80,,212.8,percent of total billed charges,,,55,,146.3,percent of total billed charges,,,55,,146.3,percent of total billed charges,,,65,,172.9,percent of total billed charges,,,78,,207.48,percent of total billed charges,,,70,,186.2,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,36111.082,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,159.75,,,,EAPG rate,100% of IL Medicaid,159.75,,,,EAPG rate,100% of IL Medicaid,159.75,,,,EAPG rate,100% of IL Medicaid,159.75,,,,EAPG rate,100% of IL Medicaid,91.79,36111.08,
XR Fluoroscopic Swallow Study,74230,CPT,,,,both,,,898,538.8,,45.5,,408.59,percent of total billed charges,,,45.3,,406.79,percent of total billed charges,,,51,,457.98,percent of total billed charges,,,,,,,,,80,,718.4,percent of total billed charges,,,61.4,,551.37,percent of total billed charges,,,57.4,,515.45,percent of total billed charges,,,81,,727.38,percent of total billed charges,,,51.5,,462.47,percent of total billed charges,,365,,,,fee schedule,,,85,,763.3,percent of total billed charges,,,85,,763.3,percent of total billed charges,,,49,,440.02,percent of total billed charges,,,90,,808.2,percent of total billed charges,,,65,,583.7,percent of total billed charges,,,80,,718.4,percent of total billed charges,,,55,,493.9,percent of total billed charges,,,55,,493.9,percent of total billed charges,,,65,,583.7,percent of total billed charges,,,78,,700.44,percent of total billed charges,,,70,,628.6,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,239.77,,,,EAPG rate,100% of IL Medicaid,239.77,,,,EAPG rate,100% of IL Medicaid,239.77,,,,EAPG rate,100% of IL Medicaid,239.77,,,,EAPG rate,100% of IL Medicaid,185.57,808.2,
SLP Fluoroscopic Evaluation Units,92611,CPT,,,GN,both,,,917,550.2,,45.5,,417.24,percent of total billed charges,,,45.3,,415.4,percent of total billed charges,,,51,,467.67,percent of total billed charges,,,,,,,,,80,,733.6,percent of total billed charges,,,61.4,,563.04,percent of total billed charges,,,57.4,,526.36,percent of total billed charges,,,81,,742.77,percent of total billed charges,,,51.5,,472.26,percent of total billed charges,,427.44,,,,fee schedule,,,85,,779.45,percent of total billed charges,,,85,,779.45,percent of total billed charges,,,49,,449.33,percent of total billed charges,,,90,,825.3,percent of total billed charges,,,65,,596.05,percent of total billed charges,,,80,,733.6,percent of total billed charges,,,55,,504.35,percent of total billed charges,,,55,,504.35,percent of total billed charges,,,65,,596.05,percent of total billed charges,,,78,,715.26,percent of total billed charges,,,70,,641.9,percent of total billed charges,,,,,,,,91.91,,,,100% of Medicare,,91.91,,,,100% of Medicare,,91.91,,,,100% of Medicare,,91.91,,,,100% of Medicare,,91.91,,,,100% of Medicare,,91.91,,,,100% of Medicare,,91.91,,,,100% of Medicare,,91.91,,,,100% of Medicare,,91.91,,,,100% of Medicare,,91.91,,,,100% of Medicare,,91.91,,,,100% of Medicare,,91.91,,,,100% of Medicare,,,91.91,,,,100% of Medicare,239.77,,,,EAPG rate,100% of IL Medicaid,239.77,,,,EAPG rate,100% of IL Medicaid,239.77,,,,EAPG rate,100% of IL Medicaid,239.77,,,,EAPG rate,100% of IL Medicaid,91.91,825.3,
MOTOR&/SENS 3-4 NRV CNDJ TST (95908),95908,CPT,,,TC,outpatient,,,688,412.8,,45.5,,313.04,percent of total billed charges,,,45.3,,311.66,percent of total billed charges,,,51,,350.88,percent of total billed charges,,,,,,,,,80,,550.4,percent of total billed charges,,,61.4,,422.43,percent of total billed charges,,,57.4,,394.91,percent of total billed charges,,,81,,557.28,percent of total billed charges,,,51.5,,354.32,percent of total billed charges,,,57.6,,396.29,percent of total billed charges,,,85,,584.8,percent of total billed charges,,,85,,584.8,percent of total billed charges,,,49,,337.12,percent of total billed charges,,,90,,619.2,percent of total billed charges,,,65,,447.2,percent of total billed charges,,,80,,550.4,percent of total billed charges,,,55,,378.4,percent of total billed charges,,,55,,378.4,percent of total billed charges,,,65,,447.2,percent of total billed charges,,,78,,536.64,percent of total billed charges,,,70,,481.6,percent of total billed charges,,,,,,,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,,324.61,,,,100% of Medicare,268.58,,,,EAPG rate,100% of IL Medicaid,268.58,,,,EAPG rate,100% of IL Medicaid,268.58,,,,EAPG rate,100% of IL Medicaid,268.58,,,,EAPG rate,100% of IL Medicaid,268.58,619.2,
MOTOR&/SENS 5-6 NRV CNDJ TST (95909),95909,CPT,,,TC,outpatient,,,960,576,,45.5,,436.8,percent of total billed charges,,,45.3,,434.88,percent of total billed charges,,,51,,489.6,percent of total billed charges,,,,,,,,,80,,768,percent of total billed charges,,,61.4,,589.44,percent of total billed charges,,,57.4,,551.04,percent of total billed charges,,,81,,777.6,percent of total billed charges,,,51.5,,494.4,percent of total billed charges,,,57.6,,552.96,percent of total billed charges,,,85,,816,percent of total billed charges,,,85,,816,percent of total billed charges,,,49,,470.4,percent of total billed charges,,,90,,864,percent of total billed charges,,,65,,624,percent of total billed charges,,,80,,768,percent of total billed charges,,,55,,528,percent of total billed charges,,,55,,528,percent of total billed charges,,,65,,624,percent of total billed charges,,,78,,748.8,percent of total billed charges,,,70,,672,percent of total billed charges,,,,,,,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,,324.61,,,,100% of Medicare,268.58,,,,EAPG rate,100% of IL Medicaid,268.58,,,,EAPG rate,100% of IL Medicaid,268.58,,,,EAPG rate,100% of IL Medicaid,268.58,,,,EAPG rate,100% of IL Medicaid,268.58,864,
CC ONLY - MOTOR&/SENS 5-6 NRV CNDJ TST (95909),95909,CPT,,,,outpatient,,,960,576,,45.5,,436.8,percent of total billed charges,,,45.3,,434.88,percent of total billed charges,,,51,,489.6,percent of total billed charges,,,,,,,,,80,,768,percent of total billed charges,,,61.4,,589.44,percent of total billed charges,,,57.4,,551.04,percent of total billed charges,,,81,,777.6,percent of total billed charges,,,51.5,,494.4,percent of total billed charges,,,57.6,,552.96,percent of total billed charges,,,85,,816,percent of total billed charges,,,85,,816,percent of total billed charges,,,49,,470.4,percent of total billed charges,,,90,,864,percent of total billed charges,,,65,,624,percent of total billed charges,,,80,,768,percent of total billed charges,,,55,,528,percent of total billed charges,,,55,,528,percent of total billed charges,,,65,,624,percent of total billed charges,,,78,,748.8,percent of total billed charges,,,70,,672,percent of total billed charges,,,,,,,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,,324.61,,,,100% of Medicare,268.58,,,,EAPG rate,100% of IL Medicaid,268.58,,,,EAPG rate,100% of IL Medicaid,268.58,,,,EAPG rate,100% of IL Medicaid,268.58,,,,EAPG rate,100% of IL Medicaid,268.58,864,
MOTOR&SENS 7-8 NRV CNDJ TEST (95910),95910,CPT,,,TC,outpatient,,,1058,634.8,,45.5,,481.39,percent of total billed charges,,,45.3,,479.27,percent of total billed charges,,,51,,539.58,percent of total billed charges,,,,,,,,,80,,846.4,percent of total billed charges,,,61.4,,649.61,percent of total billed charges,,,57.4,,607.29,percent of total billed charges,,,81,,856.98,percent of total billed charges,,,51.5,,544.87,percent of total billed charges,,,57.6,,609.41,percent of total billed charges,,,85,,899.3,percent of total billed charges,,,85,,899.3,percent of total billed charges,,,49,,518.42,percent of total billed charges,,,90,,952.2,percent of total billed charges,,,65,,687.7,percent of total billed charges,,,80,,846.4,percent of total billed charges,,,55,,581.9,percent of total billed charges,,,55,,581.9,percent of total billed charges,,,65,,687.7,percent of total billed charges,,,78,,825.24,percent of total billed charges,,,70,,740.6,percent of total billed charges,,,,,,,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,,324.61,,,,100% of Medicare,268.58,,,,EAPG rate,100% of IL Medicaid,268.58,,,,EAPG rate,100% of IL Medicaid,268.58,,,,EAPG rate,100% of IL Medicaid,268.58,,,,EAPG rate,100% of IL Medicaid,268.58,952.2,
MOTOR&SEN 9-10 NRV CNDJ TEST (95911),95911,CPT,,,TC,outpatient,,,1408,844.8,,45.5,,640.64,percent of total billed charges,,,45.3,,637.82,percent of total billed charges,,,51,,718.08,percent of total billed charges,,,,,,,,,80,,1126.4,percent of total billed charges,,,61.4,,864.51,percent of total billed charges,,,57.4,,808.19,percent of total billed charges,,,81,,1140.48,percent of total billed charges,,,51.5,,725.12,percent of total billed charges,,,57.6,,811.01,percent of total billed charges,,,85,,1196.8,percent of total billed charges,,,85,,1196.8,percent of total billed charges,,,49,,689.92,percent of total billed charges,,,90,,1267.2,percent of total billed charges,,,65,,915.2,percent of total billed charges,,,80,,1126.4,percent of total billed charges,,,55,,774.4,percent of total billed charges,,,55,,774.4,percent of total billed charges,,,65,,915.2,percent of total billed charges,,,78,,1098.24,percent of total billed charges,,,70,,985.6,percent of total billed charges,,,,,,,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,,553.11,,,,100% of Medicare,268.58,,,,EAPG rate,100% of IL Medicaid,268.58,,,,EAPG rate,100% of IL Medicaid,268.58,,,,EAPG rate,100% of IL Medicaid,268.58,,,,EAPG rate,100% of IL Medicaid,268.58,1267.2,
CC ONLY - MOTOR&SEN 9-10 NRV CNDJ TEST (95911),95911,CPT,,,,outpatient,,,1408,844.8,,45.5,,640.64,percent of total billed charges,,,45.3,,637.82,percent of total billed charges,,,51,,718.08,percent of total billed charges,,,,,,,,,80,,1126.4,percent of total billed charges,,,61.4,,864.51,percent of total billed charges,,,57.4,,808.19,percent of total billed charges,,,81,,1140.48,percent of total billed charges,,,51.5,,725.12,percent of total billed charges,,,57.6,,811.01,percent of total billed charges,,,85,,1196.8,percent of total billed charges,,,85,,1196.8,percent of total billed charges,,,49,,689.92,percent of total billed charges,,,90,,1267.2,percent of total billed charges,,,65,,915.2,percent of total billed charges,,,80,,1126.4,percent of total billed charges,,,55,,774.4,percent of total billed charges,,,55,,774.4,percent of total billed charges,,,65,,915.2,percent of total billed charges,,,78,,1098.24,percent of total billed charges,,,70,,985.6,percent of total billed charges,,,,,,,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,,553.11,,,,100% of Medicare,268.58,,,,EAPG rate,100% of IL Medicaid,268.58,,,,EAPG rate,100% of IL Medicaid,268.58,,,,EAPG rate,100% of IL Medicaid,268.58,,,,EAPG rate,100% of IL Medicaid,268.58,1267.2,
Dynamic plantar pressure meas during walk-1 Charge (96001),96001,CPT,,,,both,,,5175,3105,,45.5,,2354.63,percent of total billed charges,,,45.3,,2344.28,percent of total billed charges,,,51,,2639.25,percent of total billed charges,,,,,,,,,80,,4140,percent of total billed charges,,,61.4,,3177.45,percent of total billed charges,,,57.4,,2970.45,percent of total billed charges,,,81,,4191.75,percent of total billed charges,,,51.5,,2665.13,percent of total billed charges,,,57.6,,2980.8,percent of total billed charges,,,85,,4398.75,percent of total billed charges,,,85,,4398.75,percent of total billed charges,,,49,,2535.75,percent of total billed charges,,,90,,4657.5,percent of total billed charges,,,65,,3363.75,percent of total billed charges,,,80,,4140,percent of total billed charges,,,55,,2846.25,percent of total billed charges,,,55,,2846.25,percent of total billed charges,,,65,,3363.75,percent of total billed charges,,,78,,4036.5,percent of total billed charges,,,70,,3622.5,percent of total billed charges,,,,,,,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,,1060.55,,,,100% of Medicare,268.58,,,,EAPG,100% of IL Medicaid,268.58,,,,EAPG,100% of IL Medicaid,268.58,,,,EAPG,100% of IL Medicaid,268.58,,,,EAPG,100% of IL Medicaid,268.58,4657.5,
Dynamic plantar pressure meas during walk-2 Charge (96001),96001,CPT,,,,both,,,5400,3240,,45.5,,2457,percent of total billed charges,,,45.3,,2446.2,percent of total billed charges,,,51,,2754,percent of total billed charges,,,,,,,,,80,,4320,percent of total billed charges,,,61.4,,3315.6,percent of total billed charges,,,57.4,,3099.6,percent of total billed charges,,,81,,4374,percent of total billed charges,,,51.5,,2781,percent of total billed charges,,,57.6,,3110.4,percent of total billed charges,,,85,,4590,percent of total billed charges,,,85,,4590,percent of total billed charges,,,49,,2646,percent of total billed charges,,,90,,4860,percent of total billed charges,,,65,,3510,percent of total billed charges,,,80,,4320,percent of total billed charges,,,55,,2970,percent of total billed charges,,,55,,2970,percent of total billed charges,,,65,,3510,percent of total billed charges,,,78,,4212,percent of total billed charges,,,70,,3780,percent of total billed charges,,,,,,,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,,1060.55,,,,100% of Medicare,268.58,,,,EAPG,100% of IL Medicaid,268.58,,,,EAPG,100% of IL Medicaid,268.58,,,,EAPG,100% of IL Medicaid,268.58,,,,EAPG,100% of IL Medicaid,268.58,4860,
Dynamic plantar pressure meas during walk-3 Charge (96001),96001,CPT,,,,both,,,6900,4140,,45.5,,3139.5,percent of total billed charges,,,45.3,,3125.7,percent of total billed charges,,,51,,3519,percent of total billed charges,,,,,,,,,80,,5520,percent of total billed charges,,,61.4,,4236.6,percent of total billed charges,,,57.4,,3960.6,percent of total billed charges,,,81,,5589,percent of total billed charges,,,51.5,,3553.5,percent of total billed charges,,,57.6,,3974.4,percent of total billed charges,,,85,,5865,percent of total billed charges,,,85,,5865,percent of total billed charges,,,49,,3381,percent of total billed charges,,,90,,6210,percent of total billed charges,,,65,,4485,percent of total billed charges,,,80,,5520,percent of total billed charges,,,55,,3795,percent of total billed charges,,,55,,3795,percent of total billed charges,,,65,,4485,percent of total billed charges,,,78,,5382,percent of total billed charges,,,70,,4830,percent of total billed charges,,,,,,,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,,1060.55,,,,100% of Medicare,268.58,,,,EAPG,100% of IL Medicaid,268.58,,,,EAPG,100% of IL Medicaid,268.58,,,,EAPG,100% of IL Medicaid,268.58,,,,EAPG,100% of IL Medicaid,268.58,6210,
Dynamic plantar pressure meas during walk-4 Charge (96001),96001,CPT,,,,both,,,7019,4211.4,,45.5,,3193.65,percent of total billed charges,,,45.3,,3179.61,percent of total billed charges,,,51,,3579.69,percent of total billed charges,,,,,,,,,80,,5615.2,percent of total billed charges,,,61.4,,4309.67,percent of total billed charges,,,57.4,,4028.91,percent of total billed charges,,,81,,5685.39,percent of total billed charges,,,51.5,,3614.79,percent of total billed charges,,,57.6,,4042.94,percent of total billed charges,,,85,,5966.15,percent of total billed charges,,,85,,5966.15,percent of total billed charges,,,49,,3439.31,percent of total billed charges,,,90,,6317.1,percent of total billed charges,,,65,,4562.35,percent of total billed charges,,,80,,5615.2,percent of total billed charges,,,55,,3860.45,percent of total billed charges,,,55,,3860.45,percent of total billed charges,,,65,,4562.35,percent of total billed charges,,,78,,5474.82,percent of total billed charges,,,70,,4913.3,percent of total billed charges,,,,,,,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,,1060.55,,,,100% of Medicare,268.58,,,,EAPG,100% of IL Medicaid,268.58,,,,EAPG,100% of IL Medicaid,268.58,,,,EAPG,100% of IL Medicaid,268.58,,,,EAPG,100% of IL Medicaid,268.58,6317.1,
Dynamic plantar pressure meas during walk-5 Charge (96001),96001,CPT,,,,both,,,7231,4338.6,,45.5,,3290.11,percent of total billed charges,,,45.3,,3275.64,percent of total billed charges,,,51,,3687.81,percent of total billed charges,,,,,,,,,80,,5784.8,percent of total billed charges,,,61.4,,4439.83,percent of total billed charges,,,57.4,,4150.59,percent of total billed charges,,,81,,5857.11,percent of total billed charges,,,51.5,,3723.97,percent of total billed charges,,,57.6,,4165.06,percent of total billed charges,,,85,,6146.35,percent of total billed charges,,,85,,6146.35,percent of total billed charges,,,49,,3543.19,percent of total billed charges,,,90,,6507.9,percent of total billed charges,,,65,,4700.15,percent of total billed charges,,,80,,5784.8,percent of total billed charges,,,55,,3977.05,percent of total billed charges,,,55,,3977.05,percent of total billed charges,,,65,,4700.15,percent of total billed charges,,,78,,5640.18,percent of total billed charges,,,70,,5061.7,percent of total billed charges,,,,,,,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,,1060.55,,,,100% of Medicare,268.58,,,,EAPG,100% of IL Medicaid,268.58,,,,EAPG,100% of IL Medicaid,268.58,,,,EAPG,100% of IL Medicaid,268.58,,,,EAPG,100% of IL Medicaid,268.58,6507.9,
CC ONLY - Pump Analysis with Reprogramming Charge (62368),62368,CPT,,,,outpatient,,,949,569.4,,45.5,,431.8,percent of total billed charges,,,45.3,,429.9,percent of total billed charges,,,51,,483.99,percent of total billed charges,,,,,,,,,80,,759.2,percent of total billed charges,,,61.4,,582.69,percent of total billed charges,,,57.4,,544.73,percent of total billed charges,,,81,,768.69,percent of total billed charges,,,51.5,,488.74,percent of total billed charges,,,57.6,,546.62,percent of total billed charges,,,85,,806.65,percent of total billed charges,,,85,,806.65,percent of total billed charges,,,49,,465.01,percent of total billed charges,,,90,,854.1,percent of total billed charges,,,65,,616.85,percent of total billed charges,,,80,,759.2,percent of total billed charges,,,55,,521.95,percent of total billed charges,,,55,,521.95,percent of total billed charges,,,65,,616.85,percent of total billed charges,,,78,,740.22,percent of total billed charges,,,70,,664.3,percent of total billed charges,,,,,,,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,,312.63,,,,100% of Medicare,288.51,,,,EAPG rate,100% of IL Medicaid,288.51,,,,EAPG rate,100% of IL Medicaid,288.51,,,,EAPG rate,100% of IL Medicaid,288.51,,,,EAPG rate,100% of IL Medicaid,288.51,854.1,
Pump Analysis with Reprogramming Charge (62368),62368,CPT,,,,both,,,949,569.4,,45.5,,431.8,percent of total billed charges,,,45.3,,429.9,percent of total billed charges,,,51,,483.99,percent of total billed charges,,,,,,,,,80,,759.2,percent of total billed charges,,,61.4,,582.69,percent of total billed charges,,,57.4,,544.73,percent of total billed charges,,,81,,768.69,percent of total billed charges,,,51.5,,488.74,percent of total billed charges,,,57.6,,546.62,percent of total billed charges,,,85,,806.65,percent of total billed charges,,,85,,806.65,percent of total billed charges,,,49,,465.01,percent of total billed charges,,,90,,854.1,percent of total billed charges,,,65,,616.85,percent of total billed charges,,,80,,759.2,percent of total billed charges,,,55,,521.95,percent of total billed charges,,,55,,521.95,percent of total billed charges,,,65,,616.85,percent of total billed charges,,,78,,740.22,percent of total billed charges,,,70,,664.3,percent of total billed charges,,,,,,,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,,312.63,,,,100% of Medicare,288.51,,,,EAPG rate,100% of IL Medicaid,288.51,,,,EAPG rate,100% of IL Medicaid,288.51,,,,EAPG rate,100% of IL Medicaid,288.51,,,,EAPG rate,100% of IL Medicaid,288.51,854.1,
ANL SP infusion pmp wt/MD reprogram and refill (62370),62370,CPT,,,,both,,,740,444,,45.5,,336.7,percent of total billed charges,,,45.3,,335.22,percent of total billed charges,,,51,,377.4,percent of total billed charges,,,,,,,,,80,,592,percent of total billed charges,,,61.4,,454.36,percent of total billed charges,,,57.4,,424.76,percent of total billed charges,,,81,,599.4,percent of total billed charges,,,51.5,,381.1,percent of total billed charges,,,57.6,,426.24,percent of total billed charges,,,85,,629,percent of total billed charges,,,85,,629,percent of total billed charges,,,49,,362.6,percent of total billed charges,,,90,,666,percent of total billed charges,,,65,,481,percent of total billed charges,,,80,,592,percent of total billed charges,,,55,,407,percent of total billed charges,,,55,,407,percent of total billed charges,,,65,,481,percent of total billed charges,,,78,,577.2,percent of total billed charges,,,70,,518,percent of total billed charges,,,,,,,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,32326.89,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,,312.63,,,,100% of Medicare,288.51,,,,EAPG rate,100% of IL Medicaid,288.51,,,,EAPG rate,100% of IL Medicaid,288.51,,,,EAPG rate,100% of IL Medicaid,288.51,,,,EAPG rate,100% of IL Medicaid,288.51,32326.89,
CC ONLY - ANL SP infusion pmp wt/MD reprogram and refill (62370),62370,CPT,,,,outpatient,,,740,444,,45.5,,336.7,percent of total billed charges,,,45.3,,335.22,percent of total billed charges,,,51,,377.4,percent of total billed charges,,,,,,,,,80,,592,percent of total billed charges,,,61.4,,454.36,percent of total billed charges,,,57.4,,424.76,percent of total billed charges,,,81,,599.4,percent of total billed charges,,,51.5,,381.1,percent of total billed charges,,,57.6,,426.24,percent of total billed charges,,,85,,629,percent of total billed charges,,,85,,629,percent of total billed charges,,,49,,362.6,percent of total billed charges,,,90,,666,percent of total billed charges,,,65,,481,percent of total billed charges,,,80,,592,percent of total billed charges,,,55,,407,percent of total billed charges,,,55,,407,percent of total billed charges,,,65,,481,percent of total billed charges,,,78,,577.2,percent of total billed charges,,,70,,518,percent of total billed charges,,,,,,,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,,312.63,,,,100% of Medicare,288.51,,,,EAPG rate,100% of IL Medicaid,288.51,,,,EAPG rate,100% of IL Medicaid,288.51,,,,EAPG rate,100% of IL Medicaid,288.51,,,,EAPG rate,100% of IL Medicaid,288.51,666,
Long Arm Cast (29065),29065,CPT,,,,outpatient,,,667,400.2,,45.5,,303.49,percent of total billed charges,,,45.3,,302.15,percent of total billed charges,,,51,,340.17,percent of total billed charges,,,,,,,,,80,,533.6,percent of total billed charges,,,61.4,,409.54,percent of total billed charges,,,57.4,,382.86,percent of total billed charges,,,81,,540.27,percent of total billed charges,,,51.5,,343.51,percent of total billed charges,,,57.6,,384.19,percent of total billed charges,,,85,,566.95,percent of total billed charges,,,85,,566.95,percent of total billed charges,,,49,,326.83,percent of total billed charges,,,90,,600.3,percent of total billed charges,,,65,,433.55,percent of total billed charges,,,80,,533.6,percent of total billed charges,,,55,,366.85,percent of total billed charges,,,55,,366.85,percent of total billed charges,,,65,,433.55,percent of total billed charges,,,78,,520.26,percent of total billed charges,,,70,,466.9,percent of total billed charges,,,,,,,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,,276.85,,,,100% of Medicare,364.31,,,,EAPG Rate,100% of IL Medicaid,364.31,,,,EAPG Rate,100% of IL Medicaid,364.31,,,,EAPG Rate,100% of IL Medicaid,364.31,,,,EAPG Rate,100% of IL Medicaid,276.85,600.3,
OT Short Arm Cast Units,29075,CPT,,,GO,both,,,265,159,,45.5,,120.58,percent of total billed charges,,,45.3,,120.05,percent of total billed charges,,,51,,135.15,percent of total billed charges,,,,,,,,,80,,212,percent of total billed charges,,,61.4,,162.71,percent of total billed charges,,,57.4,,152.11,percent of total billed charges,,,81,,214.65,percent of total billed charges,,,51.5,,136.48,percent of total billed charges,,,57.6,,152.64,percent of total billed charges,,,85,,225.25,percent of total billed charges,,,85,,225.25,percent of total billed charges,,,49,,129.85,percent of total billed charges,,,90,,238.5,percent of total billed charges,,,65,,172.25,percent of total billed charges,,,80,,212,percent of total billed charges,,,55,,145.75,percent of total billed charges,,,55,,145.75,percent of total billed charges,,,65,,172.25,percent of total billed charges,,,78,,206.7,percent of total billed charges,,,70,,185.5,percent of total billed charges,,,,,,,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,,276.85,,,,100% of Medicare,364.31,,,,EAPG Rate,100% of IL Medicaid,364.31,,,,EAPG Rate,100% of IL Medicaid,364.31,,,,EAPG Rate,100% of IL Medicaid,364.31,,,,EAPG Rate,100% of IL Medicaid,120.05,364.31,
Short Arm Cast (29075),29075,CPT,,,,outpatient,,,683,409.8,,45.5,,310.77,percent of total billed charges,,,45.3,,309.4,percent of total billed charges,,,51,,348.33,percent of total billed charges,,,,,,,,,80,,546.4,percent of total billed charges,,,61.4,,419.36,percent of total billed charges,,,57.4,,392.04,percent of total billed charges,,,81,,553.23,percent of total billed charges,,,51.5,,351.75,percent of total billed charges,,,57.6,,393.41,percent of total billed charges,,,85,,580.55,percent of total billed charges,,,85,,580.55,percent of total billed charges,,,49,,334.67,percent of total billed charges,,,90,,614.7,percent of total billed charges,,,65,,443.95,percent of total billed charges,,,80,,546.4,percent of total billed charges,,,55,,375.65,percent of total billed charges,,,55,,375.65,percent of total billed charges,,,65,,443.95,percent of total billed charges,,,78,,532.74,percent of total billed charges,,,70,,478.1,percent of total billed charges,,,,,,,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,,276.85,,,,100% of Medicare,364.31,,,,EAPG Rate,100% of IL Medicaid,364.31,,,,EAPG Rate,100% of IL Medicaid,364.31,,,,EAPG Rate,100% of IL Medicaid,364.31,,,,EAPG Rate,100% of IL Medicaid,276.85,614.7,
OT Hand and Lower Forearm Cast Units,29085,CPT,,,GO,both,,,177,106.2,,45.5,,80.54,percent of total billed charges,,,45.3,,80.18,percent of total billed charges,,,51,,90.27,percent of total billed charges,,,,,,,,,80,,141.6,percent of total billed charges,,,61.4,,108.68,percent of total billed charges,,,57.4,,101.6,percent of total billed charges,,,81,,143.37,percent of total billed charges,,,51.5,,91.16,percent of total billed charges,,,57.6,,101.95,percent of total billed charges,,,85,,150.45,percent of total billed charges,,,85,,150.45,percent of total billed charges,,,49,,86.73,percent of total billed charges,,,90,,159.3,percent of total billed charges,,,65,,115.05,percent of total billed charges,,,80,,141.6,percent of total billed charges,,,55,,97.35,percent of total billed charges,,,55,,97.35,percent of total billed charges,,,65,,115.05,percent of total billed charges,,,78,,138.06,percent of total billed charges,,,70,,123.9,percent of total billed charges,,,,,,,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,,164.48,,,,100% of Medicare,364.31,,,,EAPG Rate,100% of IL Medicaid,364.31,,,,EAPG Rate,100% of IL Medicaid,364.31,,,,EAPG Rate,100% of IL Medicaid,364.31,,,,EAPG Rate,100% of IL Medicaid,80.18,364.31,
PT Short Leg Cast Application Units,29405,CPT,,,GP,both,,,265,159,,45.5,,120.58,percent of total billed charges,,,45.3,,120.05,percent of total billed charges,,,51,,135.15,percent of total billed charges,,,,,,,,,80,,212,percent of total billed charges,,,61.4,,162.71,percent of total billed charges,,,57.4,,152.11,percent of total billed charges,,,81,,214.65,percent of total billed charges,,,51.5,,136.48,percent of total billed charges,,,57.6,,152.64,percent of total billed charges,,,85,,225.25,percent of total billed charges,,,85,,225.25,percent of total billed charges,,,49,,129.85,percent of total billed charges,,,90,,238.5,percent of total billed charges,,,65,,172.25,percent of total billed charges,,,80,,212,percent of total billed charges,,,55,,145.75,percent of total billed charges,,,55,,145.75,percent of total billed charges,,,65,,172.25,percent of total billed charges,,,78,,206.7,percent of total billed charges,,,70,,185.5,percent of total billed charges,,,,,,,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,,276.85,,,,100% of Medicare,364.31,,,,EAPG rate,100% of IL Medicaid,364.31,,,,EAPG rate,100% of IL Medicaid,364.31,,,,EAPG rate,100% of IL Medicaid,364.31,,,,EAPG rate,100% of IL Medicaid,120.05,364.31,
Short Leg Cast,29405,CPT,,,,outpatient,,,808,484.8,,45.5,,367.64,percent of total billed charges,,,45.3,,366.02,percent of total billed charges,,,51,,412.08,percent of total billed charges,,,,,,,,,80,,646.4,percent of total billed charges,,,61.4,,496.11,percent of total billed charges,,,57.4,,463.79,percent of total billed charges,,,81,,654.48,percent of total billed charges,,,51.5,,416.12,percent of total billed charges,,,57.6,,465.41,percent of total billed charges,,,85,,686.8,percent of total billed charges,,,85,,686.8,percent of total billed charges,,,49,,395.92,percent of total billed charges,,,90,,727.2,percent of total billed charges,,,65,,525.2,percent of total billed charges,,,80,,646.4,percent of total billed charges,,,55,,444.4,percent of total billed charges,,,55,,444.4,percent of total billed charges,,,65,,525.2,percent of total billed charges,,,78,,630.24,percent of total billed charges,,,70,,565.6,percent of total billed charges,,,,,,,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,,276.85,,,,100% of Medicare,364.31,,,,EAPG rate,100% of IL Medicaid,364.31,,,,EAPG rate,100% of IL Medicaid,364.31,,,,EAPG rate,100% of IL Medicaid,364.31,,,,EAPG rate,100% of IL Medicaid,276.85,727.2,
"Short Leg Cast, Bilateral",29405,CPT,,,50,outpatient,,,2019,1211.4,,45.5,,918.65,percent of total billed charges,,,45.3,,914.61,percent of total billed charges,,,51,,1029.69,percent of total billed charges,,,,,,,,,80,,1615.2,percent of total billed charges,,,61.4,,1239.67,percent of total billed charges,,,57.4,,1158.91,percent of total billed charges,,,81,,1635.39,percent of total billed charges,,,51.5,,1039.79,percent of total billed charges,,,57.6,,1162.94,percent of total billed charges,,,85,,1716.15,percent of total billed charges,,,85,,1716.15,percent of total billed charges,,,49,,989.31,percent of total billed charges,,,90,,1817.1,percent of total billed charges,,,65,,1312.35,percent of total billed charges,,,80,,1615.2,percent of total billed charges,,,55,,1110.45,percent of total billed charges,,,55,,1110.45,percent of total billed charges,,,65,,1312.35,percent of total billed charges,,,78,,1574.82,percent of total billed charges,,,70,,1413.3,percent of total billed charges,,,,,,,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,,415.27,,,,150% of Medicare,364.31,,,,EAPG rate,100% of IL Medicaid,364.31,,,,EAPG rate,100% of IL Medicaid,364.31,,,,EAPG rate,100% of IL Medicaid,364.31,,,,EAPG rate,100% of IL Medicaid,364.31,1817.1,
Active Wound Care/20 cm or < Units,97597,CPT,,,GP,both,,,265,159,,45.5,,120.58,percent of total billed charges,,,45.3,,120.05,percent of total billed charges,,,51,,135.15,percent of total billed charges,,,,,,,,,80,,212,percent of total billed charges,,,61.4,,162.71,percent of total billed charges,,,57.4,,152.11,percent of total billed charges,,,81,,214.65,percent of total billed charges,,,51.5,,136.48,percent of total billed charges,,,57.6,,152.64,percent of total billed charges,,,85,,225.25,percent of total billed charges,,,85,,225.25,percent of total billed charges,,,49,,129.85,percent of total billed charges,,,90,,238.5,percent of total billed charges,,,65,,172.25,percent of total billed charges,,,80,,212,percent of total billed charges,,,55,,145.75,percent of total billed charges,,,55,,145.75,percent of total billed charges,,,65,,172.25,percent of total billed charges,,,78,,206.7,percent of total billed charges,,,70,,185.5,percent of total billed charges,,,,,,,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,,207.13,,,,100% of Medicare,369.26,,,,EAPG Rate,100% of IL Medicaid,369.26,,,,EAPG Rate,100% of IL Medicaid,369.26,,,,EAPG Rate,100% of IL Medicaid,369.26,,,,EAPG Rate,100% of IL Medicaid,120.05,369.26,
Selective Debridement Less than or Equal to 20 cm Charge (97597),97597,CPT,,,,outpatient,,,536,321.6,,45.5,,243.88,percent of total billed charges,,,45.3,,242.81,percent of total billed charges,,,51,,273.36,percent of total billed charges,,,,,,,,,80,,428.8,percent of total billed charges,,,61.4,,329.1,percent of total billed charges,,,57.4,,307.66,percent of total billed charges,,,81,,434.16,percent of total billed charges,,,51.5,,276.04,percent of total billed charges,,,57.6,,308.74,percent of total billed charges,,,85,,455.6,percent of total billed charges,,,85,,455.6,percent of total billed charges,,,49,,262.64,percent of total billed charges,,,90,,482.4,percent of total billed charges,,,65,,348.4,percent of total billed charges,,,80,,428.8,percent of total billed charges,,,55,,294.8,percent of total billed charges,,,55,,294.8,percent of total billed charges,,,65,,348.4,percent of total billed charges,,,78,,418.08,percent of total billed charges,,,70,,375.2,percent of total billed charges,,,,,,,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,,207.13,,,,100% of Medicare,369.26,,,,EAPG Rate,100% of IL Medicaid,369.26,,,,EAPG Rate,100% of IL Medicaid,369.26,,,,EAPG Rate,100% of IL Medicaid,369.26,,,,EAPG Rate,100% of IL Medicaid,207.13,482.4,
PT Evaluation Low Complexity Charge,97161,CPT,,,GP,both,,,192,115.2,,45.5,,87.36,percent of total billed charges,,,45.3,,86.98,percent of total billed charges,,280.74,,,,fee schedule,353% of fee schedule,,,,,,,,80,,153.6,percent of total billed charges,,,61.4,,117.89,percent of total billed charges,,,57.4,,110.21,percent of total billed charges,,,81,,155.52,percent of total billed charges,,269.61,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,163.2,percent of total billed charges,,,85,,163.2,percent of total billed charges,,,49,,94.08,percent of total billed charges,,,90,,172.8,percent of total billed charges,,,65,,124.8,percent of total billed charges,,,80,,153.6,percent of total billed charges,,,55,,105.6,percent of total billed charges,,,55,,105.6,percent of total billed charges,,,65,,124.8,percent of total billed charges,,,78,,149.76,percent of total billed charges,,,70,,134.4,percent of total billed charges,,,,,,,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,,100.75,,,,100% of Medicare,383.95,,,,EAPG Rate,100% of IL Medicaid,383.95,,,,EAPG Rate,100% of IL Medicaid,383.95,,,,EAPG Rate,100% of IL Medicaid,383.95,,,,EAPG Rate,100% of IL Medicaid,86.98,383.95,
PT Evaluation Moderate Complexity Charge,97162,CPT,,,GP,both,,,192,115.2,,45.5,,87.36,percent of total billed charges,,,45.3,,86.98,percent of total billed charges,,280.74,,,,fee schedule,353% of fee schedule,,,,,,,,80,,153.6,percent of total billed charges,,,61.4,,117.89,percent of total billed charges,,,57.4,,110.21,percent of total billed charges,,,81,,155.52,percent of total billed charges,,269.61,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,163.2,percent of total billed charges,,,85,,163.2,percent of total billed charges,,,49,,94.08,percent of total billed charges,,,90,,172.8,percent of total billed charges,,,65,,124.8,percent of total billed charges,,,80,,153.6,percent of total billed charges,,,55,,105.6,percent of total billed charges,,,55,,105.6,percent of total billed charges,,,65,,124.8,percent of total billed charges,,,78,,149.76,percent of total billed charges,,,70,,134.4,percent of total billed charges,,,,,,,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,,100.75,,,,100% of Medicare,383.95,,,,EAPG Rate,100% of IL Medicaid,383.95,,,,EAPG Rate,100% of IL Medicaid,383.95,,,,EAPG Rate,100% of IL Medicaid,383.95,,,,EAPG Rate,100% of IL Medicaid,86.98,383.95,
PT Evaluation High Complexity,97163,CPT,,,GP,both,,,288,172.8,,45.5,,131.04,percent of total billed charges,,,45.3,,130.46,percent of total billed charges,,280.74,,,,fee schedule,353% of fee schedule,,,,,,,,80,,230.4,percent of total billed charges,,,61.4,,176.83,percent of total billed charges,,,57.4,,165.31,percent of total billed charges,,,81,,233.28,percent of total billed charges,,269.61,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,244.8,percent of total billed charges,,,85,,244.8,percent of total billed charges,,,49,,141.12,percent of total billed charges,,,90,,259.2,percent of total billed charges,,,65,,187.2,percent of total billed charges,,,80,,230.4,percent of total billed charges,,,55,,158.4,percent of total billed charges,,,55,,158.4,percent of total billed charges,,,65,,187.2,percent of total billed charges,,,78,,224.64,percent of total billed charges,,,70,,201.6,percent of total billed charges,,,,,,,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,100.75,,,,100% of Medicare,,,100.75,,,,100% of Medicare,383.95,,,,EAPG Rate,100% of IL Medicaid,383.95,,,,EAPG Rate,100% of IL Medicaid,383.95,,,,EAPG Rate,100% of IL Medicaid,383.95,,,,EAPG Rate,100% of IL Medicaid,100.75,383.95,
PT Re-Evaluation,97164,CPT,,,GP,both,,,222,133.2,,45.5,,101.01,percent of total billed charges,,,45.3,,100.57,percent of total billed charges,,193.02,,,,fee schedule,353% of fee schedule,,,,,,,,80,,177.6,percent of total billed charges,,,61.4,,136.31,percent of total billed charges,,,57.4,,127.43,percent of total billed charges,,,81,,179.82,percent of total billed charges,,185.37,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,188.7,percent of total billed charges,,,85,,188.7,percent of total billed charges,,,49,,108.78,percent of total billed charges,,,90,,199.8,percent of total billed charges,,,65,,144.3,percent of total billed charges,,,80,,177.6,percent of total billed charges,,,55,,122.1,percent of total billed charges,,,55,,122.1,percent of total billed charges,,,65,,144.3,percent of total billed charges,,,78,,173.16,percent of total billed charges,,,70,,155.4,percent of total billed charges,,,,,,,,69.31,,,,100% of Medicare,,69.31,,,,100% of Medicare,,69.31,,,,100% of Medicare,,69.31,,,,100% of Medicare,,69.31,,,,100% of Medicare,,69.31,,,,100% of Medicare,,69.31,,,,100% of Medicare,,69.31,,,,100% of Medicare,,69.31,,,,100% of Medicare,,69.31,,,,100% of Medicare,,69.31,,,,100% of Medicare,,69.31,,,,100% of Medicare,,,69.31,,,,100% of Medicare,383.95,,,,EAPG Rate,100% of IL Medicaid,383.95,,,,EAPG Rate,100% of IL Medicaid,383.95,,,,EAPG Rate,100% of IL Medicaid,383.95,,,,EAPG Rate,100% of IL Medicaid,69.31,383.95,
OT Evaluation Low Complexity,97165,CPT,,,GO,both,,,192,115.2,,45.5,,87.36,percent of total billed charges,,,45.3,,86.98,percent of total billed charges,,272.06,,,,fee schedule,353% of fee schedule,,,,,,,,80,,153.6,percent of total billed charges,,,61.4,,117.89,percent of total billed charges,,,57.4,,110.21,percent of total billed charges,,,81,,155.52,percent of total billed charges,,261.27,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,163.2,percent of total billed charges,,,85,,163.2,percent of total billed charges,,,49,,94.08,percent of total billed charges,,,90,,172.8,percent of total billed charges,,,65,,124.8,percent of total billed charges,,,80,,153.6,percent of total billed charges,,,55,,105.6,percent of total billed charges,,,55,,105.6,percent of total billed charges,,,65,,124.8,percent of total billed charges,,,78,,149.76,percent of total billed charges,,,70,,134.4,percent of total billed charges,,,,,,,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,,103.4,,,,100% of Medicare,420.62,,,,EAPG Rate,100% of IL Medicaid,420.62,,,,EAPG Rate,100% of IL Medicaid,420.62,,,,EAPG Rate,100% of IL Medicaid,420.62,,,,EAPG Rate,100% of IL Medicaid,86.98,420.62,
OT Evaluation Moderate Complexity,97166,CPT,,,GO,both,,,288,172.8,,45.5,,131.04,percent of total billed charges,,,45.3,,130.46,percent of total billed charges,,272.06,,,,fee schedule,353% of fee schedule,,,,,,,,80,,230.4,percent of total billed charges,,,61.4,,176.83,percent of total billed charges,,,57.4,,165.31,percent of total billed charges,,,81,,233.28,percent of total billed charges,,261.27,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,244.8,percent of total billed charges,,,85,,244.8,percent of total billed charges,,,49,,141.12,percent of total billed charges,,,90,,259.2,percent of total billed charges,,,65,,187.2,percent of total billed charges,,,80,,230.4,percent of total billed charges,,,55,,158.4,percent of total billed charges,,,55,,158.4,percent of total billed charges,,,65,,187.2,percent of total billed charges,,,78,,224.64,percent of total billed charges,,,70,,201.6,percent of total billed charges,,,,,,,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,,103.4,,,,100% of Medicare,422.33,,,,EAPG Rate,100% of IL Medicaid,422.33,,,,EAPG Rate,100% of IL Medicaid,422.33,,,,EAPG Rate,100% of IL Medicaid,422.33,,,,EAPG Rate,100% of IL Medicaid,103.4,422.33,
OT Evaluation High Complexity Charge,97167,CPT,,,GO,both,,,288,172.8,,45.5,,131.04,percent of total billed charges,,,45.3,,130.46,percent of total billed charges,,272.06,,,,fee schedule,353% of fee schedule,,,,,,,,80,,230.4,percent of total billed charges,,,61.4,,176.83,percent of total billed charges,,,57.4,,165.31,percent of total billed charges,,,81,,233.28,percent of total billed charges,,261.27,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,244.8,percent of total billed charges,,,85,,244.8,percent of total billed charges,,,49,,141.12,percent of total billed charges,,,90,,259.2,percent of total billed charges,,,65,,187.2,percent of total billed charges,,,80,,230.4,percent of total billed charges,,,55,,158.4,percent of total billed charges,,,55,,158.4,percent of total billed charges,,,65,,187.2,percent of total billed charges,,,78,,224.64,percent of total billed charges,,,70,,201.6,percent of total billed charges,,,,,,,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,103.4,,,,100% of Medicare,,,103.4,,,,100% of Medicare,422.33,,,,EAPG Rate,100% of IL Medicaid,422.33,,,,EAPG Rate,100% of IL Medicaid,422.33,,,,EAPG Rate,100% of IL Medicaid,422.33,,,,EAPG Rate,100% of IL Medicaid,103.4,422.33,
OT Re-Evaluation,97168,CPT,,,GO,both,,,239,143.4,,45.5,,108.75,percent of total billed charges,,,45.3,,108.27,percent of total billed charges,,184.34,,,,fee schedule,353% of fee schedule,,,,,,,,80,,191.2,percent of total billed charges,,,61.4,,146.75,percent of total billed charges,,,57.4,,137.19,percent of total billed charges,,,81,,193.59,percent of total billed charges,,177.03,,,,fee schedule,339% of fee schedule,124.8,,,,fee schedule,,,85,,203.15,percent of total billed charges,,,85,,203.15,percent of total billed charges,,,49,,117.11,percent of total billed charges,,,90,,215.1,percent of total billed charges,,,65,,155.35,percent of total billed charges,,,80,,191.2,percent of total billed charges,,,55,,131.45,percent of total billed charges,,,55,,131.45,percent of total billed charges,,,65,,155.35,percent of total billed charges,,,78,,186.42,percent of total billed charges,,,70,,167.3,percent of total billed charges,,,,,,,,71.61,,,,100% of Medicare,,71.61,,,,100% of Medicare,,71.61,,,,100% of Medicare,,71.61,,,,100% of Medicare,,71.61,,,,100% of Medicare,,71.61,,,,100% of Medicare,,71.61,,,,100% of Medicare,,71.61,,,,100% of Medicare,,71.61,,,,100% of Medicare,,71.61,,,,100% of Medicare,,71.61,,,,100% of Medicare,,71.61,,,,100% of Medicare,,,71.61,,,,100% of Medicare,422.33,,,,EAPG Rate,100% of IL Medicaid,422.33,,,,EAPG Rate,100% of IL Medicaid,422.33,,,,EAPG Rate,100% of IL Medicaid,422.33,,,,EAPG Rate,100% of IL Medicaid,71.61,422.33,
SLP Speech AAC Eval First hour in units of 15 min,92607,CPT,,,,both,,,147,88.2,,45.5,,66.89,percent of total billed charges,,,45.3,,66.59,percent of total billed charges,,,51,,74.97,percent of total billed charges,,,,,,,,,80,,117.6,percent of total billed charges,,,61.4,,90.26,percent of total billed charges,,,57.4,,84.38,percent of total billed charges,,,81,,119.07,percent of total billed charges,,,51.5,,75.71,percent of total billed charges,,427.44,,,,fee schedule,,,85,,124.95,percent of total billed charges,,,85,,124.95,percent of total billed charges,,,49,,72.03,percent of total billed charges,,,90,,132.3,percent of total billed charges,,,65,,95.55,percent of total billed charges,,,80,,117.6,percent of total billed charges,,,55,,80.85,percent of total billed charges,,,55,,80.85,percent of total billed charges,,,65,,95.55,percent of total billed charges,,,78,,114.66,percent of total billed charges,,,70,,102.9,percent of total billed charges,,,,,,,,124.09,,,,100% of Medicare,,124.09,,,,100% of Medicare,,124.09,,,,100% of Medicare,,124.09,,,,100% of Medicare,,124.09,,,,100% of Medicare,,124.09,,,,100% of Medicare,,124.09,,,,100% of Medicare,,124.09,,,,100% of Medicare,,124.09,,,,100% of Medicare,,124.09,,,,100% of Medicare,,124.09,,,,100% of Medicare,,124.09,,,,100% of Medicare,,,124.09,,,,100% of Medicare,461.5,,,,EAPG Rate,100% of IL Medicaid,461.5,,,,EAPG Rate,100% of IL Medicaid,461.5,,,,EAPG Rate,100% of IL Medicaid,461.5,,,,EAPG Rate,100% of IL Medicaid,66.59,461.5,
MRI Brain W/Contrast,70558,CPT,,,,both,,,2971,1782.6,,45.5,,1351.81,percent of total billed charges,,,45.3,,1345.86,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,2376.8,percent of total billed charges,,,61.4,,1824.19,percent of total billed charges,,,57.4,,1705.35,percent of total billed charges,,,81,,2406.51,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,1711.3,percent of total billed charges,,,85,,2525.35,percent of total billed charges,,,85,,2525.35,percent of total billed charges,,,49,,1455.79,percent of total billed charges,,,90,,2673.9,percent of total billed charges,,,65,,1931.15,percent of total billed charges,,,80,,2376.8,percent of total billed charges,,,55,,1634.05,percent of total billed charges,,,55,,1634.05,percent of total billed charges,,,65,,1931.15,percent of total billed charges,,,78,,2317.38,percent of total billed charges,,,70,,2079.7,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,485.88,,,,EAPG Rate,100% of IL Medicaid,485.88,,,,EAPG Rate,100% of IL Medicaid,485.88,,,,EAPG Rate,100% of IL Medicaid,485.88,,,,EAPG Rate,100% of IL Medicaid,185.57,2673.9,
MRI Abdomen  W/O Contrast,74181,CPT,,,,both,,,4755,2853,,45.5,,2163.53,percent of total billed charges,,,45.3,,2154.02,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3804,percent of total billed charges,,,61.4,,2919.57,percent of total billed charges,,,57.4,,2729.37,percent of total billed charges,,,81,,3851.55,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2738.88,percent of total billed charges,,,85,,4041.75,percent of total billed charges,,,85,,4041.75,percent of total billed charges,,,49,,2329.95,percent of total billed charges,,,90,,4279.5,percent of total billed charges,,,65,,3090.75,percent of total billed charges,,,80,,3804,percent of total billed charges,,,55,,2615.25,percent of total billed charges,,,55,,2615.25,percent of total billed charges,,,65,,3090.75,percent of total billed charges,,,78,,3708.9,percent of total billed charges,,,70,,3328.5,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,485.88,,,,EAPG Rate,100% of IL Medicaid,485.88,,,,EAPG Rate,100% of IL Medicaid,485.88,,,,EAPG Rate,100% of IL Medicaid,485.88,,,,EAPG Rate,100% of IL Medicaid,251.97,4279.5,
MRI Abdomen MRCP  W/O Contrast,74181,CPT,,,,both,,,4755,2853,,45.5,,2163.53,percent of total billed charges,,,45.3,,2154.02,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3804,percent of total billed charges,,,61.4,,2919.57,percent of total billed charges,,,57.4,,2729.37,percent of total billed charges,,,81,,3851.55,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2738.88,percent of total billed charges,,,85,,4041.75,percent of total billed charges,,,85,,4041.75,percent of total billed charges,,,49,,2329.95,percent of total billed charges,,,90,,4279.5,percent of total billed charges,,,65,,3090.75,percent of total billed charges,,,80,,3804,percent of total billed charges,,,55,,2615.25,percent of total billed charges,,,55,,2615.25,percent of total billed charges,,,65,,3090.75,percent of total billed charges,,,78,,3708.9,percent of total billed charges,,,70,,3328.5,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,485.88,,,,EAPG Rate,100% of IL Medicaid,485.88,,,,EAPG Rate,100% of IL Medicaid,485.88,,,,EAPG Rate,100% of IL Medicaid,485.88,,,,EAPG Rate,100% of IL Medicaid,251.97,4279.5,
MRI Abdominal Wall  W/O Contrast,74181,CPT,,,,both,,,4755,2853,,45.5,,2163.53,percent of total billed charges,,,45.3,,2154.02,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3804,percent of total billed charges,,,61.4,,2919.57,percent of total billed charges,,,57.4,,2729.37,percent of total billed charges,,,81,,3851.55,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2738.88,percent of total billed charges,,,85,,4041.75,percent of total billed charges,,,85,,4041.75,percent of total billed charges,,,49,,2329.95,percent of total billed charges,,,90,,4279.5,percent of total billed charges,,,65,,3090.75,percent of total billed charges,,,80,,3804,percent of total billed charges,,,55,,2615.25,percent of total billed charges,,,55,,2615.25,percent of total billed charges,,,65,,3090.75,percent of total billed charges,,,78,,3708.9,percent of total billed charges,,,70,,3328.5,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,485.88,,,,EAPG Rate,100% of IL Medicaid,485.88,,,,EAPG Rate,100% of IL Medicaid,485.88,,,,EAPG Rate,100% of IL Medicaid,485.88,,,,EAPG Rate,100% of IL Medicaid,251.97,4279.5,
MRI Face/Neck W/O Contrast,70540,CPT,,,,both,,,3735,2241,,45.5,,1699.43,percent of total billed charges,,,45.3,,1691.96,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,2988,percent of total billed charges,,,61.4,,2293.29,percent of total billed charges,,,57.4,,2143.89,percent of total billed charges,,,81,,3025.35,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2151.36,percent of total billed charges,,,85,,3174.75,percent of total billed charges,,,85,,3174.75,percent of total billed charges,,,49,,1830.15,percent of total billed charges,,,90,,3361.5,percent of total billed charges,,,65,,2427.75,percent of total billed charges,,,80,,2988,percent of total billed charges,,,55,,2054.25,percent of total billed charges,,,55,,2054.25,percent of total billed charges,,,65,,2427.75,percent of total billed charges,,,78,,2913.3,percent of total billed charges,,,70,,2614.5,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,251.97,3361.5,
MRI Orbits W/O Contrast,70540,CPT,,,,both,,,3735,2241,,45.5,,1699.43,percent of total billed charges,,,45.3,,1691.96,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,2988,percent of total billed charges,,,61.4,,2293.29,percent of total billed charges,,,57.4,,2143.89,percent of total billed charges,,,81,,3025.35,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2151.36,percent of total billed charges,,,85,,3174.75,percent of total billed charges,,,85,,3174.75,percent of total billed charges,,,49,,1830.15,percent of total billed charges,,,90,,3361.5,percent of total billed charges,,,65,,2427.75,percent of total billed charges,,,80,,2988,percent of total billed charges,,,55,,2054.25,percent of total billed charges,,,55,,2054.25,percent of total billed charges,,,65,,2427.75,percent of total billed charges,,,78,,2913.3,percent of total billed charges,,,70,,2614.5,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,251.97,3361.5,
MRA Head  W/O Contrast,70544,CPT,,,,both,,,4376,2625.6,,45.5,,1991.08,percent of total billed charges,,,45.3,,1982.33,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3500.8,percent of total billed charges,,,61.4,,2686.86,percent of total billed charges,,,57.4,,2511.82,percent of total billed charges,,,81,,3544.56,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2520.58,percent of total billed charges,,,85,,3719.6,percent of total billed charges,,,85,,3719.6,percent of total billed charges,,,49,,2144.24,percent of total billed charges,,,90,,3938.4,percent of total billed charges,,,65,,2844.4,percent of total billed charges,,,80,,3500.8,percent of total billed charges,,,55,,2406.8,percent of total billed charges,,,55,,2406.8,percent of total billed charges,,,65,,2844.4,percent of total billed charges,,,78,,3413.28,percent of total billed charges,,,70,,3063.2,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,251.97,3938.4,
MRV Head W/O Contrast,70544,CPT,,,,both,,,4376,2625.6,,45.5,,1991.08,percent of total billed charges,,,45.3,,1982.33,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3500.8,percent of total billed charges,,,61.4,,2686.86,percent of total billed charges,,,57.4,,2511.82,percent of total billed charges,,,81,,3544.56,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2520.58,percent of total billed charges,,,85,,3719.6,percent of total billed charges,,,85,,3719.6,percent of total billed charges,,,49,,2144.24,percent of total billed charges,,,90,,3938.4,percent of total billed charges,,,65,,2844.4,percent of total billed charges,,,80,,3500.8,percent of total billed charges,,,55,,2406.8,percent of total billed charges,,,55,,2406.8,percent of total billed charges,,,65,,2844.4,percent of total billed charges,,,78,,3413.28,percent of total billed charges,,,70,,3063.2,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,251.97,3938.4,
MRA Neck  W/O Contrast,70547,CPT,,,,both,,,5054,3032.4,,45.5,,2299.57,percent of total billed charges,,,45.3,,2289.46,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4043.2,percent of total billed charges,,,61.4,,3103.16,percent of total billed charges,,,57.4,,2901,percent of total billed charges,,,81,,4093.74,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2911.1,percent of total billed charges,,,85,,4295.9,percent of total billed charges,,,85,,4295.9,percent of total billed charges,,,49,,2476.46,percent of total billed charges,,,90,,4548.6,percent of total billed charges,,,65,,3285.1,percent of total billed charges,,,80,,4043.2,percent of total billed charges,,,55,,2779.7,percent of total billed charges,,,55,,2779.7,percent of total billed charges,,,65,,3285.1,percent of total billed charges,,,78,,3942.12,percent of total billed charges,,,70,,3537.8,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,251.97,4548.6,
MRI Brain IAC/Cranial Nerve  W/O Contrast,70551,CPT,,,,both,,,2971,1782.6,,45.5,,1351.81,percent of total billed charges,,,45.3,,1345.86,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,2376.8,percent of total billed charges,,,61.4,,1824.19,percent of total billed charges,,,57.4,,1705.35,percent of total billed charges,,,81,,2406.51,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,1711.3,percent of total billed charges,,,85,,2525.35,percent of total billed charges,,,85,,2525.35,percent of total billed charges,,,49,,1455.79,percent of total billed charges,,,90,,2673.9,percent of total billed charges,,,65,,1931.15,percent of total billed charges,,,80,,2376.8,percent of total billed charges,,,55,,1634.05,percent of total billed charges,,,55,,1634.05,percent of total billed charges,,,65,,1931.15,percent of total billed charges,,,78,,2317.38,percent of total billed charges,,,70,,2079.7,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,251.97,2673.9,
MRI Brain  W/O Contrast,70551,CPT,,,,both,,,4394,2636.4,,45.5,,1999.27,percent of total billed charges,,,45.3,,1990.48,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3515.2,percent of total billed charges,,,61.4,,2697.92,percent of total billed charges,,,57.4,,2522.16,percent of total billed charges,,,81,,3559.14,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2530.94,percent of total billed charges,,,85,,3734.9,percent of total billed charges,,,85,,3734.9,percent of total billed charges,,,49,,2153.06,percent of total billed charges,,,90,,3954.6,percent of total billed charges,,,65,,2856.1,percent of total billed charges,,,80,,3515.2,percent of total billed charges,,,55,,2416.7,percent of total billed charges,,,55,,2416.7,percent of total billed charges,,,65,,2856.1,percent of total billed charges,,,78,,3427.32,percent of total billed charges,,,70,,3075.8,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,251.97,3954.6,
MRI Brachial Plexus  W/O Contrast Lt,71550,CPT,,,LT,both,,,5499,3299.4,,45.5,,2502.05,percent of total billed charges,,,45.3,,2491.05,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4399.2,percent of total billed charges,,,61.4,,3376.39,percent of total billed charges,,,57.4,,3156.43,percent of total billed charges,,,81,,4454.19,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3167.42,percent of total billed charges,,,85,,4674.15,percent of total billed charges,,,85,,4674.15,percent of total billed charges,,,49,,2694.51,percent of total billed charges,,,90,,4949.1,percent of total billed charges,,,65,,3574.35,percent of total billed charges,,,80,,4399.2,percent of total billed charges,,,55,,3024.45,percent of total billed charges,,,55,,3024.45,percent of total billed charges,,,65,,3574.35,percent of total billed charges,,,78,,4289.22,percent of total billed charges,,,70,,3849.3,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,251.97,4949.1,
MRI Brachial Plexus  W/O Contrast Rt,71550,CPT,,,RT,both,,,5499,3299.4,,45.5,,2502.05,percent of total billed charges,,,45.3,,2491.05,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4399.2,percent of total billed charges,,,61.4,,3376.39,percent of total billed charges,,,57.4,,3156.43,percent of total billed charges,,,81,,4454.19,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3167.42,percent of total billed charges,,,85,,4674.15,percent of total billed charges,,,85,,4674.15,percent of total billed charges,,,49,,2694.51,percent of total billed charges,,,90,,4949.1,percent of total billed charges,,,65,,3574.35,percent of total billed charges,,,80,,4399.2,percent of total billed charges,,,55,,3024.45,percent of total billed charges,,,55,,3024.45,percent of total billed charges,,,65,,3574.35,percent of total billed charges,,,78,,4289.22,percent of total billed charges,,,70,,3849.3,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,251.97,4949.1,
MRI Chest  W/O Contrast,71550,CPT,,,,both,,,5499,3299.4,,45.5,,2502.05,percent of total billed charges,,,45.3,,2491.05,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4399.2,percent of total billed charges,,,61.4,,3376.39,percent of total billed charges,,,57.4,,3156.43,percent of total billed charges,,,81,,4454.19,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3167.42,percent of total billed charges,,,85,,4674.15,percent of total billed charges,,,85,,4674.15,percent of total billed charges,,,49,,2694.51,percent of total billed charges,,,90,,4949.1,percent of total billed charges,,,65,,3574.35,percent of total billed charges,,,80,,4399.2,percent of total billed charges,,,55,,3024.45,percent of total billed charges,,,55,,3024.45,percent of total billed charges,,,65,,3574.35,percent of total billed charges,,,78,,4289.22,percent of total billed charges,,,70,,3849.3,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,251.97,4949.1,
MRI Chest Wall  W/O Contrast,71550,CPT,,,,both,,,5499,3299.4,,45.5,,2502.05,percent of total billed charges,,,45.3,,2491.05,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4399.2,percent of total billed charges,,,61.4,,3376.39,percent of total billed charges,,,57.4,,3156.43,percent of total billed charges,,,81,,4454.19,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3167.42,percent of total billed charges,,,85,,4674.15,percent of total billed charges,,,85,,4674.15,percent of total billed charges,,,49,,2694.51,percent of total billed charges,,,90,,4949.1,percent of total billed charges,,,65,,3574.35,percent of total billed charges,,,80,,4399.2,percent of total billed charges,,,55,,3024.45,percent of total billed charges,,,55,,3024.45,percent of total billed charges,,,65,,3574.35,percent of total billed charges,,,78,,4289.22,percent of total billed charges,,,70,,3849.3,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,251.97,4949.1,
MRI Spine Cervical W/O Contrast,72141,CPT,,,,both,,,5493,3295.8,,45.5,,2499.32,percent of total billed charges,,,45.3,,2488.33,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4394.4,percent of total billed charges,,,61.4,,3372.7,percent of total billed charges,,,57.4,,3152.98,percent of total billed charges,,,81,,4449.33,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3163.97,percent of total billed charges,,,85,,4669.05,percent of total billed charges,,,85,,4669.05,percent of total billed charges,,,49,,2691.57,percent of total billed charges,,,90,,4943.7,percent of total billed charges,,,65,,3570.45,percent of total billed charges,,,80,,4394.4,percent of total billed charges,,,55,,3021.15,percent of total billed charges,,,55,,3021.15,percent of total billed charges,,,65,,3570.45,percent of total billed charges,,,78,,4284.54,percent of total billed charges,,,70,,3845.1,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,251.97,4943.7,
MRI Spine Thoracic W/O Contrast,72146,CPT,,,,both,,,5190,3114,,45.5,,2361.45,percent of total billed charges,,,45.3,,2351.07,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4152,percent of total billed charges,,,61.4,,3186.66,percent of total billed charges,,,57.4,,2979.06,percent of total billed charges,,,81,,4203.9,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2989.44,percent of total billed charges,,,85,,4411.5,percent of total billed charges,,,85,,4411.5,percent of total billed charges,,,49,,2543.1,percent of total billed charges,,,90,,4671,percent of total billed charges,,,65,,3373.5,percent of total billed charges,,,80,,4152,percent of total billed charges,,,55,,2854.5,percent of total billed charges,,,55,,2854.5,percent of total billed charges,,,65,,3373.5,percent of total billed charges,,,78,,4048.2,percent of total billed charges,,,70,,3633,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,251.97,4671,
MRI Spine Lumbar W/O Contrast,72148,CPT,,,,both,,,5023,3013.8,,45.5,,2285.47,percent of total billed charges,,,45.3,,2275.42,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4018.4,percent of total billed charges,,,61.4,,3084.12,percent of total billed charges,,,57.4,,2883.2,percent of total billed charges,,,81,,4068.63,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2893.25,percent of total billed charges,,,85,,4269.55,percent of total billed charges,,,85,,4269.55,percent of total billed charges,,,49,,2461.27,percent of total billed charges,,,90,,4520.7,percent of total billed charges,,,65,,3264.95,percent of total billed charges,,,80,,4018.4,percent of total billed charges,,,55,,2762.65,percent of total billed charges,,,55,,2762.65,percent of total billed charges,,,65,,3264.95,percent of total billed charges,,,78,,3917.94,percent of total billed charges,,,70,,3516.1,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,251.97,4520.7,
MRI Lumb Plexus W/O Cont-72195,72195,CPT,,,,both,,,4543,2725.8,,45.5,,2067.07,percent of total billed charges,,,45.3,,2057.98,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3634.4,percent of total billed charges,,,61.4,,2789.4,percent of total billed charges,,,57.4,,2607.68,percent of total billed charges,,,81,,3679.83,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2616.77,percent of total billed charges,,,85,,3861.55,percent of total billed charges,,,85,,3861.55,percent of total billed charges,,,49,,2226.07,percent of total billed charges,,,90,,4088.7,percent of total billed charges,,,65,,2952.95,percent of total billed charges,,,80,,3634.4,percent of total billed charges,,,55,,2498.65,percent of total billed charges,,,55,,2498.65,percent of total billed charges,,,65,,2952.95,percent of total billed charges,,,78,,3543.54,percent of total billed charges,,,70,,3180.1,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,251.97,4088.7,
MRI Neurography Lumb W/O Cont-72195,72195,CPT,,,,both,,,4543,2725.8,,45.5,,2067.07,percent of total billed charges,,,45.3,,2057.98,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3634.4,percent of total billed charges,,,61.4,,2789.4,percent of total billed charges,,,57.4,,2607.68,percent of total billed charges,,,81,,3679.83,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2616.77,percent of total billed charges,,,85,,3861.55,percent of total billed charges,,,85,,3861.55,percent of total billed charges,,,49,,2226.07,percent of total billed charges,,,90,,4088.7,percent of total billed charges,,,65,,2952.95,percent of total billed charges,,,80,,3634.4,percent of total billed charges,,,55,,2498.65,percent of total billed charges,,,55,,2498.65,percent of total billed charges,,,65,,2952.95,percent of total billed charges,,,78,,3543.54,percent of total billed charges,,,70,,3180.1,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,251.97,4088.7,
MRI Pelvis MSK W/O Contrast,72195,CPT,,,,both,,,4543,2725.8,,45.5,,2067.07,percent of total billed charges,,,45.3,,2057.98,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3634.4,percent of total billed charges,,,61.4,,2789.4,percent of total billed charges,,,57.4,,2607.68,percent of total billed charges,,,81,,3679.83,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2616.77,percent of total billed charges,,,85,,3861.55,percent of total billed charges,,,85,,3861.55,percent of total billed charges,,,49,,2226.07,percent of total billed charges,,,90,,4088.7,percent of total billed charges,,,65,,2952.95,percent of total billed charges,,,80,,3634.4,percent of total billed charges,,,55,,2498.65,percent of total billed charges,,,55,,2498.65,percent of total billed charges,,,65,,2952.95,percent of total billed charges,,,78,,3543.54,percent of total billed charges,,,70,,3180.1,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,251.97,4088.7,
MRI Pelvis Viscera W/O Contrast,72195,CPT,,,,both,,,4543,2725.8,,45.5,,2067.07,percent of total billed charges,,,45.3,,2057.98,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3634.4,percent of total billed charges,,,61.4,,2789.4,percent of total billed charges,,,57.4,,2607.68,percent of total billed charges,,,81,,3679.83,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2616.77,percent of total billed charges,,,85,,3861.55,percent of total billed charges,,,85,,3861.55,percent of total billed charges,,,49,,2226.07,percent of total billed charges,,,90,,4088.7,percent of total billed charges,,,65,,2952.95,percent of total billed charges,,,80,,3634.4,percent of total billed charges,,,55,,2498.65,percent of total billed charges,,,55,,2498.65,percent of total billed charges,,,65,,2952.95,percent of total billed charges,,,78,,3543.54,percent of total billed charges,,,70,,3180.1,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,251.97,4088.7,
MRI Prostate W/O Contrast,72195,CPT,,,,both,,,4543,2725.8,,45.5,,2067.07,percent of total billed charges,,,45.3,,2057.98,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3634.4,percent of total billed charges,,,61.4,,2789.4,percent of total billed charges,,,57.4,,2607.68,percent of total billed charges,,,81,,3679.83,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2616.77,percent of total billed charges,,,85,,3861.55,percent of total billed charges,,,85,,3861.55,percent of total billed charges,,,49,,2226.07,percent of total billed charges,,,90,,4088.7,percent of total billed charges,,,65,,2952.95,percent of total billed charges,,,80,,3634.4,percent of total billed charges,,,55,,2498.65,percent of total billed charges,,,55,,2498.65,percent of total billed charges,,,65,,2952.95,percent of total billed charges,,,78,,3543.54,percent of total billed charges,,,70,,3180.1,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,251.97,4088.7,
MRI Sacrum Coccyx  W/O Contrast,72195,CPT,,,,both,,,4543,2725.8,,45.5,,2067.07,percent of total billed charges,,,45.3,,2057.98,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3634.4,percent of total billed charges,,,61.4,,2789.4,percent of total billed charges,,,57.4,,2607.68,percent of total billed charges,,,81,,3679.83,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2616.77,percent of total billed charges,,,85,,3861.55,percent of total billed charges,,,85,,3861.55,percent of total billed charges,,,49,,2226.07,percent of total billed charges,,,90,,4088.7,percent of total billed charges,,,65,,2952.95,percent of total billed charges,,,80,,3634.4,percent of total billed charges,,,55,,2498.65,percent of total billed charges,,,55,,2498.65,percent of total billed charges,,,65,,2952.95,percent of total billed charges,,,78,,3543.54,percent of total billed charges,,,70,,3180.1,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,251.97,4088.7,
MRI Finger W/O Contrast Left,73218,CPT,,,LT,both,,,4173,2503.8,,45.5,,1898.72,percent of total billed charges,,,45.3,,1890.37,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3338.4,percent of total billed charges,,,61.4,,2562.22,percent of total billed charges,,,57.4,,2395.3,percent of total billed charges,,,81,,3380.13,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2403.65,percent of total billed charges,,,85,,3547.05,percent of total billed charges,,,85,,3547.05,percent of total billed charges,,,49,,2044.77,percent of total billed charges,,,90,,3755.7,percent of total billed charges,,,65,,2712.45,percent of total billed charges,,,80,,3338.4,percent of total billed charges,,,55,,2295.15,percent of total billed charges,,,55,,2295.15,percent of total billed charges,,,65,,2712.45,percent of total billed charges,,,78,,3254.94,percent of total billed charges,,,70,,2921.1,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,251.97,3755.7,
MRI Forearm W/O Contrast Left,73218,CPT,,,LT,both,,,4173,2503.8,,45.5,,1898.72,percent of total billed charges,,,45.3,,1890.37,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3338.4,percent of total billed charges,,,61.4,,2562.22,percent of total billed charges,,,57.4,,2395.3,percent of total billed charges,,,81,,3380.13,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2403.65,percent of total billed charges,,,85,,3547.05,percent of total billed charges,,,85,,3547.05,percent of total billed charges,,,49,,2044.77,percent of total billed charges,,,90,,3755.7,percent of total billed charges,,,65,,2712.45,percent of total billed charges,,,80,,3338.4,percent of total billed charges,,,55,,2295.15,percent of total billed charges,,,55,,2295.15,percent of total billed charges,,,65,,2712.45,percent of total billed charges,,,78,,3254.94,percent of total billed charges,,,70,,2921.1,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,251.97,3755.7,
MRI Hand  W/O Contrast Left,73218,CPT,,,LT,both,,,4173,2503.8,,45.5,,1898.72,percent of total billed charges,,,45.3,,1890.37,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3338.4,percent of total billed charges,,,61.4,,2562.22,percent of total billed charges,,,57.4,,2395.3,percent of total billed charges,,,81,,3380.13,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2403.65,percent of total billed charges,,,85,,3547.05,percent of total billed charges,,,85,,3547.05,percent of total billed charges,,,49,,2044.77,percent of total billed charges,,,90,,3755.7,percent of total billed charges,,,65,,2712.45,percent of total billed charges,,,80,,3338.4,percent of total billed charges,,,55,,2295.15,percent of total billed charges,,,55,,2295.15,percent of total billed charges,,,65,,2712.45,percent of total billed charges,,,78,,3254.94,percent of total billed charges,,,70,,2921.1,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,251.97,3755.7,
MRI Humerus W/O Contrast Lt,73218,CPT,,,LT,both,,,4173,2503.8,,45.5,,1898.72,percent of total billed charges,,,45.3,,1890.37,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3338.4,percent of total billed charges,,,61.4,,2562.22,percent of total billed charges,,,57.4,,2395.3,percent of total billed charges,,,81,,3380.13,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2403.65,percent of total billed charges,,,85,,3547.05,percent of total billed charges,,,85,,3547.05,percent of total billed charges,,,49,,2044.77,percent of total billed charges,,,90,,3755.7,percent of total billed charges,,,65,,2712.45,percent of total billed charges,,,80,,3338.4,percent of total billed charges,,,55,,2295.15,percent of total billed charges,,,55,,2295.15,percent of total billed charges,,,65,,2712.45,percent of total billed charges,,,78,,3254.94,percent of total billed charges,,,70,,2921.1,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,251.97,3755.7,
MRI Neurography Forearm W/O Cont Lt-73218,73218,CPT,,,LT,both,,,4173,2503.8,,45.5,,1898.72,percent of total billed charges,,,45.3,,1890.37,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3338.4,percent of total billed charges,,,61.4,,2562.22,percent of total billed charges,,,57.4,,2395.3,percent of total billed charges,,,81,,3380.13,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2403.65,percent of total billed charges,,,85,,3547.05,percent of total billed charges,,,85,,3547.05,percent of total billed charges,,,49,,2044.77,percent of total billed charges,,,90,,3755.7,percent of total billed charges,,,65,,2712.45,percent of total billed charges,,,80,,3338.4,percent of total billed charges,,,55,,2295.15,percent of total billed charges,,,55,,2295.15,percent of total billed charges,,,65,,2712.45,percent of total billed charges,,,78,,3254.94,percent of total billed charges,,,70,,2921.1,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,251.97,3755.7,
MRI Neurography Humerus W/O Cont Lt-73218,73218,CPT,,,LT,both,,,4173,2503.8,,45.5,,1898.72,percent of total billed charges,,,45.3,,1890.37,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3338.4,percent of total billed charges,,,61.4,,2562.22,percent of total billed charges,,,57.4,,2395.3,percent of total billed charges,,,81,,3380.13,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2403.65,percent of total billed charges,,,85,,3547.05,percent of total billed charges,,,85,,3547.05,percent of total billed charges,,,49,,2044.77,percent of total billed charges,,,90,,3755.7,percent of total billed charges,,,65,,2712.45,percent of total billed charges,,,80,,3338.4,percent of total billed charges,,,55,,2295.15,percent of total billed charges,,,55,,2295.15,percent of total billed charges,,,65,,2712.45,percent of total billed charges,,,78,,3254.94,percent of total billed charges,,,70,,2921.1,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,251.97,3755.7,
MRI Finger W/O Contrast Right,73218,CPT,,,RT,both,,,4173,2503.8,,45.5,,1898.72,percent of total billed charges,,,45.3,,1890.37,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3338.4,percent of total billed charges,,,61.4,,2562.22,percent of total billed charges,,,57.4,,2395.3,percent of total billed charges,,,81,,3380.13,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2403.65,percent of total billed charges,,,85,,3547.05,percent of total billed charges,,,85,,3547.05,percent of total billed charges,,,49,,2044.77,percent of total billed charges,,,90,,3755.7,percent of total billed charges,,,65,,2712.45,percent of total billed charges,,,80,,3338.4,percent of total billed charges,,,55,,2295.15,percent of total billed charges,,,55,,2295.15,percent of total billed charges,,,65,,2712.45,percent of total billed charges,,,78,,3254.94,percent of total billed charges,,,70,,2921.1,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,251.97,3755.7,
MRI Forearm W/O Contrast Right,73218,CPT,,,RT,both,,,4173,2503.8,,45.5,,1898.72,percent of total billed charges,,,45.3,,1890.37,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3338.4,percent of total billed charges,,,61.4,,2562.22,percent of total billed charges,,,57.4,,2395.3,percent of total billed charges,,,81,,3380.13,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2403.65,percent of total billed charges,,,85,,3547.05,percent of total billed charges,,,85,,3547.05,percent of total billed charges,,,49,,2044.77,percent of total billed charges,,,90,,3755.7,percent of total billed charges,,,65,,2712.45,percent of total billed charges,,,80,,3338.4,percent of total billed charges,,,55,,2295.15,percent of total billed charges,,,55,,2295.15,percent of total billed charges,,,65,,2712.45,percent of total billed charges,,,78,,3254.94,percent of total billed charges,,,70,,2921.1,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,251.97,3755.7,
MRI Hand  W/O Contrast Right,73218,CPT,,,RT,both,,,4173,2503.8,,45.5,,1898.72,percent of total billed charges,,,45.3,,1890.37,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3338.4,percent of total billed charges,,,61.4,,2562.22,percent of total billed charges,,,57.4,,2395.3,percent of total billed charges,,,81,,3380.13,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2403.65,percent of total billed charges,,,85,,3547.05,percent of total billed charges,,,85,,3547.05,percent of total billed charges,,,49,,2044.77,percent of total billed charges,,,90,,3755.7,percent of total billed charges,,,65,,2712.45,percent of total billed charges,,,80,,3338.4,percent of total billed charges,,,55,,2295.15,percent of total billed charges,,,55,,2295.15,percent of total billed charges,,,65,,2712.45,percent of total billed charges,,,78,,3254.94,percent of total billed charges,,,70,,2921.1,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,251.97,3755.7,
MRI Humerus W/O Contrast Rt,73218,CPT,,,RT,both,,,4173,2503.8,,45.5,,1898.72,percent of total billed charges,,,45.3,,1890.37,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3338.4,percent of total billed charges,,,61.4,,2562.22,percent of total billed charges,,,57.4,,2395.3,percent of total billed charges,,,81,,3380.13,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2403.65,percent of total billed charges,,,85,,3547.05,percent of total billed charges,,,85,,3547.05,percent of total billed charges,,,49,,2044.77,percent of total billed charges,,,90,,3755.7,percent of total billed charges,,,65,,2712.45,percent of total billed charges,,,80,,3338.4,percent of total billed charges,,,55,,2295.15,percent of total billed charges,,,55,,2295.15,percent of total billed charges,,,65,,2712.45,percent of total billed charges,,,78,,3254.94,percent of total billed charges,,,70,,2921.1,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,251.97,3755.7,
MRI Neurography Forearm W/O Cont Rt-73218,73218,CPT,,,RT,both,,,4173,2503.8,,45.5,,1898.72,percent of total billed charges,,,45.3,,1890.37,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3338.4,percent of total billed charges,,,61.4,,2562.22,percent of total billed charges,,,57.4,,2395.3,percent of total billed charges,,,81,,3380.13,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2403.65,percent of total billed charges,,,85,,3547.05,percent of total billed charges,,,85,,3547.05,percent of total billed charges,,,49,,2044.77,percent of total billed charges,,,90,,3755.7,percent of total billed charges,,,65,,2712.45,percent of total billed charges,,,80,,3338.4,percent of total billed charges,,,55,,2295.15,percent of total billed charges,,,55,,2295.15,percent of total billed charges,,,65,,2712.45,percent of total billed charges,,,78,,3254.94,percent of total billed charges,,,70,,2921.1,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,251.97,3755.7,
MRI Neurography Humerus W/O Cont Rt-73218,73218,CPT,,,RT,both,,,4173,2503.8,,45.5,,1898.72,percent of total billed charges,,,45.3,,1890.37,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3338.4,percent of total billed charges,,,61.4,,2562.22,percent of total billed charges,,,57.4,,2395.3,percent of total billed charges,,,81,,3380.13,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2403.65,percent of total billed charges,,,85,,3547.05,percent of total billed charges,,,85,,3547.05,percent of total billed charges,,,49,,2044.77,percent of total billed charges,,,90,,3755.7,percent of total billed charges,,,65,,2712.45,percent of total billed charges,,,80,,3338.4,percent of total billed charges,,,55,,2295.15,percent of total billed charges,,,55,,2295.15,percent of total billed charges,,,65,,2712.45,percent of total billed charges,,,78,,3254.94,percent of total billed charges,,,70,,2921.1,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,488.85,,,,EAPG Rate,100% of IL Medicaid,251.97,3755.7,
MRI Elbow  W/O Contrast Left,73221,CPT,,,LT,both,,,4712,2827.2,,45.5,,2143.96,percent of total billed charges,,,45.3,,2134.54,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3769.6,percent of total billed charges,,,61.4,,2893.17,percent of total billed charges,,,57.4,,2704.69,percent of total billed charges,,,81,,3816.72,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2714.11,percent of total billed charges,,,85,,4005.2,percent of total billed charges,,,85,,4005.2,percent of total billed charges,,,49,,2308.88,percent of total billed charges,,,90,,4240.8,percent of total billed charges,,,65,,3062.8,percent of total billed charges,,,80,,3769.6,percent of total billed charges,,,55,,2591.6,percent of total billed charges,,,55,,2591.6,percent of total billed charges,,,65,,3062.8,percent of total billed charges,,,78,,3675.36,percent of total billed charges,,,70,,3298.4,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,251.97,4240.8,
MRI Shoulder W/O Contrast Lt,73221,CPT,,,LT,both,,,4712,2827.2,,45.5,,2143.96,percent of total billed charges,,,45.3,,2134.54,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3769.6,percent of total billed charges,,,61.4,,2893.17,percent of total billed charges,,,57.4,,2704.69,percent of total billed charges,,,81,,3816.72,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2714.11,percent of total billed charges,,,85,,4005.2,percent of total billed charges,,,85,,4005.2,percent of total billed charges,,,49,,2308.88,percent of total billed charges,,,90,,4240.8,percent of total billed charges,,,65,,3062.8,percent of total billed charges,,,80,,3769.6,percent of total billed charges,,,55,,2591.6,percent of total billed charges,,,55,,2591.6,percent of total billed charges,,,65,,3062.8,percent of total billed charges,,,78,,3675.36,percent of total billed charges,,,70,,3298.4,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,251.97,4240.8,
MRI Wrist W/O Contrast Lt,73221,CPT,,,LT,both,,,4712,2827.2,,45.5,,2143.96,percent of total billed charges,,,45.3,,2134.54,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3769.6,percent of total billed charges,,,61.4,,2893.17,percent of total billed charges,,,57.4,,2704.69,percent of total billed charges,,,81,,3816.72,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2714.11,percent of total billed charges,,,85,,4005.2,percent of total billed charges,,,85,,4005.2,percent of total billed charges,,,49,,2308.88,percent of total billed charges,,,90,,4240.8,percent of total billed charges,,,65,,3062.8,percent of total billed charges,,,80,,3769.6,percent of total billed charges,,,55,,2591.6,percent of total billed charges,,,55,,2591.6,percent of total billed charges,,,65,,3062.8,percent of total billed charges,,,78,,3675.36,percent of total billed charges,,,70,,3298.4,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,251.97,4240.8,
MRI Elbow W/O Contrast Right,73221,CPT,,,RT,both,,,4712,2827.2,,45.5,,2143.96,percent of total billed charges,,,45.3,,2134.54,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3769.6,percent of total billed charges,,,61.4,,2893.17,percent of total billed charges,,,57.4,,2704.69,percent of total billed charges,,,81,,3816.72,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2714.11,percent of total billed charges,,,85,,4005.2,percent of total billed charges,,,85,,4005.2,percent of total billed charges,,,49,,2308.88,percent of total billed charges,,,90,,4240.8,percent of total billed charges,,,65,,3062.8,percent of total billed charges,,,80,,3769.6,percent of total billed charges,,,55,,2591.6,percent of total billed charges,,,55,,2591.6,percent of total billed charges,,,65,,3062.8,percent of total billed charges,,,78,,3675.36,percent of total billed charges,,,70,,3298.4,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,251.97,4240.8,
MRI Shoulder W/O Contrast Rt,73221,CPT,,,RT,both,,,4712,2827.2,,45.5,,2143.96,percent of total billed charges,,,45.3,,2134.54,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3769.6,percent of total billed charges,,,61.4,,2893.17,percent of total billed charges,,,57.4,,2704.69,percent of total billed charges,,,81,,3816.72,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2714.11,percent of total billed charges,,,85,,4005.2,percent of total billed charges,,,85,,4005.2,percent of total billed charges,,,49,,2308.88,percent of total billed charges,,,90,,4240.8,percent of total billed charges,,,65,,3062.8,percent of total billed charges,,,80,,3769.6,percent of total billed charges,,,55,,2591.6,percent of total billed charges,,,55,,2591.6,percent of total billed charges,,,65,,3062.8,percent of total billed charges,,,78,,3675.36,percent of total billed charges,,,70,,3298.4,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,251.97,4240.8,
MRI Wrist W/O Contrast Rt,73221,CPT,,,RT,both,,,4712,2827.2,,45.5,,2143.96,percent of total billed charges,,,45.3,,2134.54,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3769.6,percent of total billed charges,,,61.4,,2893.17,percent of total billed charges,,,57.4,,2704.69,percent of total billed charges,,,81,,3816.72,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2714.11,percent of total billed charges,,,85,,4005.2,percent of total billed charges,,,85,,4005.2,percent of total billed charges,,,49,,2308.88,percent of total billed charges,,,90,,4240.8,percent of total billed charges,,,65,,3062.8,percent of total billed charges,,,80,,3769.6,percent of total billed charges,,,55,,2591.6,percent of total billed charges,,,55,,2591.6,percent of total billed charges,,,65,,3062.8,percent of total billed charges,,,78,,3675.36,percent of total billed charges,,,70,,3298.4,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,251.97,4240.8,
MRI Femur W/O Contrast Left,73718,CPT,,,LT,both,,,4515,2709,,45.5,,2054.33,percent of total billed charges,,,45.3,,2045.3,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3612,percent of total billed charges,,,61.4,,2772.21,percent of total billed charges,,,57.4,,2591.61,percent of total billed charges,,,81,,3657.15,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2600.64,percent of total billed charges,,,85,,3837.75,percent of total billed charges,,,85,,3837.75,percent of total billed charges,,,49,,2212.35,percent of total billed charges,,,90,,4063.5,percent of total billed charges,,,65,,2934.75,percent of total billed charges,,,80,,3612,percent of total billed charges,,,55,,2483.25,percent of total billed charges,,,55,,2483.25,percent of total billed charges,,,65,,2934.75,percent of total billed charges,,,78,,3521.7,percent of total billed charges,,,70,,3160.5,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,251.97,4063.5,
MRI Foot W/O Contrast Lt,73718,CPT,,,LT,both,,,4515,2709,,45.5,,2054.33,percent of total billed charges,,,45.3,,2045.3,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3612,percent of total billed charges,,,61.4,,2772.21,percent of total billed charges,,,57.4,,2591.61,percent of total billed charges,,,81,,3657.15,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2600.64,percent of total billed charges,,,85,,3837.75,percent of total billed charges,,,85,,3837.75,percent of total billed charges,,,49,,2212.35,percent of total billed charges,,,90,,4063.5,percent of total billed charges,,,65,,2934.75,percent of total billed charges,,,80,,3612,percent of total billed charges,,,55,,2483.25,percent of total billed charges,,,55,,2483.25,percent of total billed charges,,,65,,2934.75,percent of total billed charges,,,78,,3521.7,percent of total billed charges,,,70,,3160.5,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,251.97,4063.5,
MRI Neurography Femoral W/O Cont Lt-73718,73718,CPT,,,LT,both,,,4515,2709,,45.5,,2054.33,percent of total billed charges,,,45.3,,2045.3,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3612,percent of total billed charges,,,61.4,,2772.21,percent of total billed charges,,,57.4,,2591.61,percent of total billed charges,,,81,,3657.15,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2600.64,percent of total billed charges,,,85,,3837.75,percent of total billed charges,,,85,,3837.75,percent of total billed charges,,,49,,2212.35,percent of total billed charges,,,90,,4063.5,percent of total billed charges,,,65,,2934.75,percent of total billed charges,,,80,,3612,percent of total billed charges,,,55,,2483.25,percent of total billed charges,,,55,,2483.25,percent of total billed charges,,,65,,2934.75,percent of total billed charges,,,78,,3521.7,percent of total billed charges,,,70,,3160.5,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,251.97,4063.5,
MRI Neurography Tib W/O Cont Lt-73718,73718,CPT,,,LT,both,,,4515,2709,,45.5,,2054.33,percent of total billed charges,,,45.3,,2045.3,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3612,percent of total billed charges,,,61.4,,2772.21,percent of total billed charges,,,57.4,,2591.61,percent of total billed charges,,,81,,3657.15,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2600.64,percent of total billed charges,,,85,,3837.75,percent of total billed charges,,,85,,3837.75,percent of total billed charges,,,49,,2212.35,percent of total billed charges,,,90,,4063.5,percent of total billed charges,,,65,,2934.75,percent of total billed charges,,,80,,3612,percent of total billed charges,,,55,,2483.25,percent of total billed charges,,,55,,2483.25,percent of total billed charges,,,65,,2934.75,percent of total billed charges,,,78,,3521.7,percent of total billed charges,,,70,,3160.5,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,251.97,4063.5,
MRI Tibia W/O Contrast Lt,73718,CPT,,,LT,both,,,4515,2709,,45.5,,2054.33,percent of total billed charges,,,45.3,,2045.3,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3612,percent of total billed charges,,,61.4,,2772.21,percent of total billed charges,,,57.4,,2591.61,percent of total billed charges,,,81,,3657.15,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2600.64,percent of total billed charges,,,85,,3837.75,percent of total billed charges,,,85,,3837.75,percent of total billed charges,,,49,,2212.35,percent of total billed charges,,,90,,4063.5,percent of total billed charges,,,65,,2934.75,percent of total billed charges,,,80,,3612,percent of total billed charges,,,55,,2483.25,percent of total billed charges,,,55,,2483.25,percent of total billed charges,,,65,,2934.75,percent of total billed charges,,,78,,3521.7,percent of total billed charges,,,70,,3160.5,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,251.97,4063.5,
MRI Femur W/O Contrast Right,73718,CPT,,,RT,both,,,4515,2709,,45.5,,2054.33,percent of total billed charges,,,45.3,,2045.3,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3612,percent of total billed charges,,,61.4,,2772.21,percent of total billed charges,,,57.4,,2591.61,percent of total billed charges,,,81,,3657.15,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2600.64,percent of total billed charges,,,85,,3837.75,percent of total billed charges,,,85,,3837.75,percent of total billed charges,,,49,,2212.35,percent of total billed charges,,,90,,4063.5,percent of total billed charges,,,65,,2934.75,percent of total billed charges,,,80,,3612,percent of total billed charges,,,55,,2483.25,percent of total billed charges,,,55,,2483.25,percent of total billed charges,,,65,,2934.75,percent of total billed charges,,,78,,3521.7,percent of total billed charges,,,70,,3160.5,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,251.97,4063.5,
MRI Foot W/O Contrast Rt,73718,CPT,,,RT,both,,,4515,2709,,45.5,,2054.33,percent of total billed charges,,,45.3,,2045.3,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3612,percent of total billed charges,,,61.4,,2772.21,percent of total billed charges,,,57.4,,2591.61,percent of total billed charges,,,81,,3657.15,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2600.64,percent of total billed charges,,,85,,3837.75,percent of total billed charges,,,85,,3837.75,percent of total billed charges,,,49,,2212.35,percent of total billed charges,,,90,,4063.5,percent of total billed charges,,,65,,2934.75,percent of total billed charges,,,80,,3612,percent of total billed charges,,,55,,2483.25,percent of total billed charges,,,55,,2483.25,percent of total billed charges,,,65,,2934.75,percent of total billed charges,,,78,,3521.7,percent of total billed charges,,,70,,3160.5,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,251.97,4063.5,
MRI Neurography Femoral W/O Cont Rt-73718,73718,CPT,,,RT,both,,,4515,2709,,45.5,,2054.33,percent of total billed charges,,,45.3,,2045.3,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3612,percent of total billed charges,,,61.4,,2772.21,percent of total billed charges,,,57.4,,2591.61,percent of total billed charges,,,81,,3657.15,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2600.64,percent of total billed charges,,,85,,3837.75,percent of total billed charges,,,85,,3837.75,percent of total billed charges,,,49,,2212.35,percent of total billed charges,,,90,,4063.5,percent of total billed charges,,,65,,2934.75,percent of total billed charges,,,80,,3612,percent of total billed charges,,,55,,2483.25,percent of total billed charges,,,55,,2483.25,percent of total billed charges,,,65,,2934.75,percent of total billed charges,,,78,,3521.7,percent of total billed charges,,,70,,3160.5,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,251.97,4063.5,
MRI Neurography Tib W/O Cont Rt-73718,73718,CPT,,,RT,both,,,4515,2709,,45.5,,2054.33,percent of total billed charges,,,45.3,,2045.3,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3612,percent of total billed charges,,,61.4,,2772.21,percent of total billed charges,,,57.4,,2591.61,percent of total billed charges,,,81,,3657.15,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2600.64,percent of total billed charges,,,85,,3837.75,percent of total billed charges,,,85,,3837.75,percent of total billed charges,,,49,,2212.35,percent of total billed charges,,,90,,4063.5,percent of total billed charges,,,65,,2934.75,percent of total billed charges,,,80,,3612,percent of total billed charges,,,55,,2483.25,percent of total billed charges,,,55,,2483.25,percent of total billed charges,,,65,,2934.75,percent of total billed charges,,,78,,3521.7,percent of total billed charges,,,70,,3160.5,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,251.97,4063.5,
MRI Tibia W/O Contrast Rt,73718,CPT,,,RT,both,,,4515,2709,,45.5,,2054.33,percent of total billed charges,,,45.3,,2045.3,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3612,percent of total billed charges,,,61.4,,2772.21,percent of total billed charges,,,57.4,,2591.61,percent of total billed charges,,,81,,3657.15,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2600.64,percent of total billed charges,,,85,,3837.75,percent of total billed charges,,,85,,3837.75,percent of total billed charges,,,49,,2212.35,percent of total billed charges,,,90,,4063.5,percent of total billed charges,,,65,,2934.75,percent of total billed charges,,,80,,3612,percent of total billed charges,,,55,,2483.25,percent of total billed charges,,,55,,2483.25,percent of total billed charges,,,65,,2934.75,percent of total billed charges,,,78,,3521.7,percent of total billed charges,,,70,,3160.5,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,251.97,4063.5,
MRI Ankle/Hindfoot  W/O Contrast Left,73721,CPT,,,LT,both,,,4751,2850.6,,45.5,,2161.71,percent of total billed charges,,,45.3,,2152.2,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3800.8,percent of total billed charges,,,61.4,,2917.11,percent of total billed charges,,,57.4,,2727.07,percent of total billed charges,,,81,,3848.31,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2736.58,percent of total billed charges,,,85,,4038.35,percent of total billed charges,,,85,,4038.35,percent of total billed charges,,,49,,2327.99,percent of total billed charges,,,90,,4275.9,percent of total billed charges,,,65,,3088.15,percent of total billed charges,,,80,,3800.8,percent of total billed charges,,,55,,2613.05,percent of total billed charges,,,55,,2613.05,percent of total billed charges,,,65,,3088.15,percent of total billed charges,,,78,,3705.78,percent of total billed charges,,,70,,3325.7,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,251.97,4275.9,
MRI Hip W/O Contrast Lt,73721,CPT,,,LT,both,,,4751,2850.6,,45.5,,2161.71,percent of total billed charges,,,45.3,,2152.2,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3800.8,percent of total billed charges,,,61.4,,2917.11,percent of total billed charges,,,57.4,,2727.07,percent of total billed charges,,,81,,3848.31,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2736.58,percent of total billed charges,,,85,,4038.35,percent of total billed charges,,,85,,4038.35,percent of total billed charges,,,49,,2327.99,percent of total billed charges,,,90,,4275.9,percent of total billed charges,,,65,,3088.15,percent of total billed charges,,,80,,3800.8,percent of total billed charges,,,55,,2613.05,percent of total billed charges,,,55,,2613.05,percent of total billed charges,,,65,,3088.15,percent of total billed charges,,,78,,3705.78,percent of total billed charges,,,70,,3325.7,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,251.97,4275.9,
MRI Knee W/O Contrast Lt,73721,CPT,,,LT,both,,,4751,2850.6,,45.5,,2161.71,percent of total billed charges,,,45.3,,2152.2,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3800.8,percent of total billed charges,,,61.4,,2917.11,percent of total billed charges,,,57.4,,2727.07,percent of total billed charges,,,81,,3848.31,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2736.58,percent of total billed charges,,,85,,4038.35,percent of total billed charges,,,85,,4038.35,percent of total billed charges,,,49,,2327.99,percent of total billed charges,,,90,,4275.9,percent of total billed charges,,,65,,3088.15,percent of total billed charges,,,80,,3800.8,percent of total billed charges,,,55,,2613.05,percent of total billed charges,,,55,,2613.05,percent of total billed charges,,,65,,3088.15,percent of total billed charges,,,78,,3705.78,percent of total billed charges,,,70,,3325.7,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,251.97,4275.9,
MRI Ankle/Hindfoot  W/O Contrast Right,73721,CPT,,,RT,both,,,4751,2850.6,,45.5,,2161.71,percent of total billed charges,,,45.3,,2152.2,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3800.8,percent of total billed charges,,,61.4,,2917.11,percent of total billed charges,,,57.4,,2727.07,percent of total billed charges,,,81,,3848.31,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2736.58,percent of total billed charges,,,85,,4038.35,percent of total billed charges,,,85,,4038.35,percent of total billed charges,,,49,,2327.99,percent of total billed charges,,,90,,4275.9,percent of total billed charges,,,65,,3088.15,percent of total billed charges,,,80,,3800.8,percent of total billed charges,,,55,,2613.05,percent of total billed charges,,,55,,2613.05,percent of total billed charges,,,65,,3088.15,percent of total billed charges,,,78,,3705.78,percent of total billed charges,,,70,,3325.7,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,251.97,4275.9,
MRI Hip W/O Contrast Rt,73721,CPT,,,RT,both,,,4751,2850.6,,45.5,,2161.71,percent of total billed charges,,,45.3,,2152.2,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3800.8,percent of total billed charges,,,61.4,,2917.11,percent of total billed charges,,,57.4,,2727.07,percent of total billed charges,,,81,,3848.31,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2736.58,percent of total billed charges,,,85,,4038.35,percent of total billed charges,,,85,,4038.35,percent of total billed charges,,,49,,2327.99,percent of total billed charges,,,90,,4275.9,percent of total billed charges,,,65,,3088.15,percent of total billed charges,,,80,,3800.8,percent of total billed charges,,,55,,2613.05,percent of total billed charges,,,55,,2613.05,percent of total billed charges,,,65,,3088.15,percent of total billed charges,,,78,,3705.78,percent of total billed charges,,,70,,3325.7,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,251.97,4275.9,
MRI Knee W/O Contrast Rt,73721,CPT,,,RT,both,,,4751,2850.6,,45.5,,2161.71,percent of total billed charges,,,45.3,,2152.2,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3800.8,percent of total billed charges,,,61.4,,2917.11,percent of total billed charges,,,57.4,,2727.07,percent of total billed charges,,,81,,3848.31,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2736.58,percent of total billed charges,,,85,,4038.35,percent of total billed charges,,,85,,4038.35,percent of total billed charges,,,49,,2327.99,percent of total billed charges,,,90,,4275.9,percent of total billed charges,,,65,,3088.15,percent of total billed charges,,,80,,3800.8,percent of total billed charges,,,55,,2613.05,percent of total billed charges,,,55,,2613.05,percent of total billed charges,,,65,,3088.15,percent of total billed charges,,,78,,3705.78,percent of total billed charges,,,70,,3325.7,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,488.85,,,,EAPG rate,100% of IL Medicaid,251.97,4275.9,
"Injection Tendon Sheath, Ligament Charge (20550)",20550,CPT,,,,outpatient,,,1109,665.4,,45.5,,504.6,percent of total billed charges,,,45.3,,502.38,percent of total billed charges,,,51,,565.59,percent of total billed charges,,,,,,,,,80,,887.2,percent of total billed charges,,,61.4,,680.93,percent of total billed charges,,,57.4,,636.57,percent of total billed charges,,,81,,898.29,percent of total billed charges,,,51.5,,571.14,percent of total billed charges,,,57.6,,638.78,percent of total billed charges,,,85,,942.65,percent of total billed charges,,,85,,942.65,percent of total billed charges,,,49,,543.41,percent of total billed charges,,,90,,998.1,percent of total billed charges,,,65,,720.85,percent of total billed charges,,,80,,887.2,percent of total billed charges,,,55,,609.95,percent of total billed charges,,,55,,609.95,percent of total billed charges,,,65,,720.85,percent of total billed charges,,,78,,865.02,percent of total billed charges,,,70,,776.3,percent of total billed charges,,,,,,,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,,307.71,,,,100% of Medicare,498.75,,,,EAPG Rate,100% of IL Medicaid,498.75,,,,EAPG Rate,100% of IL Medicaid,498.75,,,,EAPG Rate,100% of IL Medicaid,498.75,,,,EAPG Rate,100% of IL Medicaid,307.71,998.1,
Injection Tendon Sheath Ligament Charge bilateral (20550-50),20550,CPT,,,50,outpatient,,,1663,997.8,,45.5,,756.67,percent of total billed charges,,,45.3,,753.34,percent of total billed charges,,,51,,848.13,percent of total billed charges,,,,,,,,,80,,1330.4,percent of total billed charges,,,61.4,,1021.08,percent of total billed charges,,,57.4,,954.56,percent of total billed charges,,,81,,1347.03,percent of total billed charges,,,51.5,,856.45,percent of total billed charges,,,57.6,,957.89,percent of total billed charges,,,85,,1413.55,percent of total billed charges,,,85,,1413.55,percent of total billed charges,,,49,,814.87,percent of total billed charges,,,90,,1496.7,percent of total billed charges,,,65,,1080.95,percent of total billed charges,,,80,,1330.4,percent of total billed charges,,,55,,914.65,percent of total billed charges,,,55,,914.65,percent of total billed charges,,,65,,1080.95,percent of total billed charges,,,78,,1297.14,percent of total billed charges,,,70,,1164.1,percent of total billed charges,,,,,,,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,,461.57,,,,150% of Medicare,498.75,,,,EAPG Rate,100% of IL Medicaid,498.75,,,,EAPG Rate,100% of IL Medicaid,498.75,,,,EAPG Rate,100% of IL Medicaid,498.75,,,,EAPG Rate,100% of IL Medicaid,461.57,1496.7,
Injection Tendon Origin/Insertion Charge (20551),20551,CPT,,,,outpatient,,,1042,625.2,,45.5,,474.11,percent of total billed charges,,,45.3,,472.03,percent of total billed charges,,,51,,531.42,percent of total billed charges,,,,,,,,,80,,833.6,percent of total billed charges,,,61.4,,639.79,percent of total billed charges,,,57.4,,598.11,percent of total billed charges,,,81,,844.02,percent of total billed charges,,,51.5,,536.63,percent of total billed charges,,,57.6,,600.19,percent of total billed charges,,,85,,885.7,percent of total billed charges,,,85,,885.7,percent of total billed charges,,,49,,510.58,percent of total billed charges,,,90,,937.8,percent of total billed charges,,,65,,677.3,percent of total billed charges,,,80,,833.6,percent of total billed charges,,,55,,573.1,percent of total billed charges,,,55,,573.1,percent of total billed charges,,,65,,677.3,percent of total billed charges,,,78,,812.76,percent of total billed charges,,,70,,729.4,percent of total billed charges,,,,,,,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,,307.71,,,,100% of Medicare,498.75,,,,EAPG Rate,100% of IL Medicaid,498.75,,,,EAPG Rate,100% of IL Medicaid,498.75,,,,EAPG Rate,100% of IL Medicaid,498.75,,,,EAPG Rate,100% of IL Medicaid,307.71,937.8,
CC ONLY - Injection Trigger Point(s): 1 or 2 Muscle(s) Charge (20552),20552,CPT,,,,outpatient,,,942,565.2,,45.5,,428.61,percent of total billed charges,,,45.3,,426.73,percent of total billed charges,,,51,,480.42,percent of total billed charges,,,,,,,,,80,,753.6,percent of total billed charges,,,61.4,,578.39,percent of total billed charges,,,57.4,,540.71,percent of total billed charges,,,81,,763.02,percent of total billed charges,,,51.5,,485.13,percent of total billed charges,,,57.6,,542.59,percent of total billed charges,,,85,,800.7,percent of total billed charges,,,85,,800.7,percent of total billed charges,,,49,,461.58,percent of total billed charges,,,90,,847.8,percent of total billed charges,,,65,,612.3,percent of total billed charges,,,80,,753.6,percent of total billed charges,,,55,,518.1,percent of total billed charges,,,55,,518.1,percent of total billed charges,,,65,,612.3,percent of total billed charges,,,78,,734.76,percent of total billed charges,,,70,,659.4,percent of total billed charges,,,,,,,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,64115.91667,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,,307.71,,,,100% of Medicare,498.75,,,,EAPG Rate,100% of IL Medicaid,498.75,,,,EAPG Rate,100% of IL Medicaid,498.75,,,,EAPG Rate,100% of IL Medicaid,498.75,,,,EAPG Rate,100% of IL Medicaid,307.71,64115.92,
Injection Trigger Point(s): 1 or 2 Muscle(s) Charge (20552),20552,CPT,,,,outpatient,,,942,565.2,,45.5,,428.61,percent of total billed charges,,,45.3,,426.73,percent of total billed charges,,,51,,480.42,percent of total billed charges,,,,,,,,,80,,753.6,percent of total billed charges,,,61.4,,578.39,percent of total billed charges,,,57.4,,540.71,percent of total billed charges,,,81,,763.02,percent of total billed charges,,,51.5,,485.13,percent of total billed charges,,,57.6,,542.59,percent of total billed charges,,,85,,800.7,percent of total billed charges,,,85,,800.7,percent of total billed charges,,,49,,461.58,percent of total billed charges,,,90,,847.8,percent of total billed charges,,,65,,612.3,percent of total billed charges,,,80,,753.6,percent of total billed charges,,,55,,518.1,percent of total billed charges,,,55,,518.1,percent of total billed charges,,,65,,612.3,percent of total billed charges,,,78,,734.76,percent of total billed charges,,,70,,659.4,percent of total billed charges,,,,,,,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,,307.71,,,,100% of Medicare,498.75,,,,EAPG Rate,100% of IL Medicaid,498.75,,,,EAPG Rate,100% of IL Medicaid,498.75,,,,EAPG Rate,100% of IL Medicaid,498.75,,,,EAPG Rate,100% of IL Medicaid,307.71,847.8,
CHEMODENERV 1 EXTREMITY 1-4 (64642),64642,CPT,,,,outpatient,,,1470,882,,45.5,,668.85,percent of total billed charges,,,45.3,,665.91,percent of total billed charges,,,51,,749.7,percent of total billed charges,,,,,,,,,80,,1176,percent of total billed charges,,,61.4,,902.58,percent of total billed charges,,,57.4,,843.78,percent of total billed charges,,,81,,1190.7,percent of total billed charges,,,51.5,,757.05,percent of total billed charges,,,57.6,,846.72,percent of total billed charges,,,85,,1249.5,percent of total billed charges,,,85,,1249.5,percent of total billed charges,,,49,,720.3,percent of total billed charges,,,90,,1323,percent of total billed charges,,,65,,955.5,percent of total billed charges,,,80,,1176,percent of total billed charges,,,55,,808.5,percent of total billed charges,,,55,,808.5,percent of total billed charges,,,65,,955.5,percent of total billed charges,,,78,,1146.6,percent of total billed charges,,,70,,1029,percent of total billed charges,,,,,,,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,,721.9,,,,100% of Medicare,808.21,,,,EAPG Rate,100% of IL Medicaid,808.21,,,,EAPG Rate,100% of IL Medicaid,808.21,,,,EAPG Rate,100% of IL Medicaid,808.21,,,,EAPG Rate,100% of IL Medicaid,665.91,1323,
CC ONLY - CHEMODENERV 1 EXTREMITY 1-4 (64642),64642,CPT,,,,outpatient,,,1479,887.4,,45.5,,672.95,percent of total billed charges,,,45.3,,669.99,percent of total billed charges,,,51,,754.29,percent of total billed charges,,,,,,,,,80,,1183.2,percent of total billed charges,,,61.4,,908.11,percent of total billed charges,,,57.4,,848.95,percent of total billed charges,,,81,,1197.99,percent of total billed charges,,,51.5,,761.69,percent of total billed charges,,,57.6,,851.9,percent of total billed charges,,,85,,1257.15,percent of total billed charges,,,85,,1257.15,percent of total billed charges,,,49,,724.71,percent of total billed charges,,,90,,1331.1,percent of total billed charges,,,65,,961.35,percent of total billed charges,,,80,,1183.2,percent of total billed charges,,,55,,813.45,percent of total billed charges,,,55,,813.45,percent of total billed charges,,,65,,961.35,percent of total billed charges,,,78,,1153.62,percent of total billed charges,,,70,,1035.3,percent of total billed charges,,,,,,,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,47331.435,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,,721.9,,,,100% of Medicare,808.21,,,,EAPG Rate,100% of IL Medicaid,808.21,,,,EAPG Rate,100% of IL Medicaid,808.21,,,,EAPG Rate,100% of IL Medicaid,808.21,,,,EAPG Rate,100% of IL Medicaid,669.99,47331.44,
CC ONLY - CHEMODENERV 1 EXTREM 5/> MUS (64644),64644,CPT,,,,outpatient,,,1472,883.2,,45.5,,669.76,percent of total billed charges,,,45.3,,666.82,percent of total billed charges,,,51,,750.72,percent of total billed charges,,,,,,,,,80,,1177.6,percent of total billed charges,,,61.4,,903.81,percent of total billed charges,,,57.4,,844.93,percent of total billed charges,,,81,,1192.32,percent of total billed charges,,,51.5,,758.08,percent of total billed charges,,,57.6,,847.87,percent of total billed charges,,,85,,1251.2,percent of total billed charges,,,85,,1251.2,percent of total billed charges,,,49,,721.28,percent of total billed charges,,,90,,1324.8,percent of total billed charges,,,65,,956.8,percent of total billed charges,,,80,,1177.6,percent of total billed charges,,,55,,809.6,percent of total billed charges,,,55,,809.6,percent of total billed charges,,,65,,956.8,percent of total billed charges,,,78,,1148.16,percent of total billed charges,,,70,,1030.4,percent of total billed charges,,,,,,,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,48055.68333,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,,721.9,,,,100% of Medicare,808.21,,,,EAPG Rate,100% of IL Medicaid,808.21,,,,EAPG Rate,100% of IL Medicaid,808.21,,,,EAPG Rate,100% of IL Medicaid,808.21,,,,EAPG Rate,100% of IL Medicaid,666.82,48055.68,
CHEMODENERV 1 EXTREM 5/> MUS (64644),64644,CPT,,,,outpatient,,,1480,888,,45.5,,673.4,percent of total billed charges,,,45.3,,670.44,percent of total billed charges,,,51,,754.8,percent of total billed charges,,,,,,,,,80,,1184,percent of total billed charges,,,61.4,,908.72,percent of total billed charges,,,57.4,,849.52,percent of total billed charges,,,81,,1198.8,percent of total billed charges,,,51.5,,762.2,percent of total billed charges,,,57.6,,852.48,percent of total billed charges,,,85,,1258,percent of total billed charges,,,85,,1258,percent of total billed charges,,,49,,725.2,percent of total billed charges,,,90,,1332,percent of total billed charges,,,65,,962,percent of total billed charges,,,80,,1184,percent of total billed charges,,,55,,814,percent of total billed charges,,,55,,814,percent of total billed charges,,,65,,962,percent of total billed charges,,,78,,1154.4,percent of total billed charges,,,70,,1036,percent of total billed charges,,,,,,,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,,721.9,,,,100% of Medicare,808.21,,,,EAPG Rate,100% of IL Medicaid,808.21,,,,EAPG Rate,100% of IL Medicaid,808.21,,,,EAPG Rate,100% of IL Medicaid,808.21,,,,EAPG Rate,100% of IL Medicaid,670.44,1332,
MRI Face/Neck W/Contrast,70542,CPT,,,,both,,,7053,4231.8,,45.5,,3209.12,percent of total billed charges,,,45.3,,3195.01,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,5642.4,percent of total billed charges,,,61.4,,4330.54,percent of total billed charges,,,57.4,,4048.42,percent of total billed charges,,,81,,5712.93,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,4062.53,percent of total billed charges,,,85,,5995.05,percent of total billed charges,,,85,,5995.05,percent of total billed charges,,,49,,3455.97,percent of total billed charges,,,90,,6347.7,percent of total billed charges,,,65,,4584.45,percent of total billed charges,,,80,,5642.4,percent of total billed charges,,,55,,3879.15,percent of total billed charges,,,55,,3879.15,percent of total billed charges,,,65,,4584.45,percent of total billed charges,,,78,,5501.34,percent of total billed charges,,,70,,4937.1,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,6347.7,
MRI Orbits W/ Contrast,70542,CPT,,,,both,,,7053,4231.8,,45.5,,3209.12,percent of total billed charges,,,45.3,,3195.01,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,5642.4,percent of total billed charges,,,61.4,,4330.54,percent of total billed charges,,,57.4,,4048.42,percent of total billed charges,,,81,,5712.93,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,4062.53,percent of total billed charges,,,85,,5995.05,percent of total billed charges,,,85,,5995.05,percent of total billed charges,,,49,,3455.97,percent of total billed charges,,,90,,6347.7,percent of total billed charges,,,65,,4584.45,percent of total billed charges,,,80,,5642.4,percent of total billed charges,,,55,,3879.15,percent of total billed charges,,,55,,3879.15,percent of total billed charges,,,65,,4584.45,percent of total billed charges,,,78,,5501.34,percent of total billed charges,,,70,,4937.1,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,6347.7,
MRI Face/Neck W&W/O Contrast,70543,CPT,,,,both,,,7909,4745.4,,45.5,,3598.6,percent of total billed charges,,,45.3,,3582.78,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,6327.2,percent of total billed charges,,,61.4,,4856.13,percent of total billed charges,,,57.4,,4539.77,percent of total billed charges,,,81,,6406.29,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,4555.58,percent of total billed charges,,,85,,6722.65,percent of total billed charges,,,85,,6722.65,percent of total billed charges,,,49,,3875.41,percent of total billed charges,,,90,,7118.1,percent of total billed charges,,,65,,5140.85,percent of total billed charges,,,80,,6327.2,percent of total billed charges,,,55,,4349.95,percent of total billed charges,,,55,,4349.95,percent of total billed charges,,,65,,5140.85,percent of total billed charges,,,78,,6169.02,percent of total billed charges,,,70,,5536.3,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,7118.1,
MRI Orbits W&W/O Contrast,70543,CPT,,,,both,,,7909,4745.4,,45.5,,3598.6,percent of total billed charges,,,45.3,,3582.78,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,6327.2,percent of total billed charges,,,61.4,,4856.13,percent of total billed charges,,,57.4,,4539.77,percent of total billed charges,,,81,,6406.29,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,4555.58,percent of total billed charges,,,85,,6722.65,percent of total billed charges,,,85,,6722.65,percent of total billed charges,,,49,,3875.41,percent of total billed charges,,,90,,7118.1,percent of total billed charges,,,65,,5140.85,percent of total billed charges,,,80,,6327.2,percent of total billed charges,,,55,,4349.95,percent of total billed charges,,,55,,4349.95,percent of total billed charges,,,65,,5140.85,percent of total billed charges,,,78,,6169.02,percent of total billed charges,,,70,,5536.3,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,7118.1,
MRA Head W/ Contrast,70545,CPT,,,,both,,,5555,3333,,45.5,,2527.53,percent of total billed charges,,,45.3,,2516.42,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4444,percent of total billed charges,,,61.4,,3410.77,percent of total billed charges,,,57.4,,3188.57,percent of total billed charges,,,81,,4499.55,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3199.68,percent of total billed charges,,,85,,4721.75,percent of total billed charges,,,85,,4721.75,percent of total billed charges,,,49,,2721.95,percent of total billed charges,,,90,,4999.5,percent of total billed charges,,,65,,3610.75,percent of total billed charges,,,80,,4444,percent of total billed charges,,,55,,3055.25,percent of total billed charges,,,55,,3055.25,percent of total billed charges,,,65,,3610.75,percent of total billed charges,,,78,,4332.9,percent of total billed charges,,,70,,3888.5,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,4999.5,
MRA Head W&W/O Contrast,70546,CPT,,,,both,,,6554,3932.4,,45.5,,2982.07,percent of total billed charges,,,45.3,,2968.96,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,5243.2,percent of total billed charges,,,61.4,,4024.16,percent of total billed charges,,,57.4,,3762,percent of total billed charges,,,81,,5308.74,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3775.1,percent of total billed charges,,,85,,5570.9,percent of total billed charges,,,85,,5570.9,percent of total billed charges,,,49,,3211.46,percent of total billed charges,,,90,,5898.6,percent of total billed charges,,,65,,4260.1,percent of total billed charges,,,80,,5243.2,percent of total billed charges,,,55,,3604.7,percent of total billed charges,,,55,,3604.7,percent of total billed charges,,,65,,4260.1,percent of total billed charges,,,78,,5112.12,percent of total billed charges,,,70,,4587.8,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5898.6,
MRV Head W&W/O Contrast,70546,CPT,,,,both,,,6554,3932.4,,45.5,,2982.07,percent of total billed charges,,,45.3,,2968.96,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,5243.2,percent of total billed charges,,,61.4,,4024.16,percent of total billed charges,,,57.4,,3762,percent of total billed charges,,,81,,5308.74,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3775.1,percent of total billed charges,,,85,,5570.9,percent of total billed charges,,,85,,5570.9,percent of total billed charges,,,49,,3211.46,percent of total billed charges,,,90,,5898.6,percent of total billed charges,,,65,,4260.1,percent of total billed charges,,,80,,5243.2,percent of total billed charges,,,55,,3604.7,percent of total billed charges,,,55,,3604.7,percent of total billed charges,,,65,,4260.1,percent of total billed charges,,,78,,5112.12,percent of total billed charges,,,70,,4587.8,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5898.6,
Thigh Gradient Comp Stocking 30-40mmHG by size each,A6534,HCPCS,,,,outpatient,,,269,161.4,,45.5,,122.4,percent of total billed charges,,,45.3,,121.86,percent of total billed charges,,,51,,137.19,percent of total billed charges,,,,,,,,,80,,215.2,percent of total billed charges,,,61.4,,165.17,percent of total billed charges,,,57.4,,154.41,percent of total billed charges,,,81,,217.89,percent of total billed charges,,,51.5,,138.54,percent of total billed charges,,,57.6,,154.94,percent of total billed charges,,,85,,228.65,percent of total billed charges,,,85,,228.65,percent of total billed charges,,,49,,131.81,percent of total billed charges,,,90,,242.1,percent of total billed charges,,,65,,174.85,percent of total billed charges,,,80,,215.2,percent of total billed charges,,,55,,147.95,percent of total billed charges,,,55,,147.95,percent of total billed charges,,,65,,174.85,percent of total billed charges,,,78,,209.82,percent of total billed charges,,,70,,188.3,percent of total billed charges,,,,,,,,61,,,,100% of Medicare,,61,,,,100% of Medicare,,61,,,,100% of Medicare,,61,,,,100% of Medicare,,61,,,,100% of Medicare,,61,,,,100% of Medicare,,61,,,,100% of Medicare,,61,,,,100% of Medicare,,61,,,,100% of Medicare,,61,,,,100% of Medicare,,61,,,,100% of Medicare,,61,,,,100% of Medicare,,,61,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,61,242.1,
"A6545 Gradient Compression Wrap, Non-Elastic, Below Knee",A6545,HCPCS,,,,outpatient,,,203,121.8,,45.5,,92.37,percent of total billed charges,,,45.3,,91.96,percent of total billed charges,,,51,,103.53,percent of total billed charges,,,,,,,,,80,,162.4,percent of total billed charges,,,61.4,,124.64,percent of total billed charges,,,57.4,,116.52,percent of total billed charges,,,81,,164.43,percent of total billed charges,,,51.5,,104.55,percent of total billed charges,,,57.6,,116.93,percent of total billed charges,,,85,,172.55,percent of total billed charges,,,85,,172.55,percent of total billed charges,,,49,,99.47,percent of total billed charges,,,90,,182.7,percent of total billed charges,,,65,,131.95,percent of total billed charges,,,80,,162.4,percent of total billed charges,,,55,,111.65,percent of total billed charges,,,55,,111.65,percent of total billed charges,,,65,,131.95,percent of total billed charges,,,78,,158.34,percent of total billed charges,,,70,,142.1,percent of total billed charges,,,,,,,,119.03,,,,100% of Medicare,,119.03,,,,100% of Medicare,,119.03,,,,100% of Medicare,,119.03,,,,100% of Medicare,,119.03,,,,100% of Medicare,,119.03,,,,100% of Medicare,,119.03,,,,100% of Medicare,,119.03,,,,100% of Medicare,,119.03,,,,100% of Medicare,,119.03,,,,100% of Medicare,,119.03,,,,100% of Medicare,,119.03,,,,100% of Medicare,,,119.03,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.96,182.7,
MRA Neck W/ Contrast,70548,CPT,,,,both,,,5279,3167.4,,45.5,,2401.95,percent of total billed charges,,,45.3,,2391.39,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4223.2,percent of total billed charges,,,61.4,,3241.31,percent of total billed charges,,,57.4,,3030.15,percent of total billed charges,,,81,,4275.99,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3040.7,percent of total billed charges,,,85,,4487.15,percent of total billed charges,,,85,,4487.15,percent of total billed charges,,,49,,2586.71,percent of total billed charges,,,90,,4751.1,percent of total billed charges,,,65,,3431.35,percent of total billed charges,,,80,,4223.2,percent of total billed charges,,,55,,2903.45,percent of total billed charges,,,55,,2903.45,percent of total billed charges,,,65,,3431.35,percent of total billed charges,,,78,,4117.62,percent of total billed charges,,,70,,3695.3,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,4751.1,
MRA Neck W&W/O Contrast,70549,CPT,,,,both,,,6893,4135.8,,45.5,,3136.32,percent of total billed charges,,,45.3,,3122.53,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,5514.4,percent of total billed charges,,,61.4,,4232.3,percent of total billed charges,,,57.4,,3956.58,percent of total billed charges,,,81,,5583.33,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3970.37,percent of total billed charges,,,85,,5859.05,percent of total billed charges,,,85,,5859.05,percent of total billed charges,,,49,,3377.57,percent of total billed charges,,,90,,6203.7,percent of total billed charges,,,65,,4480.45,percent of total billed charges,,,80,,5514.4,percent of total billed charges,,,55,,3791.15,percent of total billed charges,,,55,,3791.15,percent of total billed charges,,,65,,4480.45,percent of total billed charges,,,78,,5376.54,percent of total billed charges,,,70,,4825.1,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,6203.7,
MRI Brain W&W/O Contrast-70553,70553,CPT,,,,both,,,7498,4498.8,,45.5,,3411.59,percent of total billed charges,,,45.3,,3396.59,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,5998.4,percent of total billed charges,,,61.4,,4603.77,percent of total billed charges,,,57.4,,4303.85,percent of total billed charges,,,81,,6073.38,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,4318.85,percent of total billed charges,,,85,,6373.3,percent of total billed charges,,,85,,6373.3,percent of total billed charges,,,49,,3674.02,percent of total billed charges,,,90,,6748.2,percent of total billed charges,,,65,,4873.7,percent of total billed charges,,,80,,5998.4,percent of total billed charges,,,55,,4123.9,percent of total billed charges,,,55,,4123.9,percent of total billed charges,,,65,,4873.7,percent of total billed charges,,,78,,5848.44,percent of total billed charges,,,70,,5248.6,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,6748.2,
MRI Brain IAC/Cranial Nerve W/Contrast,70558,CPT,,,,both,,,3735,2241,,45.5,,1699.43,percent of total billed charges,,,45.3,,1691.96,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,2988,percent of total billed charges,,,61.4,,2293.29,percent of total billed charges,,,57.4,,2143.89,percent of total billed charges,,,81,,3025.35,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2151.36,percent of total billed charges,,,85,,3174.75,percent of total billed charges,,,85,,3174.75,percent of total billed charges,,,49,,1830.15,percent of total billed charges,,,90,,3361.5,percent of total billed charges,,,65,,2427.75,percent of total billed charges,,,80,,2988,percent of total billed charges,,,55,,2054.25,percent of total billed charges,,,55,,2054.25,percent of total billed charges,,,65,,2427.75,percent of total billed charges,,,78,,2913.3,percent of total billed charges,,,70,,2614.5,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,185.57,3361.5,
MRI Brain IAC/Cranial Nerve W&W/O Cont,70559,CPT,,,,both,,,4465,2679,,45.5,,2031.58,percent of total billed charges,,,45.3,,2022.65,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3572,percent of total billed charges,,,61.4,,2741.51,percent of total billed charges,,,57.4,,2562.91,percent of total billed charges,,,81,,3616.65,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2571.84,percent of total billed charges,,,85,,3795.25,percent of total billed charges,,,85,,3795.25,percent of total billed charges,,,49,,2187.85,percent of total billed charges,,,90,,4018.5,percent of total billed charges,,,65,,2902.25,percent of total billed charges,,,80,,3572,percent of total billed charges,,,55,,2455.75,percent of total billed charges,,,55,,2455.75,percent of total billed charges,,,65,,2902.25,percent of total billed charges,,,78,,3482.7,percent of total billed charges,,,70,,3125.5,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,185.57,4018.5,
MRI Chest W/Contrast,71551,CPT,,,,both,,,5569,3341.4,,45.5,,2533.9,percent of total billed charges,,,45.3,,2522.76,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4455.2,percent of total billed charges,,,61.4,,3419.37,percent of total billed charges,,,57.4,,3196.61,percent of total billed charges,,,81,,4510.89,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3207.74,percent of total billed charges,,,85,,4733.65,percent of total billed charges,,,85,,4733.65,percent of total billed charges,,,49,,2728.81,percent of total billed charges,,,90,,5012.1,percent of total billed charges,,,65,,3619.85,percent of total billed charges,,,80,,4455.2,percent of total billed charges,,,55,,3062.95,percent of total billed charges,,,55,,3062.95,percent of total billed charges,,,65,,3619.85,percent of total billed charges,,,78,,4343.82,percent of total billed charges,,,70,,3898.3,percent of total billed charges,,,,,,,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,,823.57,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,823.57,5012.1,
MRI Brachial Plexus W&W/O Contrast Lt,71552,CPT,,,LT,both,,,5951,3570.6,,45.5,,2707.71,percent of total billed charges,,,45.3,,2695.8,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4760.8,percent of total billed charges,,,61.4,,3653.91,percent of total billed charges,,,57.4,,3415.87,percent of total billed charges,,,81,,4820.31,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3427.78,percent of total billed charges,,,85,,5058.35,percent of total billed charges,,,85,,5058.35,percent of total billed charges,,,49,,2915.99,percent of total billed charges,,,90,,5355.9,percent of total billed charges,,,65,,3868.15,percent of total billed charges,,,80,,4760.8,percent of total billed charges,,,55,,3273.05,percent of total billed charges,,,55,,3273.05,percent of total billed charges,,,65,,3868.15,percent of total billed charges,,,78,,4641.78,percent of total billed charges,,,70,,4165.7,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5355.9,
MRI Brachial Plexus W/W&O Contrast Rt,71552,CPT,,,RT,both,,,5951,3570.6,,45.5,,2707.71,percent of total billed charges,,,45.3,,2695.8,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4760.8,percent of total billed charges,,,61.4,,3653.91,percent of total billed charges,,,57.4,,3415.87,percent of total billed charges,,,81,,4820.31,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3427.78,percent of total billed charges,,,85,,5058.35,percent of total billed charges,,,85,,5058.35,percent of total billed charges,,,49,,2915.99,percent of total billed charges,,,90,,5355.9,percent of total billed charges,,,65,,3868.15,percent of total billed charges,,,80,,4760.8,percent of total billed charges,,,55,,3273.05,percent of total billed charges,,,55,,3273.05,percent of total billed charges,,,65,,3868.15,percent of total billed charges,,,78,,4641.78,percent of total billed charges,,,70,,4165.7,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5355.9,
MRI Chest W&W/O Contrast,71552,CPT,,,,both,,,5951,3570.6,,45.5,,2707.71,percent of total billed charges,,,45.3,,2695.8,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4760.8,percent of total billed charges,,,61.4,,3653.91,percent of total billed charges,,,57.4,,3415.87,percent of total billed charges,,,81,,4820.31,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3427.78,percent of total billed charges,,,85,,5058.35,percent of total billed charges,,,85,,5058.35,percent of total billed charges,,,49,,2915.99,percent of total billed charges,,,90,,5355.9,percent of total billed charges,,,65,,3868.15,percent of total billed charges,,,80,,4760.8,percent of total billed charges,,,55,,3273.05,percent of total billed charges,,,55,,3273.05,percent of total billed charges,,,65,,3868.15,percent of total billed charges,,,78,,4641.78,percent of total billed charges,,,70,,4165.7,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5355.9,
MRI Chest Wall W&W/O Contrast,71552,CPT,,,,both,,,5951,3570.6,,45.5,,2707.71,percent of total billed charges,,,45.3,,2695.8,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4760.8,percent of total billed charges,,,61.4,,3653.91,percent of total billed charges,,,57.4,,3415.87,percent of total billed charges,,,81,,4820.31,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3427.78,percent of total billed charges,,,85,,5058.35,percent of total billed charges,,,85,,5058.35,percent of total billed charges,,,49,,2915.99,percent of total billed charges,,,90,,5355.9,percent of total billed charges,,,65,,3868.15,percent of total billed charges,,,80,,4760.8,percent of total billed charges,,,55,,3273.05,percent of total billed charges,,,55,,3273.05,percent of total billed charges,,,65,,3868.15,percent of total billed charges,,,78,,4641.78,percent of total billed charges,,,70,,4165.7,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5355.9,
MRI Spine Cervical W/Contrast,72142,CPT,,,,both,,,5709,3425.4,,45.5,,2597.6,percent of total billed charges,,,45.3,,2586.18,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4567.2,percent of total billed charges,,,61.4,,3505.33,percent of total billed charges,,,57.4,,3276.97,percent of total billed charges,,,81,,4624.29,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3288.38,percent of total billed charges,,,85,,4852.65,percent of total billed charges,,,85,,4852.65,percent of total billed charges,,,49,,2797.41,percent of total billed charges,,,90,,5138.1,percent of total billed charges,,,65,,3710.85,percent of total billed charges,,,80,,4567.2,percent of total billed charges,,,55,,3139.95,percent of total billed charges,,,55,,3139.95,percent of total billed charges,,,65,,3710.85,percent of total billed charges,,,78,,4453.02,percent of total billed charges,,,70,,3996.3,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5138.1,
MRI Spine Thoracic W/ Contrast,72147,CPT,,,,both,,,5996,3597.6,,45.5,,2728.18,percent of total billed charges,,,45.3,,2716.19,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4796.8,percent of total billed charges,,,61.4,,3681.54,percent of total billed charges,,,57.4,,3441.7,percent of total billed charges,,,81,,4856.76,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3453.7,percent of total billed charges,,,85,,5096.6,percent of total billed charges,,,85,,5096.6,percent of total billed charges,,,49,,2938.04,percent of total billed charges,,,90,,5396.4,percent of total billed charges,,,65,,3897.4,percent of total billed charges,,,80,,4796.8,percent of total billed charges,,,55,,3297.8,percent of total billed charges,,,55,,3297.8,percent of total billed charges,,,65,,3897.4,percent of total billed charges,,,78,,4676.88,percent of total billed charges,,,70,,4197.2,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5396.4,
MRI Spine Lumbar W/Contrast,72149,CPT,,,,both,,,5223,3133.8,,45.5,,2376.47,percent of total billed charges,,,45.3,,2366.02,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4178.4,percent of total billed charges,,,61.4,,3206.92,percent of total billed charges,,,57.4,,2998,percent of total billed charges,,,81,,4230.63,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3008.45,percent of total billed charges,,,85,,4439.55,percent of total billed charges,,,85,,4439.55,percent of total billed charges,,,49,,2559.27,percent of total billed charges,,,90,,4700.7,percent of total billed charges,,,65,,3394.95,percent of total billed charges,,,80,,4178.4,percent of total billed charges,,,55,,2872.65,percent of total billed charges,,,55,,2872.65,percent of total billed charges,,,65,,3394.95,percent of total billed charges,,,78,,4073.94,percent of total billed charges,,,70,,3656.1,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,4700.7,
MRI Spine Cervical W&W/O Contrast,72156,CPT,,,,both,,,7287,4372.2,,45.5,,3315.59,percent of total billed charges,,,45.3,,3301.01,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,5829.6,percent of total billed charges,,,61.4,,4474.22,percent of total billed charges,,,57.4,,4182.74,percent of total billed charges,,,81,,5902.47,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,4197.31,percent of total billed charges,,,85,,6193.95,percent of total billed charges,,,85,,6193.95,percent of total billed charges,,,49,,3570.63,percent of total billed charges,,,90,,6558.3,percent of total billed charges,,,65,,4736.55,percent of total billed charges,,,80,,5829.6,percent of total billed charges,,,55,,4007.85,percent of total billed charges,,,55,,4007.85,percent of total billed charges,,,65,,4736.55,percent of total billed charges,,,78,,5683.86,percent of total billed charges,,,70,,5100.9,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,6558.3,
MRI Spine Thoracic W&W/O Contrast,72157,CPT,,,,both,,,7275,4365,,45.5,,3310.13,percent of total billed charges,,,45.3,,3295.58,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,5820,percent of total billed charges,,,61.4,,4466.85,percent of total billed charges,,,57.4,,4175.85,percent of total billed charges,,,81,,5892.75,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,4190.4,percent of total billed charges,,,85,,6183.75,percent of total billed charges,,,85,,6183.75,percent of total billed charges,,,49,,3564.75,percent of total billed charges,,,90,,6547.5,percent of total billed charges,,,65,,4728.75,percent of total billed charges,,,80,,5820,percent of total billed charges,,,55,,4001.25,percent of total billed charges,,,55,,4001.25,percent of total billed charges,,,65,,4728.75,percent of total billed charges,,,78,,5674.5,percent of total billed charges,,,70,,5092.5,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,6547.5,
MRI Spine Lumbar W&W/O Contrast,72158,CPT,,,,both,,,7209,4325.4,,45.5,,3280.1,percent of total billed charges,,,45.3,,3265.68,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,5767.2,percent of total billed charges,,,61.4,,4426.33,percent of total billed charges,,,57.4,,4137.97,percent of total billed charges,,,81,,5839.29,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,4152.38,percent of total billed charges,,,85,,6127.65,percent of total billed charges,,,85,,6127.65,percent of total billed charges,,,49,,3532.41,percent of total billed charges,,,90,,6488.1,percent of total billed charges,,,65,,4685.85,percent of total billed charges,,,80,,5767.2,percent of total billed charges,,,55,,3964.95,percent of total billed charges,,,55,,3964.95,percent of total billed charges,,,65,,4685.85,percent of total billed charges,,,78,,5623.02,percent of total billed charges,,,70,,5046.3,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,6488.1,
MRI Sacrum Coccyx W/ Contrast,72196,CPT,,,,both,,,6000,3600,,45.5,,2730,percent of total billed charges,,,45.3,,2718,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4800,percent of total billed charges,,,61.4,,3684,percent of total billed charges,,,57.4,,3444,percent of total billed charges,,,81,,4860,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3456,percent of total billed charges,,,85,,5100,percent of total billed charges,,,85,,5100,percent of total billed charges,,,49,,2940,percent of total billed charges,,,90,,5400,percent of total billed charges,,,65,,3900,percent of total billed charges,,,80,,4800,percent of total billed charges,,,55,,3300,percent of total billed charges,,,55,,3300,percent of total billed charges,,,65,,3900,percent of total billed charges,,,78,,4680,percent of total billed charges,,,70,,4200,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5400,
MRI Pelvis W/ Contrast,72196,CPT,,,,both,,,6300,3780,,45.5,,2866.5,percent of total billed charges,,,45.3,,2853.9,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,5040,percent of total billed charges,,,61.4,,3868.2,percent of total billed charges,,,57.4,,3616.2,percent of total billed charges,,,81,,5103,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3628.8,percent of total billed charges,,,85,,5355,percent of total billed charges,,,85,,5355,percent of total billed charges,,,49,,3087,percent of total billed charges,,,90,,5670,percent of total billed charges,,,65,,4095,percent of total billed charges,,,80,,5040,percent of total billed charges,,,55,,3465,percent of total billed charges,,,55,,3465,percent of total billed charges,,,65,,4095,percent of total billed charges,,,78,,4914,percent of total billed charges,,,70,,4410,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5670,
MRI Lumb Plexus W&W/O Cont-72197,72197,CPT,,,,both,,,6298,3778.8,,45.5,,2865.59,percent of total billed charges,,,45.3,,2852.99,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,5038.4,percent of total billed charges,,,61.4,,3866.97,percent of total billed charges,,,57.4,,3615.05,percent of total billed charges,,,81,,5101.38,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3627.65,percent of total billed charges,,,85,,5353.3,percent of total billed charges,,,85,,5353.3,percent of total billed charges,,,49,,3086.02,percent of total billed charges,,,90,,5668.2,percent of total billed charges,,,65,,4093.7,percent of total billed charges,,,80,,5038.4,percent of total billed charges,,,55,,3463.9,percent of total billed charges,,,55,,3463.9,percent of total billed charges,,,65,,4093.7,percent of total billed charges,,,78,,4912.44,percent of total billed charges,,,70,,4408.6,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5668.2,
MRI Neurography Lumb W&W/O Cont-72197,72197,CPT,,,,both,,,6298,3778.8,,45.5,,2865.59,percent of total billed charges,,,45.3,,2852.99,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,5038.4,percent of total billed charges,,,61.4,,3866.97,percent of total billed charges,,,57.4,,3615.05,percent of total billed charges,,,81,,5101.38,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3627.65,percent of total billed charges,,,85,,5353.3,percent of total billed charges,,,85,,5353.3,percent of total billed charges,,,49,,3086.02,percent of total billed charges,,,90,,5668.2,percent of total billed charges,,,65,,4093.7,percent of total billed charges,,,80,,5038.4,percent of total billed charges,,,55,,3463.9,percent of total billed charges,,,55,,3463.9,percent of total billed charges,,,65,,4093.7,percent of total billed charges,,,78,,4912.44,percent of total billed charges,,,70,,4408.6,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5668.2,
MRI Pelvis Viscera W&W/O Contrast,72197,CPT,,,,both,,,6298,3778.8,,45.5,,2865.59,percent of total billed charges,,,45.3,,2852.99,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,5038.4,percent of total billed charges,,,61.4,,3866.97,percent of total billed charges,,,57.4,,3615.05,percent of total billed charges,,,81,,5101.38,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3627.65,percent of total billed charges,,,85,,5353.3,percent of total billed charges,,,85,,5353.3,percent of total billed charges,,,49,,3086.02,percent of total billed charges,,,90,,5668.2,percent of total billed charges,,,65,,4093.7,percent of total billed charges,,,80,,5038.4,percent of total billed charges,,,55,,3463.9,percent of total billed charges,,,55,,3463.9,percent of total billed charges,,,65,,4093.7,percent of total billed charges,,,78,,4912.44,percent of total billed charges,,,70,,4408.6,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5668.2,
MRI Prostate W&W/O Contrast,72197,CPT,,,,both,,,6298,3778.8,,45.5,,2865.59,percent of total billed charges,,,45.3,,2852.99,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,5038.4,percent of total billed charges,,,61.4,,3866.97,percent of total billed charges,,,57.4,,3615.05,percent of total billed charges,,,81,,5101.38,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3627.65,percent of total billed charges,,,85,,5353.3,percent of total billed charges,,,85,,5353.3,percent of total billed charges,,,49,,3086.02,percent of total billed charges,,,90,,5668.2,percent of total billed charges,,,65,,4093.7,percent of total billed charges,,,80,,5038.4,percent of total billed charges,,,55,,3463.9,percent of total billed charges,,,55,,3463.9,percent of total billed charges,,,65,,4093.7,percent of total billed charges,,,78,,4912.44,percent of total billed charges,,,70,,4408.6,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5668.2,
MRI Sacrum Coccyx W&W/O Contrast,72197,CPT,,,,both,,,6298,3778.8,,45.5,,2865.59,percent of total billed charges,,,45.3,,2852.99,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,5038.4,percent of total billed charges,,,61.4,,3866.97,percent of total billed charges,,,57.4,,3615.05,percent of total billed charges,,,81,,5101.38,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3627.65,percent of total billed charges,,,85,,5353.3,percent of total billed charges,,,85,,5353.3,percent of total billed charges,,,49,,3086.02,percent of total billed charges,,,90,,5668.2,percent of total billed charges,,,65,,4093.7,percent of total billed charges,,,80,,5038.4,percent of total billed charges,,,55,,3463.9,percent of total billed charges,,,55,,3463.9,percent of total billed charges,,,65,,4093.7,percent of total billed charges,,,78,,4912.44,percent of total billed charges,,,70,,4408.6,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5668.2,
MRI Pelvis MSK W&WO Contrast,72197,CPT,,,,both,,,6403,3841.8,,45.5,,2913.37,percent of total billed charges,,,45.3,,2900.56,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,5122.4,percent of total billed charges,,,61.4,,3931.44,percent of total billed charges,,,57.4,,3675.32,percent of total billed charges,,,81,,5186.43,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3688.13,percent of total billed charges,,,85,,5442.55,percent of total billed charges,,,85,,5442.55,percent of total billed charges,,,49,,3137.47,percent of total billed charges,,,90,,5762.7,percent of total billed charges,,,65,,4161.95,percent of total billed charges,,,80,,5122.4,percent of total billed charges,,,55,,3521.65,percent of total billed charges,,,55,,3521.65,percent of total billed charges,,,65,,4161.95,percent of total billed charges,,,78,,4994.34,percent of total billed charges,,,70,,4482.1,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5762.7,
MRI Upper Ext W/ Contrast Left,73219,CPT,,,LT,both,,,5866,3519.6,,45.5,,2669.03,percent of total billed charges,,,45.3,,2657.3,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4692.8,percent of total billed charges,,,61.4,,3601.72,percent of total billed charges,,,57.4,,3367.08,percent of total billed charges,,,81,,4751.46,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3378.82,percent of total billed charges,,,85,,4986.1,percent of total billed charges,,,85,,4986.1,percent of total billed charges,,,49,,2874.34,percent of total billed charges,,,90,,5279.4,percent of total billed charges,,,65,,3812.9,percent of total billed charges,,,80,,4692.8,percent of total billed charges,,,55,,3226.3,percent of total billed charges,,,55,,3226.3,percent of total billed charges,,,65,,3812.9,percent of total billed charges,,,78,,4575.48,percent of total billed charges,,,70,,4106.2,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5279.4,
MRI Upper Ext W/ Contrast Right,73219,CPT,,,RT,both,,,5866,3519.6,,45.5,,2669.03,percent of total billed charges,,,45.3,,2657.3,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4692.8,percent of total billed charges,,,61.4,,3601.72,percent of total billed charges,,,57.4,,3367.08,percent of total billed charges,,,81,,4751.46,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3378.82,percent of total billed charges,,,85,,4986.1,percent of total billed charges,,,85,,4986.1,percent of total billed charges,,,49,,2874.34,percent of total billed charges,,,90,,5279.4,percent of total billed charges,,,65,,3812.9,percent of total billed charges,,,80,,4692.8,percent of total billed charges,,,55,,3226.3,percent of total billed charges,,,55,,3226.3,percent of total billed charges,,,65,,3812.9,percent of total billed charges,,,78,,4575.48,percent of total billed charges,,,70,,4106.2,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5279.4,
MRI Finger W&W/O Contrast Left,73220,CPT,,,LT,both,,,6110,3666,,45.5,,2780.05,percent of total billed charges,,,45.3,,2767.83,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4888,percent of total billed charges,,,61.4,,3751.54,percent of total billed charges,,,57.4,,3507.14,percent of total billed charges,,,81,,4949.1,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3519.36,percent of total billed charges,,,85,,5193.5,percent of total billed charges,,,85,,5193.5,percent of total billed charges,,,49,,2993.9,percent of total billed charges,,,90,,5499,percent of total billed charges,,,65,,3971.5,percent of total billed charges,,,80,,4888,percent of total billed charges,,,55,,3360.5,percent of total billed charges,,,55,,3360.5,percent of total billed charges,,,65,,3971.5,percent of total billed charges,,,78,,4765.8,percent of total billed charges,,,70,,4277,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5499,
MRI Forearm W&W/O Contrast Left,73220,CPT,,,LT,both,,,6110,3666,,45.5,,2780.05,percent of total billed charges,,,45.3,,2767.83,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4888,percent of total billed charges,,,61.4,,3751.54,percent of total billed charges,,,57.4,,3507.14,percent of total billed charges,,,81,,4949.1,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3519.36,percent of total billed charges,,,85,,5193.5,percent of total billed charges,,,85,,5193.5,percent of total billed charges,,,49,,2993.9,percent of total billed charges,,,90,,5499,percent of total billed charges,,,65,,3971.5,percent of total billed charges,,,80,,4888,percent of total billed charges,,,55,,3360.5,percent of total billed charges,,,55,,3360.5,percent of total billed charges,,,65,,3971.5,percent of total billed charges,,,78,,4765.8,percent of total billed charges,,,70,,4277,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5499,
MRI Hand W&W/O Contrast Left,73220,CPT,,,LT,both,,,6110,3666,,45.5,,2780.05,percent of total billed charges,,,45.3,,2767.83,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4888,percent of total billed charges,,,61.4,,3751.54,percent of total billed charges,,,57.4,,3507.14,percent of total billed charges,,,81,,4949.1,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3519.36,percent of total billed charges,,,85,,5193.5,percent of total billed charges,,,85,,5193.5,percent of total billed charges,,,49,,2993.9,percent of total billed charges,,,90,,5499,percent of total billed charges,,,65,,3971.5,percent of total billed charges,,,80,,4888,percent of total billed charges,,,55,,3360.5,percent of total billed charges,,,55,,3360.5,percent of total billed charges,,,65,,3971.5,percent of total billed charges,,,78,,4765.8,percent of total billed charges,,,70,,4277,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5499,
MRI Humerus W&W/O Contrast Lt,73220,CPT,,,LT,both,,,6110,3666,,45.5,,2780.05,percent of total billed charges,,,45.3,,2767.83,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4888,percent of total billed charges,,,61.4,,3751.54,percent of total billed charges,,,57.4,,3507.14,percent of total billed charges,,,81,,4949.1,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3519.36,percent of total billed charges,,,85,,5193.5,percent of total billed charges,,,85,,5193.5,percent of total billed charges,,,49,,2993.9,percent of total billed charges,,,90,,5499,percent of total billed charges,,,65,,3971.5,percent of total billed charges,,,80,,4888,percent of total billed charges,,,55,,3360.5,percent of total billed charges,,,55,,3360.5,percent of total billed charges,,,65,,3971.5,percent of total billed charges,,,78,,4765.8,percent of total billed charges,,,70,,4277,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5499,
MRI Neurography Forearm W&W/O Cont Lt-73220,73220,CPT,,,LT,both,,,6110,3666,,45.5,,2780.05,percent of total billed charges,,,45.3,,2767.83,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4888,percent of total billed charges,,,61.4,,3751.54,percent of total billed charges,,,57.4,,3507.14,percent of total billed charges,,,81,,4949.1,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3519.36,percent of total billed charges,,,85,,5193.5,percent of total billed charges,,,85,,5193.5,percent of total billed charges,,,49,,2993.9,percent of total billed charges,,,90,,5499,percent of total billed charges,,,65,,3971.5,percent of total billed charges,,,80,,4888,percent of total billed charges,,,55,,3360.5,percent of total billed charges,,,55,,3360.5,percent of total billed charges,,,65,,3971.5,percent of total billed charges,,,78,,4765.8,percent of total billed charges,,,70,,4277,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5499,
MRI Neurography Humerus W&W/O Cont Lt-73220,73220,CPT,,,LT,both,,,6110,3666,,45.5,,2780.05,percent of total billed charges,,,45.3,,2767.83,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4888,percent of total billed charges,,,61.4,,3751.54,percent of total billed charges,,,57.4,,3507.14,percent of total billed charges,,,81,,4949.1,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3519.36,percent of total billed charges,,,85,,5193.5,percent of total billed charges,,,85,,5193.5,percent of total billed charges,,,49,,2993.9,percent of total billed charges,,,90,,5499,percent of total billed charges,,,65,,3971.5,percent of total billed charges,,,80,,4888,percent of total billed charges,,,55,,3360.5,percent of total billed charges,,,55,,3360.5,percent of total billed charges,,,65,,3971.5,percent of total billed charges,,,78,,4765.8,percent of total billed charges,,,70,,4277,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5499,
MRI Finger W&W/O Contrast Right,73220,CPT,,,RT,both,,,6110,3666,,45.5,,2780.05,percent of total billed charges,,,45.3,,2767.83,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4888,percent of total billed charges,,,61.4,,3751.54,percent of total billed charges,,,57.4,,3507.14,percent of total billed charges,,,81,,4949.1,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3519.36,percent of total billed charges,,,85,,5193.5,percent of total billed charges,,,85,,5193.5,percent of total billed charges,,,49,,2993.9,percent of total billed charges,,,90,,5499,percent of total billed charges,,,65,,3971.5,percent of total billed charges,,,80,,4888,percent of total billed charges,,,55,,3360.5,percent of total billed charges,,,55,,3360.5,percent of total billed charges,,,65,,3971.5,percent of total billed charges,,,78,,4765.8,percent of total billed charges,,,70,,4277,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5499,
MRI Forearm W&W/O Contrast Right,73220,CPT,,,RT,both,,,6110,3666,,45.5,,2780.05,percent of total billed charges,,,45.3,,2767.83,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4888,percent of total billed charges,,,61.4,,3751.54,percent of total billed charges,,,57.4,,3507.14,percent of total billed charges,,,81,,4949.1,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3519.36,percent of total billed charges,,,85,,5193.5,percent of total billed charges,,,85,,5193.5,percent of total billed charges,,,49,,2993.9,percent of total billed charges,,,90,,5499,percent of total billed charges,,,65,,3971.5,percent of total billed charges,,,80,,4888,percent of total billed charges,,,55,,3360.5,percent of total billed charges,,,55,,3360.5,percent of total billed charges,,,65,,3971.5,percent of total billed charges,,,78,,4765.8,percent of total billed charges,,,70,,4277,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5499,
"Compression Burn Mask, Custom Fabricated",A6513,HCPCS,,,,outpatient,,,3276,1965.6,,45.5,,1490.58,percent of total billed charges,,,45.3,,1484.03,percent of total billed charges,,,51,,1670.76,percent of total billed charges,,,,,,,,,80,,2620.8,percent of total billed charges,,,61.4,,2011.46,percent of total billed charges,,,57.4,,1880.42,percent of total billed charges,,,81,,2653.56,percent of total billed charges,,,51.5,,1687.14,percent of total billed charges,,,57.6,,1886.98,percent of total billed charges,,,85,,2784.6,percent of total billed charges,,,85,,2784.6,percent of total billed charges,,,49,,1605.24,percent of total billed charges,,,90,,2948.4,percent of total billed charges,,,65,,2129.4,percent of total billed charges,,,80,,2620.8,percent of total billed charges,,,55,,1801.8,percent of total billed charges,,,55,,1801.8,percent of total billed charges,,,65,,2129.4,percent of total billed charges,,,78,,2555.28,percent of total billed charges,,,70,,2293.2,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1484.03,2948.4,
MRI Hand W&W/O Contrast Right,73220,CPT,,,RT,both,,,6110,3666,,45.5,,2780.05,percent of total billed charges,,,45.3,,2767.83,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4888,percent of total billed charges,,,61.4,,3751.54,percent of total billed charges,,,57.4,,3507.14,percent of total billed charges,,,81,,4949.1,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3519.36,percent of total billed charges,,,85,,5193.5,percent of total billed charges,,,85,,5193.5,percent of total billed charges,,,49,,2993.9,percent of total billed charges,,,90,,5499,percent of total billed charges,,,65,,3971.5,percent of total billed charges,,,80,,4888,percent of total billed charges,,,55,,3360.5,percent of total billed charges,,,55,,3360.5,percent of total billed charges,,,65,,3971.5,percent of total billed charges,,,78,,4765.8,percent of total billed charges,,,70,,4277,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5499,
MRI Humerus W&W/O Contrast Rt,73220,CPT,,,RT,both,,,6110,3666,,45.5,,2780.05,percent of total billed charges,,,45.3,,2767.83,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4888,percent of total billed charges,,,61.4,,3751.54,percent of total billed charges,,,57.4,,3507.14,percent of total billed charges,,,81,,4949.1,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3519.36,percent of total billed charges,,,85,,5193.5,percent of total billed charges,,,85,,5193.5,percent of total billed charges,,,49,,2993.9,percent of total billed charges,,,90,,5499,percent of total billed charges,,,65,,3971.5,percent of total billed charges,,,80,,4888,percent of total billed charges,,,55,,3360.5,percent of total billed charges,,,55,,3360.5,percent of total billed charges,,,65,,3971.5,percent of total billed charges,,,78,,4765.8,percent of total billed charges,,,70,,4277,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5499,
MRI Neurography Forearm W&W/O Cont Rt-73220,73220,CPT,,,RT,both,,,6110,3666,,45.5,,2780.05,percent of total billed charges,,,45.3,,2767.83,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4888,percent of total billed charges,,,61.4,,3751.54,percent of total billed charges,,,57.4,,3507.14,percent of total billed charges,,,81,,4949.1,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3519.36,percent of total billed charges,,,85,,5193.5,percent of total billed charges,,,85,,5193.5,percent of total billed charges,,,49,,2993.9,percent of total billed charges,,,90,,5499,percent of total billed charges,,,65,,3971.5,percent of total billed charges,,,80,,4888,percent of total billed charges,,,55,,3360.5,percent of total billed charges,,,55,,3360.5,percent of total billed charges,,,65,,3971.5,percent of total billed charges,,,78,,4765.8,percent of total billed charges,,,70,,4277,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5499,
MRI Neurography Humerus W&W/O Cont Rt-73220,73220,CPT,,,RT,both,,,6110,3666,,45.5,,2780.05,percent of total billed charges,,,45.3,,2767.83,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4888,percent of total billed charges,,,61.4,,3751.54,percent of total billed charges,,,57.4,,3507.14,percent of total billed charges,,,81,,4949.1,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3519.36,percent of total billed charges,,,85,,5193.5,percent of total billed charges,,,85,,5193.5,percent of total billed charges,,,49,,2993.9,percent of total billed charges,,,90,,5499,percent of total billed charges,,,65,,3971.5,percent of total billed charges,,,80,,4888,percent of total billed charges,,,55,,3360.5,percent of total billed charges,,,55,,3360.5,percent of total billed charges,,,65,,3971.5,percent of total billed charges,,,78,,4765.8,percent of total billed charges,,,70,,4277,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5499,
MRI Upper Ext Joint W/Contrast Lt,73222,CPT,,,LT,both,,,5535,3321,,45.5,,2518.43,percent of total billed charges,,,45.3,,2507.36,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4428,percent of total billed charges,,,61.4,,3398.49,percent of total billed charges,,,57.4,,3177.09,percent of total billed charges,,,81,,4483.35,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3188.16,percent of total billed charges,,,85,,4704.75,percent of total billed charges,,,85,,4704.75,percent of total billed charges,,,49,,2712.15,percent of total billed charges,,,90,,4981.5,percent of total billed charges,,,65,,3597.75,percent of total billed charges,,,80,,4428,percent of total billed charges,,,55,,3044.25,percent of total billed charges,,,55,,3044.25,percent of total billed charges,,,65,,3597.75,percent of total billed charges,,,78,,4317.3,percent of total billed charges,,,70,,3874.5,percent of total billed charges,,,,,,,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,,823.57,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,823.57,4981.5,
MRI Upper Ext Joint W/Contrast Rt,73222,CPT,,,RT,both,,,5535,3321,,45.5,,2518.43,percent of total billed charges,,,45.3,,2507.36,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4428,percent of total billed charges,,,61.4,,3398.49,percent of total billed charges,,,57.4,,3177.09,percent of total billed charges,,,81,,4483.35,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3188.16,percent of total billed charges,,,85,,4704.75,percent of total billed charges,,,85,,4704.75,percent of total billed charges,,,49,,2712.15,percent of total billed charges,,,90,,4981.5,percent of total billed charges,,,65,,3597.75,percent of total billed charges,,,80,,4428,percent of total billed charges,,,55,,3044.25,percent of total billed charges,,,55,,3044.25,percent of total billed charges,,,65,,3597.75,percent of total billed charges,,,78,,4317.3,percent of total billed charges,,,70,,3874.5,percent of total billed charges,,,,,,,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,,823.57,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,823.57,4981.5,
MRI Elbow W&W/O Contrast Left,73223,CPT,,,LT,both,,,6967,4180.2,,45.5,,3169.99,percent of total billed charges,,,45.3,,3156.05,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,5573.6,percent of total billed charges,,,61.4,,4277.74,percent of total billed charges,,,57.4,,3999.06,percent of total billed charges,,,81,,5643.27,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,4012.99,percent of total billed charges,,,85,,5921.95,percent of total billed charges,,,85,,5921.95,percent of total billed charges,,,49,,3413.83,percent of total billed charges,,,90,,6270.3,percent of total billed charges,,,65,,4528.55,percent of total billed charges,,,80,,5573.6,percent of total billed charges,,,55,,3831.85,percent of total billed charges,,,55,,3831.85,percent of total billed charges,,,65,,4528.55,percent of total billed charges,,,78,,5434.26,percent of total billed charges,,,70,,4876.9,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,6270.3,
MRI Shoulder W&W/O Contrast Lt,73223,CPT,,,LT,both,,,6967,4180.2,,45.5,,3169.99,percent of total billed charges,,,45.3,,3156.05,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,5573.6,percent of total billed charges,,,61.4,,4277.74,percent of total billed charges,,,57.4,,3999.06,percent of total billed charges,,,81,,5643.27,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,4012.99,percent of total billed charges,,,85,,5921.95,percent of total billed charges,,,85,,5921.95,percent of total billed charges,,,49,,3413.83,percent of total billed charges,,,90,,6270.3,percent of total billed charges,,,65,,4528.55,percent of total billed charges,,,80,,5573.6,percent of total billed charges,,,55,,3831.85,percent of total billed charges,,,55,,3831.85,percent of total billed charges,,,65,,4528.55,percent of total billed charges,,,78,,5434.26,percent of total billed charges,,,70,,4876.9,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,6270.3,
MRI Wrist W&W/O Contrast Lt,73223,CPT,,,LT,both,,,6967,4180.2,,45.5,,3169.99,percent of total billed charges,,,45.3,,3156.05,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,5573.6,percent of total billed charges,,,61.4,,4277.74,percent of total billed charges,,,57.4,,3999.06,percent of total billed charges,,,81,,5643.27,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,4012.99,percent of total billed charges,,,85,,5921.95,percent of total billed charges,,,85,,5921.95,percent of total billed charges,,,49,,3413.83,percent of total billed charges,,,90,,6270.3,percent of total billed charges,,,65,,4528.55,percent of total billed charges,,,80,,5573.6,percent of total billed charges,,,55,,3831.85,percent of total billed charges,,,55,,3831.85,percent of total billed charges,,,65,,4528.55,percent of total billed charges,,,78,,5434.26,percent of total billed charges,,,70,,4876.9,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,6270.3,
MRI Elbow W&W/O Contrast Right,73223,CPT,,,RT,both,,,6967,4180.2,,45.5,,3169.99,percent of total billed charges,,,45.3,,3156.05,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,5573.6,percent of total billed charges,,,61.4,,4277.74,percent of total billed charges,,,57.4,,3999.06,percent of total billed charges,,,81,,5643.27,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,4012.99,percent of total billed charges,,,85,,5921.95,percent of total billed charges,,,85,,5921.95,percent of total billed charges,,,49,,3413.83,percent of total billed charges,,,90,,6270.3,percent of total billed charges,,,65,,4528.55,percent of total billed charges,,,80,,5573.6,percent of total billed charges,,,55,,3831.85,percent of total billed charges,,,55,,3831.85,percent of total billed charges,,,65,,4528.55,percent of total billed charges,,,78,,5434.26,percent of total billed charges,,,70,,4876.9,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,6270.3,
MRI Shoulder W&W/O Contrast Rt,73223,CPT,,,RT,both,,,6967,4180.2,,45.5,,3169.99,percent of total billed charges,,,45.3,,3156.05,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,5573.6,percent of total billed charges,,,61.4,,4277.74,percent of total billed charges,,,57.4,,3999.06,percent of total billed charges,,,81,,5643.27,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,4012.99,percent of total billed charges,,,85,,5921.95,percent of total billed charges,,,85,,5921.95,percent of total billed charges,,,49,,3413.83,percent of total billed charges,,,90,,6270.3,percent of total billed charges,,,65,,4528.55,percent of total billed charges,,,80,,5573.6,percent of total billed charges,,,55,,3831.85,percent of total billed charges,,,55,,3831.85,percent of total billed charges,,,65,,4528.55,percent of total billed charges,,,78,,5434.26,percent of total billed charges,,,70,,4876.9,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,6270.3,
MRI Wrist W&W/O Contrast Rt,73223,CPT,,,RT,both,,,6967,4180.2,,45.5,,3169.99,percent of total billed charges,,,45.3,,3156.05,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,5573.6,percent of total billed charges,,,61.4,,4277.74,percent of total billed charges,,,57.4,,3999.06,percent of total billed charges,,,81,,5643.27,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,4012.99,percent of total billed charges,,,85,,5921.95,percent of total billed charges,,,85,,5921.95,percent of total billed charges,,,49,,3413.83,percent of total billed charges,,,90,,6270.3,percent of total billed charges,,,65,,4528.55,percent of total billed charges,,,80,,5573.6,percent of total billed charges,,,55,,3831.85,percent of total billed charges,,,55,,3831.85,percent of total billed charges,,,65,,4528.55,percent of total billed charges,,,78,,5434.26,percent of total billed charges,,,70,,4876.9,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,6270.3,
"A4566 Shoulder sling or vest design, abduction restrainer, with or without swathe control, prefabric",A4566,HCPCS,,,,outpatient,,,271,162.6,,45.5,,123.31,percent of total billed charges,,,45.3,,122.76,percent of total billed charges,,,51,,138.21,percent of total billed charges,,,,,,,,,80,,216.8,percent of total billed charges,,,61.4,,166.39,percent of total billed charges,,,57.4,,155.55,percent of total billed charges,,,81,,219.51,percent of total billed charges,,,51.5,,139.57,percent of total billed charges,,,57.6,,156.1,percent of total billed charges,,,85,,230.35,percent of total billed charges,,,85,,230.35,percent of total billed charges,,,49,,132.79,percent of total billed charges,,,90,,243.9,percent of total billed charges,,,65,,176.15,percent of total billed charges,,,80,,216.8,percent of total billed charges,,,55,,149.05,percent of total billed charges,,,55,,149.05,percent of total billed charges,,,65,,176.15,percent of total billed charges,,,78,,211.38,percent of total billed charges,,,70,,189.7,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,122.76,243.9,
MRI Femur W&W/O Contrast Left,73720,CPT,,,LT,both,,,5736,3441.6,,45.5,,2609.88,percent of total billed charges,,,45.3,,2598.41,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4588.8,percent of total billed charges,,,61.4,,3521.9,percent of total billed charges,,,57.4,,3292.46,percent of total billed charges,,,81,,4646.16,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3303.94,percent of total billed charges,,,85,,4875.6,percent of total billed charges,,,85,,4875.6,percent of total billed charges,,,49,,2810.64,percent of total billed charges,,,90,,5162.4,percent of total billed charges,,,65,,3728.4,percent of total billed charges,,,80,,4588.8,percent of total billed charges,,,55,,3154.8,percent of total billed charges,,,55,,3154.8,percent of total billed charges,,,65,,3728.4,percent of total billed charges,,,78,,4474.08,percent of total billed charges,,,70,,4015.2,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5162.4,
MRI Foot W&W/O Contrast Lt,73720,CPT,,,LT,both,,,5736,3441.6,,45.5,,2609.88,percent of total billed charges,,,45.3,,2598.41,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4588.8,percent of total billed charges,,,61.4,,3521.9,percent of total billed charges,,,57.4,,3292.46,percent of total billed charges,,,81,,4646.16,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3303.94,percent of total billed charges,,,85,,4875.6,percent of total billed charges,,,85,,4875.6,percent of total billed charges,,,49,,2810.64,percent of total billed charges,,,90,,5162.4,percent of total billed charges,,,65,,3728.4,percent of total billed charges,,,80,,4588.8,percent of total billed charges,,,55,,3154.8,percent of total billed charges,,,55,,3154.8,percent of total billed charges,,,65,,3728.4,percent of total billed charges,,,78,,4474.08,percent of total billed charges,,,70,,4015.2,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5162.4,
MRI Neurography Femoral W&W/O Cont Lt-73720,73720,CPT,,,LT,both,,,5736,3441.6,,45.5,,2609.88,percent of total billed charges,,,45.3,,2598.41,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4588.8,percent of total billed charges,,,61.4,,3521.9,percent of total billed charges,,,57.4,,3292.46,percent of total billed charges,,,81,,4646.16,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3303.94,percent of total billed charges,,,85,,4875.6,percent of total billed charges,,,85,,4875.6,percent of total billed charges,,,49,,2810.64,percent of total billed charges,,,90,,5162.4,percent of total billed charges,,,65,,3728.4,percent of total billed charges,,,80,,4588.8,percent of total billed charges,,,55,,3154.8,percent of total billed charges,,,55,,3154.8,percent of total billed charges,,,65,,3728.4,percent of total billed charges,,,78,,4474.08,percent of total billed charges,,,70,,4015.2,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5162.4,
MRI Neurography Tib W&W/O Cont Lt-73720,73720,CPT,,,LT,both,,,5736,3441.6,,45.5,,2609.88,percent of total billed charges,,,45.3,,2598.41,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4588.8,percent of total billed charges,,,61.4,,3521.9,percent of total billed charges,,,57.4,,3292.46,percent of total billed charges,,,81,,4646.16,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3303.94,percent of total billed charges,,,85,,4875.6,percent of total billed charges,,,85,,4875.6,percent of total billed charges,,,49,,2810.64,percent of total billed charges,,,90,,5162.4,percent of total billed charges,,,65,,3728.4,percent of total billed charges,,,80,,4588.8,percent of total billed charges,,,55,,3154.8,percent of total billed charges,,,55,,3154.8,percent of total billed charges,,,65,,3728.4,percent of total billed charges,,,78,,4474.08,percent of total billed charges,,,70,,4015.2,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5162.4,
MRI Tibia W&W/O Contrast Lt,73720,CPT,,,LT,both,,,5736,3441.6,,45.5,,2609.88,percent of total billed charges,,,45.3,,2598.41,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4588.8,percent of total billed charges,,,61.4,,3521.9,percent of total billed charges,,,57.4,,3292.46,percent of total billed charges,,,81,,4646.16,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3303.94,percent of total billed charges,,,85,,4875.6,percent of total billed charges,,,85,,4875.6,percent of total billed charges,,,49,,2810.64,percent of total billed charges,,,90,,5162.4,percent of total billed charges,,,65,,3728.4,percent of total billed charges,,,80,,4588.8,percent of total billed charges,,,55,,3154.8,percent of total billed charges,,,55,,3154.8,percent of total billed charges,,,65,,3728.4,percent of total billed charges,,,78,,4474.08,percent of total billed charges,,,70,,4015.2,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5162.4,
MRI Femur W&W/O Contrast Right,73720,CPT,,,RT,both,,,5736,3441.6,,45.5,,2609.88,percent of total billed charges,,,45.3,,2598.41,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4588.8,percent of total billed charges,,,61.4,,3521.9,percent of total billed charges,,,57.4,,3292.46,percent of total billed charges,,,81,,4646.16,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3303.94,percent of total billed charges,,,85,,4875.6,percent of total billed charges,,,85,,4875.6,percent of total billed charges,,,49,,2810.64,percent of total billed charges,,,90,,5162.4,percent of total billed charges,,,65,,3728.4,percent of total billed charges,,,80,,4588.8,percent of total billed charges,,,55,,3154.8,percent of total billed charges,,,55,,3154.8,percent of total billed charges,,,65,,3728.4,percent of total billed charges,,,78,,4474.08,percent of total billed charges,,,70,,4015.2,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5162.4,
MRI Foot W&W/O Contrast Rt,73720,CPT,,,RT,both,,,5736,3441.6,,45.5,,2609.88,percent of total billed charges,,,45.3,,2598.41,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4588.8,percent of total billed charges,,,61.4,,3521.9,percent of total billed charges,,,57.4,,3292.46,percent of total billed charges,,,81,,4646.16,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3303.94,percent of total billed charges,,,85,,4875.6,percent of total billed charges,,,85,,4875.6,percent of total billed charges,,,49,,2810.64,percent of total billed charges,,,90,,5162.4,percent of total billed charges,,,65,,3728.4,percent of total billed charges,,,80,,4588.8,percent of total billed charges,,,55,,3154.8,percent of total billed charges,,,55,,3154.8,percent of total billed charges,,,65,,3728.4,percent of total billed charges,,,78,,4474.08,percent of total billed charges,,,70,,4015.2,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5162.4,
MRI Neurography Femoral W&W/O Cont Rt-73720,73720,CPT,,,RT,both,,,5736,3441.6,,45.5,,2609.88,percent of total billed charges,,,45.3,,2598.41,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4588.8,percent of total billed charges,,,61.4,,3521.9,percent of total billed charges,,,57.4,,3292.46,percent of total billed charges,,,81,,4646.16,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3303.94,percent of total billed charges,,,85,,4875.6,percent of total billed charges,,,85,,4875.6,percent of total billed charges,,,49,,2810.64,percent of total billed charges,,,90,,5162.4,percent of total billed charges,,,65,,3728.4,percent of total billed charges,,,80,,4588.8,percent of total billed charges,,,55,,3154.8,percent of total billed charges,,,55,,3154.8,percent of total billed charges,,,65,,3728.4,percent of total billed charges,,,78,,4474.08,percent of total billed charges,,,70,,4015.2,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5162.4,
MRI Neurography Tib W&W/O Cont Rt-73720,73720,CPT,,,RT,both,,,5736,3441.6,,45.5,,2609.88,percent of total billed charges,,,45.3,,2598.41,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4588.8,percent of total billed charges,,,61.4,,3521.9,percent of total billed charges,,,57.4,,3292.46,percent of total billed charges,,,81,,4646.16,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3303.94,percent of total billed charges,,,85,,4875.6,percent of total billed charges,,,85,,4875.6,percent of total billed charges,,,49,,2810.64,percent of total billed charges,,,90,,5162.4,percent of total billed charges,,,65,,3728.4,percent of total billed charges,,,80,,4588.8,percent of total billed charges,,,55,,3154.8,percent of total billed charges,,,55,,3154.8,percent of total billed charges,,,65,,3728.4,percent of total billed charges,,,78,,4474.08,percent of total billed charges,,,70,,4015.2,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5162.4,
MRI Tibia W&W/O Contrast Rt,73720,CPT,,,RT,both,,,5736,3441.6,,45.5,,2609.88,percent of total billed charges,,,45.3,,2598.41,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4588.8,percent of total billed charges,,,61.4,,3521.9,percent of total billed charges,,,57.4,,3292.46,percent of total billed charges,,,81,,4646.16,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3303.94,percent of total billed charges,,,85,,4875.6,percent of total billed charges,,,85,,4875.6,percent of total billed charges,,,49,,2810.64,percent of total billed charges,,,90,,5162.4,percent of total billed charges,,,65,,3728.4,percent of total billed charges,,,80,,4588.8,percent of total billed charges,,,55,,3154.8,percent of total billed charges,,,55,,3154.8,percent of total billed charges,,,65,,3728.4,percent of total billed charges,,,78,,4474.08,percent of total billed charges,,,70,,4015.2,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5162.4,
MRI Lower Ext W/Contrast Left,73722,CPT,,,LT,both,,,5810,3486,,45.5,,2643.55,percent of total billed charges,,,45.3,,2631.93,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4648,percent of total billed charges,,,61.4,,3567.34,percent of total billed charges,,,57.4,,3334.94,percent of total billed charges,,,81,,4706.1,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3346.56,percent of total billed charges,,,85,,4938.5,percent of total billed charges,,,85,,4938.5,percent of total billed charges,,,49,,2846.9,percent of total billed charges,,,90,,5229,percent of total billed charges,,,65,,3776.5,percent of total billed charges,,,80,,4648,percent of total billed charges,,,55,,3195.5,percent of total billed charges,,,55,,3195.5,percent of total billed charges,,,65,,3776.5,percent of total billed charges,,,78,,4531.8,percent of total billed charges,,,70,,4067,percent of total billed charges,,,,,,,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,,823.57,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,823.57,5229,
MRI Lower Ext W/Contrast Right,73722,CPT,,,RT,both,,,5810,3486,,45.5,,2643.55,percent of total billed charges,,,45.3,,2631.93,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4648,percent of total billed charges,,,61.4,,3567.34,percent of total billed charges,,,57.4,,3334.94,percent of total billed charges,,,81,,4706.1,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3346.56,percent of total billed charges,,,85,,4938.5,percent of total billed charges,,,85,,4938.5,percent of total billed charges,,,49,,2846.9,percent of total billed charges,,,90,,5229,percent of total billed charges,,,65,,3776.5,percent of total billed charges,,,80,,4648,percent of total billed charges,,,55,,3195.5,percent of total billed charges,,,55,,3195.5,percent of total billed charges,,,65,,3776.5,percent of total billed charges,,,78,,4531.8,percent of total billed charges,,,70,,4067,percent of total billed charges,,,,,,,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,823.57,,,,100% of Medicare,,,823.57,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,823.57,5229,
MRI Ankle/Hindfoot W&W/O Contrast Left,73723,CPT,,,LT,both,,,6021,3612.6,,45.5,,2739.56,percent of total billed charges,,,45.3,,2727.51,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4816.8,percent of total billed charges,,,61.4,,3696.89,percent of total billed charges,,,57.4,,3456.05,percent of total billed charges,,,81,,4877.01,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3468.1,percent of total billed charges,,,85,,5117.85,percent of total billed charges,,,85,,5117.85,percent of total billed charges,,,49,,2950.29,percent of total billed charges,,,90,,5418.9,percent of total billed charges,,,65,,3913.65,percent of total billed charges,,,80,,4816.8,percent of total billed charges,,,55,,3311.55,percent of total billed charges,,,55,,3311.55,percent of total billed charges,,,65,,3913.65,percent of total billed charges,,,78,,4696.38,percent of total billed charges,,,70,,4214.7,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5418.9,
MRI Hip W&W/O Contrast Lt,73723,CPT,,,LT,both,,,6021,3612.6,,45.5,,2739.56,percent of total billed charges,,,45.3,,2727.51,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4816.8,percent of total billed charges,,,61.4,,3696.89,percent of total billed charges,,,57.4,,3456.05,percent of total billed charges,,,81,,4877.01,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3468.1,percent of total billed charges,,,85,,5117.85,percent of total billed charges,,,85,,5117.85,percent of total billed charges,,,49,,2950.29,percent of total billed charges,,,90,,5418.9,percent of total billed charges,,,65,,3913.65,percent of total billed charges,,,80,,4816.8,percent of total billed charges,,,55,,3311.55,percent of total billed charges,,,55,,3311.55,percent of total billed charges,,,65,,3913.65,percent of total billed charges,,,78,,4696.38,percent of total billed charges,,,70,,4214.7,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5418.9,
MRI Knee W&W/O Contrast Lt,73723,CPT,,,LT,both,,,6021,3612.6,,45.5,,2739.56,percent of total billed charges,,,45.3,,2727.51,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4816.8,percent of total billed charges,,,61.4,,3696.89,percent of total billed charges,,,57.4,,3456.05,percent of total billed charges,,,81,,4877.01,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3468.1,percent of total billed charges,,,85,,5117.85,percent of total billed charges,,,85,,5117.85,percent of total billed charges,,,49,,2950.29,percent of total billed charges,,,90,,5418.9,percent of total billed charges,,,65,,3913.65,percent of total billed charges,,,80,,4816.8,percent of total billed charges,,,55,,3311.55,percent of total billed charges,,,55,,3311.55,percent of total billed charges,,,65,,3913.65,percent of total billed charges,,,78,,4696.38,percent of total billed charges,,,70,,4214.7,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5418.9,
MRI Ankle/Hindfoot W&W/O Contrast Right,73723,CPT,,,RT,both,,,6021,3612.6,,45.5,,2739.56,percent of total billed charges,,,45.3,,2727.51,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4816.8,percent of total billed charges,,,61.4,,3696.89,percent of total billed charges,,,57.4,,3456.05,percent of total billed charges,,,81,,4877.01,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3468.1,percent of total billed charges,,,85,,5117.85,percent of total billed charges,,,85,,5117.85,percent of total billed charges,,,49,,2950.29,percent of total billed charges,,,90,,5418.9,percent of total billed charges,,,65,,3913.65,percent of total billed charges,,,80,,4816.8,percent of total billed charges,,,55,,3311.55,percent of total billed charges,,,55,,3311.55,percent of total billed charges,,,65,,3913.65,percent of total billed charges,,,78,,4696.38,percent of total billed charges,,,70,,4214.7,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5418.9,
MRI Hip W&W/O Contrast Rt,73723,CPT,,,RT,both,,,6021,3612.6,,45.5,,2739.56,percent of total billed charges,,,45.3,,2727.51,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4816.8,percent of total billed charges,,,61.4,,3696.89,percent of total billed charges,,,57.4,,3456.05,percent of total billed charges,,,81,,4877.01,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3468.1,percent of total billed charges,,,85,,5117.85,percent of total billed charges,,,85,,5117.85,percent of total billed charges,,,49,,2950.29,percent of total billed charges,,,90,,5418.9,percent of total billed charges,,,65,,3913.65,percent of total billed charges,,,80,,4816.8,percent of total billed charges,,,55,,3311.55,percent of total billed charges,,,55,,3311.55,percent of total billed charges,,,65,,3913.65,percent of total billed charges,,,78,,4696.38,percent of total billed charges,,,70,,4214.7,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5418.9,
MRI Knee W&W/O Contrast Rt,73723,CPT,,,RT,both,,,6021,3612.6,,45.5,,2739.56,percent of total billed charges,,,45.3,,2727.51,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4816.8,percent of total billed charges,,,61.4,,3696.89,percent of total billed charges,,,57.4,,3456.05,percent of total billed charges,,,81,,4877.01,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3468.1,percent of total billed charges,,,85,,5117.85,percent of total billed charges,,,85,,5117.85,percent of total billed charges,,,49,,2950.29,percent of total billed charges,,,90,,5418.9,percent of total billed charges,,,65,,3913.65,percent of total billed charges,,,80,,4816.8,percent of total billed charges,,,55,,3311.55,percent of total billed charges,,,55,,3311.55,percent of total billed charges,,,65,,3913.65,percent of total billed charges,,,78,,4696.38,percent of total billed charges,,,70,,4214.7,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5418.9,
MRI Abdomen W/ Contrast,74182,CPT,,,,both,,,6002,3601.2,,45.5,,2730.91,percent of total billed charges,,,45.3,,2718.91,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4801.6,percent of total billed charges,,,61.4,,3685.23,percent of total billed charges,,,57.4,,3445.15,percent of total billed charges,,,81,,4861.62,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3457.15,percent of total billed charges,,,85,,5101.7,percent of total billed charges,,,85,,5101.7,percent of total billed charges,,,49,,2940.98,percent of total billed charges,,,90,,5401.8,percent of total billed charges,,,65,,3901.3,percent of total billed charges,,,80,,4801.6,percent of total billed charges,,,55,,3301.1,percent of total billed charges,,,55,,3301.1,percent of total billed charges,,,65,,3901.3,percent of total billed charges,,,78,,4681.56,percent of total billed charges,,,70,,4201.4,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5401.8,
MRI Abdominal Wall W/ Contrast,74182,CPT,,,,both,,,6002,3601.2,,45.5,,2730.91,percent of total billed charges,,,45.3,,2718.91,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4801.6,percent of total billed charges,,,61.4,,3685.23,percent of total billed charges,,,57.4,,3445.15,percent of total billed charges,,,81,,4861.62,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3457.15,percent of total billed charges,,,85,,5101.7,percent of total billed charges,,,85,,5101.7,percent of total billed charges,,,49,,2940.98,percent of total billed charges,,,90,,5401.8,percent of total billed charges,,,65,,3901.3,percent of total billed charges,,,80,,4801.6,percent of total billed charges,,,55,,3301.1,percent of total billed charges,,,55,,3301.1,percent of total billed charges,,,65,,3901.3,percent of total billed charges,,,78,,4681.56,percent of total billed charges,,,70,,4201.4,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5401.8,
MRI Abdomen Enterography W&W/O Contrast,74183,CPT,,,,both,,,6438,3862.8,,45.5,,2929.29,percent of total billed charges,,,45.3,,2916.41,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,5150.4,percent of total billed charges,,,61.4,,3952.93,percent of total billed charges,,,57.4,,3695.41,percent of total billed charges,,,81,,5214.78,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3708.29,percent of total billed charges,,,85,,5472.3,percent of total billed charges,,,85,,5472.3,percent of total billed charges,,,49,,3154.62,percent of total billed charges,,,90,,5794.2,percent of total billed charges,,,65,,4184.7,percent of total billed charges,,,80,,5150.4,percent of total billed charges,,,55,,3540.9,percent of total billed charges,,,55,,3540.9,percent of total billed charges,,,65,,4184.7,percent of total billed charges,,,78,,5021.64,percent of total billed charges,,,70,,4506.6,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5794.2,
MRI Abdomen MRCP W&W/O Contrast,74183,CPT,,,,both,,,6438,3862.8,,45.5,,2929.29,percent of total billed charges,,,45.3,,2916.41,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,5150.4,percent of total billed charges,,,61.4,,3952.93,percent of total billed charges,,,57.4,,3695.41,percent of total billed charges,,,81,,5214.78,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3708.29,percent of total billed charges,,,85,,5472.3,percent of total billed charges,,,85,,5472.3,percent of total billed charges,,,49,,3154.62,percent of total billed charges,,,90,,5794.2,percent of total billed charges,,,65,,4184.7,percent of total billed charges,,,80,,5150.4,percent of total billed charges,,,55,,3540.9,percent of total billed charges,,,55,,3540.9,percent of total billed charges,,,65,,4184.7,percent of total billed charges,,,78,,5021.64,percent of total billed charges,,,70,,4506.6,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5794.2,
MRI Abdomen Urography W&W/O Contrast,74183,CPT,,,,both,,,6438,3862.8,,45.5,,2929.29,percent of total billed charges,,,45.3,,2916.41,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,5150.4,percent of total billed charges,,,61.4,,3952.93,percent of total billed charges,,,57.4,,3695.41,percent of total billed charges,,,81,,5214.78,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3708.29,percent of total billed charges,,,85,,5472.3,percent of total billed charges,,,85,,5472.3,percent of total billed charges,,,49,,3154.62,percent of total billed charges,,,90,,5794.2,percent of total billed charges,,,65,,4184.7,percent of total billed charges,,,80,,5150.4,percent of total billed charges,,,55,,3540.9,percent of total billed charges,,,55,,3540.9,percent of total billed charges,,,65,,4184.7,percent of total billed charges,,,78,,5021.64,percent of total billed charges,,,70,,4506.6,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5794.2,
MRI Abdomen W&W/O Contrast,74183,CPT,,,,both,,,6438,3862.8,,45.5,,2929.29,percent of total billed charges,,,45.3,,2916.41,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,5150.4,percent of total billed charges,,,61.4,,3952.93,percent of total billed charges,,,57.4,,3695.41,percent of total billed charges,,,81,,5214.78,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3708.29,percent of total billed charges,,,85,,5472.3,percent of total billed charges,,,85,,5472.3,percent of total billed charges,,,49,,3154.62,percent of total billed charges,,,90,,5794.2,percent of total billed charges,,,65,,4184.7,percent of total billed charges,,,80,,5150.4,percent of total billed charges,,,55,,3540.9,percent of total billed charges,,,55,,3540.9,percent of total billed charges,,,65,,4184.7,percent of total billed charges,,,78,,5021.64,percent of total billed charges,,,70,,4506.6,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5794.2,
MRI Pelvis Enterography W&W/O Contrast,74183,CPT,,,,both,,,6438,3862.8,,45.5,,2929.29,percent of total billed charges,,,45.3,,2916.41,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,5150.4,percent of total billed charges,,,61.4,,3952.93,percent of total billed charges,,,57.4,,3695.41,percent of total billed charges,,,81,,5214.78,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3708.29,percent of total billed charges,,,85,,5472.3,percent of total billed charges,,,85,,5472.3,percent of total billed charges,,,49,,3154.62,percent of total billed charges,,,90,,5794.2,percent of total billed charges,,,65,,4184.7,percent of total billed charges,,,80,,5150.4,percent of total billed charges,,,55,,3540.9,percent of total billed charges,,,55,,3540.9,percent of total billed charges,,,65,,4184.7,percent of total billed charges,,,78,,5021.64,percent of total billed charges,,,70,,4506.6,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5794.2,
MRI Pelvis Urography W&W/O Contrast,74183,CPT,,,,both,,,6438,3862.8,,45.5,,2929.29,percent of total billed charges,,,45.3,,2916.41,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,5150.4,percent of total billed charges,,,61.4,,3952.93,percent of total billed charges,,,57.4,,3695.41,percent of total billed charges,,,81,,5214.78,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3708.29,percent of total billed charges,,,85,,5472.3,percent of total billed charges,,,85,,5472.3,percent of total billed charges,,,49,,3154.62,percent of total billed charges,,,90,,5794.2,percent of total billed charges,,,65,,4184.7,percent of total billed charges,,,80,,5150.4,percent of total billed charges,,,55,,3540.9,percent of total billed charges,,,55,,3540.9,percent of total billed charges,,,65,,4184.7,percent of total billed charges,,,78,,5021.64,percent of total billed charges,,,70,,4506.6,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,824.79,,,,EAPG Rate,100% of IL Medicaid,372.28,5794.2,
DRAIN/INJ MAJOR JOINT/BURSA W/US (20611),20611,CPT,,,,outpatient,,,891,534.6,,45.5,,405.41,percent of total billed charges,,,45.3,,403.62,percent of total billed charges,,,51,,454.41,percent of total billed charges,,,,,,,,,80,,712.8,percent of total billed charges,,,61.4,,547.07,percent of total billed charges,,,57.4,,511.43,percent of total billed charges,,,81,,721.71,percent of total billed charges,,,51.5,,458.87,percent of total billed charges,,,57.6,,513.22,percent of total billed charges,,,85,,757.35,percent of total billed charges,,,85,,757.35,percent of total billed charges,,,49,,436.59,percent of total billed charges,,,90,,801.9,percent of total billed charges,,,65,,579.15,percent of total billed charges,,,80,,712.8,percent of total billed charges,,,55,,490.05,percent of total billed charges,,,55,,490.05,percent of total billed charges,,,65,,579.15,percent of total billed charges,,,78,,694.98,percent of total billed charges,,,70,,623.7,percent of total billed charges,,,,,,,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,,307.71,,,,100% of Medicare,929.55,,,,EAPG rate,100% of IL Medicaid,929.55,,,,EAPG rate,100% of IL Medicaid,929.55,,,,EAPG rate,100% of IL Medicaid,929.55,,,,EAPG rate,100% of IL Medicaid,307.71,929.55,
"DRAIN/INJ MAJOR JOINT/BURSA W/US, Bilateral (20611-50)",20611,CPT,,,50,both,,,1337,802.2,,45.5,,608.34,percent of total billed charges,,,45.3,,605.66,percent of total billed charges,,,51,,681.87,percent of total billed charges,,,,,,,,,80,,1069.6,percent of total billed charges,,,61.4,,820.92,percent of total billed charges,,,57.4,,767.44,percent of total billed charges,,,81,,1082.97,percent of total billed charges,,,51.5,,688.56,percent of total billed charges,,,57.6,,770.11,percent of total billed charges,,,85,,1136.45,percent of total billed charges,,,85,,1136.45,percent of total billed charges,,,49,,655.13,percent of total billed charges,,,90,,1203.3,percent of total billed charges,,,65,,869.05,percent of total billed charges,,,80,,1069.6,percent of total billed charges,,,55,,735.35,percent of total billed charges,,,55,,735.35,percent of total billed charges,,,65,,869.05,percent of total billed charges,,,78,,1042.86,percent of total billed charges,,,70,,935.9,percent of total billed charges,,,,,,,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,,461.57,,,,150% of Medicare,1394.33,,,,EAPG rate,100% of IL Medicaid,1394.33,,,,EAPG rate,100% of IL Medicaid,1394.33,,,,EAPG rate,100% of IL Medicaid,1394.33,,,,EAPG rate,100% of IL Medicaid,461.57,1394.33,
Fine Needle Aspiration without Imaging,10021,CPT,,,,outpatient,,,529,317.4,,45.5,,240.7,percent of total billed charges,,,45.3,,239.64,percent of total billed charges,,,51,,269.79,percent of total billed charges,,,,,,,,,80,,423.2,percent of total billed charges,,,61.4,,324.81,percent of total billed charges,,,57.4,,303.65,percent of total billed charges,,,81,,428.49,,,,51.5,,272.44,percent of total billed charges,,,57.6,,304.7,percent of total billed charges,,,85,,449.65,percent of total billed charges,,,85,,449.65,percent of total billed charges,,,49,,259.21,percent of total billed charges,,,90,,476.1,percent of total billed charges,,,65,,343.85,percent of total billed charges,,,80,,423.2,percent of total billed charges,,,55,,290.95,percent of total billed charges,,,55,,290.95,percent of total billed charges,,,65,,343.85,percent of total billed charges,,,78,,412.62,percent of total billed charges,,,70,,370.3,percent of total billed charges,,,,,,,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,,416.48,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,239.64,476.1,
ACNE SURGERY MILIA CYSTS (10040),10040,CPT,,,,outpatient,,,333,199.8,,45.5,,151.52,percent of total billed charges,,,45.3,,150.85,percent of total billed charges,,,51,,169.83,percent of total billed charges,,,,,,,,,80,,266.4,percent of total billed charges,,,61.4,,204.46,percent of total billed charges,,,57.4,,191.14,percent of total billed charges,,,81,,269.73,percent of total billed charges,,,51.5,,171.5,percent of total billed charges,,,57.6,,191.81,percent of total billed charges,,,85,,283.05,percent of total billed charges,,,85,,283.05,percent of total billed charges,,,49,,163.17,percent of total billed charges,,,90,,299.7,percent of total billed charges,,,65,,216.45,percent of total billed charges,,,80,,266.4,percent of total billed charges,,,55,,183.15,percent of total billed charges,,,55,,183.15,percent of total billed charges,,,65,,216.45,percent of total billed charges,,,78,,259.74,percent of total billed charges,,,70,,233.1,percent of total billed charges,,,,,,,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,,207.13,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,150.85,299.7,
"Incision and Drainage of Abscess, single or simple (10060)",10060,CPT,,,,outpatient,,,570,342,,45.5,,259.35,percent of total billed charges,,,45.3,,258.21,percent of total billed charges,,,51,,290.7,percent of total billed charges,,,,,,,,,80,,456,percent of total billed charges,,,61.4,,349.98,percent of total billed charges,,,57.4,,327.18,percent of total billed charges,,,81,,461.7,percent of total billed charges,,,51.5,,293.55,percent of total billed charges,,,57.6,,328.32,percent of total billed charges,,,85,,484.5,percent of total billed charges,,,85,,484.5,percent of total billed charges,,,49,,279.3,percent of total billed charges,,,90,,513,percent of total billed charges,,,65,,370.5,percent of total billed charges,,,80,,456,percent of total billed charges,,,55,,313.5,percent of total billed charges,,,55,,313.5,percent of total billed charges,,,65,,370.5,percent of total billed charges,,,78,,444.6,percent of total billed charges,,,70,,399,percent of total billed charges,,,,,,,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,,207.13,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,207.13,513,
"Incision and Drainage of Abscess, complicated or multiple (10061)",10061,CPT,,,,outpatient,,,663,397.8,,45.5,,301.67,percent of total billed charges,,,45.3,,300.34,percent of total billed charges,,,51,,338.13,percent of total billed charges,,,,,,,,,80,,530.4,percent of total billed charges,,,61.4,,407.08,percent of total billed charges,,,57.4,,380.56,percent of total billed charges,,,81,,537.03,percent of total billed charges,,,51.5,,341.45,percent of total billed charges,,,57.6,,381.89,percent of total billed charges,,,85,,563.55,percent of total billed charges,,,85,,563.55,percent of total billed charges,,,49,,324.87,percent of total billed charges,,,90,,596.7,percent of total billed charges,,,65,,430.95,percent of total billed charges,,,80,,530.4,percent of total billed charges,,,55,,364.65,percent of total billed charges,,,55,,364.65,percent of total billed charges,,,65,,430.95,percent of total billed charges,,,78,,517.14,percent of total billed charges,,,70,,464.1,percent of total billed charges,,,,,,,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,,416.48,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,300.34,596.7,
I&D PILONID CYS; SMPL (10080),10080,CPT,,,,outpatient,,,592,355.2,,45.5,,269.36,percent of total billed charges,,,45.3,,268.18,percent of total billed charges,,,51,,301.92,percent of total billed charges,,,,,,,,,80,,473.6,percent of total billed charges,,,61.4,,363.49,percent of total billed charges,,,57.4,,339.81,percent of total billed charges,,,81,,479.52,percent of total billed charges,,,51.5,,304.88,percent of total billed charges,,,57.6,,340.99,percent of total billed charges,,,85,,503.2,percent of total billed charges,,,85,,503.2,percent of total billed charges,,,49,,290.08,percent of total billed charges,,,90,,532.8,percent of total billed charges,,,65,,384.8,percent of total billed charges,,,80,,473.6,percent of total billed charges,,,55,,325.6,percent of total billed charges,,,55,,325.6,percent of total billed charges,,,65,,384.8,percent of total billed charges,,,78,,461.76,percent of total billed charges,,,70,,414.4,percent of total billed charges,,,,,,,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,,733.44,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,268.18,733.44,
I&D PILONID CYST; CPLX (10081),10081,CPT,,,,outpatient,,,3246,1947.6,,45.5,,1476.93,percent of total billed charges,,,45.3,,1470.44,percent of total billed charges,,,51,,1655.46,percent of total billed charges,,,,,,,,,80,,2596.8,percent of total billed charges,,,61.4,,1993.04,percent of total billed charges,,,57.4,,1863.2,percent of total billed charges,,,81,,2629.26,percent of total billed charges,,,51.5,,1671.69,percent of total billed charges,,,57.6,,1869.7,percent of total billed charges,,,85,,2759.1,percent of total billed charges,,,85,,2759.1,percent of total billed charges,,,49,,1590.54,percent of total billed charges,,,90,,2921.4,percent of total billed charges,,,65,,2109.9,percent of total billed charges,,,80,,2596.8,percent of total billed charges,,,55,,1785.3,percent of total billed charges,,,55,,1785.3,percent of total billed charges,,,65,,2109.9,percent of total billed charges,,,78,,2531.88,percent of total billed charges,,,70,,2272.2,percent of total billed charges,,,,,,,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,,733.44,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,733.44,2921.4,
FB removal in sub q-simple,10120,CPT,,,,outpatient,,,938,562.8,,45.5,,426.79,percent of total billed charges,,,45.3,,424.91,percent of total billed charges,,,51,,478.38,percent of total billed charges,,,,,,,,,80,,750.4,percent of total billed charges,,,61.4,,575.93,percent of total billed charges,,,57.4,,538.41,percent of total billed charges,,,81,,759.78,percent of total billed charges,,,51.5,,483.07,percent of total billed charges,,,57.6,,540.29,percent of total billed charges,,,85,,797.3,percent of total billed charges,,,85,,797.3,percent of total billed charges,,,49,,459.62,percent of total billed charges,,,90,,844.2,percent of total billed charges,,,65,,609.7,percent of total billed charges,,,80,,750.4,percent of total billed charges,,,55,,515.9,percent of total billed charges,,,55,,515.9,percent of total billed charges,,,65,,609.7,percent of total billed charges,,,78,,731.64,percent of total billed charges,,,70,,656.6,percent of total billed charges,,,,,,,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,,416.48,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,416.48,844.2,
FB removal in sub q-complex,10121,CPT,,,,outpatient,,,5022,3013.2,,45.5,,2285.01,percent of total billed charges,,,45.3,,2274.97,percent of total billed charges,,,51,,2561.22,percent of total billed charges,,,,,,,,,80,,4017.6,percent of total billed charges,,,61.4,,3083.51,percent of total billed charges,,,57.4,,2882.63,percent of total billed charges,,,81,,4067.82,percent of total billed charges,,,51.5,,2586.33,percent of total billed charges,,,57.6,,2892.67,percent of total billed charges,,,85,,4268.7,percent of total billed charges,,,85,,4268.7,percent of total billed charges,,,49,,2460.78,percent of total billed charges,,,90,,4519.8,percent of total billed charges,,,65,,3264.3,percent of total billed charges,,,80,,4017.6,percent of total billed charges,,,55,,2762.1,percent of total billed charges,,,55,,2762.1,percent of total billed charges,,,65,,3264.3,percent of total billed charges,,,78,,3917.16,percent of total billed charges,,,70,,3515.4,percent of total billed charges,,,,,,,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,,1688.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1688.97,4519.8,
"Incision and Drainage of Hematoma, Seroma or Fluid Collection (10140)",10140,CPT,,,,outpatient,,,4670,2802,,45.5,,2124.85,percent of total billed charges,,,45.3,,2115.51,percent of total billed charges,,,51,,2381.7,percent of total billed charges,,,,,,,,,80,,3736,percent of total billed charges,,,61.4,,2867.38,percent of total billed charges,,,57.4,,2680.58,percent of total billed charges,,,81,,3782.7,percent of total billed charges,,,51.5,,2405.05,percent of total billed charges,,,57.6,,2689.92,percent of total billed charges,,,85,,3969.5,percent of total billed charges,,,85,,3969.5,percent of total billed charges,,,49,,2288.3,percent of total billed charges,,,90,,4203,percent of total billed charges,,,65,,3035.5,percent of total billed charges,,,80,,3736,percent of total billed charges,,,55,,2568.5,percent of total billed charges,,,55,,2568.5,percent of total billed charges,,,65,,3035.5,percent of total billed charges,,,78,,3642.6,percent of total billed charges,,,70,,3269,percent of total billed charges,,,,,,,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,,1688.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1688.97,4203,
"Incision and drainage complex, post-op infection",10180,CPT,,,,outpatient,,,5904,3542.4,,45.5,,2686.32,percent of total billed charges,,,45.3,,2674.51,percent of total billed charges,,,51,,3011.04,percent of total billed charges,,,,,,,,,80,,4723.2,percent of total billed charges,,,61.4,,3625.06,percent of total billed charges,,,57.4,,3388.9,percent of total billed charges,,,81,,4782.24,percent of total billed charges,,,51.5,,3040.56,percent of total billed charges,,,57.6,,3400.7,percent of total billed charges,,,85,,5018.4,percent of total billed charges,,,85,,5018.4,percent of total billed charges,,,49,,2892.96,percent of total billed charges,,,90,,5313.6,percent of total billed charges,,,65,,3837.6,percent of total billed charges,,,80,,4723.2,percent of total billed charges,,,55,,3247.2,percent of total billed charges,,,55,,3247.2,percent of total billed charges,,,65,,3837.6,percent of total billed charges,,,78,,4605.12,percent of total billed charges,,,70,,4132.8,percent of total billed charges,,,,,,,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,,2983.46,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,2674.51,5313.6,
DEBR EXZ/INF SKIN; 10% BS (11000),11000,CPT,,,,outpatient,,,974,584.4,,45.5,,443.17,percent of total billed charges,,,45.3,,441.22,percent of total billed charges,,,51,,496.74,percent of total billed charges,,,,,,,,,80,,779.2,percent of total billed charges,,,61.4,,598.04,percent of total billed charges,,,57.4,,559.08,percent of total billed charges,,,81,,788.94,percent of total billed charges,,,51.5,,501.61,percent of total billed charges,,,57.6,,561.02,percent of total billed charges,,,85,,827.9,percent of total billed charges,,,85,,827.9,percent of total billed charges,,,49,,477.26,percent of total billed charges,,,90,,876.6,percent of total billed charges,,,65,,633.1,percent of total billed charges,,,80,,779.2,percent of total billed charges,,,55,,535.7,percent of total billed charges,,,55,,535.7,percent of total billed charges,,,65,,633.1,percent of total billed charges,,,78,,759.72,percent of total billed charges,,,70,,681.8,percent of total billed charges,,,,,,,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,,638.1,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,441.22,876.6,
DEBRIDE INFECTED SKIN ADD-ON =<10% BS (11001),11001,CPT,,,,outpatient,,,333,199.8,,45.5,,151.52,percent of total billed charges,,,45.3,,150.85,percent of total billed charges,,,51,,169.83,percent of total billed charges,,,,,,,,,80,,266.4,percent of total billed charges,,,61.4,,204.46,percent of total billed charges,,,57.4,,191.14,percent of total billed charges,,,81,,269.73,percent of total billed charges,,,51.5,,171.5,percent of total billed charges,,,57.6,,191.81,percent of total billed charges,,,85,,283.05,percent of total billed charges,,,85,,283.05,percent of total billed charges,,,49,,163.17,percent of total billed charges,,,90,,299.7,percent of total billed charges,,,65,,216.45,percent of total billed charges,,,80,,266.4,percent of total billed charges,,,55,,183.15,percent of total billed charges,,,55,,183.15,percent of total billed charges,,,65,,216.45,percent of total billed charges,,,78,,259.74,percent of total billed charges,,,70,,233.1,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,150.85,299.7,
DEBR W OPEN FX; SKIN & SQ Charge (11010),11010,CPT,,,,outpatient,,,1505,903,,45.5,,684.78,percent of total billed charges,,,45.3,,681.77,percent of total billed charges,,,51,,767.55,percent of total billed charges,,,,,,,,,80,,1204,percent of total billed charges,,,61.4,,924.07,percent of total billed charges,,,57.4,,863.87,percent of total billed charges,,,81,,1219.05,percent of total billed charges,,,51.5,,775.08,percent of total billed charges,,,57.6,,866.88,percent of total billed charges,,,85,,1279.25,percent of total billed charges,,,85,,1279.25,percent of total billed charges,,,49,,737.45,percent of total billed charges,,,90,,1354.5,percent of total billed charges,,,65,,978.25,percent of total billed charges,,,80,,1204,percent of total billed charges,,,55,,827.75,percent of total billed charges,,,55,,827.75,percent of total billed charges,,,65,,978.25,percent of total billed charges,,,78,,1173.9,percent of total billed charges,,,70,,1053.5,percent of total billed charges,,,,,,,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,,733.44,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,681.77,1354.5,
"Debride Skin to Muscle, Open FX",11011,CPT,,,,outpatient,,,3296,1977.6,,45.5,,1499.68,percent of total billed charges,,,45.3,,1493.09,percent of total billed charges,,,51,,1680.96,percent of total billed charges,,,,,,,,,80,,2636.8,percent of total billed charges,,,61.4,,2023.74,percent of total billed charges,,,57.4,,1891.9,percent of total billed charges,,,81,,2669.76,percent of total billed charges,,,51.5,,1697.44,percent of total billed charges,,,57.6,,1898.5,percent of total billed charges,,,85,,2801.6,percent of total billed charges,,,85,,2801.6,percent of total billed charges,,,49,,1615.04,percent of total billed charges,,,90,,2966.4,percent of total billed charges,,,65,,2142.4,percent of total billed charges,,,80,,2636.8,percent of total billed charges,,,55,,1812.8,percent of total billed charges,,,55,,1812.8,percent of total billed charges,,,65,,2142.4,percent of total billed charges,,,78,,2570.88,percent of total billed charges,,,70,,2307.2,percent of total billed charges,,,,,,,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,,733.44,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,733.44,2966.4,
Deb skin bone at FX site,11012,CPT,,,,outpatient,,,3568,2140.8,,45.5,,1623.44,percent of total billed charges,,,45.3,,1616.3,percent of total billed charges,,,51,,1819.68,percent of total billed charges,,,,,,,,,80,,2854.4,percent of total billed charges,,,61.4,,2190.75,percent of total billed charges,,,57.4,,2048.03,percent of total billed charges,,,81,,2890.08,percent of total billed charges,,,51.5,,1837.52,percent of total billed charges,,,57.6,,2055.17,percent of total billed charges,,,85,,3032.8,percent of total billed charges,,,85,,3032.8,percent of total billed charges,,,49,,1748.32,percent of total billed charges,,,90,,3211.2,percent of total billed charges,,,65,,2319.2,percent of total billed charges,,,80,,2854.4,percent of total billed charges,,,55,,1962.4,percent of total billed charges,,,55,,1962.4,percent of total billed charges,,,65,,2319.2,percent of total billed charges,,,78,,2783.04,percent of total billed charges,,,70,,2497.6,percent of total billed charges,,,,,,,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,,2983.46,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1616.3,3211.2,
"Debridement-skin, 20 Sq cm/< (11042)",11042,CPT,,,,outpatient,,,990,594,,45.5,,450.45,percent of total billed charges,,,45.3,,448.47,percent of total billed charges,,,51,,504.9,percent of total billed charges,,,,,,,,,80,,792,percent of total billed charges,,,61.4,,607.86,percent of total billed charges,,,57.4,,568.26,percent of total billed charges,,,81,,801.9,percent of total billed charges,,,51.5,,509.85,percent of total billed charges,,,57.6,,570.24,percent of total billed charges,,,85,,841.5,percent of total billed charges,,,85,,841.5,percent of total billed charges,,,49,,485.1,percent of total billed charges,,,90,,891,percent of total billed charges,,,65,,643.5,percent of total billed charges,,,80,,792,percent of total billed charges,,,55,,544.5,percent of total billed charges,,,55,,544.5,percent of total billed charges,,,65,,643.5,percent of total billed charges,,,78,,772.2,percent of total billed charges,,,70,,693,percent of total billed charges,,,,,,,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,,416.48,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,416.48,891,
"Debridement-skin , sub q, muscle/fascia 20 Sq cm/< (11043)",11043,CPT,,,,outpatient,,,1396,837.6,,45.5,,635.18,percent of total billed charges,,,45.3,,632.39,percent of total billed charges,,,51,,711.96,percent of total billed charges,,,,,,,,,80,,1116.8,percent of total billed charges,,,61.4,,857.14,percent of total billed charges,,,57.4,,801.3,percent of total billed charges,,,81,,1130.76,percent of total billed charges,,,51.5,,718.94,percent of total billed charges,,,57.6,,804.1,percent of total billed charges,,,85,,1186.6,percent of total billed charges,,,85,,1186.6,percent of total billed charges,,,49,,684.04,percent of total billed charges,,,90,,1256.4,percent of total billed charges,,,65,,907.4,percent of total billed charges,,,80,,1116.8,percent of total billed charges,,,55,,767.8,percent of total billed charges,,,55,,767.8,percent of total billed charges,,,65,,907.4,percent of total billed charges,,,78,,1088.88,percent of total billed charges,,,70,,977.2,percent of total billed charges,,,,,,,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,,638.1,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,632.39,1256.4,
DEB BONE 20 SQ CM/< (11044),11044,CPT,,,,outpatient,,,2886,1731.6,,45.5,,1313.13,percent of total billed charges,,,45.3,,1307.36,percent of total billed charges,,,51,,1471.86,percent of total billed charges,,,,,,,,,80,,2308.8,percent of total billed charges,,,61.4,,1772,percent of total billed charges,,,57.4,,1656.56,percent of total billed charges,,,81,,2337.66,percent of total billed charges,,,51.5,,1486.29,percent of total billed charges,,,57.6,,1662.34,percent of total billed charges,,,85,,2453.1,percent of total billed charges,,,85,,2453.1,percent of total billed charges,,,49,,1414.14,percent of total billed charges,,,90,,2597.4,percent of total billed charges,,,65,,1875.9,percent of total billed charges,,,80,,2308.8,percent of total billed charges,,,55,,1587.3,percent of total billed charges,,,55,,1587.3,percent of total billed charges,,,65,,1875.9,percent of total billed charges,,,78,,2251.08,percent of total billed charges,,,70,,2020.2,percent of total billed charges,,,,,,,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,,1688.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1307.36,2597.4,
Deb Subq Tissue ADD-on=<20 Sq cm,11045,CPT,,,,outpatient,,,946,567.6,,45.5,,430.43,percent of total billed charges,,,45.3,,428.54,percent of total billed charges,,,51,,482.46,percent of total billed charges,,,,,,,,,80,,756.8,percent of total billed charges,,,61.4,,580.84,percent of total billed charges,,,57.4,,543,percent of total billed charges,,,81,,766.26,percent of total billed charges,,,51.5,,487.19,percent of total billed charges,,,57.6,,544.9,percent of total billed charges,,,85,,804.1,percent of total billed charges,,,85,,804.1,percent of total billed charges,,,49,,463.54,percent of total billed charges,,,90,,851.4,percent of total billed charges,,,65,,614.9,percent of total billed charges,,,80,,756.8,percent of total billed charges,,,55,,520.3,percent of total billed charges,,,55,,520.3,percent of total billed charges,,,65,,614.9,percent of total billed charges,,,78,,737.88,percent of total billed charges,,,70,,662.2,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,428.54,851.4,
DEB MUSC/FASCIA ADD-ON =<20 SQ CM,11046,CPT,,,,outpatient,,,946,567.6,,45.5,,430.43,percent of total billed charges,,,45.3,,428.54,percent of total billed charges,,,51,,482.46,percent of total billed charges,,,,,,,,,80,,756.8,percent of total billed charges,,,61.4,,580.84,percent of total billed charges,,,57.4,,543,percent of total billed charges,,,81,,766.26,percent of total billed charges,,,51.5,,487.19,percent of total billed charges,,,57.6,,544.9,percent of total billed charges,,,85,,804.1,percent of total billed charges,,,85,,804.1,percent of total billed charges,,,49,,463.54,percent of total billed charges,,,90,,851.4,percent of total billed charges,,,65,,614.9,percent of total billed charges,,,80,,756.8,percent of total billed charges,,,55,,520.3,percent of total billed charges,,,55,,520.3,percent of total billed charges,,,65,,614.9,percent of total billed charges,,,78,,737.88,percent of total billed charges,,,70,,662.2,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,428.54,851.4,
Deb Bone ADD-on =<20 Sq cm,11047,CPT,,,,outpatient,,,2947,1768.2,,45.5,,1340.89,percent of total billed charges,,,45.3,,1334.99,percent of total billed charges,,,51,,1502.97,percent of total billed charges,,,,,,,,,80,,2357.6,percent of total billed charges,,,61.4,,1809.46,percent of total billed charges,,,57.4,,1691.58,percent of total billed charges,,,81,,2387.07,percent of total billed charges,,,51.5,,1517.71,percent of total billed charges,,,57.6,,1697.47,percent of total billed charges,,,85,,2504.95,percent of total billed charges,,,85,,2504.95,percent of total billed charges,,,49,,1444.03,percent of total billed charges,,,90,,2652.3,percent of total billed charges,,,65,,1915.55,percent of total billed charges,,,80,,2357.6,percent of total billed charges,,,55,,1620.85,percent of total billed charges,,,55,,1620.85,percent of total billed charges,,,65,,1915.55,percent of total billed charges,,,78,,2298.66,percent of total billed charges,,,70,,2062.9,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1334.99,2652.3,
Removal Skin Tags,11200,CPT,,,,outpatient,,,320,192,,45.5,,145.6,percent of total billed charges,,,45.3,,144.96,percent of total billed charges,,,51,,163.2,percent of total billed charges,,,,,,,,,80,,256,percent of total billed charges,,,61.4,,196.48,percent of total billed charges,,,57.4,,183.68,percent of total billed charges,,,81,,259.2,percent of total billed charges,,,51.5,,164.8,percent of total billed charges,,,57.6,,184.32,percent of total billed charges,,,85,,272,percent of total billed charges,,,85,,272,percent of total billed charges,,,49,,156.8,percent of total billed charges,,,90,,288,percent of total billed charges,,,65,,208,percent of total billed charges,,,80,,256,percent of total billed charges,,,55,,176,percent of total billed charges,,,55,,176,percent of total billed charges,,,65,,208,percent of total billed charges,,,78,,249.6,percent of total billed charges,,,70,,224,percent of total billed charges,,,,,,,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,,207.13,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,144.96,288,
REMOVE SKIN TAGS ADD-ON =<10 LESIONS (11201),11201,CPT,,,,outpatient,,,333,199.8,,45.5,,151.52,percent of total billed charges,,,45.3,,150.85,percent of total billed charges,,,51,,169.83,percent of total billed charges,,,,,,,,,80,,266.4,percent of total billed charges,,,61.4,,204.46,percent of total billed charges,,,57.4,,191.14,percent of total billed charges,,,81,,269.73,percent of total billed charges,,,51.5,,171.5,percent of total billed charges,,,57.6,,191.81,percent of total billed charges,,,85,,283.05,percent of total billed charges,,,85,,283.05,percent of total billed charges,,,49,,163.17,percent of total billed charges,,,90,,299.7,percent of total billed charges,,,65,,216.45,percent of total billed charges,,,80,,266.4,percent of total billed charges,,,55,,183.15,percent of total billed charges,,,55,,183.15,percent of total billed charges,,,65,,216.45,percent of total billed charges,,,78,,259.74,percent of total billed charges,,,70,,233.1,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,150.85,299.7,
SHAVE LES S/N/H/F/G; 0.6-1.0CM (11306),11306,CPT,,,,outpatient,,,334,200.4,,45.5,,151.97,percent of total billed charges,,,45.3,,151.3,percent of total billed charges,,,51,,170.34,percent of total billed charges,,,,,,,,,80,,267.2,percent of total billed charges,,,61.4,,205.08,percent of total billed charges,,,57.4,,191.72,percent of total billed charges,,,81,,270.54,percent of total billed charges,,,51.5,,172.01,percent of total billed charges,,,57.6,,192.38,percent of total billed charges,,,85,,283.9,percent of total billed charges,,,85,,283.9,percent of total billed charges,,,49,,163.66,percent of total billed charges,,,90,,300.6,percent of total billed charges,,,65,,217.1,percent of total billed charges,,,80,,267.2,percent of total billed charges,,,55,,183.7,percent of total billed charges,,,55,,183.7,percent of total billed charges,,,65,,217.1,percent of total billed charges,,,78,,260.52,percent of total billed charges,,,70,,233.8,percent of total billed charges,,,,,,,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,,207.13,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,151.3,300.6,
SHAVE LES S/N/H/F/G; 1.1-2.0CM (11307),11307,CPT,,,,outpatient,,,393,235.8,,45.5,,178.82,percent of total billed charges,,,45.3,,178.03,percent of total billed charges,,,51,,200.43,percent of total billed charges,,,,,,,,,80,,314.4,percent of total billed charges,,,61.4,,241.3,percent of total billed charges,,,57.4,,225.58,percent of total billed charges,,,81,,318.33,percent of total billed charges,,,51.5,,202.4,percent of total billed charges,,,57.6,,226.37,percent of total billed charges,,,85,,334.05,percent of total billed charges,,,85,,334.05,percent of total billed charges,,,49,,192.57,percent of total billed charges,,,90,,353.7,percent of total billed charges,,,65,,255.45,percent of total billed charges,,,80,,314.4,percent of total billed charges,,,55,,216.15,percent of total billed charges,,,55,,216.15,percent of total billed charges,,,65,,255.45,percent of total billed charges,,,78,,306.54,percent of total billed charges,,,70,,275.1,percent of total billed charges,,,,,,,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,,207.13,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,178.03,353.7,
Exc. Benign Les T/A/L; 1-1-2.0 CM,11402,CPT,,,,outpatient,,,1764,1058.4,,45.5,,802.62,percent of total billed charges,,,45.3,,799.09,percent of total billed charges,,,51,,899.64,percent of total billed charges,,,,,,,,,80,,1411.2,percent of total billed charges,,,61.4,,1083.1,percent of total billed charges,,,57.4,,1012.54,percent of total billed charges,,,81,,1428.84,percent of total billed charges,,,51.5,,908.46,percent of total billed charges,,,57.6,,1016.06,percent of total billed charges,,,85,,1499.4,percent of total billed charges,,,85,,1499.4,percent of total billed charges,,,49,,864.36,percent of total billed charges,,,90,,1587.6,percent of total billed charges,,,65,,1146.6,percent of total billed charges,,,80,,1411.2,percent of total billed charges,,,55,,970.2,percent of total billed charges,,,55,,970.2,percent of total billed charges,,,65,,1146.6,percent of total billed charges,,,78,,1375.92,percent of total billed charges,,,70,,1234.8,percent of total billed charges,,,,,,,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,,733.44,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,733.44,1587.6,
EXC BLES S/N/EX G; 0.5CM/< (11420),11420,CPT,,,,outpatient,,,2613,1567.8,,45.5,,1188.92,percent of total billed charges,,,45.3,,1183.69,percent of total billed charges,,,51,,1332.63,percent of total billed charges,,,,,,,,,80,,2090.4,percent of total billed charges,,,61.4,,1604.38,percent of total billed charges,,,57.4,,1499.86,percent of total billed charges,,,81,,2116.53,percent of total billed charges,,,51.5,,1345.7,percent of total billed charges,,,57.6,,1505.09,percent of total billed charges,,,85,,2221.05,percent of total billed charges,,,85,,2221.05,percent of total billed charges,,,49,,1280.37,percent of total billed charges,,,90,,2351.7,percent of total billed charges,,,65,,1698.45,percent of total billed charges,,,80,,2090.4,percent of total billed charges,,,55,,1437.15,percent of total billed charges,,,55,,1437.15,percent of total billed charges,,,65,,1698.45,percent of total billed charges,,,78,,2038.14,percent of total billed charges,,,70,,1829.1,percent of total billed charges,,,,,,,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,,1688.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1183.69,2351.7,
EXC BLES S/N/EX G; 0.6-1.0CM (11421),11421,CPT,,,,outpatient,,,2717,1630.2,,45.5,,1236.24,percent of total billed charges,,,45.3,,1230.8,percent of total billed charges,,,51,,1385.67,percent of total billed charges,,,,,,,,,80,,2173.6,percent of total billed charges,,,61.4,,1668.24,percent of total billed charges,,,57.4,,1559.56,percent of total billed charges,,,81,,2200.77,percent of total billed charges,,,51.5,,1399.26,percent of total billed charges,,,57.6,,1564.99,percent of total billed charges,,,85,,2309.45,percent of total billed charges,,,85,,2309.45,percent of total billed charges,,,49,,1331.33,percent of total billed charges,,,90,,2445.3,percent of total billed charges,,,65,,1766.05,percent of total billed charges,,,80,,2173.6,percent of total billed charges,,,55,,1494.35,percent of total billed charges,,,55,,1494.35,percent of total billed charges,,,65,,1766.05,percent of total billed charges,,,78,,2119.26,percent of total billed charges,,,70,,1901.9,percent of total billed charges,,,,,,,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,,733.44,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,733.44,2445.3,
EXC BLES S/N/EX G; 1.1-2.0CM (11422),11422,CPT,,,,outpatient,,,2777,1666.2,,45.5,,1263.54,percent of total billed charges,,,45.3,,1257.98,percent of total billed charges,,,51,,1416.27,percent of total billed charges,,,,,,,,,80,,2221.6,percent of total billed charges,,,61.4,,1705.08,percent of total billed charges,,,57.4,,1594,percent of total billed charges,,,81,,2249.37,percent of total billed charges,,,51.5,,1430.16,percent of total billed charges,,,57.6,,1599.55,percent of total billed charges,,,85,,2360.45,percent of total billed charges,,,85,,2360.45,percent of total billed charges,,,49,,1360.73,percent of total billed charges,,,90,,2499.3,percent of total billed charges,,,65,,1805.05,percent of total billed charges,,,80,,2221.6,percent of total billed charges,,,55,,1527.35,percent of total billed charges,,,55,,1527.35,percent of total billed charges,,,65,,1805.05,percent of total billed charges,,,78,,2166.06,percent of total billed charges,,,70,,1943.9,percent of total billed charges,,,,,,,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,,1688.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1257.98,2499.3,
EXC BLES S/N/EX G; 2.1-3.0CM (11423),11423,CPT,,,,outpatient,,,4919,2951.4,,45.5,,2238.15,percent of total billed charges,,,45.3,,2228.31,percent of total billed charges,,,51,,2508.69,percent of total billed charges,,,,,,,,,80,,3935.2,percent of total billed charges,,,61.4,,3020.27,percent of total billed charges,,,57.4,,2823.51,percent of total billed charges,,,81,,3984.39,percent of total billed charges,,,51.5,,2533.29,percent of total billed charges,,,57.6,,2833.34,percent of total billed charges,,,85,,4181.15,percent of total billed charges,,,85,,4181.15,percent of total billed charges,,,49,,2410.31,percent of total billed charges,,,90,,4427.1,percent of total billed charges,,,65,,3197.35,percent of total billed charges,,,80,,3935.2,percent of total billed charges,,,55,,2705.45,percent of total billed charges,,,55,,2705.45,percent of total billed charges,,,65,,3197.35,percent of total billed charges,,,78,,3836.82,percent of total billed charges,,,70,,3443.3,percent of total billed charges,,,,,,,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,,1688.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1688.97,4427.1,
EXC BLES S/N/EX G; 3.1-4.0CM (11424),11424,CPT,,,,outpatient,,,5215,3129,,45.5,,2372.83,percent of total billed charges,,,45.3,,2362.4,percent of total billed charges,,,51,,2659.65,percent of total billed charges,,,,,,,,,80,,4172,percent of total billed charges,,,61.4,,3202.01,percent of total billed charges,,,57.4,,2993.41,percent of total billed charges,,,81,,4224.15,percent of total billed charges,,,51.5,,2685.73,percent of total billed charges,,,57.6,,3003.84,percent of total billed charges,,,85,,4432.75,percent of total billed charges,,,85,,4432.75,percent of total billed charges,,,49,,2555.35,percent of total billed charges,,,90,,4693.5,percent of total billed charges,,,65,,3389.75,percent of total billed charges,,,80,,4172,percent of total billed charges,,,55,,2868.25,percent of total billed charges,,,55,,2868.25,percent of total billed charges,,,65,,3389.75,percent of total billed charges,,,78,,4067.7,percent of total billed charges,,,70,,3650.5,percent of total billed charges,,,,,,,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,,1688.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1688.97,4693.5,
15054-0530-06 - abobotulinumtoxinA 300 units REC I,J0586,HCPCS,15054-0530-06,NDC,,both,1,UN,1928.9,1157.34,,45.5,,877.65,percent of total billed charges,,,45.3,,873.79,percent of total billed charges,,,51,,983.74,percent of total billed charges,,,,,,,,,80,,1543.12,percent of total billed charges,,,61.4,,1184.34,percent of total billed charges,,,57.4,,1107.19,percent of total billed charges,,,81,,1562.41,percent of total billed charges,,,51.5,,993.38,percent of total billed charges,,,57.6,,1111.05,percent of total billed charges,,,85,,1639.57,percent of total billed charges,,,85,,1639.57,percent of total billed charges,,,49,,945.16,percent of total billed charges,,,90,,1736.01,percent of total billed charges,,,65,,1253.79,percent of total billed charges,,,80,,1543.12,percent of total billed charges,,,55,,1060.9,percent of total billed charges,,,55,,1060.9,percent of total billed charges,,,65,,1253.79,percent of total billed charges,,,78,,1504.54,percent of total billed charges,,,70,,1350.23,percent of total billed charges,,,,,,,,9,,,,100% of Medicare,,9,,,,100% of Medicare,,9,,,,100% of Medicare,,9,,,,100% of Medicare,,9,,,,100% of Medicare,,9,,,,100% of Medicare,,9,,,,100% of Medicare,,9,,,,100% of Medicare,,9,,,,100% of Medicare,,9,,,,100% of Medicare,,9,,,,100% of Medicare,,9,,,,100% of Medicare,,,9,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,9,1736.01,
15054-0500-01 - abobotulinumtoxinA 500 units REC I,J0586,HCPCS,15054-0500-01,NDC,,both,1,UN,3214.25,1928.55,,45.5,,1462.48,percent of total billed charges,,,45.3,,1456.06,percent of total billed charges,,,51,,1639.27,percent of total billed charges,,,,,,,,,80,,2571.4,percent of total billed charges,,,61.4,,1973.55,percent of total billed charges,,,57.4,,1844.98,percent of total billed charges,,,81,,2603.54,percent of total billed charges,,,51.5,,1655.34,percent of total billed charges,,,57.6,,1851.41,percent of total billed charges,,,85,,2732.11,percent of total billed charges,,,85,,2732.11,percent of total billed charges,,,49,,1574.98,percent of total billed charges,,,90,,2892.83,percent of total billed charges,,,65,,2089.26,percent of total billed charges,,,80,,2571.4,percent of total billed charges,,,55,,1767.84,percent of total billed charges,,,55,,1767.84,percent of total billed charges,,,65,,2089.26,percent of total billed charges,,,78,,2507.12,percent of total billed charges,,,70,,2249.98,percent of total billed charges,,,,,,,,9,,,,100% of Medicare,,9,,,,100% of Medicare,,9,,,,100% of Medicare,,9,,,,100% of Medicare,,9,,,,100% of Medicare,,9,,,,100% of Medicare,,9,,,,100% of Medicare,,9,,,,100% of Medicare,,9,,,,100% of Medicare,,9,,,,100% of Medicare,,9,,,,100% of Medicare,,9,,,,100% of Medicare,,,9,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,9,2892.83,
10454-0710-10 - botulinum toxin type B 5000 units/mL Soln,J0587,HCPCS,10454-0710-10,NDC,,both,0.5,ML,1195.7,717.42,,45.5,,544.04,percent of total billed charges,,,45.3,,541.65,percent of total billed charges,,,51,,609.81,percent of total billed charges,,,,,,,,,80,,956.56,percent of total billed charges,,,61.4,,734.16,percent of total billed charges,,,57.4,,686.33,percent of total billed charges,,,81,,968.52,percent of total billed charges,,,51.5,,615.79,percent of total billed charges,,,57.6,,688.72,percent of total billed charges,,,85,,1016.35,percent of total billed charges,,,85,,1016.35,percent of total billed charges,,,49,,585.89,percent of total billed charges,,,90,,1076.13,percent of total billed charges,,,65,,777.21,percent of total billed charges,,,80,,956.56,percent of total billed charges,,,55,,657.64,percent of total billed charges,,,55,,657.64,percent of total billed charges,,,65,,777.21,percent of total billed charges,,,78,,932.65,percent of total billed charges,,,70,,836.99,percent of total billed charges,,,,,,,,13.54,,,,100% of Medicare,,13.54,,,,100% of Medicare,,13.54,,,,100% of Medicare,,13.54,,,,100% of Medicare,,13.54,,,,100% of Medicare,,13.54,,,,100% of Medicare,,13.54,,,,100% of Medicare,,13.54,,,,100% of Medicare,,13.54,,,,100% of Medicare,,13.54,,,,100% of Medicare,,13.54,,,,100% of Medicare,,13.54,,,,100% of Medicare,,,13.54,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,13.54,1076.13,
10454-0711-10 - botulinum toxin type B 5000 units/mL Soln,J0587,HCPCS,10454-0711-10,NDC,,both,1,ML,2391.4,1434.84,,45.5,,1088.09,percent of total billed charges,,,45.3,,1083.3,percent of total billed charges,,,51,,1219.61,percent of total billed charges,,,,,,,,,80,,1913.12,percent of total billed charges,,,61.4,,1468.32,percent of total billed charges,,,57.4,,1372.66,percent of total billed charges,,,81,,1937.03,percent of total billed charges,,,51.5,,1231.57,percent of total billed charges,,,57.6,,1377.45,percent of total billed charges,,,85,,2032.69,percent of total billed charges,,,85,,2032.69,percent of total billed charges,,,49,,1171.79,percent of total billed charges,,,90,,2152.26,percent of total billed charges,,,65,,1554.41,percent of total billed charges,,,80,,1913.12,percent of total billed charges,,,55,,1315.27,percent of total billed charges,,,55,,1315.27,percent of total billed charges,,,65,,1554.41,percent of total billed charges,,,78,,1865.29,percent of total billed charges,,,70,,1673.98,percent of total billed charges,,,,,,,,13.54,,,,100% of Medicare,,13.54,,,,100% of Medicare,,13.54,,,,100% of Medicare,,13.54,,,,100% of Medicare,,13.54,,,,100% of Medicare,,13.54,,,,100% of Medicare,,13.54,,,,100% of Medicare,,13.54,,,,100% of Medicare,,13.54,,,,100% of Medicare,,13.54,,,,100% of Medicare,,13.54,,,,100% of Medicare,,13.54,,,,100% of Medicare,,,13.54,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,13.54,2152.26,
F5 Gene Analysis,81241,CPT,,,,inpatient,,,359,215.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,290.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,305.15,percent of total billed charges,,,85,,305.15,percent of total billed charges,,,49,,175.91,percent of total billed charges,,,90,,323.1,percent of total billed charges,,,,,,,no IP contract,,80,,287.2,percent of total billed charges,,,,,,,no IP contract,,50,,179.5,percent of total billed charges,,,,,,no IP contract,,,78,,280.02,percent of total billed charges,,,70,,251.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,175.91,3324,
MYELOID NEOPLASMS NGS PANEL NMH,81450,CPT,,,,inpatient,,,2820,1692,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2284.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2397,percent of total billed charges,,,85,,2397,percent of total billed charges,,,49,,1381.8,percent of total billed charges,,,90,,2538,percent of total billed charges,,,,,,,no IP contract,,80,,2256,percent of total billed charges,,,,,,,no IP contract,,50,,1410,percent of total billed charges,,,,,,no IP contract,,,78,,2199.6,percent of total billed charges,,,70,,1974,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
Occult Blood Screen,82270,CPT,,,,inpatient,,,74,44.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,59.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,62.9,percent of total billed charges,,,85,,62.9,percent of total billed charges,,,49,,36.26,percent of total billed charges,,,90,,66.6,percent of total billed charges,,,,,,,no IP contract,,80,,59.2,percent of total billed charges,,,,,,,no IP contract,,50,,37,percent of total billed charges,,,,,,no IP contract,,,78,,57.72,percent of total billed charges,,,70,,51.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.26,3324,
"Occult Blood, Feces-POCT",82270,CPT,,,,inpatient,,,74,44.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,59.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,62.9,percent of total billed charges,,,85,,62.9,percent of total billed charges,,,49,,36.26,percent of total billed charges,,,90,,66.6,percent of total billed charges,,,,,,,no IP contract,,80,,59.2,percent of total billed charges,,,,,,,no IP contract,,50,,37,percent of total billed charges,,,,,,no IP contract,,,78,,57.72,percent of total billed charges,,,70,,51.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.26,3324,
Lipoprotein Fractionation,82465,CPT,,,,inpatient,,,90,54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,72.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,76.5,percent of total billed charges,,,85,,76.5,percent of total billed charges,,,49,,44.1,percent of total billed charges,,,90,,81,percent of total billed charges,,,,,,,no IP contract,,80,,72,percent of total billed charges,,,,,,,no IP contract,,50,,45,percent of total billed charges,,,,,,no IP contract,,,78,,70.2,percent of total billed charges,,,70,,63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,44.1,3324,
Cholesterol,82465,CPT,,,,inpatient,,,96,57.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,77.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,81.6,percent of total billed charges,,,85,,81.6,percent of total billed charges,,,49,,47.04,percent of total billed charges,,,90,,86.4,percent of total billed charges,,,,,,,no IP contract,,80,,76.8,percent of total billed charges,,,,,,,no IP contract,,50,,48,percent of total billed charges,,,,,,no IP contract,,,78,,74.88,percent of total billed charges,,,70,,67.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,47.04,3324,
Glucose Level,82947,CPT,,,,inpatient,,,78,46.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,63.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,66.3,percent of total billed charges,,,85,,66.3,percent of total billed charges,,,49,,38.22,percent of total billed charges,,,90,,70.2,percent of total billed charges,,,,,,,no IP contract,,80,,62.4,percent of total billed charges,,,,,,,no IP contract,,50,,39,percent of total billed charges,,,,,,no IP contract,,,78,,60.84,percent of total billed charges,,,70,,54.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,38.22,3324,
GLUCOSE NMH,82947,CPT,,,,inpatient,,,82,49.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,66.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,69.7,percent of total billed charges,,,85,,69.7,percent of total billed charges,,,49,,40.18,percent of total billed charges,,,90,,73.8,percent of total billed charges,,,,,,,no IP contract,,80,,65.6,percent of total billed charges,,,,,,,no IP contract,,50,,41,percent of total billed charges,,,,,,no IP contract,,,78,,63.96,percent of total billed charges,,,70,,57.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,40.18,3324,
"Glucose, post glucose dose, Including baseline",82950,CPT,,,,inpatient,,,121,72.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,98.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,102.85,percent of total billed charges,,,85,,102.85,percent of total billed charges,,,49,,59.29,percent of total billed charges,,,90,,108.9,percent of total billed charges,,,,,,,no IP contract,,80,,96.8,percent of total billed charges,,,,,,,no IP contract,,50,,60.5,percent of total billed charges,,,,,,no IP contract,,,78,,94.38,percent of total billed charges,,,70,,84.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,59.29,3324,
Triglycerides,84478,CPT,,,,inpatient,,,145,87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,117.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,123.25,percent of total billed charges,,,85,,123.25,percent of total billed charges,,,49,,71.05,percent of total billed charges,,,90,,130.5,percent of total billed charges,,,,,,,no IP contract,,80,,116,percent of total billed charges,,,,,,,no IP contract,,50,,72.5,percent of total billed charges,,,,,,no IP contract,,,78,,113.1,percent of total billed charges,,,70,,101.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,71.05,3324,
Triglycerides,84478,CPT,,,,inpatient,,,145,87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,117.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,123.25,percent of total billed charges,,,85,,123.25,percent of total billed charges,,,49,,71.05,percent of total billed charges,,,90,,130.5,percent of total billed charges,,,,,,,no IP contract,,80,,116,percent of total billed charges,,,,,,,no IP contract,,50,,72.5,percent of total billed charges,,,,,,no IP contract,,,78,,113.1,percent of total billed charges,,,70,,101.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,71.05,3324,
"VDRL, CSF",86592,CPT,,,,inpatient,,,90,54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,72.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,76.5,percent of total billed charges,,,85,,76.5,percent of total billed charges,,,49,,44.1,percent of total billed charges,,,90,,81,percent of total billed charges,,,,,,,no IP contract,,80,,72,percent of total billed charges,,,,,,,no IP contract,,50,,45,percent of total billed charges,,,,,,no IP contract,,,78,,70.2,percent of total billed charges,,,70,,63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,44.1,3324,
"Syphilis Antibody, Treponemal w/ Reflex",86592,CPT,,,,inpatient,,,135,81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,109.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,114.75,percent of total billed charges,,,85,,114.75,percent of total billed charges,,,49,,66.15,percent of total billed charges,,,90,,121.5,percent of total billed charges,,,,,,,no IP contract,,80,,108,percent of total billed charges,,,,,,,no IP contract,,50,,67.5,percent of total billed charges,,,,,,no IP contract,,,78,,105.3,percent of total billed charges,,,70,,94.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,66.15,3324,
Anti-Sars-COV2- Spike Protein Combo,86769,CPT,,,,inpatient,,,225,135,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,182.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,191.25,percent of total billed charges,,,85,,191.25,percent of total billed charges,,,49,,110.25,percent of total billed charges,,,90,,202.5,percent of total billed charges,,,,,,,no IP contract,,80,,180,percent of total billed charges,,,,,,,no IP contract,,50,,112.5,percent of total billed charges,,,,,,no IP contract,,,78,,175.5,percent of total billed charges,,,70,,157.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,110.25,3324,
Anti-Sars-COV2- Spike Protein Combo,86769,CPT,,,,inpatient,,,225,135,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,182.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,191.25,percent of total billed charges,,,85,,191.25,percent of total billed charges,,,49,,110.25,percent of total billed charges,,,90,,202.5,percent of total billed charges,,,,,,,no IP contract,,80,,180,percent of total billed charges,,,,,,,no IP contract,,50,,112.5,percent of total billed charges,,,,,,no IP contract,,,78,,175.5,percent of total billed charges,,,70,,157.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,110.25,3324,
Treponema Pallidum Antibody Assay,86780,CPT,,,,inpatient,,,190,114,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,153.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,161.5,percent of total billed charges,,,85,,161.5,percent of total billed charges,,,49,,93.1,percent of total billed charges,,,90,,171,percent of total billed charges,,,,,,,no IP contract,,80,,152,percent of total billed charges,,,,,,,no IP contract,,50,,95,percent of total billed charges,,,,,,no IP contract,,,78,,148.2,percent of total billed charges,,,70,,133,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,93.1,3324,
COVID-19 POC,87635,CPT,,,,inpatient,,,242,145.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,196.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,205.7,percent of total billed charges,,,85,,205.7,percent of total billed charges,,,49,,118.58,percent of total billed charges,,,90,,217.8,percent of total billed charges,,,,,,,no IP contract,,80,,193.6,percent of total billed charges,,,,,,,no IP contract,,50,,121,percent of total billed charges,,,,,,no IP contract,,,78,,188.76,percent of total billed charges,,,70,,169.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,118.58,3324,
Group Therapy Exercise 15 min,97150,CPT,,,GP,inpatient,,,131,78.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,106.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,111.35,percent of total billed charges,,,85,,111.35,percent of total billed charges,,,49,,64.19,percent of total billed charges,,,90,,117.9,percent of total billed charges,,,,,,,no IP contract,,80,,104.8,percent of total billed charges,,,,,,,no IP contract,,50,,65.5,percent of total billed charges,,,,,,no IP contract,,,78,,102.18,percent of total billed charges,,,70,,91.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,64.19,3324,
Individual Therapy Exercise 15 min,97530,CPT,,,GP,inpatient,,,248,148.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,200.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,210.8,percent of total billed charges,,,85,,210.8,percent of total billed charges,,,49,,121.52,percent of total billed charges,,,90,,223.2,percent of total billed charges,,,,,,,no IP contract,,80,,198.4,percent of total billed charges,,,,,,,no IP contract,,50,,124,percent of total billed charges,,,,,,no IP contract,,,78,,193.44,percent of total billed charges,,,70,,173.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,121.52,3324,
Individual Education 15 min,97535,CPT,,,GP,inpatient,,,224,134.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,181.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,190.4,percent of total billed charges,,,85,,190.4,percent of total billed charges,,,49,,109.76,percent of total billed charges,,,90,,201.6,percent of total billed charges,,,,,,,no IP contract,,80,,179.2,percent of total billed charges,,,,,,,no IP contract,,50,,112,percent of total billed charges,,,,,,no IP contract,,,78,,174.72,percent of total billed charges,,,70,,156.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,109.76,3324,
"Med Nutrition Assess and Intervention, Individual each 15 min",97802,CPT,,,,inpatient,,,99,59.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,80.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,84.15,percent of total billed charges,,,85,,84.15,percent of total billed charges,,,49,,48.51,percent of total billed charges,,,90,,89.1,percent of total billed charges,,,,,,,no IP contract,,80,,79.2,percent of total billed charges,,,,,,,no IP contract,,50,,49.5,percent of total billed charges,,,,,,no IP contract,,,78,,77.22,percent of total billed charges,,,70,,69.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,48.51,3324,
Med Nutrition Re-Assessment and Intervention each 15 min,97803,CPT,,,,inpatient,,,99,59.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,80.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,84.15,percent of total billed charges,,,85,,84.15,percent of total billed charges,,,49,,48.51,percent of total billed charges,,,90,,89.1,percent of total billed charges,,,,,,,no IP contract,,80,,79.2,percent of total billed charges,,,,,,,no IP contract,,50,,49.5,percent of total billed charges,,,,,,no IP contract,,,78,,77.22,percent of total billed charges,,,70,,69.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,48.51,3324,
Respiratory Pathogen Panel by Muliplex PCR,0202U,CPT,,,,inpatient,,,2141,1284.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,164% of fee schedule,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1734.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1819.85,percent of total billed charges,,,85,,1819.85,percent of total billed charges,,,49,,1049.09,percent of total billed charges,,,90,,1926.9,percent of total billed charges,,,,,,,no IP contract,,80,,1712.8,percent of total billed charges,,,,,,,no IP contract,,50,,1070.5,percent of total billed charges,,,,,,no IP contract,,,78,,1669.98,percent of total billed charges,,,70,,1498.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
"Prostate Specific Antigen, Screening",G0103,HCPCS,,,,inpatient,,,210,126,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,170.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,178.5,percent of total billed charges,,,85,,178.5,percent of total billed charges,,,49,,102.9,percent of total billed charges,,,90,,189,percent of total billed charges,,,,,,,no IP contract,,80,,168,percent of total billed charges,,,,,,,no IP contract,,50,,105,percent of total billed charges,,,,,,no IP contract,,,78,,163.8,percent of total billed charges,,,70,,147,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,102.9,3324,
Hematopathology Review,85060,CPT,,,,inpatient,,,108,64.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,87.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,91.8,percent of total billed charges,,,85,,91.8,percent of total billed charges,,,49,,52.92,percent of total billed charges,,,90,,97.2,percent of total billed charges,,,,,,,no IP contract,,80,,86.4,percent of total billed charges,,,,,,,no IP contract,,50,,54,percent of total billed charges,,,,,,no IP contract,,,78,,84.24,percent of total billed charges,,,70,,75.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,52.92,3324,
Blood Smear Path Consult without Review of Chart,85060,CPT,,,,inpatient,,,112,67.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,90.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,95.2,percent of total billed charges,,,85,,95.2,percent of total billed charges,,,49,,54.88,percent of total billed charges,,,90,,100.8,percent of total billed charges,,,,,,,no IP contract,,80,,89.6,percent of total billed charges,,,,,,,no IP contract,,50,,56,percent of total billed charges,,,,,,no IP contract,,,78,,87.36,percent of total billed charges,,,70,,78.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,54.88,3324,
Flow cytometry Interpretation 16 or more markers,88189,CPT,,,,inpatient,,,663,397.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,537.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,563.55,percent of total billed charges,,,85,,563.55,percent of total billed charges,,,49,,324.87,percent of total billed charges,,,90,,596.7,percent of total billed charges,,,,,,,no IP contract,,80,,530.4,percent of total billed charges,,,,,,,no IP contract,,50,,331.5,percent of total billed charges,,,,,,no IP contract,,,78,,517.14,percent of total billed charges,,,70,,464.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,324.87,3324,
Education Supplies,99071,CPT,,,,inpatient,,,88,52.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,71.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,74.8,percent of total billed charges,,,85,,74.8,percent of total billed charges,,,49,,43.12,percent of total billed charges,,,90,,79.2,percent of total billed charges,,,,,,,no IP contract,,80,,70.4,percent of total billed charges,,,,,,,no IP contract,,50,,44,percent of total billed charges,,,,,,no IP contract,,,78,,68.64,percent of total billed charges,,,70,,61.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,43.12,3324,
Education/Training,99071,CPT,,,,inpatient,,,108,64.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,87.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,91.8,percent of total billed charges,,,85,,91.8,percent of total billed charges,,,49,,52.92,percent of total billed charges,,,90,,97.2,percent of total billed charges,,,,,,,no IP contract,,80,,86.4,percent of total billed charges,,,,,,,no IP contract,,50,,54,percent of total billed charges,,,,,,no IP contract,,,78,,84.24,percent of total billed charges,,,70,,75.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,52.92,3324,
Non-traumatic Spinal Cord D0502,D0502,LOCAL,,,,inpatient,,,94522.95,56713.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,76563.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,80344.51,percent of total billed charges,,,85,,80344.51,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,85070.66,percent of total billed charges,,,,,,,no IP contract,,80,,75618.36,percent of total billed charges,,,,,,,no IP contract,,50,,47261.48,percent of total billed charges,,,,,,no IP contract,,,78,,73727.9,percent of total billed charges,,,70,,66166.07,percent of total billed charges,,,,,,,,,,,27984.53,100% of Medicare,,,,,46316.7,100% of Medicare,,,,,46316.7,100% of Medicare,,,,,46316.7,100% of Medicare,,,,,46316.7,100% of Medicare,,,,,46316.7,100% of Medicare,,,,,46316.7,100% of Medicare,,,,,46316.7,100% of Medicare,,,,,46316.7,100% of Medicare,,,,,46316.7,100% of Medicare,,,,,46316.7,100% of Medicare,,,,,46316.7,100% of Medicare,,,,,,46316.7,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,85070.66,
Replacement of Lower Extremity D0803,D0803,LOCAL,,,,inpatient,,,24980.2,14988.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20233.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21233.17,percent of total billed charges,,,85,,21233.17,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,22482.18,percent of total billed charges,,,,,,,no IP contract,,80,,19984.16,percent of total billed charges,,,,,,,no IP contract,,50,,12490.1,percent of total billed charges,,,,,,no IP contract,,,78,,19484.56,percent of total billed charges,,,70,,17486.14,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Replacement of Lower Extremity D0804,D0804,LOCAL,,,,inpatient,,,217160.65,130296.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,175900.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,184586.55,percent of total billed charges,,,85,,184586.55,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,195444.59,percent of total billed charges,,,,,,,no IP contract,,80,,173728.52,percent of total billed charges,,,,,,,no IP contract,,50,,108580.33,percent of total billed charges,,,,,,no IP contract,,,78,,169385.31,percent of total billed charges,,,70,,152012.46,percent of total billed charges,,,,,,,,,,,52413.81,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
00009-5182-01 - alprostadil 20 mcg REC I,J0270,HCPCS,00009-5182-01,NDC,,inpatient,0.5,ML,560.55,336.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,454.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,476.47,percent of total billed charges,,,85,,476.47,percent of total billed charges,,,49,,274.67,percent of total billed charges,,,90,,504.5,percent of total billed charges,,,,,,,no IP contract,,80,,448.44,percent of total billed charges,,,,,,,no IP contract,,50,,280.28,percent of total billed charges,,,,,,no IP contract,,,78,,437.23,percent of total billed charges,,,70,,392.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,274.67,3324,
00009-3701-05 - alprostadil 20 mcg REC I,J0270,HCPCS,00009-3701-05,NDC,,inpatient,1,ML,589.2,353.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,477.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,500.82,percent of total billed charges,,,85,,500.82,percent of total billed charges,,,49,,288.71,percent of total billed charges,,,90,,530.28,percent of total billed charges,,,,,,,no IP contract,,80,,471.36,percent of total billed charges,,,,,,,no IP contract,,50,,294.6,percent of total billed charges,,,,,,no IP contract,,,78,,459.58,percent of total billed charges,,,70,,412.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,288.71,3324,
00009-5181-01 - alprostadil 10 mcg REC I,J0270,HCPCS,00009-5181-01,NDC,,inpatient,0.5,ML,789,473.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,639.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,670.65,percent of total billed charges,,,85,,670.65,percent of total billed charges,,,49,,386.61,percent of total billed charges,,,90,,710.1,percent of total billed charges,,,,,,,no IP contract,,80,,631.2,percent of total billed charges,,,,,,,no IP contract,,50,,394.5,percent of total billed charges,,,,,,no IP contract,,,78,,615.42,percent of total billed charges,,,70,,552.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,386.61,3324,
Neurological Conditions D0601,D0601,LOCAL,,,,inpatient,,,47851,28710.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,38759.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,40673.35,percent of total billed charges,,,85,,40673.35,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,43065.9,percent of total billed charges,,,,,,,no IP contract,,80,,38280.8,percent of total billed charges,,,,,,,no IP contract,,50,,23925.5,percent of total billed charges,,,,,,no IP contract,,,78,,37323.78,percent of total billed charges,,,70,,33495.7,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,18477.46,100% of Medicare,,,,,18477.46,100% of Medicare,,,,,18477.46,100% of Medicare,,,,,18477.46,100% of Medicare,,,,,18477.46,100% of Medicare,,,,,18477.46,100% of Medicare,,,,,18477.46,100% of Medicare,,,,,18477.46,100% of Medicare,,,,,18477.46,100% of Medicare,,,,,18477.46,100% of Medicare,,,,,18477.46,100% of Medicare,,,,,,18477.46,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Neurological Conditions D0602,D0602,LOCAL,,,,inpatient,,,86575.39,51945.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,70126.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,73589.08,percent of total billed charges,,,85,,73589.08,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,77917.85,percent of total billed charges,,,,,,,no IP contract,,80,,69260.31,percent of total billed charges,,,,,,,no IP contract,,50,,43287.69,percent of total billed charges,,,,,,no IP contract,,,78,,67528.8,percent of total billed charges,,,70,,60602.77,percent of total billed charges,,,,,,,,,,,19935.64,100% of Medicare,,,,,29860.23,100% of Medicare,,,,,29860.23,100% of Medicare,,,,,29860.23,100% of Medicare,,,,,29860.23,100% of Medicare,,,,,29860.23,100% of Medicare,,,,,29860.23,100% of Medicare,,,,,29860.23,100% of Medicare,,,,,29860.23,100% of Medicare,,,,,29860.23,100% of Medicare,,,,,29860.23,100% of Medicare,,,,,29860.23,100% of Medicare,,,,,,29860.23,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,77917.85,
Neurological Conditions D0603,D0603,LOCAL,,,,inpatient,,,120775.19,72465.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,97827.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,102658.91,percent of total billed charges,,,85,,102658.91,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,108697.67,percent of total billed charges,,,,,,,no IP contract,,80,,96620.15,percent of total billed charges,,,,,,,no IP contract,,50,,60387.6,percent of total billed charges,,,,,,no IP contract,,,78,,94204.65,percent of total billed charges,,,70,,84542.64,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,56586.08,100% of Medicare,,,,,56586.08,100% of Medicare,,,,,56586.08,100% of Medicare,,,,,56586.08,100% of Medicare,,,,,56586.08,100% of Medicare,,,,,56586.08,100% of Medicare,,,,,56586.08,100% of Medicare,,,,,56586.08,100% of Medicare,,,,,56586.08,100% of Medicare,,,,,56586.08,100% of Medicare,,,,,56586.08,100% of Medicare,,,,,,56586.08,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Neurological Conditions D0604,D0604,LOCAL,,,,inpatient,,,152023.59,91214.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,123139.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,129220.05,percent of total billed charges,,,85,,129220.05,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,136821.23,percent of total billed charges,,,,,,,no IP contract,,80,,121618.88,percent of total billed charges,,,,,,,no IP contract,,50,,76011.8,percent of total billed charges,,,,,,no IP contract,,,78,,118578.4,percent of total billed charges,,,70,,106416.52,percent of total billed charges,,,,,,,,,,,46364.98,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/o TBI or SCI D1701,D1701,LOCAL,,,,inpatient,,,94693.44,56816.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,76701.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,80489.42,percent of total billed charges,,,85,,80489.42,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,85224.1,percent of total billed charges,,,,,,,no IP contract,,80,,75754.75,percent of total billed charges,,,,,,,no IP contract,,50,,47346.72,percent of total billed charges,,,,,,no IP contract,,,78,,73860.88,percent of total billed charges,,,70,,66285.41,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,28113.87,100% of Medicare,,,,,28113.87,100% of Medicare,,,,,28113.87,100% of Medicare,,,,,28113.87,100% of Medicare,,,,,28113.87,100% of Medicare,,,,,28113.87,100% of Medicare,,,,,28113.87,100% of Medicare,,,,,28113.87,100% of Medicare,,,,,28113.87,100% of Medicare,,,,,28113.87,100% of Medicare,,,,,28113.87,100% of Medicare,,,,,,28113.87,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/o TBI or SCI D1702,D1702,LOCAL,,,,inpatient,,,130383.48,78230.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,105610.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,110825.96,percent of total billed charges,,,85,,110825.96,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,117345.13,percent of total billed charges,,,,,,,no IP contract,,80,,104306.78,percent of total billed charges,,,,,,,no IP contract,,50,,65191.74,percent of total billed charges,,,,,,no IP contract,,,78,,101699.11,percent of total billed charges,,,70,,91268.43,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,36867.38,100% of Medicare,,,,,36867.38,100% of Medicare,,,,,36867.38,100% of Medicare,,,,,36867.38,100% of Medicare,,,,,36867.38,100% of Medicare,,,,,36867.38,100% of Medicare,,,,,36867.38,100% of Medicare,,,,,36867.38,100% of Medicare,,,,,36867.38,100% of Medicare,,,,,36867.38,100% of Medicare,,,,,36867.38,100% of Medicare,,,,,,36867.38,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/o TBI or SCI D1703,D1703,LOCAL,,,,inpatient,,,122809.66,73685.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,99475.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,104388.21,percent of total billed charges,,,85,,104388.21,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,110528.69,percent of total billed charges,,,,,,,no IP contract,,80,,98247.73,percent of total billed charges,,,,,,,no IP contract,,50,,61404.83,percent of total billed charges,,,,,,no IP contract,,,78,,95791.53,percent of total billed charges,,,70,,85966.76,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/o TBI or SCI D1704,D1704,LOCAL,,,,inpatient,,,184484.28,110690.57,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,149432.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,156811.64,percent of total billed charges,,,85,,156811.64,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,166035.85,percent of total billed charges,,,,,,,no IP contract,,80,,147587.42,percent of total billed charges,,,,,,,no IP contract,,50,,92242.14,percent of total billed charges,,,,,,no IP contract,,,78,,143897.74,percent of total billed charges,,,70,,129139,percent of total billed charges,,,,,,,,,,,37446.28,100% of Medicare,,,,,80534.06,100% of Medicare,,,,,80534.06,100% of Medicare,,,,,80534.06,100% of Medicare,,,,,80534.06,100% of Medicare,,,,,80534.06,100% of Medicare,,,,,80534.06,100% of Medicare,,,,,80534.06,100% of Medicare,,,,,80534.06,100% of Medicare,,,,,80534.06,100% of Medicare,,,,,80534.06,100% of Medicare,,,,,80534.06,100% of Medicare,,,,,,80534.06,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,166035.85,
Major Multi-Trauma w/o TBI or SCI D1705,D1705,LOCAL,,,,inpatient,,,104388.19,62632.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,84554.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,88729.96,percent of total billed charges,,,85,,88729.96,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,93949.37,percent of total billed charges,,,,,,,no IP contract,,80,,83510.55,percent of total billed charges,,,,,,,no IP contract,,50,,52194.1,percent of total billed charges,,,,,,no IP contract,,,78,,81422.79,percent of total billed charges,,,70,,73071.73,percent of total billed charges,,,,,,,,,,,42721.53,100% of Medicare,,,,,34125.05,100% of Medicare,,,,,34125.05,100% of Medicare,,,,,34125.05,100% of Medicare,,,,,34125.05,100% of Medicare,,,,,34125.05,100% of Medicare,,,,,34125.05,100% of Medicare,,,,,34125.05,100% of Medicare,,,,,34125.05,100% of Medicare,,,,,34125.05,100% of Medicare,,,,,34125.05,100% of Medicare,,,,,34125.05,100% of Medicare,,,,,,34125.05,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,93949.37,
Bronchoscopy NMH,31622,CPT,,,,inpatient,,,3873,2323.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3137.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3292.05,percent of total billed charges,,,85,,3292.05,percent of total billed charges,,,49,,1897.77,percent of total billed charges,,,90,,3485.7,percent of total billed charges,,,,,,,no IP contract,,80,,3098.4,percent of total billed charges,,,,,,,no IP contract,,50,,1936.5,percent of total billed charges,,,,,,no IP contract,,,78,,3020.94,percent of total billed charges,,,70,,2711.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3485.7,
TC Bronchoscopy with Brushing NMH,31623,CPT,,,,inpatient,,,4323,2593.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3501.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3674.55,percent of total billed charges,,,85,,3674.55,percent of total billed charges,,,49,,2118.27,percent of total billed charges,,,90,,3890.7,percent of total billed charges,,,,,,,no IP contract,,80,,3458.4,percent of total billed charges,,,,,,,no IP contract,,50,,2161.5,percent of total billed charges,,,,,,no IP contract,,,78,,3371.94,percent of total billed charges,,,70,,3026.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3890.7,
TC Bronchoscopy with Lavage NMH,31624,CPT,,,,inpatient,,,4323,2593.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3501.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3674.55,percent of total billed charges,,,85,,3674.55,percent of total billed charges,,,49,,2118.27,percent of total billed charges,,,90,,3890.7,percent of total billed charges,,,,,,,no IP contract,,80,,3458.4,percent of total billed charges,,,,,,,no IP contract,,50,,2161.5,percent of total billed charges,,,,,,no IP contract,,,78,,3371.94,percent of total billed charges,,,70,,3026.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3890.7,
"BRONCHOSCOPY, W/ASPIRATION TRACHTREE INIT NMH",31645,CPT,,,,inpatient,,,4323,2593.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3501.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3674.55,percent of total billed charges,,,85,,3674.55,percent of total billed charges,,,49,,2118.27,percent of total billed charges,,,90,,3890.7,percent of total billed charges,,,,,,,no IP contract,,80,,3458.4,percent of total billed charges,,,,,,,no IP contract,,50,,2161.5,percent of total billed charges,,,,,,no IP contract,,,78,,3371.94,percent of total billed charges,,,70,,3026.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3890.7,
INSERT TUNNEL CV CATH NMH,36558,CPT,,,,inpatient,,,7345,4407,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5949.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6243.25,percent of total billed charges,,,85,,6243.25,percent of total billed charges,,,49,,3599.05,percent of total billed charges,,,90,,6610.5,percent of total billed charges,,,,,,,no IP contract,,80,,5876,percent of total billed charges,,,,,,,no IP contract,,50,,3672.5,percent of total billed charges,,,,,,no IP contract,,,78,,5729.1,percent of total billed charges,,,70,,5141.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,6610.5,
IR CVA PORT PLACE NMH,36561,CPT,,,,inpatient,,,14592,8755.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11819.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12403.2,percent of total billed charges,,,85,,12403.2,percent of total billed charges,,,49,,7150.08,percent of total billed charges,,,90,,13132.8,percent of total billed charges,,,,,,,no IP contract,,80,,11673.6,percent of total billed charges,,,,,,,no IP contract,,50,,7296,percent of total billed charges,,,,,,no IP contract,,,78,,11381.76,percent of total billed charges,,,70,,10214.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,13132.8,
INS PIC Age 5 yrs/>,36569,CPT,,,,inpatient,,,4568,2740.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3700.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3882.8,percent of total billed charges,,,85,,3882.8,percent of total billed charges,,,49,,2238.32,percent of total billed charges,,,90,,4111.2,percent of total billed charges,,,,,,,no IP contract,,80,,3654.4,percent of total billed charges,,,,,,,no IP contract,,50,,2284,percent of total billed charges,,,,,,no IP contract,,,78,,3563.04,percent of total billed charges,,,70,,3197.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4111.2,
PICC Insert 5 yr or More NMH,36569,CPT,,,,inpatient,,,5154,3092.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4174.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4380.9,percent of total billed charges,,,85,,4380.9,percent of total billed charges,,,49,,2525.46,percent of total billed charges,,,90,,4638.6,percent of total billed charges,,,,,,,no IP contract,,80,,4123.2,percent of total billed charges,,,,,,,no IP contract,,50,,2577,percent of total billed charges,,,,,,no IP contract,,,78,,4020.12,percent of total billed charges,,,70,,3607.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4638.6,
INSJ PICC W/IMAGING 5 YR+ NMH,36573,CPT,,,,inpatient,,,6396,3837.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5180.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5436.6,percent of total billed charges,,,85,,5436.6,percent of total billed charges,,,49,,3134.04,percent of total billed charges,,,90,,5756.4,percent of total billed charges,,,,,,,no IP contract,,80,,5116.8,percent of total billed charges,,,,,,,no IP contract,,50,,3198,percent of total billed charges,,,,,,no IP contract,,,78,,4988.88,percent of total billed charges,,,70,,4477.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,5756.4,
CATH EXCHANGE CENTRAL TUNNELED NMH,36581,CPT,,,,inpatient,,,9892,5935.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8012.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8408.2,percent of total billed charges,,,85,,8408.2,percent of total billed charges,,,49,,4847.08,percent of total billed charges,,,90,,8902.8,percent of total billed charges,,,,,,,no IP contract,,80,,7913.6,percent of total billed charges,,,,,,,no IP contract,,50,,4946,percent of total billed charges,,,,,,no IP contract,,,78,,7715.76,percent of total billed charges,,,70,,6924.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,8902.8,
Central Venous Catheter Reposit NMH,36597,CPT,,,,inpatient,,,1552,931.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1257.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1319.2,percent of total billed charges,,,85,,1319.2,percent of total billed charges,,,49,,760.48,percent of total billed charges,,,90,,1396.8,percent of total billed charges,,,,,,,no IP contract,,80,,1241.6,percent of total billed charges,,,,,,,no IP contract,,50,,776,percent of total billed charges,,,,,,no IP contract,,,78,,1210.56,percent of total billed charges,,,70,,1086.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,760.48,3324,
THRMBC/NFS DIALYSIS CIRCUIT; S&I NMH,36904,CPT,,,,inpatient,,,5955,3573,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4823.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5061.75,percent of total billed charges,,,85,,5061.75,percent of total billed charges,,,49,,2917.95,percent of total billed charges,,,90,,5359.5,percent of total billed charges,,,,,,,no IP contract,,80,,4764,percent of total billed charges,,,,,,,no IP contract,,50,,2977.5,percent of total billed charges,,,,,,no IP contract,,,78,,4644.9,percent of total billed charges,,,70,,4168.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,5359.5,
INS ENDVAS VENACAVAFILTR NMH,37191,CPT,,,,inpatient,,,14252,8551.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11544.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12114.2,percent of total billed charges,,,85,,12114.2,percent of total billed charges,,,49,,6983.48,percent of total billed charges,,,90,,12826.8,percent of total billed charges,,,,,,,no IP contract,,80,,11401.6,percent of total billed charges,,,,,,,no IP contract,,50,,7126,percent of total billed charges,,,,,,no IP contract,,,78,,11116.56,percent of total billed charges,,,70,,9976.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,12826.8,
REM ENDVAS VENACAVA FILTER NMH,37193,CPT,,,,inpatient,,,9868,5920.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7993.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8387.8,percent of total billed charges,,,85,,8387.8,percent of total billed charges,,,49,,4835.32,percent of total billed charges,,,90,,8881.2,percent of total billed charges,,,,,,,no IP contract,,80,,7894.4,percent of total billed charges,,,,,,,no IP contract,,50,,4934,percent of total billed charges,,,,,,no IP contract,,,78,,7697.04,percent of total billed charges,,,70,,6907.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,8881.2,
BONE MARROW BIOPSY NMH,38221,CPT,,,,inpatient,,,1739,1043.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1408.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1478.15,percent of total billed charges,,,85,,1478.15,percent of total billed charges,,,49,,852.11,percent of total billed charges,,,90,,1565.1,percent of total billed charges,,,,,,,no IP contract,,80,,1391.2,percent of total billed charges,,,,,,,no IP contract,,50,,869.5,percent of total billed charges,,,,,,no IP contract,,,78,,1356.42,percent of total billed charges,,,70,,1217.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,29326.86333,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,852.11,29326.86,
Upper GI Endoscopy/G tube Placement NMH,43246,CPT,,,,inpatient,,,5262,3157.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4262.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4472.7,percent of total billed charges,,,85,,4472.7,percent of total billed charges,,,49,,2578.38,percent of total billed charges,,,90,,4735.8,percent of total billed charges,,,,,,,no IP contract,,80,,4209.6,percent of total billed charges,,,,,,,no IP contract,,50,,2631,percent of total billed charges,,,,,,no IP contract,,,78,,4104.36,percent of total billed charges,,,70,,3683.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4735.8,
Needle Biopsy Liver NMH,47000,CPT,,,,inpatient,,,5519,3311.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4470.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4691.15,percent of total billed charges,,,85,,4691.15,percent of total billed charges,,,49,,2704.31,percent of total billed charges,,,90,,4967.1,percent of total billed charges,,,,,,,no IP contract,,80,,4415.2,percent of total billed charges,,,,,,,no IP contract,,50,,2759.5,percent of total billed charges,,,,,,no IP contract,,,78,,4304.82,percent of total billed charges,,,70,,3863.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4967.1,
EXCHANGE BILIARY DRG CATH NMH,47536,CPT,,,,inpatient,,,3250,1950,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2632.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2762.5,percent of total billed charges,,,85,,2762.5,percent of total billed charges,,,49,,1592.5,percent of total billed charges,,,90,,2925,percent of total billed charges,,,,,,,no IP contract,,80,,2600,percent of total billed charges,,,,,,,no IP contract,,50,,1625,percent of total billed charges,,,,,,no IP contract,,,78,,2535,percent of total billed charges,,,70,,2275,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
IMG-GUIDE FLUID COLLECT DRN CATH PERI/RETROPERITONEAL PERQ NMH,49406,CPT,,,,inpatient,,,4968,2980.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4024.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4222.8,percent of total billed charges,,,85,,4222.8,percent of total billed charges,,,49,,2434.32,percent of total billed charges,,,90,,4471.2,percent of total billed charges,,,,,,,no IP contract,,80,,3974.4,percent of total billed charges,,,,,,,no IP contract,,50,,2484,percent of total billed charges,,,,,,no IP contract,,,78,,3875.04,percent of total billed charges,,,70,,3477.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4471.2,
EXCHANGE DRAINAGE CATHETER NMH,49423,CPT,,,,inpatient,,,4715,2829,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3819.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4007.75,percent of total billed charges,,,85,,4007.75,percent of total billed charges,,,49,,2310.35,percent of total billed charges,,,90,,4243.5,percent of total billed charges,,,,,,,no IP contract,,80,,3772,percent of total billed charges,,,,,,,no IP contract,,50,,2357.5,percent of total billed charges,,,,,,no IP contract,,,78,,3677.7,percent of total billed charges,,,70,,3300.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4243.5,
Percutaneous Placement Gastic Tube under fluoro guidance TC NMH,49440,CPT,,,,inpatient,,,6607,3964.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5351.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5615.95,percent of total billed charges,,,85,,5615.95,percent of total billed charges,,,49,,3237.43,percent of total billed charges,,,90,,5946.3,percent of total billed charges,,,,,,,no IP contract,,80,,5285.6,percent of total billed charges,,,,,,,no IP contract,,50,,3303.5,percent of total billed charges,,,,,,no IP contract,,,78,,5153.46,percent of total billed charges,,,70,,4624.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,5946.3,
CHANGE G-TUBE TO G-J PERC NMH,49446,CPT,,,,inpatient,,,5574,3344.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4514.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4737.9,percent of total billed charges,,,85,,4737.9,percent of total billed charges,,,49,,2731.26,percent of total billed charges,,,90,,5016.6,percent of total billed charges,,,,,,,no IP contract,,80,,4459.2,percent of total billed charges,,,,,,,no IP contract,,50,,2787,percent of total billed charges,,,,,,no IP contract,,,78,,4347.72,percent of total billed charges,,,70,,3901.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,5016.6,
Renal Needle Biopsy NMH,50200,CPT,,,,inpatient,,,4040,2424,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3272.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3434,percent of total billed charges,,,85,,3434,percent of total billed charges,,,49,,1979.6,percent of total billed charges,,,90,,3636,percent of total billed charges,,,,,,,no IP contract,,80,,3232,percent of total billed charges,,,,,,,no IP contract,,50,,2020,percent of total billed charges,,,,,,no IP contract,,,78,,3151.2,percent of total billed charges,,,70,,2828,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3636,
EXCHANGE NEPHROSTOMY CATH NMH,50435,CPT,,,,inpatient,,,12648,7588.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10244.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10750.8,percent of total billed charges,,,85,,10750.8,percent of total billed charges,,,49,,6197.52,percent of total billed charges,,,90,,11383.2,percent of total billed charges,,,,,,,no IP contract,,80,,10118.4,percent of total billed charges,,,,,,,no IP contract,,50,,6324,percent of total billed charges,,,,,,no IP contract,,,78,,9865.44,percent of total billed charges,,,70,,8853.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,11383.2,
GK DELIVERY COMPLEX NMH,77371,CPT,,,,inpatient,,,52872,31723.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,42826.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,44941.2,percent of total billed charges,,,85,,44941.2,percent of total billed charges,,,49,,25907.28,percent of total billed charges,,,90,,47584.8,percent of total billed charges,,,,,,,no IP contract,,80,,42297.6,percent of total billed charges,,,,,,,no IP contract,,50,,26436,percent of total billed charges,,,,,,no IP contract,,,78,,41240.16,percent of total billed charges,,,70,,37010.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,17393.63,100% of Medicare,,,,,17393.63,100% of Medicare,,,,,17393.63,100% of Medicare,,,,,17393.63,100% of Medicare,,,,,17393.63,100% of Medicare,,,,,17393.63,100% of Medicare,,,,,17393.63,100% of Medicare,,,,,17393.63,100% of Medicare,,,,,17393.63,100% of Medicare,,,,,17393.63,100% of Medicare,,,,,17393.63,100% of Medicare,,,,,,17393.63,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,47584.8,
BIOPSY OF HEART LINING NMH,93505,CPT,,,,inpatient,,,3348,2008.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2711.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2845.8,percent of total billed charges,,,85,,2845.8,percent of total billed charges,,,49,,1640.52,percent of total billed charges,,,90,,3013.2,percent of total billed charges,,,,,,,no IP contract,,80,,2678.4,percent of total billed charges,,,,,,,no IP contract,,50,,1674,percent of total billed charges,,,,,,no IP contract,,,78,,2611.44,percent of total billed charges,,,70,,2343.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
ED VISIT LEVEL 2 NMH,99282,CPT,,,,inpatient,,,1030,618,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,834.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,875.5,percent of total billed charges,,,85,,875.5,percent of total billed charges,,,49,,504.7,percent of total billed charges,,,90,,927,percent of total billed charges,,,,,,,no IP contract,,80,,824,percent of total billed charges,,,,,,,no IP contract,,50,,515,percent of total billed charges,,,,,,no IP contract,,,78,,803.4,percent of total billed charges,,,70,,721,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,504.7,3324,
ED VISIT LEVEL 3 NMH,99283,CPT,,,,inpatient,,,1832,1099.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1483.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1557.2,percent of total billed charges,,,85,,1557.2,percent of total billed charges,,,49,,897.68,percent of total billed charges,,,90,,1648.8,percent of total billed charges,,,,,,,no IP contract,,80,,1465.6,percent of total billed charges,,,,,,,no IP contract,,50,,916,percent of total billed charges,,,,,,no IP contract,,,78,,1428.96,percent of total billed charges,,,70,,1282.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,897.68,3324,
ED VISIT LEVEL 4 NMH,99284,CPT,,,,inpatient,,,3435,2061,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2782.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2919.75,percent of total billed charges,,,85,,2919.75,percent of total billed charges,,,49,,1683.15,percent of total billed charges,,,90,,3091.5,percent of total billed charges,,,,,,,no IP contract,,80,,2748,percent of total billed charges,,,,,,,no IP contract,,50,,1717.5,percent of total billed charges,,,,,,no IP contract,,,78,,2679.3,percent of total billed charges,,,70,,2404.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
ED VISIT LEVEL 5 NMH,99285,CPT,,,,inpatient,,,4809,2885.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3895.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4087.65,percent of total billed charges,,,85,,4087.65,percent of total billed charges,,,49,,2356.41,percent of total billed charges,,,90,,4328.1,percent of total billed charges,,,,,,,no IP contract,,80,,3847.2,percent of total billed charges,,,,,,,no IP contract,,50,,2404.5,percent of total billed charges,,,,,,no IP contract,,,78,,3751.02,percent of total billed charges,,,70,,3366.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4328.1,
00005-1971-05 - pneumococcal 13-valent conjugate vaccine - Susp,90670,CPT,00005-1971-05,NDC,,inpatient,0.5,ML,1708.5,1025.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1383.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1452.23,percent of total billed charges,,,85,,1452.23,percent of total billed charges,,,49,,837.17,percent of total billed charges,,,90,,1537.65,percent of total billed charges,,,,,,,no IP contract,,80,,1366.8,percent of total billed charges,,,,,,,no IP contract,,50,,854.25,percent of total billed charges,,,,,,no IP contract,,,78,,1332.63,percent of total billed charges,,,70,,1195.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,837.17,3324,
00005-2000-02 - pneumococcal 20-valent conjugate vaccine - Susp,90677,CPT,00005-2000-02,NDC,,inpatient,1,EA,2736.95,1642.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2216.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2326.41,percent of total billed charges,,,85,,2326.41,percent of total billed charges,,,49,,1341.11,percent of total billed charges,,,90,,2463.26,percent of total billed charges,,,,,,,no IP contract,,80,,2189.56,percent of total billed charges,,,,,,,no IP contract,,50,,1368.48,percent of total billed charges,,,,,,no IP contract,,,78,,2134.82,percent of total billed charges,,,70,,1915.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
00006-4943-00 - pneumococcal 23-valent vaccine - Soln,90732,CPT,00006-4943-00,NDC,,inpatient,0.5,ML,317.8,190.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,257.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,270.13,percent of total billed charges,,,85,,270.13,percent of total billed charges,,,49,,155.72,percent of total billed charges,,,90,,286.02,percent of total billed charges,,,,,,,no IP contract,,80,,254.24,percent of total billed charges,,,,,,,no IP contract,,50,,158.9,percent of total billed charges,,,,,,no IP contract,,,78,,247.88,percent of total billed charges,,,70,,222.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,155.72,3324,
00006-4827-00 - varicella virus vaccine - REC I,90716,CPT,00006-4827-00,NDC,,inpatient,0.5,ML,882.85,529.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,715.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,750.42,percent of total billed charges,,,85,,750.42,percent of total billed charges,,,49,,432.6,percent of total billed charges,,,90,,794.57,percent of total billed charges,,,,,,,no IP contract,,80,,706.28,percent of total billed charges,,,,,,,no IP contract,,50,,441.43,percent of total billed charges,,,,,,no IP contract,,,78,,688.62,percent of total billed charges,,,70,,618,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,432.6,3324,
Misc Lab NMH,300,RC,,,,inpatient,,,271.63,162.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,220.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,230.89,percent of total billed charges,,,85,,230.89,percent of total billed charges,,,49,,133.1,percent of total billed charges,,,90,,244.47,percent of total billed charges,,,,,,,no IP contract,,80,,217.3,percent of total billed charges,,,,,,,no IP contract,,50,,135.82,percent of total billed charges,,,,,,no IP contract,,,78,,211.87,percent of total billed charges,,,70,,190.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,133.1,999999999,
Intro of Cath Vena Caba NMH,36010,CPT,,,,inpatient,,,3513,2107.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2845.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2986.05,percent of total billed charges,,,85,,2986.05,percent of total billed charges,,,49,,1721.37,percent of total billed charges,,,90,,3161.7,percent of total billed charges,,,,,,,no IP contract,,80,,2810.4,percent of total billed charges,,,,,,,no IP contract,,50,,1756.5,percent of total billed charges,,,,,,no IP contract,,,78,,2740.14,percent of total billed charges,,,70,,2459.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
IR ABSCESSOGRAM NMH,49424,CPT,,,,inpatient,,,295,177,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,238.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,250.75,percent of total billed charges,,,85,,250.75,percent of total billed charges,,,49,,144.55,percent of total billed charges,,,90,,265.5,percent of total billed charges,,,,,,,no IP contract,,80,,236,percent of total billed charges,,,,,,,no IP contract,,50,,147.5,percent of total billed charges,,,,,,no IP contract,,,78,,230.1,percent of total billed charges,,,70,,206.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,144.55,3324,
Tube Change GI/GU/Abcess TC NMH,75984,CPT,,,,inpatient,,,2574,1544.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2084.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2187.9,percent of total billed charges,,,85,,2187.9,percent of total billed charges,,,49,,1261.26,percent of total billed charges,,,90,,2316.6,percent of total billed charges,,,,,,,no IP contract,,80,,2059.2,percent of total billed charges,,,,,,,no IP contract,,50,,1287,percent of total billed charges,,,,,,no IP contract,,,78,,2007.72,percent of total billed charges,,,70,,1801.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
3D Rendering AT Scanner NMH,76376,CPT,,,,inpatient,,,1373,823.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1112.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1167.05,percent of total billed charges,,,85,,1167.05,percent of total billed charges,,,49,,672.77,percent of total billed charges,,,90,,1235.7,percent of total billed charges,,,,,,,no IP contract,,80,,1098.4,percent of total billed charges,,,,,,,no IP contract,,50,,686.5,percent of total billed charges,,,,,,no IP contract,,,78,,1070.94,percent of total billed charges,,,70,,961.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,672.77,3324,
US Guide Vascular Access Charge,76937,CPT,,,,inpatient,,,1726,1035.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1398.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1467.1,percent of total billed charges,,,85,,1467.1,percent of total billed charges,,,49,,845.74,percent of total billed charges,,,90,,1553.4,percent of total billed charges,,,,,,,no IP contract,,80,,1380.8,percent of total billed charges,,,,,,,no IP contract,,50,,863,percent of total billed charges,,,,,,no IP contract,,,78,,1346.28,percent of total billed charges,,,70,,1208.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,845.74,3324,
US Guidance Vsclr Acess NMH,76937,CPT,,,,inpatient,,,1846,1107.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1495.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1569.1,percent of total billed charges,,,85,,1569.1,percent of total billed charges,,,49,,904.54,percent of total billed charges,,,90,,1661.4,percent of total billed charges,,,,,,,no IP contract,,80,,1476.8,percent of total billed charges,,,,,,,no IP contract,,50,,923,percent of total billed charges,,,,,,no IP contract,,,78,,1439.88,percent of total billed charges,,,70,,1292.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,904.54,3324,
Ultrasound Guidance Bx NMH,76942,CPT,,,,inpatient,,,2436,1461.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1973.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2070.6,percent of total billed charges,,,85,,2070.6,percent of total billed charges,,,49,,1193.64,percent of total billed charges,,,90,,2192.4,percent of total billed charges,,,,,,,no IP contract,,80,,1948.8,percent of total billed charges,,,,,,,no IP contract,,50,,1218,percent of total billed charges,,,,,,no IP contract,,,78,,1900.08,percent of total billed charges,,,70,,1705.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
"Fluoroscopic guidance for cva device placement, replacement NMH",77001,CPT,,,,inpatient,,,1428,856.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1156.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1213.8,percent of total billed charges,,,85,,1213.8,percent of total billed charges,,,49,,699.72,percent of total billed charges,,,90,,1285.2,percent of total billed charges,,,,,,,no IP contract,,80,,1142.4,percent of total billed charges,,,,,,,no IP contract,,50,,714,percent of total billed charges,,,,,,no IP contract,,,78,,1113.84,percent of total billed charges,,,70,,999.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,699.72,3324,
IR FLUORO GUIDE NDL SPINE NMH,77003,CPT,,,,inpatient,,,1657,994.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1342.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1408.45,percent of total billed charges,,,85,,1408.45,percent of total billed charges,,,49,,811.93,percent of total billed charges,,,90,,1491.3,percent of total billed charges,,,,,,,no IP contract,,80,,1325.6,percent of total billed charges,,,,,,,no IP contract,,50,,828.5,percent of total billed charges,,,,,,no IP contract,,,78,,1292.46,percent of total billed charges,,,70,,1159.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,811.93,3324,
CT GUIDANCE; NEEDLE PLACEMENT; S&I NMH,77012,CPT,,,,inpatient,,,4060,2436,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3288.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3451,percent of total billed charges,,,85,,3451,percent of total billed charges,,,49,,1989.4,percent of total billed charges,,,90,,3654,percent of total billed charges,,,,,,,no IP contract,,80,,3248,percent of total billed charges,,,,,,,no IP contract,,50,,2030,percent of total billed charges,,,,,,no IP contract,,,78,,3166.8,percent of total billed charges,,,70,,2842,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3654,
CT guidance for placement of radiation therapy fields NMH,77014,CPT,,,,inpatient,,,2138,1282.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1731.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1817.3,percent of total billed charges,,,85,,1817.3,percent of total billed charges,,,49,,1047.62,percent of total billed charges,,,90,,1924.2,percent of total billed charges,,,,,,,no IP contract,,80,,1710.4,percent of total billed charges,,,,,,,no IP contract,,50,,1069,percent of total billed charges,,,,,,no IP contract,,,78,,1667.64,percent of total billed charges,,,70,,1496.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
Ther Port Film NMH,77417,CPT,,,,inpatient,,,808,484.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,654.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,686.8,percent of total billed charges,,,85,,686.8,percent of total billed charges,,,49,,395.92,percent of total billed charges,,,90,,727.2,percent of total billed charges,,,,,,,no IP contract,,80,,646.4,percent of total billed charges,,,,,,,no IP contract,,50,,404,percent of total billed charges,,,,,,no IP contract,,,78,,630.24,percent of total billed charges,,,70,,565.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,395.92,3324,
"Flow cytometry each cell surface, cytoplasmic or nuclear marker, each additional marker",88185,CPT,,,,inpatient,,,197,118.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,159.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,167.45,percent of total billed charges,,,85,,167.45,percent of total billed charges,,,49,,96.53,percent of total billed charges,,,90,,177.3,percent of total billed charges,,,,,,,no IP contract,,80,,157.6,percent of total billed charges,,,,,,,no IP contract,,50,,98.5,percent of total billed charges,,,,,,no IP contract,,,78,,153.66,percent of total billed charges,,,70,,137.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,96.53,3324,
DECALCIFY TISSUE NMH,88311,CPT,,,,inpatient,,,209,125.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,169.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,177.65,percent of total billed charges,,,85,,177.65,percent of total billed charges,,,49,,102.41,percent of total billed charges,,,90,,188.1,percent of total billed charges,,,,,,,no IP contract,,80,,167.2,percent of total billed charges,,,,,,,no IP contract,,50,,104.5,percent of total billed charges,,,,,,no IP contract,,,78,,163.02,percent of total billed charges,,,70,,146.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,102.41,3324,
"IHC STAIN, ADDT'L GROUP 1 NMH",88341,CPT,,,,inpatient,,,374,224.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,302.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,317.9,percent of total billed charges,,,85,,317.9,percent of total billed charges,,,49,,183.26,percent of total billed charges,,,90,,336.6,percent of total billed charges,,,,,,,no IP contract,,80,,299.2,percent of total billed charges,,,,,,,no IP contract,,50,,187,percent of total billed charges,,,,,,no IP contract,,,78,,291.72,percent of total billed charges,,,70,,261.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,183.26,3324,
IMMUNIZATION ADMIN EACH ADD NMH,90472,CPT,,,,inpatient,,,76,45.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,61.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,64.6,percent of total billed charges,,,85,,64.6,percent of total billed charges,,,49,,37.24,percent of total billed charges,,,90,,68.4,percent of total billed charges,,,,,,,no IP contract,,80,,60.8,percent of total billed charges,,,,,,,no IP contract,,50,,38,percent of total billed charges,,,,,,no IP contract,,,78,,59.28,percent of total billed charges,,,70,,53.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,37.24,3324,
"49281-0860-10 - poliovirus vaccine, inactivated - Susp",90713,CPT,49281-0860-10,NDC,,inpatient,0.5,ML,248,148.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,200.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,210.8,percent of total billed charges,,,85,,210.8,percent of total billed charges,,,49,,121.52,percent of total billed charges,,,90,,223.2,percent of total billed charges,,,,,,,no IP contract,,80,,198.4,percent of total billed charges,,,,,,,no IP contract,,50,,124,percent of total billed charges,,,,,,no IP contract,,,78,,193.44,percent of total billed charges,,,70,,173.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,121.52,3324,
"49281-0860-52 - poliovirus vaccine, inactivated - Susp",90713,CPT,49281-0860-52,NDC,,inpatient,0.5,ML,274.8,164.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,222.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,233.58,percent of total billed charges,,,85,,233.58,percent of total billed charges,,,49,,134.65,percent of total billed charges,,,90,,247.32,percent of total billed charges,,,,,,,no IP contract,,80,,219.84,percent of total billed charges,,,,,,,no IP contract,,50,,137.4,percent of total billed charges,,,,,,no IP contract,,,78,,214.34,percent of total billed charges,,,70,,192.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,134.65,3324,
Echocardiogram NMH,93320,CPT,,,,inpatient,,,1483,889.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1201.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1260.55,percent of total billed charges,,,85,,1260.55,percent of total billed charges,,,49,,726.67,percent of total billed charges,,,90,,1334.7,percent of total billed charges,,,,,,,no IP contract,,80,,1186.4,percent of total billed charges,,,,,,,no IP contract,,50,,741.5,percent of total billed charges,,,,,,no IP contract,,,78,,1156.74,percent of total billed charges,,,70,,1038.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,726.67,3324,
Color Flow Mappling NMH,93325,CPT,,,,inpatient,,,1234,740.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,999.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1048.9,percent of total billed charges,,,85,,1048.9,percent of total billed charges,,,49,,604.66,percent of total billed charges,,,90,,1110.6,percent of total billed charges,,,,,,,no IP contract,,80,,987.2,percent of total billed charges,,,,,,,no IP contract,,50,,617,percent of total billed charges,,,,,,no IP contract,,,78,,962.52,percent of total billed charges,,,70,,863.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,604.66,3324,
Inspiratory Muscle Trainer,94760,CPT,,,,inpatient,,,175,105,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,141.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,148.75,percent of total billed charges,,,85,,148.75,percent of total billed charges,,,49,,85.75,percent of total billed charges,,,90,,157.5,percent of total billed charges,,,,,,,no IP contract,,80,,140,percent of total billed charges,,,,,,,no IP contract,,50,,87.5,percent of total billed charges,,,,,,no IP contract,,,78,,136.5,percent of total billed charges,,,70,,122.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,85.75,3324,
Oximetry Monitor,94760,CPT,,,,inpatient,,,175,105,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,141.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,148.75,percent of total billed charges,,,85,,148.75,percent of total billed charges,,,49,,85.75,percent of total billed charges,,,90,,157.5,percent of total billed charges,,,,,,,no IP contract,,80,,140,percent of total billed charges,,,,,,,no IP contract,,50,,87.5,percent of total billed charges,,,,,,no IP contract,,,78,,136.5,percent of total billed charges,,,70,,122.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,85.75,3324,
Oxygen Therapy 0-60 minutes,94760,CPT,,,,inpatient,,,175,105,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,141.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,148.75,percent of total billed charges,,,85,,148.75,percent of total billed charges,,,49,,85.75,percent of total billed charges,,,90,,157.5,percent of total billed charges,,,,,,,no IP contract,,80,,140,percent of total billed charges,,,,,,,no IP contract,,50,,87.5,percent of total billed charges,,,,,,no IP contract,,,78,,136.5,percent of total billed charges,,,70,,122.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,85.75,3324,
Pulse Oximeter,94760,CPT,,,,inpatient,,,175,105,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,141.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,148.75,percent of total billed charges,,,85,,148.75,percent of total billed charges,,,49,,85.75,percent of total billed charges,,,90,,157.5,percent of total billed charges,,,,,,,no IP contract,,80,,140,percent of total billed charges,,,,,,,no IP contract,,50,,87.5,percent of total billed charges,,,,,,no IP contract,,,78,,136.5,percent of total billed charges,,,70,,122.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,85.75,3324,
Pulse Oximetry,94760,CPT,,,,inpatient,,,175,105,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,141.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,148.75,percent of total billed charges,,,85,,148.75,percent of total billed charges,,,49,,85.75,percent of total billed charges,,,90,,157.5,percent of total billed charges,,,,,,,no IP contract,,80,,140,percent of total billed charges,,,,,,,no IP contract,,50,,87.5,percent of total billed charges,,,,,,no IP contract,,,78,,136.5,percent of total billed charges,,,70,,122.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,85.75,3324,
Pulse oximetry,94760,CPT,,,,inpatient,,,175,105,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,141.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,148.75,percent of total billed charges,,,85,,148.75,percent of total billed charges,,,49,,85.75,percent of total billed charges,,,90,,157.5,percent of total billed charges,,,,,,,no IP contract,,80,,140,percent of total billed charges,,,,,,,no IP contract,,50,,87.5,percent of total billed charges,,,,,,no IP contract,,,78,,136.5,percent of total billed charges,,,70,,122.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,85.75,3324,
Pulse Oximetry- Spot Check,94760,CPT,,,,inpatient,,,175,105,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,141.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,148.75,percent of total billed charges,,,85,,148.75,percent of total billed charges,,,49,,85.75,percent of total billed charges,,,90,,157.5,percent of total billed charges,,,,,,,no IP contract,,80,,140,percent of total billed charges,,,,,,,no IP contract,,50,,87.5,percent of total billed charges,,,,,,no IP contract,,,78,,136.5,percent of total billed charges,,,70,,122.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,85.75,3324,
Pulse Oximetry-Spot Check Charge,94760,CPT,,,,inpatient,,,175,105,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,141.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,148.75,percent of total billed charges,,,85,,148.75,percent of total billed charges,,,49,,85.75,percent of total billed charges,,,90,,157.5,percent of total billed charges,,,,,,,no IP contract,,80,,140,percent of total billed charges,,,,,,,no IP contract,,50,,87.5,percent of total billed charges,,,,,,no IP contract,,,78,,136.5,percent of total billed charges,,,70,,122.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,85.75,3324,
Oximetry Exercise,94761,CPT,,,,inpatient,,,367,220.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,297.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,311.95,percent of total billed charges,,,85,,311.95,percent of total billed charges,,,49,,179.83,percent of total billed charges,,,90,,330.3,percent of total billed charges,,,,,,,no IP contract,,80,,293.6,percent of total billed charges,,,,,,,no IP contract,,50,,183.5,percent of total billed charges,,,,,,no IP contract,,,78,,286.26,percent of total billed charges,,,70,,256.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,179.83,3324,
Pulmonary Exercise Oximetry Charge,94761,CPT,,,,inpatient,,,367,220.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,297.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,311.95,percent of total billed charges,,,85,,311.95,percent of total billed charges,,,49,,179.83,percent of total billed charges,,,90,,330.3,percent of total billed charges,,,,,,,no IP contract,,80,,293.6,percent of total billed charges,,,,,,,no IP contract,,50,,183.5,percent of total billed charges,,,,,,no IP contract,,,78,,286.26,percent of total billed charges,,,70,,256.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,179.83,3324,
Pulse Oximetry-Cont/Exercise,94761,CPT,,,,inpatient,,,367,220.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,297.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,311.95,percent of total billed charges,,,85,,311.95,percent of total billed charges,,,49,,179.83,percent of total billed charges,,,90,,330.3,percent of total billed charges,,,,,,,no IP contract,,80,,293.6,percent of total billed charges,,,,,,,no IP contract,,50,,183.5,percent of total billed charges,,,,,,no IP contract,,,78,,286.26,percent of total billed charges,,,70,,256.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,179.83,3324,
Pulse oximetry-multiple determinations,94761,CPT,,,,inpatient,,,367,220.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,297.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,311.95,percent of total billed charges,,,85,,311.95,percent of total billed charges,,,49,,179.83,percent of total billed charges,,,90,,330.3,percent of total billed charges,,,,,,,no IP contract,,80,,293.6,percent of total billed charges,,,,,,,no IP contract,,50,,183.5,percent of total billed charges,,,,,,no IP contract,,,78,,286.26,percent of total billed charges,,,70,,256.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,179.83,3324,
Pulse Oximetry-Multiple Determinations Charge,94761,CPT,,,,inpatient,,,367,220.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,297.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,311.95,percent of total billed charges,,,85,,311.95,percent of total billed charges,,,49,,179.83,percent of total billed charges,,,90,,330.3,percent of total billed charges,,,,,,,no IP contract,,80,,293.6,percent of total billed charges,,,,,,,no IP contract,,50,,183.5,percent of total billed charges,,,,,,no IP contract,,,78,,286.26,percent of total billed charges,,,70,,256.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,179.83,3324,
Yes - Pulmonary Exercise Oximetry Charge,94761,CPT,,,,inpatient,,,367,220.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,297.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,311.95,percent of total billed charges,,,85,,311.95,percent of total billed charges,,,49,,179.83,percent of total billed charges,,,90,,330.3,percent of total billed charges,,,,,,,no IP contract,,80,,293.6,percent of total billed charges,,,,,,,no IP contract,,50,,183.5,percent of total billed charges,,,,,,no IP contract,,,78,,286.26,percent of total billed charges,,,70,,256.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,179.83,3324,
Pulse Oximetry Cont/Exercise,94761,CPT,,,,inpatient,,,1264,758.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1023.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1074.4,percent of total billed charges,,,85,,1074.4,percent of total billed charges,,,49,,619.36,percent of total billed charges,,,90,,1137.6,percent of total billed charges,,,,,,,no IP contract,,80,,1011.2,percent of total billed charges,,,,,,,no IP contract,,50,,632,percent of total billed charges,,,,,,no IP contract,,,78,,985.92,percent of total billed charges,,,70,,884.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,619.36,3324,
TX/PRO/DX INJ SAME DRUG ADON NMH,96376,CPT,,,,inpatient,,,231,138.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,187.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,196.35,percent of total billed charges,,,85,,196.35,percent of total billed charges,,,49,,113.19,percent of total billed charges,,,90,,207.9,percent of total billed charges,,,,,,,no IP contract,,80,,184.8,percent of total billed charges,,,,,,,no IP contract,,50,,115.5,percent of total billed charges,,,,,,no IP contract,,,78,,180.18,percent of total billed charges,,,70,,161.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,113.19,3324,
MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS NMH (99152),99152,CPT,,,,inpatient,,,597,358.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,483.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,507.45,percent of total billed charges,,,85,,507.45,percent of total billed charges,,,49,,292.53,percent of total billed charges,,,90,,537.3,percent of total billed charges,,,,,,,no IP contract,,80,,477.6,percent of total billed charges,,,,,,,no IP contract,,50,,298.5,percent of total billed charges,,,,,,no IP contract,,,78,,465.66,percent of total billed charges,,,70,,417.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,292.53,3324,
MOD SED SAME PHYS/QHP EACH ADDL 15 MINS 5/> YRS NMH (99153),99153,CPT,,,,inpatient,,,254,152.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,205.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,215.9,percent of total billed charges,,,85,,215.9,percent of total billed charges,,,49,,124.46,percent of total billed charges,,,90,,228.6,percent of total billed charges,,,,,,,no IP contract,,80,,203.2,percent of total billed charges,,,,,,,no IP contract,,50,,127,percent of total billed charges,,,,,,no IP contract,,,78,,198.12,percent of total billed charges,,,70,,177.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,124.46,3324,
Miscellaneous A2001,A2001,LOCAL,,,,inpatient,,,83157.74,49894.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,67357.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,70684.08,percent of total billed charges,,,85,,70684.08,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,74841.96,percent of total billed charges,,,,,,,no IP contract,,80,,66526.19,percent of total billed charges,,,,,,,no IP contract,,50,,41578.87,percent of total billed charges,,,,,,no IP contract,,,78,,64863.04,percent of total billed charges,,,70,,58210.42,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Miscellaneous A2002,A2002,LOCAL,,,,inpatient,,,83519.79,50111.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,67651.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,70991.82,percent of total billed charges,,,85,,70991.82,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,75167.81,percent of total billed charges,,,,,,,no IP contract,,80,,66815.83,percent of total billed charges,,,,,,,no IP contract,,50,,41759.89,percent of total billed charges,,,,,,no IP contract,,,78,,65145.43,percent of total billed charges,,,70,,58463.85,percent of total billed charges,,,,,,,,,,,24168.41,100% of Medicare,,,,,20680.45,100% of Medicare,,,,,20680.45,100% of Medicare,,,,,20680.45,100% of Medicare,,,,,20680.45,100% of Medicare,,,,,20680.45,100% of Medicare,,,,,20680.45,100% of Medicare,,,,,20680.45,100% of Medicare,,,,,20680.45,100% of Medicare,,,,,20680.45,100% of Medicare,,,,,20680.45,100% of Medicare,,,,,20680.45,100% of Medicare,,,,,,20680.45,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,75167.81,
Miscellaneous A2004,A2004,LOCAL,,,,inpatient,,,116153.83,69692.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,94084.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,98730.75,percent of total billed charges,,,85,,98730.75,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,104538.44,percent of total billed charges,,,,,,,no IP contract,,80,,92923.06,percent of total billed charges,,,,,,,no IP contract,,50,,58076.91,percent of total billed charges,,,,,,no IP contract,,,78,,90599.98,percent of total billed charges,,,70,,81307.68,percent of total billed charges,,,,,,,,,,,30940.16,100% of Medicare,,,,,35084.3,100% of Medicare,,,,,35084.3,100% of Medicare,,,,,35084.3,100% of Medicare,,,,,35084.3,100% of Medicare,,,,,35084.3,100% of Medicare,,,,,35084.3,100% of Medicare,,,,,35084.3,100% of Medicare,,,,,35084.3,100% of Medicare,,,,,35084.3,100% of Medicare,,,,,35084.3,100% of Medicare,,,,,35084.3,100% of Medicare,,,,,,35084.3,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,104538.44,
Miscellaneous A2005,A2005,LOCAL,,,,inpatient,,,127347.24,76408.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,103151.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,108245.15,percent of total billed charges,,,85,,108245.15,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,114612.51,percent of total billed charges,,,,,,,no IP contract,,80,,101877.79,percent of total billed charges,,,,,,,no IP contract,,50,,63673.62,percent of total billed charges,,,,,,no IP contract,,,78,,99330.85,percent of total billed charges,,,70,,89143.07,percent of total billed charges,,,,,,,,,,,35247.24,100% of Medicare,,,,,40037.46,100% of Medicare,,,,,40037.46,100% of Medicare,,,,,40037.46,100% of Medicare,,,,,40037.46,100% of Medicare,,,,,40037.46,100% of Medicare,,,,,40037.46,100% of Medicare,,,,,40037.46,100% of Medicare,,,,,40037.46,100% of Medicare,,,,,40037.46,100% of Medicare,,,,,40037.46,100% of Medicare,,,,,40037.46,100% of Medicare,,,,,,40037.46,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,114612.51,
HYDROFERA BLUE FOAM DRESSING 4 X 5 in,A6209,HCPCS,,,,inpatient,,,6,3.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.1,percent of total billed charges,,,85,,5.1,percent of total billed charges,,,49,,2.94,percent of total billed charges,,,90,,5.4,percent of total billed charges,,,,,,,no IP contract,,80,,4.8,percent of total billed charges,,,,,,,no IP contract,,50,,3,percent of total billed charges,,,,,,no IP contract,,,78,,4.68,percent of total billed charges,,,70,,4.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.94,3324,
Nontunnelled Catheter Charge,C1752,HCPCS,,,,inpatient,,,774,464.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,626.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,657.9,percent of total billed charges,,,85,,657.9,percent of total billed charges,,,49,,379.26,percent of total billed charges,,,90,,696.6,percent of total billed charges,,,,,,,no IP contract,,80,,619.2,percent of total billed charges,,,,,,,no IP contract,,50,,387,percent of total billed charges,,,,,,no IP contract,,,78,,603.72,percent of total billed charges,,,70,,541.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,379.26,3324,
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE NMH,30901,CPT,,,,inpatient,,,1206,723.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,976.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1025.1,percent of total billed charges,,,85,,1025.1,percent of total billed charges,,,49,,590.94,percent of total billed charges,,,90,,1085.4,percent of total billed charges,,,,,,,no IP contract,,80,,964.8,percent of total billed charges,,,,,,,no IP contract,,50,,603,percent of total billed charges,,,,,,no IP contract,,,78,,940.68,percent of total billed charges,,,70,,844.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,590.94,3324,
Yes - Arterial Blood Gas Charge,36600,CPT,,,,inpatient,,,194,116.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,157.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,164.9,percent of total billed charges,,,85,,164.9,percent of total billed charges,,,49,,95.06,percent of total billed charges,,,90,,174.6,percent of total billed charges,,,,,,,no IP contract,,80,,155.2,percent of total billed charges,,,,,,,no IP contract,,50,,97,percent of total billed charges,,,,,,no IP contract,,,78,,151.32,percent of total billed charges,,,70,,135.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,95.06,3324,
Yes - Arterial Blood Gas Collection,36600,CPT,,,,inpatient,,,194,116.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,157.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,164.9,percent of total billed charges,,,85,,164.9,percent of total billed charges,,,49,,95.06,percent of total billed charges,,,90,,174.6,percent of total billed charges,,,,,,,no IP contract,,80,,155.2,percent of total billed charges,,,,,,,no IP contract,,50,,97,percent of total billed charges,,,,,,no IP contract,,,78,,151.32,percent of total billed charges,,,70,,135.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,95.06,3324,
Yes - Arterial Blood Gas Lab Charge,36600,CPT,,,,inpatient,,,194,116.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,157.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,164.9,percent of total billed charges,,,85,,164.9,percent of total billed charges,,,49,,95.06,percent of total billed charges,,,90,,174.6,percent of total billed charges,,,,,,,no IP contract,,80,,155.2,percent of total billed charges,,,,,,,no IP contract,,50,,97,percent of total billed charges,,,,,,no IP contract,,,78,,151.32,percent of total billed charges,,,70,,135.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,95.06,3324,
IR GI TUBE CHECK NMH,49465,CPT,,,,inpatient,,,2371,1422.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1920.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2015.35,percent of total billed charges,,,85,,2015.35,percent of total billed charges,,,49,,1161.79,percent of total billed charges,,,90,,2133.9,percent of total billed charges,,,,,,,no IP contract,,80,,1896.8,percent of total billed charges,,,,,,,no IP contract,,50,,1185.5,percent of total billed charges,,,,,,no IP contract,,,78,,1849.38,percent of total billed charges,,,70,,1659.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
Yes - Bladder Scan Performed,51798,CPT,,,,inpatient,,,190,114,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,153.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,161.5,percent of total billed charges,,,85,,161.5,percent of total billed charges,,,49,,93.1,percent of total billed charges,,,90,,171,percent of total billed charges,,,,,,,no IP contract,,80,,152,percent of total billed charges,,,,,,,no IP contract,,50,,95,percent of total billed charges,,,,,,no IP contract,,,78,,148.2,percent of total billed charges,,,70,,133,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,93.1,3324,
Xray-Mandible 1-3 Views NMH,70100,CPT,,,,inpatient,,,749,449.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,606.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,636.65,percent of total billed charges,,,85,,636.65,percent of total billed charges,,,49,,367.01,percent of total billed charges,,,90,,674.1,percent of total billed charges,,,,,,,no IP contract,,80,,599.2,percent of total billed charges,,,,,,,no IP contract,,50,,374.5,percent of total billed charges,,,,,,no IP contract,,,78,,584.22,percent of total billed charges,,,70,,524.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,367.01,3324,
Xray-Mastoids 3+ Views NMH,70130,CPT,,,,inpatient,,,759,455.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,614.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,645.15,percent of total billed charges,,,85,,645.15,percent of total billed charges,,,49,,371.91,percent of total billed charges,,,90,,683.1,percent of total billed charges,,,,,,,no IP contract,,80,,607.2,percent of total billed charges,,,,,,,no IP contract,,50,,379.5,percent of total billed charges,,,,,,no IP contract,,,78,,592.02,percent of total billed charges,,,70,,531.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,371.91,3324,
Xray-Facial Bones 3+ Views NMH,70150,CPT,,,,inpatient,,,1282,769.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1038.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1089.7,percent of total billed charges,,,85,,1089.7,percent of total billed charges,,,49,,628.18,percent of total billed charges,,,90,,1153.8,percent of total billed charges,,,,,,,no IP contract,,80,,1025.6,percent of total billed charges,,,,,,,no IP contract,,50,,641,percent of total billed charges,,,,,,no IP contract,,,78,,999.96,percent of total billed charges,,,70,,897.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,628.18,3324,
Xray-Nasal Bones 3+ Views NMH,70160,CPT,,,,inpatient,,,1023,613.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,828.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,869.55,percent of total billed charges,,,85,,869.55,percent of total billed charges,,,49,,501.27,percent of total billed charges,,,90,,920.7,percent of total billed charges,,,,,,,no IP contract,,80,,818.4,percent of total billed charges,,,,,,,no IP contract,,50,,511.5,percent of total billed charges,,,,,,no IP contract,,,78,,797.94,percent of total billed charges,,,70,,716.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,501.27,3324,
Xray-Orbits 4+ Views NMH,70200,CPT,,,,inpatient,,,1183,709.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,958.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1005.55,percent of total billed charges,,,85,,1005.55,percent of total billed charges,,,49,,579.67,percent of total billed charges,,,90,,1064.7,percent of total billed charges,,,,,,,no IP contract,,80,,946.4,percent of total billed charges,,,,,,,no IP contract,,50,,591.5,percent of total billed charges,,,,,,no IP contract,,,78,,922.74,percent of total billed charges,,,70,,828.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,579.67,3324,
Xray-Sinuses 3+ Views NMH,70220,CPT,,,,inpatient,,,1201,720.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,972.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1020.85,percent of total billed charges,,,85,,1020.85,percent of total billed charges,,,49,,588.49,percent of total billed charges,,,90,,1080.9,percent of total billed charges,,,,,,,no IP contract,,80,,960.8,percent of total billed charges,,,,,,,no IP contract,,50,,600.5,percent of total billed charges,,,,,,no IP contract,,,78,,936.78,percent of total billed charges,,,70,,840.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,588.49,3324,
Xray-Skull 1-3 Views NMH,70250,CPT,,,,inpatient,,,692,415.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,560.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,588.2,percent of total billed charges,,,85,,588.2,percent of total billed charges,,,49,,339.08,percent of total billed charges,,,90,,622.8,percent of total billed charges,,,,,,,no IP contract,,80,,553.6,percent of total billed charges,,,,,,,no IP contract,,50,,346,percent of total billed charges,,,,,,no IP contract,,,78,,539.76,percent of total billed charges,,,70,,484.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,339.08,3324,
Xray-Zygomas NMH,70250,CPT,,,,inpatient,,,692,415.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,560.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,588.2,percent of total billed charges,,,85,,588.2,percent of total billed charges,,,49,,339.08,percent of total billed charges,,,90,,622.8,percent of total billed charges,,,,,,,no IP contract,,80,,553.6,percent of total billed charges,,,,,,,no IP contract,,50,,346,percent of total billed charges,,,,,,no IP contract,,,78,,539.76,percent of total billed charges,,,70,,484.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,339.08,3324,
Xray-Skull 4+ Views NMH,70260,CPT,,,,inpatient,,,1160,696,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,939.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,986,percent of total billed charges,,,85,,986,percent of total billed charges,,,49,,568.4,percent of total billed charges,,,90,,1044,percent of total billed charges,,,,,,,no IP contract,,80,,928,percent of total billed charges,,,,,,,no IP contract,,50,,580,percent of total billed charges,,,,,,no IP contract,,,78,,904.8,percent of total billed charges,,,70,,812,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,568.4,3324,
Xray-Panorex NMH,70355,CPT,,,,inpatient,,,989,593.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,801.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,840.65,percent of total billed charges,,,85,,840.65,percent of total billed charges,,,49,,484.61,percent of total billed charges,,,90,,890.1,percent of total billed charges,,,,,,,no IP contract,,80,,791.2,percent of total billed charges,,,,,,,no IP contract,,50,,494.5,percent of total billed charges,,,,,,no IP contract,,,78,,771.42,percent of total billed charges,,,70,,692.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,484.61,3324,
Xray-Neck Soft Tissue NMH,70360,CPT,,,,inpatient,,,600,360,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,486,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,510,percent of total billed charges,,,85,,510,percent of total billed charges,,,49,,294,percent of total billed charges,,,90,,540,percent of total billed charges,,,,,,,no IP contract,,80,,480,percent of total billed charges,,,,,,,no IP contract,,50,,300,percent of total billed charges,,,,,,no IP contract,,,78,,468,percent of total billed charges,,,70,,420,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,294,3324,
Xray-Ribs Unilateral 3+ Views NMH,71101,CPT,,,,inpatient,,,1118,670.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,905.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,950.3,percent of total billed charges,,,85,,950.3,percent of total billed charges,,,49,,547.82,percent of total billed charges,,,90,,1006.2,percent of total billed charges,,,,,,,no IP contract,,80,,894.4,percent of total billed charges,,,,,,,no IP contract,,50,,559,percent of total billed charges,,,,,,no IP contract,,,78,,872.04,percent of total billed charges,,,70,,782.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,547.82,3324,
Xray-Sternum 2 + Views NMH,71120,CPT,,,,inpatient,,,769,461.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,622.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,653.65,percent of total billed charges,,,85,,653.65,percent of total billed charges,,,49,,376.81,percent of total billed charges,,,90,,692.1,percent of total billed charges,,,,,,,no IP contract,,80,,615.2,percent of total billed charges,,,,,,,no IP contract,,50,,384.5,percent of total billed charges,,,,,,no IP contract,,,78,,599.82,percent of total billed charges,,,70,,538.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,376.81,3324,
Xray-Sternoclavicular Joints 3 views NMH,71130,CPT,,,,inpatient,,,1009,605.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,817.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,857.65,percent of total billed charges,,,85,,857.65,percent of total billed charges,,,49,,494.41,percent of total billed charges,,,90,,908.1,percent of total billed charges,,,,,,,no IP contract,,80,,807.2,percent of total billed charges,,,,,,,no IP contract,,50,,504.5,percent of total billed charges,,,,,,no IP contract,,,78,,787.02,percent of total billed charges,,,70,,706.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,494.41,3324,
Xray-Spine 1 View NMH,72020,CPT,,,,inpatient,,,643,385.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,520.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,546.55,percent of total billed charges,,,85,,546.55,percent of total billed charges,,,49,,315.07,percent of total billed charges,,,90,,578.7,percent of total billed charges,,,,,,,no IP contract,,80,,514.4,percent of total billed charges,,,,,,,no IP contract,,50,,321.5,percent of total billed charges,,,,,,no IP contract,,,78,,501.54,percent of total billed charges,,,70,,450.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,315.07,3324,
Xray-C-Spine AP & Lateral NMH,72040,CPT,,,,inpatient,,,951,570.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,770.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,808.35,percent of total billed charges,,,85,,808.35,percent of total billed charges,,,49,,465.99,percent of total billed charges,,,90,,855.9,percent of total billed charges,,,,,,,no IP contract,,80,,760.8,percent of total billed charges,,,,,,,no IP contract,,50,,475.5,percent of total billed charges,,,,,,no IP contract,,,78,,741.78,percent of total billed charges,,,70,,665.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,465.99,3324,
Xray-C-Spine Flex-Ext NMH,72050,CPT,,,,inpatient,,,1348,808.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1091.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1145.8,percent of total billed charges,,,85,,1145.8,percent of total billed charges,,,49,,660.52,percent of total billed charges,,,90,,1213.2,percent of total billed charges,,,,,,,no IP contract,,80,,1078.4,percent of total billed charges,,,,,,,no IP contract,,50,,674,percent of total billed charges,,,,,,no IP contract,,,78,,1051.44,percent of total billed charges,,,70,,943.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,660.52,3324,
Xray-C-Spine Obliques NMH,72052,CPT,,,,inpatient,,,1408,844.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1140.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1196.8,percent of total billed charges,,,85,,1196.8,percent of total billed charges,,,49,,689.92,percent of total billed charges,,,90,,1267.2,percent of total billed charges,,,,,,,no IP contract,,80,,1126.4,percent of total billed charges,,,,,,,no IP contract,,50,,704,percent of total billed charges,,,,,,no IP contract,,,78,,1098.24,percent of total billed charges,,,70,,985.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,689.92,3324,
Xray-Thoracic AP/Lat NMH,72070,CPT,,,,inpatient,,,997,598.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,807.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,847.45,percent of total billed charges,,,85,,847.45,percent of total billed charges,,,49,,488.53,percent of total billed charges,,,90,,897.3,percent of total billed charges,,,,,,,no IP contract,,80,,797.6,percent of total billed charges,,,,,,,no IP contract,,50,,498.5,percent of total billed charges,,,,,,no IP contract,,,78,,777.66,percent of total billed charges,,,70,,697.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,488.53,3324,
Xray-T-Spine AP & Lateral & Swim NMH,72072,CPT,,,,inpatient,,,1112,667.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,900.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,945.2,percent of total billed charges,,,85,,945.2,percent of total billed charges,,,49,,544.88,percent of total billed charges,,,90,,1000.8,percent of total billed charges,,,,,,,no IP contract,,80,,889.6,percent of total billed charges,,,,,,,no IP contract,,50,,556,percent of total billed charges,,,,,,no IP contract,,,78,,867.36,percent of total billed charges,,,70,,778.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,544.88,3324,
Xray-TL-Spine AP & Lateral NMH,72080,CPT,,,,inpatient,,,928,556.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,751.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,788.8,percent of total billed charges,,,85,,788.8,percent of total billed charges,,,49,,454.72,percent of total billed charges,,,90,,835.2,percent of total billed charges,,,,,,,no IP contract,,80,,742.4,percent of total billed charges,,,,,,,no IP contract,,50,,464,percent of total billed charges,,,,,,no IP contract,,,78,,723.84,percent of total billed charges,,,70,,649.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,454.72,3324,
Xray-LS-Spine AP & Lateral NMH,72100,CPT,,,,inpatient,,,931,558.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,754.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,791.35,percent of total billed charges,,,85,,791.35,percent of total billed charges,,,49,,456.19,percent of total billed charges,,,90,,837.9,percent of total billed charges,,,,,,,no IP contract,,80,,744.8,percent of total billed charges,,,,,,,no IP contract,,50,,465.5,percent of total billed charges,,,,,,no IP contract,,,78,,726.18,percent of total billed charges,,,70,,651.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,456.19,3324,
Xray-Spine Spot Films NMH,72100,CPT,,,,inpatient,,,931,558.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,754.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,791.35,percent of total billed charges,,,85,,791.35,percent of total billed charges,,,49,,456.19,percent of total billed charges,,,90,,837.9,percent of total billed charges,,,,,,,no IP contract,,80,,744.8,percent of total billed charges,,,,,,,no IP contract,,50,,465.5,percent of total billed charges,,,,,,no IP contract,,,78,,726.18,percent of total billed charges,,,70,,651.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,456.19,3324,
Xray-LS-Spine 4+ views NMH,72110,CPT,,,,inpatient,,,1299,779.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1052.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1104.15,percent of total billed charges,,,85,,1104.15,percent of total billed charges,,,49,,636.51,percent of total billed charges,,,90,,1169.1,percent of total billed charges,,,,,,,no IP contract,,80,,1039.2,percent of total billed charges,,,,,,,no IP contract,,50,,649.5,percent of total billed charges,,,,,,no IP contract,,,78,,1013.22,percent of total billed charges,,,70,,909.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,636.51,3324,
Xray-LS-Spine Oblique 4+ views NMH,72110,CPT,,,,inpatient,,,1299,779.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1052.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1104.15,percent of total billed charges,,,85,,1104.15,percent of total billed charges,,,49,,636.51,percent of total billed charges,,,90,,1169.1,percent of total billed charges,,,,,,,no IP contract,,80,,1039.2,percent of total billed charges,,,,,,,no IP contract,,50,,649.5,percent of total billed charges,,,,,,no IP contract,,,78,,1013.22,percent of total billed charges,,,70,,909.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,636.51,3324,
Xray-LS-Spine Kinetic 6 views NMH,72114,CPT,,,,inpatient,,,1670,1002,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1352.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1419.5,percent of total billed charges,,,85,,1419.5,percent of total billed charges,,,49,,818.3,percent of total billed charges,,,90,,1503,percent of total billed charges,,,,,,,no IP contract,,80,,1336,percent of total billed charges,,,,,,,no IP contract,,50,,835,percent of total billed charges,,,,,,no IP contract,,,78,,1302.6,percent of total billed charges,,,70,,1169,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,818.3,3324,
Xray-LS-Spine Flex/Ext NMH,72120,CPT,,,,inpatient,,,910,546,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,737.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,773.5,percent of total billed charges,,,85,,773.5,percent of total billed charges,,,49,,445.9,percent of total billed charges,,,90,,819,percent of total billed charges,,,,,,,no IP contract,,80,,728,percent of total billed charges,,,,,,,no IP contract,,50,,455,percent of total billed charges,,,,,,no IP contract,,,78,,709.8,percent of total billed charges,,,70,,637,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,445.9,3324,
Xray-Ischium NMH,72170,CPT,,,,inpatient,,,823,493.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,666.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,699.55,percent of total billed charges,,,85,,699.55,percent of total billed charges,,,49,,403.27,percent of total billed charges,,,90,,740.7,percent of total billed charges,,,,,,,no IP contract,,80,,658.4,percent of total billed charges,,,,,,,no IP contract,,50,,411.5,percent of total billed charges,,,,,,no IP contract,,,78,,641.94,percent of total billed charges,,,70,,576.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,403.27,3324,
Xray-Pelvis AP Only NMH,72170,CPT,,,,inpatient,,,823,493.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,666.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,699.55,percent of total billed charges,,,85,,699.55,percent of total billed charges,,,49,,403.27,percent of total billed charges,,,90,,740.7,percent of total billed charges,,,,,,,no IP contract,,80,,658.4,percent of total billed charges,,,,,,,no IP contract,,50,,411.5,percent of total billed charges,,,,,,no IP contract,,,78,,641.94,percent of total billed charges,,,70,,576.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,403.27,3324,
Xray-Pelvis Inlet/Outlet NMH,72170,CPT,,,,inpatient,,,823,493.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,666.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,699.55,percent of total billed charges,,,85,,699.55,percent of total billed charges,,,49,,403.27,percent of total billed charges,,,90,,740.7,percent of total billed charges,,,,,,,no IP contract,,80,,658.4,percent of total billed charges,,,,,,,no IP contract,,50,,411.5,percent of total billed charges,,,,,,no IP contract,,,78,,641.94,percent of total billed charges,,,70,,576.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,403.27,3324,
Xray-Symphis Pubis NMH,72170,CPT,,,,inpatient,,,823,493.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,666.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,699.55,percent of total billed charges,,,85,,699.55,percent of total billed charges,,,49,,403.27,percent of total billed charges,,,90,,740.7,percent of total billed charges,,,,,,,no IP contract,,80,,658.4,percent of total billed charges,,,,,,,no IP contract,,50,,411.5,percent of total billed charges,,,,,,no IP contract,,,78,,641.94,percent of total billed charges,,,70,,576.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,403.27,3324,
Xray-Sacroiliac Joint 3+ NMH,72202,CPT,,,,inpatient,,,987,592.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,799.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,838.95,percent of total billed charges,,,85,,838.95,percent of total billed charges,,,49,,483.63,percent of total billed charges,,,90,,888.3,percent of total billed charges,,,,,,,no IP contract,,80,,789.6,percent of total billed charges,,,,,,,no IP contract,,50,,493.5,percent of total billed charges,,,,,,no IP contract,,,78,,769.86,percent of total billed charges,,,70,,690.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,483.63,3324,
Xray-Coccyx Min 2 Views NMH,72220,CPT,,,,inpatient,,,1063,637.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,861.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,903.55,percent of total billed charges,,,85,,903.55,percent of total billed charges,,,49,,520.87,percent of total billed charges,,,90,,956.7,percent of total billed charges,,,,,,,no IP contract,,80,,850.4,percent of total billed charges,,,,,,,no IP contract,,50,,531.5,percent of total billed charges,,,,,,no IP contract,,,78,,829.14,percent of total billed charges,,,70,,744.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,520.87,3324,
Xray-Sacrum & Coccyx 2+ NMH,72220,CPT,,,,inpatient,,,1063,637.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,861.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,903.55,percent of total billed charges,,,85,,903.55,percent of total billed charges,,,49,,520.87,percent of total billed charges,,,90,,956.7,percent of total billed charges,,,,,,,no IP contract,,80,,850.4,percent of total billed charges,,,,,,,no IP contract,,50,,531.5,percent of total billed charges,,,,,,no IP contract,,,78,,829.14,percent of total billed charges,,,70,,744.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,520.87,3324,
Xray-Sacrum Min 2 Views NMH,72220,CPT,,,,inpatient,,,1063,637.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,861.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,903.55,percent of total billed charges,,,85,,903.55,percent of total billed charges,,,49,,520.87,percent of total billed charges,,,90,,956.7,percent of total billed charges,,,,,,,no IP contract,,80,,850.4,percent of total billed charges,,,,,,,no IP contract,,50,,531.5,percent of total billed charges,,,,,,no IP contract,,,78,,829.14,percent of total billed charges,,,70,,744.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,520.87,3324,
Xray-Clavicle Complete Left NMH,73000,CPT,,,,inpatient,,,782,469.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,633.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,664.7,percent of total billed charges,,,85,,664.7,percent of total billed charges,,,49,,383.18,percent of total billed charges,,,90,,703.8,percent of total billed charges,,,,,,,no IP contract,,80,,625.6,percent of total billed charges,,,,,,,no IP contract,,50,,391,percent of total billed charges,,,,,,no IP contract,,,78,,609.96,percent of total billed charges,,,70,,547.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,383.18,3324,
Xray-Clavicle Complete Right NMH,73000,CPT,,,,inpatient,,,782,469.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,633.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,664.7,percent of total billed charges,,,85,,664.7,percent of total billed charges,,,49,,383.18,percent of total billed charges,,,90,,703.8,percent of total billed charges,,,,,,,no IP contract,,80,,625.6,percent of total billed charges,,,,,,,no IP contract,,50,,391,percent of total billed charges,,,,,,no IP contract,,,78,,609.96,percent of total billed charges,,,70,,547.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,383.18,3324,
Xray-Scapula Complete Left NMH,73010,CPT,,,,inpatient,,,715,429,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,579.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,607.75,percent of total billed charges,,,85,,607.75,percent of total billed charges,,,49,,350.35,percent of total billed charges,,,90,,643.5,percent of total billed charges,,,,,,,no IP contract,,80,,572,percent of total billed charges,,,,,,,no IP contract,,50,,357.5,percent of total billed charges,,,,,,no IP contract,,,78,,557.7,percent of total billed charges,,,70,,500.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,350.35,3324,
Xray-Scapula Complete Right NMH,73010,CPT,,,,inpatient,,,715,429,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,579.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,607.75,percent of total billed charges,,,85,,607.75,percent of total billed charges,,,49,,350.35,percent of total billed charges,,,90,,643.5,percent of total billed charges,,,,,,,no IP contract,,80,,572,percent of total billed charges,,,,,,,no IP contract,,50,,357.5,percent of total billed charges,,,,,,no IP contract,,,78,,557.7,percent of total billed charges,,,70,,500.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,350.35,3324,
Xray-Shoulder Axillary Left NMH,73020,CPT,,,,inpatient,,,593,355.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,480.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,504.05,percent of total billed charges,,,85,,504.05,percent of total billed charges,,,49,,290.57,percent of total billed charges,,,90,,533.7,percent of total billed charges,,,,,,,no IP contract,,80,,474.4,percent of total billed charges,,,,,,,no IP contract,,50,,296.5,percent of total billed charges,,,,,,no IP contract,,,78,,462.54,percent of total billed charges,,,70,,415.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,290.57,3324,
Xray-Shoulder Axillary Right NMH,73020,CPT,,,,inpatient,,,593,355.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,480.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,504.05,percent of total billed charges,,,85,,504.05,percent of total billed charges,,,49,,290.57,percent of total billed charges,,,90,,533.7,percent of total billed charges,,,,,,,no IP contract,,80,,474.4,percent of total billed charges,,,,,,,no IP contract,,50,,296.5,percent of total billed charges,,,,,,no IP contract,,,78,,462.54,percent of total billed charges,,,70,,415.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,290.57,3324,
Xray-Shoulder Thransortho Left NMH,73020,CPT,,,,inpatient,,,593,355.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,480.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,504.05,percent of total billed charges,,,85,,504.05,percent of total billed charges,,,49,,290.57,percent of total billed charges,,,90,,533.7,percent of total billed charges,,,,,,,no IP contract,,80,,474.4,percent of total billed charges,,,,,,,no IP contract,,50,,296.5,percent of total billed charges,,,,,,no IP contract,,,78,,462.54,percent of total billed charges,,,70,,415.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,290.57,3324,
Xray-Shoulder Transortho Right NMH,73020,CPT,,,,inpatient,,,593,355.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,480.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,504.05,percent of total billed charges,,,85,,504.05,percent of total billed charges,,,49,,290.57,percent of total billed charges,,,90,,533.7,percent of total billed charges,,,,,,,no IP contract,,80,,474.4,percent of total billed charges,,,,,,,no IP contract,,50,,296.5,percent of total billed charges,,,,,,no IP contract,,,78,,462.54,percent of total billed charges,,,70,,415.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,290.57,3324,
Xray-Shoulder Y View Left NMH,73020,CPT,,,,inpatient,,,593,355.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,480.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,504.05,percent of total billed charges,,,85,,504.05,percent of total billed charges,,,49,,290.57,percent of total billed charges,,,90,,533.7,percent of total billed charges,,,,,,,no IP contract,,80,,474.4,percent of total billed charges,,,,,,,no IP contract,,50,,296.5,percent of total billed charges,,,,,,no IP contract,,,78,,462.54,percent of total billed charges,,,70,,415.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,290.57,3324,
Xray-Shoulder Y View Right NMH,73020,CPT,,,,inpatient,,,593,355.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,480.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,504.05,percent of total billed charges,,,85,,504.05,percent of total billed charges,,,49,,290.57,percent of total billed charges,,,90,,533.7,percent of total billed charges,,,,,,,no IP contract,,80,,474.4,percent of total billed charges,,,,,,,no IP contract,,50,,296.5,percent of total billed charges,,,,,,no IP contract,,,78,,462.54,percent of total billed charges,,,70,,415.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,290.57,3324,
Xray-Shoulder 2+ Views Left NMH,73030,CPT,,,,inpatient,,,890,534,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,720.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,756.5,percent of total billed charges,,,85,,756.5,percent of total billed charges,,,49,,436.1,percent of total billed charges,,,90,,801,percent of total billed charges,,,,,,,no IP contract,,80,,712,percent of total billed charges,,,,,,,no IP contract,,50,,445,percent of total billed charges,,,,,,no IP contract,,,78,,694.2,percent of total billed charges,,,70,,623,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,436.1,3324,
Xray-Shoulder 2+ Views Right NMH,73030,CPT,,,,inpatient,,,890,534,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,720.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,756.5,percent of total billed charges,,,85,,756.5,percent of total billed charges,,,49,,436.1,percent of total billed charges,,,90,,801,percent of total billed charges,,,,,,,no IP contract,,80,,712,percent of total billed charges,,,,,,,no IP contract,,50,,445,percent of total billed charges,,,,,,no IP contract,,,78,,694.2,percent of total billed charges,,,70,,623,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,436.1,3324,
Xray-Humerus 2+ Views Left NMH,73060,CPT,,,,inpatient,,,885,531,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,716.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,752.25,percent of total billed charges,,,85,,752.25,percent of total billed charges,,,49,,433.65,percent of total billed charges,,,90,,796.5,percent of total billed charges,,,,,,,no IP contract,,80,,708,percent of total billed charges,,,,,,,no IP contract,,50,,442.5,percent of total billed charges,,,,,,no IP contract,,,78,,690.3,percent of total billed charges,,,70,,619.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,433.65,3324,
Xray-Humerus 2+ Views Right NMH,73060,CPT,,,,inpatient,,,885,531,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,716.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,752.25,percent of total billed charges,,,85,,752.25,percent of total billed charges,,,49,,433.65,percent of total billed charges,,,90,,796.5,percent of total billed charges,,,,,,,no IP contract,,80,,708,percent of total billed charges,,,,,,,no IP contract,,50,,442.5,percent of total billed charges,,,,,,no IP contract,,,78,,690.3,percent of total billed charges,,,70,,619.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,433.65,3324,
Xray-Elbow AP & Lateral Left NMH,73070,CPT,,,,inpatient,,,525,315,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,425.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,446.25,percent of total billed charges,,,85,,446.25,percent of total billed charges,,,49,,257.25,percent of total billed charges,,,90,,472.5,percent of total billed charges,,,,,,,no IP contract,,80,,420,percent of total billed charges,,,,,,,no IP contract,,50,,262.5,percent of total billed charges,,,,,,no IP contract,,,78,,409.5,percent of total billed charges,,,70,,367.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,257.25,3324,
Xray-Elbow AP & Lateral Right NMH,73070,CPT,,,,inpatient,,,525,315,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,425.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,446.25,percent of total billed charges,,,85,,446.25,percent of total billed charges,,,49,,257.25,percent of total billed charges,,,90,,472.5,percent of total billed charges,,,,,,,no IP contract,,80,,420,percent of total billed charges,,,,,,,no IP contract,,50,,262.5,percent of total billed charges,,,,,,no IP contract,,,78,,409.5,percent of total billed charges,,,70,,367.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,257.25,3324,
Xray Elbow CPL min 3 Views NMH,73080,CPT,,,,inpatient,,,825,495,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,668.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,701.25,percent of total billed charges,,,85,,701.25,percent of total billed charges,,,49,,404.25,percent of total billed charges,,,90,,742.5,percent of total billed charges,,,,,,,no IP contract,,80,,660,percent of total billed charges,,,,,,,no IP contract,,50,,412.5,percent of total billed charges,,,,,,no IP contract,,,78,,643.5,percent of total billed charges,,,70,,577.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,404.25,3324,
Xray-Forearm AP & Lateral Left NMH,73090,CPT,,,,inpatient,,,737,442.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,596.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,626.45,percent of total billed charges,,,85,,626.45,percent of total billed charges,,,49,,361.13,percent of total billed charges,,,90,,663.3,percent of total billed charges,,,,,,,no IP contract,,80,,589.6,percent of total billed charges,,,,,,,no IP contract,,50,,368.5,percent of total billed charges,,,,,,no IP contract,,,78,,574.86,percent of total billed charges,,,70,,515.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,361.13,3324,
Xray-Forearm AP & Lateral Right NMH,73090,CPT,,,,inpatient,,,737,442.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,596.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,626.45,percent of total billed charges,,,85,,626.45,percent of total billed charges,,,49,,361.13,percent of total billed charges,,,90,,663.3,percent of total billed charges,,,,,,,no IP contract,,80,,589.6,percent of total billed charges,,,,,,,no IP contract,,50,,368.5,percent of total billed charges,,,,,,no IP contract,,,78,,574.86,percent of total billed charges,,,70,,515.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,361.13,3324,
Xray-Navicular View Right NMH,73100,CPT,,,,inpatient,,,571,342.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,462.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,485.35,percent of total billed charges,,,85,,485.35,percent of total billed charges,,,49,,279.79,percent of total billed charges,,,90,,513.9,percent of total billed charges,,,,,,,no IP contract,,80,,456.8,percent of total billed charges,,,,,,,no IP contract,,50,,285.5,percent of total billed charges,,,,,,no IP contract,,,78,,445.38,percent of total billed charges,,,70,,399.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,279.79,3324,
Xray-Wrist Carpal Tunnel Left NMH,73100,CPT,,,,inpatient,,,571,342.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,462.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,485.35,percent of total billed charges,,,85,,485.35,percent of total billed charges,,,49,,279.79,percent of total billed charges,,,90,,513.9,percent of total billed charges,,,,,,,no IP contract,,80,,456.8,percent of total billed charges,,,,,,,no IP contract,,50,,285.5,percent of total billed charges,,,,,,no IP contract,,,78,,445.38,percent of total billed charges,,,70,,399.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,279.79,3324,
Xray-Wrist Carpal Tunnel Right NMH,73100,CPT,,,,inpatient,,,571,342.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,462.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,485.35,percent of total billed charges,,,85,,485.35,percent of total billed charges,,,49,,279.79,percent of total billed charges,,,90,,513.9,percent of total billed charges,,,,,,,no IP contract,,80,,456.8,percent of total billed charges,,,,,,,no IP contract,,50,,285.5,percent of total billed charges,,,,,,no IP contract,,,78,,445.38,percent of total billed charges,,,70,,399.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,279.79,3324,
Xray-Wrist Navicular View Left NMH,73100,CPT,,,,inpatient,,,571,342.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,462.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,485.35,percent of total billed charges,,,85,,485.35,percent of total billed charges,,,49,,279.79,percent of total billed charges,,,90,,513.9,percent of total billed charges,,,,,,,no IP contract,,80,,456.8,percent of total billed charges,,,,,,,no IP contract,,50,,285.5,percent of total billed charges,,,,,,no IP contract,,,78,,445.38,percent of total billed charges,,,70,,399.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,279.79,3324,
Xray-Wrist Radial Dev Left NMH,73100,CPT,,,,inpatient,,,571,342.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,462.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,485.35,percent of total billed charges,,,85,,485.35,percent of total billed charges,,,49,,279.79,percent of total billed charges,,,90,,513.9,percent of total billed charges,,,,,,,no IP contract,,80,,456.8,percent of total billed charges,,,,,,,no IP contract,,50,,285.5,percent of total billed charges,,,,,,no IP contract,,,78,,445.38,percent of total billed charges,,,70,,399.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,279.79,3324,
Xray-Wrist Radial Dev Right NMH,73100,CPT,,,,inpatient,,,571,342.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,462.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,485.35,percent of total billed charges,,,85,,485.35,percent of total billed charges,,,49,,279.79,percent of total billed charges,,,90,,513.9,percent of total billed charges,,,,,,,no IP contract,,80,,456.8,percent of total billed charges,,,,,,,no IP contract,,50,,285.5,percent of total billed charges,,,,,,no IP contract,,,78,,445.38,percent of total billed charges,,,70,,399.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,279.79,3324,
Xray-Hand/Wrist Left NMH,73110,CPT,,,,inpatient,,,704,422.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,570.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,598.4,percent of total billed charges,,,85,,598.4,percent of total billed charges,,,49,,344.96,percent of total billed charges,,,90,,633.6,percent of total billed charges,,,,,,,no IP contract,,80,,563.2,percent of total billed charges,,,,,,,no IP contract,,50,,352,percent of total billed charges,,,,,,no IP contract,,,78,,549.12,percent of total billed charges,,,70,,492.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,344.96,3324,
Xray-Hand/Wrist Right NMH,73110,CPT,,,,inpatient,,,704,422.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,570.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,598.4,percent of total billed charges,,,85,,598.4,percent of total billed charges,,,49,,344.96,percent of total billed charges,,,90,,633.6,percent of total billed charges,,,,,,,no IP contract,,80,,563.2,percent of total billed charges,,,,,,,no IP contract,,50,,352,percent of total billed charges,,,,,,no IP contract,,,78,,549.12,percent of total billed charges,,,70,,492.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,344.96,3324,
Xray-Wrist AP & Lateral 3+ Views Left NMH,73110,CPT,,,,inpatient,,,704,422.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,570.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,598.4,percent of total billed charges,,,85,,598.4,percent of total billed charges,,,49,,344.96,percent of total billed charges,,,90,,633.6,percent of total billed charges,,,,,,,no IP contract,,80,,563.2,percent of total billed charges,,,,,,,no IP contract,,50,,352,percent of total billed charges,,,,,,no IP contract,,,78,,549.12,percent of total billed charges,,,70,,492.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,344.96,3324,
Xray-Wrist AP & Lateral 3+ Views Right NMH,73110,CPT,,,,inpatient,,,704,422.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,570.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,598.4,percent of total billed charges,,,85,,598.4,percent of total billed charges,,,49,,344.96,percent of total billed charges,,,90,,633.6,percent of total billed charges,,,,,,,no IP contract,,80,,563.2,percent of total billed charges,,,,,,,no IP contract,,50,,352,percent of total billed charges,,,,,,no IP contract,,,78,,549.12,percent of total billed charges,,,70,,492.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,344.96,3324,
Xray-Hand & Wrist 2 Views Left NMH,73120,CPT,,,,inpatient,,,745,447,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,603.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,633.25,percent of total billed charges,,,85,,633.25,percent of total billed charges,,,49,,365.05,percent of total billed charges,,,90,,670.5,percent of total billed charges,,,,,,,no IP contract,,80,,596,percent of total billed charges,,,,,,,no IP contract,,50,,372.5,percent of total billed charges,,,,,,no IP contract,,,78,,581.1,percent of total billed charges,,,70,,521.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,365.05,3324,
Xray-Hand & Wrist 2 Views Right NMH,73120,CPT,,,,inpatient,,,745,447,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,603.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,633.25,percent of total billed charges,,,85,,633.25,percent of total billed charges,,,49,,365.05,percent of total billed charges,,,90,,670.5,percent of total billed charges,,,,,,,no IP contract,,80,,596,percent of total billed charges,,,,,,,no IP contract,,50,,372.5,percent of total billed charges,,,,,,no IP contract,,,78,,581.1,percent of total billed charges,,,70,,521.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,365.05,3324,
Xray-Hand 3+ Views Left NMH,73130,CPT,,,,inpatient,,,782,469.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,633.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,664.7,percent of total billed charges,,,85,,664.7,percent of total billed charges,,,49,,383.18,percent of total billed charges,,,90,,703.8,percent of total billed charges,,,,,,,no IP contract,,80,,625.6,percent of total billed charges,,,,,,,no IP contract,,50,,391,percent of total billed charges,,,,,,no IP contract,,,78,,609.96,percent of total billed charges,,,70,,547.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,383.18,3324,
Xray-Hand 3+ Views Right NMH,73130,CPT,,,,inpatient,,,782,469.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,633.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,664.7,percent of total billed charges,,,85,,664.7,percent of total billed charges,,,49,,383.18,percent of total billed charges,,,90,,703.8,percent of total billed charges,,,,,,,no IP contract,,80,,625.6,percent of total billed charges,,,,,,,no IP contract,,50,,391,percent of total billed charges,,,,,,no IP contract,,,78,,609.96,percent of total billed charges,,,70,,547.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,383.18,3324,
Xray-Fingers 2+ Views Left NMH,73140,CPT,,,,inpatient,,,655,393,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,530.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,556.75,percent of total billed charges,,,85,,556.75,percent of total billed charges,,,49,,320.95,percent of total billed charges,,,90,,589.5,percent of total billed charges,,,,,,,no IP contract,,80,,524,percent of total billed charges,,,,,,,no IP contract,,50,,327.5,percent of total billed charges,,,,,,no IP contract,,,78,,510.9,percent of total billed charges,,,70,,458.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,320.95,3324,
Xray-Fingers 2+ Views Right NMH,73140,CPT,,,,inpatient,,,655,393,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,530.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,556.75,percent of total billed charges,,,85,,556.75,percent of total billed charges,,,49,,320.95,percent of total billed charges,,,90,,589.5,percent of total billed charges,,,,,,,no IP contract,,80,,524,percent of total billed charges,,,,,,,no IP contract,,50,,327.5,percent of total billed charges,,,,,,no IP contract,,,78,,510.9,percent of total billed charges,,,70,,458.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,320.95,3324,
Xray-Knee AP & Lateral Left NMH,73560,CPT,,,,inpatient,,,795,477,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,643.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,675.75,percent of total billed charges,,,85,,675.75,percent of total billed charges,,,49,,389.55,percent of total billed charges,,,90,,715.5,percent of total billed charges,,,,,,,no IP contract,,80,,636,percent of total billed charges,,,,,,,no IP contract,,50,,397.5,percent of total billed charges,,,,,,no IP contract,,,78,,620.1,percent of total billed charges,,,70,,556.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,389.55,3324,
Xray-Knee AP & Lateral Right NMH,73560,CPT,,,,inpatient,,,795,477,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,643.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,675.75,percent of total billed charges,,,85,,675.75,percent of total billed charges,,,49,,389.55,percent of total billed charges,,,90,,715.5,percent of total billed charges,,,,,,,no IP contract,,80,,636,percent of total billed charges,,,,,,,no IP contract,,50,,397.5,percent of total billed charges,,,,,,no IP contract,,,78,,620.1,percent of total billed charges,,,70,,556.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,389.55,3324,
Xray-Knee Notch View Left NMH,73560,CPT,,,,inpatient,,,795,477,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,643.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,675.75,percent of total billed charges,,,85,,675.75,percent of total billed charges,,,49,,389.55,percent of total billed charges,,,90,,715.5,percent of total billed charges,,,,,,,no IP contract,,80,,636,percent of total billed charges,,,,,,,no IP contract,,50,,397.5,percent of total billed charges,,,,,,no IP contract,,,78,,620.1,percent of total billed charges,,,70,,556.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,389.55,3324,
Xray-Knee Notch View Right NMH,73560,CPT,,,,inpatient,,,795,477,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,643.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,675.75,percent of total billed charges,,,85,,675.75,percent of total billed charges,,,49,,389.55,percent of total billed charges,,,90,,715.5,percent of total billed charges,,,,,,,no IP contract,,80,,636,percent of total billed charges,,,,,,,no IP contract,,50,,397.5,percent of total billed charges,,,,,,no IP contract,,,78,,620.1,percent of total billed charges,,,70,,556.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,389.55,3324,
Xray-Knee Sunrise View Left NMH,73560,CPT,,,,inpatient,,,795,477,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,643.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,675.75,percent of total billed charges,,,85,,675.75,percent of total billed charges,,,49,,389.55,percent of total billed charges,,,90,,715.5,percent of total billed charges,,,,,,,no IP contract,,80,,636,percent of total billed charges,,,,,,,no IP contract,,50,,397.5,percent of total billed charges,,,,,,no IP contract,,,78,,620.1,percent of total billed charges,,,70,,556.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,389.55,3324,
Xray-Knee Sunrise View Right NMH,73560,CPT,,,,inpatient,,,795,477,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,643.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,675.75,percent of total billed charges,,,85,,675.75,percent of total billed charges,,,49,,389.55,percent of total billed charges,,,90,,715.5,percent of total billed charges,,,,,,,no IP contract,,80,,636,percent of total billed charges,,,,,,,no IP contract,,50,,397.5,percent of total billed charges,,,,,,no IP contract,,,78,,620.1,percent of total billed charges,,,70,,556.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,389.55,3324,
Xray-Patella Left NMH,73560,CPT,,,,inpatient,,,795,477,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,643.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,675.75,percent of total billed charges,,,85,,675.75,percent of total billed charges,,,49,,389.55,percent of total billed charges,,,90,,715.5,percent of total billed charges,,,,,,,no IP contract,,80,,636,percent of total billed charges,,,,,,,no IP contract,,50,,397.5,percent of total billed charges,,,,,,no IP contract,,,78,,620.1,percent of total billed charges,,,70,,556.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,389.55,3324,
Xray-Patella Right NMH,73560,CPT,,,,inpatient,,,795,477,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,643.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,675.75,percent of total billed charges,,,85,,675.75,percent of total billed charges,,,49,,389.55,percent of total billed charges,,,90,,715.5,percent of total billed charges,,,,,,,no IP contract,,80,,636,percent of total billed charges,,,,,,,no IP contract,,50,,397.5,percent of total billed charges,,,,,,no IP contract,,,78,,620.1,percent of total billed charges,,,70,,556.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,389.55,3324,
Xray-Knee Oblique 3+ Left NMH,73562,CPT,,,,inpatient,,,855,513,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,692.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,726.75,percent of total billed charges,,,85,,726.75,percent of total billed charges,,,49,,418.95,percent of total billed charges,,,90,,769.5,percent of total billed charges,,,,,,,no IP contract,,80,,684,percent of total billed charges,,,,,,,no IP contract,,50,,427.5,percent of total billed charges,,,,,,no IP contract,,,78,,666.9,percent of total billed charges,,,70,,598.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,418.95,3324,
Xray-Knee Oblique 3+ Right NMH,73562,CPT,,,,inpatient,,,855,513,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,692.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,726.75,percent of total billed charges,,,85,,726.75,percent of total billed charges,,,49,,418.95,percent of total billed charges,,,90,,769.5,percent of total billed charges,,,,,,,no IP contract,,80,,684,percent of total billed charges,,,,,,,no IP contract,,50,,427.5,percent of total billed charges,,,,,,no IP contract,,,78,,666.9,percent of total billed charges,,,70,,598.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,418.95,3324,
Xray Knee 4 Views NMH,73564,CPT,,,,inpatient,,,1035,621,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,838.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,879.75,percent of total billed charges,,,85,,879.75,percent of total billed charges,,,49,,507.15,percent of total billed charges,,,90,,931.5,percent of total billed charges,,,,,,,no IP contract,,80,,828,percent of total billed charges,,,,,,,no IP contract,,50,,517.5,percent of total billed charges,,,,,,no IP contract,,,78,,807.3,percent of total billed charges,,,70,,724.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,507.15,3324,
Xray-Knee AP Standing NMH,73565,CPT,,,,inpatient,,,688,412.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,557.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,584.8,percent of total billed charges,,,85,,584.8,percent of total billed charges,,,49,,337.12,percent of total billed charges,,,90,,619.2,percent of total billed charges,,,,,,,no IP contract,,80,,550.4,percent of total billed charges,,,,,,,no IP contract,,50,,344,percent of total billed charges,,,,,,no IP contract,,,78,,536.64,percent of total billed charges,,,70,,481.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,337.12,3324,
Xray-Tibia/Fibula AP & Lateral Left NMH,73590,CPT,,,,inpatient,,,767,460.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,621.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,651.95,percent of total billed charges,,,85,,651.95,percent of total billed charges,,,49,,375.83,percent of total billed charges,,,90,,690.3,percent of total billed charges,,,,,,,no IP contract,,80,,613.6,percent of total billed charges,,,,,,,no IP contract,,50,,383.5,percent of total billed charges,,,,,,no IP contract,,,78,,598.26,percent of total billed charges,,,70,,536.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,375.83,3324,
Xray-Tibia/Fibula AP & Lateral Right NMH,73590,CPT,,,,inpatient,,,767,460.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,621.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,651.95,percent of total billed charges,,,85,,651.95,percent of total billed charges,,,49,,375.83,percent of total billed charges,,,90,,690.3,percent of total billed charges,,,,,,,no IP contract,,80,,613.6,percent of total billed charges,,,,,,,no IP contract,,50,,383.5,percent of total billed charges,,,,,,no IP contract,,,78,,598.26,percent of total billed charges,,,70,,536.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,375.83,3324,
Xray-Ankle 3+ Views Left NMH,73610,CPT,,,LT,inpatient,,,774,464.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,626.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,657.9,percent of total billed charges,,,85,,657.9,percent of total billed charges,,,49,,379.26,percent of total billed charges,,,90,,696.6,percent of total billed charges,,,,,,,no IP contract,,80,,619.2,percent of total billed charges,,,,,,,no IP contract,,50,,387,percent of total billed charges,,,,,,no IP contract,,,78,,603.72,percent of total billed charges,,,70,,541.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,379.26,3324,
Xray-Foot & Ankle Left NMH,73610,CPT,,,LT,inpatient,,,774,464.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,626.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,657.9,percent of total billed charges,,,85,,657.9,percent of total billed charges,,,49,,379.26,percent of total billed charges,,,90,,696.6,percent of total billed charges,,,,,,,no IP contract,,80,,619.2,percent of total billed charges,,,,,,,no IP contract,,50,,387,percent of total billed charges,,,,,,no IP contract,,,78,,603.72,percent of total billed charges,,,70,,541.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,379.26,3324,
Xray-Ankle 3+ Views Right NMH,73610,CPT,,,RT,inpatient,,,774,464.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,626.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,657.9,percent of total billed charges,,,85,,657.9,percent of total billed charges,,,49,,379.26,percent of total billed charges,,,90,,696.6,percent of total billed charges,,,,,,,no IP contract,,80,,619.2,percent of total billed charges,,,,,,,no IP contract,,50,,387,percent of total billed charges,,,,,,no IP contract,,,78,,603.72,percent of total billed charges,,,70,,541.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,379.26,3324,
Xray-Foot & Ankle Right NMH,73610,CPT,,,RT,inpatient,,,774,464.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,626.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,657.9,percent of total billed charges,,,85,,657.9,percent of total billed charges,,,49,,379.26,percent of total billed charges,,,90,,696.6,percent of total billed charges,,,,,,,no IP contract,,80,,619.2,percent of total billed charges,,,,,,,no IP contract,,50,,387,percent of total billed charges,,,,,,no IP contract,,,78,,603.72,percent of total billed charges,,,70,,541.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,379.26,3324,
Xray-Foot 3+ Views Left NMH,73630,CPT,,,,inpatient,,,849,509.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,687.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,721.65,percent of total billed charges,,,85,,721.65,percent of total billed charges,,,49,,416.01,percent of total billed charges,,,90,,764.1,percent of total billed charges,,,,,,,no IP contract,,80,,679.2,percent of total billed charges,,,,,,,no IP contract,,50,,424.5,percent of total billed charges,,,,,,no IP contract,,,78,,662.22,percent of total billed charges,,,70,,594.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,416.01,3324,
Xray-Foot 3+ Views Right NMH,73630,CPT,,,,inpatient,,,849,509.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,687.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,721.65,percent of total billed charges,,,85,,721.65,percent of total billed charges,,,49,,416.01,percent of total billed charges,,,90,,764.1,percent of total billed charges,,,,,,,no IP contract,,80,,679.2,percent of total billed charges,,,,,,,no IP contract,,50,,424.5,percent of total billed charges,,,,,,no IP contract,,,78,,662.22,percent of total billed charges,,,70,,594.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,416.01,3324,
Xray-Heel 2+ Views Left NMH,73650,CPT,,,,inpatient,,,669,401.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,541.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,568.65,percent of total billed charges,,,85,,568.65,percent of total billed charges,,,49,,327.81,percent of total billed charges,,,90,,602.1,percent of total billed charges,,,,,,,no IP contract,,80,,535.2,percent of total billed charges,,,,,,,no IP contract,,50,,334.5,percent of total billed charges,,,,,,no IP contract,,,78,,521.82,percent of total billed charges,,,70,,468.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,327.81,3324,
Xray-Heel 2+ Views Right NMH,73650,CPT,,,,inpatient,,,669,401.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,541.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,568.65,percent of total billed charges,,,85,,568.65,percent of total billed charges,,,49,,327.81,percent of total billed charges,,,90,,602.1,percent of total billed charges,,,,,,,no IP contract,,80,,535.2,percent of total billed charges,,,,,,,no IP contract,,50,,334.5,percent of total billed charges,,,,,,no IP contract,,,78,,521.82,percent of total billed charges,,,70,,468.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,327.81,3324,
Xray-Toes 2+ Views Left NMH,73660,CPT,,,,inpatient,,,623,373.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,504.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,529.55,percent of total billed charges,,,85,,529.55,percent of total billed charges,,,49,,305.27,percent of total billed charges,,,90,,560.7,percent of total billed charges,,,,,,,no IP contract,,80,,498.4,percent of total billed charges,,,,,,,no IP contract,,50,,311.5,percent of total billed charges,,,,,,no IP contract,,,78,,485.94,percent of total billed charges,,,70,,436.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,305.27,3324,
Xray-Toes 2+ Views Right NMH,73660,CPT,,,,inpatient,,,623,373.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,504.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,529.55,percent of total billed charges,,,85,,529.55,percent of total billed charges,,,49,,305.27,percent of total billed charges,,,90,,560.7,percent of total billed charges,,,,,,,no IP contract,,80,,498.4,percent of total billed charges,,,,,,,no IP contract,,50,,311.5,percent of total billed charges,,,,,,no IP contract,,,78,,485.94,percent of total billed charges,,,70,,436.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,305.27,3324,
XRAY EXAM ABDOMEN 1 VIEW NHM,74018,CPT,,,,inpatient,,,630,378,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,510.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,535.5,percent of total billed charges,,,85,,535.5,percent of total billed charges,,,49,,308.7,percent of total billed charges,,,90,,567,percent of total billed charges,,,,,,,no IP contract,,80,,504,percent of total billed charges,,,,,,,no IP contract,,50,,315,percent of total billed charges,,,,,,no IP contract,,,78,,491.4,percent of total billed charges,,,70,,441,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,308.7,3324,
Xray-Abdomen Multiple NMH,74022,CPT,,,,inpatient,,,984,590.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,797.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,836.4,percent of total billed charges,,,85,,836.4,percent of total billed charges,,,49,,482.16,percent of total billed charges,,,90,,885.6,percent of total billed charges,,,,,,,no IP contract,,80,,787.2,percent of total billed charges,,,,,,,no IP contract,,50,,492,percent of total billed charges,,,,,,no IP contract,,,78,,767.52,percent of total billed charges,,,70,,688.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,482.16,3324,
Xray-Esophogus NMH,74220,CPT,,,,inpatient,,,1222,733.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,989.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1038.7,percent of total billed charges,,,85,,1038.7,percent of total billed charges,,,49,,598.78,percent of total billed charges,,,90,,1099.8,percent of total billed charges,,,,,,,no IP contract,,80,,977.6,percent of total billed charges,,,,,,,no IP contract,,50,,611,percent of total billed charges,,,,,,no IP contract,,,78,,953.16,percent of total billed charges,,,70,,855.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,598.78,3324,
Xray-Videofluoro Ev Explode NMH,74230,CPT,,,,inpatient,,,1058,634.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,856.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,899.3,percent of total billed charges,,,85,,899.3,percent of total billed charges,,,49,,518.42,percent of total billed charges,,,90,,952.2,percent of total billed charges,,,,,,,no IP contract,,80,,846.4,percent of total billed charges,,,,,,,no IP contract,,50,,529,percent of total billed charges,,,,,,no IP contract,,,78,,825.24,percent of total billed charges,,,70,,740.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,518.42,3324,
Xray-Videofluoro Ev Explode NMH,74230,CPT,,,,inpatient,,,1058,634.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,856.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,899.3,percent of total billed charges,,,85,,899.3,percent of total billed charges,,,49,,518.42,percent of total billed charges,,,90,,952.2,percent of total billed charges,,,,,,,no IP contract,,80,,846.4,percent of total billed charges,,,,,,,no IP contract,,50,,529,percent of total billed charges,,,,,,no IP contract,,,78,,825.24,percent of total billed charges,,,70,,740.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,518.42,3324,
Xray-Videofluoro/Swallow NMH,74230,CPT,,,,inpatient,,,1058,634.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,856.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,899.3,percent of total billed charges,,,85,,899.3,percent of total billed charges,,,49,,518.42,percent of total billed charges,,,90,,952.2,percent of total billed charges,,,,,,,no IP contract,,80,,846.4,percent of total billed charges,,,,,,,no IP contract,,50,,529,percent of total billed charges,,,,,,no IP contract,,,78,,825.24,percent of total billed charges,,,70,,740.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,518.42,3324,
Upper GI Endoscopy NMH,74240,CPT,,,,inpatient,,,1306,783.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1057.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1110.1,percent of total billed charges,,,85,,1110.1,percent of total billed charges,,,49,,639.94,percent of total billed charges,,,90,,1175.4,percent of total billed charges,,,,,,,no IP contract,,80,,1044.8,percent of total billed charges,,,,,,,no IP contract,,50,,653,percent of total billed charges,,,,,,no IP contract,,,78,,1018.68,percent of total billed charges,,,70,,914.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,639.94,3324,
Xray-Small Bowel NMH,74240,CPT,,,,inpatient,,,1306,783.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1057.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1110.1,percent of total billed charges,,,85,,1110.1,percent of total billed charges,,,49,,639.94,percent of total billed charges,,,90,,1175.4,percent of total billed charges,,,,,,,no IP contract,,80,,1044.8,percent of total billed charges,,,,,,,no IP contract,,50,,653,percent of total billed charges,,,,,,no IP contract,,,78,,1018.68,percent of total billed charges,,,70,,914.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,639.94,3324,
Xray-Stomach Upper GI NMH,74240,CPT,,,,inpatient,,,1306,783.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1057.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1110.1,percent of total billed charges,,,85,,1110.1,percent of total billed charges,,,49,,639.94,percent of total billed charges,,,90,,1175.4,percent of total billed charges,,,,,,,no IP contract,,80,,1044.8,percent of total billed charges,,,,,,,no IP contract,,50,,653,percent of total billed charges,,,,,,no IP contract,,,78,,1018.68,percent of total billed charges,,,70,,914.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,639.94,3324,
Xray-Upper GI OP,74246,CPT,,,,inpatient,,,1664,998.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1347.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1414.4,percent of total billed charges,,,85,,1414.4,percent of total billed charges,,,49,,815.36,percent of total billed charges,,,90,,1497.6,percent of total billed charges,,,,,,,no IP contract,,80,,1331.2,percent of total billed charges,,,,,,,no IP contract,,50,,832,percent of total billed charges,,,,,,no IP contract,,,78,,1297.92,percent of total billed charges,,,70,,1164.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,815.36,3324,
Xray Small Intestine Multi Films NMH,74250,CPT,,,,inpatient,,,1254,752.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1015.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1065.9,percent of total billed charges,,,85,,1065.9,percent of total billed charges,,,49,,614.46,percent of total billed charges,,,90,,1128.6,percent of total billed charges,,,,,,,no IP contract,,80,,1003.2,percent of total billed charges,,,,,,,no IP contract,,50,,627,percent of total billed charges,,,,,,no IP contract,,,78,,978.12,percent of total billed charges,,,70,,877.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,614.46,3324,
Xray-Lower GI NMH,74270,CPT,,,,inpatient,,,1751,1050.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1418.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1488.35,percent of total billed charges,,,85,,1488.35,percent of total billed charges,,,49,,857.99,percent of total billed charges,,,90,,1575.9,percent of total billed charges,,,,,,,no IP contract,,80,,1400.8,percent of total billed charges,,,,,,,no IP contract,,50,,875.5,percent of total billed charges,,,,,,no IP contract,,,78,,1365.78,percent of total billed charges,,,70,,1225.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,857.99,3324,
"CT, Limited or Localized F/U NMH",76380,CPT,,,,inpatient,,,1505,903,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1219.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1279.25,percent of total billed charges,,,85,,1279.25,percent of total billed charges,,,49,,737.45,percent of total billed charges,,,90,,1354.5,percent of total billed charges,,,,,,,no IP contract,,80,,1204,percent of total billed charges,,,,,,,no IP contract,,50,,752.5,percent of total billed charges,,,,,,no IP contract,,,78,,1173.9,percent of total billed charges,,,70,,1053.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,737.45,3324,
Xray-Miscellaneous NMH,76499,CPT,,,,inpatient,,,121,72.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,98.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,102.85,percent of total billed charges,,,85,,102.85,percent of total billed charges,,,49,,59.29,percent of total billed charges,,,90,,108.9,percent of total billed charges,,,,,,,no IP contract,,80,,96.8,percent of total billed charges,,,,,,,no IP contract,,50,,60.5,percent of total billed charges,,,,,,no IP contract,,,78,,94.38,percent of total billed charges,,,70,,84.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,59.29,3324,
"US, Soft T.H/NK B-Scan/R NMH",76536,CPT,,,,inpatient,,,1919,1151.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1554.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1631.15,percent of total billed charges,,,85,,1631.15,percent of total billed charges,,,49,,940.31,percent of total billed charges,,,90,,1727.1,percent of total billed charges,,,,,,,no IP contract,,80,,1535.2,percent of total billed charges,,,,,,,no IP contract,,50,,959.5,percent of total billed charges,,,,,,no IP contract,,,78,,1496.82,percent of total billed charges,,,70,,1343.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,940.31,3324,
US-Superficial Structure NMH,76775,CPT,,,,inpatient,,,1876,1125.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1519.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1594.6,percent of total billed charges,,,85,,1594.6,percent of total billed charges,,,49,,919.24,percent of total billed charges,,,90,,1688.4,percent of total billed charges,,,,,,,no IP contract,,80,,1500.8,percent of total billed charges,,,,,,,no IP contract,,50,,938,percent of total billed charges,,,,,,no IP contract,,,78,,1463.28,percent of total billed charges,,,70,,1313.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,919.24,3324,
Ultrasound Testicular NMH,76870,CPT,,,,inpatient,,,1967,1180.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1593.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1671.95,percent of total billed charges,,,85,,1671.95,percent of total billed charges,,,49,,963.83,percent of total billed charges,,,90,,1770.3,percent of total billed charges,,,,,,,no IP contract,,80,,1573.6,percent of total billed charges,,,,,,,no IP contract,,50,,983.5,percent of total billed charges,,,,,,no IP contract,,,78,,1534.26,percent of total billed charges,,,70,,1376.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,963.83,3324,
"US SUP STRUCT-EXTREMITY,LIMITD NMH",76882,CPT,,,,inpatient,,,1107,664.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,896.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,940.95,percent of total billed charges,,,85,,940.95,percent of total billed charges,,,49,,542.43,percent of total billed charges,,,90,,996.3,percent of total billed charges,,,,,,,no IP contract,,80,,885.6,percent of total billed charges,,,,,,,no IP contract,,50,,553.5,percent of total billed charges,,,,,,no IP contract,,,78,,863.46,percent of total billed charges,,,70,,774.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,542.43,3324,
Xray-Bone Age Wrist NMH,77072,CPT,,,,inpatient,,,660,396,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,534.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,561,percent of total billed charges,,,85,,561,percent of total billed charges,,,49,,323.4,percent of total billed charges,,,90,,594,percent of total billed charges,,,,,,,no IP contract,,80,,528,percent of total billed charges,,,,,,,no IP contract,,50,,330,percent of total billed charges,,,,,,no IP contract,,,78,,514.8,percent of total billed charges,,,70,,462,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,323.4,3324,
Xray-Scanogram NMH,77073,CPT,,,,inpatient,,,1101,660.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,891.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,935.85,percent of total billed charges,,,85,,935.85,percent of total billed charges,,,49,,539.49,percent of total billed charges,,,90,,990.9,percent of total billed charges,,,,,,,no IP contract,,80,,880.8,percent of total billed charges,,,,,,,no IP contract,,50,,550.5,percent of total billed charges,,,,,,no IP contract,,,78,,858.78,percent of total billed charges,,,70,,770.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,539.49,3324,
Xray-Arthritis Survey NMH,77074,CPT,,,,inpatient,,,1632,979.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1321.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1387.2,percent of total billed charges,,,85,,1387.2,percent of total billed charges,,,49,,799.68,percent of total billed charges,,,90,,1468.8,percent of total billed charges,,,,,,,no IP contract,,80,,1305.6,percent of total billed charges,,,,,,,no IP contract,,50,,816,percent of total billed charges,,,,,,no IP contract,,,78,,1272.96,percent of total billed charges,,,70,,1142.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,799.68,3324,
Xray-H.O. Study NMH,77074,CPT,,,,inpatient,,,1632,979.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1321.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1387.2,percent of total billed charges,,,85,,1387.2,percent of total billed charges,,,49,,799.68,percent of total billed charges,,,90,,1468.8,percent of total billed charges,,,,,,,no IP contract,,80,,1305.6,percent of total billed charges,,,,,,,no IP contract,,50,,816,percent of total billed charges,,,,,,no IP contract,,,78,,1272.96,percent of total billed charges,,,70,,1142.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,799.68,3324,
Xray-Skeletal Metast NMH,77075,CPT,,,,inpatient,,,2120,1272,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1717.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1802,percent of total billed charges,,,85,,1802,percent of total billed charges,,,49,,1038.8,percent of total billed charges,,,90,,1908,percent of total billed charges,,,,,,,no IP contract,,80,,1696,percent of total billed charges,,,,,,,no IP contract,,50,,1060,percent of total billed charges,,,,,,no IP contract,,,78,,1653.6,percent of total billed charges,,,70,,1484,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
Xray-Skeletal Survey Metabol NMH,77075,CPT,,,,inpatient,,,2120,1272,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1717.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1802,percent of total billed charges,,,85,,1802,percent of total billed charges,,,49,,1038.8,percent of total billed charges,,,90,,1908,percent of total billed charges,,,,,,,no IP contract,,80,,1696,percent of total billed charges,,,,,,,no IP contract,,50,,1060,percent of total billed charges,,,,,,no IP contract,,,78,,1653.6,percent of total billed charges,,,70,,1484,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
Antibody Screen,86850,CPT,,,,inpatient,,,233,139.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,188.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,198.05,percent of total billed charges,,,85,,198.05,percent of total billed charges,,,49,,114.17,percent of total billed charges,,,90,,209.7,percent of total billed charges,,,,,,,no IP contract,,80,,186.4,percent of total billed charges,,,,,,,no IP contract,,50,,116.5,percent of total billed charges,,,,,,no IP contract,,,78,,181.74,percent of total billed charges,,,70,,163.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,114.17,3324,
"Antibody Elution, referred",86860,CPT,,,,inpatient,,,237,142.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,191.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,201.45,percent of total billed charges,,,85,,201.45,percent of total billed charges,,,49,,116.13,percent of total billed charges,,,90,,213.3,percent of total billed charges,,,,,,,no IP contract,,80,,189.6,percent of total billed charges,,,,,,,no IP contract,,50,,118.5,percent of total billed charges,,,,,,no IP contract,,,78,,184.86,percent of total billed charges,,,70,,165.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,21940.22,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,116.13,21940.22,
Antibody Elution,86860,CPT,,,,inpatient,,,321,192.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,260.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,272.85,percent of total billed charges,,,85,,272.85,percent of total billed charges,,,49,,157.29,percent of total billed charges,,,90,,288.9,percent of total billed charges,,,,,,,no IP contract,,80,,256.8,percent of total billed charges,,,,,,,no IP contract,,50,,160.5,percent of total billed charges,,,,,,no IP contract,,,78,,250.38,percent of total billed charges,,,70,,224.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,47124.4875,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,157.29,47124.49,
"Coombs, Direct (only C3 or IgG)",86880,CPT,,,,inpatient,,,107,64.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,86.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,90.95,percent of total billed charges,,,85,,90.95,percent of total billed charges,,,49,,52.43,percent of total billed charges,,,90,,96.3,percent of total billed charges,,,,,,,no IP contract,,80,,85.6,percent of total billed charges,,,,,,,no IP contract,,50,,53.5,percent of total billed charges,,,,,,no IP contract,,,78,,83.46,percent of total billed charges,,,70,,74.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,52.43,3324,
Direct and Indirect Antiglobulin Test,86880,CPT,,,,inpatient,,,151,90.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,122.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,128.35,percent of total billed charges,,,85,,128.35,percent of total billed charges,,,49,,73.99,percent of total billed charges,,,90,,135.9,percent of total billed charges,,,,,,,no IP contract,,80,,120.8,percent of total billed charges,,,,,,,no IP contract,,50,,75.5,percent of total billed charges,,,,,,no IP contract,,,78,,117.78,percent of total billed charges,,,70,,105.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,73.99,3324,
"Coombs, Direct",86880,CPT,,,,inpatient,,,153,91.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,123.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,130.05,percent of total billed charges,,,85,,130.05,percent of total billed charges,,,49,,74.97,percent of total billed charges,,,90,,137.7,percent of total billed charges,,,,,,,no IP contract,,80,,122.4,percent of total billed charges,,,,,,,no IP contract,,50,,76.5,percent of total billed charges,,,,,,no IP contract,,,78,,119.34,percent of total billed charges,,,70,,107.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,74.97,3324,
"Coombs, Indirect",86885,CPT,,,,inpatient,,,159,95.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,128.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,135.15,percent of total billed charges,,,85,,135.15,percent of total billed charges,,,49,,77.91,percent of total billed charges,,,90,,143.1,percent of total billed charges,,,,,,,no IP contract,,80,,127.2,percent of total billed charges,,,,,,,no IP contract,,50,,79.5,percent of total billed charges,,,,,,no IP contract,,,78,,124.02,percent of total billed charges,,,70,,111.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,77.91,3324,
"Coombs test, indirect, qual",86885,CPT,,,,inpatient,,,173,103.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,140.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,147.05,percent of total billed charges,,,85,,147.05,percent of total billed charges,,,49,,84.77,percent of total billed charges,,,90,,155.7,percent of total billed charges,,,,,,,no IP contract,,80,,138.4,percent of total billed charges,,,,,,,no IP contract,,50,,86.5,percent of total billed charges,,,,,,no IP contract,,,78,,134.94,percent of total billed charges,,,70,,121.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,84.77,3324,
"Antibody Titration, indirect, each",86886,CPT,,,,inpatient,,,159,95.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,128.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,135.15,percent of total billed charges,,,85,,135.15,percent of total billed charges,,,49,,77.91,percent of total billed charges,,,90,,143.1,percent of total billed charges,,,,,,,no IP contract,,80,,127.2,percent of total billed charges,,,,,,,no IP contract,,50,,79.5,percent of total billed charges,,,,,,no IP contract,,,78,,124.02,percent of total billed charges,,,70,,111.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,77.91,3324,
Prenatal Screen,86900,CPT,,,,inpatient,,,134,80.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,108.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,113.9,percent of total billed charges,,,85,,113.9,percent of total billed charges,,,49,,65.66,percent of total billed charges,,,90,,120.6,percent of total billed charges,,,,,,,no IP contract,,80,,107.2,percent of total billed charges,,,,,,,no IP contract,,50,,67,percent of total billed charges,,,,,,no IP contract,,,78,,104.52,percent of total billed charges,,,70,,93.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,65.66,3324,
ABO Rh Type,86900,CPT,,,,inpatient,,,162,97.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,131.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,137.7,percent of total billed charges,,,85,,137.7,percent of total billed charges,,,49,,79.38,percent of total billed charges,,,90,,145.8,percent of total billed charges,,,,,,,no IP contract,,80,,129.6,percent of total billed charges,,,,,,,no IP contract,,50,,81,percent of total billed charges,,,,,,no IP contract,,,78,,126.36,percent of total billed charges,,,70,,113.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,79.38,3324,
Blood typing; ABO,86901,CPT,,,,inpatient,,,45,27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,38.25,percent of total billed charges,,,85,,38.25,percent of total billed charges,,,49,,22.05,percent of total billed charges,,,90,,40.5,percent of total billed charges,,,,,,,no IP contract,,80,,36,percent of total billed charges,,,,,,,no IP contract,,50,,22.5,percent of total billed charges,,,,,,no IP contract,,,78,,35.1,percent of total billed charges,,,70,,31.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,16795.55714,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.05,16795.56,
"Rh Typing, includes DU, each unit",86901,CPT,,,,inpatient,,,78,46.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,63.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,66.3,percent of total billed charges,,,85,,66.3,percent of total billed charges,,,49,,38.22,percent of total billed charges,,,90,,70.2,percent of total billed charges,,,,,,,no IP contract,,80,,62.4,percent of total billed charges,,,,,,,no IP contract,,50,,39,percent of total billed charges,,,,,,no IP contract,,,78,,60.84,percent of total billed charges,,,70,,54.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,38.22,3324,
"Rh Typing, each unit",86902,CPT,,,,inpatient,,,78,46.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,63.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,66.3,percent of total billed charges,,,85,,66.3,percent of total billed charges,,,49,,38.22,percent of total billed charges,,,90,,70.2,percent of total billed charges,,,,,,,no IP contract,,80,,62.4,percent of total billed charges,,,,,,,no IP contract,,50,,39,percent of total billed charges,,,,,,no IP contract,,,78,,60.84,percent of total billed charges,,,70,,54.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,38.22,3324,
"Antigen Screen on Blood, Reagent Method",86902,CPT,,,,inpatient,,,98,58.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,79.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,83.3,percent of total billed charges,,,85,,83.3,percent of total billed charges,,,49,,48.02,percent of total billed charges,,,90,,88.2,percent of total billed charges,,,,,,,no IP contract,,80,,78.4,percent of total billed charges,,,,,,,no IP contract,,50,,49,percent of total billed charges,,,,,,no IP contract,,,78,,76.44,percent of total billed charges,,,70,,68.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,48.02,3324,
P1 Typing (unit or patient),86902,CPT,,,,inpatient,,,98,58.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,79.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,83.3,percent of total billed charges,,,85,,83.3,percent of total billed charges,,,49,,48.02,percent of total billed charges,,,90,,88.2,percent of total billed charges,,,,,,,no IP contract,,80,,78.4,percent of total billed charges,,,,,,,no IP contract,,50,,49,percent of total billed charges,,,,,,no IP contract,,,78,,76.44,percent of total billed charges,,,70,,68.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,48.02,3324,
"Type & Screen, PAT",86902,CPT,,,,inpatient,,,160,96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,129.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,136,percent of total billed charges,,,85,,136,percent of total billed charges,,,49,,78.4,percent of total billed charges,,,90,,144,percent of total billed charges,,,,,,,no IP contract,,80,,128,percent of total billed charges,,,,,,,no IP contract,,50,,80,percent of total billed charges,,,,,,no IP contract,,,78,,124.8,percent of total billed charges,,,70,,112,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,78.4,3324,
"Type & Screen, PAT",86902,CPT,,,,inpatient,,,160,96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,129.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,136,percent of total billed charges,,,85,,136,percent of total billed charges,,,49,,78.4,percent of total billed charges,,,90,,144,percent of total billed charges,,,,,,,no IP contract,,80,,128,percent of total billed charges,,,,,,,no IP contract,,50,,80,percent of total billed charges,,,,,,no IP contract,,,78,,124.8,percent of total billed charges,,,70,,112,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,78.4,3324,
"K-Typing, Patient",86905,CPT,,,,inpatient,,,71,42.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,57.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,60.35,percent of total billed charges,,,85,,60.35,percent of total billed charges,,,49,,34.79,percent of total billed charges,,,90,,63.9,percent of total billed charges,,,,,,,no IP contract,,80,,56.8,percent of total billed charges,,,,,,,no IP contract,,50,,35.5,percent of total billed charges,,,,,,no IP contract,,,78,,55.38,percent of total billed charges,,,70,,49.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,34.79,3324,
"K-Typing, Unit",86905,CPT,,,,inpatient,,,71,42.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,57.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,60.35,percent of total billed charges,,,85,,60.35,percent of total billed charges,,,49,,34.79,percent of total billed charges,,,90,,63.9,percent of total billed charges,,,,,,,no IP contract,,80,,56.8,percent of total billed charges,,,,,,,no IP contract,,50,,35.5,percent of total billed charges,,,,,,no IP contract,,,78,,55.38,percent of total billed charges,,,70,,49.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,34.79,3324,
"Lewis Phenotyping, blood",86905,CPT,,,,inpatient,,,71,42.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,57.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,60.35,percent of total billed charges,,,85,,60.35,percent of total billed charges,,,49,,34.79,percent of total billed charges,,,90,,63.9,percent of total billed charges,,,,,,,no IP contract,,80,,56.8,percent of total billed charges,,,,,,,no IP contract,,50,,35.5,percent of total billed charges,,,,,,no IP contract,,,78,,55.38,percent of total billed charges,,,70,,49.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,34.79,3324,
"MN Phenotyping, blood",86905,CPT,,,,inpatient,,,71,42.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,57.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,60.35,percent of total billed charges,,,85,,60.35,percent of total billed charges,,,49,,34.79,percent of total billed charges,,,90,,63.9,percent of total billed charges,,,,,,,no IP contract,,80,,56.8,percent of total billed charges,,,,,,,no IP contract,,50,,35.5,percent of total billed charges,,,,,,no IP contract,,,78,,55.38,percent of total billed charges,,,70,,49.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,34.79,3324,
"Antigen, Other RBC, Ea NMH",86905,CPT,,,,inpatient,,,95,57,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,76.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,80.75,percent of total billed charges,,,85,,80.75,percent of total billed charges,,,49,,46.55,percent of total billed charges,,,90,,85.5,percent of total billed charges,,,,,,,no IP contract,,80,,76,percent of total billed charges,,,,,,,no IP contract,,50,,47.5,percent of total billed charges,,,,,,no IP contract,,,78,,74.1,percent of total billed charges,,,70,,66.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,46.55,3324,
Rh Phenotyping,86906,CPT,,,,inpatient,,,97,58.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,78.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,82.45,percent of total billed charges,,,85,,82.45,percent of total billed charges,,,49,,47.53,percent of total billed charges,,,90,,87.3,percent of total billed charges,,,,,,,no IP contract,,80,,77.6,percent of total billed charges,,,,,,,no IP contract,,50,,48.5,percent of total billed charges,,,,,,no IP contract,,,78,,75.66,percent of total billed charges,,,70,,67.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,47.53,3324,
Crossmatch NMH,86920,CPT,,,,inpatient,,,179,107.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,144.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,152.15,percent of total billed charges,,,85,,152.15,percent of total billed charges,,,49,,87.71,percent of total billed charges,,,90,,161.1,percent of total billed charges,,,,,,,no IP contract,,80,,143.2,percent of total billed charges,,,,,,,no IP contract,,50,,89.5,percent of total billed charges,,,,,,no IP contract,,,78,,139.62,percent of total billed charges,,,70,,125.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,87.71,3324,
"Crossmatch for Transfusion (electronic, IS or IgG)",86923,CPT,,,,inpatient,,,116,69.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,93.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,98.6,percent of total billed charges,,,85,,98.6,percent of total billed charges,,,49,,56.84,percent of total billed charges,,,90,,104.4,percent of total billed charges,,,,,,,no IP contract,,80,,92.8,percent of total billed charges,,,,,,,no IP contract,,50,,58,percent of total billed charges,,,,,,no IP contract,,,78,,90.48,percent of total billed charges,,,70,,81.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,56.84,3324,
Platelet/Cryoprecipitate Pooling,86965,CPT,,,,inpatient,,,494,296.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,400.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,419.9,percent of total billed charges,,,85,,419.9,percent of total billed charges,,,49,,242.06,percent of total billed charges,,,90,,444.6,percent of total billed charges,,,,,,,no IP contract,,80,,395.2,percent of total billed charges,,,,,,,no IP contract,,50,,247,percent of total billed charges,,,,,,no IP contract,,,78,,385.32,percent of total billed charges,,,70,,345.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,242.06,3324,
RBC Pre-treatment,86970,CPT,,,,inpatient,,,134,80.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,108.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,113.9,percent of total billed charges,,,85,,113.9,percent of total billed charges,,,49,,65.66,percent of total billed charges,,,90,,120.6,percent of total billed charges,,,,,,,no IP contract,,80,,107.2,percent of total billed charges,,,,,,,no IP contract,,50,,67,percent of total billed charges,,,,,,no IP contract,,,78,,104.52,percent of total billed charges,,,70,,93.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,65.66,3324,
Cytology Fluid Specimen,88104,CPT,,,,inpatient,,,408,244.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,330.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,346.8,percent of total billed charges,,,85,,346.8,percent of total billed charges,,,49,,199.92,percent of total billed charges,,,90,,367.2,percent of total billed charges,,,,,,,no IP contract,,80,,326.4,percent of total billed charges,,,,,,,no IP contract,,50,,204,percent of total billed charges,,,,,,no IP contract,,,78,,318.24,percent of total billed charges,,,70,,285.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,199.92,3324,
Cytology-CSF,88104,CPT,,,,inpatient,,,408,244.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,330.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,346.8,percent of total billed charges,,,85,,346.8,percent of total billed charges,,,49,,199.92,percent of total billed charges,,,90,,367.2,percent of total billed charges,,,,,,,no IP contract,,80,,326.4,percent of total billed charges,,,,,,,no IP contract,,50,,204,percent of total billed charges,,,,,,no IP contract,,,78,,318.24,percent of total billed charges,,,70,,285.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,199.92,3324,
Cytology-CSF,88104,CPT,,,,inpatient,,,408,244.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,330.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,346.8,percent of total billed charges,,,85,,346.8,percent of total billed charges,,,49,,199.92,percent of total billed charges,,,90,,367.2,percent of total billed charges,,,,,,,no IP contract,,80,,326.4,percent of total billed charges,,,,,,,no IP contract,,50,,204,percent of total billed charges,,,,,,no IP contract,,,78,,318.24,percent of total billed charges,,,70,,285.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,199.92,3324,
"Cytopath, concentrate technique",88108,CPT,,,,inpatient,,,513,307.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,415.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,436.05,percent of total billed charges,,,85,,436.05,percent of total billed charges,,,49,,251.37,percent of total billed charges,,,90,,461.7,percent of total billed charges,,,,,,,no IP contract,,80,,410.4,percent of total billed charges,,,,,,,no IP contract,,50,,256.5,percent of total billed charges,,,,,,no IP contract,,,78,,400.14,percent of total billed charges,,,70,,359.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,251.37,3324,
FLUID/BRUSH CONCENTRATION NMH,88108,CPT,,,,inpatient,,,560,336,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,453.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,476,percent of total billed charges,,,85,,476,percent of total billed charges,,,49,,274.4,percent of total billed charges,,,90,,504,percent of total billed charges,,,,,,,no IP contract,,80,,448,percent of total billed charges,,,,,,,no IP contract,,50,,280,percent of total billed charges,,,,,,no IP contract,,,78,,436.8,percent of total billed charges,,,70,,392,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,274.4,3324,
FNA ADEQUACY-1ST EPISODE NMH,88172,CPT,,,,inpatient,,,466,279.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,377.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,396.1,percent of total billed charges,,,85,,396.1,percent of total billed charges,,,49,,228.34,percent of total billed charges,,,90,,419.4,percent of total billed charges,,,,,,,no IP contract,,80,,372.8,percent of total billed charges,,,,,,,no IP contract,,50,,233,percent of total billed charges,,,,,,no IP contract,,,78,,363.48,percent of total billed charges,,,70,,326.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,228.34,3324,
CYTOPATH EVAL FNA NMH,88173,CPT,,,,inpatient,,,740,444,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,599.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,629,percent of total billed charges,,,85,,629,percent of total billed charges,,,49,,362.6,percent of total billed charges,,,90,,666,percent of total billed charges,,,,,,,no IP contract,,80,,592,percent of total billed charges,,,,,,,no IP contract,,50,,370,percent of total billed charges,,,,,,no IP contract,,,78,,577.2,percent of total billed charges,,,70,,518,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,362.6,3324,
"Surgical Pathology, Skin, Tag, Cyst, Debridement",88304,CPT,,,,inpatient,,,381,228.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,308.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,323.85,percent of total billed charges,,,85,,323.85,percent of total billed charges,,,49,,186.69,percent of total billed charges,,,90,,342.9,percent of total billed charges,,,,,,,no IP contract,,80,,304.8,percent of total billed charges,,,,,,,no IP contract,,50,,190.5,percent of total billed charges,,,,,,no IP contract,,,78,,297.18,percent of total billed charges,,,70,,266.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,186.69,3324,
"Surgical Pathology, Abscess",88304,CPT,,,,inpatient,,,534,320.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,432.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,453.9,percent of total billed charges,,,85,,453.9,percent of total billed charges,,,49,,261.66,percent of total billed charges,,,90,,480.6,percent of total billed charges,,,,,,,no IP contract,,80,,427.2,percent of total billed charges,,,,,,,no IP contract,,50,,267,percent of total billed charges,,,,,,no IP contract,,,78,,416.52,percent of total billed charges,,,70,,373.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,261.66,3324,
"Surgical Pathology, Bone Fragments Non-Pathological Fracture",88304,CPT,,,,inpatient,,,534,320.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,432.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,453.9,percent of total billed charges,,,85,,453.9,percent of total billed charges,,,49,,261.66,percent of total billed charges,,,90,,480.6,percent of total billed charges,,,,,,,no IP contract,,80,,427.2,percent of total billed charges,,,,,,,no IP contract,,50,,267,percent of total billed charges,,,,,,no IP contract,,,78,,416.52,percent of total billed charges,,,70,,373.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,261.66,3324,
Surg Path Level III NMH,88304,CPT,,,,inpatient,,,774,464.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,626.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,657.9,percent of total billed charges,,,85,,657.9,percent of total billed charges,,,49,,379.26,percent of total billed charges,,,90,,696.6,percent of total billed charges,,,,,,,no IP contract,,80,,619.2,percent of total billed charges,,,,,,,no IP contract,,50,,387,percent of total billed charges,,,,,,no IP contract,,,78,,603.72,percent of total billed charges,,,70,,541.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,379.26,3324,
"Surgical Pathology, Vulva Biopsy",88305,CPT,,,,inpatient,,,647,388.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,524.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,549.95,percent of total billed charges,,,85,,549.95,percent of total billed charges,,,49,,317.03,percent of total billed charges,,,90,,582.3,percent of total billed charges,,,,,,,no IP contract,,80,,517.6,percent of total billed charges,,,,,,,no IP contract,,50,,323.5,percent of total billed charges,,,,,,no IP contract,,,78,,504.66,percent of total billed charges,,,70,,452.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,317.03,3324,
"Surgical Pathology, Cervical Polyp",88305,CPT,,,,inpatient,,,725,435,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,587.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,616.25,percent of total billed charges,,,85,,616.25,percent of total billed charges,,,49,,355.25,percent of total billed charges,,,90,,652.5,percent of total billed charges,,,,,,,no IP contract,,80,,580,percent of total billed charges,,,,,,,no IP contract,,50,,362.5,percent of total billed charges,,,,,,no IP contract,,,78,,565.5,percent of total billed charges,,,70,,507.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,355.25,3324,
"Surgical Pathology, Endocervix Biopsy",88305,CPT,,,,inpatient,,,725,435,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,587.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,616.25,percent of total billed charges,,,85,,616.25,percent of total billed charges,,,49,,355.25,percent of total billed charges,,,90,,652.5,percent of total billed charges,,,,,,,no IP contract,,80,,580,percent of total billed charges,,,,,,,no IP contract,,50,,362.5,percent of total billed charges,,,,,,no IP contract,,,78,,565.5,percent of total billed charges,,,70,,507.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,355.25,3324,
"Surgical Pathology, Endocervix Curettings",88305,CPT,,,,inpatient,,,725,435,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,587.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,616.25,percent of total billed charges,,,85,,616.25,percent of total billed charges,,,49,,355.25,percent of total billed charges,,,90,,652.5,percent of total billed charges,,,,,,,no IP contract,,80,,580,percent of total billed charges,,,,,,,no IP contract,,50,,362.5,percent of total billed charges,,,,,,no IP contract,,,78,,565.5,percent of total billed charges,,,70,,507.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,355.25,3324,
"Surgical Pathology, Endometrium Biopsy",88305,CPT,,,,inpatient,,,725,435,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,587.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,616.25,percent of total billed charges,,,85,,616.25,percent of total billed charges,,,49,,355.25,percent of total billed charges,,,90,,652.5,percent of total billed charges,,,,,,,no IP contract,,80,,580,percent of total billed charges,,,,,,,no IP contract,,50,,362.5,percent of total billed charges,,,,,,no IP contract,,,78,,565.5,percent of total billed charges,,,70,,507.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,355.25,3324,
"Surgical Pathology, Endometrium Curettings",88305,CPT,,,,inpatient,,,725,435,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,587.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,616.25,percent of total billed charges,,,85,,616.25,percent of total billed charges,,,49,,355.25,percent of total billed charges,,,90,,652.5,percent of total billed charges,,,,,,,no IP contract,,80,,580,percent of total billed charges,,,,,,,no IP contract,,50,,362.5,percent of total billed charges,,,,,,no IP contract,,,78,,565.5,percent of total billed charges,,,70,,507.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,355.25,3324,
"Surgical Pathology, Endometrium Polyp",88305,CPT,,,,inpatient,,,725,435,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,587.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,616.25,percent of total billed charges,,,85,,616.25,percent of total billed charges,,,49,,355.25,percent of total billed charges,,,90,,652.5,percent of total billed charges,,,,,,,no IP contract,,80,,580,percent of total billed charges,,,,,,,no IP contract,,50,,362.5,percent of total billed charges,,,,,,no IP contract,,,78,,565.5,percent of total billed charges,,,70,,507.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,355.25,3324,
"Surgical Pathology, Vaginal Biopsy",88305,CPT,,,,inpatient,,,725,435,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,587.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,616.25,percent of total billed charges,,,85,,616.25,percent of total billed charges,,,49,,355.25,percent of total billed charges,,,90,,652.5,percent of total billed charges,,,,,,,no IP contract,,80,,580,percent of total billed charges,,,,,,,no IP contract,,50,,362.5,percent of total billed charges,,,,,,no IP contract,,,78,,565.5,percent of total billed charges,,,70,,507.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,355.25,3324,
"Surgical Pathology, Skin, other",88305,CPT,,,,inpatient,,,833,499.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,674.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,708.05,percent of total billed charges,,,85,,708.05,percent of total billed charges,,,49,,408.17,percent of total billed charges,,,90,,749.7,percent of total billed charges,,,,,,,no IP contract,,80,,666.4,percent of total billed charges,,,,,,,no IP contract,,50,,416.5,percent of total billed charges,,,,,,no IP contract,,,78,,649.74,percent of total billed charges,,,70,,583.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,408.17,3324,
Surg Path IV NMH,88305,CPT,,,,inpatient,,,1018,610.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,824.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,865.3,percent of total billed charges,,,85,,865.3,percent of total billed charges,,,49,,498.82,percent of total billed charges,,,90,,916.2,percent of total billed charges,,,,,,,no IP contract,,80,,814.4,percent of total billed charges,,,,,,,no IP contract,,50,,509,percent of total billed charges,,,,,,no IP contract,,,78,,794.04,percent of total billed charges,,,70,,712.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,498.82,3324,
Fungus Stain/PAS,88312,CPT,,,,inpatient,,,248,148.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,200.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,210.8,percent of total billed charges,,,85,,210.8,percent of total billed charges,,,49,,121.52,percent of total billed charges,,,90,,223.2,percent of total billed charges,,,,,,,no IP contract,,80,,198.4,percent of total billed charges,,,,,,,no IP contract,,50,,124,percent of total billed charges,,,,,,no IP contract,,,78,,193.44,percent of total billed charges,,,70,,173.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,121.52,3324,
TRICHROME STAIN NMH,88313,CPT,,,,inpatient,,,460,276,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,372.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,391,percent of total billed charges,,,85,,391,percent of total billed charges,,,49,,225.4,percent of total billed charges,,,90,,414,percent of total billed charges,,,,,,,no IP contract,,80,,368,percent of total billed charges,,,,,,,no IP contract,,50,,230,percent of total billed charges,,,,,,no IP contract,,,78,,358.8,percent of total billed charges,,,70,,322,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,225.4,3324,
FISH DEL(7Q) -7 MULTIPLEX NMH,88366,CPT,,,,inpatient,,,1220,732,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,988.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1037,percent of total billed charges,,,85,,1037,percent of total billed charges,,,49,,597.8,percent of total billed charges,,,90,,1098,percent of total billed charges,,,,,,,no IP contract,,80,,976,percent of total billed charges,,,,,,,no IP contract,,50,,610,percent of total billed charges,,,,,,no IP contract,,,78,,951.6,percent of total billed charges,,,70,,854,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,597.8,3324,
Specimen Processing,89240,CPT,,,,inpatient,,,74,44.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,59.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,62.9,percent of total billed charges,,,85,,62.9,percent of total billed charges,,,49,,36.26,percent of total billed charges,,,90,,66.6,percent of total billed charges,,,,,,,no IP contract,,80,,59.2,percent of total billed charges,,,,,,,no IP contract,,50,,37,percent of total billed charges,,,,,,no IP contract,,,78,,57.72,percent of total billed charges,,,70,,51.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.26,3324,
IMMUNIZATION ADMIN NMH,90471,CPT,,,,inpatient,,,87,52.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,70.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,73.95,percent of total billed charges,,,85,,73.95,percent of total billed charges,,,49,,42.63,percent of total billed charges,,,90,,78.3,percent of total billed charges,,,,,,,no IP contract,,80,,69.6,percent of total billed charges,,,,,,,no IP contract,,50,,43.5,percent of total billed charges,,,,,,no IP contract,,,78,,67.86,percent of total billed charges,,,70,,60.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,42.63,3324,
Flu vaccine admin 1 - Admin Charge Flu,90471,CPT,G0008,HCPCS,,inpatient,,,164,98.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,132.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,139.4,percent of total billed charges,,,85,,139.4,percent of total billed charges,,,49,,80.36,percent of total billed charges,,,90,,147.6,percent of total billed charges,,,,,,,no IP contract,,80,,131.2,percent of total billed charges,,,,,,,no IP contract,,50,,82,percent of total billed charges,,,,,,no IP contract,,,78,,127.92,percent of total billed charges,,,70,,114.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,80.36,3324,
"Pure Tone Audio, Air/Bone2 NMH",92553,CPT,,,,inpatient,,,289,173.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,234.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,245.65,percent of total billed charges,,,85,,245.65,percent of total billed charges,,,49,,141.61,percent of total billed charges,,,90,,260.1,percent of total billed charges,,,,,,,no IP contract,,80,,231.2,percent of total billed charges,,,,,,,no IP contract,,50,,144.5,percent of total billed charges,,,,,,no IP contract,,,78,,225.42,percent of total billed charges,,,70,,202.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,141.61,3324,
"Electrocardiogram, tracing only NMH",93005,CPT,,,,inpatient,,,346,207.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,280.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,294.1,percent of total billed charges,,,85,,294.1,percent of total billed charges,,,49,,169.54,percent of total billed charges,,,90,,311.4,percent of total billed charges,,,,,,,no IP contract,,80,,276.8,percent of total billed charges,,,,,,,no IP contract,,50,,173,percent of total billed charges,,,,,,no IP contract,,,78,,269.88,percent of total billed charges,,,70,,242.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,169.54,3324,
"12 Lead Ekg, Tracing Only",93005,CPT,,,,inpatient,,,379,227.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,306.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,322.15,percent of total billed charges,,,85,,322.15,percent of total billed charges,,,49,,185.71,percent of total billed charges,,,90,,341.1,percent of total billed charges,,,,,,,no IP contract,,80,,303.2,percent of total billed charges,,,,,,,no IP contract,,50,,189.5,percent of total billed charges,,,,,,no IP contract,,,78,,295.62,percent of total billed charges,,,70,,265.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,185.71,3324,
I Stress Test Monitoring NMH,93017,CPT,,,,inpatient,,,1314,788.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1064.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1116.9,percent of total billed charges,,,85,,1116.9,percent of total billed charges,,,49,,643.86,percent of total billed charges,,,90,,1182.6,percent of total billed charges,,,,,,,no IP contract,,80,,1051.2,percent of total billed charges,,,,,,,no IP contract,,50,,657,percent of total billed charges,,,,,,no IP contract,,,78,,1024.92,percent of total billed charges,,,70,,919.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,643.86,3324,
24 Hour Holter Monitor NMH,93225,CPT,,,,inpatient,,,2130,1278,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1725.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1810.5,percent of total billed charges,,,85,,1810.5,percent of total billed charges,,,49,,1043.7,percent of total billed charges,,,90,,1917,percent of total billed charges,,,,,,,no IP contract,,80,,1704,percent of total billed charges,,,,,,,no IP contract,,50,,1065,percent of total billed charges,,,,,,no IP contract,,,78,,1661.4,percent of total billed charges,,,70,,1491,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
EXTERNAL ECG REC>7D<15D RECORDING NMH,93246,CPT,,,,inpatient,,,946,567.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,766.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,804.1,percent of total billed charges,,,85,,804.1,percent of total billed charges,,,49,,463.54,percent of total billed charges,,,90,,851.4,percent of total billed charges,,,,,,,no IP contract,,80,,756.8,percent of total billed charges,,,,,,,no IP contract,,50,,473,percent of total billed charges,,,,,,no IP contract,,,78,,737.88,percent of total billed charges,,,70,,662.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,463.54,3324,
30 DAY EVENT MONITOR NMH,93270,CPT,,,,inpatient,,,2146,1287.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1738.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1824.1,percent of total billed charges,,,85,,1824.1,percent of total billed charges,,,49,,1051.54,percent of total billed charges,,,90,,1931.4,percent of total billed charges,,,,,,,no IP contract,,80,,1716.8,percent of total billed charges,,,,,,,no IP contract,,50,,1073,percent of total billed charges,,,,,,no IP contract,,,78,,1673.88,percent of total billed charges,,,70,,1502.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
UPR/L XTREMITY ART 2 LEVELS NMH,93922,CPT,,,,inpatient,,,946,567.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,766.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,804.1,percent of total billed charges,,,85,,804.1,percent of total billed charges,,,49,,463.54,percent of total billed charges,,,90,,851.4,percent of total billed charges,,,,,,,no IP contract,,80,,756.8,percent of total billed charges,,,,,,,no IP contract,,50,,473,percent of total billed charges,,,,,,no IP contract,,,78,,737.88,percent of total billed charges,,,70,,662.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,463.54,3324,
Spirometry without Bronchodilators Charge,94010,CPT,,,,inpatient,,,540,324,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,437.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,459,percent of total billed charges,,,85,,459,percent of total billed charges,,,49,,264.6,percent of total billed charges,,,90,,486,percent of total billed charges,,,,,,,no IP contract,,80,,432,percent of total billed charges,,,,,,,no IP contract,,50,,270,percent of total billed charges,,,,,,no IP contract,,,78,,421.2,percent of total billed charges,,,70,,378,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,264.6,3324,
Bronchial Hygiene Eval,94010,CPT,,,,inpatient,,,570,342,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,461.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,484.5,percent of total billed charges,,,85,,484.5,percent of total billed charges,,,49,,279.3,percent of total billed charges,,,90,,513,percent of total billed charges,,,,,,,no IP contract,,80,,456,percent of total billed charges,,,,,,,no IP contract,,50,,285,percent of total billed charges,,,,,,no IP contract,,,78,,444.6,percent of total billed charges,,,70,,399,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,279.3,3324,
Negative Inspiratory Force Charge,94150,CPT,,,,inpatient,,,310,186,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,251.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,263.5,percent of total billed charges,,,85,,263.5,percent of total billed charges,,,49,,151.9,percent of total billed charges,,,90,,279,percent of total billed charges,,,,,,,no IP contract,,80,,248,percent of total billed charges,,,,,,,no IP contract,,50,,155,percent of total billed charges,,,,,,no IP contract,,,78,,241.8,percent of total billed charges,,,70,,217,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,151.9,3324,
Peak Flow Meter Charge,94150,CPT,,,,inpatient,,,310,186,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,251.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,263.5,percent of total billed charges,,,85,,263.5,percent of total billed charges,,,49,,151.9,percent of total billed charges,,,90,,279,percent of total billed charges,,,,,,,no IP contract,,80,,248,percent of total billed charges,,,,,,,no IP contract,,50,,155,percent of total billed charges,,,,,,no IP contract,,,78,,241.8,percent of total billed charges,,,70,,217,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,151.9,3324,
Phase 3 Pulmonary Rehab,94150,CPT,,,,inpatient,,,310,186,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,251.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,263.5,percent of total billed charges,,,85,,263.5,percent of total billed charges,,,49,,151.9,percent of total billed charges,,,90,,279,percent of total billed charges,,,,,,,no IP contract,,80,,248,percent of total billed charges,,,,,,,no IP contract,,50,,155,percent of total billed charges,,,,,,no IP contract,,,78,,241.8,percent of total billed charges,,,70,,217,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,151.9,3324,
Respiratory Parameter Assessment,94150,CPT,,,,inpatient,,,310,186,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,251.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,263.5,percent of total billed charges,,,85,,263.5,percent of total billed charges,,,49,,151.9,percent of total billed charges,,,90,,279,percent of total billed charges,,,,,,,no IP contract,,80,,248,percent of total billed charges,,,,,,,no IP contract,,50,,155,percent of total billed charges,,,,,,no IP contract,,,78,,241.8,percent of total billed charges,,,70,,217,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,151.9,3324,
Total Vital Capacity Charge,94150,CPT,,,,inpatient,,,310,186,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,251.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,263.5,percent of total billed charges,,,85,,263.5,percent of total billed charges,,,49,,151.9,percent of total billed charges,,,90,,279,percent of total billed charges,,,,,,,no IP contract,,80,,248,percent of total billed charges,,,,,,,no IP contract,,50,,155,percent of total billed charges,,,,,,no IP contract,,,78,,241.8,percent of total billed charges,,,70,,217,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,151.9,3324,
Ventilatory Parameters NMH,94150,CPT,,,,inpatient,,,338,202.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,273.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,287.3,percent of total billed charges,,,85,,287.3,percent of total billed charges,,,49,,165.62,percent of total billed charges,,,90,,304.2,percent of total billed charges,,,,,,,no IP contract,,80,,270.4,percent of total billed charges,,,,,,,no IP contract,,50,,169,percent of total billed charges,,,,,,no IP contract,,,78,,263.64,percent of total billed charges,,,70,,236.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,165.62,3324,
Maximum Breathing Capacity and Maximum Voluntary Ventilation,94200,CPT,,,,inpatient,,,203,121.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,164.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,172.55,percent of total billed charges,,,85,,172.55,percent of total billed charges,,,49,,99.47,percent of total billed charges,,,90,,182.7,percent of total billed charges,,,,,,,no IP contract,,80,,162.4,percent of total billed charges,,,,,,,no IP contract,,50,,101.5,percent of total billed charges,,,,,,no IP contract,,,78,,158.34,percent of total billed charges,,,70,,142.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,99.47,3324,
Aerosol Therapy NMH,94640,CPT,,,,inpatient,,,294,176.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,238.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,249.9,percent of total billed charges,,,85,,249.9,percent of total billed charges,,,49,,144.06,percent of total billed charges,,,90,,264.6,percent of total billed charges,,,,,,,no IP contract,,80,,235.2,percent of total billed charges,,,,,,,no IP contract,,50,,147,percent of total billed charges,,,,,,no IP contract,,,78,,229.32,percent of total billed charges,,,70,,205.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,144.06,3324,
IPPB,94640,CPT,,,,inpatient,,,294,176.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,238.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,249.9,percent of total billed charges,,,85,,249.9,percent of total billed charges,,,49,,144.06,percent of total billed charges,,,90,,264.6,percent of total billed charges,,,,,,,no IP contract,,80,,235.2,percent of total billed charges,,,,,,,no IP contract,,50,,147,percent of total billed charges,,,,,,no IP contract,,,78,,229.32,percent of total billed charges,,,70,,205.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,144.06,3324,
Oxygen Therapy 0-8 hours,94640,CPT,,,,inpatient,,,294,176.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,238.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,249.9,percent of total billed charges,,,85,,249.9,percent of total billed charges,,,49,,144.06,percent of total billed charges,,,90,,264.6,percent of total billed charges,,,,,,,no IP contract,,80,,235.2,percent of total billed charges,,,,,,,no IP contract,,50,,147,percent of total billed charges,,,,,,no IP contract,,,78,,229.32,percent of total billed charges,,,70,,205.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,144.06,3324,
IPPB Charge,94640,CPT,,,,inpatient,,,310,186,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,251.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,263.5,percent of total billed charges,,,85,,263.5,percent of total billed charges,,,49,,151.9,percent of total billed charges,,,90,,279,percent of total billed charges,,,,,,,no IP contract,,80,,248,percent of total billed charges,,,,,,,no IP contract,,50,,155,percent of total billed charges,,,,,,no IP contract,,,78,,241.8,percent of total billed charges,,,70,,217,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,151.9,3324,
Small Volume Nebulizer Charge,94640,CPT,,,,inpatient,,,310,186,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,251.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,263.5,percent of total billed charges,,,85,,263.5,percent of total billed charges,,,49,,151.9,percent of total billed charges,,,90,,279,percent of total billed charges,,,,,,,no IP contract,,80,,248,percent of total billed charges,,,,,,,no IP contract,,50,,155,percent of total billed charges,,,,,,no IP contract,,,78,,241.8,percent of total billed charges,,,70,,217,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,151.9,3324,
Yes - Mechanical In-ExSufflator Charge,94640,CPT,,,,inpatient,,,310,186,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,251.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,263.5,percent of total billed charges,,,85,,263.5,percent of total billed charges,,,49,,151.9,percent of total billed charges,,,90,,279,percent of total billed charges,,,,,,,no IP contract,,80,,248,percent of total billed charges,,,,,,,no IP contract,,50,,155,percent of total billed charges,,,,,,no IP contract,,,78,,241.8,percent of total billed charges,,,70,,217,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,151.9,3324,
Sm. Volume Neb. for Delivery of Pentamidine,94642,CPT,,,,inpatient,,,444,266.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,359.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,377.4,percent of total billed charges,,,85,,377.4,percent of total billed charges,,,49,,217.56,percent of total billed charges,,,90,,399.6,percent of total billed charges,,,,,,,no IP contract,,80,,355.2,percent of total billed charges,,,,,,,no IP contract,,50,,222,percent of total billed charges,,,,,,no IP contract,,,78,,346.32,percent of total billed charges,,,70,,310.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,217.56,3324,
Aerosol Therapy with Pentamidine,94642,CPT,,,,inpatient,,,511,306.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,413.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,434.35,percent of total billed charges,,,85,,434.35,percent of total billed charges,,,49,,250.39,percent of total billed charges,,,90,,459.9,percent of total billed charges,,,,,,,no IP contract,,80,,408.8,percent of total billed charges,,,,,,,no IP contract,,50,,255.5,percent of total billed charges,,,,,,no IP contract,,,78,,398.58,percent of total billed charges,,,70,,357.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,250.39,3324,
Bronchial Hygiene Evaluation Charge,94664,CPT,,,,inpatient,,,260,156,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,210.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,221,percent of total billed charges,,,85,,221,percent of total billed charges,,,49,,127.4,percent of total billed charges,,,90,,234,percent of total billed charges,,,,,,,no IP contract,,80,,208,percent of total billed charges,,,,,,,no IP contract,,50,,130,percent of total billed charges,,,,,,no IP contract,,,78,,202.8,percent of total billed charges,,,70,,182,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,127.4,3324,
Meter Dose Inhaler,94664,CPT,,,,inpatient,,,260,156,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,210.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,221,percent of total billed charges,,,85,,221,percent of total billed charges,,,49,,127.4,percent of total billed charges,,,90,,234,percent of total billed charges,,,,,,,no IP contract,,80,,208,percent of total billed charges,,,,,,,no IP contract,,50,,130,percent of total billed charges,,,,,,no IP contract,,,78,,202.8,percent of total billed charges,,,70,,182,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,127.4,3324,
Meter dose inhaler teaching = inhaler,94664,CPT,,,,inpatient,,,260,156,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,210.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,221,percent of total billed charges,,,85,,221,percent of total billed charges,,,49,,127.4,percent of total billed charges,,,90,,234,percent of total billed charges,,,,,,,no IP contract,,80,,208,percent of total billed charges,,,,,,,no IP contract,,50,,130,percent of total billed charges,,,,,,no IP contract,,,78,,202.8,percent of total billed charges,,,70,,182,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,127.4,3324,
Meter Dose Inhaler Teaching Charge,94664,CPT,,,,inpatient,,,260,156,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,210.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,221,percent of total billed charges,,,85,,221,percent of total billed charges,,,49,,127.4,percent of total billed charges,,,90,,234,percent of total billed charges,,,,,,,no IP contract,,80,,208,percent of total billed charges,,,,,,,no IP contract,,50,,130,percent of total billed charges,,,,,,no IP contract,,,78,,202.8,percent of total billed charges,,,70,,182,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,127.4,3324,
Respiratory Aerosol Therapy- Initial,94664,CPT,,,,inpatient,,,260,156,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,210.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,221,percent of total billed charges,,,85,,221,percent of total billed charges,,,49,,127.4,percent of total billed charges,,,90,,234,percent of total billed charges,,,,,,,no IP contract,,80,,208,percent of total billed charges,,,,,,,no IP contract,,50,,130,percent of total billed charges,,,,,,no IP contract,,,78,,202.8,percent of total billed charges,,,70,,182,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,127.4,3324,
Respiratory Sputum Induction,94664,CPT,,,,inpatient,,,260,156,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,210.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,221,percent of total billed charges,,,85,,221,percent of total billed charges,,,49,,127.4,percent of total billed charges,,,90,,234,percent of total billed charges,,,,,,,no IP contract,,80,,208,percent of total billed charges,,,,,,,no IP contract,,50,,130,percent of total billed charges,,,,,,no IP contract,,,78,,202.8,percent of total billed charges,,,70,,182,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,127.4,3324,
Aerosol Therapy Demo/eval,94664,CPT,,,,inpatient,,,489,293.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,396.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,415.65,percent of total billed charges,,,85,,415.65,percent of total billed charges,,,49,,239.61,percent of total billed charges,,,90,,440.1,percent of total billed charges,,,,,,,no IP contract,,80,,391.2,percent of total billed charges,,,,,,,no IP contract,,50,,244.5,percent of total billed charges,,,,,,no IP contract,,,78,,381.42,percent of total billed charges,,,70,,342.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,239.61,3324,
USN For Sputum Induction,94664,CPT,,,,inpatient,,,489,293.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,396.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,415.65,percent of total billed charges,,,85,,415.65,percent of total billed charges,,,49,,239.61,percent of total billed charges,,,90,,440.1,percent of total billed charges,,,,,,,no IP contract,,80,,391.2,percent of total billed charges,,,,,,,no IP contract,,50,,244.5,percent of total billed charges,,,,,,no IP contract,,,78,,381.42,percent of total billed charges,,,70,,342.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,239.61,3324,
Chest Physical Therapy,94667,CPT,,,,inpatient,,,319,191.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,258.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,271.15,percent of total billed charges,,,85,,271.15,percent of total billed charges,,,49,,156.31,percent of total billed charges,,,90,,287.1,percent of total billed charges,,,,,,,no IP contract,,80,,255.2,percent of total billed charges,,,,,,,no IP contract,,50,,159.5,percent of total billed charges,,,,,,no IP contract,,,78,,248.82,percent of total billed charges,,,70,,223.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,156.31,3324,
Chest Physical Therapy Initial Charge,94667,CPT,,,,inpatient,,,319,191.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,258.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,271.15,percent of total billed charges,,,85,,271.15,percent of total billed charges,,,49,,156.31,percent of total billed charges,,,90,,287.1,percent of total billed charges,,,,,,,no IP contract,,80,,255.2,percent of total billed charges,,,,,,,no IP contract,,50,,159.5,percent of total billed charges,,,,,,no IP contract,,,78,,248.82,percent of total billed charges,,,70,,223.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,156.31,3324,
Chest physical therapy-Initial,94667,CPT,,,,inpatient,,,319,191.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,258.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,271.15,percent of total billed charges,,,85,,271.15,percent of total billed charges,,,49,,156.31,percent of total billed charges,,,90,,287.1,percent of total billed charges,,,,,,,no IP contract,,80,,255.2,percent of total billed charges,,,,,,,no IP contract,,50,,159.5,percent of total billed charges,,,,,,no IP contract,,,78,,248.82,percent of total billed charges,,,70,,223.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,156.31,3324,
Pulmonary Flutter Valve-Initial Charge,94667,CPT,,,,inpatient,,,319,191.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,258.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,271.15,percent of total billed charges,,,85,,271.15,percent of total billed charges,,,49,,156.31,percent of total billed charges,,,90,,287.1,percent of total billed charges,,,,,,,no IP contract,,80,,255.2,percent of total billed charges,,,,,,,no IP contract,,50,,159.5,percent of total billed charges,,,,,,no IP contract,,,78,,248.82,percent of total billed charges,,,70,,223.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,156.31,3324,
Chest PT,94667,CPT,,,,inpatient,,,359,215.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,290.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,305.15,percent of total billed charges,,,85,,305.15,percent of total billed charges,,,49,,175.91,percent of total billed charges,,,90,,323.1,percent of total billed charges,,,,,,,no IP contract,,80,,287.2,percent of total billed charges,,,,,,,no IP contract,,50,,179.5,percent of total billed charges,,,,,,no IP contract,,,78,,280.02,percent of total billed charges,,,70,,251.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,175.91,3324,
Chest Percussion- Subsequent,94668,CPT,,,,inpatient,,,262,157.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,212.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,222.7,percent of total billed charges,,,85,,222.7,percent of total billed charges,,,49,,128.38,percent of total billed charges,,,90,,235.8,percent of total billed charges,,,,,,,no IP contract,,80,,209.6,percent of total billed charges,,,,,,,no IP contract,,50,,131,percent of total billed charges,,,,,,no IP contract,,,78,,204.36,percent of total billed charges,,,70,,183.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,128.38,3324,
Chest Physical Therapy Subsequent Charge,94668,CPT,,,,inpatient,,,262,157.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,212.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,222.7,percent of total billed charges,,,85,,222.7,percent of total billed charges,,,49,,128.38,percent of total billed charges,,,90,,235.8,percent of total billed charges,,,,,,,no IP contract,,80,,209.6,percent of total billed charges,,,,,,,no IP contract,,50,,131,percent of total billed charges,,,,,,no IP contract,,,78,,204.36,percent of total billed charges,,,70,,183.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,128.38,3324,
Chest physical therapy-Subsequent,94668,CPT,,,,inpatient,,,262,157.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,212.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,222.7,percent of total billed charges,,,85,,222.7,percent of total billed charges,,,49,,128.38,percent of total billed charges,,,90,,235.8,percent of total billed charges,,,,,,,no IP contract,,80,,209.6,percent of total billed charges,,,,,,,no IP contract,,50,,131,percent of total billed charges,,,,,,no IP contract,,,78,,204.36,percent of total billed charges,,,70,,183.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,128.38,3324,
Pulmonary Flutter Valve-Subsequent Charge,94668,CPT,,,,inpatient,,,262,157.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,212.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,222.7,percent of total billed charges,,,85,,222.7,percent of total billed charges,,,49,,128.38,percent of total billed charges,,,90,,235.8,percent of total billed charges,,,,,,,no IP contract,,80,,209.6,percent of total billed charges,,,,,,,no IP contract,,50,,131,percent of total billed charges,,,,,,no IP contract,,,78,,204.36,percent of total billed charges,,,70,,183.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,128.38,3324,
Pulmonary Recheck,94668,CPT,,,,inpatient,,,262,157.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,212.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,222.7,percent of total billed charges,,,85,,222.7,percent of total billed charges,,,49,,128.38,percent of total billed charges,,,90,,235.8,percent of total billed charges,,,,,,,no IP contract,,80,,209.6,percent of total billed charges,,,,,,,no IP contract,,50,,131,percent of total billed charges,,,,,,no IP contract,,,78,,204.36,percent of total billed charges,,,70,,183.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,128.38,3324,
Chest Percussion Subsequent,94668,CPT,,,,inpatient,,,312,187.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,252.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,265.2,percent of total billed charges,,,85,,265.2,percent of total billed charges,,,49,,152.88,percent of total billed charges,,,90,,280.8,percent of total billed charges,,,,,,,no IP contract,,80,,249.6,percent of total billed charges,,,,,,,no IP contract,,50,,156,percent of total billed charges,,,,,,no IP contract,,,78,,243.36,percent of total billed charges,,,70,,218.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,152.88,3324,
Chest Wall Oscillation Therapy-Subsequent Charge,94669,CPT,,,,inpatient,,,233,139.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,188.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,198.05,percent of total billed charges,,,85,,198.05,percent of total billed charges,,,49,,114.17,percent of total billed charges,,,90,,209.7,percent of total billed charges,,,,,,,no IP contract,,80,,186.4,percent of total billed charges,,,,,,,no IP contract,,50,,116.5,percent of total billed charges,,,,,,no IP contract,,,78,,181.74,percent of total billed charges,,,70,,163.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,114.17,3324,
Yes - Chest Wall Oscillation Therapy-Initial Charge,94669,CPT,,,,inpatient,,,233,139.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,188.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,198.05,percent of total billed charges,,,85,,198.05,percent of total billed charges,,,49,,114.17,percent of total billed charges,,,90,,209.7,percent of total billed charges,,,,,,,no IP contract,,80,,186.4,percent of total billed charges,,,,,,,no IP contract,,50,,116.5,percent of total billed charges,,,,,,no IP contract,,,78,,181.74,percent of total billed charges,,,70,,163.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,114.17,3324,
Yes - Chest Wall Oscillation Therapy-Subsequent Charge,94669,CPT,,,,inpatient,,,233,139.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,188.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,198.05,percent of total billed charges,,,85,,198.05,percent of total billed charges,,,49,,114.17,percent of total billed charges,,,90,,209.7,percent of total billed charges,,,,,,,no IP contract,,80,,186.4,percent of total billed charges,,,,,,,no IP contract,,50,,116.5,percent of total billed charges,,,,,,no IP contract,,,78,,181.74,percent of total billed charges,,,70,,163.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,114.17,3324,
Yes - Metaneb Charge,94669,CPT,,,,inpatient,,,233,139.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,188.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,198.05,percent of total billed charges,,,85,,198.05,percent of total billed charges,,,49,,114.17,percent of total billed charges,,,90,,209.7,percent of total billed charges,,,,,,,no IP contract,,80,,186.4,percent of total billed charges,,,,,,,no IP contract,,50,,116.5,percent of total billed charges,,,,,,no IP contract,,,78,,181.74,percent of total billed charges,,,70,,163.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,114.17,3324,
Yes - CO2 Monitoring Charge,94799,CPT,,,,inpatient,,,492,295.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,398.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,418.2,percent of total billed charges,,,85,,418.2,percent of total billed charges,,,49,,241.08,percent of total billed charges,,,90,,442.8,percent of total billed charges,,,,,,,no IP contract,,80,,393.6,percent of total billed charges,,,,,,,no IP contract,,50,,246,percent of total billed charges,,,,,,no IP contract,,,78,,383.76,percent of total billed charges,,,70,,344.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,241.08,3324,
Miscellaneous Respiratory,94799,CPT,,,,inpatient,,,539,323.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,436.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,458.15,percent of total billed charges,,,85,,458.15,percent of total billed charges,,,49,,264.11,percent of total billed charges,,,90,,485.1,percent of total billed charges,,,,,,,no IP contract,,80,,431.2,percent of total billed charges,,,,,,,no IP contract,,50,,269.5,percent of total billed charges,,,,,,no IP contract,,,78,,420.42,percent of total billed charges,,,70,,377.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,264.11,3324,
Resp Service,94799,CPT,,,,inpatient,,,539,323.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,436.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,458.15,percent of total billed charges,,,85,,458.15,percent of total billed charges,,,49,,264.11,percent of total billed charges,,,90,,485.1,percent of total billed charges,,,,,,,no IP contract,,80,,431.2,percent of total billed charges,,,,,,,no IP contract,,50,,269.5,percent of total billed charges,,,,,,no IP contract,,,78,,420.42,percent of total billed charges,,,70,,377.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,264.11,3324,
THER/PROPH/DIAG INJ SC/IM NMH,96372,CPT,,,,inpatient,,,48,28.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,38.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,40.8,percent of total billed charges,,,85,,40.8,percent of total billed charges,,,49,,23.52,percent of total billed charges,,,90,,43.2,percent of total billed charges,,,,,,,no IP contract,,80,,38.4,percent of total billed charges,,,,,,,no IP contract,,50,,24,percent of total billed charges,,,,,,no IP contract,,,78,,37.44,percent of total billed charges,,,70,,33.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.52,3324,
Fracture of Lower Extremity D0701,D0701,LOCAL,,,,inpatient,,,72691.65,43614.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,58880.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,61787.9,percent of total billed charges,,,85,,61787.9,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,65422.49,percent of total billed charges,,,,,,,no IP contract,,80,,58153.32,percent of total billed charges,,,,,,,no IP contract,,50,,36345.83,percent of total billed charges,,,,,,no IP contract,,,78,,56699.49,percent of total billed charges,,,70,,50884.16,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,23928.37,100% of Medicare,,,,,23928.37,100% of Medicare,,,,,23928.37,100% of Medicare,,,,,23928.37,100% of Medicare,,,,,23928.37,100% of Medicare,,,,,23928.37,100% of Medicare,,,,,23928.37,100% of Medicare,,,,,23928.37,100% of Medicare,,,,,23928.37,100% of Medicare,,,,,23928.37,100% of Medicare,,,,,23928.37,100% of Medicare,,,,,,23928.37,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Fracture of Lower Extremity D0702,D0702,LOCAL,,,,inpatient,,,87793.74,52676.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,71112.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,74624.68,percent of total billed charges,,,85,,74624.68,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,79014.37,percent of total billed charges,,,,,,,no IP contract,,80,,70234.99,percent of total billed charges,,,,,,,no IP contract,,50,,43896.87,percent of total billed charges,,,,,,no IP contract,,,78,,68479.12,percent of total billed charges,,,70,,61455.62,percent of total billed charges,,,,,,,,,,,24579.91,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Fracture of Lower Extremity D0703,D0703,LOCAL,,,,inpatient,,,101378.2,60826.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,82116.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,86171.47,percent of total billed charges,,,85,,86171.47,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,91240.38,percent of total billed charges,,,,,,,no IP contract,,80,,81102.56,percent of total billed charges,,,,,,,no IP contract,,50,,50689.1,percent of total billed charges,,,,,,no IP contract,,,78,,79075,percent of total billed charges,,,70,,70964.74,percent of total billed charges,,,,,,,,,,,31902.09,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
BIPAP Initial,94660,CPT,,,,inpatient,,,388,232.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,314.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,329.8,percent of total billed charges,,,85,,329.8,percent of total billed charges,,,49,,190.12,percent of total billed charges,,,90,,349.2,percent of total billed charges,,,,,,,no IP contract,,80,,310.4,percent of total billed charges,,,,,,,no IP contract,,50,,194,percent of total billed charges,,,,,,no IP contract,,,78,,302.64,percent of total billed charges,,,70,,271.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,190.12,3324,
CPAP Initail/Mgt 0-8 hrs,94660,CPT,,,,inpatient,,,692,415.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,560.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,588.2,percent of total billed charges,,,85,,588.2,percent of total billed charges,,,49,,339.08,percent of total billed charges,,,90,,622.8,percent of total billed charges,,,,,,,no IP contract,,80,,553.6,percent of total billed charges,,,,,,,no IP contract,,50,,346,percent of total billed charges,,,,,,no IP contract,,,78,,539.76,percent of total billed charges,,,70,,484.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,339.08,3324,
BiPAP Initial Charge,94660,CPT,,,,inpatient,,,993,595.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,804.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,844.05,percent of total billed charges,,,85,,844.05,percent of total billed charges,,,49,,486.57,percent of total billed charges,,,90,,893.7,percent of total billed charges,,,,,,,no IP contract,,80,,794.4,percent of total billed charges,,,,,,,no IP contract,,50,,496.5,percent of total billed charges,,,,,,no IP contract,,,78,,774.54,percent of total billed charges,,,70,,695.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,486.57,3324,
BiPAP Subsequent Charge,94660,CPT,,,,inpatient,,,993,595.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,804.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,844.05,percent of total billed charges,,,85,,844.05,percent of total billed charges,,,49,,486.57,percent of total billed charges,,,90,,893.7,percent of total billed charges,,,,,,,no IP contract,,80,,794.4,percent of total billed charges,,,,,,,no IP contract,,50,,496.5,percent of total billed charges,,,,,,no IP contract,,,78,,774.54,percent of total billed charges,,,70,,695.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,486.57,3324,
CPAP Initiation and Management Charge,94660,CPT,,,,inpatient,,,993,595.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,804.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,844.05,percent of total billed charges,,,85,,844.05,percent of total billed charges,,,49,,486.57,percent of total billed charges,,,90,,893.7,percent of total billed charges,,,,,,,no IP contract,,80,,794.4,percent of total billed charges,,,,,,,no IP contract,,50,,496.5,percent of total billed charges,,,,,,no IP contract,,,78,,774.54,percent of total billed charges,,,70,,695.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,486.57,3324,
CPAP/BiPAP Initial Charge,94660,CPT,,,,inpatient,,,993,595.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,804.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,844.05,percent of total billed charges,,,85,,844.05,percent of total billed charges,,,49,,486.57,percent of total billed charges,,,90,,893.7,percent of total billed charges,,,,,,,no IP contract,,80,,794.4,percent of total billed charges,,,,,,,no IP contract,,50,,496.5,percent of total billed charges,,,,,,no IP contract,,,78,,774.54,percent of total billed charges,,,70,,695.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,486.57,3324,
CPAP/BiPAP Subsequent Charge,94660,CPT,,,,inpatient,,,993,595.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,804.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,844.05,percent of total billed charges,,,85,,844.05,percent of total billed charges,,,49,,486.57,percent of total billed charges,,,90,,893.7,percent of total billed charges,,,,,,,no IP contract,,80,,794.4,percent of total billed charges,,,,,,,no IP contract,,50,,496.5,percent of total billed charges,,,,,,no IP contract,,,78,,774.54,percent of total billed charges,,,70,,695.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,486.57,3324,
Portacath Removal NMH,36589,CPT,,,,inpatient,,,3229,1937.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2615.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2744.65,percent of total billed charges,,,85,,2744.65,percent of total billed charges,,,49,,1582.21,percent of total billed charges,,,90,,2906.1,percent of total billed charges,,,,,,,no IP contract,,80,,2583.2,percent of total billed charges,,,,,,,no IP contract,,50,,1614.5,percent of total billed charges,,,,,,no IP contract,,,78,,2518.62,percent of total billed charges,,,70,,2260.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
INJECTION FOR CHOLANGIOGRAM; EXIST ACCESS NMH,47531,CPT,,,,inpatient,,,3190,1914,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2583.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2711.5,percent of total billed charges,,,85,,2711.5,percent of total billed charges,,,49,,1563.1,percent of total billed charges,,,90,,2871,percent of total billed charges,,,,,,,no IP contract,,80,,2552,percent of total billed charges,,,,,,,no IP contract,,50,,1595,percent of total billed charges,,,,,,no IP contract,,,78,,2488.2,percent of total billed charges,,,70,,2233,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
Contrast Xray Hip TC NMH,73525,CPT,,,,inpatient,,,2234,1340.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1809.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1898.9,percent of total billed charges,,,85,,1898.9,percent of total billed charges,,,49,,1094.66,percent of total billed charges,,,90,,2010.6,percent of total billed charges,,,,,,,no IP contract,,80,,1787.2,percent of total billed charges,,,,,,,no IP contract,,50,,1117,percent of total billed charges,,,,,,no IP contract,,,78,,1742.52,percent of total billed charges,,,70,,1563.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
Xray-Loopogram NMH,74425,CPT,,,,inpatient,,,2004,1202.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1623.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1703.4,percent of total billed charges,,,85,,1703.4,percent of total billed charges,,,49,,981.96,percent of total billed charges,,,90,,1803.6,percent of total billed charges,,,,,,,no IP contract,,80,,1603.2,percent of total billed charges,,,,,,,no IP contract,,50,,1002,percent of total billed charges,,,,,,no IP contract,,,78,,1563.12,percent of total billed charges,,,70,,1402.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
Xray-Shunt Series NMH,75809,CPT,,,,inpatient,,,831,498.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,673.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,706.35,percent of total billed charges,,,85,,706.35,percent of total billed charges,,,49,,407.19,percent of total billed charges,,,90,,747.9,percent of total billed charges,,,,,,,no IP contract,,80,,664.8,percent of total billed charges,,,,,,,no IP contract,,50,,415.5,percent of total billed charges,,,,,,no IP contract,,,78,,648.18,percent of total billed charges,,,70,,581.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,407.19,3324,
IVC-Gram NMH,75825,CPT,,,,inpatient,,,6228,3736.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5044.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5293.8,percent of total billed charges,,,85,,5293.8,percent of total billed charges,,,49,,3051.72,percent of total billed charges,,,90,,5605.2,percent of total billed charges,,,,,,,no IP contract,,80,,4982.4,percent of total billed charges,,,,,,,no IP contract,,50,,3114,percent of total billed charges,,,,,,no IP contract,,,78,,4857.84,percent of total billed charges,,,70,,4359.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,5605.2,
IR FIST/SINUS STUDY S&I NMH,76080,CPT,,,,inpatient,,,2114,1268.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1712.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1796.9,percent of total billed charges,,,85,,1796.9,percent of total billed charges,,,49,,1035.86,percent of total billed charges,,,90,,1902.6,percent of total billed charges,,,,,,,no IP contract,,80,,1691.2,percent of total billed charges,,,,,,,no IP contract,,50,,1057,percent of total billed charges,,,,,,no IP contract,,,78,,1648.92,percent of total billed charges,,,70,,1479.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
BONE MARROW ASPIRATE SMEAR NMH,85097,CPT,,,,inpatient,,,884,530.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,716.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,751.4,percent of total billed charges,,,85,,751.4,percent of total billed charges,,,49,,433.16,percent of total billed charges,,,90,,795.6,percent of total billed charges,,,,,,,no IP contract,,80,,707.2,percent of total billed charges,,,,,,,no IP contract,,50,,442,percent of total billed charges,,,,,,no IP contract,,,78,,689.52,percent of total billed charges,,,70,,618.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,20318.58,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,433.16,20318.58,
Antibody Identification (blood bank),86870,CPT,,,,inpatient,,,315,189,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,255.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,267.75,percent of total billed charges,,,85,,267.75,percent of total billed charges,,,49,,154.35,percent of total billed charges,,,90,,283.5,percent of total billed charges,,,,,,,no IP contract,,80,,252,percent of total billed charges,,,,,,,no IP contract,,50,,157.5,percent of total billed charges,,,,,,no IP contract,,,78,,245.7,percent of total billed charges,,,70,,220.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,154.35,3324,
Antibody Identification Interpretation,86870,CPT,,,,inpatient,,,315,189,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,255.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,267.75,percent of total billed charges,,,85,,267.75,percent of total billed charges,,,49,,154.35,percent of total billed charges,,,90,,283.5,percent of total billed charges,,,,,,,no IP contract,,80,,252,percent of total billed charges,,,,,,,no IP contract,,50,,157.5,percent of total billed charges,,,,,,no IP contract,,,78,,245.7,percent of total billed charges,,,70,,220.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,36352.615,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,154.35,36352.62,
"Antibody ID, ea Panel NMH",86870,CPT,,,,inpatient,,,415,249,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,336.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,352.75,percent of total billed charges,,,85,,352.75,percent of total billed charges,,,49,,203.35,percent of total billed charges,,,90,,373.5,percent of total billed charges,,,,,,,no IP contract,,80,,332,percent of total billed charges,,,,,,,no IP contract,,50,,207.5,percent of total billed charges,,,,,,no IP contract,,,78,,323.7,percent of total billed charges,,,70,,290.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,25570.34,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,203.35,25570.34,
Fetal Hemoglobin,88184,CPT,,,,inpatient,,,655,393,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,530.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,556.75,percent of total billed charges,,,85,,556.75,percent of total billed charges,,,49,,320.95,percent of total billed charges,,,90,,589.5,percent of total billed charges,,,,,,,no IP contract,,80,,524,percent of total billed charges,,,,,,,no IP contract,,50,,327.5,percent of total billed charges,,,,,,no IP contract,,,78,,510.9,percent of total billed charges,,,70,,458.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,320.95,3324,
Fetal Hemoglobin,88184,CPT,,,,inpatient,,,655,393,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,530.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,556.75,percent of total billed charges,,,85,,556.75,percent of total billed charges,,,49,,320.95,percent of total billed charges,,,90,,589.5,percent of total billed charges,,,,,,,no IP contract,,80,,524,percent of total billed charges,,,,,,,no IP contract,,50,,327.5,percent of total billed charges,,,,,,no IP contract,,,78,,510.9,percent of total billed charges,,,70,,458.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,320.95,3324,
"Surgical Pathology, Soft Tissue Biopsy",88307,CPT,,,,inpatient,,,1613,967.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1306.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1371.05,percent of total billed charges,,,85,,1371.05,percent of total billed charges,,,49,,790.37,percent of total billed charges,,,90,,1451.7,percent of total billed charges,,,,,,,no IP contract,,80,,1290.4,percent of total billed charges,,,,,,,no IP contract,,50,,806.5,percent of total billed charges,,,,,,no IP contract,,,78,,1258.14,percent of total billed charges,,,70,,1129.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,790.37,3324,
"Surgical Pathology, Soft Tissue Simple Excision",88307,CPT,,,,inpatient,,,1613,967.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1306.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1371.05,percent of total billed charges,,,85,,1371.05,percent of total billed charges,,,49,,790.37,percent of total billed charges,,,90,,1451.7,percent of total billed charges,,,,,,,no IP contract,,80,,1290.4,percent of total billed charges,,,,,,,no IP contract,,50,,806.5,percent of total billed charges,,,,,,no IP contract,,,78,,1258.14,percent of total billed charges,,,70,,1129.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,790.37,3324,
"IHC STAIN, 1ST, GROUP 4 NMH",88342,CPT,,,,inpatient,,,536,321.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,434.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,455.6,percent of total billed charges,,,85,,455.6,percent of total billed charges,,,49,,262.64,percent of total billed charges,,,90,,482.4,percent of total billed charges,,,,,,,no IP contract,,80,,428.8,percent of total billed charges,,,,,,,no IP contract,,50,,268,percent of total billed charges,,,,,,no IP contract,,,78,,418.08,percent of total billed charges,,,70,,375.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,262.64,3324,
IMMUNOFLUOR ANTB 1ST STAIN NMH,88346,CPT,,,,inpatient,,,408,244.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,330.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,346.8,percent of total billed charges,,,85,,346.8,percent of total billed charges,,,49,,199.92,percent of total billed charges,,,90,,367.2,percent of total billed charges,,,,,,,no IP contract,,80,,326.4,percent of total billed charges,,,,,,,no IP contract,,50,,204,percent of total billed charges,,,,,,no IP contract,,,78,,318.24,percent of total billed charges,,,70,,285.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,199.92,3324,
IHC STAIN TUMOR QUANTITATIVE GROUP 2 NMH,88360,CPT,,,,inpatient,,,515,309,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,417.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,437.75,percent of total billed charges,,,85,,437.75,percent of total billed charges,,,49,,252.35,percent of total billed charges,,,90,,463.5,percent of total billed charges,,,,,,,no IP contract,,80,,412,percent of total billed charges,,,,,,,no IP contract,,50,,257.5,percent of total billed charges,,,,,,no IP contract,,,78,,401.7,percent of total billed charges,,,70,,360.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,252.35,3324,
CT Brain Scan Straight NMH,70450,CPT,,,,inpatient,,,3535,2121,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2863.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3004.75,percent of total billed charges,,,85,,3004.75,percent of total billed charges,,,49,,1732.15,percent of total billed charges,,,90,,3181.5,percent of total billed charges,,,,,,,no IP contract,,80,,2828,percent of total billed charges,,,,,,,no IP contract,,50,,1767.5,percent of total billed charges,,,,,,no IP contract,,,78,,2757.3,percent of total billed charges,,,70,,2474.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
CT Brain Scan With Contrast NMH,70460,CPT,,,,inpatient,,,4174,2504.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3380.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3547.9,percent of total billed charges,,,85,,3547.9,percent of total billed charges,,,49,,2045.26,percent of total billed charges,,,90,,3756.6,percent of total billed charges,,,,,,,no IP contract,,80,,3339.2,percent of total billed charges,,,,,,,no IP contract,,50,,2087,percent of total billed charges,,,,,,no IP contract,,,78,,3255.72,percent of total billed charges,,,70,,2921.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3756.6,
CT Brain W&W/O Contrast NMH,70470,CPT,,,,inpatient,,,5367,3220.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4347.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4561.95,percent of total billed charges,,,85,,4561.95,percent of total billed charges,,,49,,2629.83,percent of total billed charges,,,90,,4830.3,percent of total billed charges,,,,,,,no IP contract,,80,,4293.6,percent of total billed charges,,,,,,,no IP contract,,50,,2683.5,percent of total billed charges,,,,,,no IP contract,,,78,,4186.26,percent of total billed charges,,,70,,3756.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4830.3,
CT Temp Bone/Pertrous PYR NMH,70480,CPT,,,,inpatient,,,4697,2818.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3804.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3992.45,percent of total billed charges,,,85,,3992.45,percent of total billed charges,,,49,,2301.53,percent of total billed charges,,,90,,4227.3,percent of total billed charges,,,,,,,no IP contract,,80,,3757.6,percent of total billed charges,,,,,,,no IP contract,,50,,2348.5,percent of total billed charges,,,,,,no IP contract,,,78,,3663.66,percent of total billed charges,,,70,,3287.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4227.3,
CT Face Straight NMH,70486,CPT,,,,inpatient,,,3723,2233.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3015.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3164.55,percent of total billed charges,,,85,,3164.55,percent of total billed charges,,,49,,1824.27,percent of total billed charges,,,90,,3350.7,percent of total billed charges,,,,,,,no IP contract,,80,,2978.4,percent of total billed charges,,,,,,,no IP contract,,50,,1861.5,percent of total billed charges,,,,,,no IP contract,,,78,,2903.94,percent of total billed charges,,,70,,2606.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3350.7,
CT Neck with Larynx Without Contrast NMH,70490,CPT,,,,inpatient,,,3666,2199.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2969.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3116.1,percent of total billed charges,,,85,,3116.1,percent of total billed charges,,,49,,1796.34,percent of total billed charges,,,90,,3299.4,percent of total billed charges,,,,,,,no IP contract,,80,,2932.8,percent of total billed charges,,,,,,,no IP contract,,50,,1833,percent of total billed charges,,,,,,no IP contract,,,78,,2859.48,percent of total billed charges,,,70,,2566.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
CT Neck/Larynx Infusion NMH,70491,CPT,,,,inpatient,,,4644,2786.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3761.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3947.4,percent of total billed charges,,,85,,3947.4,percent of total billed charges,,,49,,2275.56,percent of total billed charges,,,90,,4179.6,percent of total billed charges,,,,,,,no IP contract,,80,,3715.2,percent of total billed charges,,,,,,,no IP contract,,50,,2322,percent of total billed charges,,,,,,no IP contract,,,78,,3622.32,percent of total billed charges,,,70,,3250.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4179.6,
CT Angiograph Head With and/or Without Contrast NMH,70496,CPT,,,,inpatient,,,5223,3133.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4230.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4439.55,percent of total billed charges,,,85,,4439.55,percent of total billed charges,,,49,,2559.27,percent of total billed charges,,,90,,4700.7,percent of total billed charges,,,,,,,no IP contract,,80,,4178.4,percent of total billed charges,,,,,,,no IP contract,,50,,2611.5,percent of total billed charges,,,,,,no IP contract,,,78,,4073.94,percent of total billed charges,,,70,,3656.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4700.7,
CT Angiography NEC NMH,70498,CPT,,,,inpatient,,,5440,3264,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4406.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4624,percent of total billed charges,,,85,,4624,percent of total billed charges,,,49,,2665.6,percent of total billed charges,,,90,,4896,percent of total billed charges,,,,,,,no IP contract,,80,,4352,percent of total billed charges,,,,,,,no IP contract,,50,,2720,percent of total billed charges,,,,,,no IP contract,,,78,,4243.2,percent of total billed charges,,,70,,3808,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4896,
MRI Face/Neck W&W/O Contrast NMH,70543,CPT,,,,inpatient,,,7265,4359,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5884.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6175.25,percent of total billed charges,,,85,,6175.25,percent of total billed charges,,,49,,3559.85,percent of total billed charges,,,90,,6538.5,percent of total billed charges,,,,,,,no IP contract,,80,,5812,percent of total billed charges,,,,,,,no IP contract,,50,,3632.5,percent of total billed charges,,,,,,no IP contract,,,78,,5666.7,percent of total billed charges,,,70,,5085.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,6538.5,
MRA head Without Contrast NMH,70544,CPT,,,,inpatient,,,5638,3382.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4566.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4792.3,percent of total billed charges,,,85,,4792.3,percent of total billed charges,,,49,,2762.62,percent of total billed charges,,,90,,5074.2,percent of total billed charges,,,,,,,no IP contract,,80,,4510.4,percent of total billed charges,,,,,,,no IP contract,,50,,2819,percent of total billed charges,,,,,,no IP contract,,,78,,4397.64,percent of total billed charges,,,70,,3946.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,5074.2,
MRA Head W&W/O Contrast NMH,70546,CPT,,,,inpatient,,,8158,4894.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6607.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6934.3,percent of total billed charges,,,85,,6934.3,percent of total billed charges,,,49,,3997.42,percent of total billed charges,,,90,,7342.2,percent of total billed charges,,,,,,,no IP contract,,80,,6526.4,percent of total billed charges,,,,,,,no IP contract,,50,,4079,percent of total billed charges,,,,,,no IP contract,,,78,,6363.24,percent of total billed charges,,,70,,5710.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,7342.2,
MRA Neck Without Contrast NMH,70547,CPT,,,,inpatient,,,4827,2896.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3909.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4102.95,percent of total billed charges,,,85,,4102.95,percent of total billed charges,,,49,,2365.23,percent of total billed charges,,,90,,4344.3,percent of total billed charges,,,,,,,no IP contract,,80,,3861.6,percent of total billed charges,,,,,,,no IP contract,,50,,2413.5,percent of total billed charges,,,,,,no IP contract,,,78,,3765.06,percent of total billed charges,,,70,,3378.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4344.3,
MRA Neck With Contrast NMH,70548,CPT,,,,inpatient,,,5490,3294,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4446.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4666.5,percent of total billed charges,,,85,,4666.5,percent of total billed charges,,,49,,2690.1,percent of total billed charges,,,90,,4941,percent of total billed charges,,,,,,,no IP contract,,80,,4392,percent of total billed charges,,,,,,,no IP contract,,50,,2745,percent of total billed charges,,,,,,no IP contract,,,78,,4282.2,percent of total billed charges,,,70,,3843,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4941,
MRA Neck W&W/O Contrast NMH,70549,CPT,,,,inpatient,,,6243,3745.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5056.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5306.55,percent of total billed charges,,,85,,5306.55,percent of total billed charges,,,49,,3059.07,percent of total billed charges,,,90,,5618.7,percent of total billed charges,,,,,,,no IP contract,,80,,4994.4,percent of total billed charges,,,,,,,no IP contract,,50,,3121.5,percent of total billed charges,,,,,,no IP contract,,,78,,4869.54,percent of total billed charges,,,70,,4370.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,5618.7,
MR Brain Without Contrast NMH,70551,CPT,,,,inpatient,,,5553,3331.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4497.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4720.05,percent of total billed charges,,,85,,4720.05,percent of total billed charges,,,49,,2720.97,percent of total billed charges,,,90,,4997.7,percent of total billed charges,,,,,,,no IP contract,,80,,4442.4,percent of total billed charges,,,,,,,no IP contract,,50,,2776.5,percent of total billed charges,,,,,,no IP contract,,,78,,4331.34,percent of total billed charges,,,70,,3887.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4997.7,
"MRI, Brain with contrast NMH",70552,CPT,,,,inpatient,,,6130,3678,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4965.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5210.5,percent of total billed charges,,,85,,5210.5,percent of total billed charges,,,49,,3003.7,percent of total billed charges,,,90,,5517,percent of total billed charges,,,,,,,no IP contract,,80,,4904,percent of total billed charges,,,,,,,no IP contract,,50,,3065,percent of total billed charges,,,,,,no IP contract,,,78,,4781.4,percent of total billed charges,,,70,,4291,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,5517,
MR Brain W&W/O Contrast NMH,70553,CPT,,,,inpatient,,,7693,4615.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6231.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6539.05,percent of total billed charges,,,85,,6539.05,percent of total billed charges,,,49,,3769.57,percent of total billed charges,,,90,,6923.7,percent of total billed charges,,,,,,,no IP contract,,80,,6154.4,percent of total billed charges,,,,,,,no IP contract,,50,,3846.5,percent of total billed charges,,,,,,no IP contract,,,78,,6000.54,percent of total billed charges,,,70,,5385.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,6923.7,
X-RAY CHEST SINGLE VIEW NMH,71045,CPT,,,,inpatient,,,768,460.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,622.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,652.8,percent of total billed charges,,,85,,652.8,percent of total billed charges,,,49,,376.32,percent of total billed charges,,,90,,691.2,percent of total billed charges,,,,,,,no IP contract,,80,,614.4,percent of total billed charges,,,,,,,no IP contract,,50,,384,percent of total billed charges,,,,,,no IP contract,,,78,,599.04,percent of total billed charges,,,70,,537.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,376.32,3324,
XRAY EXAM CHEST 2 VIEWS NMH 71046,71046,CPT,,,,inpatient,,,963,577.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,780.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,818.55,percent of total billed charges,,,85,,818.55,percent of total billed charges,,,49,,471.87,percent of total billed charges,,,90,,866.7,percent of total billed charges,,,,,,,no IP contract,,80,,770.4,percent of total billed charges,,,,,,,no IP contract,,50,,481.5,percent of total billed charges,,,,,,no IP contract,,,78,,751.14,percent of total billed charges,,,70,,674.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,471.87,3324,
CT Scan Lung Without Infusion TC NMH,71250,CPT,,,,inpatient,,,3730,2238,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3021.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3170.5,percent of total billed charges,,,85,,3170.5,percent of total billed charges,,,49,,1827.7,percent of total billed charges,,,90,,3357,percent of total billed charges,,,,,,,no IP contract,,80,,2984,percent of total billed charges,,,,,,,no IP contract,,50,,1865,percent of total billed charges,,,,,,no IP contract,,,78,,2909.4,percent of total billed charges,,,70,,2611,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3357,
CT Lung Infusion NMH,71260,CPT,,,,inpatient,,,4534,2720.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3672.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3853.9,percent of total billed charges,,,85,,3853.9,percent of total billed charges,,,49,,2221.66,percent of total billed charges,,,90,,4080.6,percent of total billed charges,,,,,,,no IP contract,,80,,3627.2,percent of total billed charges,,,,,,,no IP contract,,50,,2267,percent of total billed charges,,,,,,no IP contract,,,78,,3536.52,percent of total billed charges,,,70,,3173.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4080.6,
CT Lung W&W/O Infusion NMH,71270,CPT,,,,inpatient,,,4880,2928,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3952.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4148,percent of total billed charges,,,85,,4148,percent of total billed charges,,,49,,2391.2,percent of total billed charges,,,90,,4392,percent of total billed charges,,,,,,,no IP contract,,80,,3904,percent of total billed charges,,,,,,,no IP contract,,50,,2440,percent of total billed charges,,,,,,no IP contract,,,78,,3806.4,percent of total billed charges,,,70,,3416,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4392,
"CT Angiograph, Chest With and/or Without NMH",71275,CPT,,,,inpatient,,,5004,3002.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4053.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4253.4,percent of total billed charges,,,85,,4253.4,percent of total billed charges,,,49,,2451.96,percent of total billed charges,,,90,,4503.6,percent of total billed charges,,,,,,,no IP contract,,80,,4003.2,percent of total billed charges,,,,,,,no IP contract,,50,,2502,percent of total billed charges,,,,,,no IP contract,,,78,,3903.12,percent of total billed charges,,,70,,3502.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4503.6,
MRI CHEST W/O CONTRAST NMH,71550,CPT,,,,inpatient,,,4192,2515.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3395.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3563.2,percent of total billed charges,,,85,,3563.2,percent of total billed charges,,,49,,2054.08,percent of total billed charges,,,90,,3772.8,percent of total billed charges,,,,,,,no IP contract,,80,,3353.6,percent of total billed charges,,,,,,,no IP contract,,50,,2096,percent of total billed charges,,,,,,no IP contract,,,78,,3269.76,percent of total billed charges,,,70,,2934.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3772.8,
MRI Chest W&W/O Contrast NMH,71552,CPT,,,,inpatient,,,6246,3747.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5059.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5309.1,percent of total billed charges,,,85,,5309.1,percent of total billed charges,,,49,,3060.54,percent of total billed charges,,,90,,5621.4,percent of total billed charges,,,,,,,no IP contract,,80,,4996.8,percent of total billed charges,,,,,,,no IP contract,,50,,3123,percent of total billed charges,,,,,,no IP contract,,,78,,4871.88,percent of total billed charges,,,70,,4372.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,5621.4,
CT Cervical Spine Scan NMH,72125,CPT,,,,inpatient,,,4526,2715.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3666.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3847.1,percent of total billed charges,,,85,,3847.1,percent of total billed charges,,,49,,2217.74,percent of total billed charges,,,90,,4073.4,percent of total billed charges,,,,,,,no IP contract,,80,,3620.8,percent of total billed charges,,,,,,,no IP contract,,50,,2263,percent of total billed charges,,,,,,no IP contract,,,78,,3530.28,percent of total billed charges,,,70,,3168.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4073.4,
CT Cervical Spine Inf NMH,72126,CPT,,,,inpatient,,,4996,2997.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4046.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4246.6,percent of total billed charges,,,85,,4246.6,percent of total billed charges,,,49,,2448.04,percent of total billed charges,,,90,,4496.4,percent of total billed charges,,,,,,,no IP contract,,80,,3996.8,percent of total billed charges,,,,,,,no IP contract,,50,,2498,percent of total billed charges,,,,,,no IP contract,,,78,,3896.88,percent of total billed charges,,,70,,3497.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4496.4,
CT Scan Thor SP without Infusion NMH,72128,CPT,,,,inpatient,,,4017,2410.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3253.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3414.45,percent of total billed charges,,,85,,3414.45,percent of total billed charges,,,49,,1968.33,percent of total billed charges,,,90,,3615.3,percent of total billed charges,,,,,,,no IP contract,,80,,3213.6,percent of total billed charges,,,,,,,no IP contract,,50,,2008.5,percent of total billed charges,,,,,,no IP contract,,,78,,3133.26,percent of total billed charges,,,70,,2811.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3615.3,
CT Scan Thor Sp with Infusion NMH,72129,CPT,,,,inpatient,,,4210,2526,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3410.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3578.5,percent of total billed charges,,,85,,3578.5,percent of total billed charges,,,49,,2062.9,percent of total billed charges,,,90,,3789,percent of total billed charges,,,,,,,no IP contract,,80,,3368,percent of total billed charges,,,,,,,no IP contract,,50,,2105,percent of total billed charges,,,,,,no IP contract,,,78,,3283.8,percent of total billed charges,,,70,,2947,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3789,
CT Scan Lumbar Spine Without Infusion NMH,72131,CPT,,,,inpatient,,,4405,2643,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3568.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3744.25,percent of total billed charges,,,85,,3744.25,percent of total billed charges,,,49,,2158.45,percent of total billed charges,,,90,,3964.5,percent of total billed charges,,,,,,,no IP contract,,80,,3524,percent of total billed charges,,,,,,,no IP contract,,50,,2202.5,percent of total billed charges,,,,,,no IP contract,,,78,,3435.9,percent of total billed charges,,,70,,3083.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3964.5,
CT Scan Lumbar Spine With Infusion NMH,72132,CPT,,,,inpatient,,,5009,3005.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4057.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4257.65,percent of total billed charges,,,85,,4257.65,percent of total billed charges,,,49,,2454.41,percent of total billed charges,,,90,,4508.1,percent of total billed charges,,,,,,,no IP contract,,80,,4007.2,percent of total billed charges,,,,,,,no IP contract,,50,,2504.5,percent of total billed charges,,,,,,no IP contract,,,78,,3907.02,percent of total billed charges,,,70,,3506.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4508.1,
MR Cervical Spine Without Contrast NMH,72141,CPT,,,,inpatient,,,5959,3575.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4826.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5065.15,percent of total billed charges,,,85,,5065.15,percent of total billed charges,,,49,,2919.91,percent of total billed charges,,,90,,5363.1,percent of total billed charges,,,,,,,no IP contract,,80,,4767.2,percent of total billed charges,,,,,,,no IP contract,,50,,2979.5,percent of total billed charges,,,,,,no IP contract,,,78,,4648.02,percent of total billed charges,,,70,,4171.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,5363.1,
MRI T Spine W/O Contrast NMH,72146,CPT,,,,inpatient,,,5442,3265.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4408.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4625.7,percent of total billed charges,,,85,,4625.7,percent of total billed charges,,,49,,2666.58,percent of total billed charges,,,90,,4897.8,percent of total billed charges,,,,,,,no IP contract,,80,,4353.6,percent of total billed charges,,,,,,,no IP contract,,50,,2721,percent of total billed charges,,,,,,no IP contract,,,78,,4244.76,percent of total billed charges,,,70,,3809.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4897.8,
MR LS Spine Without Contrast NMH,72148,CPT,,,,inpatient,,,5482,3289.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4440.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4659.7,percent of total billed charges,,,85,,4659.7,percent of total billed charges,,,49,,2686.18,percent of total billed charges,,,90,,4933.8,percent of total billed charges,,,,,,,no IP contract,,80,,4385.6,percent of total billed charges,,,,,,,no IP contract,,50,,2741,percent of total billed charges,,,,,,no IP contract,,,78,,4275.96,percent of total billed charges,,,70,,3837.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4933.8,
MR Cervical Spine W&W/O Contrast NMH,72156,CPT,,,,inpatient,,,7347,4408.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5951.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6244.95,percent of total billed charges,,,85,,6244.95,percent of total billed charges,,,49,,3600.03,percent of total billed charges,,,90,,6612.3,percent of total billed charges,,,,,,,no IP contract,,80,,5877.6,percent of total billed charges,,,,,,,no IP contract,,50,,3673.5,percent of total billed charges,,,,,,no IP contract,,,78,,5730.66,percent of total billed charges,,,70,,5142.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,6612.3,
MRI Thoracic Spine W&W/O Contrast NMH,72157,CPT,,,,inpatient,,,6709,4025.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5434.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5702.65,percent of total billed charges,,,85,,5702.65,percent of total billed charges,,,49,,3287.41,percent of total billed charges,,,90,,6038.1,percent of total billed charges,,,,,,,no IP contract,,80,,5367.2,percent of total billed charges,,,,,,,no IP contract,,50,,3354.5,percent of total billed charges,,,,,,no IP contract,,,78,,5233.02,percent of total billed charges,,,70,,4696.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,6038.1,
MRI TL Spine W&W/O Contrast NMH,72158,CPT,,,,inpatient,,,6724,4034.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5446.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5715.4,percent of total billed charges,,,85,,5715.4,percent of total billed charges,,,49,,3294.76,percent of total billed charges,,,90,,6051.6,percent of total billed charges,,,,,,,no IP contract,,80,,5379.2,percent of total billed charges,,,,,,,no IP contract,,50,,3362,percent of total billed charges,,,,,,no IP contract,,,78,,5244.72,percent of total billed charges,,,70,,4706.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,6051.6,
CT Angiograph Pelvis NMH,72191,CPT,,,,inpatient,,,4832,2899.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3913.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4107.2,percent of total billed charges,,,85,,4107.2,percent of total billed charges,,,49,,2367.68,percent of total billed charges,,,90,,4348.8,percent of total billed charges,,,,,,,no IP contract,,80,,3865.6,percent of total billed charges,,,,,,,no IP contract,,50,,2416,percent of total billed charges,,,,,,no IP contract,,,78,,3768.96,percent of total billed charges,,,70,,3382.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4348.8,
CT Pelvis S/Scan NMH,72192,CPT,,,,inpatient,,,3081,1848.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2495.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2618.85,percent of total billed charges,,,85,,2618.85,percent of total billed charges,,,49,,1509.69,percent of total billed charges,,,90,,2772.9,percent of total billed charges,,,,,,,no IP contract,,80,,2464.8,percent of total billed charges,,,,,,,no IP contract,,50,,1540.5,percent of total billed charges,,,,,,no IP contract,,,78,,2403.18,percent of total billed charges,,,70,,2156.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
CT Scan Pelvis With Contrast NMH,72193,CPT,,,,inpatient,,,4154,2492.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3364.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3530.9,percent of total billed charges,,,85,,3530.9,percent of total billed charges,,,49,,2035.46,percent of total billed charges,,,90,,3738.6,percent of total billed charges,,,,,,,no IP contract,,80,,3323.2,percent of total billed charges,,,,,,,no IP contract,,50,,2077,percent of total billed charges,,,,,,no IP contract,,,78,,3240.12,percent of total billed charges,,,70,,2907.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3738.6,
CT Pelvis And Infusion NMH,72194,CPT,,,,inpatient,,,4740,2844,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3839.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4029,percent of total billed charges,,,85,,4029,percent of total billed charges,,,49,,2322.6,percent of total billed charges,,,90,,4266,percent of total billed charges,,,,,,,no IP contract,,80,,3792,percent of total billed charges,,,,,,,no IP contract,,50,,2370,percent of total billed charges,,,,,,no IP contract,,,78,,3697.2,percent of total billed charges,,,70,,3318,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4266,
MRI Pelvis Without Contrast NMH,72195,CPT,,,,inpatient,,,5165,3099,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4183.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4390.25,percent of total billed charges,,,85,,4390.25,percent of total billed charges,,,49,,2530.85,percent of total billed charges,,,90,,4648.5,percent of total billed charges,,,,,,,no IP contract,,80,,4132,percent of total billed charges,,,,,,,no IP contract,,50,,2582.5,percent of total billed charges,,,,,,no IP contract,,,78,,4028.7,percent of total billed charges,,,70,,3615.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4648.5,
MRI Pelvis W&W/O Contrast NMH,72197,CPT,,,,inpatient,,,6808,4084.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5514.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5786.8,percent of total billed charges,,,85,,5786.8,percent of total billed charges,,,49,,3335.92,percent of total billed charges,,,90,,6127.2,percent of total billed charges,,,,,,,no IP contract,,80,,5446.4,percent of total billed charges,,,,,,,no IP contract,,50,,3404,percent of total billed charges,,,,,,no IP contract,,,78,,5310.24,percent of total billed charges,,,70,,4765.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,6127.2,
CT Scan UE without Infusion NMH,73200,CPT,,,,inpatient,,,3662,2197.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2966.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3112.7,percent of total billed charges,,,85,,3112.7,percent of total billed charges,,,49,,1794.38,percent of total billed charges,,,90,,3295.8,percent of total billed charges,,,,,,,no IP contract,,80,,2929.6,percent of total billed charges,,,,,,,no IP contract,,50,,1831,percent of total billed charges,,,,,,no IP contract,,,78,,2856.36,percent of total billed charges,,,70,,2563.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
MRI Upper Extremity Joint Without Contrast NMH,73221,CPT,,,,inpatient,,,5131,3078.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4156.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4361.35,percent of total billed charges,,,85,,4361.35,percent of total billed charges,,,49,,2514.19,percent of total billed charges,,,90,,4617.9,percent of total billed charges,,,,,,,no IP contract,,80,,4104.8,percent of total billed charges,,,,,,,no IP contract,,50,,2565.5,percent of total billed charges,,,,,,no IP contract,,,78,,4002.18,percent of total billed charges,,,70,,3591.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4617.9,
CT Scan LE Without Infusion NMH,73700,CPT,,,,inpatient,,,3747,2248.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3035.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3184.95,percent of total billed charges,,,85,,3184.95,percent of total billed charges,,,49,,1836.03,percent of total billed charges,,,90,,3372.3,percent of total billed charges,,,,,,,no IP contract,,80,,2997.6,percent of total billed charges,,,,,,,no IP contract,,50,,1873.5,percent of total billed charges,,,,,,no IP contract,,,78,,2922.66,percent of total billed charges,,,70,,2622.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3372.3,
CT Scan LE with Infusion NMH,73701,CPT,,,,inpatient,,,4251,2550.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3443.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3613.35,percent of total billed charges,,,85,,3613.35,percent of total billed charges,,,49,,2082.99,percent of total billed charges,,,90,,3825.9,percent of total billed charges,,,,,,,no IP contract,,80,,3400.8,percent of total billed charges,,,,,,,no IP contract,,50,,2125.5,percent of total billed charges,,,,,,no IP contract,,,78,,3315.78,percent of total billed charges,,,70,,2975.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3825.9,
CT Skel Ext Low W&W/O Infusion NMH,73702,CPT,,,,inpatient,,,4827,2896.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3909.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4102.95,percent of total billed charges,,,85,,4102.95,percent of total billed charges,,,49,,2365.23,percent of total billed charges,,,90,,4344.3,percent of total billed charges,,,,,,,no IP contract,,80,,3861.6,percent of total billed charges,,,,,,,no IP contract,,50,,2413.5,percent of total billed charges,,,,,,no IP contract,,,78,,3765.06,percent of total billed charges,,,70,,3378.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4344.3,
MRI Lower  Ext  w/o Cont NMH,73718,CPT,,,,inpatient,,,4904,2942.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3972.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4168.4,percent of total billed charges,,,85,,4168.4,percent of total billed charges,,,49,,2402.96,percent of total billed charges,,,90,,4413.6,percent of total billed charges,,,,,,,no IP contract,,80,,3923.2,percent of total billed charges,,,,,,,no IP contract,,50,,2452,percent of total billed charges,,,,,,no IP contract,,,78,,3825.12,percent of total billed charges,,,70,,3432.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4413.6,
MRI Lower Extremity W&W/O Contrast NMH,73720,CPT,,,,inpatient,,,5790,3474,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4689.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4921.5,percent of total billed charges,,,85,,4921.5,percent of total billed charges,,,49,,2837.1,percent of total billed charges,,,90,,5211,percent of total billed charges,,,,,,,no IP contract,,80,,4632,percent of total billed charges,,,,,,,no IP contract,,50,,2895,percent of total billed charges,,,,,,no IP contract,,,78,,4516.2,percent of total billed charges,,,70,,4053,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,5211,
MRI Lower Extremity Jt Without Contrast NMH,73721,CPT,,,,inpatient,,,5479,3287.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4437.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4657.15,percent of total billed charges,,,85,,4657.15,percent of total billed charges,,,49,,2684.71,percent of total billed charges,,,90,,4931.1,percent of total billed charges,,,,,,,no IP contract,,80,,4383.2,percent of total billed charges,,,,,,,no IP contract,,50,,2739.5,percent of total billed charges,,,,,,no IP contract,,,78,,4273.62,percent of total billed charges,,,70,,3835.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4931.1,
MRI Lower Extemity JT W&W/O Contrast NMH,73723,CPT,,,,inpatient,,,6327,3796.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5124.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5377.95,percent of total billed charges,,,85,,5377.95,percent of total billed charges,,,49,,3100.23,percent of total billed charges,,,90,,5694.3,percent of total billed charges,,,,,,,no IP contract,,80,,5061.6,percent of total billed charges,,,,,,,no IP contract,,50,,3163.5,percent of total billed charges,,,,,,no IP contract,,,78,,4935.06,percent of total billed charges,,,70,,4428.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,5694.3,
CT Abdomen Without Contrast NMH,74150,CPT,,,,inpatient,,,3680,2208,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2980.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3128,percent of total billed charges,,,85,,3128,percent of total billed charges,,,49,,1803.2,percent of total billed charges,,,90,,3312,percent of total billed charges,,,,,,,no IP contract,,80,,2944,percent of total billed charges,,,,,,,no IP contract,,50,,1840,percent of total billed charges,,,,,,no IP contract,,,78,,2870.4,percent of total billed charges,,,70,,2576,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
CT Abdomen With Contrast NMH,74160,CPT,,,,inpatient,,,4573,2743.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3704.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3887.05,percent of total billed charges,,,85,,3887.05,percent of total billed charges,,,49,,2240.77,percent of total billed charges,,,90,,4115.7,percent of total billed charges,,,,,,,no IP contract,,80,,3658.4,percent of total billed charges,,,,,,,no IP contract,,50,,2286.5,percent of total billed charges,,,,,,no IP contract,,,78,,3566.94,percent of total billed charges,,,70,,3201.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4115.7,
CT Abdomen W&W/O Contrast NMH,74170,CPT,,,,inpatient,,,5227,3136.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4233.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4442.95,percent of total billed charges,,,85,,4442.95,percent of total billed charges,,,49,,2561.23,percent of total billed charges,,,90,,4704.3,percent of total billed charges,,,,,,,no IP contract,,80,,4181.6,percent of total billed charges,,,,,,,no IP contract,,50,,2613.5,percent of total billed charges,,,,,,no IP contract,,,78,,4077.06,percent of total billed charges,,,70,,3658.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4704.3,
CT Angiograph Abdomen NMH,74175,CPT,,,,inpatient,,,6161,3696.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4990.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5236.85,percent of total billed charges,,,85,,5236.85,percent of total billed charges,,,49,,3018.89,percent of total billed charges,,,90,,5544.9,percent of total billed charges,,,,,,,no IP contract,,80,,4928.8,percent of total billed charges,,,,,,,no IP contract,,50,,3080.5,percent of total billed charges,,,,,,no IP contract,,,78,,4805.58,percent of total billed charges,,,70,,4312.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,5544.9,
CT AB/PELVIS WO CONTRAS NMH,74176,CPT,,,,inpatient,,,6860,4116,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5556.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5831,percent of total billed charges,,,85,,5831,percent of total billed charges,,,49,,3361.4,percent of total billed charges,,,90,,6174,percent of total billed charges,,,,,,,no IP contract,,80,,5488,percent of total billed charges,,,,,,,no IP contract,,50,,3430,percent of total billed charges,,,,,,no IP contract,,,78,,5350.8,percent of total billed charges,,,70,,4802,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,6174,
CT Abdomen & Pelvis W/Contrast NMH,74177,CPT,,,,inpatient,,,8642,5185.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7000.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7345.7,percent of total billed charges,,,85,,7345.7,percent of total billed charges,,,49,,4234.58,percent of total billed charges,,,90,,7777.8,percent of total billed charges,,,,,,,no IP contract,,80,,6913.6,percent of total billed charges,,,,,,,no IP contract,,50,,4321,percent of total billed charges,,,,,,no IP contract,,,78,,6740.76,percent of total billed charges,,,70,,6049.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,7777.8,
CT AB/PELVIS WWO CONTRAST NMH,74178,CPT,,,,inpatient,,,10151,6090.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8222.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8628.35,percent of total billed charges,,,85,,8628.35,percent of total billed charges,,,49,,4973.99,percent of total billed charges,,,90,,9135.9,percent of total billed charges,,,,,,,no IP contract,,80,,8120.8,percent of total billed charges,,,,,,,no IP contract,,50,,5075.5,percent of total billed charges,,,,,,no IP contract,,,78,,7917.78,percent of total billed charges,,,70,,7105.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,9135.9,
MRA ABD W/O CONTRAST NMH,74181,CPT,,,,inpatient,,,5286,3171.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4281.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4493.1,percent of total billed charges,,,85,,4493.1,percent of total billed charges,,,49,,2590.14,percent of total billed charges,,,90,,4757.4,percent of total billed charges,,,,,,,no IP contract,,80,,4228.8,percent of total billed charges,,,,,,,no IP contract,,50,,2643,percent of total billed charges,,,,,,no IP contract,,,78,,4123.08,percent of total billed charges,,,70,,3700.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4757.4,
MRI Abdomen W&W/O Contrast NMH,74183,CPT,,,,inpatient,,,6265,3759,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5074.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5325.25,percent of total billed charges,,,85,,5325.25,percent of total billed charges,,,49,,3069.85,percent of total billed charges,,,90,,5638.5,percent of total billed charges,,,,,,,no IP contract,,80,,5012,percent of total billed charges,,,,,,,no IP contract,,50,,3132.5,percent of total billed charges,,,,,,no IP contract,,,78,,4886.7,percent of total billed charges,,,70,,4385.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,5638.5,
Xray-US-Abdomen Complete NMH,76700,CPT,,,,inpatient,,,2532,1519.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2050.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2152.2,percent of total billed charges,,,85,,2152.2,percent of total billed charges,,,49,,1240.68,percent of total billed charges,,,90,,2278.8,percent of total billed charges,,,,,,,no IP contract,,80,,2025.6,percent of total billed charges,,,,,,,no IP contract,,50,,1266,percent of total billed charges,,,,,,no IP contract,,,78,,1974.96,percent of total billed charges,,,70,,1772.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
Xray-US-Abdomen Partial NMH,76705,CPT,,,,inpatient,,,2292,1375.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1856.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1948.2,percent of total billed charges,,,85,,1948.2,percent of total billed charges,,,49,,1123.08,percent of total billed charges,,,90,,2062.8,percent of total billed charges,,,,,,,no IP contract,,80,,1833.6,percent of total billed charges,,,,,,,no IP contract,,50,,1146,percent of total billed charges,,,,,,no IP contract,,,78,,1787.76,percent of total billed charges,,,70,,1604.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
Xray-US-Abscess NMH,76705,CPT,,,,inpatient,,,2292,1375.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1856.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1948.2,percent of total billed charges,,,85,,1948.2,percent of total billed charges,,,49,,1123.08,percent of total billed charges,,,90,,2062.8,percent of total billed charges,,,,,,,no IP contract,,80,,1833.6,percent of total billed charges,,,,,,,no IP contract,,50,,1146,percent of total billed charges,,,,,,no IP contract,,,78,,1787.76,percent of total billed charges,,,70,,1604.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
Xray-US-Ascities NMH,76705,CPT,,,,inpatient,,,2292,1375.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1856.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1948.2,percent of total billed charges,,,85,,1948.2,percent of total billed charges,,,49,,1123.08,percent of total billed charges,,,90,,2062.8,percent of total billed charges,,,,,,,no IP contract,,80,,1833.6,percent of total billed charges,,,,,,,no IP contract,,50,,1146,percent of total billed charges,,,,,,no IP contract,,,78,,1787.76,percent of total billed charges,,,70,,1604.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
Xray-US-Gallbladder NMH,76705,CPT,,,,inpatient,,,2292,1375.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1856.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1948.2,percent of total billed charges,,,85,,1948.2,percent of total billed charges,,,49,,1123.08,percent of total billed charges,,,90,,2062.8,percent of total billed charges,,,,,,,no IP contract,,80,,1833.6,percent of total billed charges,,,,,,,no IP contract,,50,,1146,percent of total billed charges,,,,,,no IP contract,,,78,,1787.76,percent of total billed charges,,,70,,1604.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
Xray-US-Liver NMH,76705,CPT,,,,inpatient,,,2292,1375.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1856.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1948.2,percent of total billed charges,,,85,,1948.2,percent of total billed charges,,,49,,1123.08,percent of total billed charges,,,90,,2062.8,percent of total billed charges,,,,,,,no IP contract,,80,,1833.6,percent of total billed charges,,,,,,,no IP contract,,50,,1146,percent of total billed charges,,,,,,no IP contract,,,78,,1787.76,percent of total billed charges,,,70,,1604.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
Xray-US-Pancreas NMH,76705,CPT,,,,inpatient,,,2292,1375.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1856.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1948.2,percent of total billed charges,,,85,,1948.2,percent of total billed charges,,,49,,1123.08,percent of total billed charges,,,90,,2062.8,percent of total billed charges,,,,,,,no IP contract,,80,,1833.6,percent of total billed charges,,,,,,,no IP contract,,50,,1146,percent of total billed charges,,,,,,no IP contract,,,78,,1787.76,percent of total billed charges,,,70,,1604.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
Xray-US-Single Organ NMH,76705,CPT,,,,inpatient,,,2292,1375.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1856.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1948.2,percent of total billed charges,,,85,,1948.2,percent of total billed charges,,,49,,1123.08,percent of total billed charges,,,90,,2062.8,percent of total billed charges,,,,,,,no IP contract,,80,,1833.6,percent of total billed charges,,,,,,,no IP contract,,50,,1146,percent of total billed charges,,,,,,no IP contract,,,78,,1787.76,percent of total billed charges,,,70,,1604.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
Xray-US-Spleen NMH,76705,CPT,,,,inpatient,,,2292,1375.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1856.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1948.2,percent of total billed charges,,,85,,1948.2,percent of total billed charges,,,49,,1123.08,percent of total billed charges,,,90,,2062.8,percent of total billed charges,,,,,,,no IP contract,,80,,1833.6,percent of total billed charges,,,,,,,no IP contract,,50,,1146,percent of total billed charges,,,,,,no IP contract,,,78,,1787.76,percent of total billed charges,,,70,,1604.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
Xray-US-Aorta NMH,76770,CPT,,,,inpatient,,,2106,1263.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1705.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1790.1,percent of total billed charges,,,85,,1790.1,percent of total billed charges,,,49,,1031.94,percent of total billed charges,,,90,,1895.4,percent of total billed charges,,,,,,,no IP contract,,80,,1684.8,percent of total billed charges,,,,,,,no IP contract,,50,,1053,percent of total billed charges,,,,,,no IP contract,,,78,,1642.68,percent of total billed charges,,,70,,1474.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
Xray-US-Renal NMH,76770,CPT,,,,inpatient,,,2106,1263.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1705.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1790.1,percent of total billed charges,,,85,,1790.1,percent of total billed charges,,,49,,1031.94,percent of total billed charges,,,90,,1895.4,percent of total billed charges,,,,,,,no IP contract,,80,,1684.8,percent of total billed charges,,,,,,,no IP contract,,50,,1053,percent of total billed charges,,,,,,no IP contract,,,78,,1642.68,percent of total billed charges,,,70,,1474.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
US Kidney Transplant WDOP NMH,76776,CPT,,,,inpatient,,,1768,1060.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1432.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1502.8,percent of total billed charges,,,85,,1502.8,percent of total billed charges,,,49,,866.32,percent of total billed charges,,,90,,1591.2,percent of total billed charges,,,,,,,no IP contract,,80,,1414.4,percent of total billed charges,,,,,,,no IP contract,,50,,884,percent of total billed charges,,,,,,no IP contract,,,78,,1379.04,percent of total billed charges,,,70,,1237.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,866.32,3324,
"Xray-US-Kidney,Renal,Bladder NMH",76856,CPT,,,,inpatient,,,2157,1294.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1747.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1833.45,percent of total billed charges,,,85,,1833.45,percent of total billed charges,,,49,,1056.93,percent of total billed charges,,,90,,1941.3,percent of total billed charges,,,,,,,no IP contract,,80,,1725.6,percent of total billed charges,,,,,,,no IP contract,,50,,1078.5,percent of total billed charges,,,,,,no IP contract,,,78,,1682.46,percent of total billed charges,,,70,,1509.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
Xray-US-Pelvis NMH,76856,CPT,,,,inpatient,,,2157,1294.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1747.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1833.45,percent of total billed charges,,,85,,1833.45,percent of total billed charges,,,49,,1056.93,percent of total billed charges,,,90,,1941.3,percent of total billed charges,,,,,,,no IP contract,,80,,1725.6,percent of total billed charges,,,,,,,no IP contract,,50,,1078.5,percent of total billed charges,,,,,,no IP contract,,,78,,1682.46,percent of total billed charges,,,70,,1509.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
"US PELVIS, LIMITED NMH",76857,CPT,,,,inpatient,,,1232,739.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,997.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1047.2,percent of total billed charges,,,85,,1047.2,percent of total billed charges,,,49,,603.68,percent of total billed charges,,,90,,1108.8,percent of total billed charges,,,,,,,no IP contract,,80,,985.6,percent of total billed charges,,,,,,,no IP contract,,50,,616,percent of total billed charges,,,,,,no IP contract,,,78,,960.96,percent of total billed charges,,,70,,862.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,603.68,3324,
"Ventilation Mgt, Initial",94002,CPT,,,,inpatient,,,1661,996.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1345.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1411.85,percent of total billed charges,,,85,,1411.85,percent of total billed charges,,,49,,813.89,percent of total billed charges,,,90,,1494.9,percent of total billed charges,,,,,,,no IP contract,,80,,1328.8,percent of total billed charges,,,,,,,no IP contract,,50,,830.5,percent of total billed charges,,,,,,no IP contract,,,78,,1295.58,percent of total billed charges,,,70,,1162.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,813.89,3324,
Ventilatory Support 0-8 hrs,94002,CPT,,,,inpatient,,,1661,996.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1345.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1411.85,percent of total billed charges,,,85,,1411.85,percent of total billed charges,,,49,,813.89,percent of total billed charges,,,90,,1494.9,percent of total billed charges,,,,,,,no IP contract,,80,,1328.8,percent of total billed charges,,,,,,,no IP contract,,50,,830.5,percent of total billed charges,,,,,,no IP contract,,,78,,1295.58,percent of total billed charges,,,70,,1162.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,813.89,3324,
Mechanical Ventilation Initiation Charge,94002,CPT,,,,inpatient,,,1724,1034.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1396.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1465.4,percent of total billed charges,,,85,,1465.4,percent of total billed charges,,,49,,844.76,percent of total billed charges,,,90,,1551.6,percent of total billed charges,,,,,,,no IP contract,,80,,1379.2,percent of total billed charges,,,,,,,no IP contract,,50,,862,percent of total billed charges,,,,,,no IP contract,,,78,,1344.72,percent of total billed charges,,,70,,1206.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,844.76,3324,
Vent Mgmt Inpat Initial Day (94002),94002,CPT,,,,inpatient,,,1724,1034.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1396.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1465.4,percent of total billed charges,,,85,,1465.4,percent of total billed charges,,,49,,844.76,percent of total billed charges,,,90,,1551.6,percent of total billed charges,,,,,,,no IP contract,,80,,1379.2,percent of total billed charges,,,,,,,no IP contract,,50,,862,percent of total billed charges,,,,,,no IP contract,,,78,,1344.72,percent of total billed charges,,,70,,1206.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,844.76,3324,
Chronic/Acute Vent Support,94003,CPT,,,,inpatient,,,1544,926.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1250.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1312.4,percent of total billed charges,,,85,,1312.4,percent of total billed charges,,,49,,756.56,percent of total billed charges,,,90,,1389.6,percent of total billed charges,,,,,,,no IP contract,,80,,1235.2,percent of total billed charges,,,,,,,no IP contract,,50,,772,percent of total billed charges,,,,,,no IP contract,,,78,,1204.32,percent of total billed charges,,,70,,1080.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,756.56,3324,
Mechanical Ventilation Subsequent Days Charge,94003,CPT,,,,inpatient,,,1644,986.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1331.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1397.4,percent of total billed charges,,,85,,1397.4,percent of total billed charges,,,49,,805.56,percent of total billed charges,,,90,,1479.6,percent of total billed charges,,,,,,,no IP contract,,80,,1315.2,percent of total billed charges,,,,,,,no IP contract,,50,,822,percent of total billed charges,,,,,,no IP contract,,,78,,1282.32,percent of total billed charges,,,70,,1150.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,805.56,3324,
"Vent Mgmt Inpat, subq Day (94003)",94003,CPT,,,,inpatient,,,1644,986.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1331.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1397.4,percent of total billed charges,,,85,,1397.4,percent of total billed charges,,,49,,805.56,percent of total billed charges,,,90,,1479.6,percent of total billed charges,,,,,,,no IP contract,,80,,1315.2,percent of total billed charges,,,,,,,no IP contract,,50,,822,percent of total billed charges,,,,,,no IP contract,,,78,,1282.32,percent of total billed charges,,,70,,1150.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,805.56,3324,
Oximetry Night,94762,CPT,,,,inpatient,,,704,422.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,570.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,598.4,percent of total billed charges,,,85,,598.4,percent of total billed charges,,,49,,344.96,percent of total billed charges,,,90,,633.6,percent of total billed charges,,,,,,,no IP contract,,80,,563.2,percent of total billed charges,,,,,,,no IP contract,,50,,352,percent of total billed charges,,,,,,no IP contract,,,78,,549.12,percent of total billed charges,,,70,,492.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,344.96,3324,
Pulse Oximetry- Overnight,94762,CPT,,,,inpatient,,,704,422.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,570.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,598.4,percent of total billed charges,,,85,,598.4,percent of total billed charges,,,49,,344.96,percent of total billed charges,,,90,,633.6,percent of total billed charges,,,,,,,no IP contract,,80,,563.2,percent of total billed charges,,,,,,,no IP contract,,50,,352,percent of total billed charges,,,,,,no IP contract,,,78,,549.12,percent of total billed charges,,,70,,492.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,344.96,3324,
Pulse oximetry-by continuous overnight monitoring,94762,CPT,,,,inpatient,,,704,422.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,570.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,598.4,percent of total billed charges,,,85,,598.4,percent of total billed charges,,,49,,344.96,percent of total billed charges,,,90,,633.6,percent of total billed charges,,,,,,,no IP contract,,80,,563.2,percent of total billed charges,,,,,,,no IP contract,,50,,352,percent of total billed charges,,,,,,no IP contract,,,78,,549.12,percent of total billed charges,,,70,,492.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,344.96,3324,
Yes - Pulse Oximetry Overnight Monitoring Charge,94762,CPT,,,,inpatient,,,704,422.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,570.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,598.4,percent of total billed charges,,,85,,598.4,percent of total billed charges,,,49,,344.96,percent of total billed charges,,,90,,633.6,percent of total billed charges,,,,,,,no IP contract,,80,,563.2,percent of total billed charges,,,,,,,no IP contract,,50,,352,percent of total billed charges,,,,,,no IP contract,,,78,,549.12,percent of total billed charges,,,70,,492.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,344.96,3324,
Pulse Oximetry Cont/Overnight,94762,CPT,,,,inpatient,,,1009,605.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,817.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,857.65,percent of total billed charges,,,85,,857.65,percent of total billed charges,,,49,,494.41,percent of total billed charges,,,90,,908.1,percent of total billed charges,,,,,,,no IP contract,,80,,807.2,percent of total billed charges,,,,,,,no IP contract,,50,,504.5,percent of total billed charges,,,,,,no IP contract,,,78,,787.02,percent of total billed charges,,,70,,706.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,494.41,3324,
VENIPUNCTURE NMH,36415,CPT,,,,inpatient,,,49,29.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,39.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,41.65,percent of total billed charges,,,85,,41.65,percent of total billed charges,,,49,,24.01,percent of total billed charges,,,90,,44.1,percent of total billed charges,,,,,,,no IP contract,,80,,39.2,percent of total billed charges,,,,,,,no IP contract,,50,,24.5,percent of total billed charges,,,,,,no IP contract,,,78,,38.22,percent of total billed charges,,,70,,34.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.01,3324,
BASIC METABOLIC PANEL NMH,80048,CPT,,,,inpatient,,,314,188.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,254.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,266.9,percent of total billed charges,,,85,,266.9,percent of total billed charges,,,49,,153.86,percent of total billed charges,,,90,,282.6,percent of total billed charges,,,,,,,no IP contract,,80,,251.2,percent of total billed charges,,,,,,,no IP contract,,50,,157,percent of total billed charges,,,,,,no IP contract,,,78,,244.92,percent of total billed charges,,,70,,219.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,73274.295,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,153.86,73274.3,
RENAL FUNCTION PANEL NMH,80069,CPT,,,,inpatient,,,223,133.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,180.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,189.55,percent of total billed charges,,,85,,189.55,percent of total billed charges,,,49,,109.27,percent of total billed charges,,,90,,200.7,percent of total billed charges,,,,,,,no IP contract,,80,,178.4,percent of total billed charges,,,,,,,no IP contract,,50,,111.5,percent of total billed charges,,,,,,no IP contract,,,78,,173.94,percent of total billed charges,,,70,,156.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,109.27,3324,
Liver Chemistry Panel,80076,CPT,,,,inpatient,,,366,219.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,296.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,311.1,percent of total billed charges,,,85,,311.1,percent of total billed charges,,,49,,179.34,percent of total billed charges,,,90,,329.4,percent of total billed charges,,,,,,,no IP contract,,80,,292.8,percent of total billed charges,,,,,,,no IP contract,,50,,183,percent of total billed charges,,,,,,no IP contract,,,78,,285.48,percent of total billed charges,,,70,,256.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,179.34,3324,
Amikacin-Peak,80150,CPT,,,,inpatient,,,397,238.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,321.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,337.45,percent of total billed charges,,,85,,337.45,percent of total billed charges,,,49,,194.53,percent of total billed charges,,,90,,357.3,percent of total billed charges,,,,,,,no IP contract,,80,,317.6,percent of total billed charges,,,,,,,no IP contract,,50,,198.5,percent of total billed charges,,,,,,no IP contract,,,78,,309.66,percent of total billed charges,,,70,,277.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,194.53,3324,
Amikacin-Random,80150,CPT,,,,inpatient,,,397,238.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,321.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,337.45,percent of total billed charges,,,85,,337.45,percent of total billed charges,,,49,,194.53,percent of total billed charges,,,90,,357.3,percent of total billed charges,,,,,,,no IP contract,,80,,317.6,percent of total billed charges,,,,,,,no IP contract,,50,,198.5,percent of total billed charges,,,,,,no IP contract,,,78,,309.66,percent of total billed charges,,,70,,277.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,194.53,3324,
Amikacin-Trough,80150,CPT,,,,inpatient,,,397,238.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,321.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,337.45,percent of total billed charges,,,85,,337.45,percent of total billed charges,,,49,,194.53,percent of total billed charges,,,90,,357.3,percent of total billed charges,,,,,,,no IP contract,,80,,317.6,percent of total billed charges,,,,,,,no IP contract,,50,,198.5,percent of total billed charges,,,,,,no IP contract,,,78,,309.66,percent of total billed charges,,,70,,277.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,194.53,3324,
Tegretol/Carbamezapine,80156,CPT,,,,inpatient,,,204,122.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,165.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,173.4,percent of total billed charges,,,85,,173.4,percent of total billed charges,,,49,,99.96,percent of total billed charges,,,90,,183.6,percent of total billed charges,,,,,,,no IP contract,,80,,163.2,percent of total billed charges,,,,,,,no IP contract,,50,,102,percent of total billed charges,,,,,,no IP contract,,,78,,159.12,percent of total billed charges,,,70,,142.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,99.96,3324,
Cyclosporine Level,80158,CPT,,,,inpatient,,,400,240,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,324,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,340,percent of total billed charges,,,85,,340,percent of total billed charges,,,49,,196,percent of total billed charges,,,90,,360,percent of total billed charges,,,,,,,no IP contract,,80,,320,percent of total billed charges,,,,,,,no IP contract,,50,,200,percent of total billed charges,,,,,,no IP contract,,,78,,312,percent of total billed charges,,,70,,280,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,196,3324,
Digoxin/Ditgitalis Level,80162,CPT,,,,inpatient,,,260,156,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,210.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,221,percent of total billed charges,,,85,,221,percent of total billed charges,,,49,,127.4,percent of total billed charges,,,90,,234,percent of total billed charges,,,,,,,no IP contract,,80,,208,percent of total billed charges,,,,,,,no IP contract,,50,,130,percent of total billed charges,,,,,,no IP contract,,,78,,202.8,percent of total billed charges,,,70,,182,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,127.4,3324,
"Valproic Acid, Free",80164,CPT,,,,inpatient,,,170,102,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,137.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,144.5,percent of total billed charges,,,85,,144.5,percent of total billed charges,,,49,,83.3,percent of total billed charges,,,90,,153,percent of total billed charges,,,,,,,no IP contract,,80,,136,percent of total billed charges,,,,,,,no IP contract,,50,,85,percent of total billed charges,,,,,,no IP contract,,,78,,132.6,percent of total billed charges,,,70,,119,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,83.3,3324,
Valproic Acid Level,80164,CPT,,,,inpatient,,,257,154.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,208.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,218.45,percent of total billed charges,,,85,,218.45,percent of total billed charges,,,49,,125.93,percent of total billed charges,,,90,,231.3,percent of total billed charges,,,,,,,no IP contract,,80,,205.6,percent of total billed charges,,,,,,,no IP contract,,50,,128.5,percent of total billed charges,,,,,,no IP contract,,,78,,200.46,percent of total billed charges,,,70,,179.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,125.93,3324,
Everolimus Level,80169,CPT,,,,inpatient,,,155,93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,125.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,131.75,percent of total billed charges,,,85,,131.75,percent of total billed charges,,,49,,75.95,percent of total billed charges,,,90,,139.5,percent of total billed charges,,,,,,,no IP contract,,80,,124,percent of total billed charges,,,,,,,no IP contract,,50,,77.5,percent of total billed charges,,,,,,no IP contract,,,78,,120.9,percent of total billed charges,,,70,,108.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,75.95,3324,
Gentamicin-Random,80170,CPT,,,,inpatient,,,217,130.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,175.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,184.45,percent of total billed charges,,,85,,184.45,percent of total billed charges,,,49,,106.33,percent of total billed charges,,,90,,195.3,percent of total billed charges,,,,,,,no IP contract,,80,,173.6,percent of total billed charges,,,,,,,no IP contract,,50,,108.5,percent of total billed charges,,,,,,no IP contract,,,78,,169.26,percent of total billed charges,,,70,,151.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,106.33,3324,
Gentamicin-Trough,80170,CPT,,,,inpatient,,,217,130.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,175.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,184.45,percent of total billed charges,,,85,,184.45,percent of total billed charges,,,49,,106.33,percent of total billed charges,,,90,,195.3,percent of total billed charges,,,,,,,no IP contract,,80,,173.6,percent of total billed charges,,,,,,,no IP contract,,50,,108.5,percent of total billed charges,,,,,,no IP contract,,,78,,169.26,percent of total billed charges,,,70,,151.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,106.33,3324,
Gentamicin-Peak,80170,CPT,,,,inpatient,,,282,169.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,228.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,239.7,percent of total billed charges,,,85,,239.7,percent of total billed charges,,,49,,138.18,percent of total billed charges,,,90,,253.8,percent of total billed charges,,,,,,,no IP contract,,80,,225.6,percent of total billed charges,,,,,,,no IP contract,,50,,141,percent of total billed charges,,,,,,no IP contract,,,78,,219.96,percent of total billed charges,,,70,,197.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,138.18,3324,
Lamotrigine Level,80175,CPT,,,,inpatient,,,190,114,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,153.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,161.5,percent of total billed charges,,,85,,161.5,percent of total billed charges,,,49,,93.1,percent of total billed charges,,,90,,171,percent of total billed charges,,,,,,,no IP contract,,80,,152,percent of total billed charges,,,,,,,no IP contract,,50,,95,percent of total billed charges,,,,,,no IP contract,,,78,,148.2,percent of total billed charges,,,70,,133,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,93.1,3324,
Lithium Level,80178,CPT,,,,inpatient,,,186,111.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,150.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,158.1,percent of total billed charges,,,85,,158.1,percent of total billed charges,,,49,,91.14,percent of total billed charges,,,90,,167.4,percent of total billed charges,,,,,,,no IP contract,,80,,148.8,percent of total billed charges,,,,,,,no IP contract,,50,,93,percent of total billed charges,,,,,,no IP contract,,,78,,145.08,percent of total billed charges,,,70,,130.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,91.14,3324,
Mycophenolic acid Level,80180,CPT,,,,inpatient,,,215,129,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,174.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,182.75,percent of total billed charges,,,85,,182.75,percent of total billed charges,,,49,,105.35,percent of total billed charges,,,90,,193.5,percent of total billed charges,,,,,,,no IP contract,,80,,172,percent of total billed charges,,,,,,,no IP contract,,50,,107.5,percent of total billed charges,,,,,,no IP contract,,,78,,167.7,percent of total billed charges,,,70,,150.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,105.35,3324,
Oxcarbazepine Level,80183,CPT,,,,inpatient,,,246,147.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,199.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,209.1,percent of total billed charges,,,85,,209.1,percent of total billed charges,,,49,,120.54,percent of total billed charges,,,90,,221.4,percent of total billed charges,,,,,,,no IP contract,,80,,196.8,percent of total billed charges,,,,,,,no IP contract,,50,,123,percent of total billed charges,,,,,,no IP contract,,,78,,191.88,percent of total billed charges,,,70,,172.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,120.54,3324,
Phenobarbital Level,80184,CPT,,,,inpatient,,,226,135.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,183.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,192.1,percent of total billed charges,,,85,,192.1,percent of total billed charges,,,49,,110.74,percent of total billed charges,,,90,,203.4,percent of total billed charges,,,,,,,no IP contract,,80,,180.8,percent of total billed charges,,,,,,,no IP contract,,50,,113,percent of total billed charges,,,,,,no IP contract,,,78,,176.28,percent of total billed charges,,,70,,158.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,110.74,3324,
"Dilantin/Phenytoin, Free",80186,CPT,,,,inpatient,,,255,153,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,206.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,216.75,percent of total billed charges,,,85,,216.75,percent of total billed charges,,,49,,124.95,percent of total billed charges,,,90,,229.5,percent of total billed charges,,,,,,,no IP contract,,80,,204,percent of total billed charges,,,,,,,no IP contract,,50,,127.5,percent of total billed charges,,,,,,no IP contract,,,78,,198.9,percent of total billed charges,,,70,,178.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,124.95,3324,
Mysoline Level,80188,CPT,,,,inpatient,,,217,130.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,175.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,184.45,percent of total billed charges,,,85,,184.45,percent of total billed charges,,,49,,106.33,percent of total billed charges,,,90,,195.3,percent of total billed charges,,,,,,,no IP contract,,80,,173.6,percent of total billed charges,,,,,,,no IP contract,,50,,108.5,percent of total billed charges,,,,,,no IP contract,,,78,,169.26,percent of total billed charges,,,70,,151.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,106.33,3324,
Primidone Level,80188,CPT,,,,inpatient,,,217,130.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,175.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,184.45,percent of total billed charges,,,85,,184.45,percent of total billed charges,,,49,,106.33,percent of total billed charges,,,90,,195.3,percent of total billed charges,,,,,,,no IP contract,,80,,173.6,percent of total billed charges,,,,,,,no IP contract,,50,,108.5,percent of total billed charges,,,,,,no IP contract,,,78,,169.26,percent of total billed charges,,,70,,151.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,106.33,3324,
Pronestyl Level,80190,CPT,,,,inpatient,,,339,203.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,274.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,288.15,percent of total billed charges,,,85,,288.15,percent of total billed charges,,,49,,166.11,percent of total billed charges,,,90,,305.1,percent of total billed charges,,,,,,,no IP contract,,80,,271.2,percent of total billed charges,,,,,,,no IP contract,,50,,169.5,percent of total billed charges,,,,,,no IP contract,,,78,,264.42,percent of total billed charges,,,70,,237.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,166.11,3324,
Procainamide and NAPA,80192,CPT,,,,inpatient,,,173,103.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,140.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,147.05,percent of total billed charges,,,85,,147.05,percent of total billed charges,,,49,,84.77,percent of total billed charges,,,90,,155.7,percent of total billed charges,,,,,,,no IP contract,,80,,138.4,percent of total billed charges,,,,,,,no IP contract,,50,,86.5,percent of total billed charges,,,,,,no IP contract,,,78,,134.94,percent of total billed charges,,,70,,121.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,84.77,3324,
Quinidine Level,80194,CPT,,,,inpatient,,,217,130.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,175.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,184.45,percent of total billed charges,,,85,,184.45,percent of total billed charges,,,49,,106.33,percent of total billed charges,,,90,,195.3,percent of total billed charges,,,,,,,no IP contract,,80,,173.6,percent of total billed charges,,,,,,,no IP contract,,50,,108.5,percent of total billed charges,,,,,,no IP contract,,,78,,169.26,percent of total billed charges,,,70,,151.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,106.33,3324,
Tacrolimus Level,80197,CPT,,,,inpatient,,,394,236.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,319.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,334.9,percent of total billed charges,,,85,,334.9,percent of total billed charges,,,49,,193.06,percent of total billed charges,,,90,,354.6,percent of total billed charges,,,,,,,no IP contract,,80,,315.2,percent of total billed charges,,,,,,,no IP contract,,50,,197,percent of total billed charges,,,,,,no IP contract,,,78,,307.32,percent of total billed charges,,,70,,275.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,193.06,3324,
Theophylline/Aminophylline,80198,CPT,,,,inpatient,,,190,114,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,153.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,161.5,percent of total billed charges,,,85,,161.5,percent of total billed charges,,,49,,93.1,percent of total billed charges,,,90,,171,percent of total billed charges,,,,,,,no IP contract,,80,,152,percent of total billed charges,,,,,,,no IP contract,,50,,95,percent of total billed charges,,,,,,no IP contract,,,78,,148.2,percent of total billed charges,,,70,,133,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,93.1,3324,
Tobramycin-Peak,80200,CPT,,,,inpatient,,,400,240,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,324,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,340,percent of total billed charges,,,85,,340,percent of total billed charges,,,49,,196,percent of total billed charges,,,90,,360,percent of total billed charges,,,,,,,no IP contract,,80,,320,percent of total billed charges,,,,,,,no IP contract,,50,,200,percent of total billed charges,,,,,,no IP contract,,,78,,312,percent of total billed charges,,,70,,280,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,196,3324,
Tobramycin-Random,80200,CPT,,,,inpatient,,,400,240,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,324,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,340,percent of total billed charges,,,85,,340,percent of total billed charges,,,49,,196,percent of total billed charges,,,90,,360,percent of total billed charges,,,,,,,no IP contract,,80,,320,percent of total billed charges,,,,,,,no IP contract,,50,,200,percent of total billed charges,,,,,,no IP contract,,,78,,312,percent of total billed charges,,,70,,280,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,196,3324,
Tobramycin-Trough,80200,CPT,,,,inpatient,,,400,240,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,324,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,340,percent of total billed charges,,,85,,340,percent of total billed charges,,,49,,196,percent of total billed charges,,,90,,360,percent of total billed charges,,,,,,,no IP contract,,80,,320,percent of total billed charges,,,,,,,no IP contract,,50,,200,percent of total billed charges,,,,,,no IP contract,,,78,,312,percent of total billed charges,,,70,,280,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,196,3324,
Topiramate Level,80201,CPT,,,,inpatient,,,271,162.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,219.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,230.35,percent of total billed charges,,,85,,230.35,percent of total billed charges,,,49,,132.79,percent of total billed charges,,,90,,243.9,percent of total billed charges,,,,,,,no IP contract,,80,,216.8,percent of total billed charges,,,,,,,no IP contract,,50,,135.5,percent of total billed charges,,,,,,no IP contract,,,78,,211.38,percent of total billed charges,,,70,,189.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,132.79,3324,
Vancomycin Level,80202,CPT,,,,inpatient,,,335,201,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,271.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,284.75,percent of total billed charges,,,85,,284.75,percent of total billed charges,,,49,,164.15,percent of total billed charges,,,90,,301.5,percent of total billed charges,,,,,,,no IP contract,,80,,268,percent of total billed charges,,,,,,,no IP contract,,50,,167.5,percent of total billed charges,,,,,,no IP contract,,,78,,261.3,percent of total billed charges,,,70,,234.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,164.15,3324,
Posaconazole Level,80299,CPT,,,,inpatient,,,204,122.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,165.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,173.4,percent of total billed charges,,,85,,173.4,percent of total billed charges,,,49,,99.96,percent of total billed charges,,,90,,183.6,percent of total billed charges,,,,,,,no IP contract,,80,,163.2,percent of total billed charges,,,,,,,no IP contract,,50,,102,percent of total billed charges,,,,,,no IP contract,,,78,,159.12,percent of total billed charges,,,70,,142.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,99.96,3324,
Propanolol Level,80299,CPT,,,,inpatient,,,204,122.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,165.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,173.4,percent of total billed charges,,,85,,173.4,percent of total billed charges,,,49,,99.96,percent of total billed charges,,,90,,183.6,percent of total billed charges,,,,,,,no IP contract,,80,,163.2,percent of total billed charges,,,,,,,no IP contract,,50,,102,percent of total billed charges,,,,,,no IP contract,,,78,,159.12,percent of total billed charges,,,70,,142.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,99.96,3324,
Propanolol Level,80299,CPT,,,,inpatient,,,204,122.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,165.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,173.4,percent of total billed charges,,,85,,173.4,percent of total billed charges,,,49,,99.96,percent of total billed charges,,,90,,183.6,percent of total billed charges,,,,,,,no IP contract,,80,,163.2,percent of total billed charges,,,,,,,no IP contract,,50,,102,percent of total billed charges,,,,,,no IP contract,,,78,,159.12,percent of total billed charges,,,70,,142.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,99.96,3324,
Voriconazole Level,80299,CPT,,,,inpatient,,,407,244.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,329.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,345.95,percent of total billed charges,,,85,,345.95,percent of total billed charges,,,49,,199.43,percent of total billed charges,,,90,,366.3,percent of total billed charges,,,,,,,no IP contract,,80,,325.6,percent of total billed charges,,,,,,,no IP contract,,50,,203.5,percent of total billed charges,,,,,,no IP contract,,,78,,317.46,percent of total billed charges,,,70,,284.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,199.43,3324,
Fluoxetine & Norfluoxetine,80299,CPT,,,,inpatient,,,462,277.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,374.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,392.7,percent of total billed charges,,,85,,392.7,percent of total billed charges,,,49,,226.38,percent of total billed charges,,,90,,415.8,percent of total billed charges,,,,,,,no IP contract,,80,,369.6,percent of total billed charges,,,,,,,no IP contract,,50,,231,percent of total billed charges,,,,,,no IP contract,,,78,,360.36,percent of total billed charges,,,70,,323.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,226.38,3324,
Itraconazole Level,80299,CPT,,,,inpatient,,,462,277.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,374.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,392.7,percent of total billed charges,,,85,,392.7,percent of total billed charges,,,49,,226.38,percent of total billed charges,,,90,,415.8,percent of total billed charges,,,,,,,no IP contract,,80,,369.6,percent of total billed charges,,,,,,,no IP contract,,50,,231,percent of total billed charges,,,,,,no IP contract,,,78,,360.36,percent of total billed charges,,,70,,323.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,226.38,3324,
Klonopin Level,80299,CPT,,,,inpatient,,,462,277.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,374.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,392.7,percent of total billed charges,,,85,,392.7,percent of total billed charges,,,49,,226.38,percent of total billed charges,,,90,,415.8,percent of total billed charges,,,,,,,no IP contract,,80,,369.6,percent of total billed charges,,,,,,,no IP contract,,50,,231,percent of total billed charges,,,,,,no IP contract,,,78,,360.36,percent of total billed charges,,,70,,323.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,226.38,3324,
Levetiracetam Level,80299,CPT,,,,inpatient,,,462,277.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,374.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,392.7,percent of total billed charges,,,85,,392.7,percent of total billed charges,,,49,,226.38,percent of total billed charges,,,90,,415.8,percent of total billed charges,,,,,,,no IP contract,,80,,369.6,percent of total billed charges,,,,,,,no IP contract,,50,,231,percent of total billed charges,,,,,,no IP contract,,,78,,360.36,percent of total billed charges,,,70,,323.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,226.38,3324,
Methotrexate Level,80299,CPT,,,,inpatient,,,462,277.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,374.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,392.7,percent of total billed charges,,,85,,392.7,percent of total billed charges,,,49,,226.38,percent of total billed charges,,,90,,415.8,percent of total billed charges,,,,,,,no IP contract,,80,,369.6,percent of total billed charges,,,,,,,no IP contract,,50,,231,percent of total billed charges,,,,,,no IP contract,,,78,,360.36,percent of total billed charges,,,70,,323.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,226.38,3324,
Mirtazapine Level,80299,CPT,,,,inpatient,,,462,277.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,374.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,392.7,percent of total billed charges,,,85,,392.7,percent of total billed charges,,,49,,226.38,percent of total billed charges,,,90,,415.8,percent of total billed charges,,,,,,,no IP contract,,80,,369.6,percent of total billed charges,,,,,,,no IP contract,,50,,231,percent of total billed charges,,,,,,no IP contract,,,78,,360.36,percent of total billed charges,,,70,,323.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,226.38,3324,
Norpace (Disopyramide) Level,80299,CPT,,,,inpatient,,,462,277.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,374.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,392.7,percent of total billed charges,,,85,,392.7,percent of total billed charges,,,49,,226.38,percent of total billed charges,,,90,,415.8,percent of total billed charges,,,,,,,no IP contract,,80,,369.6,percent of total billed charges,,,,,,,no IP contract,,50,,231,percent of total billed charges,,,,,,no IP contract,,,78,,360.36,percent of total billed charges,,,70,,323.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,226.38,3324,
Trazodone Level,80299,CPT,,,,inpatient,,,462,277.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,374.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,392.7,percent of total billed charges,,,85,,392.7,percent of total billed charges,,,49,,226.38,percent of total billed charges,,,90,,415.8,percent of total billed charges,,,,,,,no IP contract,,80,,369.6,percent of total billed charges,,,,,,,no IP contract,,50,,231,percent of total billed charges,,,,,,no IP contract,,,78,,360.36,percent of total billed charges,,,70,,323.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,226.38,3324,
Urinalysis with Microscopic,81001,CPT,,,,inpatient,,,116,69.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,93.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,98.6,percent of total billed charges,,,85,,98.6,percent of total billed charges,,,49,,56.84,percent of total billed charges,,,90,,104.4,percent of total billed charges,,,,,,,no IP contract,,80,,92.8,percent of total billed charges,,,,,,,no IP contract,,50,,58,percent of total billed charges,,,,,,no IP contract,,,78,,90.48,percent of total billed charges,,,70,,81.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,56.84,3324,
Urinalysis NMH,81001,CPT,,,,inpatient,,,132,79.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,106.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,112.2,percent of total billed charges,,,85,,112.2,percent of total billed charges,,,49,,64.68,percent of total billed charges,,,90,,118.8,percent of total billed charges,,,,,,,no IP contract,,80,,105.6,percent of total billed charges,,,,,,,no IP contract,,50,,66,percent of total billed charges,,,,,,no IP contract,,,78,,102.96,percent of total billed charges,,,70,,92.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,64.68,3324,
Urinalysis,81003,CPT,,,,inpatient,,,94,56.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,76.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,79.9,percent of total billed charges,,,85,,79.9,percent of total billed charges,,,49,,46.06,percent of total billed charges,,,90,,84.6,percent of total billed charges,,,,,,,no IP contract,,80,,75.2,percent of total billed charges,,,,,,,no IP contract,,50,,47,percent of total billed charges,,,,,,no IP contract,,,78,,73.32,percent of total billed charges,,,70,,65.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,46.06,3324,
URINALYSIS; QUAL NOT IA,81005,CPT,,,,inpatient,,,38,22.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.3,percent of total billed charges,,,85,,32.3,percent of total billed charges,,,49,,18.62,percent of total billed charges,,,90,,34.2,percent of total billed charges,,,,,,,no IP contract,,80,,30.4,percent of total billed charges,,,,,,,no IP contract,,50,,19,percent of total billed charges,,,,,,no IP contract,,,78,,29.64,percent of total billed charges,,,70,,26.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.62,3324,
Urine Pregnancy POC,81025,CPT,,,,inpatient,,,160,96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,129.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,136,percent of total billed charges,,,85,,136,percent of total billed charges,,,49,,78.4,percent of total billed charges,,,90,,144,percent of total billed charges,,,,,,,no IP contract,,80,,128,percent of total billed charges,,,,,,,no IP contract,,50,,80,percent of total billed charges,,,,,,no IP contract,,,78,,124.8,percent of total billed charges,,,70,,112,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,78.4,3324,
"Pregnancy, Urine",81025,CPT,,,,inpatient,,,169,101.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,136.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,143.65,percent of total billed charges,,,85,,143.65,percent of total billed charges,,,49,,82.81,percent of total billed charges,,,90,,152.1,percent of total billed charges,,,,,,,no IP contract,,80,,135.2,percent of total billed charges,,,,,,,no IP contract,,50,,84.5,percent of total billed charges,,,,,,no IP contract,,,78,,131.82,percent of total billed charges,,,70,,118.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,82.81,3324,
"Acetone, Serum",82009,CPT,,,,inpatient,,,67,40.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,54.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.95,percent of total billed charges,,,85,,56.95,percent of total billed charges,,,49,,32.83,percent of total billed charges,,,90,,60.3,percent of total billed charges,,,,,,,no IP contract,,80,,53.6,percent of total billed charges,,,,,,,no IP contract,,50,,33.5,percent of total billed charges,,,,,,no IP contract,,,78,,52.26,percent of total billed charges,,,70,,46.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.83,3324,
Adrenocorticotropic Hormone (ACTH),82024,CPT,,,,inpatient,,,560,336,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,453.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,476,percent of total billed charges,,,85,,476,percent of total billed charges,,,49,,274.4,percent of total billed charges,,,90,,504,percent of total billed charges,,,,,,,no IP contract,,80,,448,percent of total billed charges,,,,,,,no IP contract,,50,,280,percent of total billed charges,,,,,,no IP contract,,,78,,436.8,percent of total billed charges,,,70,,392,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,274.4,3324,
Albumin Level,82040,CPT,,,,inpatient,,,107,64.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,86.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,90.95,percent of total billed charges,,,85,,90.95,percent of total billed charges,,,49,,52.43,percent of total billed charges,,,90,,96.3,percent of total billed charges,,,,,,,no IP contract,,80,,85.6,percent of total billed charges,,,,,,,no IP contract,,50,,53.5,percent of total billed charges,,,,,,no IP contract,,,78,,83.46,percent of total billed charges,,,70,,74.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,52.43,3324,
"ALBUMIN, FLUID NMH",82042,CPT,,,,inpatient,,,24,14.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.4,percent of total billed charges,,,85,,20.4,percent of total billed charges,,,49,,11.76,percent of total billed charges,,,90,,21.6,percent of total billed charges,,,,,,,no IP contract,,80,,19.2,percent of total billed charges,,,,,,,no IP contract,,50,,12,percent of total billed charges,,,,,,no IP contract,,,78,,18.72,percent of total billed charges,,,70,,16.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.76,3324,
Albumin-Fluid,82042,CPT,,,,inpatient,,,67,40.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,54.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.95,percent of total billed charges,,,85,,56.95,percent of total billed charges,,,49,,32.83,percent of total billed charges,,,90,,60.3,percent of total billed charges,,,,,,,no IP contract,,80,,53.6,percent of total billed charges,,,,,,,no IP contract,,50,,33.5,percent of total billed charges,,,,,,no IP contract,,,78,,52.26,percent of total billed charges,,,70,,46.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.83,3324,
"Microalbumin with Creatinine, Urine Timed",82043,CPT,,,,inpatient,,,84,50.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,68.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,71.4,percent of total billed charges,,,85,,71.4,percent of total billed charges,,,49,,41.16,percent of total billed charges,,,90,,75.6,percent of total billed charges,,,,,,,no IP contract,,80,,67.2,percent of total billed charges,,,,,,,no IP contract,,50,,42,percent of total billed charges,,,,,,no IP contract,,,78,,65.52,percent of total billed charges,,,70,,58.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,41.16,3324,
"Microalbumin with Creatinine, Urine, Random",82043,CPT,,,,inpatient,,,115,69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,93.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,97.75,percent of total billed charges,,,85,,97.75,percent of total billed charges,,,49,,56.35,percent of total billed charges,,,90,,103.5,percent of total billed charges,,,,,,,no IP contract,,80,,92,percent of total billed charges,,,,,,,no IP contract,,50,,57.5,percent of total billed charges,,,,,,no IP contract,,,78,,89.7,percent of total billed charges,,,70,,80.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,56.35,3324,
Aldolase,82085,CPT,,,,inpatient,,,130,78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,105.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,110.5,percent of total billed charges,,,85,,110.5,percent of total billed charges,,,49,,63.7,percent of total billed charges,,,90,,117,percent of total billed charges,,,,,,,no IP contract,,80,,104,percent of total billed charges,,,,,,,no IP contract,,50,,65,percent of total billed charges,,,,,,no IP contract,,,78,,101.4,percent of total billed charges,,,70,,91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,63.7,3324,
"Aldosterone, random Urine",82088,CPT,,,,inpatient,,,430,258,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,348.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,365.5,percent of total billed charges,,,85,,365.5,percent of total billed charges,,,49,,210.7,percent of total billed charges,,,90,,387,percent of total billed charges,,,,,,,no IP contract,,80,,344,percent of total billed charges,,,,,,,no IP contract,,50,,215,percent of total billed charges,,,,,,no IP contract,,,78,,335.4,percent of total billed charges,,,70,,301,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,210.7,3324,
Aldosterone,82088,CPT,,,,inpatient,,,572,343.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,463.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,486.2,percent of total billed charges,,,85,,486.2,percent of total billed charges,,,49,,280.28,percent of total billed charges,,,90,,514.8,percent of total billed charges,,,,,,,no IP contract,,80,,457.6,percent of total billed charges,,,,,,,no IP contract,,50,,286,percent of total billed charges,,,,,,no IP contract,,,78,,446.16,percent of total billed charges,,,70,,400.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,280.28,3324,
"Aldosterone, Urine timed",82088,CPT,,,,inpatient,,,572,343.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,463.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,486.2,percent of total billed charges,,,85,,486.2,percent of total billed charges,,,49,,280.28,percent of total billed charges,,,90,,514.8,percent of total billed charges,,,,,,,no IP contract,,80,,457.6,percent of total billed charges,,,,,,,no IP contract,,50,,286,percent of total billed charges,,,,,,no IP contract,,,78,,446.16,percent of total billed charges,,,70,,400.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,280.28,3324,
Alpha 1 Antitrypsin Total,82103,CPT,,,,inpatient,,,259,155.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,209.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,220.15,percent of total billed charges,,,85,,220.15,percent of total billed charges,,,49,,126.91,percent of total billed charges,,,90,,233.1,percent of total billed charges,,,,,,,no IP contract,,80,,207.2,percent of total billed charges,,,,,,,no IP contract,,50,,129.5,percent of total billed charges,,,,,,no IP contract,,,78,,202.02,percent of total billed charges,,,70,,181.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,126.91,3324,
Alpha 1 Antitrypsin Phenotype,82104,CPT,,,,inpatient,,,115,69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,93.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,97.75,percent of total billed charges,,,85,,97.75,percent of total billed charges,,,49,,56.35,percent of total billed charges,,,90,,103.5,percent of total billed charges,,,,,,,no IP contract,,80,,92,percent of total billed charges,,,,,,,no IP contract,,50,,57.5,percent of total billed charges,,,,,,no IP contract,,,78,,89.7,percent of total billed charges,,,70,,80.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,56.35,3324,
"Alpha Fetoprotein, Tumor Marker",82105,CPT,,,,inpatient,,,276,165.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,223.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,234.6,percent of total billed charges,,,85,,234.6,percent of total billed charges,,,49,,135.24,percent of total billed charges,,,90,,248.4,percent of total billed charges,,,,,,,no IP contract,,80,,220.8,percent of total billed charges,,,,,,,no IP contract,,50,,138,percent of total billed charges,,,,,,no IP contract,,,78,,215.28,percent of total billed charges,,,70,,193.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,135.24,3324,
Alpha Fetoprotein,82105,CPT,,,,inpatient,,,336,201.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,272.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,285.6,percent of total billed charges,,,85,,285.6,percent of total billed charges,,,49,,164.64,percent of total billed charges,,,90,,302.4,percent of total billed charges,,,,,,,no IP contract,,80,,268.8,percent of total billed charges,,,,,,,no IP contract,,50,,168,percent of total billed charges,,,,,,no IP contract,,,78,,262.08,percent of total billed charges,,,70,,235.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,164.64,3324,
Panel-Alpha Fetoprotein (Maternal),82105,CPT,,,,inpatient,,,336,201.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,272.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,285.6,percent of total billed charges,,,85,,285.6,percent of total billed charges,,,49,,164.64,percent of total billed charges,,,90,,302.4,percent of total billed charges,,,,,,,no IP contract,,80,,268.8,percent of total billed charges,,,,,,,no IP contract,,50,,168,percent of total billed charges,,,,,,no IP contract,,,78,,262.08,percent of total billed charges,,,70,,235.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,164.64,3324,
"Aluminum Level, Serum",82108,CPT,,,,inpatient,,,205,123,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,166.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,174.25,percent of total billed charges,,,85,,174.25,percent of total billed charges,,,49,,100.45,percent of total billed charges,,,90,,184.5,percent of total billed charges,,,,,,,no IP contract,,80,,164,percent of total billed charges,,,,,,,no IP contract,,50,,102.5,percent of total billed charges,,,,,,no IP contract,,,78,,159.9,percent of total billed charges,,,70,,143.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,100.45,3324,
"Aluminum Level, Urine Random",82108,CPT,,,,inpatient,,,287,172.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,232.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,243.95,percent of total billed charges,,,85,,243.95,percent of total billed charges,,,49,,140.63,percent of total billed charges,,,90,,258.3,percent of total billed charges,,,,,,,no IP contract,,80,,229.6,percent of total billed charges,,,,,,,no IP contract,,50,,143.5,percent of total billed charges,,,,,,no IP contract,,,78,,223.86,percent of total billed charges,,,70,,200.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,140.63,3324,
"Aluminum Level, Urine timed",82108,CPT,,,,inpatient,,,287,172.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,232.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,243.95,percent of total billed charges,,,85,,243.95,percent of total billed charges,,,49,,140.63,percent of total billed charges,,,90,,258.3,percent of total billed charges,,,,,,,no IP contract,,80,,229.6,percent of total billed charges,,,,,,,no IP contract,,50,,143.5,percent of total billed charges,,,,,,no IP contract,,,78,,223.86,percent of total billed charges,,,70,,200.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,140.63,3324,
"Aminolevulinic Acid, Urine",82135,CPT,,,,inpatient,,,308,184.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,249.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,261.8,percent of total billed charges,,,85,,261.8,percent of total billed charges,,,49,,150.92,percent of total billed charges,,,90,,277.2,percent of total billed charges,,,,,,,no IP contract,,80,,246.4,percent of total billed charges,,,,,,,no IP contract,,50,,154,percent of total billed charges,,,,,,no IP contract,,,78,,240.24,percent of total billed charges,,,70,,215.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,150.92,3324,
"Amino Acid Profile, Quantitative",82139,CPT,,,,inpatient,,,559,335.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,452.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,475.15,percent of total billed charges,,,85,,475.15,percent of total billed charges,,,49,,273.91,percent of total billed charges,,,90,,503.1,percent of total billed charges,,,,,,,no IP contract,,80,,447.2,percent of total billed charges,,,,,,,no IP contract,,50,,279.5,percent of total billed charges,,,,,,no IP contract,,,78,,436.02,percent of total billed charges,,,70,,391.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,273.91,3324,
Ammonia,82140,CPT,,,,inpatient,,,179,107.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,144.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,152.15,percent of total billed charges,,,85,,152.15,percent of total billed charges,,,49,,87.71,percent of total billed charges,,,90,,161.1,percent of total billed charges,,,,,,,no IP contract,,80,,143.2,percent of total billed charges,,,,,,,no IP contract,,50,,89.5,percent of total billed charges,,,,,,no IP contract,,,78,,139.62,percent of total billed charges,,,70,,125.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,87.71,3324,
"Amylase, Fluid",82150,CPT,,,,inpatient,,,138,82.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,111.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,117.3,percent of total billed charges,,,85,,117.3,percent of total billed charges,,,49,,67.62,percent of total billed charges,,,90,,124.2,percent of total billed charges,,,,,,,no IP contract,,80,,110.4,percent of total billed charges,,,,,,,no IP contract,,50,,69,percent of total billed charges,,,,,,no IP contract,,,78,,107.64,percent of total billed charges,,,70,,96.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,67.62,3324,
"Amylase, Timed Urine",82150,CPT,,,,inpatient,,,161,96.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,130.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,136.85,percent of total billed charges,,,85,,136.85,percent of total billed charges,,,49,,78.89,percent of total billed charges,,,90,,144.9,percent of total billed charges,,,,,,,no IP contract,,80,,128.8,percent of total billed charges,,,,,,,no IP contract,,50,,80.5,percent of total billed charges,,,,,,no IP contract,,,78,,125.58,percent of total billed charges,,,70,,112.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,78.89,3324,
"Amylase Level, Random Urine",82150,CPT,,,,inpatient,,,166,99.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,134.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,141.1,percent of total billed charges,,,85,,141.1,percent of total billed charges,,,49,,81.34,percent of total billed charges,,,90,,149.4,percent of total billed charges,,,,,,,no IP contract,,80,,132.8,percent of total billed charges,,,,,,,no IP contract,,50,,83,percent of total billed charges,,,,,,no IP contract,,,78,,129.48,percent of total billed charges,,,70,,116.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,22217.57,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,81.34,22217.57,
"Amylase Level, Serum",82150,CPT,,,,inpatient,,,212,127.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,171.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,180.2,percent of total billed charges,,,85,,180.2,percent of total billed charges,,,49,,103.88,percent of total billed charges,,,90,,190.8,percent of total billed charges,,,,,,,no IP contract,,80,,169.6,percent of total billed charges,,,,,,,no IP contract,,50,,106,percent of total billed charges,,,,,,no IP contract,,,78,,165.36,percent of total billed charges,,,70,,148.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,103.88,3324,
Androstenedione,82157,CPT,,,,inpatient,,,451,270.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,365.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,383.35,percent of total billed charges,,,85,,383.35,percent of total billed charges,,,49,,220.99,percent of total billed charges,,,90,,405.9,percent of total billed charges,,,,,,,no IP contract,,80,,360.8,percent of total billed charges,,,,,,,no IP contract,,50,,225.5,percent of total billed charges,,,,,,no IP contract,,,78,,351.78,percent of total billed charges,,,70,,315.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,21076.97,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,220.99,21076.97,
Angiotensin Converting Enzyme,82164,CPT,,,,inpatient,,,186,111.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,150.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,158.1,percent of total billed charges,,,85,,158.1,percent of total billed charges,,,49,,91.14,percent of total billed charges,,,90,,167.4,percent of total billed charges,,,,,,,no IP contract,,80,,148.8,percent of total billed charges,,,,,,,no IP contract,,50,,93,percent of total billed charges,,,,,,no IP contract,,,78,,145.08,percent of total billed charges,,,70,,130.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,20832.10286,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,91.14,20832.1,
Angiotensin Converting Enzyme-CSF,82164,CPT,,,,inpatient,,,186,111.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,150.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,158.1,percent of total billed charges,,,85,,158.1,percent of total billed charges,,,49,,91.14,percent of total billed charges,,,90,,167.4,percent of total billed charges,,,,,,,no IP contract,,80,,148.8,percent of total billed charges,,,,,,,no IP contract,,50,,93,percent of total billed charges,,,,,,no IP contract,,,78,,145.08,percent of total billed charges,,,70,,130.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,26291.358,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,91.14,26291.36,
Apolipoprotein (a),82172,CPT,,,,inpatient,,,125,75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,101.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,106.25,percent of total billed charges,,,85,,106.25,percent of total billed charges,,,49,,61.25,percent of total billed charges,,,90,,112.5,percent of total billed charges,,,,,,,no IP contract,,80,,100,percent of total billed charges,,,,,,,no IP contract,,50,,62.5,percent of total billed charges,,,,,,no IP contract,,,78,,97.5,percent of total billed charges,,,70,,87.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,23034.04,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,61.25,23034.04,
Apolipoprotein B,82172,CPT,,,,inpatient,,,125,75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,101.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,106.25,percent of total billed charges,,,85,,106.25,percent of total billed charges,,,49,,61.25,percent of total billed charges,,,90,,112.5,percent of total billed charges,,,,,,,no IP contract,,80,,100,percent of total billed charges,,,,,,,no IP contract,,50,,62.5,percent of total billed charges,,,,,,no IP contract,,,78,,97.5,percent of total billed charges,,,70,,87.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,27846.39,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,61.25,27846.39,
Apolipoprotein E,82172,CPT,,,,inpatient,,,125,75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,101.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,106.25,percent of total billed charges,,,85,,106.25,percent of total billed charges,,,49,,61.25,percent of total billed charges,,,90,,112.5,percent of total billed charges,,,,,,,no IP contract,,80,,100,percent of total billed charges,,,,,,,no IP contract,,50,,62.5,percent of total billed charges,,,,,,no IP contract,,,78,,97.5,percent of total billed charges,,,70,,87.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,61.25,3324,
"Arsenic Level, Urine timed",82175,CPT,,,,inpatient,,,172,103.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,139.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,146.2,percent of total billed charges,,,85,,146.2,percent of total billed charges,,,49,,84.28,percent of total billed charges,,,90,,154.8,percent of total billed charges,,,,,,,no IP contract,,80,,137.6,percent of total billed charges,,,,,,,no IP contract,,50,,86,percent of total billed charges,,,,,,no IP contract,,,78,,134.16,percent of total billed charges,,,70,,120.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,36060.51,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,84.28,36060.51,
"Arsenic, random Urine",82175,CPT,,,,inpatient,,,172,103.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,139.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,146.2,percent of total billed charges,,,85,,146.2,percent of total billed charges,,,49,,84.28,percent of total billed charges,,,90,,154.8,percent of total billed charges,,,,,,,no IP contract,,80,,137.6,percent of total billed charges,,,,,,,no IP contract,,50,,86,percent of total billed charges,,,,,,no IP contract,,,78,,134.16,percent of total billed charges,,,70,,120.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,44125.85,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,84.28,44125.85,
Arsenic,82175,CPT,,,,inpatient,,,256,153.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,207.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,217.6,percent of total billed charges,,,85,,217.6,percent of total billed charges,,,49,,125.44,percent of total billed charges,,,90,,230.4,percent of total billed charges,,,,,,,no IP contract,,80,,204.8,percent of total billed charges,,,,,,,no IP contract,,50,,128,percent of total billed charges,,,,,,no IP contract,,,78,,199.68,percent of total billed charges,,,70,,179.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,125.44,3324,
Vitamin C Level,82180,CPT,,,,inpatient,,,109,65.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,88.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,92.65,percent of total billed charges,,,85,,92.65,percent of total billed charges,,,49,,53.41,percent of total billed charges,,,90,,98.1,percent of total billed charges,,,,,,,no IP contract,,80,,87.2,percent of total billed charges,,,,,,,no IP contract,,50,,54.5,percent of total billed charges,,,,,,no IP contract,,,78,,85.02,percent of total billed charges,,,70,,76.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,53.41,3324,
"Beta 2 Mircroglobulin, Serum",82232,CPT,,,,inpatient,,,181,108.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,146.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,153.85,percent of total billed charges,,,85,,153.85,percent of total billed charges,,,49,,88.69,percent of total billed charges,,,90,,162.9,percent of total billed charges,,,,,,,no IP contract,,80,,144.8,percent of total billed charges,,,,,,,no IP contract,,50,,90.5,percent of total billed charges,,,,,,no IP contract,,,78,,141.18,percent of total billed charges,,,70,,126.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,29465.065,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,88.69,29465.07,
Bilirubin-Total NMH,82247,CPT,,,,inpatient,,,68,40.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,55.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,57.8,percent of total billed charges,,,85,,57.8,percent of total billed charges,,,49,,33.32,percent of total billed charges,,,90,,61.2,percent of total billed charges,,,,,,,no IP contract,,80,,54.4,percent of total billed charges,,,,,,,no IP contract,,50,,34,percent of total billed charges,,,,,,no IP contract,,,78,,53.04,percent of total billed charges,,,70,,47.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,19749.25357,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,33.32,19749.25,
"Bilirubin, Fluid",82247,CPT,,,,inpatient,,,88,52.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,71.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,74.8,percent of total billed charges,,,85,,74.8,percent of total billed charges,,,49,,43.12,percent of total billed charges,,,90,,79.2,percent of total billed charges,,,,,,,no IP contract,,80,,70.4,percent of total billed charges,,,,,,,no IP contract,,50,,44,percent of total billed charges,,,,,,no IP contract,,,78,,68.64,percent of total billed charges,,,70,,61.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,38332.896,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,43.12,38332.9,
"Bilirubin, Total",82247,CPT,,,,inpatient,,,88,52.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,71.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,74.8,percent of total billed charges,,,85,,74.8,percent of total billed charges,,,49,,43.12,percent of total billed charges,,,90,,79.2,percent of total billed charges,,,,,,,no IP contract,,80,,70.4,percent of total billed charges,,,,,,,no IP contract,,50,,44,percent of total billed charges,,,,,,no IP contract,,,78,,68.64,percent of total billed charges,,,70,,61.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,52197.09455,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,43.12,52197.09,
"Bilirubin, Direct",82248,CPT,,,,inpatient,,,132,79.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,106.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,112.2,percent of total billed charges,,,85,,112.2,percent of total billed charges,,,49,,64.68,percent of total billed charges,,,90,,118.8,percent of total billed charges,,,,,,,no IP contract,,80,,105.6,percent of total billed charges,,,,,,,no IP contract,,50,,66,percent of total billed charges,,,,,,no IP contract,,,78,,102.96,percent of total billed charges,,,70,,92.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,30221.35,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,64.68,30221.35,
Occult Blood Exam,82271,CPT,,,,inpatient,,,89,53.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,72.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,75.65,percent of total billed charges,,,85,,75.65,percent of total billed charges,,,49,,43.61,percent of total billed charges,,,90,,80.1,percent of total billed charges,,,,,,,no IP contract,,80,,71.2,percent of total billed charges,,,,,,,no IP contract,,50,,44.5,percent of total billed charges,,,,,,no IP contract,,,78,,69.42,percent of total billed charges,,,70,,62.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,43.61,3324,
"Cadmium,random Urine with Creatinine Ratio",82300,CPT,,,,inpatient,,,227,136.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,183.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,192.95,percent of total billed charges,,,85,,192.95,percent of total billed charges,,,49,,111.23,percent of total billed charges,,,90,,204.3,percent of total billed charges,,,,,,,no IP contract,,80,,181.6,percent of total billed charges,,,,,,,no IP contract,,50,,113.5,percent of total billed charges,,,,,,no IP contract,,,78,,177.06,percent of total billed charges,,,70,,158.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,111.23,3324,
Vitamin D NMH,82306,CPT,,,,inpatient,,,273,163.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,221.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,232.05,percent of total billed charges,,,85,,232.05,percent of total billed charges,,,49,,133.77,percent of total billed charges,,,90,,245.7,percent of total billed charges,,,,,,,no IP contract,,80,,218.4,percent of total billed charges,,,,,,,no IP contract,,50,,136.5,percent of total billed charges,,,,,,no IP contract,,,78,,212.94,percent of total billed charges,,,70,,191.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,133.77,3324,
"Vitamin D, 125-Dihydroxy",82306,CPT,,,,inpatient,,,380,228,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,307.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,323,percent of total billed charges,,,85,,323,percent of total billed charges,,,49,,186.2,percent of total billed charges,,,90,,342,percent of total billed charges,,,,,,,no IP contract,,80,,304,percent of total billed charges,,,,,,,no IP contract,,50,,190,percent of total billed charges,,,,,,no IP contract,,,78,,296.4,percent of total billed charges,,,70,,266,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,186.2,3324,
"Vitamin D, 25-Hydroxy",82306,CPT,,,,inpatient,,,380,228,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,307.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,323,percent of total billed charges,,,85,,323,percent of total billed charges,,,49,,186.2,percent of total billed charges,,,90,,342,percent of total billed charges,,,,,,,no IP contract,,80,,304,percent of total billed charges,,,,,,,no IP contract,,50,,190,percent of total billed charges,,,,,,no IP contract,,,78,,296.4,percent of total billed charges,,,70,,266,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,186.2,3324,
"Vitamin D, 25-Hydroxy",82306,CPT,,,,inpatient,,,380,228,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,307.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,323,percent of total billed charges,,,85,,323,percent of total billed charges,,,49,,186.2,percent of total billed charges,,,90,,342,percent of total billed charges,,,,,,,no IP contract,,80,,304,percent of total billed charges,,,,,,,no IP contract,,50,,190,percent of total billed charges,,,,,,no IP contract,,,78,,296.4,percent of total billed charges,,,70,,266,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,186.2,3324,
Calcitonin Level,82308,CPT,,,,inpatient,,,216,129.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,174.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,183.6,percent of total billed charges,,,85,,183.6,percent of total billed charges,,,49,,105.84,percent of total billed charges,,,90,,194.4,percent of total billed charges,,,,,,,no IP contract,,80,,172.8,percent of total billed charges,,,,,,,no IP contract,,50,,108,percent of total billed charges,,,,,,no IP contract,,,78,,168.48,percent of total billed charges,,,70,,151.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,105.84,3324,
Calcium/CA++ Level,82310,CPT,,,,inpatient,,,126,75.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,102.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,107.1,percent of total billed charges,,,85,,107.1,percent of total billed charges,,,49,,61.74,percent of total billed charges,,,90,,113.4,percent of total billed charges,,,,,,,no IP contract,,80,,100.8,percent of total billed charges,,,,,,,no IP contract,,50,,63,percent of total billed charges,,,,,,no IP contract,,,78,,98.28,percent of total billed charges,,,70,,88.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,61.74,3324,
Calcium Ionized,82330,CPT,,,,inpatient,,,275,165,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,222.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,233.75,percent of total billed charges,,,85,,233.75,percent of total billed charges,,,49,,134.75,percent of total billed charges,,,90,,247.5,percent of total billed charges,,,,,,,no IP contract,,80,,220,percent of total billed charges,,,,,,,no IP contract,,50,,137.5,percent of total billed charges,,,,,,no IP contract,,,78,,214.5,percent of total billed charges,,,70,,192.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,23387.24,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,134.75,23387.24,
"Calcium, Urine Random",82340,CPT,,,,inpatient,,,115,69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,93.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,97.75,percent of total billed charges,,,85,,97.75,percent of total billed charges,,,49,,56.35,percent of total billed charges,,,90,,103.5,percent of total billed charges,,,,,,,no IP contract,,80,,92,percent of total billed charges,,,,,,,no IP contract,,50,,57.5,percent of total billed charges,,,,,,no IP contract,,,78,,89.7,percent of total billed charges,,,70,,80.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,56.35,3324,
"Calcium, Urine Timed",82340,CPT,,,,inpatient,,,140,84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,113.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,119,percent of total billed charges,,,85,,119,percent of total billed charges,,,49,,68.6,percent of total billed charges,,,90,,126,percent of total billed charges,,,,,,,no IP contract,,80,,112,percent of total billed charges,,,,,,,no IP contract,,50,,70,percent of total billed charges,,,,,,no IP contract,,,78,,109.2,percent of total billed charges,,,70,,98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,68.6,3324,
Calculus Analysis,82365,CPT,,,,inpatient,,,127,76.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,102.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,107.95,percent of total billed charges,,,85,,107.95,percent of total billed charges,,,49,,62.23,percent of total billed charges,,,90,,114.3,percent of total billed charges,,,,,,,no IP contract,,80,,101.6,percent of total billed charges,,,,,,,no IP contract,,50,,63.5,percent of total billed charges,,,,,,no IP contract,,,78,,99.06,percent of total billed charges,,,70,,88.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,62.23,3324,
"Stone Analysis, Kidney",82365,CPT,,,,inpatient,,,127,76.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,102.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,107.95,percent of total billed charges,,,85,,107.95,percent of total billed charges,,,49,,62.23,percent of total billed charges,,,90,,114.3,percent of total billed charges,,,,,,,no IP contract,,80,,101.6,percent of total billed charges,,,,,,,no IP contract,,50,,63.5,percent of total billed charges,,,,,,no IP contract,,,78,,99.06,percent of total billed charges,,,70,,88.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,62.23,3324,
"Stone Analysis, Non-Kidney",82365,CPT,,,,inpatient,,,127,76.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,102.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,107.95,percent of total billed charges,,,85,,107.95,percent of total billed charges,,,49,,62.23,percent of total billed charges,,,90,,114.3,percent of total billed charges,,,,,,,no IP contract,,80,,101.6,percent of total billed charges,,,,,,,no IP contract,,50,,63.5,percent of total billed charges,,,,,,no IP contract,,,78,,99.06,percent of total billed charges,,,70,,88.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,62.23,3324,
CO2/Bicarb,82374,CPT,,,,inpatient,,,78,46.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,63.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,66.3,percent of total billed charges,,,85,,66.3,percent of total billed charges,,,49,,38.22,percent of total billed charges,,,90,,70.2,percent of total billed charges,,,,,,,no IP contract,,80,,62.4,percent of total billed charges,,,,,,,no IP contract,,50,,39,percent of total billed charges,,,,,,no IP contract,,,78,,60.84,percent of total billed charges,,,70,,54.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,38.22,3324,
"Carbon Dioxide, Urine",82374,CPT,,,,inpatient,,,130,78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,105.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,110.5,percent of total billed charges,,,85,,110.5,percent of total billed charges,,,49,,63.7,percent of total billed charges,,,90,,117,percent of total billed charges,,,,,,,no IP contract,,80,,104,percent of total billed charges,,,,,,,no IP contract,,50,,65,percent of total billed charges,,,,,,no IP contract,,,78,,101.4,percent of total billed charges,,,70,,91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,63.7,3324,
Carboxyhemoglobin NMH,82375,CPT,,,,inpatient,,,53,31.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,42.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,45.05,percent of total billed charges,,,85,,45.05,percent of total billed charges,,,49,,25.97,percent of total billed charges,,,90,,47.7,percent of total billed charges,,,,,,,no IP contract,,80,,42.4,percent of total billed charges,,,,,,,no IP contract,,50,,26.5,percent of total billed charges,,,,,,no IP contract,,,78,,41.34,percent of total billed charges,,,70,,37.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.97,3324,
"Carbon Monoxide, quant.",82375,CPT,,,,inpatient,,,110,66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,89.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,93.5,percent of total billed charges,,,85,,93.5,percent of total billed charges,,,49,,53.9,percent of total billed charges,,,90,,99,percent of total billed charges,,,,,,,no IP contract,,80,,88,percent of total billed charges,,,,,,,no IP contract,,50,,55,percent of total billed charges,,,,,,no IP contract,,,78,,85.8,percent of total billed charges,,,70,,77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,53.9,3324,
Fluid CEA,82378,CPT,,,,inpatient,,,208,124.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,168.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,176.8,percent of total billed charges,,,85,,176.8,percent of total billed charges,,,49,,101.92,percent of total billed charges,,,90,,187.2,percent of total billed charges,,,,,,,no IP contract,,80,,166.4,percent of total billed charges,,,,,,,no IP contract,,50,,104,percent of total billed charges,,,,,,no IP contract,,,78,,162.24,percent of total billed charges,,,70,,145.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,101.92,3324,
Carcinoembryonic Antigen,82378,CPT,,,,inpatient,,,400,240,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,324,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,340,percent of total billed charges,,,85,,340,percent of total billed charges,,,49,,196,percent of total billed charges,,,90,,360,percent of total billed charges,,,,,,,no IP contract,,80,,320,percent of total billed charges,,,,,,,no IP contract,,50,,200,percent of total billed charges,,,,,,no IP contract,,,78,,312,percent of total billed charges,,,70,,280,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,196,3324,
Carotene Level,82380,CPT,,,,inpatient,,,202,121.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,163.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,171.7,percent of total billed charges,,,85,,171.7,percent of total billed charges,,,49,,98.98,percent of total billed charges,,,90,,181.8,percent of total billed charges,,,,,,,no IP contract,,80,,161.6,percent of total billed charges,,,,,,,no IP contract,,50,,101,percent of total billed charges,,,,,,no IP contract,,,78,,157.56,percent of total billed charges,,,70,,141.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,34803.72,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,98.98,34803.72,
"Catecholamines, Plasma, Fractionated",82383,CPT,,,,inpatient,,,326,195.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,264.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,277.1,percent of total billed charges,,,85,,277.1,percent of total billed charges,,,49,,159.74,percent of total billed charges,,,90,,293.4,percent of total billed charges,,,,,,,no IP contract,,80,,260.8,percent of total billed charges,,,,,,,no IP contract,,50,,163,percent of total billed charges,,,,,,no IP contract,,,78,,254.28,percent of total billed charges,,,70,,228.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,159.74,3324,
"Catecholamines, Fractionated, Urine, Random",82384,CPT,,,,inpatient,,,355,213,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,287.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,301.75,percent of total billed charges,,,85,,301.75,percent of total billed charges,,,49,,173.95,percent of total billed charges,,,90,,319.5,percent of total billed charges,,,,,,,no IP contract,,80,,284,percent of total billed charges,,,,,,,no IP contract,,50,,177.5,percent of total billed charges,,,,,,no IP contract,,,78,,276.9,percent of total billed charges,,,70,,248.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,58129.45278,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,173.95,58129.45,
"Catecholamines-Fractionated, Urine timed",82384,CPT,,,,inpatient,,,379,227.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,306.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,322.15,percent of total billed charges,,,85,,322.15,percent of total billed charges,,,49,,185.71,percent of total billed charges,,,90,,341.1,percent of total billed charges,,,,,,,no IP contract,,80,,303.2,percent of total billed charges,,,,,,,no IP contract,,50,,189.5,percent of total billed charges,,,,,,no IP contract,,,78,,295.62,percent of total billed charges,,,70,,265.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,185.71,3324,
VMA/CAT/MET Profile,82384,CPT,,,,inpatient,,,564,338.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,456.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,479.4,percent of total billed charges,,,85,,479.4,percent of total billed charges,,,49,,276.36,percent of total billed charges,,,90,,507.6,percent of total billed charges,,,,,,,no IP contract,,80,,451.2,percent of total billed charges,,,,,,,no IP contract,,50,,282,percent of total billed charges,,,,,,no IP contract,,,78,,439.92,percent of total billed charges,,,70,,394.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,276.36,3324,
Ceruloplasmin,82390,CPT,,,,inpatient,,,201,120.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,162.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,170.85,percent of total billed charges,,,85,,170.85,percent of total billed charges,,,49,,98.49,percent of total billed charges,,,90,,180.9,percent of total billed charges,,,,,,,no IP contract,,80,,160.8,percent of total billed charges,,,,,,,no IP contract,,50,,100.5,percent of total billed charges,,,,,,no IP contract,,,78,,156.78,percent of total billed charges,,,70,,140.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,98.49,3324,
Interleukin-6,82397,CPT,,,,inpatient,,,335,201,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,271.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,284.75,percent of total billed charges,,,85,,284.75,percent of total billed charges,,,49,,164.15,percent of total billed charges,,,90,,301.5,percent of total billed charges,,,,,,,no IP contract,,80,,268,percent of total billed charges,,,,,,,no IP contract,,50,,167.5,percent of total billed charges,,,,,,no IP contract,,,78,,261.3,percent of total billed charges,,,70,,234.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,164.15,3324,
Chloride,82435,CPT,,,,inpatient,,,49,29.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,39.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,41.65,percent of total billed charges,,,85,,41.65,percent of total billed charges,,,49,,24.01,percent of total billed charges,,,90,,44.1,percent of total billed charges,,,,,,,no IP contract,,80,,39.2,percent of total billed charges,,,,,,,no IP contract,,50,,24.5,percent of total billed charges,,,,,,no IP contract,,,78,,38.22,percent of total billed charges,,,70,,34.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.01,3324,
"Chloride, Urine Random",82436,CPT,,,,inpatient,,,115,69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,93.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,97.75,percent of total billed charges,,,85,,97.75,percent of total billed charges,,,49,,56.35,percent of total billed charges,,,90,,103.5,percent of total billed charges,,,,,,,no IP contract,,80,,92,percent of total billed charges,,,,,,,no IP contract,,50,,57.5,percent of total billed charges,,,,,,no IP contract,,,78,,89.7,percent of total billed charges,,,70,,80.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,56.35,3324,
"Chloride, Timed Urine",82436,CPT,,,,inpatient,,,133,79.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,107.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,113.05,percent of total billed charges,,,85,,113.05,percent of total billed charges,,,49,,65.17,percent of total billed charges,,,90,,119.7,percent of total billed charges,,,,,,,no IP contract,,80,,106.4,percent of total billed charges,,,,,,,no IP contract,,50,,66.5,percent of total billed charges,,,,,,no IP contract,,,78,,103.74,percent of total billed charges,,,70,,93.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,65.17,3324,
"Citrate, Urine Timed",82507,CPT,,,,inpatient,,,165,99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,133.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,140.25,percent of total billed charges,,,85,,140.25,percent of total billed charges,,,49,,80.85,percent of total billed charges,,,90,,148.5,percent of total billed charges,,,,,,,no IP contract,,80,,132,percent of total billed charges,,,,,,,no IP contract,,50,,82.5,percent of total billed charges,,,,,,no IP contract,,,78,,128.7,percent of total billed charges,,,70,,115.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,80.85,3324,
Deoxypyridin,82523,CPT,,,,inpatient,,,273,163.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,221.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,232.05,percent of total billed charges,,,85,,232.05,percent of total billed charges,,,49,,133.77,percent of total billed charges,,,90,,245.7,percent of total billed charges,,,,,,,no IP contract,,80,,218.4,percent of total billed charges,,,,,,,no IP contract,,50,,136.5,percent of total billed charges,,,,,,no IP contract,,,78,,212.94,percent of total billed charges,,,70,,191.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,133.77,3324,
"N-Telopeptides (NTX), Urine Timed",82523,CPT,,,,inpatient,,,296,177.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,239.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,251.6,percent of total billed charges,,,85,,251.6,percent of total billed charges,,,49,,145.04,percent of total billed charges,,,90,,266.4,percent of total billed charges,,,,,,,no IP contract,,80,,236.8,percent of total billed charges,,,,,,,no IP contract,,50,,148,percent of total billed charges,,,,,,no IP contract,,,78,,230.88,percent of total billed charges,,,70,,207.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,145.04,3324,
"N-Telopeptides (NTX) with Creatinine, Urine Random",82523,CPT,,,,inpatient,,,297,178.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,240.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,252.45,percent of total billed charges,,,85,,252.45,percent of total billed charges,,,49,,145.53,percent of total billed charges,,,90,,267.3,percent of total billed charges,,,,,,,no IP contract,,80,,237.6,percent of total billed charges,,,,,,,no IP contract,,50,,148.5,percent of total billed charges,,,,,,no IP contract,,,78,,231.66,percent of total billed charges,,,70,,207.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,145.53,3324,
Copper Level,82525,CPT,,,,inpatient,,,208,124.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,168.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,176.8,percent of total billed charges,,,85,,176.8,percent of total billed charges,,,49,,101.92,percent of total billed charges,,,90,,187.2,percent of total billed charges,,,,,,,no IP contract,,80,,166.4,percent of total billed charges,,,,,,,no IP contract,,50,,104,percent of total billed charges,,,,,,no IP contract,,,78,,162.24,percent of total billed charges,,,70,,145.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,101.92,3324,
"Copper Level, Urine random",82525,CPT,,,,inpatient,,,208,124.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,168.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,176.8,percent of total billed charges,,,85,,176.8,percent of total billed charges,,,49,,101.92,percent of total billed charges,,,90,,187.2,percent of total billed charges,,,,,,,no IP contract,,80,,166.4,percent of total billed charges,,,,,,,no IP contract,,50,,104,percent of total billed charges,,,,,,no IP contract,,,78,,162.24,percent of total billed charges,,,70,,145.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,101.92,3324,
"Copper Level, Urine Timed",82525,CPT,,,,inpatient,,,208,124.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,168.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,176.8,percent of total billed charges,,,85,,176.8,percent of total billed charges,,,49,,101.92,percent of total billed charges,,,90,,187.2,percent of total billed charges,,,,,,,no IP contract,,80,,166.4,percent of total billed charges,,,,,,,no IP contract,,50,,104,percent of total billed charges,,,,,,no IP contract,,,78,,162.24,percent of total billed charges,,,70,,145.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,101.92,3324,
"Cortisol, Free & Creatinine, Urine Timed",82530,CPT,,,,inpatient,,,333,199.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,269.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,283.05,percent of total billed charges,,,85,,283.05,percent of total billed charges,,,49,,163.17,percent of total billed charges,,,90,,299.7,percent of total billed charges,,,,,,,no IP contract,,80,,266.4,percent of total billed charges,,,,,,,no IP contract,,50,,166.5,percent of total billed charges,,,,,,no IP contract,,,78,,259.74,percent of total billed charges,,,70,,233.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,163.17,3324,
Cortisol-Total,82533,CPT,,,,inpatient,,,382,229.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,309.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,324.7,percent of total billed charges,,,85,,324.7,percent of total billed charges,,,49,,187.18,percent of total billed charges,,,90,,343.8,percent of total billed charges,,,,,,,no IP contract,,80,,305.6,percent of total billed charges,,,,,,,no IP contract,,50,,191,percent of total billed charges,,,,,,no IP contract,,,78,,297.96,percent of total billed charges,,,70,,267.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,187.18,3324,
"Creatine with Creatinine, Urine Timed",82540,CPT,,,,inpatient,,,160,96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,129.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,136,percent of total billed charges,,,85,,136,percent of total billed charges,,,49,,78.4,percent of total billed charges,,,90,,144,percent of total billed charges,,,,,,,no IP contract,,80,,128,percent of total billed charges,,,,,,,no IP contract,,50,,80,percent of total billed charges,,,,,,no IP contract,,,78,,124.8,percent of total billed charges,,,70,,112,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,78.4,3324,
Sirolimus,82542,CPT,,,,inpatient,,,248,148.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,200.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,210.8,percent of total billed charges,,,85,,210.8,percent of total billed charges,,,49,,121.52,percent of total billed charges,,,90,,223.2,percent of total billed charges,,,,,,,no IP contract,,80,,198.4,percent of total billed charges,,,,,,,no IP contract,,50,,124,percent of total billed charges,,,,,,no IP contract,,,78,,193.44,percent of total billed charges,,,70,,173.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,121.52,3324,
Lamictal Level,82542,CPT,,,,inpatient,,,320,192,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,259.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,272,percent of total billed charges,,,85,,272,percent of total billed charges,,,49,,156.8,percent of total billed charges,,,90,,288,percent of total billed charges,,,,,,,no IP contract,,80,,256,percent of total billed charges,,,,,,,no IP contract,,50,,160,percent of total billed charges,,,,,,no IP contract,,,78,,249.6,percent of total billed charges,,,70,,224,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,156.8,3324,
CK/CPK,82550,CPT,,,,inpatient,,,226,135.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,183.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,192.1,percent of total billed charges,,,85,,192.1,percent of total billed charges,,,49,,110.74,percent of total billed charges,,,90,,203.4,percent of total billed charges,,,,,,,no IP contract,,80,,180.8,percent of total billed charges,,,,,,,no IP contract,,50,,113,percent of total billed charges,,,,,,no IP contract,,,78,,176.28,percent of total billed charges,,,70,,158.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,110.74,3324,
CKMB Fraction,82553,CPT,,,,inpatient,,,183,109.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,148.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,155.55,percent of total billed charges,,,85,,155.55,percent of total billed charges,,,49,,89.67,percent of total billed charges,,,90,,164.7,percent of total billed charges,,,,,,,no IP contract,,80,,146.4,percent of total billed charges,,,,,,,no IP contract,,50,,91.5,percent of total billed charges,,,,,,no IP contract,,,78,,142.74,percent of total billed charges,,,70,,128.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,89.67,3324,
CKMB Fraction,82553,CPT,,,,inpatient,,,183,109.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,148.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,155.55,percent of total billed charges,,,85,,155.55,percent of total billed charges,,,49,,89.67,percent of total billed charges,,,90,,164.7,percent of total billed charges,,,,,,,no IP contract,,80,,146.4,percent of total billed charges,,,,,,,no IP contract,,50,,91.5,percent of total billed charges,,,,,,no IP contract,,,78,,142.74,percent of total billed charges,,,70,,128.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,89.67,3324,
Creatinine,82565,CPT,,,,inpatient,,,81,48.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,65.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,68.85,percent of total billed charges,,,85,,68.85,percent of total billed charges,,,49,,39.69,percent of total billed charges,,,90,,72.9,percent of total billed charges,,,,,,,no IP contract,,80,,64.8,percent of total billed charges,,,,,,,no IP contract,,50,,40.5,percent of total billed charges,,,,,,no IP contract,,,78,,63.18,percent of total billed charges,,,70,,56.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,39.69,3324,
CREATININE; NOT BLOOD,82570,CPT,,,,inpatient,,,67,40.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,54.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.95,percent of total billed charges,,,85,,56.95,percent of total billed charges,,,49,,32.83,percent of total billed charges,,,90,,60.3,percent of total billed charges,,,,,,,no IP contract,,80,,53.6,percent of total billed charges,,,,,,,no IP contract,,50,,33.5,percent of total billed charges,,,,,,no IP contract,,,78,,52.26,percent of total billed charges,,,70,,46.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.83,3324,
"Metanephrines, Fractionated -24 Hr Urine",82570,CPT,,,,inpatient,,,101,60.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,81.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,85.85,percent of total billed charges,,,85,,85.85,percent of total billed charges,,,49,,49.49,percent of total billed charges,,,90,,90.9,percent of total billed charges,,,,,,,no IP contract,,80,,80.8,percent of total billed charges,,,,,,,no IP contract,,50,,50.5,percent of total billed charges,,,,,,no IP contract,,,78,,78.78,percent of total billed charges,,,70,,70.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,49.49,3324,
Urine Creatinine,82570,CPT,,,,inpatient,,,101,60.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,81.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,85.85,percent of total billed charges,,,85,,85.85,percent of total billed charges,,,49,,49.49,percent of total billed charges,,,90,,90.9,percent of total billed charges,,,,,,,no IP contract,,80,,80.8,percent of total billed charges,,,,,,,no IP contract,,50,,50.5,percent of total billed charges,,,,,,no IP contract,,,78,,78.78,percent of total billed charges,,,70,,70.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,49.49,3324,
Creatinine Clearance,82570,CPT,,,,inpatient,,,124,74.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,100.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,105.4,percent of total billed charges,,,85,,105.4,percent of total billed charges,,,49,,60.76,percent of total billed charges,,,90,,111.6,percent of total billed charges,,,,,,,no IP contract,,80,,99.2,percent of total billed charges,,,,,,,no IP contract,,50,,62,percent of total billed charges,,,,,,no IP contract,,,78,,96.72,percent of total billed charges,,,70,,86.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,60.76,3324,
"Creatinine, Fluid",82570,CPT,,,,inpatient,,,124,74.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,100.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,105.4,percent of total billed charges,,,85,,105.4,percent of total billed charges,,,49,,60.76,percent of total billed charges,,,90,,111.6,percent of total billed charges,,,,,,,no IP contract,,80,,99.2,percent of total billed charges,,,,,,,no IP contract,,50,,62,percent of total billed charges,,,,,,no IP contract,,,78,,96.72,percent of total billed charges,,,70,,86.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,60.76,3324,
"Creatinine, Urine Random",82570,CPT,,,,inpatient,,,124,74.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,100.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,105.4,percent of total billed charges,,,85,,105.4,percent of total billed charges,,,49,,60.76,percent of total billed charges,,,90,,111.6,percent of total billed charges,,,,,,,no IP contract,,80,,99.2,percent of total billed charges,,,,,,,no IP contract,,50,,62,percent of total billed charges,,,,,,no IP contract,,,78,,96.72,percent of total billed charges,,,70,,86.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,60.76,3324,
Timed Urine Creatinine,82570,CPT,,,,inpatient,,,124,74.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,100.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,105.4,percent of total billed charges,,,85,,105.4,percent of total billed charges,,,49,,60.76,percent of total billed charges,,,90,,111.6,percent of total billed charges,,,,,,,no IP contract,,80,,99.2,percent of total billed charges,,,,,,,no IP contract,,50,,62,percent of total billed charges,,,,,,no IP contract,,,78,,96.72,percent of total billed charges,,,70,,86.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,60.76,3324,
Cryoglobulin Identification,82595,CPT,,,,inpatient,,,155,93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,125.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,131.75,percent of total billed charges,,,85,,131.75,percent of total billed charges,,,49,,75.95,percent of total billed charges,,,90,,139.5,percent of total billed charges,,,,,,,no IP contract,,80,,124,percent of total billed charges,,,,,,,no IP contract,,50,,77.5,percent of total billed charges,,,,,,no IP contract,,,78,,120.9,percent of total billed charges,,,70,,108.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,75.95,3324,
Cryoglobulin Screen,82595,CPT,,,,inpatient,,,155,93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,125.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,131.75,percent of total billed charges,,,85,,131.75,percent of total billed charges,,,49,,75.95,percent of total billed charges,,,90,,139.5,percent of total billed charges,,,,,,,no IP contract,,80,,124,percent of total billed charges,,,,,,,no IP contract,,50,,77.5,percent of total billed charges,,,,,,no IP contract,,,78,,120.9,percent of total billed charges,,,70,,108.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,75.95,3324,
Cyanide,82600,CPT,,,,inpatient,,,228,136.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,184.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,193.8,percent of total billed charges,,,85,,193.8,percent of total billed charges,,,49,,111.72,percent of total billed charges,,,90,,205.2,percent of total billed charges,,,,,,,no IP contract,,80,,182.4,percent of total billed charges,,,,,,,no IP contract,,50,,114,percent of total billed charges,,,,,,no IP contract,,,78,,177.84,percent of total billed charges,,,70,,159.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,111.72,3324,
Vitamin B12 and Folate,82607,CPT,,,,inpatient,,,316,189.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,255.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,268.6,percent of total billed charges,,,85,,268.6,percent of total billed charges,,,49,,154.84,percent of total billed charges,,,90,,284.4,percent of total billed charges,,,,,,,no IP contract,,80,,252.8,percent of total billed charges,,,,,,,no IP contract,,50,,158,percent of total billed charges,,,,,,no IP contract,,,78,,246.48,percent of total billed charges,,,70,,221.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,154.84,3324,
Vitamin B-12 Level,82607,CPT,,,,inpatient,,,316,189.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,255.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,268.6,percent of total billed charges,,,85,,268.6,percent of total billed charges,,,49,,154.84,percent of total billed charges,,,90,,284.4,percent of total billed charges,,,,,,,no IP contract,,80,,252.8,percent of total billed charges,,,,,,,no IP contract,,50,,158,percent of total billed charges,,,,,,no IP contract,,,78,,246.48,percent of total billed charges,,,70,,221.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,154.84,3324,
Cystatin C,82610,CPT,,,,inpatient,,,220,132,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,178.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,187,percent of total billed charges,,,85,,187,percent of total billed charges,,,49,,107.8,percent of total billed charges,,,90,,198,percent of total billed charges,,,,,,,no IP contract,,80,,176,percent of total billed charges,,,,,,,no IP contract,,50,,110,percent of total billed charges,,,,,,no IP contract,,,78,,171.6,percent of total billed charges,,,70,,154,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,107.8,3324,
Homocysteine-Urine,82615,CPT,,,,inpatient,,,217,130.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,175.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,184.45,percent of total billed charges,,,85,,184.45,percent of total billed charges,,,49,,106.33,percent of total billed charges,,,90,,195.3,percent of total billed charges,,,,,,,no IP contract,,80,,173.6,percent of total billed charges,,,,,,,no IP contract,,50,,108.5,percent of total billed charges,,,,,,no IP contract,,,78,,169.26,percent of total billed charges,,,70,,151.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,106.33,3324,
Dehydroepiandrosterone,82626,CPT,,,,inpatient,,,362,217.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,293.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,307.7,percent of total billed charges,,,85,,307.7,percent of total billed charges,,,49,,177.38,percent of total billed charges,,,90,,325.8,percent of total billed charges,,,,,,,no IP contract,,80,,289.6,percent of total billed charges,,,,,,,no IP contract,,50,,181,percent of total billed charges,,,,,,no IP contract,,,78,,282.36,percent of total billed charges,,,70,,253.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,177.38,3324,
DHEA Sulfate,82626,CPT,,,,inpatient,,,362,217.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,293.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,307.7,percent of total billed charges,,,85,,307.7,percent of total billed charges,,,49,,177.38,percent of total billed charges,,,90,,325.8,percent of total billed charges,,,,,,,no IP contract,,80,,289.6,percent of total billed charges,,,,,,,no IP contract,,50,,181,percent of total billed charges,,,,,,no IP contract,,,78,,282.36,percent of total billed charges,,,70,,253.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,177.38,3324,
"11-Deoxycortisol, Urine Random",82634,CPT,,,,inpatient,,,363,217.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,294.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,308.55,percent of total billed charges,,,85,,308.55,percent of total billed charges,,,49,,177.87,percent of total billed charges,,,90,,326.7,percent of total billed charges,,,,,,,no IP contract,,80,,290.4,percent of total billed charges,,,,,,,no IP contract,,50,,181.5,percent of total billed charges,,,,,,no IP contract,,,78,,283.14,percent of total billed charges,,,70,,254.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,177.87,3324,
Viamin D 125 Dihy NMH,82652,CPT,,,,inpatient,,,213,127.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,172.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,181.05,percent of total billed charges,,,85,,181.05,percent of total billed charges,,,49,,104.37,percent of total billed charges,,,90,,191.7,percent of total billed charges,,,,,,,no IP contract,,80,,170.4,percent of total billed charges,,,,,,,no IP contract,,50,,106.5,percent of total billed charges,,,,,,no IP contract,,,78,,166.14,percent of total billed charges,,,70,,149.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,104.37,3324,
"Vitamin D, 125-Dihydroxy",82652,CPT,,,,inpatient,,,380,228,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,307.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,323,percent of total billed charges,,,85,,323,percent of total billed charges,,,49,,186.2,percent of total billed charges,,,90,,342,percent of total billed charges,,,,,,,no IP contract,,80,,304,percent of total billed charges,,,,,,,no IP contract,,50,,190,percent of total billed charges,,,,,,no IP contract,,,78,,296.4,percent of total billed charges,,,70,,266,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,186.2,3324,
Erythropoietin Level,82668,CPT,,,,inpatient,,,337,202.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,272.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,286.45,percent of total billed charges,,,85,,286.45,percent of total billed charges,,,49,,165.13,percent of total billed charges,,,90,,303.3,percent of total billed charges,,,,,,,no IP contract,,80,,269.6,percent of total billed charges,,,,,,,no IP contract,,50,,168.5,percent of total billed charges,,,,,,no IP contract,,,78,,262.86,percent of total billed charges,,,70,,235.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,165.13,3324,
Estradiol,82670,CPT,,,,inpatient,,,400,240,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,324,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,340,percent of total billed charges,,,85,,340,percent of total billed charges,,,49,,196,percent of total billed charges,,,90,,360,percent of total billed charges,,,,,,,no IP contract,,80,,320,percent of total billed charges,,,,,,,no IP contract,,50,,200,percent of total billed charges,,,,,,no IP contract,,,78,,312,percent of total billed charges,,,70,,280,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,196,3324,
Estrogen-Total Serum,82672,CPT,,,,inpatient,,,287,172.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,232.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,243.95,percent of total billed charges,,,85,,243.95,percent of total billed charges,,,49,,140.63,percent of total billed charges,,,90,,258.3,percent of total billed charges,,,,,,,no IP contract,,80,,229.6,percent of total billed charges,,,,,,,no IP contract,,50,,143.5,percent of total billed charges,,,,,,no IP contract,,,78,,223.86,percent of total billed charges,,,70,,200.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,140.63,3324,
Estriol,82677,CPT,,,,inpatient,,,122,73.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,98.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,103.7,percent of total billed charges,,,85,,103.7,percent of total billed charges,,,49,,59.78,percent of total billed charges,,,90,,109.8,percent of total billed charges,,,,,,,no IP contract,,80,,97.6,percent of total billed charges,,,,,,,no IP contract,,50,,61,percent of total billed charges,,,,,,no IP contract,,,78,,95.16,percent of total billed charges,,,70,,85.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,59.78,3324,
Estrone Level,82679,CPT,,,,inpatient,,,114,68.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,92.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,96.9,percent of total billed charges,,,85,,96.9,percent of total billed charges,,,49,,55.86,percent of total billed charges,,,90,,102.6,percent of total billed charges,,,,,,,no IP contract,,80,,91.2,percent of total billed charges,,,,,,,no IP contract,,50,,57,percent of total billed charges,,,,,,no IP contract,,,78,,88.92,percent of total billed charges,,,70,,79.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,55.86,3324,
Fecal Fat Timed Collection,82710,CPT,,,,inpatient,,,270,162,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,218.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,229.5,percent of total billed charges,,,85,,229.5,percent of total billed charges,,,49,,132.3,percent of total billed charges,,,90,,243,percent of total billed charges,,,,,,,no IP contract,,80,,216,percent of total billed charges,,,,,,,no IP contract,,50,,135,percent of total billed charges,,,,,,no IP contract,,,78,,210.6,percent of total billed charges,,,70,,189,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,132.3,3324,
FERRITIN NMH,82728,CPT,,,,inpatient,,,206,123.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,166.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,175.1,percent of total billed charges,,,85,,175.1,percent of total billed charges,,,49,,100.94,percent of total billed charges,,,90,,185.4,percent of total billed charges,,,,,,,no IP contract,,80,,164.8,percent of total billed charges,,,,,,,no IP contract,,50,,103,percent of total billed charges,,,,,,no IP contract,,,78,,160.68,percent of total billed charges,,,70,,144.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,100.94,3324,
Ferritin,82728,CPT,,,,inpatient,,,245,147,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,198.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,208.25,percent of total billed charges,,,85,,208.25,percent of total billed charges,,,49,,120.05,percent of total billed charges,,,90,,220.5,percent of total billed charges,,,,,,,no IP contract,,80,,196,percent of total billed charges,,,,,,,no IP contract,,50,,122.5,percent of total billed charges,,,,,,no IP contract,,,78,,191.1,percent of total billed charges,,,70,,171.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,120.05,3324,
Hemochromatosis Panel,82728,CPT,,,,inpatient,,,292,175.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,236.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,248.2,percent of total billed charges,,,85,,248.2,percent of total billed charges,,,49,,143.08,percent of total billed charges,,,90,,262.8,percent of total billed charges,,,,,,,no IP contract,,80,,233.6,percent of total billed charges,,,,,,,no IP contract,,50,,146,percent of total billed charges,,,,,,no IP contract,,,78,,227.76,percent of total billed charges,,,70,,204.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,143.08,3324,
Folate-Folic Acid Level,82746,CPT,,,,inpatient,,,212,127.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,171.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,180.2,percent of total billed charges,,,85,,180.2,percent of total billed charges,,,49,,103.88,percent of total billed charges,,,90,,190.8,percent of total billed charges,,,,,,,no IP contract,,80,,169.6,percent of total billed charges,,,,,,,no IP contract,,50,,106,percent of total billed charges,,,,,,no IP contract,,,78,,165.36,percent of total billed charges,,,70,,148.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,103.88,3324,
Folate-Folic Acid Level,82746,CPT,,,,inpatient,,,212,127.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,171.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,180.2,percent of total billed charges,,,85,,180.2,percent of total billed charges,,,49,,103.88,percent of total billed charges,,,90,,190.8,percent of total billed charges,,,,,,,no IP contract,,80,,169.6,percent of total billed charges,,,,,,,no IP contract,,50,,106,percent of total billed charges,,,,,,no IP contract,,,78,,165.36,percent of total billed charges,,,70,,148.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,103.88,3324,
Folate-RBC,82747,CPT,,,,inpatient,,,143,85.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,115.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,121.55,percent of total billed charges,,,85,,121.55,percent of total billed charges,,,49,,70.07,percent of total billed charges,,,90,,128.7,percent of total billed charges,,,,,,,no IP contract,,80,,114.4,percent of total billed charges,,,,,,,no IP contract,,50,,71.5,percent of total billed charges,,,,,,no IP contract,,,78,,111.54,percent of total billed charges,,,70,,100.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,70.07,3324,
Low Level IgM,82784,CPT,,,,inpatient,,,122,73.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,98.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,103.7,percent of total billed charges,,,85,,103.7,percent of total billed charges,,,49,,59.78,percent of total billed charges,,,90,,109.8,percent of total billed charges,,,,,,,no IP contract,,80,,97.6,percent of total billed charges,,,,,,,no IP contract,,50,,61,percent of total billed charges,,,,,,no IP contract,,,78,,95.16,percent of total billed charges,,,70,,85.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,59.78,3324,
Quantitative IgA,82784,CPT,,,,inpatient,,,122,73.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,98.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,103.7,percent of total billed charges,,,85,,103.7,percent of total billed charges,,,49,,59.78,percent of total billed charges,,,90,,109.8,percent of total billed charges,,,,,,,no IP contract,,80,,97.6,percent of total billed charges,,,,,,,no IP contract,,50,,61,percent of total billed charges,,,,,,no IP contract,,,78,,95.16,percent of total billed charges,,,70,,85.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,59.78,3324,
Quantitative IgG,82784,CPT,,,,inpatient,,,122,73.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,98.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,103.7,percent of total billed charges,,,85,,103.7,percent of total billed charges,,,49,,59.78,percent of total billed charges,,,90,,109.8,percent of total billed charges,,,,,,,no IP contract,,80,,97.6,percent of total billed charges,,,,,,,no IP contract,,50,,61,percent of total billed charges,,,,,,no IP contract,,,78,,95.16,percent of total billed charges,,,70,,85.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,59.78,3324,
Quantitative IgM,82784,CPT,,,,inpatient,,,122,73.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,98.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,103.7,percent of total billed charges,,,85,,103.7,percent of total billed charges,,,49,,59.78,percent of total billed charges,,,90,,109.8,percent of total billed charges,,,,,,,no IP contract,,80,,97.6,percent of total billed charges,,,,,,,no IP contract,,50,,61,percent of total billed charges,,,,,,no IP contract,,,78,,95.16,percent of total billed charges,,,70,,85.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,59.78,3324,
Assay IgA/IgD/IgG/IgM Each,82784,CPT,,,,inpatient,,,124,74.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,100.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,105.4,percent of total billed charges,,,85,,105.4,percent of total billed charges,,,49,,60.76,percent of total billed charges,,,90,,111.6,percent of total billed charges,,,,,,,no IP contract,,80,,99.2,percent of total billed charges,,,,,,,no IP contract,,50,,62,percent of total billed charges,,,,,,no IP contract,,,78,,96.72,percent of total billed charges,,,70,,86.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,31025.86714,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,60.76,31025.87,
Kappa/Lambda Ratio,82784,CPT,,,,inpatient,,,158,94.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,127.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,134.3,percent of total billed charges,,,85,,134.3,percent of total billed charges,,,49,,77.42,percent of total billed charges,,,90,,142.2,percent of total billed charges,,,,,,,no IP contract,,80,,126.4,percent of total billed charges,,,,,,,no IP contract,,50,,79,percent of total billed charges,,,,,,no IP contract,,,78,,123.24,percent of total billed charges,,,70,,110.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,77.42,3324,
"IgG/Albumin Index, CSF",82784,CPT,,,,inpatient,,,179,107.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,144.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,152.15,percent of total billed charges,,,85,,152.15,percent of total billed charges,,,49,,87.71,percent of total billed charges,,,90,,161.1,percent of total billed charges,,,,,,,no IP contract,,80,,143.2,percent of total billed charges,,,,,,,no IP contract,,50,,89.5,percent of total billed charges,,,,,,no IP contract,,,78,,139.62,percent of total billed charges,,,70,,125.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,87.71,3324,
Immunoglobulins,82784,CPT,,,,inpatient,,,232,139.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,187.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,197.2,percent of total billed charges,,,85,,197.2,percent of total billed charges,,,49,,113.68,percent of total billed charges,,,90,,208.8,percent of total billed charges,,,,,,,no IP contract,,80,,185.6,percent of total billed charges,,,,,,,no IP contract,,50,,116,percent of total billed charges,,,,,,no IP contract,,,78,,180.96,percent of total billed charges,,,70,,162.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,113.68,3324,
IgE Level,82785,CPT,,,,inpatient,,,70,42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,56.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,59.5,percent of total billed charges,,,85,,59.5,percent of total billed charges,,,49,,34.3,percent of total billed charges,,,90,,63,percent of total billed charges,,,,,,,no IP contract,,80,,56,percent of total billed charges,,,,,,,no IP contract,,50,,35,percent of total billed charges,,,,,,no IP contract,,,78,,54.6,percent of total billed charges,,,70,,49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,34.3,3324,
ABG Test NMH,82803,CPT,,,,inpatient,,,396,237.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,320.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,336.6,percent of total billed charges,,,85,,336.6,percent of total billed charges,,,49,,194.04,percent of total billed charges,,,90,,356.4,percent of total billed charges,,,,,,,no IP contract,,80,,316.8,percent of total billed charges,,,,,,,no IP contract,,50,,198,percent of total billed charges,,,,,,no IP contract,,,78,,308.88,percent of total billed charges,,,70,,277.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,194.04,3324,
"Blood Gas, Adult VBG w Measured Sat",82805,CPT,,,,inpatient,,,270,162,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,218.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,229.5,percent of total billed charges,,,85,,229.5,percent of total billed charges,,,49,,132.3,percent of total billed charges,,,90,,243,percent of total billed charges,,,,,,,no IP contract,,80,,216,percent of total billed charges,,,,,,,no IP contract,,50,,135,percent of total billed charges,,,,,,no IP contract,,,78,,210.6,percent of total billed charges,,,70,,189,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,132.3,3324,
"Blood Gas, Adult ABG w Measured Sat",82805,CPT,,,,inpatient,,,358,214.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,289.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,304.3,percent of total billed charges,,,85,,304.3,percent of total billed charges,,,49,,175.42,percent of total billed charges,,,90,,322.2,percent of total billed charges,,,,,,,no IP contract,,80,,286.4,percent of total billed charges,,,,,,,no IP contract,,50,,179,percent of total billed charges,,,,,,no IP contract,,,78,,279.24,percent of total billed charges,,,70,,250.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,175.42,3324,
"OXIMETRY PANEL, VENOUS POCT NMH",82810,CPT,,,,inpatient,,,76,45.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,61.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,64.6,percent of total billed charges,,,85,,64.6,percent of total billed charges,,,49,,37.24,percent of total billed charges,,,90,,68.4,percent of total billed charges,,,,,,,no IP contract,,80,,60.8,percent of total billed charges,,,,,,,no IP contract,,50,,38,percent of total billed charges,,,,,,no IP contract,,,78,,59.28,percent of total billed charges,,,70,,53.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,37.24,3324,
Gastrin Level,82941,CPT,,,,inpatient,,,268,160.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,217.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,227.8,percent of total billed charges,,,85,,227.8,percent of total billed charges,,,49,,131.32,percent of total billed charges,,,90,,241.2,percent of total billed charges,,,,,,,no IP contract,,80,,214.4,percent of total billed charges,,,,,,,no IP contract,,50,,134,percent of total billed charges,,,,,,no IP contract,,,78,,209.04,percent of total billed charges,,,70,,187.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,131.32,3324,
Glucagon Level,82943,CPT,,,,inpatient,,,95,57,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,76.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,80.75,percent of total billed charges,,,85,,80.75,percent of total billed charges,,,49,,46.55,percent of total billed charges,,,90,,85.5,percent of total billed charges,,,,,,,no IP contract,,80,,76,percent of total billed charges,,,,,,,no IP contract,,50,,47.5,percent of total billed charges,,,,,,no IP contract,,,78,,74.1,percent of total billed charges,,,70,,66.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,46.55,3324,
"Glucose, Timed Urine",82945,CPT,,,,inpatient,,,70,42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,56.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,59.5,percent of total billed charges,,,85,,59.5,percent of total billed charges,,,49,,34.3,percent of total billed charges,,,90,,63,percent of total billed charges,,,,,,,no IP contract,,80,,56,percent of total billed charges,,,,,,,no IP contract,,50,,35,percent of total billed charges,,,,,,no IP contract,,,78,,54.6,percent of total billed charges,,,70,,49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,34.3,3324,
"Glucose, Urine, Random",82945,CPT,,,,inpatient,,,70,42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,56.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,59.5,percent of total billed charges,,,85,,59.5,percent of total billed charges,,,49,,34.3,percent of total billed charges,,,90,,63,percent of total billed charges,,,,,,,no IP contract,,80,,56,percent of total billed charges,,,,,,,no IP contract,,50,,35,percent of total billed charges,,,,,,no IP contract,,,78,,54.6,percent of total billed charges,,,70,,49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,34.3,3324,
Glucose-CSF,82945,CPT,,,,inpatient,,,70,42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,56.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,59.5,percent of total billed charges,,,85,,59.5,percent of total billed charges,,,49,,34.3,percent of total billed charges,,,90,,63,percent of total billed charges,,,,,,,no IP contract,,80,,56,percent of total billed charges,,,,,,,no IP contract,,50,,35,percent of total billed charges,,,,,,no IP contract,,,78,,54.6,percent of total billed charges,,,70,,49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,34.3,3324,
"Glucose, Fluid",82945,CPT,,,,inpatient,,,82,49.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,66.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,69.7,percent of total billed charges,,,85,,69.7,percent of total billed charges,,,49,,40.18,percent of total billed charges,,,90,,73.8,percent of total billed charges,,,,,,,no IP contract,,80,,65.6,percent of total billed charges,,,,,,,no IP contract,,50,,41,percent of total billed charges,,,,,,no IP contract,,,78,,63.96,percent of total billed charges,,,70,,57.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,40.18,3324,
"GLUCOSE, FLUID NMH",82945,CPT,,,,inpatient,,,123,73.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,99.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,104.55,percent of total billed charges,,,85,,104.55,percent of total billed charges,,,49,,60.27,percent of total billed charges,,,90,,110.7,percent of total billed charges,,,,,,,no IP contract,,80,,98.4,percent of total billed charges,,,,,,,no IP contract,,50,,61.5,percent of total billed charges,,,,,,no IP contract,,,78,,95.94,percent of total billed charges,,,70,,86.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,60.27,3324,
Glucose 6 PD,82960,CPT,,,,inpatient,,,215,129,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,174.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,182.75,percent of total billed charges,,,85,,182.75,percent of total billed charges,,,49,,105.35,percent of total billed charges,,,90,,193.5,percent of total billed charges,,,,,,,no IP contract,,80,,172,percent of total billed charges,,,,,,,no IP contract,,50,,107.5,percent of total billed charges,,,,,,no IP contract,,,78,,167.7,percent of total billed charges,,,70,,150.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,105.35,3324,
Bedside Glucose Test NMH,82962,CPT,,,,inpatient,,,63,37.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,51.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,53.55,percent of total billed charges,,,85,,53.55,percent of total billed charges,,,49,,30.87,percent of total billed charges,,,90,,56.7,percent of total billed charges,,,,,,,no IP contract,,80,,50.4,percent of total billed charges,,,,,,,no IP contract,,50,,31.5,percent of total billed charges,,,,,,no IP contract,,,78,,49.14,percent of total billed charges,,,70,,44.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,21565.8325,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,30.87,21565.83,
Blood Glucose POC,82962,CPT,,,,inpatient,,,68,40.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,55.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,57.8,percent of total billed charges,,,85,,57.8,percent of total billed charges,,,49,,33.32,percent of total billed charges,,,90,,61.2,percent of total billed charges,,,,,,,no IP contract,,80,,54.4,percent of total billed charges,,,,,,,no IP contract,,50,,34,percent of total billed charges,,,,,,no IP contract,,,78,,53.04,percent of total billed charges,,,70,,47.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,33.32,3324,
"Bld Glucose, Capillary",82962,CPT,,,,inpatient,,,69,41.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,55.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,58.65,percent of total billed charges,,,85,,58.65,percent of total billed charges,,,49,,33.81,percent of total billed charges,,,90,,62.1,percent of total billed charges,,,,,,,no IP contract,,80,,55.2,percent of total billed charges,,,,,,,no IP contract,,50,,34.5,percent of total billed charges,,,,,,no IP contract,,,78,,53.82,percent of total billed charges,,,70,,48.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,33.81,3324,
GGTP/GGT,82977,CPT,,,,inpatient,,,143,85.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,115.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,121.55,percent of total billed charges,,,85,,121.55,percent of total billed charges,,,49,,70.07,percent of total billed charges,,,90,,128.7,percent of total billed charges,,,,,,,no IP contract,,80,,114.4,percent of total billed charges,,,,,,,no IP contract,,50,,71.5,percent of total billed charges,,,,,,no IP contract,,,78,,111.54,percent of total billed charges,,,70,,100.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,70.07,3324,
Follicle Stimulating Hormone,83001,CPT,,,,inpatient,,,336,201.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,272.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,285.6,percent of total billed charges,,,85,,285.6,percent of total billed charges,,,49,,164.64,percent of total billed charges,,,90,,302.4,percent of total billed charges,,,,,,,no IP contract,,80,,268.8,percent of total billed charges,,,,,,,no IP contract,,50,,168,percent of total billed charges,,,,,,no IP contract,,,78,,262.08,percent of total billed charges,,,70,,235.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,164.64,3324,
Luteinizing Hormone,83002,CPT,,,,inpatient,,,363,217.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,294.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,308.55,percent of total billed charges,,,85,,308.55,percent of total billed charges,,,49,,177.87,percent of total billed charges,,,90,,326.7,percent of total billed charges,,,,,,,no IP contract,,80,,290.4,percent of total billed charges,,,,,,,no IP contract,,50,,181.5,percent of total billed charges,,,,,,no IP contract,,,78,,283.14,percent of total billed charges,,,70,,254.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,177.87,3324,
Growth Hormone Level,83003,CPT,,,,inpatient,,,305,183,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,247.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,259.25,percent of total billed charges,,,85,,259.25,percent of total billed charges,,,49,,149.45,percent of total billed charges,,,90,,274.5,percent of total billed charges,,,,,,,no IP contract,,80,,244,percent of total billed charges,,,,,,,no IP contract,,50,,152.5,percent of total billed charges,,,,,,no IP contract,,,78,,237.9,percent of total billed charges,,,70,,213.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,149.45,3324,
Haptoglobin,83010,CPT,,,,inpatient,,,275,165,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,222.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,233.75,percent of total billed charges,,,85,,233.75,percent of total billed charges,,,49,,134.75,percent of total billed charges,,,90,,247.5,percent of total billed charges,,,,,,,no IP contract,,80,,220,percent of total billed charges,,,,,,,no IP contract,,50,,137.5,percent of total billed charges,,,,,,no IP contract,,,78,,214.5,percent of total billed charges,,,70,,192.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,134.75,3324,
"Heavy Metal Screen, Urine, Random",83015,CPT,,,,inpatient,,,835,501,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,676.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,709.75,percent of total billed charges,,,85,,709.75,percent of total billed charges,,,49,,409.15,percent of total billed charges,,,90,,751.5,percent of total billed charges,,,,,,,no IP contract,,80,,668,percent of total billed charges,,,,,,,no IP contract,,50,,417.5,percent of total billed charges,,,,,,no IP contract,,,78,,651.3,percent of total billed charges,,,70,,584.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,409.15,3324,
"Heavy Metals Screen, Urine timed",83015,CPT,,,,inpatient,,,835,501,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,676.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,709.75,percent of total billed charges,,,85,,709.75,percent of total billed charges,,,49,,409.15,percent of total billed charges,,,90,,751.5,percent of total billed charges,,,,,,,no IP contract,,80,,668,percent of total billed charges,,,,,,,no IP contract,,50,,417.5,percent of total billed charges,,,,,,no IP contract,,,78,,651.3,percent of total billed charges,,,70,,584.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,409.15,3324,
"Heavy Metals Screen, Whole Blood",83015,CPT,,,,inpatient,,,835,501,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,676.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,709.75,percent of total billed charges,,,85,,709.75,percent of total billed charges,,,49,,409.15,percent of total billed charges,,,90,,751.5,percent of total billed charges,,,,,,,no IP contract,,80,,668,percent of total billed charges,,,,,,,no IP contract,,50,,417.5,percent of total billed charges,,,,,,no IP contract,,,78,,651.3,percent of total billed charges,,,70,,584.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,409.15,3324,
Hemoglobin Electrophoresis,83020,CPT,,,,inpatient,,,341,204.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,276.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,289.85,percent of total billed charges,,,85,,289.85,percent of total billed charges,,,49,,167.09,percent of total billed charges,,,90,,306.9,percent of total billed charges,,,,,,,no IP contract,,80,,272.8,percent of total billed charges,,,,,,,no IP contract,,50,,170.5,percent of total billed charges,,,,,,no IP contract,,,78,,265.98,percent of total billed charges,,,70,,238.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,167.09,3324,
Hemoglobin A2 Quantitation,83021,CPT,,,,inpatient,,,234,140.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,189.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,198.9,percent of total billed charges,,,85,,198.9,percent of total billed charges,,,49,,114.66,percent of total billed charges,,,90,,210.6,percent of total billed charges,,,,,,,no IP contract,,80,,187.2,percent of total billed charges,,,,,,,no IP contract,,50,,117,percent of total billed charges,,,,,,no IP contract,,,78,,182.52,percent of total billed charges,,,70,,163.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,114.66,3324,
Hemoglobin Glycosated,83036,CPT,,,,inpatient,,,197,118.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,159.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,167.45,percent of total billed charges,,,85,,167.45,percent of total billed charges,,,49,,96.53,percent of total billed charges,,,90,,177.3,percent of total billed charges,,,,,,,no IP contract,,80,,157.6,percent of total billed charges,,,,,,,no IP contract,,50,,98.5,percent of total billed charges,,,,,,no IP contract,,,78,,153.66,percent of total billed charges,,,70,,137.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,96.53,3324,
"Hemoglobin, Urine",83069,CPT,,,,inpatient,,,32,19.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,25.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,27.2,percent of total billed charges,,,85,,27.2,percent of total billed charges,,,49,,15.68,percent of total billed charges,,,90,,28.8,percent of total billed charges,,,,,,,no IP contract,,80,,25.6,percent of total billed charges,,,,,,,no IP contract,,50,,16,percent of total billed charges,,,,,,no IP contract,,,78,,24.96,percent of total billed charges,,,70,,22.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.68,3324,
Homocysteine-Serum,83090,CPT,,,,inpatient,,,166,99.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,134.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,141.1,percent of total billed charges,,,85,,141.1,percent of total billed charges,,,49,,81.34,percent of total billed charges,,,90,,149.4,percent of total billed charges,,,,,,,no IP contract,,80,,132.8,percent of total billed charges,,,,,,,no IP contract,,50,,83,percent of total billed charges,,,,,,no IP contract,,,78,,129.48,percent of total billed charges,,,70,,116.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,81.34,3324,
"17 Hydroxycorticosteroids, Urine Timed",83491,CPT,,,,inpatient,,,232,139.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,187.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,197.2,percent of total billed charges,,,85,,197.2,percent of total billed charges,,,49,,113.68,percent of total billed charges,,,90,,208.8,percent of total billed charges,,,,,,,no IP contract,,80,,185.6,percent of total billed charges,,,,,,,no IP contract,,50,,116,percent of total billed charges,,,,,,no IP contract,,,78,,180.96,percent of total billed charges,,,70,,162.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,113.68,3324,
5-HIAA-24 Hr Urine,83497,CPT,,,,inpatient,,,125,75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,101.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,106.25,percent of total billed charges,,,85,,106.25,percent of total billed charges,,,49,,61.25,percent of total billed charges,,,90,,112.5,percent of total billed charges,,,,,,,no IP contract,,80,,100,percent of total billed charges,,,,,,,no IP contract,,50,,62.5,percent of total billed charges,,,,,,no IP contract,,,78,,97.5,percent of total billed charges,,,70,,87.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,61.25,3324,
"17 Hydroxyprogesterone, Serum",83498,CPT,,,,inpatient,,,218,130.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,176.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,185.3,percent of total billed charges,,,85,,185.3,percent of total billed charges,,,49,,106.82,percent of total billed charges,,,90,,196.2,percent of total billed charges,,,,,,,no IP contract,,80,,174.4,percent of total billed charges,,,,,,,no IP contract,,50,,109,percent of total billed charges,,,,,,no IP contract,,,78,,170.04,percent of total billed charges,,,70,,152.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,106.82,3324,
Anodal Trypsin Assay- HAT,83516,CPT,,,,inpatient,,,112,67.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,90.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,95.2,percent of total billed charges,,,85,,95.2,percent of total billed charges,,,49,,54.88,percent of total billed charges,,,90,,100.8,percent of total billed charges,,,,,,,no IP contract,,80,,89.6,percent of total billed charges,,,,,,,no IP contract,,50,,56,percent of total billed charges,,,,,,no IP contract,,,78,,87.36,percent of total billed charges,,,70,,78.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,42984.17,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,54.88,42984.17,
Immunoassay Nonantibody (Histone),83516,CPT,,,,inpatient,,,115,69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,93.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,97.75,percent of total billed charges,,,85,,97.75,percent of total billed charges,,,49,,56.35,percent of total billed charges,,,90,,103.5,percent of total billed charges,,,,,,,no IP contract,,80,,92,percent of total billed charges,,,,,,,no IP contract,,50,,57.5,percent of total billed charges,,,,,,no IP contract,,,78,,89.7,percent of total billed charges,,,70,,80.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,56.35,3324,
Antibodies *,83516,CPT,,,,inpatient,,,161,96.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,130.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,136.85,percent of total billed charges,,,85,,136.85,percent of total billed charges,,,49,,78.89,percent of total billed charges,,,90,,144.9,percent of total billed charges,,,,,,,no IP contract,,80,,128.8,percent of total billed charges,,,,,,,no IP contract,,50,,80.5,percent of total billed charges,,,,,,no IP contract,,,78,,125.58,percent of total billed charges,,,70,,112.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,78.89,3324,
Glutamic Decarboxylast Abs,83519,CPT,,,,inpatient,,,232,139.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,187.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,197.2,percent of total billed charges,,,85,,197.2,percent of total billed charges,,,49,,113.68,percent of total billed charges,,,90,,208.8,percent of total billed charges,,,,,,,no IP contract,,80,,185.6,percent of total billed charges,,,,,,,no IP contract,,50,,116,percent of total billed charges,,,,,,no IP contract,,,78,,180.96,percent of total billed charges,,,70,,162.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,113.68,3324,
PTH-Related Protein,83519,CPT,,,,inpatient,,,246,147.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,199.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,209.1,percent of total billed charges,,,85,,209.1,percent of total billed charges,,,49,,120.54,percent of total billed charges,,,90,,221.4,percent of total billed charges,,,,,,,no IP contract,,80,,196.8,percent of total billed charges,,,,,,,no IP contract,,50,,123,percent of total billed charges,,,,,,no IP contract,,,78,,191.88,percent of total billed charges,,,70,,172.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,120.54,3324,
"Immunoassay,other analytes",83519,CPT,,,,inpatient,,,296,177.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,239.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,251.6,percent of total billed charges,,,85,,251.6,percent of total billed charges,,,49,,145.04,percent of total billed charges,,,90,,266.4,percent of total billed charges,,,,,,,no IP contract,,80,,236.8,percent of total billed charges,,,,,,,no IP contract,,50,,148,percent of total billed charges,,,,,,no IP contract,,,78,,230.88,percent of total billed charges,,,70,,207.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,145.04,3324,
Procollagen Type 1-N Terminal Propeptide,83519,CPT,,,,inpatient,,,477,286.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,386.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,405.45,percent of total billed charges,,,85,,405.45,percent of total billed charges,,,49,,233.73,percent of total billed charges,,,90,,429.3,percent of total billed charges,,,,,,,no IP contract,,80,,381.6,percent of total billed charges,,,,,,,no IP contract,,50,,238.5,percent of total billed charges,,,,,,no IP contract,,,78,,372.06,percent of total billed charges,,,70,,333.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,233.73,3324,
MUSK Antibody,83519,CPT,,,,inpatient,,,1176,705.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,952.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,999.6,percent of total billed charges,,,85,,999.6,percent of total billed charges,,,49,,576.24,percent of total billed charges,,,90,,1058.4,percent of total billed charges,,,,,,,no IP contract,,80,,940.8,percent of total billed charges,,,,,,,no IP contract,,50,,588,percent of total billed charges,,,,,,no IP contract,,,78,,917.28,percent of total billed charges,,,70,,823.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,576.24,3324,
Immunoassay Quant NOS NONAB,83520,CPT,,,,inpatient,,,108,64.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,87.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,91.8,percent of total billed charges,,,85,,91.8,percent of total billed charges,,,49,,52.92,percent of total billed charges,,,90,,97.2,percent of total billed charges,,,,,,,no IP contract,,80,,86.4,percent of total billed charges,,,,,,,no IP contract,,50,,54,percent of total billed charges,,,,,,no IP contract,,,78,,84.24,percent of total billed charges,,,70,,75.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,52.92,3324,
Antibodies,83520,CPT,,,,inpatient,,,161,96.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,130.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,136.85,percent of total billed charges,,,85,,136.85,percent of total billed charges,,,49,,78.89,percent of total billed charges,,,90,,144.9,percent of total billed charges,,,,,,,no IP contract,,80,,128.8,percent of total billed charges,,,,,,,no IP contract,,50,,80.5,percent of total billed charges,,,,,,no IP contract,,,78,,125.58,percent of total billed charges,,,70,,112.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,78.89,3324,
"Gliadin AB's IgG, IgA",83520,CPT,,,,inpatient,,,192,115.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,155.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,163.2,percent of total billed charges,,,85,,163.2,percent of total billed charges,,,49,,94.08,percent of total billed charges,,,90,,172.8,percent of total billed charges,,,,,,,no IP contract,,80,,153.6,percent of total billed charges,,,,,,,no IP contract,,50,,96,percent of total billed charges,,,,,,no IP contract,,,78,,149.76,percent of total billed charges,,,70,,134.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,94.08,3324,
GM 1 Autoantibodies,83520,CPT,,,,inpatient,,,192,115.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,155.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,163.2,percent of total billed charges,,,85,,163.2,percent of total billed charges,,,49,,94.08,percent of total billed charges,,,90,,172.8,percent of total billed charges,,,,,,,no IP contract,,80,,153.6,percent of total billed charges,,,,,,,no IP contract,,50,,96,percent of total billed charges,,,,,,no IP contract,,,78,,149.76,percent of total billed charges,,,70,,134.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,94.08,3324,
GM 1 Autoantibodies,83520,CPT,,,,inpatient,,,192,115.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,155.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,163.2,percent of total billed charges,,,85,,163.2,percent of total billed charges,,,49,,94.08,percent of total billed charges,,,90,,172.8,percent of total billed charges,,,,,,,no IP contract,,80,,153.6,percent of total billed charges,,,,,,,no IP contract,,50,,96,percent of total billed charges,,,,,,no IP contract,,,78,,149.76,percent of total billed charges,,,70,,134.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,94.08,3324,
Human Anti-Mouse IgG Antibodies,83520,CPT,,,,inpatient,,,192,115.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,155.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,163.2,percent of total billed charges,,,85,,163.2,percent of total billed charges,,,49,,94.08,percent of total billed charges,,,90,,172.8,percent of total billed charges,,,,,,,no IP contract,,80,,153.6,percent of total billed charges,,,,,,,no IP contract,,50,,96,percent of total billed charges,,,,,,no IP contract,,,78,,149.76,percent of total billed charges,,,70,,134.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,94.08,3324,
Basement Membrane IgG Abs,83520,CPT,,,,inpatient,,,240,144,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,194.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,204,percent of total billed charges,,,85,,204,percent of total billed charges,,,49,,117.6,percent of total billed charges,,,90,,216,percent of total billed charges,,,,,,,no IP contract,,80,,192,percent of total billed charges,,,,,,,no IP contract,,50,,120,percent of total billed charges,,,,,,no IP contract,,,78,,187.2,percent of total billed charges,,,70,,168,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,39455.875,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,117.6,39455.88,
"Immunoassay, RIA, not elsewhere specified",83520,CPT,,,,inpatient,,,301,180.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,243.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,255.85,percent of total billed charges,,,85,,255.85,percent of total billed charges,,,49,,147.49,percent of total billed charges,,,90,,270.9,percent of total billed charges,,,,,,,no IP contract,,80,,240.8,percent of total billed charges,,,,,,,no IP contract,,50,,150.5,percent of total billed charges,,,,,,no IP contract,,,78,,234.78,percent of total billed charges,,,70,,210.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,147.49,3324,
Transglutaminase IgG and IgA Autoantibodies,83520,CPT,,,,inpatient,,,431,258.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,349.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,366.35,percent of total billed charges,,,85,,366.35,percent of total billed charges,,,49,,211.19,percent of total billed charges,,,90,,387.9,percent of total billed charges,,,,,,,no IP contract,,80,,344.8,percent of total billed charges,,,,,,,no IP contract,,50,,215.5,percent of total billed charges,,,,,,no IP contract,,,78,,336.18,percent of total billed charges,,,70,,301.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,211.19,3324,
Insulin Level,83525,CPT,,,,inpatient,,,188,112.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,152.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,159.8,percent of total billed charges,,,85,,159.8,percent of total billed charges,,,49,,92.12,percent of total billed charges,,,90,,169.2,percent of total billed charges,,,,,,,no IP contract,,80,,150.4,percent of total billed charges,,,,,,,no IP contract,,50,,94,percent of total billed charges,,,,,,no IP contract,,,78,,146.64,percent of total billed charges,,,70,,131.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,92.12,3324,
IRON LEVEL NMH,83540,CPT,,,,inpatient,,,113,67.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,91.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,96.05,percent of total billed charges,,,85,,96.05,percent of total billed charges,,,49,,55.37,percent of total billed charges,,,90,,101.7,percent of total billed charges,,,,,,,no IP contract,,80,,90.4,percent of total billed charges,,,,,,,no IP contract,,50,,56.5,percent of total billed charges,,,,,,no IP contract,,,78,,88.14,percent of total billed charges,,,70,,79.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,55.37,3324,
Iron and Iron Binding Capacity,83540,CPT,,,,inpatient,,,155,93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,125.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,131.75,percent of total billed charges,,,85,,131.75,percent of total billed charges,,,49,,75.95,percent of total billed charges,,,90,,139.5,percent of total billed charges,,,,,,,no IP contract,,80,,124,percent of total billed charges,,,,,,,no IP contract,,50,,77.5,percent of total billed charges,,,,,,no IP contract,,,78,,120.9,percent of total billed charges,,,70,,108.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,75.95,3324,
Iron Level,83540,CPT,,,,inpatient,,,155,93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,125.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,131.75,percent of total billed charges,,,85,,131.75,percent of total billed charges,,,49,,75.95,percent of total billed charges,,,90,,139.5,percent of total billed charges,,,,,,,no IP contract,,80,,124,percent of total billed charges,,,,,,,no IP contract,,50,,77.5,percent of total billed charges,,,,,,no IP contract,,,78,,120.9,percent of total billed charges,,,70,,108.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,75.95,3324,
Iron and Iron Binding Capacity with Transferrin,83540,CPT,,,,inpatient,,,159,95.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,128.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,135.15,percent of total billed charges,,,85,,135.15,percent of total billed charges,,,49,,77.91,percent of total billed charges,,,90,,143.1,percent of total billed charges,,,,,,,no IP contract,,80,,127.2,percent of total billed charges,,,,,,,no IP contract,,50,,79.5,percent of total billed charges,,,,,,no IP contract,,,78,,124.02,percent of total billed charges,,,70,,111.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,77.91,3324,
Iron,83540,CPT,,,,inpatient,,,167,100.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,135.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,141.95,percent of total billed charges,,,85,,141.95,percent of total billed charges,,,49,,81.83,percent of total billed charges,,,90,,150.3,percent of total billed charges,,,,,,,no IP contract,,80,,133.6,percent of total billed charges,,,,,,,no IP contract,,50,,83.5,percent of total billed charges,,,,,,no IP contract,,,78,,130.26,percent of total billed charges,,,70,,116.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,81.83,3324,
Iron Binding Capacity,83550,CPT,,,,inpatient,,,240,144,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,194.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,204,percent of total billed charges,,,85,,204,percent of total billed charges,,,49,,117.6,percent of total billed charges,,,90,,216,percent of total billed charges,,,,,,,no IP contract,,80,,192,percent of total billed charges,,,,,,,no IP contract,,50,,120,percent of total billed charges,,,,,,no IP contract,,,78,,187.2,percent of total billed charges,,,70,,168,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,117.6,3324,
"17 Ketosteroids, Urine Timed",83586,CPT,,,,inpatient,,,345,207,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,279.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,293.25,percent of total billed charges,,,85,,293.25,percent of total billed charges,,,49,,169.05,percent of total billed charges,,,90,,310.5,percent of total billed charges,,,,,,,no IP contract,,80,,276,percent of total billed charges,,,,,,,no IP contract,,50,,172.5,percent of total billed charges,,,,,,no IP contract,,,78,,269.1,percent of total billed charges,,,70,,241.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,169.05,3324,
"17-Ketosteroids with Creatinine, Urine Random",83586,CPT,,,,inpatient,,,345,207,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,279.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,293.25,percent of total billed charges,,,85,,293.25,percent of total billed charges,,,49,,169.05,percent of total billed charges,,,90,,310.5,percent of total billed charges,,,,,,,no IP contract,,80,,276,percent of total billed charges,,,,,,,no IP contract,,50,,172.5,percent of total billed charges,,,,,,no IP contract,,,78,,269.1,percent of total billed charges,,,70,,241.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,169.05,3324,
"Lactic Acid, Venous Specimen",83605,CPT,,,,inpatient,,,166,99.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,134.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,141.1,percent of total billed charges,,,85,,141.1,percent of total billed charges,,,49,,81.34,percent of total billed charges,,,90,,149.4,percent of total billed charges,,,,,,,no IP contract,,80,,132.8,percent of total billed charges,,,,,,,no IP contract,,50,,83,percent of total billed charges,,,,,,no IP contract,,,78,,129.48,percent of total billed charges,,,70,,116.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,81.34,3324,
LACTIC ACID (BG) NMH,83605,CPT,,,,inpatient,,,273,163.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,221.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,232.05,percent of total billed charges,,,85,,232.05,percent of total billed charges,,,49,,133.77,percent of total billed charges,,,90,,245.7,percent of total billed charges,,,,,,,no IP contract,,80,,218.4,percent of total billed charges,,,,,,,no IP contract,,50,,136.5,percent of total billed charges,,,,,,no IP contract,,,78,,212.94,percent of total billed charges,,,70,,191.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,133.77,3324,
LACTATE DEHYDROGENASE (LDH) NMH,83615,CPT,,,,inpatient,,,116,69.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,93.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,98.6,percent of total billed charges,,,85,,98.6,percent of total billed charges,,,49,,56.84,percent of total billed charges,,,90,,104.4,percent of total billed charges,,,,,,,no IP contract,,80,,92.8,percent of total billed charges,,,,,,,no IP contract,,50,,58,percent of total billed charges,,,,,,no IP contract,,,78,,90.48,percent of total billed charges,,,70,,81.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,56.84,3324,
Lactate Dehydrogenase Isoenzymes (contains LDH),83615,CPT,,,,inpatient,,,119,71.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,96.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,101.15,percent of total billed charges,,,85,,101.15,percent of total billed charges,,,49,,58.31,percent of total billed charges,,,90,,107.1,percent of total billed charges,,,,,,,no IP contract,,80,,95.2,percent of total billed charges,,,,,,,no IP contract,,50,,59.5,percent of total billed charges,,,,,,no IP contract,,,78,,92.82,percent of total billed charges,,,70,,83.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.31,3324,
"Lactate Dehydrogenase, Fluid",83615,CPT,,,,inpatient,,,119,71.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,96.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,101.15,percent of total billed charges,,,85,,101.15,percent of total billed charges,,,49,,58.31,percent of total billed charges,,,90,,107.1,percent of total billed charges,,,,,,,no IP contract,,80,,95.2,percent of total billed charges,,,,,,,no IP contract,,50,,59.5,percent of total billed charges,,,,,,no IP contract,,,78,,92.82,percent of total billed charges,,,70,,83.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.31,3324,
Lactate Dehydrogenase/LDH,83615,CPT,,,,inpatient,,,142,85.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,115.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,120.7,percent of total billed charges,,,85,,120.7,percent of total billed charges,,,49,,69.58,percent of total billed charges,,,90,,127.8,percent of total billed charges,,,,,,,no IP contract,,80,,113.6,percent of total billed charges,,,,,,,no IP contract,,50,,71,percent of total billed charges,,,,,,no IP contract,,,78,,110.76,percent of total billed charges,,,70,,99.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,69.58,3324,
LDH Isoenzymes,83625,CPT,,,,inpatient,,,119,71.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,96.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,101.15,percent of total billed charges,,,85,,101.15,percent of total billed charges,,,49,,58.31,percent of total billed charges,,,90,,107.1,percent of total billed charges,,,,,,,no IP contract,,80,,95.2,percent of total billed charges,,,,,,,no IP contract,,50,,59.5,percent of total billed charges,,,,,,no IP contract,,,78,,92.82,percent of total billed charges,,,70,,83.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.31,3324,
Lead Level,83655,CPT,,,,inpatient,,,176,105.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,142.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,149.6,percent of total billed charges,,,85,,149.6,percent of total billed charges,,,49,,86.24,percent of total billed charges,,,90,,158.4,percent of total billed charges,,,,,,,no IP contract,,80,,140.8,percent of total billed charges,,,,,,,no IP contract,,50,,88,percent of total billed charges,,,,,,no IP contract,,,78,,137.28,percent of total billed charges,,,70,,123.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,86.24,3324,
Lipase,83690,CPT,,,,inpatient,,,262,157.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,212.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,222.7,percent of total billed charges,,,85,,222.7,percent of total billed charges,,,49,,128.38,percent of total billed charges,,,90,,235.8,percent of total billed charges,,,,,,,no IP contract,,80,,209.6,percent of total billed charges,,,,,,,no IP contract,,50,,131,percent of total billed charges,,,,,,no IP contract,,,78,,204.36,percent of total billed charges,,,70,,183.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,128.38,3324,
"Lipase, Fluid",83690,CPT,,,,inpatient,,,262,157.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,212.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,222.7,percent of total billed charges,,,85,,222.7,percent of total billed charges,,,49,,128.38,percent of total billed charges,,,90,,235.8,percent of total billed charges,,,,,,,no IP contract,,80,,209.6,percent of total billed charges,,,,,,,no IP contract,,50,,131,percent of total billed charges,,,,,,no IP contract,,,78,,204.36,percent of total billed charges,,,70,,183.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,128.38,3324,
Lipoprotein (a),83695,CPT,,,,inpatient,,,157,94.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,127.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,133.45,percent of total billed charges,,,85,,133.45,percent of total billed charges,,,49,,76.93,percent of total billed charges,,,90,,141.3,percent of total billed charges,,,,,,,no IP contract,,80,,125.6,percent of total billed charges,,,,,,,no IP contract,,50,,78.5,percent of total billed charges,,,,,,no IP contract,,,78,,122.46,percent of total billed charges,,,70,,109.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,76.93,3324,
"Lipoprotein, blood",83700,CPT,,,,inpatient,,,118,70.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,95.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,100.3,percent of total billed charges,,,85,,100.3,percent of total billed charges,,,49,,57.82,percent of total billed charges,,,90,,106.2,percent of total billed charges,,,,,,,no IP contract,,80,,94.4,percent of total billed charges,,,,,,,no IP contract,,50,,59,percent of total billed charges,,,,,,no IP contract,,,78,,92.04,percent of total billed charges,,,70,,82.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,57.82,3324,
Lipoprotein Electrophoresis,83700,CPT,,,,inpatient,,,297,178.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,240.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,252.45,percent of total billed charges,,,85,,252.45,percent of total billed charges,,,49,,145.53,percent of total billed charges,,,90,,267.3,percent of total billed charges,,,,,,,no IP contract,,80,,237.6,percent of total billed charges,,,,,,,no IP contract,,50,,148.5,percent of total billed charges,,,,,,no IP contract,,,78,,231.66,percent of total billed charges,,,70,,207.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,145.53,3324,
High Density Lipoprotein,83718,CPT,,,,inpatient,,,152,91.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,123.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,129.2,percent of total billed charges,,,85,,129.2,percent of total billed charges,,,49,,74.48,percent of total billed charges,,,90,,136.8,percent of total billed charges,,,,,,,no IP contract,,80,,121.6,percent of total billed charges,,,,,,,no IP contract,,50,,76,percent of total billed charges,,,,,,no IP contract,,,78,,118.56,percent of total billed charges,,,70,,106.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,74.48,3324,
"Magnesium, Random Urine",83735,CPT,,,,inpatient,,,82,49.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,66.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,69.7,percent of total billed charges,,,85,,69.7,percent of total billed charges,,,49,,40.18,percent of total billed charges,,,90,,73.8,percent of total billed charges,,,,,,,no IP contract,,80,,65.6,percent of total billed charges,,,,,,,no IP contract,,50,,41,percent of total billed charges,,,,,,no IP contract,,,78,,63.96,percent of total billed charges,,,70,,57.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,40.18,3324,
"Magnesium, Timed Urine",83735,CPT,,,,inpatient,,,82,49.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,66.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,69.7,percent of total billed charges,,,85,,69.7,percent of total billed charges,,,49,,40.18,percent of total billed charges,,,90,,73.8,percent of total billed charges,,,,,,,no IP contract,,80,,65.6,percent of total billed charges,,,,,,,no IP contract,,50,,41,percent of total billed charges,,,,,,no IP contract,,,78,,63.96,percent of total billed charges,,,70,,57.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,40.18,3324,
MAGNESIUM LEVEL NMH,83735,CPT,,,,inpatient,,,116,69.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,93.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,98.6,percent of total billed charges,,,85,,98.6,percent of total billed charges,,,49,,56.84,percent of total billed charges,,,90,,104.4,percent of total billed charges,,,,,,,no IP contract,,80,,92.8,percent of total billed charges,,,,,,,no IP contract,,50,,58,percent of total billed charges,,,,,,no IP contract,,,78,,90.48,percent of total billed charges,,,70,,81.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,56.84,3324,
Magnesium Level,83735,CPT,,,,inpatient,,,141,84.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,114.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,119.85,percent of total billed charges,,,85,,119.85,percent of total billed charges,,,49,,69.09,percent of total billed charges,,,90,,126.9,percent of total billed charges,,,,,,,no IP contract,,80,,112.8,percent of total billed charges,,,,,,,no IP contract,,50,,70.5,percent of total billed charges,,,,,,no IP contract,,,78,,109.98,percent of total billed charges,,,70,,98.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,69.09,3324,
"Manganese, RBC",83785,CPT,,,,inpatient,,,246,147.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,199.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,209.1,percent of total billed charges,,,85,,209.1,percent of total billed charges,,,49,,120.54,percent of total billed charges,,,90,,221.4,percent of total billed charges,,,,,,,no IP contract,,80,,196.8,percent of total billed charges,,,,,,,no IP contract,,50,,123,percent of total billed charges,,,,,,no IP contract,,,78,,191.88,percent of total billed charges,,,70,,172.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,120.54,3324,
Amiodarone & Metabolites (Desethylamiodarone),83789,CPT,,,,inpatient,,,164,98.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,132.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,139.4,percent of total billed charges,,,85,,139.4,percent of total billed charges,,,49,,80.36,percent of total billed charges,,,90,,147.6,percent of total billed charges,,,,,,,no IP contract,,80,,131.2,percent of total billed charges,,,,,,,no IP contract,,50,,82,percent of total billed charges,,,,,,no IP contract,,,78,,127.92,percent of total billed charges,,,70,,114.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,80.36,3324,
"Mercury Level, Serum",83825,CPT,,,,inpatient,,,235,141,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,190.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,199.75,percent of total billed charges,,,85,,199.75,percent of total billed charges,,,49,,115.15,percent of total billed charges,,,90,,211.5,percent of total billed charges,,,,,,,no IP contract,,80,,188,percent of total billed charges,,,,,,,no IP contract,,50,,117.5,percent of total billed charges,,,,,,no IP contract,,,78,,183.3,percent of total billed charges,,,70,,164.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,115.15,3324,
Metanephrines,83835,CPT,,,,inpatient,,,131,78.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,106.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,111.35,percent of total billed charges,,,85,,111.35,percent of total billed charges,,,49,,64.19,percent of total billed charges,,,90,,117.9,percent of total billed charges,,,,,,,no IP contract,,80,,104.8,percent of total billed charges,,,,,,,no IP contract,,50,,65.5,percent of total billed charges,,,,,,no IP contract,,,78,,102.18,percent of total billed charges,,,70,,91.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,64.19,3324,
"Metanephrines, Plasma Free",83835,CPT,,,,inpatient,,,294,176.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,238.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,249.9,percent of total billed charges,,,85,,249.9,percent of total billed charges,,,49,,144.06,percent of total billed charges,,,90,,264.6,percent of total billed charges,,,,,,,no IP contract,,80,,235.2,percent of total billed charges,,,,,,,no IP contract,,50,,147,percent of total billed charges,,,,,,no IP contract,,,78,,229.32,percent of total billed charges,,,70,,205.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,144.06,3324,
"Myelin Basic Protein, CSF",83873,CPT,,,,inpatient,,,127,76.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,102.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,107.95,percent of total billed charges,,,85,,107.95,percent of total billed charges,,,49,,62.23,percent of total billed charges,,,90,,114.3,percent of total billed charges,,,,,,,no IP contract,,80,,101.6,percent of total billed charges,,,,,,,no IP contract,,50,,63.5,percent of total billed charges,,,,,,no IP contract,,,78,,99.06,percent of total billed charges,,,70,,88.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,62.23,3324,
Myoglobin Serum,83874,CPT,,,,inpatient,,,226,135.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,183.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,192.1,percent of total billed charges,,,85,,192.1,percent of total billed charges,,,49,,110.74,percent of total billed charges,,,90,,203.4,percent of total billed charges,,,,,,,no IP contract,,80,,180.8,percent of total billed charges,,,,,,,no IP contract,,50,,113,percent of total billed charges,,,,,,no IP contract,,,78,,176.28,percent of total billed charges,,,70,,158.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,110.74,3324,
"Myoglobin, Urine Random",83874,CPT,,,,inpatient,,,226,135.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,183.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,192.1,percent of total billed charges,,,85,,192.1,percent of total billed charges,,,49,,110.74,percent of total billed charges,,,90,,203.4,percent of total billed charges,,,,,,,no IP contract,,80,,180.8,percent of total billed charges,,,,,,,no IP contract,,50,,113,percent of total billed charges,,,,,,no IP contract,,,78,,176.28,percent of total billed charges,,,70,,158.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,110.74,3324,
B-Natiuretic Peptide,83880,CPT,,,,inpatient,,,475,285,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,384.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,403.75,percent of total billed charges,,,85,,403.75,percent of total billed charges,,,49,,232.75,percent of total billed charges,,,90,,427.5,percent of total billed charges,,,,,,,no IP contract,,80,,380,percent of total billed charges,,,,,,,no IP contract,,50,,237.5,percent of total billed charges,,,,,,no IP contract,,,78,,370.5,percent of total billed charges,,,70,,332.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,26223.57,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,232.75,26223.57,
Free Light Chains,83883,CPT,,,,inpatient,,,146,87.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,118.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,124.1,percent of total billed charges,,,85,,124.1,percent of total billed charges,,,49,,71.54,percent of total billed charges,,,90,,131.4,percent of total billed charges,,,,,,,no IP contract,,80,,116.8,percent of total billed charges,,,,,,,no IP contract,,50,,73,percent of total billed charges,,,,,,no IP contract,,,78,,113.88,percent of total billed charges,,,70,,102.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,71.54,3324,
"Heavy and Light Chain, IgA",83883,CPT,,,,inpatient,,,146,87.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,118.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,124.1,percent of total billed charges,,,85,,124.1,percent of total billed charges,,,49,,71.54,percent of total billed charges,,,90,,131.4,percent of total billed charges,,,,,,,no IP contract,,80,,116.8,percent of total billed charges,,,,,,,no IP contract,,50,,73,percent of total billed charges,,,,,,no IP contract,,,78,,113.88,percent of total billed charges,,,70,,102.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,71.54,3324,
"Heavy and Light Chain, IgA",83883,CPT,,,,inpatient,,,146,87.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,118.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,124.1,percent of total billed charges,,,85,,124.1,percent of total billed charges,,,49,,71.54,percent of total billed charges,,,90,,131.4,percent of total billed charges,,,,,,,no IP contract,,80,,116.8,percent of total billed charges,,,,,,,no IP contract,,50,,73,percent of total billed charges,,,,,,no IP contract,,,78,,113.88,percent of total billed charges,,,70,,102.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,71.54,3324,
"Heavy and Light Chain, IgG",83883,CPT,,,,inpatient,,,146,87.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,118.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,124.1,percent of total billed charges,,,85,,124.1,percent of total billed charges,,,49,,71.54,percent of total billed charges,,,90,,131.4,percent of total billed charges,,,,,,,no IP contract,,80,,116.8,percent of total billed charges,,,,,,,no IP contract,,50,,73,percent of total billed charges,,,,,,no IP contract,,,78,,113.88,percent of total billed charges,,,70,,102.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,71.54,3324,
"Heavy and Light Chain, IgG",83883,CPT,,,,inpatient,,,146,87.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,118.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,124.1,percent of total billed charges,,,85,,124.1,percent of total billed charges,,,49,,71.54,percent of total billed charges,,,90,,131.4,percent of total billed charges,,,,,,,no IP contract,,80,,116.8,percent of total billed charges,,,,,,,no IP contract,,50,,73,percent of total billed charges,,,,,,no IP contract,,,78,,113.88,percent of total billed charges,,,70,,102.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,71.54,3324,
"Heavy and Light Chain, IgM",83883,CPT,,,,inpatient,,,146,87.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,118.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,124.1,percent of total billed charges,,,85,,124.1,percent of total billed charges,,,49,,71.54,percent of total billed charges,,,90,,131.4,percent of total billed charges,,,,,,,no IP contract,,80,,116.8,percent of total billed charges,,,,,,,no IP contract,,50,,73,percent of total billed charges,,,,,,no IP contract,,,78,,113.88,percent of total billed charges,,,70,,102.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,71.54,3324,
Nephelometry,83883,CPT,,,,inpatient,,,146,87.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,118.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,124.1,percent of total billed charges,,,85,,124.1,percent of total billed charges,,,49,,71.54,percent of total billed charges,,,90,,131.4,percent of total billed charges,,,,,,,no IP contract,,80,,116.8,percent of total billed charges,,,,,,,no IP contract,,50,,73,percent of total billed charges,,,,,,no IP contract,,,78,,113.88,percent of total billed charges,,,70,,102.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,71.54,3324,
Retinol Binding Protein,83883,CPT,,,,inpatient,,,146,87.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,118.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,124.1,percent of total billed charges,,,85,,124.1,percent of total billed charges,,,49,,71.54,percent of total billed charges,,,90,,131.4,percent of total billed charges,,,,,,,no IP contract,,80,,116.8,percent of total billed charges,,,,,,,no IP contract,,50,,73,percent of total billed charges,,,,,,no IP contract,,,78,,113.88,percent of total billed charges,,,70,,102.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,71.54,3324,
"5' Nucleotidase, Serum",83915,CPT,,,,inpatient,,,172,103.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,139.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,146.2,percent of total billed charges,,,85,,146.2,percent of total billed charges,,,49,,84.28,percent of total billed charges,,,90,,154.8,percent of total billed charges,,,,,,,no IP contract,,80,,137.6,percent of total billed charges,,,,,,,no IP contract,,50,,86,percent of total billed charges,,,,,,no IP contract,,,78,,134.16,percent of total billed charges,,,70,,120.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,84.28,3324,
Oligoclonal Bands,83916,CPT,,,,inpatient,,,259,155.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,209.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,220.15,percent of total billed charges,,,85,,220.15,percent of total billed charges,,,49,,126.91,percent of total billed charges,,,90,,233.1,percent of total billed charges,,,,,,,no IP contract,,80,,207.2,percent of total billed charges,,,,,,,no IP contract,,50,,129.5,percent of total billed charges,,,,,,no IP contract,,,78,,202.02,percent of total billed charges,,,70,,181.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,126.91,3324,
Methylmalonic Acid,83918,CPT,,,,inpatient,,,426,255.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,345.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,362.1,percent of total billed charges,,,85,,362.1,percent of total billed charges,,,49,,208.74,percent of total billed charges,,,90,,383.4,percent of total billed charges,,,,,,,no IP contract,,80,,340.8,percent of total billed charges,,,,,,,no IP contract,,50,,213,percent of total billed charges,,,,,,no IP contract,,,78,,332.28,percent of total billed charges,,,70,,298.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,208.74,3324,
"Organic Acids Total, Quant NMH",83918,CPT,,,,inpatient,,,2086,1251.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1689.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1773.1,percent of total billed charges,,,85,,1773.1,percent of total billed charges,,,49,,1022.14,percent of total billed charges,,,90,,1877.4,percent of total billed charges,,,,,,,no IP contract,,80,,1668.8,percent of total billed charges,,,,,,,no IP contract,,50,,1043,percent of total billed charges,,,,,,no IP contract,,,78,,1627.08,percent of total billed charges,,,70,,1460.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
Osmolality,83930,CPT,,,,inpatient,,,147,88.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,119.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,124.95,percent of total billed charges,,,85,,124.95,percent of total billed charges,,,49,,72.03,percent of total billed charges,,,90,,132.3,percent of total billed charges,,,,,,,no IP contract,,80,,117.6,percent of total billed charges,,,,,,,no IP contract,,50,,73.5,percent of total billed charges,,,,,,no IP contract,,,78,,114.66,percent of total billed charges,,,70,,102.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,72.03,3324,
"Osmolality, Urine Random",83935,CPT,,,,inpatient,,,138,82.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,111.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,117.3,percent of total billed charges,,,85,,117.3,percent of total billed charges,,,49,,67.62,percent of total billed charges,,,90,,124.2,percent of total billed charges,,,,,,,no IP contract,,80,,110.4,percent of total billed charges,,,,,,,no IP contract,,50,,69,percent of total billed charges,,,,,,no IP contract,,,78,,107.64,percent of total billed charges,,,70,,96.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,67.62,3324,
Urine Osmolality,83935,CPT,,,,inpatient,,,138,82.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,111.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,117.3,percent of total billed charges,,,85,,117.3,percent of total billed charges,,,49,,67.62,percent of total billed charges,,,90,,124.2,percent of total billed charges,,,,,,,no IP contract,,80,,110.4,percent of total billed charges,,,,,,,no IP contract,,50,,69,percent of total billed charges,,,,,,no IP contract,,,78,,107.64,percent of total billed charges,,,70,,96.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,67.62,3324,
"Osmolality, Urine Timed",83935,CPT,,,,inpatient,,,182,109.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,147.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,154.7,percent of total billed charges,,,85,,154.7,percent of total billed charges,,,49,,89.18,percent of total billed charges,,,90,,163.8,percent of total billed charges,,,,,,,no IP contract,,80,,145.6,percent of total billed charges,,,,,,,no IP contract,,50,,91,percent of total billed charges,,,,,,no IP contract,,,78,,141.96,percent of total billed charges,,,70,,127.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,89.18,3324,
Osteocalcin NMH,83937,CPT,,,,inpatient,,,189,113.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,153.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,160.65,percent of total billed charges,,,85,,160.65,percent of total billed charges,,,49,,92.61,percent of total billed charges,,,90,,170.1,percent of total billed charges,,,,,,,no IP contract,,80,,151.2,percent of total billed charges,,,,,,,no IP contract,,50,,94.5,percent of total billed charges,,,,,,no IP contract,,,78,,147.42,percent of total billed charges,,,70,,132.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,92.61,3324,
Osteocalcin,83937,CPT,,,,inpatient,,,281,168.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,227.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,238.85,percent of total billed charges,,,85,,238.85,percent of total billed charges,,,49,,137.69,percent of total billed charges,,,90,,252.9,percent of total billed charges,,,,,,,no IP contract,,80,,224.8,percent of total billed charges,,,,,,,no IP contract,,50,,140.5,percent of total billed charges,,,,,,no IP contract,,,78,,219.18,percent of total billed charges,,,70,,196.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,137.69,3324,
Osteocalcin,83937,CPT,,,,inpatient,,,281,168.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,227.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,238.85,percent of total billed charges,,,85,,238.85,percent of total billed charges,,,49,,137.69,percent of total billed charges,,,90,,252.9,percent of total billed charges,,,,,,,no IP contract,,80,,224.8,percent of total billed charges,,,,,,,no IP contract,,50,,140.5,percent of total billed charges,,,,,,no IP contract,,,78,,219.18,percent of total billed charges,,,70,,196.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,137.69,3324,
"Oxalate, Urine timed",83945,CPT,,,,inpatient,,,166,99.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,134.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,141.1,percent of total billed charges,,,85,,141.1,percent of total billed charges,,,49,,81.34,percent of total billed charges,,,90,,149.4,percent of total billed charges,,,,,,,no IP contract,,80,,132.8,percent of total billed charges,,,,,,,no IP contract,,50,,83,percent of total billed charges,,,,,,no IP contract,,,78,,129.48,percent of total billed charges,,,70,,116.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,81.34,3324,
Parathyroid Hormone NMH,83970,CPT,,,,inpatient,,,445,267,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,360.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,378.25,percent of total billed charges,,,85,,378.25,percent of total billed charges,,,49,,218.05,percent of total billed charges,,,90,,400.5,percent of total billed charges,,,,,,,no IP contract,,80,,356,percent of total billed charges,,,,,,,no IP contract,,50,,222.5,percent of total billed charges,,,,,,no IP contract,,,78,,347.1,percent of total billed charges,,,70,,311.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,218.05,3324,
Intact Parathyroid Hormone,83970,CPT,,,,inpatient,,,490,294,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,396.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,416.5,percent of total billed charges,,,85,,416.5,percent of total billed charges,,,49,,240.1,percent of total billed charges,,,90,,441,percent of total billed charges,,,,,,,no IP contract,,80,,392,percent of total billed charges,,,,,,,no IP contract,,50,,245,percent of total billed charges,,,,,,no IP contract,,,78,,382.2,percent of total billed charges,,,70,,343,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,240.1,3324,
PTH Intact,83970,CPT,,,,inpatient,,,490,294,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,396.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,416.5,percent of total billed charges,,,85,,416.5,percent of total billed charges,,,49,,240.1,percent of total billed charges,,,90,,441,percent of total billed charges,,,,,,,no IP contract,,80,,392,percent of total billed charges,,,,,,,no IP contract,,50,,245,percent of total billed charges,,,,,,no IP contract,,,78,,382.2,percent of total billed charges,,,70,,343,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,240.1,3324,
"Parathyroid Hormone , C-Terminal",83970,CPT,,,,inpatient,,,686,411.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,555.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,583.1,percent of total billed charges,,,85,,583.1,percent of total billed charges,,,49,,336.14,percent of total billed charges,,,90,,617.4,percent of total billed charges,,,,,,,no IP contract,,80,,548.8,percent of total billed charges,,,,,,,no IP contract,,50,,343,percent of total billed charges,,,,,,no IP contract,,,78,,535.08,percent of total billed charges,,,70,,480.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,336.14,3324,
"Parathyroid Hormone , C-Terminal",83970,CPT,,,,inpatient,,,686,411.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,555.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,583.1,percent of total billed charges,,,85,,583.1,percent of total billed charges,,,49,,336.14,percent of total billed charges,,,90,,617.4,percent of total billed charges,,,,,,,no IP contract,,80,,548.8,percent of total billed charges,,,,,,,no IP contract,,50,,343,percent of total billed charges,,,,,,no IP contract,,,78,,535.08,percent of total billed charges,,,70,,480.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,336.14,3324,
ASSAY PH BODY FLUID NOS,83986,CPT,,,,inpatient,,,50,30,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,40.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,42.5,percent of total billed charges,,,85,,42.5,percent of total billed charges,,,49,,24.5,percent of total billed charges,,,90,,45,percent of total billed charges,,,,,,,no IP contract,,80,,40,percent of total billed charges,,,,,,,no IP contract,,50,,25,percent of total billed charges,,,,,,no IP contract,,,78,,39,percent of total billed charges,,,70,,35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,45959.4319,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.5,45959.43,
Body Fluid pH,83986,CPT,,,,inpatient,,,109,65.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,88.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,92.65,percent of total billed charges,,,85,,92.65,percent of total billed charges,,,49,,53.41,percent of total billed charges,,,90,,98.1,percent of total billed charges,,,,,,,no IP contract,,80,,87.2,percent of total billed charges,,,,,,,no IP contract,,50,,54.5,percent of total billed charges,,,,,,no IP contract,,,78,,85.02,percent of total billed charges,,,70,,76.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,53.41,3324,
"pH, Urine Timed",83986,CPT,,,,inpatient,,,109,65.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,88.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,92.65,percent of total billed charges,,,85,,92.65,percent of total billed charges,,,49,,53.41,percent of total billed charges,,,90,,98.1,percent of total billed charges,,,,,,,no IP contract,,80,,87.2,percent of total billed charges,,,,,,,no IP contract,,50,,54.5,percent of total billed charges,,,,,,no IP contract,,,78,,85.02,percent of total billed charges,,,70,,76.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,53.41,3324,
"pH, Timed Urine",83986,CPT,,,,inpatient,,,131,78.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,106.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,111.35,percent of total billed charges,,,85,,111.35,percent of total billed charges,,,49,,64.19,percent of total billed charges,,,90,,117.9,percent of total billed charges,,,,,,,no IP contract,,80,,104.8,percent of total billed charges,,,,,,,no IP contract,,50,,65.5,percent of total billed charges,,,,,,no IP contract,,,78,,102.18,percent of total billed charges,,,70,,91.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,64.19,3324,
Gastric Fluid pH,83986,CPT,,,,inpatient,,,161,96.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,130.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,136.85,percent of total billed charges,,,85,,136.85,percent of total billed charges,,,49,,78.89,percent of total billed charges,,,90,,144.9,percent of total billed charges,,,,,,,no IP contract,,80,,128.8,percent of total billed charges,,,,,,,no IP contract,,50,,80.5,percent of total billed charges,,,,,,no IP contract,,,78,,125.58,percent of total billed charges,,,70,,112.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,78.89,3324,
Acid Phosphatase,84066,CPT,,,,inpatient,,,82,49.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,66.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,69.7,percent of total billed charges,,,85,,69.7,percent of total billed charges,,,49,,40.18,percent of total billed charges,,,90,,73.8,percent of total billed charges,,,,,,,no IP contract,,80,,65.6,percent of total billed charges,,,,,,,no IP contract,,50,,41,percent of total billed charges,,,,,,no IP contract,,,78,,63.96,percent of total billed charges,,,70,,57.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,40.18,3324,
"Acid Phosphatase, Prostatic fraction",84066,CPT,,,,inpatient,,,82,49.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,66.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,69.7,percent of total billed charges,,,85,,69.7,percent of total billed charges,,,49,,40.18,percent of total billed charges,,,90,,73.8,percent of total billed charges,,,,,,,no IP contract,,80,,65.6,percent of total billed charges,,,,,,,no IP contract,,50,,41,percent of total billed charges,,,,,,no IP contract,,,78,,63.96,percent of total billed charges,,,70,,57.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,40.18,3324,
Alkaline Phospha NMH,84075,CPT,,,,inpatient,,,65,39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,52.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,55.25,percent of total billed charges,,,85,,55.25,percent of total billed charges,,,49,,31.85,percent of total billed charges,,,90,,58.5,percent of total billed charges,,,,,,,no IP contract,,80,,52,percent of total billed charges,,,,,,,no IP contract,,50,,32.5,percent of total billed charges,,,,,,no IP contract,,,78,,50.7,percent of total billed charges,,,70,,45.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.85,3324,
Alkaline Phosphatase,84075,CPT,,,,inpatient,,,88,52.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,71.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,74.8,percent of total billed charges,,,85,,74.8,percent of total billed charges,,,49,,43.12,percent of total billed charges,,,90,,79.2,percent of total billed charges,,,,,,,no IP contract,,80,,70.4,percent of total billed charges,,,,,,,no IP contract,,50,,44,percent of total billed charges,,,,,,no IP contract,,,78,,68.64,percent of total billed charges,,,70,,61.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,43.12,3324,
Alkaline Phosphatase-Bone Specific,84078,CPT,,,,inpatient,,,110,66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,89.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,93.5,percent of total billed charges,,,85,,93.5,percent of total billed charges,,,49,,53.9,percent of total billed charges,,,90,,99,percent of total billed charges,,,,,,,no IP contract,,80,,88,percent of total billed charges,,,,,,,no IP contract,,50,,55,percent of total billed charges,,,,,,no IP contract,,,78,,85.8,percent of total billed charges,,,70,,77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,53.9,3324,
Alkaline Phosphatase-Iso,84080,CPT,,,,inpatient,,,212,127.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,171.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,180.2,percent of total billed charges,,,85,,180.2,percent of total billed charges,,,49,,103.88,percent of total billed charges,,,90,,190.8,percent of total billed charges,,,,,,,no IP contract,,80,,169.6,percent of total billed charges,,,,,,,no IP contract,,50,,106,percent of total billed charges,,,,,,no IP contract,,,78,,165.36,percent of total billed charges,,,70,,148.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,103.88,3324,
Alkaline Phosphatase-Isoenzymes,84080,CPT,,,,inpatient,,,212,127.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,171.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,180.2,percent of total billed charges,,,85,,180.2,percent of total billed charges,,,49,,103.88,percent of total billed charges,,,90,,190.8,percent of total billed charges,,,,,,,no IP contract,,80,,169.6,percent of total billed charges,,,,,,,no IP contract,,50,,106,percent of total billed charges,,,,,,no IP contract,,,78,,165.36,percent of total billed charges,,,70,,148.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,103.88,3324,
Phosphorous Level,84100,CPT,,,,inpatient,,,108,64.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,87.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,91.8,percent of total billed charges,,,85,,91.8,percent of total billed charges,,,49,,52.92,percent of total billed charges,,,90,,97.2,percent of total billed charges,,,,,,,no IP contract,,80,,86.4,percent of total billed charges,,,,,,,no IP contract,,50,,54,percent of total billed charges,,,,,,no IP contract,,,78,,84.24,percent of total billed charges,,,70,,75.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,52.92,3324,
"Phosphorus, Random Urine",84105,CPT,,,,inpatient,,,59,35.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,47.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,50.15,percent of total billed charges,,,85,,50.15,percent of total billed charges,,,49,,28.91,percent of total billed charges,,,90,,53.1,percent of total billed charges,,,,,,,no IP contract,,80,,47.2,percent of total billed charges,,,,,,,no IP contract,,50,,29.5,percent of total billed charges,,,,,,no IP contract,,,78,,46.02,percent of total billed charges,,,70,,41.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,28.91,3324,
"Phosphorous, Urine timed",84105,CPT,,,,inpatient,,,128,76.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,103.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,108.8,percent of total billed charges,,,85,,108.8,percent of total billed charges,,,49,,62.72,percent of total billed charges,,,90,,115.2,percent of total billed charges,,,,,,,no IP contract,,80,,102.4,percent of total billed charges,,,,,,,no IP contract,,50,,64,percent of total billed charges,,,,,,no IP contract,,,78,,99.84,percent of total billed charges,,,70,,89.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,62.72,3324,
"Porphobilinogen, Random Urine Quant.",84110,CPT,,,,inpatient,,,176,105.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,142.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,149.6,percent of total billed charges,,,85,,149.6,percent of total billed charges,,,49,,86.24,percent of total billed charges,,,90,,158.4,percent of total billed charges,,,,,,,no IP contract,,80,,140.8,percent of total billed charges,,,,,,,no IP contract,,50,,88,percent of total billed charges,,,,,,no IP contract,,,78,,137.28,percent of total billed charges,,,70,,123.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,86.24,3324,
"Porphyrins, Fractionated, Urine, Random",84120,CPT,,,,inpatient,,,223,133.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,180.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,189.55,percent of total billed charges,,,85,,189.55,percent of total billed charges,,,49,,109.27,percent of total billed charges,,,90,,200.7,percent of total billed charges,,,,,,,no IP contract,,80,,178.4,percent of total billed charges,,,,,,,no IP contract,,50,,111.5,percent of total billed charges,,,,,,no IP contract,,,78,,173.94,percent of total billed charges,,,70,,156.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,109.27,3324,
"Porphyrins-Fractionated, Urine timed",84120,CPT,,,,inpatient,,,223,133.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,180.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,189.55,percent of total billed charges,,,85,,189.55,percent of total billed charges,,,49,,109.27,percent of total billed charges,,,90,,200.7,percent of total billed charges,,,,,,,no IP contract,,80,,178.4,percent of total billed charges,,,,,,,no IP contract,,50,,111.5,percent of total billed charges,,,,,,no IP contract,,,78,,173.94,percent of total billed charges,,,70,,156.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,109.27,3324,
Potassium/Sodium,84132,CPT,,,,inpatient,,,78,46.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,63.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,66.3,percent of total billed charges,,,85,,66.3,percent of total billed charges,,,49,,38.22,percent of total billed charges,,,90,,70.2,percent of total billed charges,,,,,,,no IP contract,,80,,62.4,percent of total billed charges,,,,,,,no IP contract,,50,,39,percent of total billed charges,,,,,,no IP contract,,,78,,60.84,percent of total billed charges,,,70,,54.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,38.22,3324,
Potassium/K+ Level,84132,CPT,,,,inpatient,,,96,57.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,77.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,81.6,percent of total billed charges,,,85,,81.6,percent of total billed charges,,,49,,47.04,percent of total billed charges,,,90,,86.4,percent of total billed charges,,,,,,,no IP contract,,80,,76.8,percent of total billed charges,,,,,,,no IP contract,,50,,48,percent of total billed charges,,,,,,no IP contract,,,78,,74.88,percent of total billed charges,,,70,,67.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,47.04,3324,
"Potassium, Urine Timed",84133,CPT,,,,inpatient,,,45,27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,38.25,percent of total billed charges,,,85,,38.25,percent of total billed charges,,,49,,22.05,percent of total billed charges,,,90,,40.5,percent of total billed charges,,,,,,,no IP contract,,80,,36,percent of total billed charges,,,,,,,no IP contract,,50,,22.5,percent of total billed charges,,,,,,no IP contract,,,78,,35.1,percent of total billed charges,,,70,,31.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.05,3324,
"Potassium, Urine Random",84133,CPT,,,,inpatient,,,93,55.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,75.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,79.05,percent of total billed charges,,,85,,79.05,percent of total billed charges,,,49,,45.57,percent of total billed charges,,,90,,83.7,percent of total billed charges,,,,,,,no IP contract,,80,,74.4,percent of total billed charges,,,,,,,no IP contract,,50,,46.5,percent of total billed charges,,,,,,no IP contract,,,78,,72.54,percent of total billed charges,,,70,,65.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,45.57,3324,
Prealbumin,84134,CPT,,,,inpatient,,,214,128.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,173.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,181.9,percent of total billed charges,,,85,,181.9,percent of total billed charges,,,49,,104.86,percent of total billed charges,,,90,,192.6,percent of total billed charges,,,,,,,no IP contract,,80,,171.2,percent of total billed charges,,,,,,,no IP contract,,50,,107,percent of total billed charges,,,,,,no IP contract,,,78,,166.92,percent of total billed charges,,,70,,149.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,104.86,3324,
"Pregnanetriol, Urine timed",84138,CPT,,,,inpatient,,,517,310.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,418.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,439.45,percent of total billed charges,,,85,,439.45,percent of total billed charges,,,49,,253.33,percent of total billed charges,,,90,,465.3,percent of total billed charges,,,,,,,no IP contract,,80,,413.6,percent of total billed charges,,,,,,,no IP contract,,50,,258.5,percent of total billed charges,,,,,,no IP contract,,,78,,403.26,percent of total billed charges,,,70,,361.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,253.33,3324,
Pregnenolone Level,84140,CPT,,,,inpatient,,,285,171,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,230.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,242.25,percent of total billed charges,,,85,,242.25,percent of total billed charges,,,49,,139.65,percent of total billed charges,,,90,,256.5,percent of total billed charges,,,,,,,no IP contract,,80,,228,percent of total billed charges,,,,,,,no IP contract,,50,,142.5,percent of total billed charges,,,,,,no IP contract,,,78,,222.3,percent of total billed charges,,,70,,199.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,139.65,3324,
Progesterone Level,84144,CPT,,,,inpatient,,,246,147.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,199.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,209.1,percent of total billed charges,,,85,,209.1,percent of total billed charges,,,49,,120.54,percent of total billed charges,,,90,,221.4,percent of total billed charges,,,,,,,no IP contract,,80,,196.8,percent of total billed charges,,,,,,,no IP contract,,50,,123,percent of total billed charges,,,,,,no IP contract,,,78,,191.88,percent of total billed charges,,,70,,172.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,120.54,3324,
Procalcitonin,84145,CPT,,,,inpatient,,,266,159.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,215.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,226.1,percent of total billed charges,,,85,,226.1,percent of total billed charges,,,49,,130.34,percent of total billed charges,,,90,,239.4,percent of total billed charges,,,,,,,no IP contract,,80,,212.8,percent of total billed charges,,,,,,,no IP contract,,50,,133,percent of total billed charges,,,,,,no IP contract,,,78,,207.48,percent of total billed charges,,,70,,186.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,130.34,3324,
Prolactin,84146,CPT,,,,inpatient,,,370,222,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,299.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,314.5,percent of total billed charges,,,85,,314.5,percent of total billed charges,,,49,,181.3,percent of total billed charges,,,90,,333,percent of total billed charges,,,,,,,no IP contract,,80,,296,percent of total billed charges,,,,,,,no IP contract,,50,,185,percent of total billed charges,,,,,,no IP contract,,,78,,288.6,percent of total billed charges,,,70,,259,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,181.3,3324,
"Prostate Specific Antigen, Diagnostic",84153,CPT,,,,inpatient,,,120,72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,97.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,102,percent of total billed charges,,,85,,102,percent of total billed charges,,,49,,58.8,percent of total billed charges,,,90,,108,percent of total billed charges,,,,,,,no IP contract,,80,,96,percent of total billed charges,,,,,,,no IP contract,,50,,60,percent of total billed charges,,,,,,no IP contract,,,78,,93.6,percent of total billed charges,,,70,,84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.8,3324,
"Prostate Specific Antigen, Diagnostic",84153,CPT,,,,inpatient,,,120,72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,97.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,102,percent of total billed charges,,,85,,102,percent of total billed charges,,,49,,58.8,percent of total billed charges,,,90,,108,percent of total billed charges,,,,,,,no IP contract,,80,,96,percent of total billed charges,,,,,,,no IP contract,,50,,60,percent of total billed charges,,,,,,no IP contract,,,78,,93.6,percent of total billed charges,,,70,,84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.8,3324,
"Prostate Specific Antigen, Diagnostic",84153,CPT,,,,inpatient,,,120,72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,97.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,102,percent of total billed charges,,,85,,102,percent of total billed charges,,,49,,58.8,percent of total billed charges,,,90,,108,percent of total billed charges,,,,,,,no IP contract,,80,,96,percent of total billed charges,,,,,,,no IP contract,,50,,60,percent of total billed charges,,,,,,no IP contract,,,78,,93.6,percent of total billed charges,,,70,,84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.8,3324,
"Assay of PSA, free",84154,CPT,,,,inpatient,,,184,110.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,149.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,156.4,percent of total billed charges,,,85,,156.4,percent of total billed charges,,,49,,90.16,percent of total billed charges,,,90,,165.6,percent of total billed charges,,,,,,,no IP contract,,80,,147.2,percent of total billed charges,,,,,,,no IP contract,,50,,92,percent of total billed charges,,,,,,no IP contract,,,78,,143.52,percent of total billed charges,,,70,,128.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,44264.82,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,90.16,44264.82,
"Total Protein, Fluid",84155,CPT,,,,inpatient,,,50,30,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,40.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,42.5,percent of total billed charges,,,85,,42.5,percent of total billed charges,,,49,,24.5,percent of total billed charges,,,90,,45,percent of total billed charges,,,,,,,no IP contract,,80,,40,percent of total billed charges,,,,,,,no IP contract,,50,,25,percent of total billed charges,,,,,,no IP contract,,,78,,39,percent of total billed charges,,,70,,35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.5,3324,
"Protein, Total",84155,CPT,,,,inpatient,,,132,79.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,106.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,112.2,percent of total billed charges,,,85,,112.2,percent of total billed charges,,,49,,64.68,percent of total billed charges,,,90,,118.8,percent of total billed charges,,,,,,,no IP contract,,80,,105.6,percent of total billed charges,,,,,,,no IP contract,,50,,66,percent of total billed charges,,,,,,no IP contract,,,78,,102.96,percent of total billed charges,,,70,,92.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,64.68,3324,
"Protein, Urine Timed",84156,CPT,,,,inpatient,,,86,51.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,69.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,73.1,percent of total billed charges,,,85,,73.1,percent of total billed charges,,,49,,42.14,percent of total billed charges,,,90,,77.4,percent of total billed charges,,,,,,,no IP contract,,80,,68.8,percent of total billed charges,,,,,,,no IP contract,,50,,43,percent of total billed charges,,,,,,no IP contract,,,78,,67.08,percent of total billed charges,,,70,,60.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,42.14,3324,
"Protein, Urine",84156,CPT,,,,inpatient,,,156,93.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,126.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,132.6,percent of total billed charges,,,85,,132.6,percent of total billed charges,,,49,,76.44,percent of total billed charges,,,90,,140.4,percent of total billed charges,,,,,,,no IP contract,,80,,124.8,percent of total billed charges,,,,,,,no IP contract,,50,,78,percent of total billed charges,,,,,,no IP contract,,,78,,121.68,percent of total billed charges,,,70,,109.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,76.44,3324,
"Protein, Total, Spinal Fluid",84157,CPT,,,,inpatient,,,80,48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,64.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,68,percent of total billed charges,,,85,,68,percent of total billed charges,,,49,,39.2,percent of total billed charges,,,90,,72,percent of total billed charges,,,,,,,no IP contract,,80,,64,percent of total billed charges,,,,,,,no IP contract,,50,,40,percent of total billed charges,,,,,,no IP contract,,,78,,62.4,percent of total billed charges,,,70,,56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,39.2,3324,
"PROTEIN, TOTAL, OTHER NMH",84157,CPT,,,,inpatient,,,119,71.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,96.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,101.15,percent of total billed charges,,,85,,101.15,percent of total billed charges,,,49,,58.31,percent of total billed charges,,,90,,107.1,percent of total billed charges,,,,,,,no IP contract,,80,,95.2,percent of total billed charges,,,,,,,no IP contract,,50,,59.5,percent of total billed charges,,,,,,no IP contract,,,78,,92.82,percent of total billed charges,,,70,,83.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.31,3324,
"Protein Electrophoresis, Serum",84165,CPT,,,,inpatient,,,277,166.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,224.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,235.45,percent of total billed charges,,,85,,235.45,percent of total billed charges,,,49,,135.73,percent of total billed charges,,,90,,249.3,percent of total billed charges,,,,,,,no IP contract,,80,,221.6,percent of total billed charges,,,,,,,no IP contract,,50,,138.5,percent of total billed charges,,,,,,no IP contract,,,78,,216.06,percent of total billed charges,,,70,,193.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,135.73,3324,
"Protein Electrophoresis, Random Urine",84166,CPT,,,,inpatient,,,247,148.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,200.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,209.95,percent of total billed charges,,,85,,209.95,percent of total billed charges,,,49,,121.03,percent of total billed charges,,,90,,222.3,percent of total billed charges,,,,,,,no IP contract,,80,,197.6,percent of total billed charges,,,,,,,no IP contract,,50,,123.5,percent of total billed charges,,,,,,no IP contract,,,78,,192.66,percent of total billed charges,,,70,,172.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,121.03,3324,
"Protein Electrophoresis, Timed Urine",84166,CPT,,,,inpatient,,,265,159,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,214.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,225.25,percent of total billed charges,,,85,,225.25,percent of total billed charges,,,49,,129.85,percent of total billed charges,,,90,,238.5,percent of total billed charges,,,,,,,no IP contract,,80,,212,percent of total billed charges,,,,,,,no IP contract,,50,,132.5,percent of total billed charges,,,,,,no IP contract,,,78,,206.7,percent of total billed charges,,,70,,185.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,129.85,3324,
Purkinje Cell (Yo) Autoantibodies,84182,CPT,,,,inpatient,,,143,85.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,115.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,121.55,percent of total billed charges,,,85,,121.55,percent of total billed charges,,,49,,70.07,percent of total billed charges,,,90,,128.7,percent of total billed charges,,,,,,,no IP contract,,80,,114.4,percent of total billed charges,,,,,,,no IP contract,,50,,71.5,percent of total billed charges,,,,,,no IP contract,,,78,,111.54,percent of total billed charges,,,70,,100.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,70.07,3324,
Protein Probe ID band,84182,CPT,,,,inpatient,,,540,324,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,437.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,459,percent of total billed charges,,,85,,459,percent of total billed charges,,,49,,264.6,percent of total billed charges,,,90,,486,percent of total billed charges,,,,,,,no IP contract,,80,,432,percent of total billed charges,,,,,,,no IP contract,,50,,270,percent of total billed charges,,,,,,no IP contract,,,78,,421.2,percent of total billed charges,,,70,,378,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,264.6,3324,
Zinc Protoporphyrins,84202,CPT,,,,inpatient,,,115,69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,93.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,97.75,percent of total billed charges,,,85,,97.75,percent of total billed charges,,,49,,56.35,percent of total billed charges,,,90,,103.5,percent of total billed charges,,,,,,,no IP contract,,80,,92,percent of total billed charges,,,,,,,no IP contract,,50,,57.5,percent of total billed charges,,,,,,no IP contract,,,78,,89.7,percent of total billed charges,,,70,,80.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,56.35,3324,
Vitamin B6 Level,84207,CPT,,,,inpatient,,,385,231,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,311.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,327.25,percent of total billed charges,,,85,,327.25,percent of total billed charges,,,49,,188.65,percent of total billed charges,,,90,,346.5,percent of total billed charges,,,,,,,no IP contract,,80,,308,percent of total billed charges,,,,,,,no IP contract,,50,,192.5,percent of total billed charges,,,,,,no IP contract,,,78,,300.3,percent of total billed charges,,,70,,269.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,188.65,3324,
Pyruvic Acid Level,84210,CPT,,,,inpatient,,,186,111.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,150.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,158.1,percent of total billed charges,,,85,,158.1,percent of total billed charges,,,49,,91.14,percent of total billed charges,,,90,,167.4,percent of total billed charges,,,,,,,no IP contract,,80,,148.8,percent of total billed charges,,,,,,,no IP contract,,50,,93,percent of total billed charges,,,,,,no IP contract,,,78,,145.08,percent of total billed charges,,,70,,130.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,91.14,3324,
Acetylcholine Receptor  Binding Antibody,84238,CPT,,,,inpatient,,,513,307.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,415.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,436.05,percent of total billed charges,,,85,,436.05,percent of total billed charges,,,49,,251.37,percent of total billed charges,,,90,,461.7,percent of total billed charges,,,,,,,no IP contract,,80,,410.4,percent of total billed charges,,,,,,,no IP contract,,50,,256.5,percent of total billed charges,,,,,,no IP contract,,,78,,400.14,percent of total billed charges,,,70,,359.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,251.37,3324,
"Renin Activity, Plasma",84244,CPT,,,,inpatient,,,270,162,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,218.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,229.5,percent of total billed charges,,,85,,229.5,percent of total billed charges,,,49,,132.3,percent of total billed charges,,,90,,243,percent of total billed charges,,,,,,,no IP contract,,80,,216,percent of total billed charges,,,,,,,no IP contract,,50,,135,percent of total billed charges,,,,,,no IP contract,,,78,,210.6,percent of total billed charges,,,70,,189,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,132.3,3324,
Selenium Level,84255,CPT,,,,inpatient,,,251,150.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,203.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,213.35,percent of total billed charges,,,85,,213.35,percent of total billed charges,,,49,,122.99,percent of total billed charges,,,90,,225.9,percent of total billed charges,,,,,,,no IP contract,,80,,200.8,percent of total billed charges,,,,,,,no IP contract,,50,,125.5,percent of total billed charges,,,,,,no IP contract,,,78,,195.78,percent of total billed charges,,,70,,175.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,122.99,3324,
Serotonin,84260,CPT,,,,inpatient,,,533,319.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,431.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,453.05,percent of total billed charges,,,85,,453.05,percent of total billed charges,,,49,,261.17,percent of total billed charges,,,90,,479.7,percent of total billed charges,,,,,,,no IP contract,,80,,426.4,percent of total billed charges,,,,,,,no IP contract,,50,,266.5,percent of total billed charges,,,,,,no IP contract,,,78,,415.74,percent of total billed charges,,,70,,373.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,261.17,3324,
Sex Hormone Binding Globulin,84270,CPT,,,,inpatient,,,205,123,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,166.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,174.25,percent of total billed charges,,,85,,174.25,percent of total billed charges,,,49,,100.45,percent of total billed charges,,,90,,184.5,percent of total billed charges,,,,,,,no IP contract,,80,,164,percent of total billed charges,,,,,,,no IP contract,,50,,102.5,percent of total billed charges,,,,,,no IP contract,,,78,,159.9,percent of total billed charges,,,70,,143.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,100.45,3324,
Sodium Level,84295,CPT,,,,inpatient,,,117,70.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,94.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,99.45,percent of total billed charges,,,85,,99.45,percent of total billed charges,,,49,,57.33,percent of total billed charges,,,90,,105.3,percent of total billed charges,,,,,,,no IP contract,,80,,93.6,percent of total billed charges,,,,,,,no IP contract,,50,,58.5,percent of total billed charges,,,,,,no IP contract,,,78,,91.26,percent of total billed charges,,,70,,81.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,57.33,3324,
"Sodium, Urine Random",84300,CPT,,,,inpatient,,,115,69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,93.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,97.75,percent of total billed charges,,,85,,97.75,percent of total billed charges,,,49,,56.35,percent of total billed charges,,,90,,103.5,percent of total billed charges,,,,,,,no IP contract,,80,,92,percent of total billed charges,,,,,,,no IP contract,,50,,57.5,percent of total billed charges,,,,,,no IP contract,,,78,,89.7,percent of total billed charges,,,70,,80.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,56.35,3324,
"Sodium, Urine Timed",84300,CPT,,,,inpatient,,,115,69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,93.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,97.75,percent of total billed charges,,,85,,97.75,percent of total billed charges,,,49,,56.35,percent of total billed charges,,,90,,103.5,percent of total billed charges,,,,,,,no IP contract,,80,,92,percent of total billed charges,,,,,,,no IP contract,,50,,57.5,percent of total billed charges,,,,,,no IP contract,,,78,,89.7,percent of total billed charges,,,70,,80.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,56.35,3324,
Somatomedin C,84305,CPT,,,,inpatient,,,335,201,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,271.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,284.75,percent of total billed charges,,,85,,284.75,percent of total billed charges,,,49,,164.15,percent of total billed charges,,,90,,301.5,percent of total billed charges,,,,,,,no IP contract,,80,,268,percent of total billed charges,,,,,,,no IP contract,,50,,167.5,percent of total billed charges,,,,,,no IP contract,,,78,,261.3,percent of total billed charges,,,70,,234.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,164.15,3324,
Somatostatin,84307,CPT,,,,inpatient,,,258,154.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,208.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,219.3,percent of total billed charges,,,85,,219.3,percent of total billed charges,,,49,,126.42,percent of total billed charges,,,90,,232.2,percent of total billed charges,,,,,,,no IP contract,,80,,206.4,percent of total billed charges,,,,,,,no IP contract,,50,,129,percent of total billed charges,,,,,,no IP contract,,,78,,201.24,percent of total billed charges,,,70,,180.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,126.42,3324,
"CHOLESTEROL, FLUID NMH",84311,CPT,,,,inpatient,,,32,19.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,25.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,27.2,percent of total billed charges,,,85,,27.2,percent of total billed charges,,,49,,15.68,percent of total billed charges,,,90,,28.8,percent of total billed charges,,,,,,,no IP contract,,80,,25.6,percent of total billed charges,,,,,,,no IP contract,,50,,16,percent of total billed charges,,,,,,no IP contract,,,78,,24.96,percent of total billed charges,,,70,,22.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.68,3324,
"Specific Gravity, Fluid",84315,CPT,,,,inpatient,,,26,15.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.1,percent of total billed charges,,,85,,22.1,percent of total billed charges,,,49,,12.74,percent of total billed charges,,,90,,23.4,percent of total billed charges,,,,,,,no IP contract,,80,,20.8,percent of total billed charges,,,,,,,no IP contract,,50,,13,percent of total billed charges,,,,,,no IP contract,,,78,,20.28,percent of total billed charges,,,70,,18.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.74,3324,
"Testosterone, Free & Total",84402,CPT,,,,inpatient,,,271,162.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,219.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,230.35,percent of total billed charges,,,85,,230.35,percent of total billed charges,,,49,,132.79,percent of total billed charges,,,90,,243.9,percent of total billed charges,,,,,,,no IP contract,,80,,216.8,percent of total billed charges,,,,,,,no IP contract,,50,,135.5,percent of total billed charges,,,,,,no IP contract,,,78,,211.38,percent of total billed charges,,,70,,189.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,132.79,3324,
"Testosterone, total",84403,CPT,,,,inpatient,,,238,142.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,192.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,202.3,percent of total billed charges,,,85,,202.3,percent of total billed charges,,,49,,116.62,percent of total billed charges,,,90,,214.2,percent of total billed charges,,,,,,,no IP contract,,80,,190.4,percent of total billed charges,,,,,,,no IP contract,,50,,119,percent of total billed charges,,,,,,no IP contract,,,78,,185.64,percent of total billed charges,,,70,,166.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,116.62,3324,
"Testosterone, Total",84403,CPT,,,,inpatient,,,238,142.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,192.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,202.3,percent of total billed charges,,,85,,202.3,percent of total billed charges,,,49,,116.62,percent of total billed charges,,,90,,214.2,percent of total billed charges,,,,,,,no IP contract,,80,,190.4,percent of total billed charges,,,,,,,no IP contract,,50,,119,percent of total billed charges,,,,,,no IP contract,,,78,,185.64,percent of total billed charges,,,70,,166.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,116.62,3324,
Vitamin B1 Level,84425,CPT,,,,inpatient,,,363,217.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,294.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,308.55,percent of total billed charges,,,85,,308.55,percent of total billed charges,,,49,,177.87,percent of total billed charges,,,90,,326.7,percent of total billed charges,,,,,,,no IP contract,,80,,290.4,percent of total billed charges,,,,,,,no IP contract,,50,,181.5,percent of total billed charges,,,,,,no IP contract,,,78,,283.14,percent of total billed charges,,,70,,254.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,177.87,3324,
Thyroglobulin,84432,CPT,,,,inpatient,,,130,78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,105.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,110.5,percent of total billed charges,,,85,,110.5,percent of total billed charges,,,49,,63.7,percent of total billed charges,,,90,,117,percent of total billed charges,,,,,,,no IP contract,,80,,104,percent of total billed charges,,,,,,,no IP contract,,50,,65,percent of total billed charges,,,,,,no IP contract,,,78,,101.4,percent of total billed charges,,,70,,91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,63.7,3324,
Thyroglobulin Evaluation,84432,CPT,,,,inpatient,,,130,78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,105.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,110.5,percent of total billed charges,,,85,,110.5,percent of total billed charges,,,49,,63.7,percent of total billed charges,,,90,,117,percent of total billed charges,,,,,,,no IP contract,,80,,104,percent of total billed charges,,,,,,,no IP contract,,50,,65,percent of total billed charges,,,,,,no IP contract,,,78,,101.4,percent of total billed charges,,,70,,91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,63.7,3324,
"T4, Total",84436,CPT,,,,inpatient,,,197,118.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,159.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,167.45,percent of total billed charges,,,85,,167.45,percent of total billed charges,,,49,,96.53,percent of total billed charges,,,90,,177.3,percent of total billed charges,,,,,,,no IP contract,,80,,157.6,percent of total billed charges,,,,,,,no IP contract,,50,,98.5,percent of total billed charges,,,,,,no IP contract,,,78,,153.66,percent of total billed charges,,,70,,137.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,96.53,3324,
Thyroxine 4 RIA,84436,CPT,,,,inpatient,,,197,118.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,159.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,167.45,percent of total billed charges,,,85,,167.45,percent of total billed charges,,,49,,96.53,percent of total billed charges,,,90,,177.3,percent of total billed charges,,,,,,,no IP contract,,80,,157.6,percent of total billed charges,,,,,,,no IP contract,,50,,98.5,percent of total billed charges,,,,,,no IP contract,,,78,,153.66,percent of total billed charges,,,70,,137.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,96.53,3324,
Thyroxine Free,84439,CPT,,,,inpatient,,,120,72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,97.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,102,percent of total billed charges,,,85,,102,percent of total billed charges,,,49,,58.8,percent of total billed charges,,,90,,108,percent of total billed charges,,,,,,,no IP contract,,80,,96,percent of total billed charges,,,,,,,no IP contract,,50,,60,percent of total billed charges,,,,,,no IP contract,,,78,,93.6,percent of total billed charges,,,70,,84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.8,3324,
THYROID STIMULATING HORMONE (TSH) NMH,84443,CPT,,,,inpatient,,,232,139.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,187.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,197.2,percent of total billed charges,,,85,,197.2,percent of total billed charges,,,49,,113.68,percent of total billed charges,,,90,,208.8,percent of total billed charges,,,,,,,no IP contract,,80,,185.6,percent of total billed charges,,,,,,,no IP contract,,50,,116,percent of total billed charges,,,,,,no IP contract,,,78,,180.96,percent of total billed charges,,,70,,162.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,113.68,3324,
Thyroid Stimulating Immunogloblins w/TSH,84443,CPT,,,,inpatient,,,250,150,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,202.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,212.5,percent of total billed charges,,,85,,212.5,percent of total billed charges,,,49,,122.5,percent of total billed charges,,,90,,225,percent of total billed charges,,,,,,,no IP contract,,80,,200,percent of total billed charges,,,,,,,no IP contract,,50,,125,percent of total billed charges,,,,,,no IP contract,,,78,,195,percent of total billed charges,,,70,,175,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,122.5,3324,
TSH w/Reflex to FT4,84443,CPT,,,,inpatient,,,250,150,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,202.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,212.5,percent of total billed charges,,,85,,212.5,percent of total billed charges,,,49,,122.5,percent of total billed charges,,,90,,225,percent of total billed charges,,,,,,,no IP contract,,80,,200,percent of total billed charges,,,,,,,no IP contract,,50,,125,percent of total billed charges,,,,,,no IP contract,,,78,,195,percent of total billed charges,,,70,,175,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,122.5,3324,
"TSH, 3rd Generation",84443,CPT,,,,inpatient,,,250,150,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,202.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,212.5,percent of total billed charges,,,85,,212.5,percent of total billed charges,,,49,,122.5,percent of total billed charges,,,90,,225,percent of total billed charges,,,,,,,no IP contract,,80,,200,percent of total billed charges,,,,,,,no IP contract,,50,,125,percent of total billed charges,,,,,,no IP contract,,,78,,195,percent of total billed charges,,,70,,175,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,122.5,3324,
Vitamin E Level,84446,CPT,,,,inpatient,,,108,64.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,87.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,91.8,percent of total billed charges,,,85,,91.8,percent of total billed charges,,,49,,52.92,percent of total billed charges,,,90,,97.2,percent of total billed charges,,,,,,,no IP contract,,80,,86.4,percent of total billed charges,,,,,,,no IP contract,,50,,54,percent of total billed charges,,,,,,no IP contract,,,78,,84.24,percent of total billed charges,,,70,,75.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,52.92,3324,
AST/SGOT,84450,CPT,,,,inpatient,,,89,53.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,72.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,75.65,percent of total billed charges,,,85,,75.65,percent of total billed charges,,,49,,43.61,percent of total billed charges,,,90,,80.1,percent of total billed charges,,,,,,,no IP contract,,80,,71.2,percent of total billed charges,,,,,,,no IP contract,,50,,44.5,percent of total billed charges,,,,,,no IP contract,,,78,,69.42,percent of total billed charges,,,70,,62.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,25564.34214,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,43.61,25564.34,
ALT/SGPT,84460,CPT,,,,inpatient,,,85,51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,68.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,72.25,percent of total billed charges,,,85,,72.25,percent of total billed charges,,,49,,41.65,percent of total billed charges,,,90,,76.5,percent of total billed charges,,,,,,,no IP contract,,80,,68,percent of total billed charges,,,,,,,no IP contract,,50,,42.5,percent of total billed charges,,,,,,no IP contract,,,78,,66.3,percent of total billed charges,,,70,,59.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,41.65,3324,
TRANSFERRIN LEVEL NMH,84466,CPT,,,,inpatient,,,98,58.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,79.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,83.3,percent of total billed charges,,,85,,83.3,percent of total billed charges,,,49,,48.02,percent of total billed charges,,,90,,88.2,percent of total billed charges,,,,,,,no IP contract,,80,,78.4,percent of total billed charges,,,,,,,no IP contract,,50,,49,percent of total billed charges,,,,,,no IP contract,,,78,,76.44,percent of total billed charges,,,70,,68.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,48.02,3324,
Transferrin,84466,CPT,,,,inpatient,,,106,63.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,85.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,90.1,percent of total billed charges,,,85,,90.1,percent of total billed charges,,,49,,51.94,percent of total billed charges,,,90,,95.4,percent of total billed charges,,,,,,,no IP contract,,80,,84.8,percent of total billed charges,,,,,,,no IP contract,,50,,53,percent of total billed charges,,,,,,no IP contract,,,78,,82.68,percent of total billed charges,,,70,,74.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,51.94,3324,
Transferrin,84466,CPT,,,,inpatient,,,106,63.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,85.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,90.1,percent of total billed charges,,,85,,90.1,percent of total billed charges,,,49,,51.94,percent of total billed charges,,,90,,95.4,percent of total billed charges,,,,,,,no IP contract,,80,,84.8,percent of total billed charges,,,,,,,no IP contract,,50,,53,percent of total billed charges,,,,,,no IP contract,,,78,,82.68,percent of total billed charges,,,70,,74.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,51.94,3324,
T3 Uptake,84479,CPT,,,,inpatient,,,161,96.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,130.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,136.85,percent of total billed charges,,,85,,136.85,percent of total billed charges,,,49,,78.89,percent of total billed charges,,,90,,144.9,percent of total billed charges,,,,,,,no IP contract,,80,,128.8,percent of total billed charges,,,,,,,no IP contract,,50,,80.5,percent of total billed charges,,,,,,no IP contract,,,78,,125.58,percent of total billed charges,,,70,,112.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,78.89,3324,
T3 Total,84480,CPT,,,,inpatient,,,234,140.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,189.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,198.9,percent of total billed charges,,,85,,198.9,percent of total billed charges,,,49,,114.66,percent of total billed charges,,,90,,210.6,percent of total billed charges,,,,,,,no IP contract,,80,,187.2,percent of total billed charges,,,,,,,no IP contract,,50,,117,percent of total billed charges,,,,,,no IP contract,,,78,,182.52,percent of total billed charges,,,70,,163.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,114.66,3324,
"T3, Total",84480,CPT,,,,inpatient,,,234,140.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,189.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,198.9,percent of total billed charges,,,85,,198.9,percent of total billed charges,,,49,,114.66,percent of total billed charges,,,90,,210.6,percent of total billed charges,,,,,,,no IP contract,,80,,187.2,percent of total billed charges,,,,,,,no IP contract,,50,,117,percent of total billed charges,,,,,,no IP contract,,,78,,182.52,percent of total billed charges,,,70,,163.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,114.66,3324,
T3 Free,84481,CPT,,,,inpatient,,,154,92.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,124.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,130.9,percent of total billed charges,,,85,,130.9,percent of total billed charges,,,49,,75.46,percent of total billed charges,,,90,,138.6,percent of total billed charges,,,,,,,no IP contract,,80,,123.2,percent of total billed charges,,,,,,,no IP contract,,50,,77,percent of total billed charges,,,,,,no IP contract,,,78,,120.12,percent of total billed charges,,,70,,107.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,75.46,3324,
"T3, Free",84481,CPT,,,,inpatient,,,154,92.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,124.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,130.9,percent of total billed charges,,,85,,130.9,percent of total billed charges,,,49,,75.46,percent of total billed charges,,,90,,138.6,percent of total billed charges,,,,,,,no IP contract,,80,,123.2,percent of total billed charges,,,,,,,no IP contract,,50,,77,percent of total billed charges,,,,,,no IP contract,,,78,,120.12,percent of total billed charges,,,70,,107.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,75.46,3324,
Reverse T3,84482,CPT,,,,inpatient,,,127,76.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,102.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,107.95,percent of total billed charges,,,85,,107.95,percent of total billed charges,,,49,,62.23,percent of total billed charges,,,90,,114.3,percent of total billed charges,,,,,,,no IP contract,,80,,101.6,percent of total billed charges,,,,,,,no IP contract,,50,,63.5,percent of total billed charges,,,,,,no IP contract,,,78,,99.06,percent of total billed charges,,,70,,88.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,62.23,3324,
TROPONIN NMH,84484,CPT,,,,inpatient,,,244,146.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,197.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,207.4,percent of total billed charges,,,85,,207.4,percent of total billed charges,,,49,,119.56,percent of total billed charges,,,90,,219.6,percent of total billed charges,,,,,,,no IP contract,,80,,195.2,percent of total billed charges,,,,,,,no IP contract,,50,,122,percent of total billed charges,,,,,,no IP contract,,,78,,190.32,percent of total billed charges,,,70,,170.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,119.56,3324,
Troponin I,84484,CPT,,,,inpatient,,,348,208.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,281.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,295.8,percent of total billed charges,,,85,,295.8,percent of total billed charges,,,49,,170.52,percent of total billed charges,,,90,,313.2,percent of total billed charges,,,,,,,no IP contract,,80,,278.4,percent of total billed charges,,,,,,,no IP contract,,50,,174,percent of total billed charges,,,,,,no IP contract,,,78,,271.44,percent of total billed charges,,,70,,243.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,170.52,3324,
Troponin I with CKMB Reflex,84484,CPT,,,,inpatient,,,348,208.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,281.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,295.8,percent of total billed charges,,,85,,295.8,percent of total billed charges,,,49,,170.52,percent of total billed charges,,,90,,313.2,percent of total billed charges,,,,,,,no IP contract,,80,,278.4,percent of total billed charges,,,,,,,no IP contract,,50,,174,percent of total billed charges,,,,,,no IP contract,,,78,,271.44,percent of total billed charges,,,70,,243.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,170.52,3324,
"BUN, Fluid",84520,CPT,,,,inpatient,,,76,45.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,61.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,64.6,percent of total billed charges,,,85,,64.6,percent of total billed charges,,,49,,37.24,percent of total billed charges,,,90,,68.4,percent of total billed charges,,,,,,,no IP contract,,80,,60.8,percent of total billed charges,,,,,,,no IP contract,,50,,38,percent of total billed charges,,,,,,no IP contract,,,78,,59.28,percent of total billed charges,,,70,,53.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,37.24,3324,
"BUN, Serum",84520,CPT,,,,inpatient,,,76,45.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,61.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,64.6,percent of total billed charges,,,85,,64.6,percent of total billed charges,,,49,,37.24,percent of total billed charges,,,90,,68.4,percent of total billed charges,,,,,,,no IP contract,,80,,60.8,percent of total billed charges,,,,,,,no IP contract,,50,,38,percent of total billed charges,,,,,,no IP contract,,,78,,59.28,percent of total billed charges,,,70,,53.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,37.24,3324,
"Urea Nitrogen, Random Urine",84540,CPT,,,,inpatient,,,100,60,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,85,percent of total billed charges,,,85,,85,percent of total billed charges,,,49,,49,percent of total billed charges,,,90,,90,percent of total billed charges,,,,,,,no IP contract,,80,,80,percent of total billed charges,,,,,,,no IP contract,,50,,50,percent of total billed charges,,,,,,no IP contract,,,78,,78,percent of total billed charges,,,70,,70,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,49,3324,
"Urea Nitrogen, Timed Urine",84540,CPT,,,,inpatient,,,100,60,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,85,percent of total billed charges,,,85,,85,percent of total billed charges,,,49,,49,percent of total billed charges,,,90,,90,percent of total billed charges,,,,,,,no IP contract,,80,,80,percent of total billed charges,,,,,,,no IP contract,,50,,50,percent of total billed charges,,,,,,no IP contract,,,78,,78,percent of total billed charges,,,70,,70,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,49,3324,
Uric Acid,84550,CPT,,,,inpatient,,,89,53.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,72.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,75.65,percent of total billed charges,,,85,,75.65,percent of total billed charges,,,49,,43.61,percent of total billed charges,,,90,,80.1,percent of total billed charges,,,,,,,no IP contract,,80,,71.2,percent of total billed charges,,,,,,,no IP contract,,50,,44.5,percent of total billed charges,,,,,,no IP contract,,,78,,69.42,percent of total billed charges,,,70,,62.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,43.61,3324,
"Uric Acid, Urine Random",84560,CPT,,,,inpatient,,,97,58.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,78.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,82.45,percent of total billed charges,,,85,,82.45,percent of total billed charges,,,49,,47.53,percent of total billed charges,,,90,,87.3,percent of total billed charges,,,,,,,no IP contract,,80,,77.6,percent of total billed charges,,,,,,,no IP contract,,50,,48.5,percent of total billed charges,,,,,,no IP contract,,,78,,75.66,percent of total billed charges,,,70,,67.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,47.53,3324,
"Uric Acid, Urine Timed",84560,CPT,,,,inpatient,,,97,58.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,78.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,82.45,percent of total billed charges,,,85,,82.45,percent of total billed charges,,,49,,47.53,percent of total billed charges,,,90,,87.3,percent of total billed charges,,,,,,,no IP contract,,80,,77.6,percent of total billed charges,,,,,,,no IP contract,,50,,48.5,percent of total billed charges,,,,,,no IP contract,,,78,,75.66,percent of total billed charges,,,70,,67.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,47.53,3324,
VMA,84585,CPT,,,,inpatient,,,151,90.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,122.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,128.35,percent of total billed charges,,,85,,128.35,percent of total billed charges,,,49,,73.99,percent of total billed charges,,,90,,135.9,percent of total billed charges,,,,,,,no IP contract,,80,,120.8,percent of total billed charges,,,,,,,no IP contract,,50,,75.5,percent of total billed charges,,,,,,no IP contract,,,78,,117.78,percent of total billed charges,,,70,,105.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,73.99,3324,
"VMA (vanilylmandelic Acid), Urine Timed",84585,CPT,,,,inpatient,,,260,156,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,210.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,221,percent of total billed charges,,,85,,221,percent of total billed charges,,,49,,127.4,percent of total billed charges,,,90,,234,percent of total billed charges,,,,,,,no IP contract,,80,,208,percent of total billed charges,,,,,,,no IP contract,,50,,130,percent of total billed charges,,,,,,no IP contract,,,78,,202.8,percent of total billed charges,,,70,,182,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,127.4,3324,
Antidiuretic Hormone,84588,CPT,,,,inpatient,,,227,136.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,183.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,192.95,percent of total billed charges,,,85,,192.95,percent of total billed charges,,,49,,111.23,percent of total billed charges,,,90,,204.3,percent of total billed charges,,,,,,,no IP contract,,80,,181.6,percent of total billed charges,,,,,,,no IP contract,,50,,113.5,percent of total billed charges,,,,,,no IP contract,,,78,,177.06,percent of total billed charges,,,70,,158.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,87222.8,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,111.23,87222.8,
Vitamin A Level,84590,CPT,,,,inpatient,,,192,115.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,155.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,163.2,percent of total billed charges,,,85,,163.2,percent of total billed charges,,,49,,94.08,percent of total billed charges,,,90,,172.8,percent of total billed charges,,,,,,,no IP contract,,80,,153.6,percent of total billed charges,,,,,,,no IP contract,,50,,96,percent of total billed charges,,,,,,no IP contract,,,78,,149.76,percent of total billed charges,,,70,,134.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,94.08,3324,
Vitamin K Level,84597,CPT,,,,inpatient,,,130,78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,105.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,110.5,percent of total billed charges,,,85,,110.5,percent of total billed charges,,,49,,63.7,percent of total billed charges,,,90,,117,percent of total billed charges,,,,,,,no IP contract,,80,,104,percent of total billed charges,,,,,,,no IP contract,,50,,65,percent of total billed charges,,,,,,no IP contract,,,78,,101.4,percent of total billed charges,,,70,,91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,63.7,3324,
"D-Xylose, 1Hr Blood",84620,CPT,,,,inpatient,,,101,60.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,81.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,85.85,percent of total billed charges,,,85,,85.85,percent of total billed charges,,,49,,49.49,percent of total billed charges,,,90,,90.9,percent of total billed charges,,,,,,,no IP contract,,80,,80.8,percent of total billed charges,,,,,,,no IP contract,,50,,50.5,percent of total billed charges,,,,,,no IP contract,,,78,,78.78,percent of total billed charges,,,70,,70.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,49.49,3324,
"D-Xylose, 2Hr Blood",84620,CPT,,,,inpatient,,,101,60.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,81.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,85.85,percent of total billed charges,,,85,,85.85,percent of total billed charges,,,49,,49.49,percent of total billed charges,,,90,,90.9,percent of total billed charges,,,,,,,no IP contract,,80,,80.8,percent of total billed charges,,,,,,,no IP contract,,50,,50.5,percent of total billed charges,,,,,,no IP contract,,,78,,78.78,percent of total billed charges,,,70,,70.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,49.49,3324,
"D-Xylose, 5 Hr Urine",84620,CPT,,,,inpatient,,,347,208.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,281.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,294.95,percent of total billed charges,,,85,,294.95,percent of total billed charges,,,49,,170.03,percent of total billed charges,,,90,,312.3,percent of total billed charges,,,,,,,no IP contract,,80,,277.6,percent of total billed charges,,,,,,,no IP contract,,50,,173.5,percent of total billed charges,,,,,,no IP contract,,,78,,270.66,percent of total billed charges,,,70,,242.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,170.03,3324,
Zinc Level,84630,CPT,,,,inpatient,,,165,99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,133.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,140.25,percent of total billed charges,,,85,,140.25,percent of total billed charges,,,49,,80.85,percent of total billed charges,,,90,,148.5,percent of total billed charges,,,,,,,no IP contract,,80,,132,percent of total billed charges,,,,,,,no IP contract,,50,,82.5,percent of total billed charges,,,,,,no IP contract,,,78,,128.7,percent of total billed charges,,,70,,115.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,80.85,3324,
C-Peptide,84681,CPT,,,,inpatient,,,204,122.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,165.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,173.4,percent of total billed charges,,,85,,173.4,percent of total billed charges,,,49,,99.96,percent of total billed charges,,,90,,183.6,percent of total billed charges,,,,,,,no IP contract,,80,,163.2,percent of total billed charges,,,,,,,no IP contract,,50,,102,percent of total billed charges,,,,,,no IP contract,,,78,,159.12,percent of total billed charges,,,70,,142.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,99.96,3324,
"Gonadotropin, chorionic",84702,CPT,,,,inpatient,,,190,114,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,153.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,161.5,percent of total billed charges,,,85,,161.5,percent of total billed charges,,,49,,93.1,percent of total billed charges,,,90,,171,percent of total billed charges,,,,,,,no IP contract,,80,,152,percent of total billed charges,,,,,,,no IP contract,,50,,95,percent of total billed charges,,,,,,no IP contract,,,78,,148.2,percent of total billed charges,,,70,,133,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,93.1,3324,
HCG/Serum Pregnancy Test,84702,CPT,,,,inpatient,,,289,173.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,234.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,245.65,percent of total billed charges,,,85,,245.65,percent of total billed charges,,,49,,141.61,percent of total billed charges,,,90,,260.1,percent of total billed charges,,,,,,,no IP contract,,80,,231.2,percent of total billed charges,,,,,,,no IP contract,,50,,144.5,percent of total billed charges,,,,,,no IP contract,,,78,,225.42,percent of total billed charges,,,70,,202.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,141.61,3324,
"Hematocrit, Fluid",85014,CPT,,,,inpatient,,,53,31.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,42.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,45.05,percent of total billed charges,,,85,,45.05,percent of total billed charges,,,49,,25.97,percent of total billed charges,,,90,,47.7,percent of total billed charges,,,,,,,no IP contract,,80,,42.4,percent of total billed charges,,,,,,,no IP contract,,50,,26.5,percent of total billed charges,,,,,,no IP contract,,,78,,41.34,percent of total billed charges,,,70,,37.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.97,3324,
CBC-Hemoglobin and Hematocrit Only,85014,CPT,,,,inpatient,,,67,40.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,54.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.95,percent of total billed charges,,,85,,56.95,percent of total billed charges,,,49,,32.83,percent of total billed charges,,,90,,60.3,percent of total billed charges,,,,,,,no IP contract,,80,,53.6,percent of total billed charges,,,,,,,no IP contract,,50,,33.5,percent of total billed charges,,,,,,no IP contract,,,78,,52.26,percent of total billed charges,,,70,,46.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,30114.23,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.83,30114.23,
Hemoglobin,85018,CPT,,,,inpatient,,,54,32.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,43.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,45.9,percent of total billed charges,,,85,,45.9,percent of total billed charges,,,49,,26.46,percent of total billed charges,,,90,,48.6,percent of total billed charges,,,,,,,no IP contract,,80,,43.2,percent of total billed charges,,,,,,,no IP contract,,50,,27,percent of total billed charges,,,,,,no IP contract,,,78,,42.12,percent of total billed charges,,,70,,37.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.46,3324,
CBC WITH DIFFERENTIAL NMH,85025,CPT,,,,inpatient,,,162,97.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,131.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,137.7,percent of total billed charges,,,85,,137.7,percent of total billed charges,,,49,,79.38,percent of total billed charges,,,90,,145.8,percent of total billed charges,,,,,,,no IP contract,,80,,129.6,percent of total billed charges,,,,,,,no IP contract,,50,,81,percent of total billed charges,,,,,,no IP contract,,,78,,126.36,percent of total billed charges,,,70,,113.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,79.38,3324,
CBC-Compete Blood Count with Differential and Platelets,85025,CPT,,,,inpatient,,,189,113.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,153.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,160.65,percent of total billed charges,,,85,,160.65,percent of total billed charges,,,49,,92.61,percent of total billed charges,,,90,,170.1,percent of total billed charges,,,,,,,no IP contract,,80,,151.2,percent of total billed charges,,,,,,,no IP contract,,50,,94.5,percent of total billed charges,,,,,,no IP contract,,,78,,147.42,percent of total billed charges,,,70,,132.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,55337.24167,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,92.61,55337.24,
CBC NMH,85027,CPT,,,,inpatient,,,123,73.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,99.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,104.55,percent of total billed charges,,,85,,104.55,percent of total billed charges,,,49,,60.27,percent of total billed charges,,,90,,110.7,percent of total billed charges,,,,,,,no IP contract,,80,,98.4,percent of total billed charges,,,,,,,no IP contract,,50,,61.5,percent of total billed charges,,,,,,no IP contract,,,78,,95.94,percent of total billed charges,,,70,,86.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,60.27,3324,
CBC with Platelets,85027,CPT,,,,inpatient,,,169,101.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,136.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,143.65,percent of total billed charges,,,85,,143.65,percent of total billed charges,,,49,,82.81,percent of total billed charges,,,90,,152.1,percent of total billed charges,,,,,,,no IP contract,,80,,135.2,percent of total billed charges,,,,,,,no IP contract,,50,,84.5,percent of total billed charges,,,,,,no IP contract,,,78,,131.82,percent of total billed charges,,,70,,118.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,84230.41,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,82.81,84230.41,
CBC with Platelets,85027,CPT,,,,inpatient,,,169,101.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,136.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,143.65,percent of total billed charges,,,85,,143.65,percent of total billed charges,,,49,,82.81,percent of total billed charges,,,90,,152.1,percent of total billed charges,,,,,,,no IP contract,,80,,135.2,percent of total billed charges,,,,,,,no IP contract,,50,,84.5,percent of total billed charges,,,,,,no IP contract,,,78,,131.82,percent of total billed charges,,,70,,118.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,82.81,3324,
CBC with Platelets,85027,CPT,,,,inpatient,,,169,101.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,136.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,143.65,percent of total billed charges,,,85,,143.65,percent of total billed charges,,,49,,82.81,percent of total billed charges,,,90,,152.1,percent of total billed charges,,,,,,,no IP contract,,80,,135.2,percent of total billed charges,,,,,,,no IP contract,,50,,84.5,percent of total billed charges,,,,,,no IP contract,,,78,,131.82,percent of total billed charges,,,70,,118.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,82.81,3324,
CBC with Manual Differential,85027,CPT,,,,inpatient,,,226,135.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,183.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,192.1,percent of total billed charges,,,85,,192.1,percent of total billed charges,,,49,,110.74,percent of total billed charges,,,90,,203.4,percent of total billed charges,,,,,,,no IP contract,,80,,180.8,percent of total billed charges,,,,,,,no IP contract,,50,,113,percent of total billed charges,,,,,,no IP contract,,,78,,176.28,percent of total billed charges,,,70,,158.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,44637.37,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,110.74,44637.37,
Reticulocyte Count Manual,85045,CPT,,,,inpatient,,,78,46.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,63.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,66.3,percent of total billed charges,,,85,,66.3,percent of total billed charges,,,49,,38.22,percent of total billed charges,,,90,,70.2,percent of total billed charges,,,,,,,no IP contract,,80,,62.4,percent of total billed charges,,,,,,,no IP contract,,50,,39,percent of total billed charges,,,,,,no IP contract,,,78,,60.84,percent of total billed charges,,,70,,54.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,38.22,3324,
Platelet Count,85049,CPT,,,,inpatient,,,129,77.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,104.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,109.65,percent of total billed charges,,,85,,109.65,percent of total billed charges,,,49,,63.21,percent of total billed charges,,,90,,116.1,percent of total billed charges,,,,,,,no IP contract,,80,,103.2,percent of total billed charges,,,,,,,no IP contract,,50,,64.5,percent of total billed charges,,,,,,no IP contract,,,78,,100.62,percent of total billed charges,,,70,,90.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,63.21,3324,
Factor II Assay,85210,CPT,,,,inpatient,,,169,101.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,136.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,143.65,percent of total billed charges,,,85,,143.65,percent of total billed charges,,,49,,82.81,percent of total billed charges,,,90,,152.1,percent of total billed charges,,,,,,,no IP contract,,80,,135.2,percent of total billed charges,,,,,,,no IP contract,,50,,84.5,percent of total billed charges,,,,,,no IP contract,,,78,,131.82,percent of total billed charges,,,70,,118.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,82.81,3324,
Factor V Assay,85220,CPT,,,,inpatient,,,278,166.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,225.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,236.3,percent of total billed charges,,,85,,236.3,percent of total billed charges,,,49,,136.22,percent of total billed charges,,,90,,250.2,percent of total billed charges,,,,,,,no IP contract,,80,,222.4,percent of total billed charges,,,,,,,no IP contract,,50,,139,percent of total billed charges,,,,,,no IP contract,,,78,,216.84,percent of total billed charges,,,70,,194.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,136.22,3324,
Factor VII Assay,85230,CPT,,,,inpatient,,,227,136.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,183.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,192.95,percent of total billed charges,,,85,,192.95,percent of total billed charges,,,49,,111.23,percent of total billed charges,,,90,,204.3,percent of total billed charges,,,,,,,no IP contract,,80,,181.6,percent of total billed charges,,,,,,,no IP contract,,50,,113.5,percent of total billed charges,,,,,,no IP contract,,,78,,177.06,percent of total billed charges,,,70,,158.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,111.23,3324,
Factor VIII Assay,85240,CPT,,,,inpatient,,,278,166.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,225.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,236.3,percent of total billed charges,,,85,,236.3,percent of total billed charges,,,49,,136.22,percent of total billed charges,,,90,,250.2,percent of total billed charges,,,,,,,no IP contract,,80,,222.4,percent of total billed charges,,,,,,,no IP contract,,50,,139,percent of total billed charges,,,,,,no IP contract,,,78,,216.84,percent of total billed charges,,,70,,194.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,136.22,3324,
Ristocetin Cofactor,85245,CPT,,,,inpatient,,,406,243.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,328.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,345.1,percent of total billed charges,,,85,,345.1,percent of total billed charges,,,49,,198.94,percent of total billed charges,,,90,,365.4,percent of total billed charges,,,,,,,no IP contract,,80,,324.8,percent of total billed charges,,,,,,,no IP contract,,50,,203,percent of total billed charges,,,,,,no IP contract,,,78,,316.68,percent of total billed charges,,,70,,284.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,198.94,3324,
Von Willebrand Antigen,85246,CPT,,,,inpatient,,,195,117,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,157.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,165.75,percent of total billed charges,,,85,,165.75,percent of total billed charges,,,49,,95.55,percent of total billed charges,,,90,,175.5,percent of total billed charges,,,,,,,no IP contract,,80,,156,percent of total billed charges,,,,,,,no IP contract,,50,,97.5,percent of total billed charges,,,,,,no IP contract,,,78,,152.1,percent of total billed charges,,,70,,136.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,95.55,3324,
Factor IX Assay,85250,CPT,,,,inpatient,,,245,147,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,198.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,208.25,percent of total billed charges,,,85,,208.25,percent of total billed charges,,,49,,120.05,percent of total billed charges,,,90,,220.5,percent of total billed charges,,,,,,,no IP contract,,80,,196,percent of total billed charges,,,,,,,no IP contract,,50,,122.5,percent of total billed charges,,,,,,no IP contract,,,78,,191.1,percent of total billed charges,,,70,,171.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,120.05,3324,
Factor X Assay,85260,CPT,,,,inpatient,,,278,166.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,225.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,236.3,percent of total billed charges,,,85,,236.3,percent of total billed charges,,,49,,136.22,percent of total billed charges,,,90,,250.2,percent of total billed charges,,,,,,,no IP contract,,80,,222.4,percent of total billed charges,,,,,,,no IP contract,,50,,139,percent of total billed charges,,,,,,no IP contract,,,78,,216.84,percent of total billed charges,,,70,,194.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,136.22,3324,
Factor XI Assay,85270,CPT,,,,inpatient,,,278,166.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,225.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,236.3,percent of total billed charges,,,85,,236.3,percent of total billed charges,,,49,,136.22,percent of total billed charges,,,90,,250.2,percent of total billed charges,,,,,,,no IP contract,,80,,222.4,percent of total billed charges,,,,,,,no IP contract,,50,,139,percent of total billed charges,,,,,,no IP contract,,,78,,216.84,percent of total billed charges,,,70,,194.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,136.22,3324,
Factor XII Assay,85280,CPT,,,,inpatient,,,278,166.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,225.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,236.3,percent of total billed charges,,,85,,236.3,percent of total billed charges,,,49,,136.22,percent of total billed charges,,,90,,250.2,percent of total billed charges,,,,,,,no IP contract,,80,,222.4,percent of total billed charges,,,,,,,no IP contract,,50,,139,percent of total billed charges,,,,,,no IP contract,,,78,,216.84,percent of total billed charges,,,70,,194.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,136.22,3324,
Factor XIII Assay,85291,CPT,,,,inpatient,,,114,68.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,92.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,96.9,percent of total billed charges,,,85,,96.9,percent of total billed charges,,,49,,55.86,percent of total billed charges,,,90,,102.6,percent of total billed charges,,,,,,,no IP contract,,80,,91.2,percent of total billed charges,,,,,,,no IP contract,,50,,57,percent of total billed charges,,,,,,no IP contract,,,78,,88.92,percent of total billed charges,,,70,,79.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,55.86,3324,
Antithrombin III,85300,CPT,,,,inpatient,,,298,178.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,241.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,253.3,percent of total billed charges,,,85,,253.3,percent of total billed charges,,,49,,146.02,percent of total billed charges,,,90,,268.2,percent of total billed charges,,,,,,,no IP contract,,80,,238.4,percent of total billed charges,,,,,,,no IP contract,,50,,149,percent of total billed charges,,,,,,no IP contract,,,78,,232.44,percent of total billed charges,,,70,,208.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,35321.57,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,146.02,35321.57,
Protein C Antigen,85302,CPT,,,,inpatient,,,190,114,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,153.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,161.5,percent of total billed charges,,,85,,161.5,percent of total billed charges,,,49,,93.1,percent of total billed charges,,,90,,171,percent of total billed charges,,,,,,,no IP contract,,80,,152,percent of total billed charges,,,,,,,no IP contract,,50,,95,percent of total billed charges,,,,,,no IP contract,,,78,,148.2,percent of total billed charges,,,70,,133,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,93.1,3324,
Protein C Activity,85303,CPT,,,,inpatient,,,211,126.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,170.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,179.35,percent of total billed charges,,,85,,179.35,percent of total billed charges,,,49,,103.39,percent of total billed charges,,,90,,189.9,percent of total billed charges,,,,,,,no IP contract,,80,,168.8,percent of total billed charges,,,,,,,no IP contract,,50,,105.5,percent of total billed charges,,,,,,no IP contract,,,78,,164.58,percent of total billed charges,,,70,,147.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,103.39,3324,
Protein S Activity,85306,CPT,,,,inpatient,,,237,142.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,191.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,201.45,percent of total billed charges,,,85,,201.45,percent of total billed charges,,,49,,116.13,percent of total billed charges,,,90,,213.3,percent of total billed charges,,,,,,,no IP contract,,80,,189.6,percent of total billed charges,,,,,,,no IP contract,,50,,118.5,percent of total billed charges,,,,,,no IP contract,,,78,,184.86,percent of total billed charges,,,70,,165.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,116.13,3324,
"Protein S Antigen, Free",85306,CPT,,,,inpatient,,,237,142.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,191.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,201.45,percent of total billed charges,,,85,,201.45,percent of total billed charges,,,49,,116.13,percent of total billed charges,,,90,,213.3,percent of total billed charges,,,,,,,no IP contract,,80,,189.6,percent of total billed charges,,,,,,,no IP contract,,50,,118.5,percent of total billed charges,,,,,,no IP contract,,,78,,184.86,percent of total billed charges,,,70,,165.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,116.13,3324,
APC Resistance,85307,CPT,,,,inpatient,,,166,99.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,134.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,141.1,percent of total billed charges,,,85,,141.1,percent of total billed charges,,,49,,81.34,percent of total billed charges,,,90,,149.4,percent of total billed charges,,,,,,,no IP contract,,80,,132.8,percent of total billed charges,,,,,,,no IP contract,,50,,83,percent of total billed charges,,,,,,no IP contract,,,78,,129.48,percent of total billed charges,,,70,,116.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,81.34,3324,
Factor VIII Inhibitor,85335,CPT,,,,inpatient,,,329,197.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,266.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,279.65,percent of total billed charges,,,85,,279.65,percent of total billed charges,,,49,,161.21,percent of total billed charges,,,90,,296.1,percent of total billed charges,,,,,,,no IP contract,,80,,263.2,percent of total billed charges,,,,,,,no IP contract,,50,,164.5,percent of total billed charges,,,,,,no IP contract,,,78,,256.62,percent of total billed charges,,,70,,230.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,161.21,3324,
Fibrin Degradation Product,85362,CPT,,,,inpatient,,,109,65.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,88.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,92.65,percent of total billed charges,,,85,,92.65,percent of total billed charges,,,49,,53.41,percent of total billed charges,,,90,,98.1,percent of total billed charges,,,,,,,no IP contract,,80,,87.2,percent of total billed charges,,,,,,,no IP contract,,50,,54.5,percent of total billed charges,,,,,,no IP contract,,,78,,85.02,percent of total billed charges,,,70,,76.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,53.41,3324,
D-Dimer,85378,CPT,,,,inpatient,,,169,101.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,136.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,143.65,percent of total billed charges,,,85,,143.65,percent of total billed charges,,,49,,82.81,percent of total billed charges,,,90,,152.1,percent of total billed charges,,,,,,,no IP contract,,80,,135.2,percent of total billed charges,,,,,,,no IP contract,,50,,84.5,percent of total billed charges,,,,,,no IP contract,,,78,,131.82,percent of total billed charges,,,70,,118.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,82.81,3324,
D-Dimer,85379,CPT,,,,inpatient,,,169,101.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,136.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,143.65,percent of total billed charges,,,85,,143.65,percent of total billed charges,,,49,,82.81,percent of total billed charges,,,90,,152.1,percent of total billed charges,,,,,,,no IP contract,,80,,135.2,percent of total billed charges,,,,,,,no IP contract,,50,,84.5,percent of total billed charges,,,,,,no IP contract,,,78,,131.82,percent of total billed charges,,,70,,118.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,82.81,3324,
"Firbrin degradation products, quant.",85379,CPT,,,,inpatient,,,192,115.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,155.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,163.2,percent of total billed charges,,,85,,163.2,percent of total billed charges,,,49,,94.08,percent of total billed charges,,,90,,172.8,percent of total billed charges,,,,,,,no IP contract,,80,,153.6,percent of total billed charges,,,,,,,no IP contract,,50,,96,percent of total billed charges,,,,,,no IP contract,,,78,,149.76,percent of total billed charges,,,70,,134.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,94.08,3324,
Fibrinogen,85384,CPT,,,,inpatient,,,136,81.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,110.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,115.6,percent of total billed charges,,,85,,115.6,percent of total billed charges,,,49,,66.64,percent of total billed charges,,,90,,122.4,percent of total billed charges,,,,,,,no IP contract,,80,,108.8,percent of total billed charges,,,,,,,no IP contract,,50,,68,percent of total billed charges,,,,,,no IP contract,,,78,,106.08,percent of total billed charges,,,70,,95.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,66.64,3324,
Fibrinogen,85384,CPT,,,,inpatient,,,136,81.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,110.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,115.6,percent of total billed charges,,,85,,115.6,percent of total billed charges,,,49,,66.64,percent of total billed charges,,,90,,122.4,percent of total billed charges,,,,,,,no IP contract,,80,,108.8,percent of total billed charges,,,,,,,no IP contract,,50,,68,percent of total billed charges,,,,,,no IP contract,,,78,,106.08,percent of total billed charges,,,70,,95.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,66.64,3324,
Fibrinogen Antigen,85385,CPT,,,,inpatient,,,154,92.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,124.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,130.9,percent of total billed charges,,,85,,130.9,percent of total billed charges,,,49,,75.46,percent of total billed charges,,,90,,138.6,percent of total billed charges,,,,,,,no IP contract,,80,,123.2,percent of total billed charges,,,,,,,no IP contract,,50,,77,percent of total billed charges,,,,,,no IP contract,,,78,,120.12,percent of total billed charges,,,70,,107.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,75.46,3324,
"Heinz Body Prep, Direct",85441,CPT,,,,inpatient,,,56,33.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,45.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,47.6,percent of total billed charges,,,85,,47.6,percent of total billed charges,,,49,,27.44,percent of total billed charges,,,90,,50.4,percent of total billed charges,,,,,,,no IP contract,,80,,44.8,percent of total billed charges,,,,,,,no IP contract,,50,,28,percent of total billed charges,,,,,,no IP contract,,,78,,43.68,percent of total billed charges,,,70,,39.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.44,3324,
Anti Xa Assay - Atrixtra,85520,CPT,,,,inpatient,,,238,142.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,192.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,202.3,percent of total billed charges,,,85,,202.3,percent of total billed charges,,,49,,116.62,percent of total billed charges,,,90,,214.2,percent of total billed charges,,,,,,,no IP contract,,80,,190.4,percent of total billed charges,,,,,,,no IP contract,,50,,119,percent of total billed charges,,,,,,no IP contract,,,78,,185.64,percent of total billed charges,,,70,,166.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,3591.7,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,116.62,3591.7,
Anti Xa Assay - Fragmin,85520,CPT,,,,inpatient,,,238,142.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,192.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,202.3,percent of total billed charges,,,85,,202.3,percent of total billed charges,,,49,,116.62,percent of total billed charges,,,90,,214.2,percent of total billed charges,,,,,,,no IP contract,,80,,190.4,percent of total billed charges,,,,,,,no IP contract,,50,,119,percent of total billed charges,,,,,,no IP contract,,,78,,185.64,percent of total billed charges,,,70,,166.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,116.62,3324,
Anti Xa Assay - Lovenox,85520,CPT,,,,inpatient,,,238,142.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,192.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,202.3,percent of total billed charges,,,85,,202.3,percent of total billed charges,,,49,,116.62,percent of total billed charges,,,90,,214.2,percent of total billed charges,,,,,,,no IP contract,,80,,190.4,percent of total billed charges,,,,,,,no IP contract,,50,,119,percent of total billed charges,,,,,,no IP contract,,,78,,185.64,percent of total billed charges,,,70,,166.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,116.62,3324,
Anti Xa Assay - Rivaroxaban,85520,CPT,,,,inpatient,,,238,142.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,192.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,202.3,percent of total billed charges,,,85,,202.3,percent of total billed charges,,,49,,116.62,percent of total billed charges,,,90,,214.2,percent of total billed charges,,,,,,,no IP contract,,80,,190.4,percent of total billed charges,,,,,,,no IP contract,,50,,119,percent of total billed charges,,,,,,no IP contract,,,78,,185.64,percent of total billed charges,,,70,,166.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,116.62,3324,
Anti Xa Assay - Unfractionated Heparin,85520,CPT,,,,inpatient,,,238,142.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,192.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,202.3,percent of total billed charges,,,85,,202.3,percent of total billed charges,,,49,,116.62,percent of total billed charges,,,90,,214.2,percent of total billed charges,,,,,,,no IP contract,,80,,190.4,percent of total billed charges,,,,,,,no IP contract,,50,,119,percent of total billed charges,,,,,,no IP contract,,,78,,185.64,percent of total billed charges,,,70,,166.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,116.62,3324,
Platelet Aggregation,85576,CPT,,,,inpatient,,,248,148.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,200.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,210.8,percent of total billed charges,,,85,,210.8,percent of total billed charges,,,49,,121.52,percent of total billed charges,,,90,,223.2,percent of total billed charges,,,,,,,no IP contract,,80,,198.4,percent of total billed charges,,,,,,,no IP contract,,50,,124,percent of total billed charges,,,,,,no IP contract,,,78,,193.44,percent of total billed charges,,,70,,173.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,121.52,3324,
Platelet Function Analysis,85576,CPT,,,,inpatient,,,248,148.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,200.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,210.8,percent of total billed charges,,,85,,210.8,percent of total billed charges,,,49,,121.52,percent of total billed charges,,,90,,223.2,percent of total billed charges,,,,,,,no IP contract,,80,,198.4,percent of total billed charges,,,,,,,no IP contract,,50,,124,percent of total billed charges,,,,,,no IP contract,,,78,,193.44,percent of total billed charges,,,70,,173.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,121.52,3324,
Platelet Function Analysis II,85576,CPT,,,,inpatient,,,248,148.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,200.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,210.8,percent of total billed charges,,,85,,210.8,percent of total billed charges,,,49,,121.52,percent of total billed charges,,,90,,223.2,percent of total billed charges,,,,,,,no IP contract,,80,,198.4,percent of total billed charges,,,,,,,no IP contract,,50,,124,percent of total billed charges,,,,,,no IP contract,,,78,,193.44,percent of total billed charges,,,70,,173.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,121.52,3324,
Platelet Function Studies NMH,85576,CPT,,,,inpatient,,,318,190.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,257.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,270.3,percent of total billed charges,,,85,,270.3,percent of total billed charges,,,49,,155.82,percent of total billed charges,,,90,,286.2,percent of total billed charges,,,,,,,no IP contract,,80,,254.4,percent of total billed charges,,,,,,,no IP contract,,50,,159,percent of total billed charges,,,,,,no IP contract,,,78,,248.04,percent of total billed charges,,,70,,222.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,155.82,3324,
"Platelet Aggregation, Plavix",85576,CPT,,,,inpatient,,,326,195.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,264.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,277.1,percent of total billed charges,,,85,,277.1,percent of total billed charges,,,49,,159.74,percent of total billed charges,,,90,,293.4,percent of total billed charges,,,,,,,no IP contract,,80,,260.8,percent of total billed charges,,,,,,,no IP contract,,50,,163,percent of total billed charges,,,,,,no IP contract,,,78,,254.28,percent of total billed charges,,,70,,228.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,159.74,3324,
Prothrombin Time/PT,85610,CPT,,,,inpatient,,,115,69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,93.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,97.75,percent of total billed charges,,,85,,97.75,percent of total billed charges,,,49,,56.35,percent of total billed charges,,,90,,103.5,percent of total billed charges,,,,,,,no IP contract,,80,,92,percent of total billed charges,,,,,,,no IP contract,,50,,57.5,percent of total billed charges,,,,,,no IP contract,,,78,,89.7,percent of total billed charges,,,70,,80.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,56.35,3324,
Prothrombin Time/PT,85610,CPT,,,,inpatient,,,115,69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,93.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,97.75,percent of total billed charges,,,85,,97.75,percent of total billed charges,,,49,,56.35,percent of total billed charges,,,90,,103.5,percent of total billed charges,,,,,,,no IP contract,,80,,92,percent of total billed charges,,,,,,,no IP contract,,50,,57.5,percent of total billed charges,,,,,,no IP contract,,,78,,89.7,percent of total billed charges,,,70,,80.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,56.35,3324,
PROTHROMBIN TIME NMH,85610,CPT,,,,inpatient,,,119,71.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,96.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,101.15,percent of total billed charges,,,85,,101.15,percent of total billed charges,,,49,,58.31,percent of total billed charges,,,90,,107.1,percent of total billed charges,,,,,,,no IP contract,,80,,95.2,percent of total billed charges,,,,,,,no IP contract,,50,,59.5,percent of total billed charges,,,,,,no IP contract,,,78,,92.82,percent of total billed charges,,,70,,83.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.31,3324,
PT/INR Point of Care,85610,CPT,,,,inpatient,,,130,78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,105.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,110.5,percent of total billed charges,,,85,,110.5,percent of total billed charges,,,49,,63.7,percent of total billed charges,,,90,,117,percent of total billed charges,,,,,,,no IP contract,,80,,104,percent of total billed charges,,,,,,,no IP contract,,50,,65,percent of total billed charges,,,,,,no IP contract,,,78,,101.4,percent of total billed charges,,,70,,91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,63.7,3324,
DIC Panel,85610,CPT,,,,inpatient,,,144,86.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,116.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,122.4,percent of total billed charges,,,85,,122.4,percent of total billed charges,,,49,,70.56,percent of total billed charges,,,90,,129.6,percent of total billed charges,,,,,,,no IP contract,,80,,115.2,percent of total billed charges,,,,,,,no IP contract,,50,,72,percent of total billed charges,,,,,,no IP contract,,,78,,112.32,percent of total billed charges,,,70,,100.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,70.56,3324,
PT Mixing Studies,85610,CPT,,,,inpatient,,,144,86.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,116.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,122.4,percent of total billed charges,,,85,,122.4,percent of total billed charges,,,49,,70.56,percent of total billed charges,,,90,,129.6,percent of total billed charges,,,,,,,no IP contract,,80,,115.2,percent of total billed charges,,,,,,,no IP contract,,50,,72,percent of total billed charges,,,,,,no IP contract,,,78,,112.32,percent of total billed charges,,,70,,100.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,70.56,3324,
PT Mixing Study,85610,CPT,,,,inpatient,,,144,86.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,116.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,122.4,percent of total billed charges,,,85,,122.4,percent of total billed charges,,,49,,70.56,percent of total billed charges,,,90,,129.6,percent of total billed charges,,,,,,,no IP contract,,80,,115.2,percent of total billed charges,,,,,,,no IP contract,,50,,72,percent of total billed charges,,,,,,no IP contract,,,78,,112.32,percent of total billed charges,,,70,,100.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,70.56,3324,
"Russell viper venom time, diluted",85613,CPT,,,,inpatient,,,220,132,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,178.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,187,percent of total billed charges,,,85,,187,percent of total billed charges,,,49,,107.8,percent of total billed charges,,,90,,198,percent of total billed charges,,,,,,,no IP contract,,80,,176,percent of total billed charges,,,,,,,no IP contract,,50,,110,percent of total billed charges,,,,,,no IP contract,,,78,,171.6,percent of total billed charges,,,70,,154,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,107.8,3324,
Sedimentation Rate Non-automated,85651,CPT,,,,inpatient,,,93,55.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,75.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,79.05,percent of total billed charges,,,85,,79.05,percent of total billed charges,,,49,,45.57,percent of total billed charges,,,90,,83.7,percent of total billed charges,,,,,,,no IP contract,,80,,74.4,percent of total billed charges,,,,,,,no IP contract,,50,,46.5,percent of total billed charges,,,,,,no IP contract,,,78,,72.54,percent of total billed charges,,,70,,65.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,45.57,3324,
Sickle Cell Screen,85660,CPT,,,,inpatient,,,71,42.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,57.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,60.35,percent of total billed charges,,,85,,60.35,percent of total billed charges,,,49,,34.79,percent of total billed charges,,,90,,63.9,percent of total billed charges,,,,,,,no IP contract,,80,,56.8,percent of total billed charges,,,,,,,no IP contract,,50,,35.5,percent of total billed charges,,,,,,no IP contract,,,78,,55.38,percent of total billed charges,,,70,,49.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,34.79,3324,
Activated PTT/Partial Thromboplastin Time,85730,CPT,,,,inpatient,,,168,100.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,136.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,142.8,percent of total billed charges,,,85,,142.8,percent of total billed charges,,,49,,82.32,percent of total billed charges,,,90,,151.2,percent of total billed charges,,,,,,,no IP contract,,80,,134.4,percent of total billed charges,,,,,,,no IP contract,,50,,84,percent of total billed charges,,,,,,no IP contract,,,78,,131.04,percent of total billed charges,,,70,,117.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,82.32,3324,
PARTIAL THROMBOPLASTIN TIME NMH,85730,CPT,,,,inpatient,,,172,103.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,139.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,146.2,percent of total billed charges,,,85,,146.2,percent of total billed charges,,,49,,84.28,percent of total billed charges,,,90,,154.8,percent of total billed charges,,,,,,,no IP contract,,80,,137.6,percent of total billed charges,,,,,,,no IP contract,,50,,86,percent of total billed charges,,,,,,no IP contract,,,78,,134.16,percent of total billed charges,,,70,,120.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,84.28,3324,
APTT-Activated PTT/Partial Thromboplastin Time,85730,CPT,,,,inpatient,,,200,120,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,162,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,170,percent of total billed charges,,,85,,170,percent of total billed charges,,,49,,98,percent of total billed charges,,,90,,180,percent of total billed charges,,,,,,,no IP contract,,80,,160,percent of total billed charges,,,,,,,no IP contract,,50,,100,percent of total billed charges,,,,,,no IP contract,,,78,,156,percent of total billed charges,,,70,,140,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,18708.56,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,98,18708.56,
PTT Mixing Studies,85730,CPT,,,,inpatient,,,261,156.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,211.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,221.85,percent of total billed charges,,,85,,221.85,percent of total billed charges,,,49,,127.89,percent of total billed charges,,,90,,234.9,percent of total billed charges,,,,,,,no IP contract,,80,,208.8,percent of total billed charges,,,,,,,no IP contract,,50,,130.5,percent of total billed charges,,,,,,no IP contract,,,78,,203.58,percent of total billed charges,,,70,,182.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,127.89,3324,
PTT Mixing Studies,85730,CPT,,,,inpatient,,,261,156.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,211.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,221.85,percent of total billed charges,,,85,,221.85,percent of total billed charges,,,49,,127.89,percent of total billed charges,,,90,,234.9,percent of total billed charges,,,,,,,no IP contract,,80,,208.8,percent of total billed charges,,,,,,,no IP contract,,50,,130.5,percent of total billed charges,,,,,,no IP contract,,,78,,203.58,percent of total billed charges,,,70,,182.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,127.89,3324,
Viscosity,85810,CPT,,,,inpatient,,,120,72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,97.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,102,percent of total billed charges,,,85,,102,percent of total billed charges,,,49,,58.8,percent of total billed charges,,,90,,108,percent of total billed charges,,,,,,,no IP contract,,80,,96,percent of total billed charges,,,,,,,no IP contract,,50,,60,percent of total billed charges,,,,,,no IP contract,,,78,,93.6,percent of total billed charges,,,70,,84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.8,3324,
Viscosity,85810,CPT,,,,inpatient,,,120,72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,97.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,102,percent of total billed charges,,,85,,102,percent of total billed charges,,,49,,58.8,percent of total billed charges,,,90,,108,percent of total billed charges,,,,,,,no IP contract,,80,,96,percent of total billed charges,,,,,,,no IP contract,,50,,60,percent of total billed charges,,,,,,no IP contract,,,78,,93.6,percent of total billed charges,,,70,,84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.8,3324,
Allergen-Latex Enhanced IgE,86003,CPT,,,,inpatient,,,71,42.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,57.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,60.35,percent of total billed charges,,,85,,60.35,percent of total billed charges,,,49,,34.79,percent of total billed charges,,,90,,63.9,percent of total billed charges,,,,,,,no IP contract,,80,,56.8,percent of total billed charges,,,,,,,no IP contract,,50,,35.5,percent of total billed charges,,,,,,no IP contract,,,78,,55.38,percent of total billed charges,,,70,,49.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,34.79,3324,
Myeloperoxidase,86021,CPT,,,,inpatient,,,236,141.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,191.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,200.6,percent of total billed charges,,,85,,200.6,percent of total billed charges,,,49,,115.64,percent of total billed charges,,,90,,212.4,percent of total billed charges,,,,,,,no IP contract,,80,,188.8,percent of total billed charges,,,,,,,no IP contract,,50,,118,percent of total billed charges,,,,,,no IP contract,,,78,,184.08,percent of total billed charges,,,70,,165.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,115.64,3324,
Anti Neutrophil Cytoplasmic AB by IF,86021,CPT,,,,inpatient,,,382,229.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,309.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,324.7,percent of total billed charges,,,85,,324.7,percent of total billed charges,,,49,,187.18,percent of total billed charges,,,90,,343.8,percent of total billed charges,,,,,,,no IP contract,,80,,305.6,percent of total billed charges,,,,,,,no IP contract,,50,,191,percent of total billed charges,,,,,,no IP contract,,,78,,297.96,percent of total billed charges,,,70,,267.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,24016.02667,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,187.18,24016.03,
Heparin Induced Antibody,86022,CPT,,,,inpatient,,,392,235.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,317.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,333.2,percent of total billed charges,,,85,,333.2,percent of total billed charges,,,49,,192.08,percent of total billed charges,,,90,,352.8,percent of total billed charges,,,,,,,no IP contract,,80,,313.6,percent of total billed charges,,,,,,,no IP contract,,50,,196,percent of total billed charges,,,,,,no IP contract,,,78,,305.76,percent of total billed charges,,,70,,274.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,192.08,3324,
Platelet Antibody Screen,86022,CPT,,,,inpatient,,,392,235.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,317.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,333.2,percent of total billed charges,,,85,,333.2,percent of total billed charges,,,49,,192.08,percent of total billed charges,,,90,,352.8,percent of total billed charges,,,,,,,no IP contract,,80,,313.6,percent of total billed charges,,,,,,,no IP contract,,50,,196,percent of total billed charges,,,,,,no IP contract,,,78,,305.76,percent of total billed charges,,,70,,274.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,192.08,3324,
"Serotonin Release Assay, 1 Drug",86022,CPT,,,,inpatient,,,534,320.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,432.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,453.9,percent of total billed charges,,,85,,453.9,percent of total billed charges,,,49,,261.66,percent of total billed charges,,,90,,480.6,percent of total billed charges,,,,,,,no IP contract,,80,,427.2,percent of total billed charges,,,,,,,no IP contract,,50,,267,percent of total billed charges,,,,,,no IP contract,,,78,,416.52,percent of total billed charges,,,70,,373.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,261.66,3324,
Platelet Antibody Screen/Identification Referred,86022,CPT,,,,inpatient,,,789,473.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,639.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,670.65,percent of total billed charges,,,85,,670.65,percent of total billed charges,,,49,,386.61,percent of total billed charges,,,90,,710.1,percent of total billed charges,,,,,,,no IP contract,,80,,631.2,percent of total billed charges,,,,,,,no IP contract,,50,,394.5,percent of total billed charges,,,,,,no IP contract,,,78,,615.42,percent of total billed charges,,,70,,552.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,386.61,3324,
Platelet Antib Heparin Induced NMH,86022,CPT,,,,inpatient,,,1049,629.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,849.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,891.65,percent of total billed charges,,,85,,891.65,percent of total billed charges,,,49,,514.01,percent of total billed charges,,,90,,944.1,percent of total billed charges,,,,,,,no IP contract,,80,,839.2,percent of total billed charges,,,,,,,no IP contract,,50,,524.5,percent of total billed charges,,,,,,no IP contract,,,78,,818.22,percent of total billed charges,,,70,,734.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,514.01,3324,
ANTINUCLEAR AB (ANA),86038,CPT,,,,inpatient,,,125,75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,101.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,106.25,percent of total billed charges,,,85,,106.25,percent of total billed charges,,,49,,61.25,percent of total billed charges,,,90,,112.5,percent of total billed charges,,,,,,,no IP contract,,80,,100,percent of total billed charges,,,,,,,no IP contract,,50,,62.5,percent of total billed charges,,,,,,no IP contract,,,78,,97.5,percent of total billed charges,,,70,,87.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,61.25,3324,
Antinuclear Antibody,86038,CPT,,,,inpatient,,,195,117,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,157.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,165.75,percent of total billed charges,,,85,,165.75,percent of total billed charges,,,49,,95.55,percent of total billed charges,,,90,,175.5,percent of total billed charges,,,,,,,no IP contract,,80,,156,percent of total billed charges,,,,,,,no IP contract,,50,,97.5,percent of total billed charges,,,,,,no IP contract,,,78,,152.1,percent of total billed charges,,,70,,136.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,42797.58,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,95.55,42797.58,
Anti Streptolysin O AB,86060,CPT,,,,inpatient,,,66,39.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,53.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.1,percent of total billed charges,,,85,,56.1,percent of total billed charges,,,49,,32.34,percent of total billed charges,,,90,,59.4,percent of total billed charges,,,,,,,no IP contract,,80,,52.8,percent of total billed charges,,,,,,,no IP contract,,50,,33,percent of total billed charges,,,,,,no IP contract,,,78,,51.48,percent of total billed charges,,,70,,46.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,35590.15875,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.34,35590.16,
C Reactive Protein,86140,CPT,,,,inpatient,,,145,87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,117.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,123.25,percent of total billed charges,,,85,,123.25,percent of total billed charges,,,49,,71.05,percent of total billed charges,,,90,,130.5,percent of total billed charges,,,,,,,no IP contract,,80,,116,percent of total billed charges,,,,,,,no IP contract,,50,,72.5,percent of total billed charges,,,,,,no IP contract,,,78,,113.1,percent of total billed charges,,,70,,101.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,23079.846,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,71.05,23079.85,
C-Reactive Protein-Hi Sensitivity,86140,CPT,,,,inpatient,,,145,87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,117.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,123.25,percent of total billed charges,,,85,,123.25,percent of total billed charges,,,49,,71.05,percent of total billed charges,,,90,,130.5,percent of total billed charges,,,,,,,no IP contract,,80,,116,percent of total billed charges,,,,,,,no IP contract,,50,,72.5,percent of total billed charges,,,,,,no IP contract,,,78,,113.1,percent of total billed charges,,,70,,101.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,71.05,3324,
Beta-2 GPI Antoantibodies,86146,CPT,,,,inpatient,,,266,159.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,215.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,226.1,percent of total billed charges,,,85,,226.1,percent of total billed charges,,,49,,130.34,percent of total billed charges,,,90,,239.4,percent of total billed charges,,,,,,,no IP contract,,80,,212.8,percent of total billed charges,,,,,,,no IP contract,,50,,133,percent of total billed charges,,,,,,no IP contract,,,78,,207.48,percent of total billed charges,,,70,,186.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,76063.435,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,130.34,76063.44,
CADIOLIPIN AB EA IG CLASS,86147,CPT,,,,inpatient,,,173,103.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,140.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,147.05,percent of total billed charges,,,85,,147.05,percent of total billed charges,,,49,,84.77,percent of total billed charges,,,90,,155.7,percent of total billed charges,,,,,,,no IP contract,,80,,138.4,percent of total billed charges,,,,,,,no IP contract,,50,,86.5,percent of total billed charges,,,,,,no IP contract,,,78,,134.94,percent of total billed charges,,,70,,121.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,84.77,3324,
Anticardiolipin Antibody,86147,CPT,,,,inpatient,,,333,199.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,269.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,283.05,percent of total billed charges,,,85,,283.05,percent of total billed charges,,,49,,163.17,percent of total billed charges,,,90,,299.7,percent of total billed charges,,,,,,,no IP contract,,80,,266.4,percent of total billed charges,,,,,,,no IP contract,,50,,166.5,percent of total billed charges,,,,,,no IP contract,,,78,,259.74,percent of total billed charges,,,70,,233.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,163.17,3324,
Anticardiolipin Antibody,86147,CPT,,,,inpatient,,,333,199.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,269.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,283.05,percent of total billed charges,,,85,,283.05,percent of total billed charges,,,49,,163.17,percent of total billed charges,,,90,,299.7,percent of total billed charges,,,,,,,no IP contract,,80,,266.4,percent of total billed charges,,,,,,,no IP contract,,50,,166.5,percent of total billed charges,,,,,,no IP contract,,,78,,259.74,percent of total billed charges,,,70,,233.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,163.17,3324,
Cardiolipin antibody,86147,CPT,,,,inpatient,,,333,199.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,269.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,283.05,percent of total billed charges,,,85,,283.05,percent of total billed charges,,,49,,163.17,percent of total billed charges,,,90,,299.7,percent of total billed charges,,,,,,,no IP contract,,80,,266.4,percent of total billed charges,,,,,,,no IP contract,,50,,166.5,percent of total billed charges,,,,,,no IP contract,,,78,,259.74,percent of total billed charges,,,70,,233.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,39604.4402,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,163.17,39604.44,
C3,86160,CPT,,,,inpatient,,,136,81.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,110.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,115.6,percent of total billed charges,,,85,,115.6,percent of total billed charges,,,49,,66.64,percent of total billed charges,,,90,,122.4,percent of total billed charges,,,,,,,no IP contract,,80,,108.8,percent of total billed charges,,,,,,,no IP contract,,50,,68,percent of total billed charges,,,,,,no IP contract,,,78,,106.08,percent of total billed charges,,,70,,95.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,66.64,3324,
C3,86160,CPT,,,,inpatient,,,136,81.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,110.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,115.6,percent of total billed charges,,,85,,115.6,percent of total billed charges,,,49,,66.64,percent of total billed charges,,,90,,122.4,percent of total billed charges,,,,,,,no IP contract,,80,,108.8,percent of total billed charges,,,,,,,no IP contract,,50,,68,percent of total billed charges,,,,,,no IP contract,,,78,,106.08,percent of total billed charges,,,70,,95.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,66.64,3324,
C4,86160,CPT,,,,inpatient,,,136,81.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,110.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,115.6,percent of total billed charges,,,85,,115.6,percent of total billed charges,,,49,,66.64,percent of total billed charges,,,90,,122.4,percent of total billed charges,,,,,,,no IP contract,,80,,108.8,percent of total billed charges,,,,,,,no IP contract,,50,,68,percent of total billed charges,,,,,,no IP contract,,,78,,106.08,percent of total billed charges,,,70,,95.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,29682.2,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,66.64,29682.2,
C4,86160,CPT,,,,inpatient,,,136,81.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,110.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,115.6,percent of total billed charges,,,85,,115.6,percent of total billed charges,,,49,,66.64,percent of total billed charges,,,90,,122.4,percent of total billed charges,,,,,,,no IP contract,,80,,108.8,percent of total billed charges,,,,,,,no IP contract,,50,,68,percent of total billed charges,,,,,,no IP contract,,,78,,106.08,percent of total billed charges,,,70,,95.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,24519.8,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,66.64,24519.8,
"Complement C3,C4",86160,CPT,,,,inpatient,,,136,81.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,110.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,115.6,percent of total billed charges,,,85,,115.6,percent of total billed charges,,,49,,66.64,percent of total billed charges,,,90,,122.4,percent of total billed charges,,,,,,,no IP contract,,80,,108.8,percent of total billed charges,,,,,,,no IP contract,,50,,68,percent of total billed charges,,,,,,no IP contract,,,78,,106.08,percent of total billed charges,,,70,,95.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,66.64,3324,
"Complement, Antigen",86160,CPT,,,,inpatient,,,136,81.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,110.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,115.6,percent of total billed charges,,,85,,115.6,percent of total billed charges,,,49,,66.64,percent of total billed charges,,,90,,122.4,percent of total billed charges,,,,,,,no IP contract,,80,,108.8,percent of total billed charges,,,,,,,no IP contract,,50,,68,percent of total billed charges,,,,,,no IP contract,,,78,,106.08,percent of total billed charges,,,70,,95.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,66.64,3324,
COMPLEMENT; AG EA,86160,CPT,,,,inpatient,,,136,81.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,110.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,115.6,percent of total billed charges,,,85,,115.6,percent of total billed charges,,,49,,66.64,percent of total billed charges,,,90,,122.4,percent of total billed charges,,,,,,,no IP contract,,80,,108.8,percent of total billed charges,,,,,,,no IP contract,,50,,68,percent of total billed charges,,,,,,no IP contract,,,78,,106.08,percent of total billed charges,,,70,,95.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,66.64,3324,
C1 Esterase Inhibitor,86160,CPT,,,,inpatient,,,142,85.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,115.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,120.7,percent of total billed charges,,,85,,120.7,percent of total billed charges,,,49,,69.58,percent of total billed charges,,,90,,127.8,percent of total billed charges,,,,,,,no IP contract,,80,,113.6,percent of total billed charges,,,,,,,no IP contract,,50,,71,percent of total billed charges,,,,,,no IP contract,,,78,,110.76,percent of total billed charges,,,70,,99.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,34445.965,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,69.58,34445.97,
"CD3,4 Peripheral Blood",86160,CPT,,,,inpatient,,,319,191.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,258.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,271.15,percent of total billed charges,,,85,,271.15,percent of total billed charges,,,49,,156.31,percent of total billed charges,,,90,,287.1,percent of total billed charges,,,,,,,no IP contract,,80,,255.2,percent of total billed charges,,,,,,,no IP contract,,50,,159.5,percent of total billed charges,,,,,,no IP contract,,,78,,248.82,percent of total billed charges,,,70,,223.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,156.31,3324,
Complement Functional Activity,86161,CPT,,,,inpatient,,,108,64.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,87.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,91.8,percent of total billed charges,,,85,,91.8,percent of total billed charges,,,49,,52.92,percent of total billed charges,,,90,,97.2,percent of total billed charges,,,,,,,no IP contract,,80,,86.4,percent of total billed charges,,,,,,,no IP contract,,50,,54,percent of total billed charges,,,,,,no IP contract,,,78,,84.24,percent of total billed charges,,,70,,75.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,52.92,3324,
C3 *,86161,CPT,,,,inpatient,,,133,79.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,107.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,113.05,percent of total billed charges,,,85,,113.05,percent of total billed charges,,,49,,65.17,percent of total billed charges,,,90,,119.7,percent of total billed charges,,,,,,,no IP contract,,80,,106.4,percent of total billed charges,,,,,,,no IP contract,,50,,66.5,percent of total billed charges,,,,,,no IP contract,,,78,,103.74,percent of total billed charges,,,70,,93.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,65.17,3324,
C4 *,86161,CPT,,,,inpatient,,,133,79.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,107.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,113.05,percent of total billed charges,,,85,,113.05,percent of total billed charges,,,49,,65.17,percent of total billed charges,,,90,,119.7,percent of total billed charges,,,,,,,no IP contract,,80,,106.4,percent of total billed charges,,,,,,,no IP contract,,50,,66.5,percent of total billed charges,,,,,,no IP contract,,,78,,103.74,percent of total billed charges,,,70,,93.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,65.17,3324,
CH50,86162,CPT,,,,inpatient,,,316,189.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,255.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,268.6,percent of total billed charges,,,85,,268.6,percent of total billed charges,,,49,,154.84,percent of total billed charges,,,90,,284.4,percent of total billed charges,,,,,,,no IP contract,,80,,252.8,percent of total billed charges,,,,,,,no IP contract,,50,,158,percent of total billed charges,,,,,,no IP contract,,,78,,246.48,percent of total billed charges,,,70,,221.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,154.84,3324,
"Complement, Total (CH50, C3 & C4)",86162,CPT,,,,inpatient,,,316,189.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,255.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,268.6,percent of total billed charges,,,85,,268.6,percent of total billed charges,,,49,,154.84,percent of total billed charges,,,90,,284.4,percent of total billed charges,,,,,,,no IP contract,,80,,252.8,percent of total billed charges,,,,,,,no IP contract,,50,,158,percent of total billed charges,,,,,,no IP contract,,,78,,246.48,percent of total billed charges,,,70,,221.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,154.84,3324,
Cyclic Citrulinated Peptide,86200,CPT,,,,inpatient,,,82,49.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,66.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,69.7,percent of total billed charges,,,85,,69.7,percent of total billed charges,,,49,,40.18,percent of total billed charges,,,90,,73.8,percent of total billed charges,,,,,,,no IP contract,,80,,65.6,percent of total billed charges,,,,,,,no IP contract,,50,,41,percent of total billed charges,,,,,,no IP contract,,,78,,63.96,percent of total billed charges,,,70,,57.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,40.18,3324,
"Anti-Dnase B Antibodies, Streptococcal",86215,CPT,,,,inpatient,,,109,65.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,88.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,92.65,percent of total billed charges,,,85,,92.65,percent of total billed charges,,,49,,53.41,percent of total billed charges,,,90,,98.1,percent of total billed charges,,,,,,,no IP contract,,80,,87.2,percent of total billed charges,,,,,,,no IP contract,,50,,54.5,percent of total billed charges,,,,,,no IP contract,,,78,,85.02,percent of total billed charges,,,70,,76.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,53.41,3324,
DNA,86225,CPT,,,,inpatient,,,143,85.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,115.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,121.55,percent of total billed charges,,,85,,121.55,percent of total billed charges,,,49,,70.07,percent of total billed charges,,,90,,128.7,percent of total billed charges,,,,,,,no IP contract,,80,,114.4,percent of total billed charges,,,,,,,no IP contract,,50,,71.5,percent of total billed charges,,,,,,no IP contract,,,78,,111.54,percent of total billed charges,,,70,,100.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,70.07,3324,
DNA *,86225,CPT,,,,inpatient,,,143,85.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,115.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,121.55,percent of total billed charges,,,85,,121.55,percent of total billed charges,,,49,,70.07,percent of total billed charges,,,90,,128.7,percent of total billed charges,,,,,,,no IP contract,,80,,114.4,percent of total billed charges,,,,,,,no IP contract,,50,,71.5,percent of total billed charges,,,,,,no IP contract,,,78,,111.54,percent of total billed charges,,,70,,100.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,70.07,3324,
DNA **,86225,CPT,,,,inpatient,,,143,85.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,115.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,121.55,percent of total billed charges,,,85,,121.55,percent of total billed charges,,,49,,70.07,percent of total billed charges,,,90,,128.7,percent of total billed charges,,,,,,,no IP contract,,80,,114.4,percent of total billed charges,,,,,,,no IP contract,,50,,71.5,percent of total billed charges,,,,,,no IP contract,,,78,,111.54,percent of total billed charges,,,70,,100.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,70.07,3324,
Anti-DNA Antibody,86225,CPT,,,,inpatient,,,220,132,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,178.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,187,percent of total billed charges,,,85,,187,percent of total billed charges,,,49,,107.8,percent of total billed charges,,,90,,198,percent of total billed charges,,,,,,,no IP contract,,80,,176,percent of total billed charges,,,,,,,no IP contract,,50,,110,percent of total billed charges,,,,,,no IP contract,,,78,,171.6,percent of total billed charges,,,70,,154,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,30867.43,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,107.8,30867.43,
Anti-DNA Antibody,86225,CPT,,,,inpatient,,,220,132,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,178.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,187,percent of total billed charges,,,85,,187,percent of total billed charges,,,49,,107.8,percent of total billed charges,,,90,,198,percent of total billed charges,,,,,,,no IP contract,,80,,176,percent of total billed charges,,,,,,,no IP contract,,50,,110,percent of total billed charges,,,,,,no IP contract,,,78,,171.6,percent of total billed charges,,,70,,154,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,24874.865,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,107.8,24874.87,
Lupus Activity Reporter,86225,CPT,,,,inpatient,,,220,132,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,178.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,187,percent of total billed charges,,,85,,187,percent of total billed charges,,,49,,107.8,percent of total billed charges,,,90,,198,percent of total billed charges,,,,,,,no IP contract,,80,,176,percent of total billed charges,,,,,,,no IP contract,,50,,110,percent of total billed charges,,,,,,no IP contract,,,78,,171.6,percent of total billed charges,,,70,,154,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,107.8,3324,
Extractable nuclear antigen,86235,CPT,,,,inpatient,,,128,76.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,103.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,108.8,percent of total billed charges,,,85,,108.8,percent of total billed charges,,,49,,62.72,percent of total billed charges,,,90,,115.2,percent of total billed charges,,,,,,,no IP contract,,80,,102.4,percent of total billed charges,,,,,,,no IP contract,,50,,64,percent of total billed charges,,,,,,no IP contract,,,78,,99.84,percent of total billed charges,,,70,,89.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,62.72,3324,
Extractable nuclear antigen *,86235,CPT,,,,inpatient,,,128,76.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,103.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,108.8,percent of total billed charges,,,85,,108.8,percent of total billed charges,,,49,,62.72,percent of total billed charges,,,90,,115.2,percent of total billed charges,,,,,,,no IP contract,,80,,102.4,percent of total billed charges,,,,,,,no IP contract,,50,,64,percent of total billed charges,,,,,,no IP contract,,,78,,99.84,percent of total billed charges,,,70,,89.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,62.72,3324,
Extractable nuclear antigen **,86235,CPT,,,,inpatient,,,128,76.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,103.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,108.8,percent of total billed charges,,,85,,108.8,percent of total billed charges,,,49,,62.72,percent of total billed charges,,,90,,115.2,percent of total billed charges,,,,,,,no IP contract,,80,,102.4,percent of total billed charges,,,,,,,no IP contract,,50,,64,percent of total billed charges,,,,,,no IP contract,,,78,,99.84,percent of total billed charges,,,70,,89.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,62.72,3324,
Histone Semi-Quantitative,86235,CPT,,,,inpatient,,,184,110.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,149.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,156.4,percent of total billed charges,,,85,,156.4,percent of total billed charges,,,49,,90.16,percent of total billed charges,,,90,,165.6,percent of total billed charges,,,,,,,no IP contract,,80,,147.2,percent of total billed charges,,,,,,,no IP contract,,50,,92,percent of total billed charges,,,,,,no IP contract,,,78,,143.52,percent of total billed charges,,,70,,128.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,90.16,3324,
Jo-1 Quantitative,86235,CPT,,,,inpatient,,,184,110.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,149.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,156.4,percent of total billed charges,,,85,,156.4,percent of total billed charges,,,49,,90.16,percent of total billed charges,,,90,,165.6,percent of total billed charges,,,,,,,no IP contract,,80,,147.2,percent of total billed charges,,,,,,,no IP contract,,50,,92,percent of total billed charges,,,,,,no IP contract,,,78,,143.52,percent of total billed charges,,,70,,128.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,90.16,3324,
RNP/Sm Quantitative,86235,CPT,,,,inpatient,,,184,110.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,149.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,156.4,percent of total billed charges,,,85,,156.4,percent of total billed charges,,,49,,90.16,percent of total billed charges,,,90,,165.6,percent of total billed charges,,,,,,,no IP contract,,80,,147.2,percent of total billed charges,,,,,,,no IP contract,,50,,92,percent of total billed charges,,,,,,no IP contract,,,78,,143.52,percent of total billed charges,,,70,,128.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,90.16,3324,
Scl-70 Quantitative,86235,CPT,,,,inpatient,,,184,110.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,149.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,156.4,percent of total billed charges,,,85,,156.4,percent of total billed charges,,,49,,90.16,percent of total billed charges,,,90,,165.6,percent of total billed charges,,,,,,,no IP contract,,80,,147.2,percent of total billed charges,,,,,,,no IP contract,,50,,92,percent of total billed charges,,,,,,no IP contract,,,78,,143.52,percent of total billed charges,,,70,,128.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,90.16,3324,
Sjogren's Antibodies,86235,CPT,,,,inpatient,,,184,110.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,149.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,156.4,percent of total billed charges,,,85,,156.4,percent of total billed charges,,,49,,90.16,percent of total billed charges,,,90,,165.6,percent of total billed charges,,,,,,,no IP contract,,80,,147.2,percent of total billed charges,,,,,,,no IP contract,,50,,92,percent of total billed charges,,,,,,no IP contract,,,78,,143.52,percent of total billed charges,,,70,,128.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,90.16,3324,
Sm Quantitative,86235,CPT,,,,inpatient,,,184,110.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,149.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,156.4,percent of total billed charges,,,85,,156.4,percent of total billed charges,,,49,,90.16,percent of total billed charges,,,90,,165.6,percent of total billed charges,,,,,,,no IP contract,,80,,147.2,percent of total billed charges,,,,,,,no IP contract,,50,,92,percent of total billed charges,,,,,,no IP contract,,,78,,143.52,percent of total billed charges,,,70,,128.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,90.16,3324,
SSA (Ro) Quantitative,86235,CPT,,,,inpatient,,,247,148.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,200.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,209.95,percent of total billed charges,,,85,,209.95,percent of total billed charges,,,49,,121.03,percent of total billed charges,,,90,,222.3,percent of total billed charges,,,,,,,no IP contract,,80,,197.6,percent of total billed charges,,,,,,,no IP contract,,50,,123.5,percent of total billed charges,,,,,,no IP contract,,,78,,192.66,percent of total billed charges,,,70,,172.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,121.03,3324,
SSB (La) Quantitative,86235,CPT,,,,inpatient,,,247,148.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,200.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,209.95,percent of total billed charges,,,85,,209.95,percent of total billed charges,,,49,,121.03,percent of total billed charges,,,90,,222.3,percent of total billed charges,,,,,,,no IP contract,,80,,197.6,percent of total billed charges,,,,,,,no IP contract,,50,,123.5,percent of total billed charges,,,,,,no IP contract,,,78,,192.66,percent of total billed charges,,,70,,172.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,121.03,3324,
Anticentromere Antibodies,86255,CPT,,,,inpatient,,,46,27.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,37.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,39.1,percent of total billed charges,,,85,,39.1,percent of total billed charges,,,49,,22.54,percent of total billed charges,,,90,,41.4,percent of total billed charges,,,,,,,no IP contract,,80,,36.8,percent of total billed charges,,,,,,,no IP contract,,50,,23,percent of total billed charges,,,,,,no IP contract,,,78,,35.88,percent of total billed charges,,,70,,32.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.54,3324,
Anti-Smooth Muscle AB,86255,CPT,,,,inpatient,,,212,127.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,171.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,180.2,percent of total billed charges,,,85,,180.2,percent of total billed charges,,,49,,103.88,percent of total billed charges,,,90,,190.8,percent of total billed charges,,,,,,,no IP contract,,80,,169.6,percent of total billed charges,,,,,,,no IP contract,,50,,106,percent of total billed charges,,,,,,no IP contract,,,78,,165.36,percent of total billed charges,,,70,,148.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,103.88,3324,
Anti-Parietal Cell AB,86255,CPT,,,,inpatient,,,218,130.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,176.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,185.3,percent of total billed charges,,,85,,185.3,percent of total billed charges,,,49,,106.82,percent of total billed charges,,,90,,196.2,percent of total billed charges,,,,,,,no IP contract,,80,,174.4,percent of total billed charges,,,,,,,no IP contract,,50,,109,percent of total billed charges,,,,,,no IP contract,,,78,,170.04,percent of total billed charges,,,70,,152.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,68665.29333,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,106.82,68665.29,
Neuromyelitis Optica IgG,86255,CPT,,,,inpatient,,,408,244.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,330.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,346.8,percent of total billed charges,,,85,,346.8,percent of total billed charges,,,49,,199.92,percent of total billed charges,,,90,,367.2,percent of total billed charges,,,,,,,no IP contract,,80,,326.4,percent of total billed charges,,,,,,,no IP contract,,50,,204,percent of total billed charges,,,,,,no IP contract,,,78,,318.24,percent of total billed charges,,,70,,285.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,199.92,3324,
Fluorescent AB; Titer Ea AB,86256,CPT,,,,inpatient,,,110,66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,89.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,93.5,percent of total billed charges,,,85,,93.5,percent of total billed charges,,,49,,53.9,percent of total billed charges,,,90,,99,percent of total billed charges,,,,,,,no IP contract,,80,,88,percent of total billed charges,,,,,,,no IP contract,,50,,55,percent of total billed charges,,,,,,no IP contract,,,78,,85.8,percent of total billed charges,,,70,,77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,53.9,3324,
"Endomysial Autoantibodies, IgG",86256,CPT,,,,inpatient,,,190,114,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,153.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,161.5,percent of total billed charges,,,85,,161.5,percent of total billed charges,,,49,,93.1,percent of total billed charges,,,90,,171,percent of total billed charges,,,,,,,no IP contract,,80,,152,percent of total billed charges,,,,,,,no IP contract,,50,,95,percent of total billed charges,,,,,,no IP contract,,,78,,148.2,percent of total billed charges,,,70,,133,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,93.1,3324,
Rabies Antibodies Titer,86256,CPT,,,,inpatient,,,190,114,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,153.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,161.5,percent of total billed charges,,,85,,161.5,percent of total billed charges,,,49,,93.1,percent of total billed charges,,,90,,171,percent of total billed charges,,,,,,,no IP contract,,80,,152,percent of total billed charges,,,,,,,no IP contract,,50,,95,percent of total billed charges,,,,,,no IP contract,,,78,,148.2,percent of total billed charges,,,70,,133,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,93.1,3324,
Anti-Mitochondrial AB,86256,CPT,,,,inpatient,,,202,121.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,163.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,171.7,percent of total billed charges,,,85,,171.7,percent of total billed charges,,,49,,98.98,percent of total billed charges,,,90,,181.8,percent of total billed charges,,,,,,,no IP contract,,80,,161.6,percent of total billed charges,,,,,,,no IP contract,,50,,101,percent of total billed charges,,,,,,no IP contract,,,78,,157.56,percent of total billed charges,,,70,,141.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,98.98,3324,
Anti OKT3 Ab Titers,86256,CPT,,,,inpatient,,,359,215.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,290.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,305.15,percent of total billed charges,,,85,,305.15,percent of total billed charges,,,49,,175.91,percent of total billed charges,,,90,,323.1,percent of total billed charges,,,,,,,no IP contract,,80,,287.2,percent of total billed charges,,,,,,,no IP contract,,50,,179.5,percent of total billed charges,,,,,,no IP contract,,,78,,280.02,percent of total billed charges,,,70,,251.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,27338.66333,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,175.91,27338.66,
CA27.29,86300,CPT,,,,inpatient,,,104,62.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,84.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,88.4,percent of total billed charges,,,85,,88.4,percent of total billed charges,,,49,,50.96,percent of total billed charges,,,90,,93.6,percent of total billed charges,,,,,,,no IP contract,,80,,83.2,percent of total billed charges,,,,,,,no IP contract,,50,,52,percent of total billed charges,,,,,,no IP contract,,,78,,81.12,percent of total billed charges,,,70,,72.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,50.96,3324,
CA19-9,86301,CPT,,,,inpatient,,,167,100.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,135.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,141.95,percent of total billed charges,,,85,,141.95,percent of total billed charges,,,49,,81.83,percent of total billed charges,,,90,,150.3,percent of total billed charges,,,,,,,no IP contract,,80,,133.6,percent of total billed charges,,,,,,,no IP contract,,50,,83.5,percent of total billed charges,,,,,,no IP contract,,,78,,130.26,percent of total billed charges,,,70,,116.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,81.83,3324,
Cancer Antigen 125,86304,CPT,,,,inpatient,,,348,208.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,281.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,295.8,percent of total billed charges,,,85,,295.8,percent of total billed charges,,,49,,170.52,percent of total billed charges,,,90,,313.2,percent of total billed charges,,,,,,,no IP contract,,80,,278.4,percent of total billed charges,,,,,,,no IP contract,,50,,174,percent of total billed charges,,,,,,no IP contract,,,78,,271.44,percent of total billed charges,,,70,,243.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,170.52,3324,
Heterophile Screen,86308,CPT,,,,inpatient,,,140,84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,113.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,119,percent of total billed charges,,,85,,119,percent of total billed charges,,,49,,68.6,percent of total billed charges,,,90,,126,percent of total billed charges,,,,,,,no IP contract,,80,,112,percent of total billed charges,,,,,,,no IP contract,,50,,70,percent of total billed charges,,,,,,no IP contract,,,78,,109.2,percent of total billed charges,,,70,,98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,68.6,3324,
"Hepatitis B Surface Antibody, Quant, End",86317,CPT,,,,inpatient,,,221,132.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,179.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,187.85,percent of total billed charges,,,85,,187.85,percent of total billed charges,,,49,,108.29,percent of total billed charges,,,90,,198.9,percent of total billed charges,,,,,,,no IP contract,,80,,176.8,percent of total billed charges,,,,,,,no IP contract,,50,,110.5,percent of total billed charges,,,,,,no IP contract,,,78,,172.38,percent of total billed charges,,,70,,154.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,108.29,3324,
Immunofixation Profile,86334,CPT,,,,inpatient,,,277,166.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,224.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,235.45,percent of total billed charges,,,85,,235.45,percent of total billed charges,,,49,,135.73,percent of total billed charges,,,90,,249.3,percent of total billed charges,,,,,,,no IP contract,,80,,221.6,percent of total billed charges,,,,,,,no IP contract,,50,,138.5,percent of total billed charges,,,,,,no IP contract,,,78,,216.06,percent of total billed charges,,,70,,193.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,135.73,3324,
"Immunofixation Electrophoresis, Urine",86334,CPT,,,,inpatient,,,407,244.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,329.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,345.95,percent of total billed charges,,,85,,345.95,percent of total billed charges,,,49,,199.43,percent of total billed charges,,,90,,366.3,percent of total billed charges,,,,,,,no IP contract,,80,,325.6,percent of total billed charges,,,,,,,no IP contract,,50,,203.5,percent of total billed charges,,,,,,no IP contract,,,78,,317.46,percent of total billed charges,,,70,,284.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,199.43,3324,
"immunofixation electrophoresis, other fluid requiring concentration",86335,CPT,,,,inpatient,,,341,204.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,276.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,289.85,percent of total billed charges,,,85,,289.85,percent of total billed charges,,,49,,167.09,percent of total billed charges,,,90,,306.9,percent of total billed charges,,,,,,,no IP contract,,80,,272.8,percent of total billed charges,,,,,,,no IP contract,,50,,170.5,percent of total billed charges,,,,,,no IP contract,,,78,,265.98,percent of total billed charges,,,70,,238.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,167.09,3324,
"Immunofixation Electrophoresis, Timed Urine",86335,CPT,,,,inpatient,,,341,204.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,276.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,289.85,percent of total billed charges,,,85,,289.85,percent of total billed charges,,,49,,167.09,percent of total billed charges,,,90,,306.9,percent of total billed charges,,,,,,,no IP contract,,80,,272.8,percent of total billed charges,,,,,,,no IP contract,,50,,170.5,percent of total billed charges,,,,,,no IP contract,,,78,,265.98,percent of total billed charges,,,70,,238.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,167.09,3324,
Beta-2-Transferrin,86335,CPT,,,,inpatient,,,358,214.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,289.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,304.3,percent of total billed charges,,,85,,304.3,percent of total billed charges,,,49,,175.42,percent of total billed charges,,,90,,322.2,percent of total billed charges,,,,,,,no IP contract,,80,,286.4,percent of total billed charges,,,,,,,no IP contract,,50,,179,percent of total billed charges,,,,,,no IP contract,,,78,,279.24,percent of total billed charges,,,70,,250.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,21006.35333,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,175.42,21006.35,
Alpha Fetoprotein Quad 4,86336,CPT,,,,inpatient,,,334,200.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,270.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,283.9,percent of total billed charges,,,85,,283.9,percent of total billed charges,,,49,,163.66,percent of total billed charges,,,90,,300.6,percent of total billed charges,,,,,,,no IP contract,,80,,267.2,percent of total billed charges,,,,,,,no IP contract,,50,,167,percent of total billed charges,,,,,,no IP contract,,,78,,260.52,percent of total billed charges,,,70,,233.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,163.66,3324,
Intrinsic Factor Antibody NMH,86340,CPT,,,,inpatient,,,144,86.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,116.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,122.4,percent of total billed charges,,,85,,122.4,percent of total billed charges,,,49,,70.56,percent of total billed charges,,,90,,129.6,percent of total billed charges,,,,,,,no IP contract,,80,,115.2,percent of total billed charges,,,,,,,no IP contract,,50,,72,percent of total billed charges,,,,,,no IP contract,,,78,,112.32,percent of total billed charges,,,70,,100.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,70.56,3324,
REF IMMUNE CELL FUNCTION NMH,86352,CPT,,,,inpatient,,,497,298.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,402.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,422.45,percent of total billed charges,,,85,,422.45,percent of total billed charges,,,49,,243.53,percent of total billed charges,,,90,,447.3,percent of total billed charges,,,,,,,no IP contract,,80,,397.6,percent of total billed charges,,,,,,,no IP contract,,50,,248.5,percent of total billed charges,,,,,,no IP contract,,,78,,387.66,percent of total billed charges,,,70,,347.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,243.53,3324,
Natural Killer Cells(NK cells),86357,CPT,,,,inpatient,,,293,175.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,237.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,249.05,percent of total billed charges,,,85,,249.05,percent of total billed charges,,,49,,143.57,percent of total billed charges,,,90,,263.7,percent of total billed charges,,,,,,,no IP contract,,80,,234.4,percent of total billed charges,,,,,,,no IP contract,,50,,146.5,percent of total billed charges,,,,,,no IP contract,,,78,,228.54,percent of total billed charges,,,70,,205.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,143.57,3324,
CD3,86359,CPT,,,,inpatient,,,299,179.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,242.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,254.15,percent of total billed charges,,,85,,254.15,percent of total billed charges,,,49,,146.51,percent of total billed charges,,,90,,269.1,percent of total billed charges,,,,,,,no IP contract,,80,,239.2,percent of total billed charges,,,,,,,no IP contract,,50,,149.5,percent of total billed charges,,,,,,no IP contract,,,78,,233.22,percent of total billed charges,,,70,,209.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,146.51,3324,
"Flow Cytometry, CSF",86359,CPT,,,,inpatient,,,299,179.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,242.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,254.15,percent of total billed charges,,,85,,254.15,percent of total billed charges,,,49,,146.51,percent of total billed charges,,,90,,269.1,percent of total billed charges,,,,,,,no IP contract,,80,,239.2,percent of total billed charges,,,,,,,no IP contract,,50,,149.5,percent of total billed charges,,,,,,no IP contract,,,78,,233.22,percent of total billed charges,,,70,,209.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,146.51,3324,
T Cell Monitoring,86360,CPT,,,,inpatient,,,441,264.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,357.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,374.85,percent of total billed charges,,,85,,374.85,percent of total billed charges,,,49,,216.09,percent of total billed charges,,,90,,396.9,percent of total billed charges,,,,,,,no IP contract,,80,,352.8,percent of total billed charges,,,,,,,no IP contract,,50,,220.5,percent of total billed charges,,,,,,no IP contract,,,78,,343.98,percent of total billed charges,,,70,,308.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,216.09,3324,
T Cell Monitoring,86360,CPT,,,,inpatient,,,441,264.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,357.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,374.85,percent of total billed charges,,,85,,374.85,percent of total billed charges,,,49,,216.09,percent of total billed charges,,,90,,396.9,percent of total billed charges,,,,,,,no IP contract,,80,,352.8,percent of total billed charges,,,,,,,no IP contract,,50,,220.5,percent of total billed charges,,,,,,no IP contract,,,78,,343.98,percent of total billed charges,,,70,,308.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,216.09,3324,
CD34,86367,CPT,,,,inpatient,,,327,196.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,264.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,277.95,percent of total billed charges,,,85,,277.95,percent of total billed charges,,,49,,160.23,percent of total billed charges,,,90,,294.3,percent of total billed charges,,,,,,,no IP contract,,80,,261.6,percent of total billed charges,,,,,,,no IP contract,,50,,163.5,percent of total billed charges,,,,,,no IP contract,,,78,,255.06,percent of total billed charges,,,70,,228.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,160.23,3324,
Thyroid Peroxidase Antibodies,86376,CPT,,,,inpatient,,,43,25.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36.55,percent of total billed charges,,,85,,36.55,percent of total billed charges,,,49,,21.07,percent of total billed charges,,,90,,38.7,percent of total billed charges,,,,,,,no IP contract,,80,,34.4,percent of total billed charges,,,,,,,no IP contract,,50,,21.5,percent of total billed charges,,,,,,no IP contract,,,78,,33.54,percent of total billed charges,,,70,,30.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.07,3324,
Thyroid Peroxidase Antibodies,86376,CPT,,,,inpatient,,,43,25.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36.55,percent of total billed charges,,,85,,36.55,percent of total billed charges,,,49,,21.07,percent of total billed charges,,,90,,38.7,percent of total billed charges,,,,,,,no IP contract,,80,,34.4,percent of total billed charges,,,,,,,no IP contract,,50,,21.5,percent of total billed charges,,,,,,no IP contract,,,78,,33.54,percent of total billed charges,,,70,,30.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.07,3324,
Thyroid Peroxidase Antibodies *,86376,CPT,,,,inpatient,,,43,25.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36.55,percent of total billed charges,,,85,,36.55,percent of total billed charges,,,49,,21.07,percent of total billed charges,,,90,,38.7,percent of total billed charges,,,,,,,no IP contract,,80,,34.4,percent of total billed charges,,,,,,,no IP contract,,50,,21.5,percent of total billed charges,,,,,,no IP contract,,,78,,33.54,percent of total billed charges,,,70,,30.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.07,3324,
Liver-Kidney Microsome Autoantibodies,86376,CPT,,,,inpatient,,,317,190.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,256.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,269.45,percent of total billed charges,,,85,,269.45,percent of total billed charges,,,49,,155.33,percent of total billed charges,,,90,,285.3,percent of total billed charges,,,,,,,no IP contract,,80,,253.6,percent of total billed charges,,,,,,,no IP contract,,50,,158.5,percent of total billed charges,,,,,,no IP contract,,,78,,247.26,percent of total billed charges,,,70,,221.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,155.33,3324,
Cryptococcal Screen-Blood,86403,CPT,,,,inpatient,,,106,63.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,85.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,90.1,percent of total billed charges,,,85,,90.1,percent of total billed charges,,,49,,51.94,percent of total billed charges,,,90,,95.4,percent of total billed charges,,,,,,,no IP contract,,80,,84.8,percent of total billed charges,,,,,,,no IP contract,,50,,53,percent of total billed charges,,,,,,no IP contract,,,78,,82.68,percent of total billed charges,,,70,,74.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,51.94,3324,
Cryptococcal Screen-CSF,86403,CPT,,,,inpatient,,,106,63.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,85.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,90.1,percent of total billed charges,,,85,,90.1,percent of total billed charges,,,49,,51.94,percent of total billed charges,,,90,,95.4,percent of total billed charges,,,,,,,no IP contract,,80,,84.8,percent of total billed charges,,,,,,,no IP contract,,50,,53,percent of total billed charges,,,,,,no IP contract,,,78,,82.68,percent of total billed charges,,,70,,74.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,51.94,3324,
Cryptococcal Screen-Stool,86403,CPT,,,,inpatient,,,106,63.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,85.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,90.1,percent of total billed charges,,,85,,90.1,percent of total billed charges,,,49,,51.94,percent of total billed charges,,,90,,95.4,percent of total billed charges,,,,,,,no IP contract,,80,,84.8,percent of total billed charges,,,,,,,no IP contract,,50,,53,percent of total billed charges,,,,,,no IP contract,,,78,,82.68,percent of total billed charges,,,70,,74.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,51.94,3324,
Rheumatoid Factor Quntitative,86431,CPT,,,,inpatient,,,40,24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34,percent of total billed charges,,,85,,34,percent of total billed charges,,,49,,19.6,percent of total billed charges,,,90,,36,percent of total billed charges,,,,,,,no IP contract,,80,,32,percent of total billed charges,,,,,,,no IP contract,,50,,20,percent of total billed charges,,,,,,no IP contract,,,78,,31.2,percent of total billed charges,,,70,,28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.6,3324,
Rheumatoid Factor Quntitative *,86431,CPT,,,,inpatient,,,40,24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34,percent of total billed charges,,,85,,34,percent of total billed charges,,,49,,19.6,percent of total billed charges,,,90,,36,percent of total billed charges,,,,,,,no IP contract,,80,,32,percent of total billed charges,,,,,,,no IP contract,,50,,20,percent of total billed charges,,,,,,no IP contract,,,78,,31.2,percent of total billed charges,,,70,,28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.6,3324,
Rheumatoid Factor Quant.,86431,CPT,,,,inpatient,,,126,75.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,102.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,107.1,percent of total billed charges,,,85,,107.1,percent of total billed charges,,,49,,61.74,percent of total billed charges,,,90,,113.4,percent of total billed charges,,,,,,,no IP contract,,80,,100.8,percent of total billed charges,,,,,,,no IP contract,,50,,63,percent of total billed charges,,,,,,no IP contract,,,78,,98.28,percent of total billed charges,,,70,,88.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,61.74,3324,
Tuberculosis Immunity Test,86480,CPT,,,,inpatient,,,548,328.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,443.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,465.8,percent of total billed charges,,,85,,465.8,percent of total billed charges,,,49,,268.52,percent of total billed charges,,,90,,493.2,percent of total billed charges,,,,,,,no IP contract,,80,,438.4,percent of total billed charges,,,,,,,no IP contract,,50,,274,percent of total billed charges,,,,,,no IP contract,,,78,,427.44,percent of total billed charges,,,70,,383.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,268.52,3324,
Adenovirus Antibody,86603,CPT,,,,inpatient,,,109,65.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,88.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,92.65,percent of total billed charges,,,85,,92.65,percent of total billed charges,,,49,,53.41,percent of total billed charges,,,90,,98.1,percent of total billed charges,,,,,,,no IP contract,,80,,87.2,percent of total billed charges,,,,,,,no IP contract,,50,,54.5,percent of total billed charges,,,,,,no IP contract,,,78,,85.02,percent of total billed charges,,,70,,76.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,53.41,3324,
Streptococcus Pneumoniae IgG Antibodies,86609,CPT,,,,inpatient,,,133,79.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,107.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,113.05,percent of total billed charges,,,85,,113.05,percent of total billed charges,,,49,,65.17,percent of total billed charges,,,90,,119.7,percent of total billed charges,,,,,,,no IP contract,,80,,106.4,percent of total billed charges,,,,,,,no IP contract,,50,,66.5,percent of total billed charges,,,,,,no IP contract,,,78,,103.74,percent of total billed charges,,,70,,93.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,65.17,3324,
Streptococcus Pneumoniae IgG Antibodies,86609,CPT,,,,inpatient,,,133,79.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,107.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,113.05,percent of total billed charges,,,85,,113.05,percent of total billed charges,,,49,,65.17,percent of total billed charges,,,90,,119.7,percent of total billed charges,,,,,,,no IP contract,,80,,106.4,percent of total billed charges,,,,,,,no IP contract,,50,,66.5,percent of total billed charges,,,,,,no IP contract,,,78,,103.74,percent of total billed charges,,,70,,93.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,65.17,3324,
"Lyme Disease, Serum (Confirmatory IgG & IgM)",86617,CPT,,,,inpatient,,,137,82.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,110.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,116.45,percent of total billed charges,,,85,,116.45,percent of total billed charges,,,49,,67.13,percent of total billed charges,,,90,,123.3,percent of total billed charges,,,,,,,no IP contract,,80,,109.6,percent of total billed charges,,,,,,,no IP contract,,50,,68.5,percent of total billed charges,,,,,,no IP contract,,,78,,106.86,percent of total billed charges,,,70,,95.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,67.13,3324,
"Lymes Disease, Serum Confirmatory IgM",86617,CPT,,,,inpatient,,,165,99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,133.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,140.25,percent of total billed charges,,,85,,140.25,percent of total billed charges,,,49,,80.85,percent of total billed charges,,,90,,148.5,percent of total billed charges,,,,,,,no IP contract,,80,,132,percent of total billed charges,,,,,,,no IP contract,,50,,82.5,percent of total billed charges,,,,,,no IP contract,,,78,,128.7,percent of total billed charges,,,70,,115.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,80.85,3324,
Lyme Disease by PCR,86618,CPT,,,,inpatient,,,264,158.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,213.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,224.4,percent of total billed charges,,,85,,224.4,percent of total billed charges,,,49,,129.36,percent of total billed charges,,,90,,237.6,percent of total billed charges,,,,,,,no IP contract,,80,,211.2,percent of total billed charges,,,,,,,no IP contract,,50,,132,percent of total billed charges,,,,,,no IP contract,,,78,,205.92,percent of total billed charges,,,70,,184.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,129.36,3324,
Lyme's Disease Antibodies (Total IgG/IgM) Serum,86618,CPT,,,,inpatient,,,282,169.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,228.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,239.7,percent of total billed charges,,,85,,239.7,percent of total billed charges,,,49,,138.18,percent of total billed charges,,,90,,253.8,percent of total billed charges,,,,,,,no IP contract,,80,,225.6,percent of total billed charges,,,,,,,no IP contract,,50,,141,percent of total billed charges,,,,,,no IP contract,,,78,,219.96,percent of total billed charges,,,70,,197.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,138.18,3324,
Brucella Abortus IgG Ab,86622,CPT,,,,inpatient,,,61,36.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,49.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,51.85,percent of total billed charges,,,85,,51.85,percent of total billed charges,,,49,,29.89,percent of total billed charges,,,90,,54.9,percent of total billed charges,,,,,,,no IP contract,,80,,48.8,percent of total billed charges,,,,,,,no IP contract,,50,,30.5,percent of total billed charges,,,,,,no IP contract,,,78,,47.58,percent of total billed charges,,,70,,42.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,29.89,3324,
"Brucella Abortus IgG,IgM,IgA Ab",86622,CPT,,,,inpatient,,,177,106.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,143.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,150.45,percent of total billed charges,,,85,,150.45,percent of total billed charges,,,49,,86.73,percent of total billed charges,,,90,,159.3,percent of total billed charges,,,,,,,no IP contract,,80,,141.6,percent of total billed charges,,,,,,,no IP contract,,50,,88.5,percent of total billed charges,,,,,,no IP contract,,,78,,138.06,percent of total billed charges,,,70,,123.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,86.73,3324,
"Serology, Fungus",86635,CPT,,,,inpatient,,,91,54.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,73.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,77.35,percent of total billed charges,,,85,,77.35,percent of total billed charges,,,49,,44.59,percent of total billed charges,,,90,,81.9,percent of total billed charges,,,,,,,no IP contract,,80,,72.8,percent of total billed charges,,,,,,,no IP contract,,50,,45.5,percent of total billed charges,,,,,,no IP contract,,,78,,70.98,percent of total billed charges,,,70,,63.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,44.59,3324,
"Cytomegalovirus Antibody(IgG & IgM), Serum",86644,CPT,,,,inpatient,,,270,162,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,218.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,229.5,percent of total billed charges,,,85,,229.5,percent of total billed charges,,,49,,132.3,percent of total billed charges,,,90,,243,percent of total billed charges,,,,,,,no IP contract,,80,,216,percent of total billed charges,,,,,,,no IP contract,,50,,135,percent of total billed charges,,,,,,no IP contract,,,78,,210.6,percent of total billed charges,,,70,,189,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,132.3,3324,
"Coxsackievirus Antibodies, CSF",86658,CPT,,,,inpatient,,,108,64.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,87.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,91.8,percent of total billed charges,,,85,,91.8,percent of total billed charges,,,49,,52.92,percent of total billed charges,,,90,,97.2,percent of total billed charges,,,,,,,no IP contract,,80,,86.4,percent of total billed charges,,,,,,,no IP contract,,50,,54,percent of total billed charges,,,,,,no IP contract,,,78,,84.24,percent of total billed charges,,,70,,75.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,52.92,3324,
"Coxsackie B Antibodies, Serum",86658,CPT,,,,inpatient,,,130,78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,105.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,110.5,percent of total billed charges,,,85,,110.5,percent of total billed charges,,,49,,63.7,percent of total billed charges,,,90,,117,percent of total billed charges,,,,,,,no IP contract,,80,,104,percent of total billed charges,,,,,,,no IP contract,,50,,65,percent of total billed charges,,,,,,no IP contract,,,78,,101.4,percent of total billed charges,,,70,,91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,63.7,3324,
"Coxsackie B Antibodies, Serum",86658,CPT,,,,inpatient,,,130,78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,105.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,110.5,percent of total billed charges,,,85,,110.5,percent of total billed charges,,,49,,63.7,percent of total billed charges,,,90,,117,percent of total billed charges,,,,,,,no IP contract,,80,,104,percent of total billed charges,,,,,,,no IP contract,,50,,65,percent of total billed charges,,,,,,no IP contract,,,78,,101.4,percent of total billed charges,,,70,,91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,63.7,3324,
Epstein-Barr Viral Antibody-IgG,86665,CPT,,,,inpatient,,,74,44.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,59.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,62.9,percent of total billed charges,,,85,,62.9,percent of total billed charges,,,49,,36.26,percent of total billed charges,,,90,,66.6,percent of total billed charges,,,,,,,no IP contract,,80,,59.2,percent of total billed charges,,,,,,,no IP contract,,50,,37,percent of total billed charges,,,,,,no IP contract,,,78,,57.72,percent of total billed charges,,,70,,51.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.26,3324,
Epstein Barr Viral Antibody-IgM,86665,CPT,,,,inpatient,,,84,50.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,68.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,71.4,percent of total billed charges,,,85,,71.4,percent of total billed charges,,,49,,41.16,percent of total billed charges,,,90,,75.6,percent of total billed charges,,,,,,,no IP contract,,80,,67.2,percent of total billed charges,,,,,,,no IP contract,,50,,42,percent of total billed charges,,,,,,no IP contract,,,78,,65.52,percent of total billed charges,,,70,,58.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,41.16,3324,
Epstein-Barr Virus IgG,86665,CPT,,,,inpatient,,,98,58.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,79.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,83.3,percent of total billed charges,,,85,,83.3,percent of total billed charges,,,49,,48.02,percent of total billed charges,,,90,,88.2,percent of total billed charges,,,,,,,no IP contract,,80,,78.4,percent of total billed charges,,,,,,,no IP contract,,50,,49,percent of total billed charges,,,,,,no IP contract,,,78,,76.44,percent of total billed charges,,,70,,68.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,48.02,3324,
Epstein-Barr Virus IGM,86665,CPT,,,,inpatient,,,98,58.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,79.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,83.3,percent of total billed charges,,,85,,83.3,percent of total billed charges,,,49,,48.02,percent of total billed charges,,,90,,88.2,percent of total billed charges,,,,,,,no IP contract,,80,,78.4,percent of total billed charges,,,,,,,no IP contract,,50,,49,percent of total billed charges,,,,,,no IP contract,,,78,,76.44,percent of total billed charges,,,70,,68.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,48.02,3324,
Epstein-Barr Virus by PCR,86665,CPT,,,,inpatient,,,169,101.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,136.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,143.65,percent of total billed charges,,,85,,143.65,percent of total billed charges,,,49,,82.81,percent of total billed charges,,,90,,152.1,percent of total billed charges,,,,,,,no IP contract,,80,,135.2,percent of total billed charges,,,,,,,no IP contract,,50,,84.5,percent of total billed charges,,,,,,no IP contract,,,78,,131.82,percent of total billed charges,,,70,,118.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,82.81,3324,
"Saccharomyces Cerevisae IgG, IgA",86671,CPT,,,,inpatient,,,228,136.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,184.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,193.8,percent of total billed charges,,,85,,193.8,percent of total billed charges,,,49,,111.72,percent of total billed charges,,,90,,205.2,percent of total billed charges,,,,,,,no IP contract,,80,,182.4,percent of total billed charges,,,,,,,no IP contract,,50,,114,percent of total billed charges,,,,,,no IP contract,,,78,,177.84,percent of total billed charges,,,70,,159.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,111.72,3324,
Helicobacter Pylori- IgG Elisa,86677,CPT,,,,inpatient,,,222,133.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,179.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,188.7,percent of total billed charges,,,85,,188.7,percent of total billed charges,,,49,,108.78,percent of total billed charges,,,90,,199.8,percent of total billed charges,,,,,,,no IP contract,,80,,177.6,percent of total billed charges,,,,,,,no IP contract,,50,,111,percent of total billed charges,,,,,,no IP contract,,,78,,173.16,percent of total billed charges,,,70,,155.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,108.78,3324,
"HTLV, IgG",86687,CPT,,,,inpatient,,,71,42.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,57.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,60.35,percent of total billed charges,,,85,,60.35,percent of total billed charges,,,49,,34.79,percent of total billed charges,,,90,,63.9,percent of total billed charges,,,,,,,no IP contract,,80,,56.8,percent of total billed charges,,,,,,,no IP contract,,50,,35.5,percent of total billed charges,,,,,,no IP contract,,,78,,55.38,percent of total billed charges,,,70,,49.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,34.79,3324,
HIV-2 IgG with Confirmation,86689,CPT,,,,inpatient,,,324,194.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,262.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,275.4,percent of total billed charges,,,85,,275.4,percent of total billed charges,,,49,,158.76,percent of total billed charges,,,90,,291.6,percent of total billed charges,,,,,,,no IP contract,,80,,259.2,percent of total billed charges,,,,,,,no IP contract,,50,,162,percent of total billed charges,,,,,,no IP contract,,,78,,252.72,percent of total billed charges,,,70,,226.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,158.76,3324,
Hepatitis D Virus Antibody Panel (IgG & IgM),86692,CPT,,,,inpatient,,,157,94.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,127.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,133.45,percent of total billed charges,,,85,,133.45,percent of total billed charges,,,49,,76.93,percent of total billed charges,,,90,,141.3,percent of total billed charges,,,,,,,no IP contract,,80,,125.6,percent of total billed charges,,,,,,,no IP contract,,50,,78.5,percent of total billed charges,,,,,,no IP contract,,,78,,122.46,percent of total billed charges,,,70,,109.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,76.93,3324,
Hepatitis D Virus IgM,86692,CPT,,,,inpatient,,,189,113.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,153.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,160.65,percent of total billed charges,,,85,,160.65,percent of total billed charges,,,49,,92.61,percent of total billed charges,,,90,,170.1,percent of total billed charges,,,,,,,no IP contract,,80,,151.2,percent of total billed charges,,,,,,,no IP contract,,50,,94.5,percent of total billed charges,,,,,,no IP contract,,,78,,147.42,percent of total billed charges,,,70,,132.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,92.61,3324,
Herpes Simplex AB IgG,86694,CPT,,,,inpatient,,,186,111.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,150.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,158.1,percent of total billed charges,,,85,,158.1,percent of total billed charges,,,49,,91.14,percent of total billed charges,,,90,,167.4,percent of total billed charges,,,,,,,no IP contract,,80,,148.8,percent of total billed charges,,,,,,,no IP contract,,50,,93,percent of total billed charges,,,,,,no IP contract,,,78,,145.08,percent of total billed charges,,,70,,130.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,91.14,3324,
Herpes Simplex AB IgM,86694,CPT,,,,inpatient,,,186,111.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,150.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,158.1,percent of total billed charges,,,85,,158.1,percent of total billed charges,,,49,,91.14,percent of total billed charges,,,90,,167.4,percent of total billed charges,,,,,,,no IP contract,,80,,148.8,percent of total billed charges,,,,,,,no IP contract,,50,,93,percent of total billed charges,,,,,,no IP contract,,,78,,145.08,percent of total billed charges,,,70,,130.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,91.14,3324,
HIV Antigen/Antibody Combo,86703,CPT,,,,inpatient,,,146,87.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,118.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,124.1,percent of total billed charges,,,85,,124.1,percent of total billed charges,,,49,,71.54,percent of total billed charges,,,90,,131.4,percent of total billed charges,,,,,,,no IP contract,,80,,116.8,percent of total billed charges,,,,,,,no IP contract,,50,,73,percent of total billed charges,,,,,,no IP contract,,,78,,113.88,percent of total billed charges,,,70,,102.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,71.54,3324,
HEPATITIS B CORE ANTIBODY (TOTAL) NMH,86704,CPT,,,,inpatient,,,269,161.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,217.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,228.65,percent of total billed charges,,,85,,228.65,percent of total billed charges,,,49,,131.81,percent of total billed charges,,,90,,242.1,percent of total billed charges,,,,,,,no IP contract,,80,,215.2,percent of total billed charges,,,,,,,no IP contract,,50,,134.5,percent of total billed charges,,,,,,no IP contract,,,78,,209.82,percent of total billed charges,,,70,,188.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,131.81,3324,
Hepatitis B Core Antibody IgG + IgM,86704,CPT,,,,inpatient,,,281,168.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,227.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,238.85,percent of total billed charges,,,85,,238.85,percent of total billed charges,,,49,,137.69,percent of total billed charges,,,90,,252.9,percent of total billed charges,,,,,,,no IP contract,,80,,224.8,percent of total billed charges,,,,,,,no IP contract,,50,,140.5,percent of total billed charges,,,,,,no IP contract,,,78,,219.18,percent of total billed charges,,,70,,196.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,137.69,3324,
Hepatitis B Core IgM,86705,CPT,,,,inpatient,,,277,166.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,224.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,235.45,percent of total billed charges,,,85,,235.45,percent of total billed charges,,,49,,135.73,percent of total billed charges,,,90,,249.3,percent of total billed charges,,,,,,,no IP contract,,80,,221.6,percent of total billed charges,,,,,,,no IP contract,,50,,138.5,percent of total billed charges,,,,,,no IP contract,,,78,,216.06,percent of total billed charges,,,70,,193.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,135.73,3324,
Hepatitis B Core Antibody IgM Acute Titer,86705,CPT,,,,inpatient,,,299,179.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,242.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,254.15,percent of total billed charges,,,85,,254.15,percent of total billed charges,,,49,,146.51,percent of total billed charges,,,90,,269.1,percent of total billed charges,,,,,,,no IP contract,,80,,239.2,percent of total billed charges,,,,,,,no IP contract,,50,,149.5,percent of total billed charges,,,,,,no IP contract,,,78,,233.22,percent of total billed charges,,,70,,209.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,146.51,3324,
Hepatitis B Surface Antibody,86706,CPT,,,,inpatient,,,161,96.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,130.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,136.85,percent of total billed charges,,,85,,136.85,percent of total billed charges,,,49,,78.89,percent of total billed charges,,,90,,144.9,percent of total billed charges,,,,,,,no IP contract,,80,,128.8,percent of total billed charges,,,,,,,no IP contract,,50,,80.5,percent of total billed charges,,,,,,no IP contract,,,78,,125.58,percent of total billed charges,,,70,,112.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,78.89,3324,
HEPATITIS B SURFACE ANTIBODY NMH,86706,CPT,,,,inpatient,,,178,106.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,144.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,151.3,percent of total billed charges,,,85,,151.3,percent of total billed charges,,,49,,87.22,percent of total billed charges,,,90,,160.2,percent of total billed charges,,,,,,,no IP contract,,80,,142.4,percent of total billed charges,,,,,,,no IP contract,,50,,89,percent of total billed charges,,,,,,no IP contract,,,78,,138.84,percent of total billed charges,,,70,,124.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,87.22,3324,
Hepatitis BE Antigen/Antibody,86707,CPT,,,,inpatient,,,186,111.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,150.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,158.1,percent of total billed charges,,,85,,158.1,percent of total billed charges,,,49,,91.14,percent of total billed charges,,,90,,167.4,percent of total billed charges,,,,,,,no IP contract,,80,,148.8,percent of total billed charges,,,,,,,no IP contract,,50,,93,percent of total billed charges,,,,,,no IP contract,,,78,,145.08,percent of total billed charges,,,70,,130.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,91.14,3324,
"Hepatitis A Antibody, Total",86708,CPT,,,,inpatient,,,253,151.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,204.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,215.05,percent of total billed charges,,,85,,215.05,percent of total billed charges,,,49,,123.97,percent of total billed charges,,,90,,227.7,percent of total billed charges,,,,,,,no IP contract,,80,,202.4,percent of total billed charges,,,,,,,no IP contract,,50,,126.5,percent of total billed charges,,,,,,no IP contract,,,78,,197.34,percent of total billed charges,,,70,,177.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,123.97,3324,
Hepatitis A IgM,86709,CPT,,,,inpatient,,,253,151.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,204.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,215.05,percent of total billed charges,,,85,,215.05,percent of total billed charges,,,49,,123.97,percent of total billed charges,,,90,,227.7,percent of total billed charges,,,,,,,no IP contract,,80,,202.4,percent of total billed charges,,,,,,,no IP contract,,50,,126.5,percent of total billed charges,,,,,,no IP contract,,,78,,197.34,percent of total billed charges,,,70,,177.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,123.97,3324,
"Influenza A+B IgG, IgA & IgM Antibodies",86710,CPT,,,,inpatient,,,110,66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,89.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,93.5,percent of total billed charges,,,85,,93.5,percent of total billed charges,,,49,,53.9,percent of total billed charges,,,90,,99,percent of total billed charges,,,,,,,no IP contract,,80,,88,percent of total billed charges,,,,,,,no IP contract,,50,,55,percent of total billed charges,,,,,,no IP contract,,,78,,85.8,percent of total billed charges,,,70,,77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,53.9,3324,
"Influenza A + B IgG, IgA, & IgM Antibodies",86710,CPT,,,,inpatient,,,132,79.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,106.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,112.2,percent of total billed charges,,,85,,112.2,percent of total billed charges,,,49,,64.68,percent of total billed charges,,,90,,118.8,percent of total billed charges,,,,,,,no IP contract,,80,,105.6,percent of total billed charges,,,,,,,no IP contract,,50,,66,percent of total billed charges,,,,,,no IP contract,,,78,,102.96,percent of total billed charges,,,70,,92.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,64.68,3324,
"Legionella Pneumophila IgG  & IgM Antibodies, Serotypes 1-14",86713,CPT,,,,inpatient,,,201,120.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,162.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,170.85,percent of total billed charges,,,85,,170.85,percent of total billed charges,,,49,,98.49,percent of total billed charges,,,90,,180.9,percent of total billed charges,,,,,,,no IP contract,,80,,160.8,percent of total billed charges,,,,,,,no IP contract,,50,,100.5,percent of total billed charges,,,,,,no IP contract,,,78,,156.78,percent of total billed charges,,,70,,140.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,98.49,3324,
Leishmania Antibodies,86717,CPT,,,,inpatient,,,98,58.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,79.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,83.3,percent of total billed charges,,,85,,83.3,percent of total billed charges,,,49,,48.02,percent of total billed charges,,,90,,88.2,percent of total billed charges,,,,,,,no IP contract,,80,,78.4,percent of total billed charges,,,,,,,no IP contract,,50,,49,percent of total billed charges,,,,,,no IP contract,,,78,,76.44,percent of total billed charges,,,70,,68.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,48.02,3324,
Mumps Antibody IgM,86735,CPT,,,,inpatient,,,133,79.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,107.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,113.05,percent of total billed charges,,,85,,113.05,percent of total billed charges,,,49,,65.17,percent of total billed charges,,,90,,119.7,percent of total billed charges,,,,,,,no IP contract,,80,,106.4,percent of total billed charges,,,,,,,no IP contract,,50,,66.5,percent of total billed charges,,,,,,no IP contract,,,78,,103.74,percent of total billed charges,,,70,,93.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,65.17,3324,
Mumps Antibody IgG (Immunity),86735,CPT,,,,inpatient,,,186,111.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,150.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,158.1,percent of total billed charges,,,85,,158.1,percent of total billed charges,,,49,,91.14,percent of total billed charges,,,90,,167.4,percent of total billed charges,,,,,,,no IP contract,,80,,148.8,percent of total billed charges,,,,,,,no IP contract,,50,,93,percent of total billed charges,,,,,,no IP contract,,,78,,145.08,percent of total billed charges,,,70,,130.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,91.14,3324,
Mycoplasma Antibody,86738,CPT,,,,inpatient,,,109,65.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,88.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,92.65,percent of total billed charges,,,85,,92.65,percent of total billed charges,,,49,,53.41,percent of total billed charges,,,90,,98.1,percent of total billed charges,,,,,,,no IP contract,,80,,87.2,percent of total billed charges,,,,,,,no IP contract,,50,,54.5,percent of total billed charges,,,,,,no IP contract,,,78,,85.02,percent of total billed charges,,,70,,76.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,53.41,3324,
"Parvovirus B19 IgG, IgM Antibodies",86747,CPT,,,,inpatient,,,216,129.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,174.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,183.6,percent of total billed charges,,,85,,183.6,percent of total billed charges,,,49,,105.84,percent of total billed charges,,,90,,194.4,percent of total billed charges,,,,,,,no IP contract,,80,,172.8,percent of total billed charges,,,,,,,no IP contract,,50,,108,percent of total billed charges,,,,,,no IP contract,,,78,,168.48,percent of total billed charges,,,70,,151.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,105.84,3324,
E. Histolytica Antibodies,86753,CPT,,,,inpatient,,,100,60,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,85,percent of total billed charges,,,85,,85,percent of total billed charges,,,49,,49,percent of total billed charges,,,90,,90,percent of total billed charges,,,,,,,no IP contract,,80,,80,percent of total billed charges,,,,,,,no IP contract,,50,,50,percent of total billed charges,,,,,,no IP contract,,,78,,78,percent of total billed charges,,,70,,70,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,49,3324,
Rubella,86762,CPT,,,,inpatient,,,91,54.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,73.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,77.35,percent of total billed charges,,,85,,77.35,percent of total billed charges,,,49,,44.59,percent of total billed charges,,,90,,81.9,percent of total billed charges,,,,,,,no IP contract,,80,,72.8,percent of total billed charges,,,,,,,no IP contract,,50,,45.5,percent of total billed charges,,,,,,no IP contract,,,78,,70.98,percent of total billed charges,,,70,,63.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,44.59,3324,
Rubeola (Immunity) Antibody IgG,86765,CPT,,,,inpatient,,,202,121.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,163.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,171.7,percent of total billed charges,,,85,,171.7,percent of total billed charges,,,49,,98.98,percent of total billed charges,,,90,,181.8,percent of total billed charges,,,,,,,no IP contract,,80,,161.6,percent of total billed charges,,,,,,,no IP contract,,50,,101,percent of total billed charges,,,,,,no IP contract,,,78,,157.56,percent of total billed charges,,,70,,141.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,98.98,3324,
Rubeola (measles) Antibody IgM,86765,CPT,,,,inpatient,,,202,121.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,163.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,171.7,percent of total billed charges,,,85,,171.7,percent of total billed charges,,,49,,98.98,percent of total billed charges,,,90,,181.8,percent of total billed charges,,,,,,,no IP contract,,80,,161.6,percent of total billed charges,,,,,,,no IP contract,,50,,101,percent of total billed charges,,,,,,no IP contract,,,78,,157.56,percent of total billed charges,,,70,,141.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,98.98,3324,
Toxoplasma Antibody,86777,CPT,,,,inpatient,,,253,151.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,204.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,215.05,percent of total billed charges,,,85,,215.05,percent of total billed charges,,,49,,123.97,percent of total billed charges,,,90,,227.7,percent of total billed charges,,,,,,,no IP contract,,80,,202.4,percent of total billed charges,,,,,,,no IP contract,,50,,126.5,percent of total billed charges,,,,,,no IP contract,,,78,,197.34,percent of total billed charges,,,70,,177.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,123.97,3324,
Toxoplasma Antibody IgM,86778,CPT,,,,inpatient,,,186,111.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,150.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,158.1,percent of total billed charges,,,85,,158.1,percent of total billed charges,,,49,,91.14,percent of total billed charges,,,90,,167.4,percent of total billed charges,,,,,,,no IP contract,,80,,148.8,percent of total billed charges,,,,,,,no IP contract,,50,,93,percent of total billed charges,,,,,,no IP contract,,,78,,145.08,percent of total billed charges,,,70,,130.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,91.14,3324,
Varicella Zoster Antibody IgG,86787,CPT,,,,inpatient,,,202,121.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,163.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,171.7,percent of total billed charges,,,85,,171.7,percent of total billed charges,,,49,,98.98,percent of total billed charges,,,90,,181.8,percent of total billed charges,,,,,,,no IP contract,,80,,161.6,percent of total billed charges,,,,,,,no IP contract,,50,,101,percent of total billed charges,,,,,,no IP contract,,,78,,157.56,percent of total billed charges,,,70,,141.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,98.98,3324,
Varicella Zoster Antibody IgM,86787,CPT,,,,inpatient,,,202,121.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,163.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,171.7,percent of total billed charges,,,85,,171.7,percent of total billed charges,,,49,,98.98,percent of total billed charges,,,90,,181.8,percent of total billed charges,,,,,,,no IP contract,,80,,161.6,percent of total billed charges,,,,,,,no IP contract,,50,,101,percent of total billed charges,,,,,,no IP contract,,,78,,157.56,percent of total billed charges,,,70,,141.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,98.98,3324,
Thyroid Antibodies,86800,CPT,,,,inpatient,,,240,144,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,194.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,204,percent of total billed charges,,,85,,204,percent of total billed charges,,,49,,117.6,percent of total billed charges,,,90,,216,percent of total billed charges,,,,,,,no IP contract,,80,,192,percent of total billed charges,,,,,,,no IP contract,,50,,120,percent of total billed charges,,,,,,no IP contract,,,78,,187.2,percent of total billed charges,,,70,,168,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,117.6,3324,
Anti-Thyroglobulin AB,86800,CPT,,,,inpatient,,,289,173.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,234.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,245.65,percent of total billed charges,,,85,,245.65,percent of total billed charges,,,49,,141.61,percent of total billed charges,,,90,,260.1,percent of total billed charges,,,,,,,no IP contract,,80,,231.2,percent of total billed charges,,,,,,,no IP contract,,50,,144.5,percent of total billed charges,,,,,,no IP contract,,,78,,225.42,percent of total billed charges,,,70,,202.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,53160.74,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,141.61,53160.74,
Anti-Thyroglobulin AB,86800,CPT,,,,inpatient,,,289,173.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,234.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,245.65,percent of total billed charges,,,85,,245.65,percent of total billed charges,,,49,,141.61,percent of total billed charges,,,90,,260.1,percent of total billed charges,,,,,,,no IP contract,,80,,231.2,percent of total billed charges,,,,,,,no IP contract,,50,,144.5,percent of total billed charges,,,,,,no IP contract,,,78,,225.42,percent of total billed charges,,,70,,202.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,41080.44333,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,141.61,41080.44,
HCV PCR Qualtitative,86803,CPT,,,,inpatient,,,178,106.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,144.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,151.3,percent of total billed charges,,,85,,151.3,percent of total billed charges,,,49,,87.22,percent of total billed charges,,,90,,160.2,percent of total billed charges,,,,,,,no IP contract,,80,,142.4,percent of total billed charges,,,,,,,no IP contract,,50,,89,percent of total billed charges,,,,,,no IP contract,,,78,,138.84,percent of total billed charges,,,70,,124.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,87.22,3324,
Hepatitis C Antibody IgM + IgG,86803,CPT,,,,inpatient,,,282,169.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,228.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,239.7,percent of total billed charges,,,85,,239.7,percent of total billed charges,,,49,,138.18,percent of total billed charges,,,90,,253.8,percent of total billed charges,,,,,,,no IP contract,,80,,225.6,percent of total billed charges,,,,,,,no IP contract,,50,,141,percent of total billed charges,,,,,,no IP contract,,,78,,219.96,percent of total billed charges,,,70,,197.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,138.18,3324,
Hepatitis C Virus Antibodies (RIBA) & Bands,86804,CPT,,,,inpatient,,,328,196.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,265.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,278.8,percent of total billed charges,,,85,,278.8,percent of total billed charges,,,49,,160.72,percent of total billed charges,,,90,,295.2,percent of total billed charges,,,,,,,no IP contract,,80,,262.4,percent of total billed charges,,,,,,,no IP contract,,50,,164,percent of total billed charges,,,,,,no IP contract,,,78,,255.84,percent of total billed charges,,,70,,229.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,160.72,3324,
HLA B27,86812,CPT,,,,inpatient,,,186,111.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,150.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,158.1,percent of total billed charges,,,85,,158.1,percent of total billed charges,,,49,,91.14,percent of total billed charges,,,90,,167.4,percent of total billed charges,,,,,,,no IP contract,,80,,148.8,percent of total billed charges,,,,,,,no IP contract,,50,,93,percent of total billed charges,,,,,,no IP contract,,,78,,145.08,percent of total billed charges,,,70,,130.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,91.14,3324,
REF POST LUMINEX HLA CLASS I SA FP OL TITERS NMH,86834,CPT,,,,inpatient,,,4301,2580.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3483.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3655.85,percent of total billed charges,,,85,,3655.85,percent of total billed charges,,,49,,2107.49,percent of total billed charges,,,90,,3870.9,percent of total billed charges,,,,,,,no IP contract,,80,,3440.8,percent of total billed charges,,,,,,,no IP contract,,50,,2150.5,percent of total billed charges,,,,,,no IP contract,,,78,,3354.78,percent of total billed charges,,,70,,3010.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3870.9,
REF LUMINEX CLASS II TITERS NMH,86835,CPT,,,,inpatient,,,2238,1342.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1812.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1902.3,percent of total billed charges,,,85,,1902.3,percent of total billed charges,,,49,,1096.62,percent of total billed charges,,,90,,2014.2,percent of total billed charges,,,,,,,no IP contract,,80,,1790.4,percent of total billed charges,,,,,,,no IP contract,,50,,1119,percent of total billed charges,,,,,,no IP contract,,,78,,1745.64,percent of total billed charges,,,70,,1566.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
"CONCENTRATION, MICROBIOLOGY NMH",87015,CPT,,,,inpatient,,,57,34.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,46.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,48.45,percent of total billed charges,,,85,,48.45,percent of total billed charges,,,49,,27.93,percent of total billed charges,,,90,,51.3,percent of total billed charges,,,,,,,no IP contract,,80,,45.6,percent of total billed charges,,,,,,,no IP contract,,50,,28.5,percent of total billed charges,,,,,,no IP contract,,,78,,44.46,percent of total billed charges,,,70,,39.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.93,3324,
Culture-Blood,87040,CPT,,,,inpatient,,,289,173.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,234.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,245.65,percent of total billed charges,,,85,,245.65,percent of total billed charges,,,49,,141.61,percent of total billed charges,,,90,,260.1,percent of total billed charges,,,,,,,no IP contract,,80,,231.2,percent of total billed charges,,,,,,,no IP contract,,50,,144.5,percent of total billed charges,,,,,,no IP contract,,,78,,225.42,percent of total billed charges,,,70,,202.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,141.61,3324,
Culture-Stool,87045,CPT,,,,inpatient,,,216,129.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,174.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,183.6,percent of total billed charges,,,85,,183.6,percent of total billed charges,,,49,,105.84,percent of total billed charges,,,90,,194.4,percent of total billed charges,,,,,,,no IP contract,,80,,172.8,percent of total billed charges,,,,,,,no IP contract,,50,,108,percent of total billed charges,,,,,,no IP contract,,,78,,168.48,percent of total billed charges,,,70,,151.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,105.84,3324,
Culture-Surveillance,87045,CPT,,,,inpatient,,,216,129.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,174.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,183.6,percent of total billed charges,,,85,,183.6,percent of total billed charges,,,49,,105.84,percent of total billed charges,,,90,,194.4,percent of total billed charges,,,,,,,no IP contract,,80,,172.8,percent of total billed charges,,,,,,,no IP contract,,50,,108,percent of total billed charges,,,,,,no IP contract,,,78,,168.48,percent of total billed charges,,,70,,151.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,105.84,3324,
Culture- Bone Aerobic/Anaerobic w/ Gram Stain,87070,CPT,,,,inpatient,,,97,58.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,78.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,82.45,percent of total billed charges,,,85,,82.45,percent of total billed charges,,,49,,47.53,percent of total billed charges,,,90,,87.3,percent of total billed charges,,,,,,,no IP contract,,80,,77.6,percent of total billed charges,,,,,,,no IP contract,,50,,48.5,percent of total billed charges,,,,,,no IP contract,,,78,,75.66,percent of total billed charges,,,70,,67.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,47.53,3324,
Routine Respiratory Culture and Gram Stain,87070,CPT,,,,inpatient,,,159,95.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,128.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,135.15,percent of total billed charges,,,85,,135.15,percent of total billed charges,,,49,,77.91,percent of total billed charges,,,90,,143.1,percent of total billed charges,,,,,,,no IP contract,,80,,127.2,percent of total billed charges,,,,,,,no IP contract,,50,,79.5,percent of total billed charges,,,,,,no IP contract,,,78,,124.02,percent of total billed charges,,,70,,111.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,77.91,3324,
Culture-Genital with Gram Stain,87070,CPT,,,,inpatient,,,165,99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,133.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,140.25,percent of total billed charges,,,85,,140.25,percent of total billed charges,,,49,,80.85,percent of total billed charges,,,90,,148.5,percent of total billed charges,,,,,,,no IP contract,,80,,132,percent of total billed charges,,,,,,,no IP contract,,50,,82.5,percent of total billed charges,,,,,,no IP contract,,,78,,128.7,percent of total billed charges,,,70,,115.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,80.85,3324,
Culture-Wound Aerobic with Gram Stain,87070,CPT,,,,inpatient,,,214,128.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,173.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,181.9,percent of total billed charges,,,85,,181.9,percent of total billed charges,,,49,,104.86,percent of total billed charges,,,90,,192.6,percent of total billed charges,,,,,,,no IP contract,,80,,171.2,percent of total billed charges,,,,,,,no IP contract,,50,,107,percent of total billed charges,,,,,,no IP contract,,,78,,166.92,percent of total billed charges,,,70,,149.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,104.86,3324,
Culture-IV Cath Tip,87070,CPT,,,,inpatient,,,236,141.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,191.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,200.6,percent of total billed charges,,,85,,200.6,percent of total billed charges,,,49,,115.64,percent of total billed charges,,,90,,212.4,percent of total billed charges,,,,,,,no IP contract,,80,,188.8,percent of total billed charges,,,,,,,no IP contract,,50,,118,percent of total billed charges,,,,,,no IP contract,,,78,,184.08,percent of total billed charges,,,70,,165.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,115.64,3324,
Culture-Eye with Gram Stain,87070,CPT,,,,inpatient,,,286,171.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,231.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,243.1,percent of total billed charges,,,85,,243.1,percent of total billed charges,,,49,,140.14,percent of total billed charges,,,90,,257.4,percent of total billed charges,,,,,,,no IP contract,,80,,228.8,percent of total billed charges,,,,,,,no IP contract,,50,,143,percent of total billed charges,,,,,,no IP contract,,,78,,223.08,percent of total billed charges,,,70,,200.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,140.14,3324,
Culture-Wound Aerobic/Anaerobic w/Gm Stain,87070,CPT,,,,inpatient,,,291,174.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,235.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,247.35,percent of total billed charges,,,85,,247.35,percent of total billed charges,,,49,,142.59,percent of total billed charges,,,90,,261.9,percent of total billed charges,,,,,,,no IP contract,,80,,232.8,percent of total billed charges,,,,,,,no IP contract,,50,,145.5,percent of total billed charges,,,,,,no IP contract,,,78,,226.98,percent of total billed charges,,,70,,203.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,142.59,3324,
Culture-CSF with Gram Stain,87070,CPT,,,,inpatient,,,317,190.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,256.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,269.45,percent of total billed charges,,,85,,269.45,percent of total billed charges,,,49,,155.33,percent of total billed charges,,,90,,285.3,percent of total billed charges,,,,,,,no IP contract,,80,,253.6,percent of total billed charges,,,,,,,no IP contract,,50,,158.5,percent of total billed charges,,,,,,no IP contract,,,78,,247.26,percent of total billed charges,,,70,,221.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,155.33,3324,
Culture-Eye,87070,CPT,,,,inpatient,,,317,190.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,256.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,269.45,percent of total billed charges,,,85,,269.45,percent of total billed charges,,,49,,155.33,percent of total billed charges,,,90,,285.3,percent of total billed charges,,,,,,,no IP contract,,80,,253.6,percent of total billed charges,,,,,,,no IP contract,,50,,158.5,percent of total billed charges,,,,,,no IP contract,,,78,,247.26,percent of total billed charges,,,70,,221.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,155.33,3324,
Culture-Fluid & Anaerobic w/Gram Stain,87070,CPT,,,,inpatient,,,317,190.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,256.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,269.45,percent of total billed charges,,,85,,269.45,percent of total billed charges,,,49,,155.33,percent of total billed charges,,,90,,285.3,percent of total billed charges,,,,,,,no IP contract,,80,,253.6,percent of total billed charges,,,,,,,no IP contract,,50,,158.5,percent of total billed charges,,,,,,no IP contract,,,78,,247.26,percent of total billed charges,,,70,,221.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,155.33,3324,
Culture-Sputum Respiratory w/ Gm Stain,87070,CPT,,,,inpatient,,,317,190.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,256.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,269.45,percent of total billed charges,,,85,,269.45,percent of total billed charges,,,49,,155.33,percent of total billed charges,,,90,,285.3,percent of total billed charges,,,,,,,no IP contract,,80,,253.6,percent of total billed charges,,,,,,,no IP contract,,50,,158.5,percent of total billed charges,,,,,,no IP contract,,,78,,247.26,percent of total billed charges,,,70,,221.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,155.33,3324,
Culture-Tissue with Gram Stain,87070,CPT,,,,inpatient,,,317,190.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,256.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,269.45,percent of total billed charges,,,85,,269.45,percent of total billed charges,,,49,,155.33,percent of total billed charges,,,90,,285.3,percent of total billed charges,,,,,,,no IP contract,,80,,253.6,percent of total billed charges,,,,,,,no IP contract,,50,,158.5,percent of total billed charges,,,,,,no IP contract,,,78,,247.26,percent of total billed charges,,,70,,221.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,155.33,3324,
Culture-CSF Aerobic/Anaerobic Culture w/Gm Stain,87070,CPT,,,,inpatient,,,364,218.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,294.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,309.4,percent of total billed charges,,,85,,309.4,percent of total billed charges,,,49,,178.36,percent of total billed charges,,,90,,327.6,percent of total billed charges,,,,,,,no IP contract,,80,,291.2,percent of total billed charges,,,,,,,no IP contract,,50,,182,percent of total billed charges,,,,,,no IP contract,,,78,,283.92,percent of total billed charges,,,70,,254.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,178.36,3324,
Culture-GC,87071,CPT,,,,inpatient,,,130,78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,105.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,110.5,percent of total billed charges,,,85,,110.5,percent of total billed charges,,,49,,63.7,percent of total billed charges,,,90,,117,percent of total billed charges,,,,,,,no IP contract,,80,,104,percent of total billed charges,,,,,,,no IP contract,,50,,65,percent of total billed charges,,,,,,no IP contract,,,78,,101.4,percent of total billed charges,,,70,,91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,63.7,3324,
Culture-Other Aerobic/Anaerobic w/Gm Stain,87075,CPT,,,,inpatient,,,265,159,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,214.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,225.25,percent of total billed charges,,,85,,225.25,percent of total billed charges,,,49,,129.85,percent of total billed charges,,,90,,238.5,percent of total billed charges,,,,,,,no IP contract,,80,,212,percent of total billed charges,,,,,,,no IP contract,,50,,132.5,percent of total billed charges,,,,,,no IP contract,,,78,,206.7,percent of total billed charges,,,70,,185.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,129.85,3324,
"CULTURE, ANAEROBIC NMH",87075,CPT,,,,inpatient,,,320,192,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,259.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,272,percent of total billed charges,,,85,,272,percent of total billed charges,,,49,,156.8,percent of total billed charges,,,90,,288,percent of total billed charges,,,,,,,no IP contract,,80,,256,percent of total billed charges,,,,,,,no IP contract,,50,,160,percent of total billed charges,,,,,,no IP contract,,,78,,249.6,percent of total billed charges,,,70,,224,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,156.8,3324,
C Difficile Culture & Toxin,87075,CPT,,,,inpatient,,,379,227.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,306.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,322.15,percent of total billed charges,,,85,,322.15,percent of total billed charges,,,49,,185.71,percent of total billed charges,,,90,,341.1,percent of total billed charges,,,,,,,no IP contract,,80,,303.2,percent of total billed charges,,,,,,,no IP contract,,50,,189.5,percent of total billed charges,,,,,,no IP contract,,,78,,295.62,percent of total billed charges,,,70,,265.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,12525.3725,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,185.71,12525.37,
Culture-C. Difficile,87075,CPT,,,,inpatient,,,400,240,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,324,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,340,percent of total billed charges,,,85,,340,percent of total billed charges,,,49,,196,percent of total billed charges,,,90,,360,percent of total billed charges,,,,,,,no IP contract,,80,,320,percent of total billed charges,,,,,,,no IP contract,,50,,200,percent of total billed charges,,,,,,no IP contract,,,78,,312,percent of total billed charges,,,70,,280,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,196,3324,
Culture-C. Difficile Surveillance,87075,CPT,,,,inpatient,,,431,258.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,349.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,366.35,percent of total billed charges,,,85,,366.35,percent of total billed charges,,,49,,211.19,percent of total billed charges,,,90,,387.9,percent of total billed charges,,,,,,,no IP contract,,80,,344.8,percent of total billed charges,,,,,,,no IP contract,,50,,215.5,percent of total billed charges,,,,,,no IP contract,,,78,,336.18,percent of total billed charges,,,70,,301.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,211.19,3324,
Tissue/Biopsy & Anaerobic Culture with Gram Stain,87075,CPT,,,,inpatient,,,463,277.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,375.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,393.55,percent of total billed charges,,,85,,393.55,percent of total billed charges,,,49,,226.87,percent of total billed charges,,,90,,416.7,percent of total billed charges,,,,,,,no IP contract,,80,,370.4,percent of total billed charges,,,,,,,no IP contract,,50,,231.5,percent of total billed charges,,,,,,no IP contract,,,78,,361.14,percent of total billed charges,,,70,,324.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,226.87,3324,
"ORGANISM ID, AEROBIC ISOLATE NMH",87077,CPT,,,,inpatient,,,77,46.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,62.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,65.45,percent of total billed charges,,,85,,65.45,percent of total billed charges,,,49,,37.73,percent of total billed charges,,,90,,69.3,percent of total billed charges,,,,,,,no IP contract,,80,,61.6,percent of total billed charges,,,,,,,no IP contract,,50,,38.5,percent of total billed charges,,,,,,no IP contract,,,78,,60.06,percent of total billed charges,,,70,,53.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,37.73,3324,
Culture-Legionella,87081,CPT,,,,inpatient,,,100,60,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,85,percent of total billed charges,,,85,,85,percent of total billed charges,,,49,,49,percent of total billed charges,,,90,,90,percent of total billed charges,,,,,,,no IP contract,,80,,80,percent of total billed charges,,,,,,,no IP contract,,50,,50,percent of total billed charges,,,,,,no IP contract,,,78,,78,percent of total billed charges,,,70,,70,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,49,3324,
Culture-Nose,87081,CPT,,,,inpatient,,,100,60,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,85,percent of total billed charges,,,85,,85,percent of total billed charges,,,49,,49,percent of total billed charges,,,90,,90,percent of total billed charges,,,,,,,no IP contract,,80,,80,percent of total billed charges,,,,,,,no IP contract,,50,,50,percent of total billed charges,,,,,,no IP contract,,,78,,78,percent of total billed charges,,,70,,70,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,49,3324,
VRE Screen,87081,CPT,,,,inpatient,,,100,60,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,85,percent of total billed charges,,,85,,85,percent of total billed charges,,,49,,49,percent of total billed charges,,,90,,90,percent of total billed charges,,,,,,,no IP contract,,80,,80,percent of total billed charges,,,,,,,no IP contract,,50,,50,percent of total billed charges,,,,,,no IP contract,,,78,,78,percent of total billed charges,,,70,,70,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,49,3324,
Culture-Candida Auris Screen,87081,CPT,,,,inpatient,,,118,70.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,95.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,100.3,percent of total billed charges,,,85,,100.3,percent of total billed charges,,,49,,57.82,percent of total billed charges,,,90,,106.2,percent of total billed charges,,,,,,,no IP contract,,80,,94.4,percent of total billed charges,,,,,,,no IP contract,,50,,59,percent of total billed charges,,,,,,no IP contract,,,78,,92.04,percent of total billed charges,,,70,,82.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,57.82,3324,
Culture-Throat,87081,CPT,,,,inpatient,,,180,108,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,145.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,153,percent of total billed charges,,,85,,153,percent of total billed charges,,,49,,88.2,percent of total billed charges,,,90,,162,percent of total billed charges,,,,,,,no IP contract,,80,,144,percent of total billed charges,,,,,,,no IP contract,,50,,90,percent of total billed charges,,,,,,no IP contract,,,78,,140.4,percent of total billed charges,,,70,,126,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,88.2,3324,
Throat Strept Screen,87081,CPT,,,,inpatient,,,180,108,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,145.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,153,percent of total billed charges,,,85,,153,percent of total billed charges,,,49,,88.2,percent of total billed charges,,,90,,162,percent of total billed charges,,,,,,,no IP contract,,80,,144,percent of total billed charges,,,,,,,no IP contract,,50,,90,percent of total billed charges,,,,,,no IP contract,,,78,,140.4,percent of total billed charges,,,70,,126,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,88.2,3324,
ESBL Screen,87081,CPT,,,,inpatient,,,191,114.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,154.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,162.35,percent of total billed charges,,,85,,162.35,percent of total billed charges,,,49,,93.59,percent of total billed charges,,,90,,171.9,percent of total billed charges,,,,,,,no IP contract,,80,,152.8,percent of total billed charges,,,,,,,no IP contract,,50,,95.5,percent of total billed charges,,,,,,no IP contract,,,78,,148.98,percent of total billed charges,,,70,,133.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,93.59,3324,
"CULTURE, URINE NMH",87086,CPT,,,,inpatient,,,132,79.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,106.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,112.2,percent of total billed charges,,,85,,112.2,percent of total billed charges,,,49,,64.68,percent of total billed charges,,,90,,118.8,percent of total billed charges,,,,,,,no IP contract,,80,,105.6,percent of total billed charges,,,,,,,no IP contract,,50,,66,percent of total billed charges,,,,,,no IP contract,,,78,,102.96,percent of total billed charges,,,70,,92.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,64.68,3324,
Culture-Urine,87086,CPT,,,,inpatient,,,226,135.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,183.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,192.1,percent of total billed charges,,,85,,192.1,percent of total billed charges,,,49,,110.74,percent of total billed charges,,,90,,203.4,percent of total billed charges,,,,,,,no IP contract,,80,,180.8,percent of total billed charges,,,,,,,no IP contract,,50,,113,percent of total billed charges,,,,,,no IP contract,,,78,,176.28,percent of total billed charges,,,70,,158.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,110.74,3324,
Culture-Fungus Blood,87102,CPT,,,,inpatient,,,254,152.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,205.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,215.9,percent of total billed charges,,,85,,215.9,percent of total billed charges,,,49,,124.46,percent of total billed charges,,,90,,228.6,percent of total billed charges,,,,,,,no IP contract,,80,,203.2,percent of total billed charges,,,,,,,no IP contract,,50,,127,percent of total billed charges,,,,,,no IP contract,,,78,,198.12,percent of total billed charges,,,70,,177.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,124.46,3324,
Culture-Fungus CSF,87102,CPT,,,,inpatient,,,254,152.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,205.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,215.9,percent of total billed charges,,,85,,215.9,percent of total billed charges,,,49,,124.46,percent of total billed charges,,,90,,228.6,percent of total billed charges,,,,,,,no IP contract,,80,,203.2,percent of total billed charges,,,,,,,no IP contract,,50,,127,percent of total billed charges,,,,,,no IP contract,,,78,,198.12,percent of total billed charges,,,70,,177.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,124.46,3324,
Culture-Other Fungal w/Smear,87102,CPT,,,,inpatient,,,254,152.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,205.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,215.9,percent of total billed charges,,,85,,215.9,percent of total billed charges,,,49,,124.46,percent of total billed charges,,,90,,228.6,percent of total billed charges,,,,,,,no IP contract,,80,,203.2,percent of total billed charges,,,,,,,no IP contract,,50,,127,percent of total billed charges,,,,,,no IP contract,,,78,,198.12,percent of total billed charges,,,70,,177.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,124.46,3324,
Culture-Fungus with Smear,87103,CPT,,,,inpatient,,,142,85.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,115.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,120.7,percent of total billed charges,,,85,,120.7,percent of total billed charges,,,49,,69.58,percent of total billed charges,,,90,,127.8,percent of total billed charges,,,,,,,no IP contract,,80,,113.6,percent of total billed charges,,,,,,,no IP contract,,50,,71,percent of total billed charges,,,,,,no IP contract,,,78,,110.76,percent of total billed charges,,,70,,99.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,69.58,3324,
"YEAST, DEFINITIVE ID NMH",87106,CPT,,,,inpatient,,,132,79.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,106.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,112.2,percent of total billed charges,,,85,,112.2,percent of total billed charges,,,49,,64.68,percent of total billed charges,,,90,,118.8,percent of total billed charges,,,,,,,no IP contract,,80,,105.6,percent of total billed charges,,,,,,,no IP contract,,50,,66,percent of total billed charges,,,,,,no IP contract,,,78,,102.96,percent of total billed charges,,,70,,92.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,64.68,3324,
Culture-Chlamydia,87110,CPT,,,,inpatient,,,189,113.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,153.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,160.65,percent of total billed charges,,,85,,160.65,percent of total billed charges,,,49,,92.61,percent of total billed charges,,,90,,170.1,percent of total billed charges,,,,,,,no IP contract,,80,,151.2,percent of total billed charges,,,,,,,no IP contract,,50,,94.5,percent of total billed charges,,,,,,no IP contract,,,78,,147.42,percent of total billed charges,,,70,,132.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,92.61,3324,
Culture-Mycobacteria Blood,87116,CPT,,,,inpatient,,,174,104.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,140.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,147.9,percent of total billed charges,,,85,,147.9,percent of total billed charges,,,49,,85.26,percent of total billed charges,,,90,,156.6,percent of total billed charges,,,,,,,no IP contract,,80,,139.2,percent of total billed charges,,,,,,,no IP contract,,50,,87,percent of total billed charges,,,,,,no IP contract,,,78,,135.72,percent of total billed charges,,,70,,121.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,85.26,3324,
Culture-AFB Culture (non-blood),87116,CPT,,,,inpatient,,,233,139.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,188.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,198.05,percent of total billed charges,,,85,,198.05,percent of total billed charges,,,49,,114.17,percent of total billed charges,,,90,,209.7,percent of total billed charges,,,,,,,no IP contract,,80,,186.4,percent of total billed charges,,,,,,,no IP contract,,50,,116.5,percent of total billed charges,,,,,,no IP contract,,,78,,181.74,percent of total billed charges,,,70,,163.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,114.17,3324,
Culture-Mycobacteria no Smear,87116,CPT,,,,inpatient,,,233,139.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,188.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,198.05,percent of total billed charges,,,85,,198.05,percent of total billed charges,,,49,,114.17,percent of total billed charges,,,90,,209.7,percent of total billed charges,,,,,,,no IP contract,,80,,186.4,percent of total billed charges,,,,,,,no IP contract,,50,,116.5,percent of total billed charges,,,,,,no IP contract,,,78,,181.74,percent of total billed charges,,,70,,163.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,114.17,3324,
PNEUMONIA PANEL; ANTIMICROBIAL RESIST GENES PCR NMH,87150,CPT,,,,inpatient,,,226,135.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,183.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,192.1,percent of total billed charges,,,85,,192.1,percent of total billed charges,,,49,,110.74,percent of total billed charges,,,90,,203.4,percent of total billed charges,,,,,,,no IP contract,,80,,180.8,percent of total billed charges,,,,,,,no IP contract,,50,,113,percent of total billed charges,,,,,,no IP contract,,,78,,176.28,percent of total billed charges,,,70,,158.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,110.74,3324,
Parasite Identification,87169,CPT,,,,inpatient,,,137,82.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,110.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,116.45,percent of total billed charges,,,85,,116.45,percent of total billed charges,,,49,,67.13,percent of total billed charges,,,90,,123.3,percent of total billed charges,,,,,,,no IP contract,,80,,109.6,percent of total billed charges,,,,,,,no IP contract,,50,,68.5,percent of total billed charges,,,,,,no IP contract,,,78,,106.86,percent of total billed charges,,,70,,95.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,67.13,3324,
Worm Identification,87169,CPT,,,,inpatient,,,146,87.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,118.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,124.1,percent of total billed charges,,,85,,124.1,percent of total billed charges,,,49,,71.54,percent of total billed charges,,,90,,131.4,percent of total billed charges,,,,,,,no IP contract,,80,,116.8,percent of total billed charges,,,,,,,no IP contract,,50,,73,percent of total billed charges,,,,,,no IP contract,,,78,,113.88,percent of total billed charges,,,70,,102.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,71.54,3324,
Ova and Parasites-Stool,87177,CPT,,,,inpatient,,,229,137.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,185.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,194.65,percent of total billed charges,,,85,,194.65,percent of total billed charges,,,49,,112.21,percent of total billed charges,,,90,,206.1,percent of total billed charges,,,,,,,no IP contract,,80,,183.2,percent of total billed charges,,,,,,,no IP contract,,50,,114.5,percent of total billed charges,,,,,,no IP contract,,,78,,178.62,percent of total billed charges,,,70,,160.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,112.21,3324,
Susceptibility studies,87181,CPT,,,,inpatient,,,72,43.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,58.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,61.2,percent of total billed charges,,,85,,61.2,percent of total billed charges,,,49,,35.28,percent of total billed charges,,,90,,64.8,percent of total billed charges,,,,,,,no IP contract,,80,,57.6,percent of total billed charges,,,,,,,no IP contract,,50,,36,percent of total billed charges,,,,,,no IP contract,,,78,,56.16,percent of total billed charges,,,70,,50.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,35.28,3324,
Susceptibility studies,87181,CPT,,,,inpatient,,,72,43.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,58.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,61.2,percent of total billed charges,,,85,,61.2,percent of total billed charges,,,49,,35.28,percent of total billed charges,,,90,,64.8,percent of total billed charges,,,,,,,no IP contract,,80,,57.6,percent of total billed charges,,,,,,,no IP contract,,50,,36,percent of total billed charges,,,,,,no IP contract,,,78,,56.16,percent of total billed charges,,,70,,50.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,35.28,3324,
Susceptibility Studies x1,87181,CPT,,,,inpatient,,,72,43.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,58.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,61.2,percent of total billed charges,,,85,,61.2,percent of total billed charges,,,49,,35.28,percent of total billed charges,,,90,,64.8,percent of total billed charges,,,,,,,no IP contract,,80,,57.6,percent of total billed charges,,,,,,,no IP contract,,50,,36,percent of total billed charges,,,,,,no IP contract,,,78,,56.16,percent of total billed charges,,,70,,50.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,35.28,3324,
Susceptibility Studies x2,87181,CPT,,,,inpatient,,,72,43.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,58.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,61.2,percent of total billed charges,,,85,,61.2,percent of total billed charges,,,49,,35.28,percent of total billed charges,,,90,,64.8,percent of total billed charges,,,,,,,no IP contract,,80,,57.6,percent of total billed charges,,,,,,,no IP contract,,50,,36,percent of total billed charges,,,,,,no IP contract,,,78,,56.16,percent of total billed charges,,,70,,50.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,35.28,3324,
Susceptibility Studies x3,87181,CPT,,,,inpatient,,,72,43.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,58.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,61.2,percent of total billed charges,,,85,,61.2,percent of total billed charges,,,49,,35.28,percent of total billed charges,,,90,,64.8,percent of total billed charges,,,,,,,no IP contract,,80,,57.6,percent of total billed charges,,,,,,,no IP contract,,50,,36,percent of total billed charges,,,,,,no IP contract,,,78,,56.16,percent of total billed charges,,,70,,50.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,35.28,3324,
Susceptibility Studies x4,87181,CPT,,,,inpatient,,,72,43.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,58.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,61.2,percent of total billed charges,,,85,,61.2,percent of total billed charges,,,49,,35.28,percent of total billed charges,,,90,,64.8,percent of total billed charges,,,,,,,no IP contract,,80,,57.6,percent of total billed charges,,,,,,,no IP contract,,50,,36,percent of total billed charges,,,,,,no IP contract,,,78,,56.16,percent of total billed charges,,,70,,50.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,35.28,3324,
Susceptibility Studies x5,87181,CPT,,,,inpatient,,,72,43.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,58.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,61.2,percent of total billed charges,,,85,,61.2,percent of total billed charges,,,49,,35.28,percent of total billed charges,,,90,,64.8,percent of total billed charges,,,,,,,no IP contract,,80,,57.6,percent of total billed charges,,,,,,,no IP contract,,50,,36,percent of total billed charges,,,,,,no IP contract,,,78,,56.16,percent of total billed charges,,,70,,50.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,35.28,3324,
HB SUSCEPTIBILITY; DISC NMH,87184,CPT,,,,inpatient,,,114,68.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,92.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,96.9,percent of total billed charges,,,85,,96.9,percent of total billed charges,,,49,,55.86,percent of total billed charges,,,90,,102.6,percent of total billed charges,,,,,,,no IP contract,,80,,91.2,percent of total billed charges,,,,,,,no IP contract,,50,,57,percent of total billed charges,,,,,,no IP contract,,,78,,88.92,percent of total billed charges,,,70,,79.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,55.86,3324,
"SUSCEPTIBILITY, MICROTITER NMH",87186,CPT,,,,inpatient,,,301,180.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,243.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,255.85,percent of total billed charges,,,85,,255.85,percent of total billed charges,,,49,,147.49,percent of total billed charges,,,90,,270.9,percent of total billed charges,,,,,,,no IP contract,,80,,240.8,percent of total billed charges,,,,,,,no IP contract,,50,,150.5,percent of total billed charges,,,,,,no IP contract,,,78,,234.78,percent of total billed charges,,,70,,210.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,147.49,3324,
"Smear, primary source, with interpretation",87205,CPT,,,,inpatient,,,80,48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,64.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,68,percent of total billed charges,,,85,,68,percent of total billed charges,,,49,,39.2,percent of total billed charges,,,90,,72,percent of total billed charges,,,,,,,no IP contract,,80,,64,percent of total billed charges,,,,,,,no IP contract,,50,,40,percent of total billed charges,,,,,,no IP contract,,,78,,62.4,percent of total billed charges,,,70,,56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,39.2,3324,
GRAM STAIN NMH,87205,CPT,,,,inpatient,,,88,52.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,71.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,74.8,percent of total billed charges,,,85,,74.8,percent of total billed charges,,,49,,43.12,percent of total billed charges,,,90,,79.2,percent of total billed charges,,,,,,,no IP contract,,80,,70.4,percent of total billed charges,,,,,,,no IP contract,,50,,44,percent of total billed charges,,,,,,no IP contract,,,78,,68.64,percent of total billed charges,,,70,,61.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,43.12,3324,
Vaginitis Screen,87205,CPT,,,,inpatient,,,152,91.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,123.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,129.2,percent of total billed charges,,,85,,129.2,percent of total billed charges,,,49,,74.48,percent of total billed charges,,,90,,136.8,percent of total billed charges,,,,,,,no IP contract,,80,,121.6,percent of total billed charges,,,,,,,no IP contract,,50,,76,percent of total billed charges,,,,,,no IP contract,,,78,,118.56,percent of total billed charges,,,70,,106.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,74.48,3324,
CALCOFLUOR WHITE STAIN NMH,87206,CPT,,,,inpatient,,,52,31.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,42.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,44.2,percent of total billed charges,,,85,,44.2,percent of total billed charges,,,49,,25.48,percent of total billed charges,,,90,,46.8,percent of total billed charges,,,,,,,no IP contract,,80,,41.6,percent of total billed charges,,,,,,,no IP contract,,50,,26,percent of total billed charges,,,,,,no IP contract,,,78,,40.56,percent of total billed charges,,,70,,36.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,18599.08,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.48,18599.08,
Cryptosporidium Exam - Other,87206,CPT,,,,inpatient,,,154,92.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,124.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,130.9,percent of total billed charges,,,85,,130.9,percent of total billed charges,,,49,,75.46,percent of total billed charges,,,90,,138.6,percent of total billed charges,,,,,,,no IP contract,,80,,123.2,percent of total billed charges,,,,,,,no IP contract,,50,,77,percent of total billed charges,,,,,,no IP contract,,,78,,120.12,percent of total billed charges,,,70,,107.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,75.46,3324,
Culture-Mycobacteria with AFB Smear,87206,CPT,,,,inpatient,,,154,92.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,124.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,130.9,percent of total billed charges,,,85,,130.9,percent of total billed charges,,,49,,75.46,percent of total billed charges,,,90,,138.6,percent of total billed charges,,,,,,,no IP contract,,80,,123.2,percent of total billed charges,,,,,,,no IP contract,,50,,77,percent of total billed charges,,,,,,no IP contract,,,78,,120.12,percent of total billed charges,,,70,,107.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,75.46,3324,
Cyclospora,87206,CPT,,,,inpatient,,,154,92.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,124.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,130.9,percent of total billed charges,,,85,,130.9,percent of total billed charges,,,49,,75.46,percent of total billed charges,,,90,,138.6,percent of total billed charges,,,,,,,no IP contract,,80,,123.2,percent of total billed charges,,,,,,,no IP contract,,50,,77,percent of total billed charges,,,,,,no IP contract,,,78,,120.12,percent of total billed charges,,,70,,107.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,75.46,3324,
Isospora Exam,87206,CPT,,,,inpatient,,,154,92.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,124.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,130.9,percent of total billed charges,,,85,,130.9,percent of total billed charges,,,49,,75.46,percent of total billed charges,,,90,,138.6,percent of total billed charges,,,,,,,no IP contract,,80,,123.2,percent of total billed charges,,,,,,,no IP contract,,50,,77,percent of total billed charges,,,,,,no IP contract,,,78,,120.12,percent of total billed charges,,,70,,107.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,75.46,3324,
Microsporidium,87206,CPT,,,,inpatient,,,154,92.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,124.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,130.9,percent of total billed charges,,,85,,130.9,percent of total billed charges,,,49,,75.46,percent of total billed charges,,,90,,138.6,percent of total billed charges,,,,,,,no IP contract,,80,,123.2,percent of total billed charges,,,,,,,no IP contract,,50,,77,percent of total billed charges,,,,,,no IP contract,,,78,,120.12,percent of total billed charges,,,70,,107.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,75.46,3324,
Mycobacteria Smear,87206,CPT,,,,inpatient,,,154,92.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,124.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,130.9,percent of total billed charges,,,85,,130.9,percent of total billed charges,,,49,,75.46,percent of total billed charges,,,90,,138.6,percent of total billed charges,,,,,,,no IP contract,,80,,123.2,percent of total billed charges,,,,,,,no IP contract,,50,,77,percent of total billed charges,,,,,,no IP contract,,,78,,120.12,percent of total billed charges,,,70,,107.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,75.46,3324,
Malarial Prep,87207,CPT,,,,inpatient,,,95,57,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,76.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,80.75,percent of total billed charges,,,85,,80.75,percent of total billed charges,,,49,,46.55,percent of total billed charges,,,90,,85.5,percent of total billed charges,,,,,,,no IP contract,,80,,76,percent of total billed charges,,,,,,,no IP contract,,50,,47.5,percent of total billed charges,,,,,,no IP contract,,,78,,74.1,percent of total billed charges,,,70,,66.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,46.55,3324,
Wet mount,87210,CPT,,,,inpatient,,,77,46.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,62.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,65.45,percent of total billed charges,,,85,,65.45,percent of total billed charges,,,49,,37.73,percent of total billed charges,,,90,,69.3,percent of total billed charges,,,,,,,no IP contract,,80,,61.6,percent of total billed charges,,,,,,,no IP contract,,50,,38.5,percent of total billed charges,,,,,,no IP contract,,,78,,60.06,percent of total billed charges,,,70,,53.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,37.73,3324,
KOH Prep,87220,CPT,,,,inpatient,,,89,53.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,72.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,75.65,percent of total billed charges,,,85,,75.65,percent of total billed charges,,,49,,43.61,percent of total billed charges,,,90,,80.1,percent of total billed charges,,,,,,,no IP contract,,80,,71.2,percent of total billed charges,,,,,,,no IP contract,,50,,44.5,percent of total billed charges,,,,,,no IP contract,,,78,,69.42,percent of total billed charges,,,70,,62.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,43.61,3324,
KOH Prep,87220,CPT,,,,inpatient,,,89,53.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,72.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,75.65,percent of total billed charges,,,85,,75.65,percent of total billed charges,,,49,,43.61,percent of total billed charges,,,90,,80.1,percent of total billed charges,,,,,,,no IP contract,,80,,71.2,percent of total billed charges,,,,,,,no IP contract,,50,,44.5,percent of total billed charges,,,,,,no IP contract,,,78,,69.42,percent of total billed charges,,,70,,62.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,43.61,3324,
Mumps Virus Culture,87252,CPT,,,,inpatient,,,209,125.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,169.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,177.65,percent of total billed charges,,,85,,177.65,percent of total billed charges,,,49,,102.41,percent of total billed charges,,,90,,188.1,percent of total billed charges,,,,,,,no IP contract,,80,,167.2,percent of total billed charges,,,,,,,no IP contract,,50,,104.5,percent of total billed charges,,,,,,no IP contract,,,78,,163.02,percent of total billed charges,,,70,,146.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,102.41,3324,
"Virus isolation, tissue culture inoculation",87252,CPT,,,,inpatient,,,224,134.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,181.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,190.4,percent of total billed charges,,,85,,190.4,percent of total billed charges,,,49,,109.76,percent of total billed charges,,,90,,201.6,percent of total billed charges,,,,,,,no IP contract,,80,,179.2,percent of total billed charges,,,,,,,no IP contract,,50,,112,percent of total billed charges,,,,,,no IP contract,,,78,,174.72,percent of total billed charges,,,70,,156.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,109.76,3324,
Culture-CMV Non-Blood,87252,CPT,,,,inpatient,,,296,177.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,239.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,251.6,percent of total billed charges,,,85,,251.6,percent of total billed charges,,,49,,145.04,percent of total billed charges,,,90,,266.4,percent of total billed charges,,,,,,,no IP contract,,80,,236.8,percent of total billed charges,,,,,,,no IP contract,,50,,148,percent of total billed charges,,,,,,no IP contract,,,78,,230.88,percent of total billed charges,,,70,,207.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,145.04,3324,
Culture-Virus,87252,CPT,,,,inpatient,,,296,177.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,239.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,251.6,percent of total billed charges,,,85,,251.6,percent of total billed charges,,,49,,145.04,percent of total billed charges,,,90,,266.4,percent of total billed charges,,,,,,,no IP contract,,80,,236.8,percent of total billed charges,,,,,,,no IP contract,,50,,148,percent of total billed charges,,,,,,no IP contract,,,78,,230.88,percent of total billed charges,,,70,,207.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,145.04,3324,
Viral Titre CSF,87252,CPT,,,,inpatient,,,301,180.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,243.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,255.85,percent of total billed charges,,,85,,255.85,percent of total billed charges,,,49,,147.49,percent of total billed charges,,,90,,270.9,percent of total billed charges,,,,,,,no IP contract,,80,,240.8,percent of total billed charges,,,,,,,no IP contract,,50,,150.5,percent of total billed charges,,,,,,no IP contract,,,78,,234.78,percent of total billed charges,,,70,,210.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,147.49,3324,
Herpes Culture,87252,CPT,,,,inpatient,,,338,202.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,273.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,287.3,percent of total billed charges,,,85,,287.3,percent of total billed charges,,,49,,165.62,percent of total billed charges,,,90,,304.2,percent of total billed charges,,,,,,,no IP contract,,80,,270.4,percent of total billed charges,,,,,,,no IP contract,,50,,169,percent of total billed charges,,,,,,no IP contract,,,78,,263.64,percent of total billed charges,,,70,,236.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,165.62,3324,
Virus Shell Isolation,87254,CPT,,,,inpatient,,,178,106.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,144.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,151.3,percent of total billed charges,,,85,,151.3,percent of total billed charges,,,49,,87.22,percent of total billed charges,,,90,,160.2,percent of total billed charges,,,,,,,no IP contract,,80,,142.4,percent of total billed charges,,,,,,,no IP contract,,50,,89,percent of total billed charges,,,,,,no IP contract,,,78,,138.84,percent of total billed charges,,,70,,124.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,87.22,3324,
Legionella DFA Stain,87278,CPT,,,,inpatient,,,237,142.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,191.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,201.45,percent of total billed charges,,,85,,201.45,percent of total billed charges,,,49,,116.13,percent of total billed charges,,,90,,213.3,percent of total billed charges,,,,,,,no IP contract,,80,,189.6,percent of total billed charges,,,,,,,no IP contract,,50,,118.5,percent of total billed charges,,,,,,no IP contract,,,78,,184.86,percent of total billed charges,,,70,,165.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,116.13,3324,
Respiratory Synctial Virus DFA,87280,CPT,,,,inpatient,,,174,104.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,140.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,147.9,percent of total billed charges,,,85,,147.9,percent of total billed charges,,,49,,85.26,percent of total billed charges,,,90,,156.6,percent of total billed charges,,,,,,,no IP contract,,80,,139.2,percent of total billed charges,,,,,,,no IP contract,,50,,87,percent of total billed charges,,,,,,no IP contract,,,78,,135.72,percent of total billed charges,,,70,,121.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,85.26,3324,
Infectious agent antigen detection,87300,CPT,,,,inpatient,,,146,87.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,118.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,124.1,percent of total billed charges,,,85,,124.1,percent of total billed charges,,,49,,71.54,percent of total billed charges,,,90,,131.4,percent of total billed charges,,,,,,,no IP contract,,80,,116.8,percent of total billed charges,,,,,,,no IP contract,,50,,73,percent of total billed charges,,,,,,no IP contract,,,78,,113.88,percent of total billed charges,,,70,,102.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,71.54,3324,
ASPERGILLUS AG IA NMH,87305,CPT,,,,inpatient,,,250,150,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,202.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,212.5,percent of total billed charges,,,85,,212.5,percent of total billed charges,,,49,,122.5,percent of total billed charges,,,90,,225,percent of total billed charges,,,,,,,no IP contract,,80,,200,percent of total billed charges,,,,,,,no IP contract,,50,,125,percent of total billed charges,,,,,,no IP contract,,,78,,195,percent of total billed charges,,,70,,175,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,24508.745,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,122.5,24508.75,
C. Difficile Toxin NMH,87324,CPT,,,,inpatient,,,138,82.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,111.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,117.3,percent of total billed charges,,,85,,117.3,percent of total billed charges,,,49,,67.62,percent of total billed charges,,,90,,124.2,percent of total billed charges,,,,,,,no IP contract,,80,,110.4,percent of total billed charges,,,,,,,no IP contract,,50,,69,percent of total billed charges,,,,,,no IP contract,,,78,,107.64,percent of total billed charges,,,70,,96.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,31929.63,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,67.62,31929.63,
C Difficile Toxin,87324,CPT,,,,inpatient,,,217,130.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,175.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,184.45,percent of total billed charges,,,85,,184.45,percent of total billed charges,,,49,,106.33,percent of total billed charges,,,90,,195.3,percent of total billed charges,,,,,,,no IP contract,,80,,173.6,percent of total billed charges,,,,,,,no IP contract,,50,,108.5,percent of total billed charges,,,,,,no IP contract,,,78,,169.26,percent of total billed charges,,,70,,151.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,106.33,3324,
C Difficile by PCR,87324,CPT,,,,inpatient,,,298,178.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,241.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,253.3,percent of total billed charges,,,85,,253.3,percent of total billed charges,,,49,,146.02,percent of total billed charges,,,90,,268.2,percent of total billed charges,,,,,,,no IP contract,,80,,238.4,percent of total billed charges,,,,,,,no IP contract,,50,,149,percent of total billed charges,,,,,,no IP contract,,,78,,232.44,percent of total billed charges,,,70,,208.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,34907.5475,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,146.02,34907.55,
Cryptospordium Exam - Stool,87328,CPT,,,,inpatient,,,187,112.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,151.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,158.95,percent of total billed charges,,,85,,158.95,percent of total billed charges,,,49,,91.63,percent of total billed charges,,,90,,168.3,percent of total billed charges,,,,,,,no IP contract,,80,,149.6,percent of total billed charges,,,,,,,no IP contract,,50,,93.5,percent of total billed charges,,,,,,no IP contract,,,78,,145.86,percent of total billed charges,,,70,,130.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,91.63,3324,
"Giardia Antigen, Stool",87329,CPT,,,,inpatient,,,149,89.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,120.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,126.65,percent of total billed charges,,,85,,126.65,percent of total billed charges,,,49,,73.01,percent of total billed charges,,,90,,134.1,percent of total billed charges,,,,,,,no IP contract,,80,,119.2,percent of total billed charges,,,,,,,no IP contract,,50,,74.5,percent of total billed charges,,,,,,no IP contract,,,78,,116.22,percent of total billed charges,,,70,,104.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,73.01,3324,
Entamoeba Histolytica Antigen,87337,CPT,,,,inpatient,,,138,82.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,111.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,117.3,percent of total billed charges,,,85,,117.3,percent of total billed charges,,,49,,67.62,percent of total billed charges,,,90,,124.2,percent of total billed charges,,,,,,,no IP contract,,80,,110.4,percent of total billed charges,,,,,,,no IP contract,,50,,69,percent of total billed charges,,,,,,no IP contract,,,78,,107.64,percent of total billed charges,,,70,,96.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,67.62,3324,
"H. Pylori Antigen, Stool",87338,CPT,,,,inpatient,,,255,153,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,206.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,216.75,percent of total billed charges,,,85,,216.75,percent of total billed charges,,,49,,124.95,percent of total billed charges,,,90,,229.5,percent of total billed charges,,,,,,,no IP contract,,80,,204,percent of total billed charges,,,,,,,no IP contract,,50,,127.5,percent of total billed charges,,,,,,no IP contract,,,78,,198.9,percent of total billed charges,,,70,,178.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,124.95,3324,
HEPATITIS B SURFACE ANTIGEN NMH,87340,CPT,,,,inpatient,,,153,91.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,123.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,130.05,percent of total billed charges,,,85,,130.05,percent of total billed charges,,,49,,74.97,percent of total billed charges,,,90,,137.7,percent of total billed charges,,,,,,,no IP contract,,80,,122.4,percent of total billed charges,,,,,,,no IP contract,,50,,76.5,percent of total billed charges,,,,,,no IP contract,,,78,,119.34,percent of total billed charges,,,70,,107.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,74.97,3324,
Hepatitis B Surface Antigen,87340,CPT,,,,inpatient,,,204,122.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,165.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,173.4,percent of total billed charges,,,85,,173.4,percent of total billed charges,,,49,,99.96,percent of total billed charges,,,90,,183.6,percent of total billed charges,,,,,,,no IP contract,,80,,163.2,percent of total billed charges,,,,,,,no IP contract,,50,,102,percent of total billed charges,,,,,,no IP contract,,,78,,159.12,percent of total billed charges,,,70,,142.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,99.96,3324,
Hepatitis B Surface Antigen,87340,CPT,,,,inpatient,,,204,122.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,165.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,173.4,percent of total billed charges,,,85,,173.4,percent of total billed charges,,,49,,99.96,percent of total billed charges,,,90,,183.6,percent of total billed charges,,,,,,,no IP contract,,80,,163.2,percent of total billed charges,,,,,,,no IP contract,,50,,102,percent of total billed charges,,,,,,no IP contract,,,78,,159.12,percent of total billed charges,,,70,,142.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,99.96,3324,
Hepatitis BE Antigen,87350,CPT,,,,inpatient,,,102,61.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,82.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,86.7,percent of total billed charges,,,85,,86.7,percent of total billed charges,,,49,,49.98,percent of total billed charges,,,90,,91.8,percent of total billed charges,,,,,,,no IP contract,,80,,81.6,percent of total billed charges,,,,,,,no IP contract,,50,,51,percent of total billed charges,,,,,,no IP contract,,,78,,79.56,percent of total billed charges,,,70,,71.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,49.98,3324,
"Histoplasma Antigen, Urine",87385,CPT,,,,inpatient,,,176,105.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,142.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,149.6,percent of total billed charges,,,85,,149.6,percent of total billed charges,,,49,,86.24,percent of total billed charges,,,90,,158.4,percent of total billed charges,,,,,,,no IP contract,,80,,140.8,percent of total billed charges,,,,,,,no IP contract,,50,,88,percent of total billed charges,,,,,,no IP contract,,,78,,137.28,percent of total billed charges,,,70,,123.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,86.24,3324,
"Rotavirus Antigen, Stool",87425,CPT,,,,inpatient,,,188,112.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,152.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,159.8,percent of total billed charges,,,85,,159.8,percent of total billed charges,,,49,,92.12,percent of total billed charges,,,90,,169.2,percent of total billed charges,,,,,,,no IP contract,,80,,150.4,percent of total billed charges,,,,,,,no IP contract,,50,,94,percent of total billed charges,,,,,,no IP contract,,,78,,146.64,percent of total billed charges,,,70,,131.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,92.12,3324,
"Legionella Antigen, Urine",87449,CPT,,,,inpatient,,,138,82.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,111.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,117.3,percent of total billed charges,,,85,,117.3,percent of total billed charges,,,49,,67.62,percent of total billed charges,,,90,,124.2,percent of total billed charges,,,,,,,no IP contract,,80,,110.4,percent of total billed charges,,,,,,,no IP contract,,50,,69,percent of total billed charges,,,,,,no IP contract,,,78,,107.64,percent of total billed charges,,,70,,96.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,67.62,3324,
Norovirus,87449,CPT,,,,inpatient,,,269,161.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,217.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,228.65,percent of total billed charges,,,85,,228.65,percent of total billed charges,,,49,,131.81,percent of total billed charges,,,90,,242.1,percent of total billed charges,,,,,,,no IP contract,,80,,215.2,percent of total billed charges,,,,,,,no IP contract,,50,,134.5,percent of total billed charges,,,,,,no IP contract,,,78,,209.82,percent of total billed charges,,,70,,188.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,131.81,3324,
"Blastomyces Antigen, Urine",87449,CPT,,,,inpatient,,,342,205.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,277.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,290.7,percent of total billed charges,,,85,,290.7,percent of total billed charges,,,49,,167.58,percent of total billed charges,,,90,,307.8,percent of total billed charges,,,,,,,no IP contract,,80,,273.6,percent of total billed charges,,,,,,,no IP contract,,50,,171,percent of total billed charges,,,,,,no IP contract,,,78,,266.76,percent of total billed charges,,,70,,239.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,167.58,3324,
Lyme Disease by PCR,87476,CPT,,,,inpatient,,,264,158.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,213.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,224.4,percent of total billed charges,,,85,,224.4,percent of total billed charges,,,49,,129.36,percent of total billed charges,,,90,,237.6,percent of total billed charges,,,,,,,no IP contract,,80,,211.2,percent of total billed charges,,,,,,,no IP contract,,50,,132,percent of total billed charges,,,,,,no IP contract,,,78,,205.92,percent of total billed charges,,,70,,184.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,129.36,3324,
"Lyme Disease DNA, Real-Time PCR, Blood",87476,CPT,,,,inpatient,,,645,387,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,522.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,548.25,percent of total billed charges,,,85,,548.25,percent of total billed charges,,,49,,316.05,percent of total billed charges,,,90,,580.5,percent of total billed charges,,,,,,,no IP contract,,80,,516,percent of total billed charges,,,,,,,no IP contract,,50,,322.5,percent of total billed charges,,,,,,no IP contract,,,78,,503.1,percent of total billed charges,,,70,,451.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,316.05,3324,
CANDIDA AURIS SCREEN BY PCR,87481,CPT,,,,inpatient,,,133,79.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,107.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,113.05,percent of total billed charges,,,85,,113.05,percent of total billed charges,,,49,,65.17,percent of total billed charges,,,90,,119.7,percent of total billed charges,,,,,,,no IP contract,,80,,106.4,percent of total billed charges,,,,,,,no IP contract,,50,,66.5,percent of total billed charges,,,,,,no IP contract,,,78,,103.74,percent of total billed charges,,,70,,93.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,65.17,3324,
CANDIDA AURIS SCREEN BY PCR NMH,87481,CPT,,,,inpatient,,,163,97.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,132.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,138.55,percent of total billed charges,,,85,,138.55,percent of total billed charges,,,49,,79.87,percent of total billed charges,,,90,,146.7,percent of total billed charges,,,,,,,no IP contract,,80,,130.4,percent of total billed charges,,,,,,,no IP contract,,50,,81.5,percent of total billed charges,,,,,,no IP contract,,,78,,127.14,percent of total billed charges,,,70,,114.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,79.87,3324,
PNEUMONIA PANEL CHLAMYDOPHILA PNEUMONIAE PCR NMH,87486,CPT,,,,inpatient,,,226,135.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,183.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,192.1,percent of total billed charges,,,85,,192.1,percent of total billed charges,,,49,,110.74,percent of total billed charges,,,90,,203.4,percent of total billed charges,,,,,,,no IP contract,,80,,180.8,percent of total billed charges,,,,,,,no IP contract,,50,,113,percent of total billed charges,,,,,,no IP contract,,,78,,176.28,percent of total billed charges,,,70,,158.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,110.74,3324,
Chlamydia by PCR,87491,CPT,,,,inpatient,,,209,125.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,169.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,177.65,percent of total billed charges,,,85,,177.65,percent of total billed charges,,,49,,102.41,percent of total billed charges,,,90,,188.1,percent of total billed charges,,,,,,,no IP contract,,80,,167.2,percent of total billed charges,,,,,,,no IP contract,,50,,104.5,percent of total billed charges,,,,,,no IP contract,,,78,,163.02,percent of total billed charges,,,70,,146.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,102.41,3324,
"CMV DNA Qualitative, Blood",87495,CPT,,,,inpatient,,,161,96.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,130.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,136.85,percent of total billed charges,,,85,,136.85,percent of total billed charges,,,49,,78.89,percent of total billed charges,,,90,,144.9,percent of total billed charges,,,,,,,no IP contract,,80,,128.8,percent of total billed charges,,,,,,,no IP contract,,50,,80.5,percent of total billed charges,,,,,,no IP contract,,,78,,125.58,percent of total billed charges,,,70,,112.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,78.89,3324,
"Cytomegalovirus by PCR, CSF Qualitative",87496,CPT,,,,inpatient,,,344,206.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,278.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,292.4,percent of total billed charges,,,85,,292.4,percent of total billed charges,,,49,,168.56,percent of total billed charges,,,90,,309.6,percent of total billed charges,,,,,,,no IP contract,,80,,275.2,percent of total billed charges,,,,,,,no IP contract,,50,,172,percent of total billed charges,,,,,,no IP contract,,,78,,268.32,percent of total billed charges,,,70,,240.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,168.56,3324,
"Cytomegalovirus Viral Load PCR, blood",87496,CPT,,,,inpatient,,,565,339,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,457.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,480.25,percent of total billed charges,,,85,,480.25,percent of total billed charges,,,49,,276.85,percent of total billed charges,,,90,,508.5,percent of total billed charges,,,,,,,no IP contract,,80,,452,percent of total billed charges,,,,,,,no IP contract,,50,,282.5,percent of total billed charges,,,,,,no IP contract,,,78,,440.7,percent of total billed charges,,,70,,395.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,276.85,3324,
"Cytomegalovirus by PCR, Urine, Qualitative",87496,CPT,,,,inpatient,,,737,442.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,596.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,626.45,percent of total billed charges,,,85,,626.45,percent of total billed charges,,,49,,361.13,percent of total billed charges,,,90,,663.3,percent of total billed charges,,,,,,,no IP contract,,80,,589.6,percent of total billed charges,,,,,,,no IP contract,,50,,368.5,percent of total billed charges,,,,,,no IP contract,,,78,,574.86,percent of total billed charges,,,70,,515.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,361.13,3324,
"CYTOMEGALOVIRUS, QUANTITATIVE, PCR NMH",87497,CPT,,,,inpatient,,,589,353.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,477.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,500.65,percent of total billed charges,,,85,,500.65,percent of total billed charges,,,49,,288.61,percent of total billed charges,,,90,,530.1,percent of total billed charges,,,,,,,no IP contract,,80,,471.2,percent of total billed charges,,,,,,,no IP contract,,50,,294.5,percent of total billed charges,,,,,,no IP contract,,,78,,459.42,percent of total billed charges,,,70,,412.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,288.61,3324,
"Hepatitis B Viral DNA, Qualitative",87516,CPT,,,,inpatient,,,365,219,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,295.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,310.25,percent of total billed charges,,,85,,310.25,percent of total billed charges,,,49,,178.85,percent of total billed charges,,,90,,328.5,percent of total billed charges,,,,,,,no IP contract,,80,,292,percent of total billed charges,,,,,,,no IP contract,,50,,182.5,percent of total billed charges,,,,,,no IP contract,,,78,,284.7,percent of total billed charges,,,70,,255.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,178.85,3324,
Hepatitis B Virus Viral Load PCR,87517,CPT,,,,inpatient,,,551,330.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,446.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,468.35,percent of total billed charges,,,85,,468.35,percent of total billed charges,,,49,,269.99,percent of total billed charges,,,90,,495.9,percent of total billed charges,,,,,,,no IP contract,,80,,440.8,percent of total billed charges,,,,,,,no IP contract,,50,,275.5,percent of total billed charges,,,,,,no IP contract,,,78,,429.78,percent of total billed charges,,,70,,385.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,269.99,3324,
Hepatitis C Virus Qualitative RT-PCR,87521,CPT,,,,inpatient,,,391,234.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,316.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,332.35,percent of total billed charges,,,85,,332.35,percent of total billed charges,,,49,,191.59,percent of total billed charges,,,90,,351.9,percent of total billed charges,,,,,,,no IP contract,,80,,312.8,percent of total billed charges,,,,,,,no IP contract,,50,,195.5,percent of total billed charges,,,,,,no IP contract,,,78,,304.98,percent of total billed charges,,,70,,273.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,191.59,3324,
HCV PCR Quantitation Regular,87522,CPT,,,,inpatient,,,676,405.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,547.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,574.6,percent of total billed charges,,,85,,574.6,percent of total billed charges,,,49,,331.24,percent of total billed charges,,,90,,608.4,percent of total billed charges,,,,,,,no IP contract,,80,,540.8,percent of total billed charges,,,,,,,no IP contract,,50,,338,percent of total billed charges,,,,,,no IP contract,,,78,,527.28,percent of total billed charges,,,70,,473.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,331.24,3324,
Hepatitis C Virus-Quantitative,87522,CPT,,,,inpatient,,,676,405.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,547.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,574.6,percent of total billed charges,,,85,,574.6,percent of total billed charges,,,49,,331.24,percent of total billed charges,,,90,,608.4,percent of total billed charges,,,,,,,no IP contract,,80,,540.8,percent of total billed charges,,,,,,,no IP contract,,50,,338,percent of total billed charges,,,,,,no IP contract,,,78,,527.28,percent of total billed charges,,,70,,473.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,331.24,3324,
Herpes Simplex Virus 1&2 PCR,87529,CPT,,,,inpatient,,,491,294.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,397.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,417.35,percent of total billed charges,,,85,,417.35,percent of total billed charges,,,49,,240.59,percent of total billed charges,,,90,,441.9,percent of total billed charges,,,,,,,no IP contract,,80,,392.8,percent of total billed charges,,,,,,,no IP contract,,50,,245.5,percent of total billed charges,,,,,,no IP contract,,,78,,382.98,percent of total billed charges,,,70,,343.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,240.59,3324,
Herpes Simplex Virus PCR,87530,CPT,,,,inpatient,,,561,336.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,454.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,476.85,percent of total billed charges,,,85,,476.85,percent of total billed charges,,,49,,274.89,percent of total billed charges,,,90,,504.9,percent of total billed charges,,,,,,,no IP contract,,80,,448.8,percent of total billed charges,,,,,,,no IP contract,,50,,280.5,percent of total billed charges,,,,,,no IP contract,,,78,,437.58,percent of total billed charges,,,70,,392.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,274.89,3324,
PNEUMONIA PANEL LEGIONELLA PNEUMOPHILA PCR NMH,87541,CPT,,,,inpatient,,,226,135.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,183.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,192.1,percent of total billed charges,,,85,,192.1,percent of total billed charges,,,49,,110.74,percent of total billed charges,,,90,,203.4,percent of total billed charges,,,,,,,no IP contract,,80,,180.8,percent of total billed charges,,,,,,,no IP contract,,50,,113,percent of total billed charges,,,,,,no IP contract,,,78,,176.28,percent of total billed charges,,,70,,158.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,110.74,3324,
Mycobacterium Tuberculosis PCR,87556,CPT,,,,inpatient,,,475,285,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,384.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,403.75,percent of total billed charges,,,85,,403.75,percent of total billed charges,,,49,,232.75,percent of total billed charges,,,90,,427.5,percent of total billed charges,,,,,,,no IP contract,,80,,380,percent of total billed charges,,,,,,,no IP contract,,50,,237.5,percent of total billed charges,,,,,,no IP contract,,,78,,370.5,percent of total billed charges,,,70,,332.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,232.75,3324,
PNEUMONIA PANEL MYCOPLASMA PNEUMONIAE PCR NMH,87581,CPT,,,,inpatient,,,226,135.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,183.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,192.1,percent of total billed charges,,,85,,192.1,percent of total billed charges,,,49,,110.74,percent of total billed charges,,,90,,203.4,percent of total billed charges,,,,,,,no IP contract,,80,,180.8,percent of total billed charges,,,,,,,no IP contract,,50,,113,percent of total billed charges,,,,,,no IP contract,,,78,,176.28,percent of total billed charges,,,70,,158.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,110.74,3324,
Gonorrhoeae by PCR,87591,CPT,,,,inpatient,,,251,150.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,203.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,213.35,percent of total billed charges,,,85,,213.35,percent of total billed charges,,,49,,122.99,percent of total billed charges,,,90,,225.9,percent of total billed charges,,,,,,,no IP contract,,80,,200.8,percent of total billed charges,,,,,,,no IP contract,,50,,125.5,percent of total billed charges,,,,,,no IP contract,,,78,,195.78,percent of total billed charges,,,70,,175.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,122.99,3324,
PNEUMONIA PANEL VIRUS DETECTION; MULTIPLEX PCR NMH,87632,CPT,,,,inpatient,,,1013,607.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,820.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,861.05,percent of total billed charges,,,85,,861.05,percent of total billed charges,,,49,,496.37,percent of total billed charges,,,90,,911.7,percent of total billed charges,,,,,,,no IP contract,,80,,810.4,percent of total billed charges,,,,,,,no IP contract,,50,,506.5,percent of total billed charges,,,,,,no IP contract,,,78,,790.14,percent of total billed charges,,,70,,709.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,496.37,3324,
"MRSA Screen, PCR",87641,CPT,,,,inpatient,,,286,171.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,231.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,243.1,percent of total billed charges,,,85,,243.1,percent of total billed charges,,,49,,140.14,percent of total billed charges,,,90,,257.4,percent of total billed charges,,,,,,,no IP contract,,80,,228.8,percent of total billed charges,,,,,,,no IP contract,,50,,143,percent of total billed charges,,,,,,no IP contract,,,78,,223.08,percent of total billed charges,,,70,,200.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,140.14,3324,
"Infectious Agent Detection by Nucleic Acid,Amplification probe technique",87798,CPT,,,,inpatient,,,133,79.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,107.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,113.05,percent of total billed charges,,,85,,113.05,percent of total billed charges,,,49,,65.17,percent of total billed charges,,,90,,119.7,percent of total billed charges,,,,,,,no IP contract,,80,,106.4,percent of total billed charges,,,,,,,no IP contract,,50,,66.5,percent of total billed charges,,,,,,no IP contract,,,78,,103.74,percent of total billed charges,,,70,,93.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,65.17,3324,
Coronavirus nCOV-19 by PCR (2019),87798,CPT,,,,inpatient,,,203,121.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,164.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,172.55,percent of total billed charges,,,85,,172.55,percent of total billed charges,,,49,,99.47,percent of total billed charges,,,90,,182.7,percent of total billed charges,,,,,,,no IP contract,,80,,162.4,percent of total billed charges,,,,,,,no IP contract,,50,,101.5,percent of total billed charges,,,,,,no IP contract,,,78,,158.34,percent of total billed charges,,,70,,142.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,99.47,3324,
Covid-19 (m2000),87798,CPT,,,,inpatient,,,203,121.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,164.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,172.55,percent of total billed charges,,,85,,172.55,percent of total billed charges,,,49,,99.47,percent of total billed charges,,,90,,182.7,percent of total billed charges,,,,,,,no IP contract,,80,,162.4,percent of total billed charges,,,,,,,no IP contract,,50,,101.5,percent of total billed charges,,,,,,no IP contract,,,78,,158.34,percent of total billed charges,,,70,,142.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,99.47,3324,
"EBV Qualitative by PCR, Blood",87798,CPT,,,,inpatient,,,331,198.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,268.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,281.35,percent of total billed charges,,,85,,281.35,percent of total billed charges,,,49,,162.19,percent of total billed charges,,,90,,297.9,percent of total billed charges,,,,,,,no IP contract,,80,,264.8,percent of total billed charges,,,,,,,no IP contract,,50,,165.5,percent of total billed charges,,,,,,no IP contract,,,78,,258.18,percent of total billed charges,,,70,,231.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,162.19,3324,
Varicella Zoster PCR,87798,CPT,,,,inpatient,,,479,287.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,387.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,407.15,percent of total billed charges,,,85,,407.15,percent of total billed charges,,,49,,234.71,percent of total billed charges,,,90,,431.1,percent of total billed charges,,,,,,,no IP contract,,80,,383.2,percent of total billed charges,,,,,,,no IP contract,,50,,239.5,percent of total billed charges,,,,,,no IP contract,,,78,,373.62,percent of total billed charges,,,70,,335.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,234.71,3324,
Toxoplasma DNA by PCR,87798,CPT,,,,inpatient,,,586,351.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,474.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,498.1,percent of total billed charges,,,85,,498.1,percent of total billed charges,,,49,,287.14,percent of total billed charges,,,90,,527.4,percent of total billed charges,,,,,,,no IP contract,,80,,468.8,percent of total billed charges,,,,,,,no IP contract,,50,,293,percent of total billed charges,,,,,,no IP contract,,,78,,457.08,percent of total billed charges,,,70,,410.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,287.14,3324,
Viracore Quant Adenovirus PCR,87799,CPT,,,,inpatient,,,715,429,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,579.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,607.75,percent of total billed charges,,,85,,607.75,percent of total billed charges,,,49,,350.35,percent of total billed charges,,,90,,643.5,percent of total billed charges,,,,,,,no IP contract,,80,,572,percent of total billed charges,,,,,,,no IP contract,,50,,357.5,percent of total billed charges,,,,,,no IP contract,,,78,,557.7,percent of total billed charges,,,70,,500.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,350.35,3324,
"BK Virus Quant, Bld",87799,CPT,,,,inpatient,,,769,461.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,622.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,653.65,percent of total billed charges,,,85,,653.65,percent of total billed charges,,,49,,376.81,percent of total billed charges,,,90,,692.1,percent of total billed charges,,,,,,,no IP contract,,80,,615.2,percent of total billed charges,,,,,,,no IP contract,,50,,384.5,percent of total billed charges,,,,,,no IP contract,,,78,,599.82,percent of total billed charges,,,70,,538.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,376.81,3324,
"BK Virus Quant, Urine",87799,CPT,,,,inpatient,,,769,461.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,622.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,653.65,percent of total billed charges,,,85,,653.65,percent of total billed charges,,,49,,376.81,percent of total billed charges,,,90,,692.1,percent of total billed charges,,,,,,,no IP contract,,80,,615.2,percent of total billed charges,,,,,,,no IP contract,,50,,384.5,percent of total billed charges,,,,,,no IP contract,,,78,,599.82,percent of total billed charges,,,70,,538.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,376.81,3324,
"Epstein-Barr Quantitative, CSF",87799,CPT,,,,inpatient,,,784,470.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,635.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,666.4,percent of total billed charges,,,85,,666.4,percent of total billed charges,,,49,,384.16,percent of total billed charges,,,90,,705.6,percent of total billed charges,,,,,,,no IP contract,,80,,627.2,percent of total billed charges,,,,,,,no IP contract,,50,,392,percent of total billed charges,,,,,,no IP contract,,,78,,611.52,percent of total billed charges,,,70,,548.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,384.16,3324,
"Epstein-Barr Quantitative, Serum",87799,CPT,,,,inpatient,,,784,470.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,635.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,666.4,percent of total billed charges,,,85,,666.4,percent of total billed charges,,,49,,384.16,percent of total billed charges,,,90,,705.6,percent of total billed charges,,,,,,,no IP contract,,80,,627.2,percent of total billed charges,,,,,,,no IP contract,,50,,392,percent of total billed charges,,,,,,no IP contract,,,78,,611.52,percent of total billed charges,,,70,,548.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,384.16,3324,
Culture-Group B Streptococcus,87802,CPT,,,,inpatient,,,122,73.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,98.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,103.7,percent of total billed charges,,,85,,103.7,percent of total billed charges,,,49,,59.78,percent of total billed charges,,,90,,109.8,percent of total billed charges,,,,,,,no IP contract,,80,,97.6,percent of total billed charges,,,,,,,no IP contract,,50,,61,percent of total billed charges,,,,,,no IP contract,,,78,,95.16,percent of total billed charges,,,70,,85.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,59.78,3324,
"Strep Pneumoniae Antigen Test, Urine",87899,CPT,,,,inpatient,,,249,149.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,201.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,211.65,percent of total billed charges,,,85,,211.65,percent of total billed charges,,,49,,122.01,percent of total billed charges,,,90,,224.1,percent of total billed charges,,,,,,,no IP contract,,80,,199.2,percent of total billed charges,,,,,,,no IP contract,,50,,124.5,percent of total billed charges,,,,,,no IP contract,,,78,,194.22,percent of total billed charges,,,70,,174.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,122.01,3324,
Hepatitis C Genotype,87902,CPT,,,,inpatient,,,2057,1234.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1666.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1748.45,percent of total billed charges,,,85,,1748.45,percent of total billed charges,,,49,,1007.93,percent of total billed charges,,,90,,1851.3,percent of total billed charges,,,,,,,no IP contract,,80,,1645.6,percent of total billed charges,,,,,,,no IP contract,,50,,1028.5,percent of total billed charges,,,,,,no IP contract,,,78,,1604.46,percent of total billed charges,,,70,,1439.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
Pap Smear-Liquid and Thin Prep,88142,CPT,,,,inpatient,,,199,119.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,161.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,169.15,percent of total billed charges,,,85,,169.15,percent of total billed charges,,,49,,97.51,percent of total billed charges,,,90,,179.1,percent of total billed charges,,,,,,,no IP contract,,80,,159.2,percent of total billed charges,,,,,,,no IP contract,,50,,99.5,percent of total billed charges,,,,,,no IP contract,,,78,,155.22,percent of total billed charges,,,70,,139.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,97.51,3324,
Pap Smear-Diagnostic,88150,CPT,,,,inpatient,,,99,59.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,80.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,84.15,percent of total billed charges,,,85,,84.15,percent of total billed charges,,,49,,48.51,percent of total billed charges,,,90,,89.1,percent of total billed charges,,,,,,,no IP contract,,80,,79.2,percent of total billed charges,,,,,,,no IP contract,,50,,49.5,percent of total billed charges,,,,,,no IP contract,,,78,,77.22,percent of total billed charges,,,70,,69.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,48.51,3324,
Pap Smear-Screening,88150,CPT,,,,inpatient,,,99,59.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,80.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,84.15,percent of total billed charges,,,85,,84.15,percent of total billed charges,,,49,,48.51,percent of total billed charges,,,90,,89.1,percent of total billed charges,,,,,,,no IP contract,,80,,79.2,percent of total billed charges,,,,,,,no IP contract,,50,,49.5,percent of total billed charges,,,,,,no IP contract,,,78,,77.22,percent of total billed charges,,,70,,69.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,48.51,3324,
TISSUE CULTURE BONE MARROW NMH,88237,CPT,,,,inpatient,,,602,361.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,487.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,511.7,percent of total billed charges,,,85,,511.7,percent of total billed charges,,,49,,294.98,percent of total billed charges,,,90,,541.8,percent of total billed charges,,,,,,,no IP contract,,80,,481.6,percent of total billed charges,,,,,,,no IP contract,,50,,301,percent of total billed charges,,,,,,no IP contract,,,78,,469.56,percent of total billed charges,,,70,,421.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,294.98,3324,
CHROM ANAL BONE MRW CORE BODY FLUID 15-20 CELLS NMH,88262,CPT,,,,inpatient,,,1177,706.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,953.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1000.45,percent of total billed charges,,,85,,1000.45,percent of total billed charges,,,49,,576.73,percent of total billed charges,,,90,,1059.3,percent of total billed charges,,,,,,,no IP contract,,80,,941.6,percent of total billed charges,,,,,,,no IP contract,,50,,588.5,percent of total billed charges,,,,,,no IP contract,,,78,,918.06,percent of total billed charges,,,70,,823.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,576.73,3324,
"Cell Count and Differential, Fluid",89050,CPT,,,,inpatient,,,94,56.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,76.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,79.9,percent of total billed charges,,,85,,79.9,percent of total billed charges,,,49,,46.06,percent of total billed charges,,,90,,84.6,percent of total billed charges,,,,,,,no IP contract,,80,,75.2,percent of total billed charges,,,,,,,no IP contract,,50,,47,percent of total billed charges,,,,,,no IP contract,,,78,,73.32,percent of total billed charges,,,70,,65.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,46.06,3324,
"Cell Count and Differential, CSF",89051,CPT,,,,inpatient,,,101,60.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,81.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,85.85,percent of total billed charges,,,85,,85.85,percent of total billed charges,,,49,,49.49,percent of total billed charges,,,90,,90.9,percent of total billed charges,,,,,,,no IP contract,,80,,80.8,percent of total billed charges,,,,,,,no IP contract,,50,,50.5,percent of total billed charges,,,,,,no IP contract,,,78,,78.78,percent of total billed charges,,,70,,70.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,49.49,3324,
Body Fluid Cell Count and Differential,89051,CPT,,,,inpatient,,,150,90,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,121.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,127.5,percent of total billed charges,,,85,,127.5,percent of total billed charges,,,49,,73.5,percent of total billed charges,,,90,,135,percent of total billed charges,,,,,,,no IP contract,,80,,120,percent of total billed charges,,,,,,,no IP contract,,50,,75,percent of total billed charges,,,,,,no IP contract,,,78,,117,percent of total billed charges,,,70,,105,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,73.5,3324,
"CELL COUNT, BODY FLUID OR CSF W/DIFFERENTIAL NMH",89051,CPT,,,,inpatient,,,319,191.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,258.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,271.15,percent of total billed charges,,,85,,271.15,percent of total billed charges,,,49,,156.31,percent of total billed charges,,,90,,287.1,percent of total billed charges,,,,,,,no IP contract,,80,,255.2,percent of total billed charges,,,,,,,no IP contract,,50,,159.5,percent of total billed charges,,,,,,no IP contract,,,78,,248.82,percent of total billed charges,,,70,,223.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,156.31,3324,
Fecal Leukocytes,89055,CPT,,,,inpatient,,,92,55.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,74.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,78.2,percent of total billed charges,,,85,,78.2,percent of total billed charges,,,49,,45.08,percent of total billed charges,,,90,,82.8,percent of total billed charges,,,,,,,no IP contract,,80,,73.6,percent of total billed charges,,,,,,,no IP contract,,50,,46,percent of total billed charges,,,,,,no IP contract,,,78,,71.76,percent of total billed charges,,,70,,64.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,45.08,3324,
"Crystal Identification, Fluid",89060,CPT,,,,inpatient,,,90,54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,72.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,76.5,percent of total billed charges,,,85,,76.5,percent of total billed charges,,,49,,44.1,percent of total billed charges,,,90,,81,percent of total billed charges,,,,,,,no IP contract,,80,,72,percent of total billed charges,,,,,,,no IP contract,,50,,45,percent of total billed charges,,,,,,no IP contract,,,78,,70.2,percent of total billed charges,,,70,,63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,44.1,3324,
"Crystals Analysis, Fluid",89060,CPT,,,,inpatient,,,112,67.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,90.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,95.2,percent of total billed charges,,,85,,95.2,percent of total billed charges,,,49,,54.88,percent of total billed charges,,,90,,100.8,percent of total billed charges,,,,,,,no IP contract,,80,,89.6,percent of total billed charges,,,,,,,no IP contract,,50,,56,percent of total billed charges,,,,,,no IP contract,,,78,,87.36,percent of total billed charges,,,70,,78.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,54.88,3324,
"Eosinophil Count, Urine & Body Fluid",89190,CPT,,,,inpatient,,,77,46.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,62.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,65.45,percent of total billed charges,,,85,,65.45,percent of total billed charges,,,49,,37.73,percent of total billed charges,,,90,,69.3,percent of total billed charges,,,,,,,no IP contract,,80,,61.6,percent of total billed charges,,,,,,,no IP contract,,50,,38.5,percent of total billed charges,,,,,,no IP contract,,,78,,60.06,percent of total billed charges,,,70,,53.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,37.73,3324,
CBC-Complete Blood Count without Platelets,G0307,HCPCS,,,,inpatient,,,63,37.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,51.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,53.55,percent of total billed charges,,,85,,53.55,percent of total billed charges,,,49,,30.87,percent of total billed charges,,,90,,56.7,percent of total billed charges,,,,,,,no IP contract,,80,,50.4,percent of total billed charges,,,,,,,no IP contract,,50,,31.5,percent of total billed charges,,,,,,no IP contract,,,78,,49.14,percent of total billed charges,,,70,,44.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,30.87,3324,
"Blood, split unit, 175 mL",P9011,HCPCS,,,,inpatient,,,508,304.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,411.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,431.8,percent of total billed charges,,,85,,431.8,percent of total billed charges,,,49,,248.92,percent of total billed charges,,,90,,457.2,percent of total billed charges,,,,,,,no IP contract,,80,,406.4,percent of total billed charges,,,,,,,no IP contract,,50,,254,percent of total billed charges,,,,,,no IP contract,,,78,,396.24,percent of total billed charges,,,70,,355.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,23732.2325,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,248.92,23732.23,
Cryoprecipitate - Blood Unit Product:,P9012,HCPCS,,,,inpatient,,,128,76.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,103.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,108.8,percent of total billed charges,,,85,,108.8,percent of total billed charges,,,49,,62.72,percent of total billed charges,,,90,,115.2,percent of total billed charges,,,,,,,no IP contract,,80,,102.4,percent of total billed charges,,,,,,,no IP contract,,50,,64,percent of total billed charges,,,,,,no IP contract,,,78,,99.84,percent of total billed charges,,,70,,89.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,62.72,3324,
Cryoprecipitate Charge,P9012,HCPCS,,,,inpatient,,,131,78.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,106.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,111.35,percent of total billed charges,,,85,,111.35,percent of total billed charges,,,49,,64.19,percent of total billed charges,,,90,,117.9,percent of total billed charges,,,,,,,no IP contract,,80,,104.8,percent of total billed charges,,,,,,,no IP contract,,50,,65.5,percent of total billed charges,,,,,,no IP contract,,,78,,102.18,percent of total billed charges,,,70,,91.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,64.19,3324,
Leukoreduced RBCs - Blood Unit Product:,P9016,HCPCS,,,,inpatient,,,756,453.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,612.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,642.6,percent of total billed charges,,,85,,642.6,percent of total billed charges,,,49,,370.44,percent of total billed charges,,,90,,680.4,percent of total billed charges,,,,,,,no IP contract,,80,,604.8,percent of total billed charges,,,,,,,no IP contract,,50,,378,percent of total billed charges,,,,,,no IP contract,,,78,,589.68,percent of total billed charges,,,70,,529.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,370.44,3324,
RBC's Leukoreduced,P9016,HCPCS,,,,inpatient,,,775,465,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,627.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,658.75,percent of total billed charges,,,85,,658.75,percent of total billed charges,,,49,,379.75,percent of total billed charges,,,90,,697.5,percent of total billed charges,,,,,,,no IP contract,,80,,620,percent of total billed charges,,,,,,,no IP contract,,50,,387.5,percent of total billed charges,,,,,,no IP contract,,,78,,604.5,percent of total billed charges,,,70,,542.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,379.75,3324,
Fresh frozen plasma - Blood Unit Product:,P9017,HCPCS,,,,inpatient,,,284,170.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,230.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,241.4,percent of total billed charges,,,85,,241.4,percent of total billed charges,,,49,,139.16,percent of total billed charges,,,90,,255.6,percent of total billed charges,,,,,,,no IP contract,,80,,227.2,percent of total billed charges,,,,,,,no IP contract,,50,,142,percent of total billed charges,,,,,,no IP contract,,,78,,221.52,percent of total billed charges,,,70,,198.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,139.16,3324,
"Platelets for transfusion, each unit",P9019,HCPCS,,,,inpatient,,,415,249,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,336.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,352.75,percent of total billed charges,,,85,,352.75,percent of total billed charges,,,49,,203.35,percent of total billed charges,,,90,,373.5,percent of total billed charges,,,,,,,no IP contract,,80,,332,percent of total billed charges,,,,,,,no IP contract,,50,,207.5,percent of total billed charges,,,,,,no IP contract,,,78,,323.7,percent of total billed charges,,,70,,290.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,203.35,3324,
"RBC's for transfusion, each unit",P9021,HCPCS,,,,inpatient,,,448,268.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,362.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,380.8,percent of total billed charges,,,85,,380.8,percent of total billed charges,,,49,,219.52,percent of total billed charges,,,90,,403.2,percent of total billed charges,,,,,,,no IP contract,,80,,358.4,percent of total billed charges,,,,,,,no IP contract,,50,,224,percent of total billed charges,,,,,,no IP contract,,,78,,349.44,percent of total billed charges,,,70,,313.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,219.52,3324,
Leukoreduced Washed RBCs - Blood Unit Product:,P9022,HCPCS,,,,inpatient,,,937,562.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,758.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,796.45,percent of total billed charges,,,85,,796.45,percent of total billed charges,,,49,,459.13,percent of total billed charges,,,90,,843.3,percent of total billed charges,,,,,,,no IP contract,,80,,749.6,percent of total billed charges,,,,,,,no IP contract,,50,,468.5,percent of total billed charges,,,,,,no IP contract,,,78,,730.86,percent of total billed charges,,,70,,655.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,459.13,3324,
"RBC's for transfusion,washed,each unit",P9022,HCPCS,,,,inpatient,,,961,576.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,778.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,816.85,percent of total billed charges,,,85,,816.85,percent of total billed charges,,,49,,470.89,percent of total billed charges,,,90,,864.9,percent of total billed charges,,,,,,,no IP contract,,80,,768.8,percent of total billed charges,,,,,,,no IP contract,,50,,480.5,percent of total billed charges,,,,,,no IP contract,,,78,,749.58,percent of total billed charges,,,70,,672.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,470.89,3324,
Leukoreduced Platelets - Blood Unit Product:,P9031,HCPCS,,,,inpatient,,,360,216,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,291.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,306,percent of total billed charges,,,85,,306,percent of total billed charges,,,49,,176.4,percent of total billed charges,,,90,,324,percent of total billed charges,,,,,,,no IP contract,,80,,288,percent of total billed charges,,,,,,,no IP contract,,50,,180,percent of total billed charges,,,,,,no IP contract,,,78,,280.8,percent of total billed charges,,,70,,252,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,176.4,3324,
"Platelets for transfusion, leukoreduced,each unit",P9031,HCPCS,,,,inpatient,,,360,216,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,291.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,306,percent of total billed charges,,,85,,306,percent of total billed charges,,,49,,176.4,percent of total billed charges,,,90,,324,percent of total billed charges,,,,,,,no IP contract,,80,,288,percent of total billed charges,,,,,,,no IP contract,,50,,180,percent of total billed charges,,,,,,no IP contract,,,78,,280.8,percent of total billed charges,,,70,,252,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,176.4,3324,
"Platelets for transfusion,leukoreduced,irradiated",P9033,HCPCS,,,,inpatient,,,468,280.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,379.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,397.8,percent of total billed charges,,,85,,397.8,percent of total billed charges,,,49,,229.32,percent of total billed charges,,,90,,421.2,percent of total billed charges,,,,,,,no IP contract,,80,,374.4,percent of total billed charges,,,,,,,no IP contract,,50,,234,percent of total billed charges,,,,,,no IP contract,,,78,,365.04,percent of total billed charges,,,70,,327.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,229.32,3324,
"Platelets, PRH, LR, each unit",P9035,HCPCS,,,,inpatient,,,2027,1216.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1641.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1722.95,percent of total billed charges,,,85,,1722.95,percent of total billed charges,,,49,,993.23,percent of total billed charges,,,90,,1824.3,percent of total billed charges,,,,,,,no IP contract,,80,,1621.6,percent of total billed charges,,,,,,,no IP contract,,50,,1013.5,percent of total billed charges,,,,,,no IP contract,,,78,,1581.06,percent of total billed charges,,,70,,1418.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
Leukoreduced Washed Platelets - Blood Unit Product:,P9035,HCPCS,,,,inpatient,,,3357,2014.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2719.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2853.45,percent of total billed charges,,,85,,2853.45,percent of total billed charges,,,49,,1644.93,percent of total billed charges,,,90,,3021.3,percent of total billed charges,,,,,,,no IP contract,,80,,2685.6,percent of total billed charges,,,,,,,no IP contract,,50,,1678.5,percent of total billed charges,,,,,,no IP contract,,,78,,2618.46,percent of total billed charges,,,70,,2349.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
Leukoreduced Irradiated Platelets - Blood Unit Product:,P9037,HCPCS,,,,inpatient,,,468,280.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,379.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,397.8,percent of total billed charges,,,85,,397.8,percent of total billed charges,,,49,,229.32,percent of total billed charges,,,90,,421.2,percent of total billed charges,,,,,,,no IP contract,,80,,374.4,percent of total billed charges,,,,,,,no IP contract,,50,,234,percent of total billed charges,,,,,,no IP contract,,,78,,365.04,percent of total billed charges,,,70,,327.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,229.32,3324,
"Platelets, PHR, LR, IR, each unit",P9037,HCPCS,,,,inpatient,,,2711,1626.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2195.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2304.35,percent of total billed charges,,,85,,2304.35,percent of total billed charges,,,49,,1328.39,percent of total billed charges,,,90,,2439.9,percent of total billed charges,,,,,,,no IP contract,,80,,2168.8,percent of total billed charges,,,,,,,no IP contract,,50,,1355.5,percent of total billed charges,,,,,,no IP contract,,,78,,2114.58,percent of total billed charges,,,70,,1897.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
"RBC's, irradiated, each unit",P9038,HCPCS,,,,inpatient,,,888,532.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,719.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,754.8,percent of total billed charges,,,85,,754.8,percent of total billed charges,,,49,,435.12,percent of total billed charges,,,90,,799.2,percent of total billed charges,,,,,,,no IP contract,,80,,710.4,percent of total billed charges,,,,,,,no IP contract,,50,,444,percent of total billed charges,,,,,,no IP contract,,,78,,692.64,percent of total billed charges,,,70,,621.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,435.12,3324,
Leukoreduced Irradiated RBCs - Blood Unit Product:,P9040,HCPCS,,,,inpatient,,,999,599.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,809.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,849.15,percent of total billed charges,,,85,,849.15,percent of total billed charges,,,49,,489.51,percent of total billed charges,,,90,,899.1,percent of total billed charges,,,,,,,no IP contract,,80,,799.2,percent of total billed charges,,,,,,,no IP contract,,50,,499.5,percent of total billed charges,,,,,,no IP contract,,,78,,779.22,percent of total billed charges,,,70,,699.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,489.51,3324,
"RBC's,irradiated,leukoreduced,each unit",P9040,HCPCS,,,,inpatient,,,1025,615,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,830.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,871.25,percent of total billed charges,,,85,,871.25,percent of total billed charges,,,49,,502.25,percent of total billed charges,,,90,,922.5,percent of total billed charges,,,,,,,no IP contract,,80,,820,percent of total billed charges,,,,,,,no IP contract,,50,,512.5,percent of total billed charges,,,,,,no IP contract,,,78,,799.5,percent of total billed charges,,,70,,717.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,502.25,3324,
Fresh Frozen Plasma Charge,P9059,HCPCS,,,,inpatient,,,284,170.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,230.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,241.4,percent of total billed charges,,,85,,241.4,percent of total billed charges,,,49,,139.16,percent of total billed charges,,,90,,255.6,percent of total billed charges,,,,,,,no IP contract,,80,,227.2,percent of total billed charges,,,,,,,no IP contract,,50,,142,percent of total billed charges,,,,,,no IP contract,,,78,,221.52,percent of total billed charges,,,70,,198.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,139.16,3324,
Initiate - Blood Unit Activities:,36430,CPT,,,,inpatient,,,126,75.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,102.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,107.1,percent of total billed charges,,,85,,107.1,percent of total billed charges,,,49,,61.74,percent of total billed charges,,,90,,113.4,percent of total billed charges,,,,,,,no IP contract,,80,,100.8,percent of total billed charges,,,,,,,no IP contract,,50,,63,percent of total billed charges,,,,,,no IP contract,,,78,,98.28,percent of total billed charges,,,70,,88.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,61.74,3324,
Pump Analysis Without Reprogramming (62367),62367,CPT,,,,inpatient,,,1108,664.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,897.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,941.8,percent of total billed charges,,,85,,941.8,percent of total billed charges,,,49,,542.92,percent of total billed charges,,,90,,997.2,percent of total billed charges,,,,,,,no IP contract,,80,,886.4,percent of total billed charges,,,,,,,no IP contract,,50,,554,percent of total billed charges,,,,,,no IP contract,,,78,,864.24,percent of total billed charges,,,70,,775.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,542.92,3324,
Pump Analysis with Reprogramming (62368),62368,CPT,,,,inpatient,,,949,569.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,768.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,806.65,percent of total billed charges,,,85,,806.65,percent of total billed charges,,,49,,465.01,percent of total billed charges,,,90,,854.1,percent of total billed charges,,,,,,,no IP contract,,80,,759.2,percent of total billed charges,,,,,,,no IP contract,,50,,474.5,percent of total billed charges,,,,,,no IP contract,,,78,,740.22,percent of total billed charges,,,70,,664.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,465.01,3324,
Anal SP inf pmp wt reprog/refill RN(62369),62369,CPT,,,,inpatient,,,896,537.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,725.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,761.6,percent of total billed charges,,,85,,761.6,percent of total billed charges,,,49,,439.04,percent of total billed charges,,,90,,806.4,percent of total billed charges,,,,,,,no IP contract,,80,,716.8,percent of total billed charges,,,,,,,no IP contract,,50,,448,percent of total billed charges,,,,,,no IP contract,,,78,,698.88,percent of total billed charges,,,70,,627.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,439.04,3324,
MRI Brain Functional MD/PHD NMH,70555,CPT,,,,inpatient,,,5946,3567.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4816.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5054.1,percent of total billed charges,,,85,,5054.1,percent of total billed charges,,,49,,2913.54,percent of total billed charges,,,90,,5351.4,percent of total billed charges,,,,,,,no IP contract,,80,,4756.8,percent of total billed charges,,,,,,,no IP contract,,50,,2973,percent of total billed charges,,,,,,no IP contract,,,78,,4637.88,percent of total billed charges,,,70,,4162.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,5351.4,
CT ANGIOGRAPHY ABDOMEN/PELVIS NMH (74174,74174,CPT,,,,inpatient,,,7743,4645.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6271.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6581.55,percent of total billed charges,,,85,,6581.55,percent of total billed charges,,,49,,3794.07,percent of total billed charges,,,90,,6968.7,percent of total billed charges,,,,,,,no IP contract,,80,,6194.4,percent of total billed charges,,,,,,,no IP contract,,50,,3871.5,percent of total billed charges,,,,,,no IP contract,,,78,,6039.54,percent of total billed charges,,,70,,5420.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,6968.7,
CT ANGIO HRT W/3D IMAGE NMH,75574,CPT,,,,inpatient,,,5202,3121.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4213.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4421.7,percent of total billed charges,,,85,,4421.7,percent of total billed charges,,,49,,2548.98,percent of total billed charges,,,90,,4681.8,percent of total billed charges,,,,,,,no IP contract,,80,,4161.6,percent of total billed charges,,,,,,,no IP contract,,50,,2601,percent of total billed charges,,,,,,no IP contract,,,78,,4057.56,percent of total billed charges,,,70,,3641.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4681.8,
Fluoroscope Examination NMH,76000,CPT,,,,inpatient,,,1652,991.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1338.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1404.2,percent of total billed charges,,,85,,1404.2,percent of total billed charges,,,49,,809.48,percent of total billed charges,,,90,,1486.8,percent of total billed charges,,,,,,,no IP contract,,80,,1321.6,percent of total billed charges,,,,,,,no IP contract,,50,,826,percent of total billed charges,,,,,,no IP contract,,,78,,1288.56,percent of total billed charges,,,70,,1156.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,809.48,3324,
US XTR NON-VASC COMPLETE NMH,76881,CPT,,,,inpatient,,,1814,1088.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1469.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1541.9,percent of total billed charges,,,85,,1541.9,percent of total billed charges,,,49,,888.86,percent of total billed charges,,,90,,1632.6,percent of total billed charges,,,,,,,no IP contract,,80,,1451.2,percent of total billed charges,,,,,,,no IP contract,,50,,907,percent of total billed charges,,,,,,no IP contract,,,78,,1414.92,percent of total billed charges,,,70,,1269.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,888.86,3324,
Stimulator Assist Simple NMH,77280,CPT,,,,inpatient,,,1817,1090.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1471.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1544.45,percent of total billed charges,,,85,,1544.45,percent of total billed charges,,,49,,890.33,percent of total billed charges,,,90,,1635.3,percent of total billed charges,,,,,,,no IP contract,,80,,1453.6,percent of total billed charges,,,,,,,no IP contract,,50,,908.5,percent of total billed charges,,,,,,no IP contract,,,78,,1417.26,percent of total billed charges,,,70,,1271.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,890.33,3324,
Stimulator Assist Intermed NMH,77285,CPT,,,,inpatient,,,5424,3254.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4393.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4610.4,percent of total billed charges,,,85,,4610.4,percent of total billed charges,,,49,,2657.76,percent of total billed charges,,,90,,4881.6,percent of total billed charges,,,,,,,no IP contract,,80,,4339.2,percent of total billed charges,,,,,,,no IP contract,,50,,2712,percent of total billed charges,,,,,,no IP contract,,,78,,4230.72,percent of total billed charges,,,70,,3796.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4881.6,
Stimulator Assist Complex NMH,77290,CPT,,,,inpatient,,,6185,3711,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5009.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5257.25,percent of total billed charges,,,85,,5257.25,percent of total billed charges,,,49,,3030.65,percent of total billed charges,,,90,,5566.5,percent of total billed charges,,,,,,,no IP contract,,80,,4948,percent of total billed charges,,,,,,,no IP contract,,50,,3092.5,percent of total billed charges,,,,,,no IP contract,,,78,,4824.3,percent of total billed charges,,,70,,4329.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,5566.5,
Therapeutic Radiology; 3D NMH,77295,CPT,,,,inpatient,,,7385,4431,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5981.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6277.25,percent of total billed charges,,,85,,6277.25,percent of total billed charges,,,49,,3618.65,percent of total billed charges,,,90,,6646.5,percent of total billed charges,,,,,,,no IP contract,,80,,5908,percent of total billed charges,,,,,,,no IP contract,,50,,3692.5,percent of total billed charges,,,,,,no IP contract,,,78,,5760.3,percent of total billed charges,,,70,,5169.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,6646.5,
CALCULATION BASE DOSIMETRY NMH,77300,CPT,,,,inpatient,,,893,535.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,723.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,759.05,percent of total billed charges,,,85,,759.05,percent of total billed charges,,,49,,437.57,percent of total billed charges,,,90,,803.7,percent of total billed charges,,,,,,,no IP contract,,80,,714.4,percent of total billed charges,,,,,,,no IP contract,,50,,446.5,percent of total billed charges,,,,,,no IP contract,,,78,,696.54,percent of total billed charges,,,70,,625.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,437.57,3324,
Central Axis Depth Dose NMH,77300,CPT,,,,inpatient,,,893,535.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,723.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,759.05,percent of total billed charges,,,85,,759.05,percent of total billed charges,,,49,,437.57,percent of total billed charges,,,90,,803.7,percent of total billed charges,,,,,,,no IP contract,,80,,714.4,percent of total billed charges,,,,,,,no IP contract,,50,,446.5,percent of total billed charges,,,,,,no IP contract,,,78,,696.54,percent of total billed charges,,,70,,625.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,437.57,3324,
Gap Calculation NMH,77300,CPT,,,,inpatient,,,893,535.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,723.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,759.05,percent of total billed charges,,,85,,759.05,percent of total billed charges,,,49,,437.57,percent of total billed charges,,,90,,803.7,percent of total billed charges,,,,,,,no IP contract,,80,,714.4,percent of total billed charges,,,,,,,no IP contract,,50,,446.5,percent of total billed charges,,,,,,no IP contract,,,78,,696.54,percent of total billed charges,,,70,,625.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,437.57,3324,
IMRT Planning NMH,77301,CPT,,,TC,inpatient,,,27054,16232.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21913.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22995.9,percent of total billed charges,,,85,,22995.9,percent of total billed charges,,,49,,13256.46,percent of total billed charges,,,90,,24348.6,percent of total billed charges,,,,,,,no IP contract,,80,,21643.2,percent of total billed charges,,,,,,,no IP contract,,50,,13527,percent of total billed charges,,,,,,no IP contract,,,78,,21102.12,percent of total billed charges,,,70,,18937.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
PLN ISO COMPLEX W/CALC NMH (77307),77307,CPT,,,,inpatient,,,6919,4151.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5604.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5881.15,percent of total billed charges,,,85,,5881.15,percent of total billed charges,,,49,,3390.31,percent of total billed charges,,,90,,6227.1,percent of total billed charges,,,,,,,no IP contract,,80,,5535.2,percent of total billed charges,,,,,,,no IP contract,,50,,3459.5,percent of total billed charges,,,,,,no IP contract,,,78,,5396.82,percent of total billed charges,,,70,,4843.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,6227.1,
Device Treatment Complex NMH,77334,CPT,,,,inpatient,,,2643,1585.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2140.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2246.55,percent of total billed charges,,,85,,2246.55,percent of total billed charges,,,49,,1295.07,percent of total billed charges,,,90,,2378.7,percent of total billed charges,,,,,,,no IP contract,,80,,2114.4,percent of total billed charges,,,,,,,no IP contract,,50,,1321.5,percent of total billed charges,,,,,,no IP contract,,,78,,2061.54,percent of total billed charges,,,70,,1850.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
Continuing Radiation Physi NMH,77336,CPT,,,,inpatient,,,1141,684.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,924.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,969.85,percent of total billed charges,,,85,,969.85,percent of total billed charges,,,49,,559.09,percent of total billed charges,,,90,,1026.9,percent of total billed charges,,,,,,,no IP contract,,80,,912.8,percent of total billed charges,,,,,,,no IP contract,,50,,570.5,percent of total billed charges,,,,,,no IP contract,,,78,,889.98,percent of total billed charges,,,70,,798.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,559.09,3324,
MLC DEVICE TX: IMRT NMH,77338,CPT,,,,inpatient,,,2394,1436.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1939.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2034.9,percent of total billed charges,,,85,,2034.9,percent of total billed charges,,,49,,1173.06,percent of total billed charges,,,90,,2154.6,percent of total billed charges,,,,,,,no IP contract,,80,,1915.2,percent of total billed charges,,,,,,,no IP contract,,50,,1197,percent of total billed charges,,,,,,no IP contract,,,78,,1867.32,percent of total billed charges,,,70,,1675.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
IMRT TREATMENT COMPLEX NMH,77386,CPT,,,,inpatient,,,4630,2778,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3750.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3935.5,percent of total billed charges,,,85,,3935.5,percent of total billed charges,,,49,,2268.7,percent of total billed charges,,,90,,4167,percent of total billed charges,,,,,,,no IP contract,,80,,3704,percent of total billed charges,,,,,,,no IP contract,,50,,2315,percent of total billed charges,,,,,,no IP contract,,,78,,3611.4,percent of total billed charges,,,70,,3241,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4167,
TRMT INTERMEDIATE > 1 MEV NMH (77407,77407,CPT,,,,inpatient,,,1500,900,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1215,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1275,percent of total billed charges,,,85,,1275,percent of total billed charges,,,49,,735,percent of total billed charges,,,90,,1350,percent of total billed charges,,,,,,,no IP contract,,80,,1200,percent of total billed charges,,,,,,,no IP contract,,50,,750,percent of total billed charges,,,,,,no IP contract,,,78,,1170,percent of total billed charges,,,70,,1050,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,735,3324,
TRMT COMPLEX > 1MEV NMH,77412,CPT,,,,inpatient,,,2163,1297.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1752.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1838.55,percent of total billed charges,,,85,,1838.55,percent of total billed charges,,,49,,1059.87,percent of total billed charges,,,90,,1946.7,percent of total billed charges,,,,,,,no IP contract,,80,,1730.4,percent of total billed charges,,,,,,,no IP contract,,50,,1081.5,percent of total billed charges,,,,,,no IP contract,,,78,,1687.14,percent of total billed charges,,,70,,1514.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
Treatment Special Procedure NMH,77470,CPT,,,,inpatient,,,4214,2528.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3413.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3581.9,percent of total billed charges,,,85,,3581.9,percent of total billed charges,,,49,,2064.86,percent of total billed charges,,,90,,3792.6,percent of total billed charges,,,,,,,no IP contract,,80,,3371.2,percent of total billed charges,,,,,,,no IP contract,,50,,2107,percent of total billed charges,,,,,,no IP contract,,,78,,3286.92,percent of total billed charges,,,70,,2949.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3792.6,
Bone Scan NMH,78306,CPT,,,,inpatient,,,3622,2173.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2933.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3078.7,percent of total billed charges,,,85,,3078.7,percent of total billed charges,,,49,,1774.78,percent of total billed charges,,,90,,3259.8,percent of total billed charges,,,,,,,no IP contract,,80,,2897.6,percent of total billed charges,,,,,,,no IP contract,,50,,1811,percent of total billed charges,,,,,,no IP contract,,,78,,2825.16,percent of total billed charges,,,70,,2535.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
"Bone/Joint Imaging, 3 Phase NMH",78315,CPT,,,,inpatient,,,2722,1633.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2204.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2313.7,percent of total billed charges,,,85,,2313.7,percent of total billed charges,,,49,,1333.78,percent of total billed charges,,,90,,2449.8,percent of total billed charges,,,,,,,no IP contract,,80,,2177.6,percent of total billed charges,,,,,,,no IP contract,,50,,1361,percent of total billed charges,,,,,,no IP contract,,,78,,2123.16,percent of total billed charges,,,70,,1905.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,34867.516,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,34867.52,
Gated Ventricular Function NMH,78472,CPT,,,,inpatient,,,4078,2446.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3303.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3466.3,percent of total billed charges,,,85,,3466.3,percent of total billed charges,,,49,,1998.22,percent of total billed charges,,,90,,3670.2,percent of total billed charges,,,,,,,no IP contract,,80,,3262.4,percent of total billed charges,,,,,,,no IP contract,,50,,2039,percent of total billed charges,,,,,,no IP contract,,,78,,3180.84,percent of total billed charges,,,70,,2854.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3670.2,
Lung Scan-Perfusion TC NMH,78580,CPT,,,,inpatient,,,2628,1576.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2128.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2233.8,percent of total billed charges,,,85,,2233.8,percent of total billed charges,,,49,,1287.72,percent of total billed charges,,,90,,2365.2,percent of total billed charges,,,,,,,no IP contract,,80,,2102.4,percent of total billed charges,,,,,,,no IP contract,,50,,1314,percent of total billed charges,,,,,,no IP contract,,,78,,2049.84,percent of total billed charges,,,70,,1839.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
RNL IMG W/FLO-FNC;1 NO PH NMH,78707,CPT,,,,inpatient,,,3334,2000.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2700.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2833.9,percent of total billed charges,,,85,,2833.9,percent of total billed charges,,,49,,1633.66,percent of total billed charges,,,90,,3000.6,percent of total billed charges,,,,,,,no IP contract,,80,,2667.2,percent of total billed charges,,,,,,,no IP contract,,50,,1667,percent of total billed charges,,,,,,no IP contract,,,78,,2600.52,percent of total billed charges,,,70,,2333.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
Ostreoscan NMH,78804,CPT,,,,inpatient,,,6010,3606,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4868.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5108.5,percent of total billed charges,,,85,,5108.5,percent of total billed charges,,,49,,2944.9,percent of total billed charges,,,90,,5409,percent of total billed charges,,,,,,,no IP contract,,80,,4808,percent of total billed charges,,,,,,,no IP contract,,50,,3005,percent of total billed charges,,,,,,no IP contract,,,78,,4687.8,percent of total billed charges,,,70,,4207,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,5409,
Admin SARSCOV2  vaccine 1 - Admin Charge SARSCOV2,90480,CPT,,,,inpatient,,,164,98.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,132.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,139.4,percent of total billed charges,,,85,,139.4,percent of total billed charges,,,49,,80.36,percent of total billed charges,,,90,,147.6,percent of total billed charges,,,,,,,no IP contract,,80,,131.2,percent of total billed charges,,,,,,,no IP contract,,50,,82,percent of total billed charges,,,,,,no IP contract,,,78,,127.92,percent of total billed charges,,,70,,114.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,80.36,3324,
"Hemodialysis, One Eval NMH",90935,CPT,,,,inpatient,,,2416,1449.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1956.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2053.6,percent of total billed charges,,,85,,2053.6,percent of total billed charges,,,49,,1183.84,percent of total billed charges,,,90,,2174.4,percent of total billed charges,,,,,,,no IP contract,,80,,1932.8,percent of total billed charges,,,,,,,no IP contract,,50,,1208,percent of total billed charges,,,,,,no IP contract,,,78,,1884.48,percent of total billed charges,,,70,,1691.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
Otoacoustic Emission SCR NMH,92587,CPT,,,,inpatient,,,545,327,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,441.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,463.25,percent of total billed charges,,,85,,463.25,percent of total billed charges,,,49,,267.05,percent of total billed charges,,,90,,490.5,percent of total billed charges,,,,,,,no IP contract,,80,,436,percent of total billed charges,,,,,,,no IP contract,,50,,272.5,percent of total billed charges,,,,,,no IP contract,,,78,,425.1,percent of total billed charges,,,70,,381.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,267.05,3324,
CPR,92950,CPT,,,,inpatient,,,907,544.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,734.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,770.95,percent of total billed charges,,,85,,770.95,percent of total billed charges,,,49,,444.43,percent of total billed charges,,,90,,816.3,percent of total billed charges,,,,,,,no IP contract,,80,,725.6,percent of total billed charges,,,,,,,no IP contract,,50,,453.5,percent of total billed charges,,,,,,no IP contract,,,78,,707.46,percent of total billed charges,,,70,,634.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,444.43,3324,
CPR Charge,92950,CPT,,,,inpatient,,,1322,793.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1070.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1123.7,percent of total billed charges,,,85,,1123.7,percent of total billed charges,,,49,,647.78,percent of total billed charges,,,90,,1189.8,percent of total billed charges,,,,,,,no IP contract,,80,,1057.6,percent of total billed charges,,,,,,,no IP contract,,50,,661,percent of total billed charges,,,,,,no IP contract,,,78,,1031.16,percent of total billed charges,,,70,,925.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,647.78,3324,
Echo 2 D M-Mode C Doppler NMH,93306,CPT,,,,inpatient,,,4683,2809.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3793.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3980.55,percent of total billed charges,,,85,,3980.55,percent of total billed charges,,,49,,2294.67,percent of total billed charges,,,90,,4214.7,percent of total billed charges,,,,,,,no IP contract,,80,,3746.4,percent of total billed charges,,,,,,,no IP contract,,50,,2341.5,percent of total billed charges,,,,,,no IP contract,,,78,,3652.74,percent of total billed charges,,,70,,3278.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4214.7,
Echo 2D Mode C Doppler NMH,93307,CPT,,,,inpatient,,,2853,1711.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2310.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2425.05,percent of total billed charges,,,85,,2425.05,percent of total billed charges,,,49,,1397.97,percent of total billed charges,,,90,,2567.7,percent of total billed charges,,,,,,,no IP contract,,80,,2282.4,percent of total billed charges,,,,,,,no IP contract,,50,,1426.5,percent of total billed charges,,,,,,no IP contract,,,78,,2225.34,percent of total billed charges,,,70,,1997.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
TTE F-UP OR LMTD NMH,93308,CPT,,,,inpatient,,,1865,1119,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1510.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1585.25,percent of total billed charges,,,85,,1585.25,percent of total billed charges,,,49,,913.85,percent of total billed charges,,,90,,1678.5,percent of total billed charges,,,,,,,no IP contract,,80,,1492,percent of total billed charges,,,,,,,no IP contract,,50,,932.5,percent of total billed charges,,,,,,no IP contract,,,78,,1454.7,percent of total billed charges,,,70,,1305.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,913.85,3324,
Echo 2D NMH,93350,CPT,,,,inpatient,,,4468,2680.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3619.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3797.8,percent of total billed charges,,,85,,3797.8,percent of total billed charges,,,49,,2189.32,percent of total billed charges,,,90,,4021.2,percent of total billed charges,,,,,,,no IP contract,,80,,3574.4,percent of total billed charges,,,,,,,no IP contract,,50,,2234,percent of total billed charges,,,,,,no IP contract,,,78,,3485.04,percent of total billed charges,,,70,,3127.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4021.2,
STRESS ECHO-PHARM AGENT NMH,93351,CPT,,,,inpatient,,,6415,3849,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5196.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5452.75,percent of total billed charges,,,85,,5452.75,percent of total billed charges,,,49,,3143.35,percent of total billed charges,,,90,,5773.5,percent of total billed charges,,,,,,,no IP contract,,80,,5132,percent of total billed charges,,,,,,,no IP contract,,50,,3207.5,percent of total billed charges,,,,,,no IP contract,,,78,,5003.7,percent of total billed charges,,,70,,4490.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,5773.5,
Cerebrovascular Exam-Full NMH,93880,CPT,,,,inpatient,,,3338,2002.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2703.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2837.3,percent of total billed charges,,,85,,2837.3,percent of total billed charges,,,49,,1635.62,percent of total billed charges,,,90,,3004.2,percent of total billed charges,,,,,,,no IP contract,,80,,2670.4,percent of total billed charges,,,,,,,no IP contract,,50,,1669,percent of total billed charges,,,,,,no IP contract,,,78,,2603.64,percent of total billed charges,,,70,,2336.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
UPR/LXTR ART STDY 3+ LVLS  NMH,93923,CPT,,,,inpatient,,,1315,789,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1065.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1117.75,percent of total billed charges,,,85,,1117.75,percent of total billed charges,,,49,,644.35,percent of total billed charges,,,90,,1183.5,percent of total billed charges,,,,,,,no IP contract,,80,,1052,percent of total billed charges,,,,,,,no IP contract,,50,,657.5,percent of total billed charges,,,,,,no IP contract,,,78,,1025.7,percent of total billed charges,,,70,,920.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,644.35,3324,
Duplex Scan-Arterial NMH,93925,CPT,,,,inpatient,,,2480,1488,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2008.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2108,percent of total billed charges,,,85,,2108,percent of total billed charges,,,49,,1215.2,percent of total billed charges,,,90,,2232,percent of total billed charges,,,,,,,no IP contract,,80,,1984,percent of total billed charges,,,,,,,no IP contract,,50,,1240,percent of total billed charges,,,,,,no IP contract,,,78,,1934.4,percent of total billed charges,,,70,,1736,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
X ray Venous Duplex Scan NMH,93970,CPT,,,,inpatient,,,3752,2251.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3039.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3189.2,percent of total billed charges,,,85,,3189.2,percent of total billed charges,,,49,,1838.48,percent of total billed charges,,,90,,3376.8,percent of total billed charges,,,,,,,no IP contract,,80,,3001.6,percent of total billed charges,,,,,,,no IP contract,,50,,1876,percent of total billed charges,,,,,,no IP contract,,,78,,2926.56,percent of total billed charges,,,70,,2626.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3376.8,
Xray Venous Duplex Upper and Lower Extremities NMH,93970,CPT,,,,inpatient,,,3752,2251.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3039.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3189.2,percent of total billed charges,,,85,,3189.2,percent of total billed charges,,,49,,1838.48,percent of total billed charges,,,90,,3376.8,percent of total billed charges,,,,,,,no IP contract,,80,,3001.6,percent of total billed charges,,,,,,,no IP contract,,50,,1876,percent of total billed charges,,,,,,no IP contract,,,78,,2926.56,percent of total billed charges,,,70,,2626.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3376.8,
Renal ArtheryDuplex Scan TC NMH,93975,CPT,,,,inpatient,,,2679,1607.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2169.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2277.15,percent of total billed charges,,,85,,2277.15,percent of total billed charges,,,49,,1312.71,percent of total billed charges,,,90,,2411.1,percent of total billed charges,,,,,,,no IP contract,,80,,2143.2,percent of total billed charges,,,,,,,no IP contract,,50,,1339.5,percent of total billed charges,,,,,,no IP contract,,,78,,2089.62,percent of total billed charges,,,70,,1875.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
ARTERIAL DUPLEX ABDOMEN/PELVIC/RETROPERITONEAL; LTD NMH,93976,CPT,,,,inpatient,,,1665,999,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1348.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1415.25,percent of total billed charges,,,85,,1415.25,percent of total billed charges,,,49,,815.85,percent of total billed charges,,,90,,1498.5,percent of total billed charges,,,,,,,no IP contract,,80,,1332,percent of total billed charges,,,,,,,no IP contract,,50,,832.5,percent of total billed charges,,,,,,no IP contract,,,78,,1298.7,percent of total billed charges,,,70,,1165.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,20325.29333,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,815.85,20325.29,
Spirometry with Bronchodilators Charge,94060,CPT,,,,inpatient,,,747,448.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,605.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,634.95,percent of total billed charges,,,85,,634.95,percent of total billed charges,,,49,,366.03,percent of total billed charges,,,90,,672.3,percent of total billed charges,,,,,,,no IP contract,,80,,597.6,percent of total billed charges,,,,,,,no IP contract,,50,,373.5,percent of total billed charges,,,,,,no IP contract,,,78,,582.66,percent of total billed charges,,,70,,522.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,366.03,3324,
SLEEP STUDY UNATTENDED NMH,95800,CPT,,,,inpatient,,,1552,931.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1257.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1319.2,percent of total billed charges,,,85,,1319.2,percent of total billed charges,,,49,,760.48,percent of total billed charges,,,90,,1396.8,percent of total billed charges,,,,,,,no IP contract,,80,,1241.6,percent of total billed charges,,,,,,,no IP contract,,50,,776,percent of total billed charges,,,,,,no IP contract,,,78,,1210.56,percent of total billed charges,,,70,,1086.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,760.48,3324,
SLEEP STUDY UNATT & RESP EFFT,95806,CPT,,,,inpatient,,,1210,726,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,980.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1028.5,percent of total billed charges,,,85,,1028.5,percent of total billed charges,,,49,,592.9,percent of total billed charges,,,90,,1089,percent of total billed charges,,,,,,,no IP contract,,80,,968,percent of total billed charges,,,,,,,no IP contract,,50,,605,percent of total billed charges,,,,,,no IP contract,,,78,,943.8,percent of total billed charges,,,70,,847,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,592.9,3324,
Sleep Disorder Study,95810,CPT,,,,inpatient,,,5700,3420,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4617,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4845,percent of total billed charges,,,85,,4845,percent of total billed charges,,,49,,2793,percent of total billed charges,,,90,,5130,percent of total billed charges,,,,,,,no IP contract,,80,,4560,percent of total billed charges,,,,,,,no IP contract,,50,,2850,percent of total billed charges,,,,,,no IP contract,,,78,,4446,percent of total billed charges,,,70,,3990,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,5130,
Polysomnogram with CPAP NMH,95811,CPT,,,,inpatient,,,7113,4267.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5761.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6046.05,percent of total billed charges,,,85,,6046.05,percent of total billed charges,,,49,,3485.37,percent of total billed charges,,,90,,6401.7,percent of total billed charges,,,,,,,no IP contract,,80,,5690.4,percent of total billed charges,,,,,,,no IP contract,,50,,3556.5,percent of total billed charges,,,,,,no IP contract,,,78,,5548.14,percent of total billed charges,,,70,,4979.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,6401.7,
EEG-NMH,95812,CPT,,,,inpatient,,,1605,963,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1300.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1364.25,percent of total billed charges,,,85,,1364.25,percent of total billed charges,,,49,,786.45,percent of total billed charges,,,90,,1444.5,percent of total billed charges,,,,,,,no IP contract,,80,,1284,percent of total billed charges,,,,,,,no IP contract,,50,,802.5,percent of total billed charges,,,,,,no IP contract,,,78,,1251.9,percent of total billed charges,,,70,,1123.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,786.45,3324,
EEG Awake Droswey NMH,95816,CPT,,,,inpatient,,,1406,843.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1138.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1195.1,percent of total billed charges,,,85,,1195.1,percent of total billed charges,,,49,,688.94,percent of total billed charges,,,90,,1265.4,percent of total billed charges,,,,,,,no IP contract,,80,,1124.8,percent of total billed charges,,,,,,,no IP contract,,50,,703,percent of total billed charges,,,,,,no IP contract,,,78,,1096.68,percent of total billed charges,,,70,,984.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,688.94,3324,
EEG SRALab,95819,CPT,,,,inpatient,,,1012,607.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,819.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,860.2,percent of total billed charges,,,85,,860.2,percent of total billed charges,,,49,,495.88,percent of total billed charges,,,90,,910.8,percent of total billed charges,,,,,,,no IP contract,,80,,809.6,percent of total billed charges,,,,,,,no IP contract,,50,,506,percent of total billed charges,,,,,,no IP contract,,,78,,789.36,percent of total billed charges,,,70,,708.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,495.88,3324,
EEG AWAKE/ASLEEP,95819,CPT,,,,inpatient,,,1733,1039.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1403.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1473.05,percent of total billed charges,,,85,,1473.05,percent of total billed charges,,,49,,849.17,percent of total billed charges,,,90,,1559.7,percent of total billed charges,,,,,,,no IP contract,,80,,1386.4,percent of total billed charges,,,,,,,no IP contract,,50,,866.5,percent of total billed charges,,,,,,no IP contract,,,78,,1351.74,percent of total billed charges,,,70,,1213.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,849.17,3324,
SSEP UE 2 Limbs NMH,95925,CPT,,,,inpatient,,,1567,940.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1269.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1331.95,percent of total billed charges,,,85,,1331.95,percent of total billed charges,,,49,,767.83,percent of total billed charges,,,90,,1410.3,percent of total billed charges,,,,,,,no IP contract,,80,,1253.6,percent of total billed charges,,,,,,,no IP contract,,50,,783.5,percent of total billed charges,,,,,,no IP contract,,,78,,1222.26,percent of total billed charges,,,70,,1096.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,767.83,3324,
SSEP LE 2 Limbs NMH,95926,CPT,,,,inpatient,,,1567,940.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1269.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1331.95,percent of total billed charges,,,85,,1331.95,percent of total billed charges,,,49,,767.83,percent of total billed charges,,,90,,1410.3,percent of total billed charges,,,,,,,no IP contract,,80,,1253.6,percent of total billed charges,,,,,,,no IP contract,,50,,783.5,percent of total billed charges,,,,,,no IP contract,,,78,,1222.26,percent of total billed charges,,,70,,1096.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,767.83,3324,
VISUAL EVOKED POTENTIAL TEST NMH,95930,CPT,,,,inpatient,,,1067,640.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,864.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,906.95,percent of total billed charges,,,85,,906.95,percent of total billed charges,,,49,,522.83,percent of total billed charges,,,90,,960.3,percent of total billed charges,,,,,,,no IP contract,,80,,853.6,percent of total billed charges,,,,,,,no IP contract,,50,,533.5,percent of total billed charges,,,,,,no IP contract,,,78,,832.26,percent of total billed charges,,,70,,746.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,522.83,3324,
IV HYDRATION INFUS INIT; 31 MINS - 1 HOUR NMH,96360,CPT,,,,inpatient,,,478,286.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,387.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,406.3,percent of total billed charges,,,85,,406.3,percent of total billed charges,,,49,,234.22,percent of total billed charges,,,90,,430.2,percent of total billed charges,,,,,,,no IP contract,,80,,382.4,percent of total billed charges,,,,,,,no IP contract,,50,,239,percent of total billed charges,,,,,,no IP contract,,,78,,372.84,percent of total billed charges,,,70,,334.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,234.22,3324,
IV HYDRATION INFUSION EA ADDL HOUR NMH,96361,CPT,,,,inpatient,,,488,292.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,395.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,414.8,percent of total billed charges,,,85,,414.8,percent of total billed charges,,,49,,239.12,percent of total billed charges,,,90,,439.2,percent of total billed charges,,,,,,,no IP contract,,80,,390.4,percent of total billed charges,,,,,,,no IP contract,,50,,244,percent of total billed charges,,,,,,no IP contract,,,78,,380.64,percent of total billed charges,,,70,,341.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,239.12,3324,
"IV INFUSION, MEDICINE (TX/PX/D); INTIAL UP TO 1 HOUR NMH",96365,CPT,,,,inpatient,,,522,313.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,422.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,443.7,percent of total billed charges,,,85,,443.7,percent of total billed charges,,,49,,255.78,percent of total billed charges,,,90,,469.8,percent of total billed charges,,,,,,,no IP contract,,80,,417.6,percent of total billed charges,,,,,,,no IP contract,,50,,261,percent of total billed charges,,,,,,no IP contract,,,78,,407.16,percent of total billed charges,,,70,,365.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,255.78,3324,
"IV INFUSION, MEDICINE (TX/PX/D); EACH ADDL HOUR NMH",96366,CPT,,,,inpatient,,,488,292.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,395.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,414.8,percent of total billed charges,,,85,,414.8,percent of total billed charges,,,49,,239.12,percent of total billed charges,,,90,,439.2,percent of total billed charges,,,,,,,no IP contract,,80,,390.4,percent of total billed charges,,,,,,,no IP contract,,50,,244,percent of total billed charges,,,,,,no IP contract,,,78,,380.64,percent of total billed charges,,,70,,341.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,239.12,3324,
THER/PROPH/DIAG INJ IV PUSH NMH,96374,CPT,,,,inpatient,,,263,157.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,213.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,223.55,percent of total billed charges,,,85,,223.55,percent of total billed charges,,,49,,128.87,percent of total billed charges,,,90,,236.7,percent of total billed charges,,,,,,,no IP contract,,80,,210.4,percent of total billed charges,,,,,,,no IP contract,,50,,131.5,percent of total billed charges,,,,,,no IP contract,,,78,,205.14,percent of total billed charges,,,70,,184.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,128.87,3324,
TX/PRO/DX INJ NEW DRUG ADDON NMH,96375,CPT,,,,inpatient,,,231,138.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,187.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,196.35,percent of total billed charges,,,85,,196.35,percent of total billed charges,,,49,,113.19,percent of total billed charges,,,90,,207.9,percent of total billed charges,,,,,,,no IP contract,,80,,184.8,percent of total billed charges,,,,,,,no IP contract,,50,,115.5,percent of total billed charges,,,,,,no IP contract,,,78,,180.18,percent of total billed charges,,,70,,161.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,113.19,3324,
STRESS TTE COMPLETE W CONTRAST NMH,C8930,HCPCS,,,,inpatient,,,6800,4080,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5508,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5780,percent of total billed charges,,,85,,5780,percent of total billed charges,,,49,,3332,percent of total billed charges,,,90,,6120,percent of total billed charges,,,,,,,no IP contract,,80,,5440,percent of total billed charges,,,,,,,no IP contract,,50,,3400,percent of total billed charges,,,,,,no IP contract,,,78,,5304,percent of total billed charges,,,70,,4760,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,6120,
Other Respiratory Procedure Group 15 min,G0239,HCPCS,,,,inpatient,,,116,69.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,93.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,98.6,percent of total billed charges,,,85,,98.6,percent of total billed charges,,,49,,56.84,percent of total billed charges,,,90,,104.4,percent of total billed charges,,,,,,,no IP contract,,80,,92.8,percent of total billed charges,,,,,,,no IP contract,,50,,58,percent of total billed charges,,,,,,no IP contract,,,78,,90.48,percent of total billed charges,,,70,,81.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,56.84,3324,
UNSCHEDULED HEMODIALYSIS ESRD ONE EVAL NMH,G0257,HCPCS,,,,inpatient,,,3482,2089.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2820.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2959.7,percent of total billed charges,,,85,,2959.7,percent of total billed charges,,,49,,1706.18,percent of total billed charges,,,90,,3133.8,percent of total billed charges,,,,,,,no IP contract,,80,,2785.6,percent of total billed charges,,,,,,,no IP contract,,50,,1741,percent of total billed charges,,,,,,no IP contract,,,78,,2715.96,percent of total billed charges,,,70,,2437.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
TYPE III PORTABLE SLEEP STUDY NMH (G0399,G0399,HCPCS,,,,inpatient,,,1552,931.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1257.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1319.2,percent of total billed charges,,,85,,1319.2,percent of total billed charges,,,49,,760.48,percent of total billed charges,,,90,,1396.8,percent of total billed charges,,,,,,,no IP contract,,80,,1241.6,percent of total billed charges,,,,,,,no IP contract,,50,,776,percent of total billed charges,,,,,,no IP contract,,,78,,1210.56,percent of total billed charges,,,70,,1086.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,760.48,3324,
ARTHROCENTESIS; ASPIR/INJ MAJOR JOINT/BURSA NMH,20610,CPT,,,,inpatient,,,1617,970.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1309.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1374.45,percent of total billed charges,,,85,,1374.45,percent of total billed charges,,,49,,792.33,percent of total billed charges,,,90,,1455.3,percent of total billed charges,,,,,,,no IP contract,,80,,1293.6,percent of total billed charges,,,,,,,no IP contract,,50,,808.5,percent of total billed charges,,,,,,no IP contract,,,78,,1261.26,percent of total billed charges,,,70,,1131.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,29000.59143,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,792.33,29000.59,
US GUIDED ASP/INJ MAJOR JOINT NMH,20611,CPT,,,,inpatient,,,3527,2116.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2856.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2997.95,percent of total billed charges,,,85,,2997.95,percent of total billed charges,,,49,,1728.23,percent of total billed charges,,,90,,3174.3,percent of total billed charges,,,,,,,no IP contract,,80,,2821.6,percent of total billed charges,,,,,,,no IP contract,,50,,1763.5,percent of total billed charges,,,,,,no IP contract,,,78,,2751.06,percent of total billed charges,,,70,,2468.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
Tracheostomy Tube Management Charge,31502,CPT,,,,inpatient,,,582,349.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,471.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,494.7,percent of total billed charges,,,85,,494.7,percent of total billed charges,,,49,,285.18,percent of total billed charges,,,90,,523.8,percent of total billed charges,,,,,,,no IP contract,,80,,465.6,percent of total billed charges,,,,,,,no IP contract,,50,,291,percent of total billed charges,,,,,,no IP contract,,,78,,453.96,percent of total billed charges,,,70,,407.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,285.18,3324,
NB BAL TRANSTRACH INJ NMH,31899,CPT,,,,inpatient,,,1271,762.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1029.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1080.35,percent of total billed charges,,,85,,1080.35,percent of total billed charges,,,49,,622.79,percent of total billed charges,,,90,,1143.9,percent of total billed charges,,,,,,,no IP contract,,80,,1016.8,percent of total billed charges,,,,,,,no IP contract,,50,,635.5,percent of total billed charges,,,,,,no IP contract,,,78,,991.38,percent of total billed charges,,,70,,889.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,622.79,3324,
THORACNTSIS-NDL/CTH W IMG NMH,32555,CPT,,,,inpatient,,,5068,3040.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4105.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4307.8,percent of total billed charges,,,85,,4307.8,percent of total billed charges,,,49,,2483.32,percent of total billed charges,,,90,,4561.2,percent of total billed charges,,,,,,,no IP contract,,80,,4054.4,percent of total billed charges,,,,,,,no IP contract,,50,,2534,percent of total billed charges,,,,,,no IP contract,,,78,,3953.04,percent of total billed charges,,,70,,3547.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4561.2,
Declot Vascular Device,36593,CPT,,,,inpatient,,,943,565.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,763.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,801.55,percent of total billed charges,,,85,,801.55,percent of total billed charges,,,49,,462.07,percent of total billed charges,,,90,,848.7,percent of total billed charges,,,,,,,no IP contract,,80,,754.4,percent of total billed charges,,,,,,,no IP contract,,50,,471.5,percent of total billed charges,,,,,,no IP contract,,,78,,735.54,percent of total billed charges,,,70,,660.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,462.07,3324,
EGD Diagnostic NMH,43235,CPT,,,,inpatient,,,4354,2612.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3526.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3700.9,percent of total billed charges,,,85,,3700.9,percent of total billed charges,,,49,,2133.46,percent of total billed charges,,,90,,3918.6,percent of total billed charges,,,,,,,no IP contract,,80,,3483.2,percent of total billed charges,,,,,,,no IP contract,,50,,2177,percent of total billed charges,,,,,,no IP contract,,,78,,3396.12,percent of total billed charges,,,70,,3047.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3918.6,
"Upper GI Endoscopy, Biopsy",43239,CPT,,,,inpatient,,,5108,3064.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4137.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4341.8,percent of total billed charges,,,85,,4341.8,percent of total billed charges,,,49,,2502.92,percent of total billed charges,,,90,,4597.2,percent of total billed charges,,,,,,,no IP contract,,80,,4086.4,percent of total billed charges,,,,,,,no IP contract,,50,,2554,percent of total billed charges,,,,,,no IP contract,,,78,,3984.24,percent of total billed charges,,,70,,3575.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4597.2,
Sigmoidoscopy Dx TC NMH,45330,CPT,,,,inpatient,,,4433,2659.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3590.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3768.05,percent of total billed charges,,,85,,3768.05,percent of total billed charges,,,49,,2172.17,percent of total billed charges,,,90,,3989.7,percent of total billed charges,,,,,,,no IP contract,,80,,3546.4,percent of total billed charges,,,,,,,no IP contract,,50,,2216.5,percent of total billed charges,,,,,,no IP contract,,,78,,3457.74,percent of total billed charges,,,70,,3103.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3989.7,
Colon Flx Diagnostic NMH,45378,CPT,,,,inpatient,,,3607,2164.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2921.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3065.95,percent of total billed charges,,,85,,3065.95,percent of total billed charges,,,49,,1767.43,percent of total billed charges,,,90,,3246.3,percent of total billed charges,,,,,,,no IP contract,,80,,2885.6,percent of total billed charges,,,,,,,no IP contract,,50,,1803.5,percent of total billed charges,,,,,,no IP contract,,,78,,2813.46,percent of total billed charges,,,70,,2524.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
Colonoscopy w/BX NMH,45380,CPT,,,,inpatient,,,5849,3509.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4737.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4971.65,percent of total billed charges,,,85,,4971.65,percent of total billed charges,,,49,,2866.01,percent of total billed charges,,,90,,5264.1,percent of total billed charges,,,,,,,no IP contract,,80,,4679.2,percent of total billed charges,,,,,,,no IP contract,,50,,2924.5,percent of total billed charges,,,,,,no IP contract,,,78,,4562.22,percent of total billed charges,,,70,,4094.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,5264.1,
Colonoscopy with Removal Tumor NMH,45384,CPT,,,,inpatient,,,4504,2702.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3648.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3828.4,percent of total billed charges,,,85,,3828.4,percent of total billed charges,,,49,,2206.96,percent of total billed charges,,,90,,4053.6,percent of total billed charges,,,,,,,no IP contract,,80,,3603.2,percent of total billed charges,,,,,,,no IP contract,,50,,2252,percent of total billed charges,,,,,,no IP contract,,,78,,3513.12,percent of total billed charges,,,70,,3152.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4053.6,
ABD PARACENTESIS WIMAGING NMH,49083,CPT,,,,inpatient,,,4577,2746.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3707.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3890.45,percent of total billed charges,,,85,,3890.45,percent of total billed charges,,,49,,2242.73,percent of total billed charges,,,90,,4119.3,percent of total billed charges,,,,,,,no IP contract,,80,,3661.6,percent of total billed charges,,,,,,,no IP contract,,50,,2288.5,percent of total billed charges,,,,,,no IP contract,,,78,,3570.06,percent of total billed charges,,,70,,3203.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4119.3,
IR REPLACE G- OR C-TUBE NMH,49450,CPT,,,,inpatient,,,4265,2559,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3454.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3625.25,percent of total billed charges,,,85,,3625.25,percent of total billed charges,,,49,,2089.85,percent of total billed charges,,,90,,3838.5,percent of total billed charges,,,,,,,no IP contract,,80,,3412,percent of total billed charges,,,,,,,no IP contract,,50,,2132.5,percent of total billed charges,,,,,,no IP contract,,,78,,3326.7,percent of total billed charges,,,70,,2985.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3838.5,
REPLACE G-J TUBE PERC NMH,49452,CPT,,,,inpatient,,,4265,2559,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3454.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3625.25,percent of total billed charges,,,85,,3625.25,percent of total billed charges,,,49,,2089.85,percent of total billed charges,,,90,,3838.5,percent of total billed charges,,,,,,,no IP contract,,80,,3412,percent of total billed charges,,,,,,,no IP contract,,50,,2132.5,percent of total billed charges,,,,,,no IP contract,,,78,,3326.7,percent of total billed charges,,,70,,2985.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3838.5,
Electroejaculation Charge,55870,CPT,,,,inpatient,,,2796,1677.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2264.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2376.6,percent of total billed charges,,,85,,2376.6,percent of total billed charges,,,49,,1370.04,percent of total billed charges,,,90,,2516.4,percent of total billed charges,,,,,,,no IP contract,,80,,2236.8,percent of total billed charges,,,,,,,no IP contract,,50,,1398,percent of total billed charges,,,,,,no IP contract,,,78,,2180.88,percent of total billed charges,,,70,,1957.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
PERCUTANEOUS ASPIRATION INTERVERTEBRAL DISC NMH,62267,CPT,,,,inpatient,,,3083,1849.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2497.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2620.55,percent of total billed charges,,,85,,2620.55,percent of total billed charges,,,49,,1510.67,percent of total billed charges,,,90,,2774.7,percent of total billed charges,,,,,,,no IP contract,,80,,2466.4,percent of total billed charges,,,,,,,no IP contract,,50,,1541.5,percent of total billed charges,,,,,,no IP contract,,,78,,2404.74,percent of total billed charges,,,70,,2158.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
DX LUMBAR SPINAL PUNCT W/FLUOR OR CT NMH,62328,CPT,,,,inpatient,,,3640,2184,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2948.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3094,percent of total billed charges,,,85,,3094,percent of total billed charges,,,49,,1783.6,percent of total billed charges,,,90,,3276,percent of total billed charges,,,,,,,no IP contract,,80,,2912,percent of total billed charges,,,,,,,no IP contract,,50,,1820,percent of total billed charges,,,,,,no IP contract,,,78,,2839.2,percent of total billed charges,,,70,,2548,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
Expiratory Resistance Valve,E1399,HCPCS,,,,inpatient,,,376,225.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,304.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,319.6,percent of total billed charges,,,85,,319.6,percent of total billed charges,,,49,,184.24,percent of total billed charges,,,90,,338.4,percent of total billed charges,,,,,,,no IP contract,,80,,300.8,percent of total billed charges,,,,,,,no IP contract,,50,,188,percent of total billed charges,,,,,,no IP contract,,,78,,293.28,percent of total billed charges,,,70,,263.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,184.24,3324,
Misc Pharmacy NMH,250,RC,,,,inpatient,,,73.61,44.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,59.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,62.57,percent of total billed charges,,,85,,62.57,percent of total billed charges,,,49,,36.07,percent of total billed charges,,,90,,66.25,percent of total billed charges,,,,,,,no IP contract,,80,,58.89,percent of total billed charges,,,,,,,no IP contract,,50,,36.81,percent of total billed charges,,,,,,no IP contract,,,78,,57.42,percent of total billed charges,,,70,,51.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.07,999999999,
Misc Supply NMH,270,RC,,,,inpatient,,,297.69,178.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,241.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,253.04,percent of total billed charges,,,85,,253.04,percent of total billed charges,,,49,,145.87,percent of total billed charges,,,90,,267.92,percent of total billed charges,,,,,,,no IP contract,,80,,238.15,percent of total billed charges,,,,,,,no IP contract,,50,,148.85,percent of total billed charges,,,,,,no IP contract,,,78,,232.2,percent of total billed charges,,,70,,208.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,145.87,999999999,
TRACH SIZE 5 (7.0MM) DISPOS INNER CANN-10EA,272,RC,,,,inpatient,,,118,70.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,95.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,100.3,percent of total billed charges,,,85,,100.3,percent of total billed charges,,,49,,57.82,percent of total billed charges,,,90,,106.2,percent of total billed charges,,,,,,,no IP contract,,80,,94.4,percent of total billed charges,,,,,,,no IP contract,,50,,59,percent of total billed charges,,,,,,no IP contract,,,78,,92.04,percent of total billed charges,,,70,,82.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,57.82,3324,
TRACH SIZE 7 (8.0MM) DISPOS INNER CANN-10EA,272,RC,,,,inpatient,,,118,70.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,95.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,100.3,percent of total billed charges,,,85,,100.3,percent of total billed charges,,,49,,57.82,percent of total billed charges,,,90,,106.2,percent of total billed charges,,,,,,,no IP contract,,80,,94.4,percent of total billed charges,,,,,,,no IP contract,,50,,59,percent of total billed charges,,,,,,no IP contract,,,78,,92.04,percent of total billed charges,,,70,,82.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,57.82,3324,
TRACH SIZE 8 (8.5MM) DISPOS INNER CANN-10EA,272,RC,,,,inpatient,,,118,70.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,95.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,100.3,percent of total billed charges,,,85,,100.3,percent of total billed charges,,,49,,57.82,percent of total billed charges,,,90,,106.2,percent of total billed charges,,,,,,,no IP contract,,80,,94.4,percent of total billed charges,,,,,,,no IP contract,,50,,59,percent of total billed charges,,,,,,no IP contract,,,78,,92.04,percent of total billed charges,,,70,,82.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,57.82,3324,
"TRACH, 6.0MM DISPOS INNER CANN",272,RC,,,,inpatient,,,118,70.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,95.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,100.3,percent of total billed charges,,,85,,100.3,percent of total billed charges,,,49,,57.82,percent of total billed charges,,,90,,106.2,percent of total billed charges,,,,,,,no IP contract,,80,,94.4,percent of total billed charges,,,,,,,no IP contract,,50,,59,percent of total billed charges,,,,,,no IP contract,,,78,,92.04,percent of total billed charges,,,70,,82.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,57.82,3324,
TRACH SIZE 4 (6.5MM) DISPOS INNER CANN-10EA,272,RC,,,,inpatient,,,231,138.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,187.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,196.35,percent of total billed charges,,,85,,196.35,percent of total billed charges,,,49,,113.19,percent of total billed charges,,,90,,207.9,percent of total billed charges,,,,,,,no IP contract,,80,,184.8,percent of total billed charges,,,,,,,no IP contract,,50,,115.5,percent of total billed charges,,,,,,no IP contract,,,78,,180.18,percent of total billed charges,,,70,,161.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,113.19,3324,
Misc Surgical Procedure NMH,361,RC,,,,inpatient,,,3906.31,2343.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3164.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3320.36,percent of total billed charges,,,85,,3320.36,percent of total billed charges,,,49,,1914.09,percent of total billed charges,,,90,,3515.68,percent of total billed charges,,,,,,,no IP contract,,80,,3125.05,percent of total billed charges,,,,,,,no IP contract,,50,,1953.16,percent of total billed charges,,,,,,no IP contract,,,78,,3046.92,percent of total billed charges,,,70,,2734.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
00002-3228-30 - atomoxetine 25 mg Cap,00002-3228-30,NDC,,,,inpatient,1,EA,36.6,21.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.11,percent of total billed charges,,,85,,31.11,percent of total billed charges,,,49,,17.93,percent of total billed charges,,,90,,32.94,percent of total billed charges,,,,,,,no IP contract,,80,,29.28,percent of total billed charges,,,,,,,no IP contract,,50,,18.3,percent of total billed charges,,,,,,no IP contract,,,78,,28.55,percent of total billed charges,,,70,,25.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.93,3324,
00002-4112-33 - olanzapine 2.5 mg Tab,00002-4112-33,NDC,,,,inpatient,1,EA,58.6,35.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,47.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,49.81,percent of total billed charges,,,85,,49.81,percent of total billed charges,,,49,,28.71,percent of total billed charges,,,90,,52.74,percent of total billed charges,,,,,,,no IP contract,,80,,46.88,percent of total billed charges,,,,,,,no IP contract,,50,,29.3,percent of total billed charges,,,,,,no IP contract,,,78,,45.71,percent of total billed charges,,,70,,41.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,28.71,3324,
00002-4115-33 - olanzapine 5 mg Tab,00002-4115-33,NDC,,,,inpatient,1,EA,68.45,41.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,55.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,58.18,percent of total billed charges,,,85,,58.18,percent of total billed charges,,,49,,33.54,percent of total billed charges,,,90,,61.61,percent of total billed charges,,,,,,,no IP contract,,80,,54.76,percent of total billed charges,,,,,,,no IP contract,,50,,34.23,percent of total billed charges,,,,,,no IP contract,,,78,,53.39,percent of total billed charges,,,70,,47.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,33.54,3324,
00002-7510-17 - insulin lispro 100 units/mL Soln,00002-7510-17,NDC,,,,inpatient,1,ML,220.6,132.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,178.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,187.51,percent of total billed charges,,,85,,187.51,percent of total billed charges,,,49,,108.09,percent of total billed charges,,,90,,198.54,percent of total billed charges,,,,,,,no IP contract,,80,,176.48,percent of total billed charges,,,,,,,no IP contract,,50,,110.3,percent of total billed charges,,,,,,no IP contract,,,78,,172.07,percent of total billed charges,,,70,,154.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,108.09,3324,
00002-7597-01 - olanzapine 10 mg REC I,00002-7597-01,NDC,,,,inpatient,2,ML,369.95,221.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,299.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,314.46,percent of total billed charges,,,85,,314.46,percent of total billed charges,,,49,,181.28,percent of total billed charges,,,90,,332.96,percent of total billed charges,,,,,,,no IP contract,,80,,295.96,percent of total billed charges,,,,,,,no IP contract,,50,,184.98,percent of total billed charges,,,,,,no IP contract,,,78,,288.56,percent of total billed charges,,,70,,258.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,181.28,3324,
00002-8031-01 - glucagon recombinant 1 mg REC Inj,00002-8031-01,NDC,,,,inpatient,1,ML,1299.1,779.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1052.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1104.24,percent of total billed charges,,,85,,1104.24,percent of total billed charges,,,49,,636.56,percent of total billed charges,,,90,,1169.19,percent of total billed charges,,,,,,,no IP contract,,80,,1039.28,percent of total billed charges,,,,,,,no IP contract,,50,,649.55,percent of total billed charges,,,,,,no IP contract,,,78,,1013.3,percent of total billed charges,,,70,,909.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,636.56,3324,
00002-8215-17 - insulin regular human recombinant 100 units/mL Soln,00002-8215-17,NDC,,,,inpatient,1,ML,189.35,113.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,153.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,160.95,percent of total billed charges,,,85,,160.95,percent of total billed charges,,,49,,92.78,percent of total billed charges,,,90,,170.42,percent of total billed charges,,,,,,,no IP contract,,80,,151.48,percent of total billed charges,,,,,,,no IP contract,,50,,94.68,percent of total billed charges,,,,,,no IP contract,,,78,,147.69,percent of total billed charges,,,70,,132.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,92.78,3324,
00002-8315-01 - insulin isophane human recombinant 100 units/mL Injec,00002-8315-01,NDC,,,,inpatient,0.01,ML,272.7,163.62,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,220.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,231.8,percent of total billed charges,,,85,,231.8,percent of total billed charges,,,49,,133.62,percent of total billed charges,,,90,,245.43,percent of total billed charges,,,,,,,no IP contract,,80,,218.16,percent of total billed charges,,,,,,,no IP contract,,50,,136.35,percent of total billed charges,,,,,,no IP contract,,,78,,212.71,percent of total billed charges,,,70,,190.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,133.62,3324,
00002-8715-17 - insulin isophane (NPH)-insulin regular human recombinant 70 units-30 units/mL Susp,00002-8715-17,NDC,,,,inpatient,1,ML,189.35,113.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,153.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,160.95,percent of total billed charges,,,85,,160.95,percent of total billed charges,,,49,,92.78,percent of total billed charges,,,90,,170.42,percent of total billed charges,,,,,,,no IP contract,,80,,151.48,percent of total billed charges,,,,,,,no IP contract,,50,,94.68,percent of total billed charges,,,,,,no IP contract,,,78,,147.69,percent of total billed charges,,,70,,132.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,92.78,3324,
00003-0101-50 - amoxicillin 250 mg Cap,00003-0101-50,NDC,,,,inpatient,1,EA,5.8,3.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.93,percent of total billed charges,,,85,,4.93,percent of total billed charges,,,49,,2.84,percent of total billed charges,,,90,,5.22,percent of total billed charges,,,,,,,no IP contract,,80,,4.64,percent of total billed charges,,,,,,,no IP contract,,50,,2.9,percent of total billed charges,,,,,,no IP contract,,,78,,4.52,percent of total billed charges,,,70,,4.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.84,3324,
00003-0122-50 - ampicillin 250 mg Cap,00003-0122-50,NDC,,,,inpatient,1,EA,5.65,3.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.8,percent of total billed charges,,,85,,4.8,percent of total billed charges,,,49,,2.77,percent of total billed charges,,,90,,5.09,percent of total billed charges,,,,,,,no IP contract,,80,,4.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.83,percent of total billed charges,,,,,,no IP contract,,,78,,4.41,percent of total billed charges,,,70,,3.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.77,3324,
00003-0134-50 - ampicillin 500 mg Cap,00003-0134-50,NDC,,,,inpatient,1,EA,7,4.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.95,percent of total billed charges,,,85,,5.95,percent of total billed charges,,,49,,3.43,percent of total billed charges,,,90,,6.3,percent of total billed charges,,,,,,,no IP contract,,80,,5.6,percent of total billed charges,,,,,,,no IP contract,,50,,3.5,percent of total billed charges,,,,,,no IP contract,,,78,,5.46,percent of total billed charges,,,70,,4.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.43,3324,
triamcinolone acetonide 40 mg/mL Susp,00003-0293-05,NDC,,,,inpatient,1,EA,88,52.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,71.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,74.8,percent of total billed charges,,,85,,74.8,percent of total billed charges,,,49,,43.12,percent of total billed charges,,,90,,79.2,percent of total billed charges,,,,,,,no IP contract,,80,,70.4,percent of total billed charges,,,,,,,no IP contract,,50,,44,percent of total billed charges,,,,,,no IP contract,,,78,,68.64,percent of total billed charges,,,70,,61.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,43.12,3324,
triamcinolone acetonide 40 mg/mL Susp,00003-0293-28,NDC,,,,inpatient,1,EA,605.35,363.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,490.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,514.55,percent of total billed charges,,,85,,514.55,percent of total billed charges,,,49,,296.62,percent of total billed charges,,,90,,544.82,percent of total billed charges,,,,,,,no IP contract,,80,,484.28,percent of total billed charges,,,,,,,no IP contract,,50,,302.68,percent of total billed charges,,,,,,no IP contract,,,78,,472.17,percent of total billed charges,,,70,,423.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,296.62,3324,
00003-0371-13 - belatacept 250 mg REC I,00003-0371-13,NDC,,,,inpatient,10,ML,8657,5194.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7012.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7358.45,percent of total billed charges,,,85,,7358.45,percent of total billed charges,,,49,,4241.93,percent of total billed charges,,,90,,7791.3,percent of total billed charges,,,,,,,no IP contract,,80,,6925.6,percent of total billed charges,,,,,,,no IP contract,,50,,4328.5,percent of total billed charges,,,,,,no IP contract,,,78,,6752.46,percent of total billed charges,,,70,,6059.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,7791.3,
00003-0466-30 - nystatin-triamcinolone Topical 100000 units/g-0.1% Ointm,00003-0466-30,NDC,,,,inpatient,1,UN,356.6,213.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,288.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,303.11,percent of total billed charges,,,85,,303.11,percent of total billed charges,,,49,,174.73,percent of total billed charges,,,90,,320.94,percent of total billed charges,,,,,,,no IP contract,,80,,285.28,percent of total billed charges,,,,,,,no IP contract,,50,,178.3,percent of total billed charges,,,,,,no IP contract,,,78,,278.15,percent of total billed charges,,,70,,249.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,174.73,3324,
00003-0528-11 - dasatinib 50 mg Tab,00003-0528-11,NDC,,,,inpatient,1,EA,1222.3,733.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,990.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1038.96,percent of total billed charges,,,85,,1038.96,percent of total billed charges,,,49,,598.93,percent of total billed charges,,,90,,1100.07,percent of total billed charges,,,,,,,no IP contract,,80,,977.84,percent of total billed charges,,,,,,,no IP contract,,50,,611.15,percent of total billed charges,,,,,,no IP contract,,,78,,953.39,percent of total billed charges,,,70,,855.61,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,598.93,3324,
00003-0830-50 - hydroxyurea 500 mg Cap,00003-0830-50,NDC,,,,inpatient,1,EA,15.1,9.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.84,percent of total billed charges,,,85,,12.84,percent of total billed charges,,,49,,7.4,percent of total billed charges,,,90,,13.59,percent of total billed charges,,,,,,,no IP contract,,80,,12.08,percent of total billed charges,,,,,,,no IP contract,,50,,7.55,percent of total billed charges,,,,,,no IP contract,,,78,,11.78,percent of total billed charges,,,70,,10.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.4,3324,
00003-0893-21 - apixaban 2.5 mg Tab,00003-0893-21,NDC,,,,inpatient,1,EA,53.9,32.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,43.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,45.82,percent of total billed charges,,,85,,45.82,percent of total billed charges,,,49,,26.41,percent of total billed charges,,,90,,48.51,percent of total billed charges,,,,,,,no IP contract,,80,,43.12,percent of total billed charges,,,,,,,no IP contract,,50,,26.95,percent of total billed charges,,,,,,no IP contract,,,78,,42.04,percent of total billed charges,,,70,,37.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.41,3324,
00003-0893-31 - apixaban 2.5 mg Tab,00003-0893-31,NDC,,,,inpatient,1,EA,53.9,32.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,43.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,45.82,percent of total billed charges,,,85,,45.82,percent of total billed charges,,,49,,26.41,percent of total billed charges,,,90,,48.51,percent of total billed charges,,,,,,,no IP contract,,80,,43.12,percent of total billed charges,,,,,,,no IP contract,,50,,26.95,percent of total billed charges,,,,,,no IP contract,,,78,,42.04,percent of total billed charges,,,70,,37.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.41,3324,
00003-0894-31 - apixaban 5 mg Tab,00003-0894-31,NDC,,,,inpatient,1,EA,53.9,32.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,43.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,45.82,percent of total billed charges,,,85,,45.82,percent of total billed charges,,,49,,26.41,percent of total billed charges,,,90,,48.51,percent of total billed charges,,,,,,,no IP contract,,80,,43.12,percent of total billed charges,,,,,,,no IP contract,,50,,26.95,percent of total billed charges,,,,,,no IP contract,,,78,,42.04,percent of total billed charges,,,70,,37.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.41,3324,
00003-1611-12 - entecavir 0.5 mg Tab,00003-1611-12,NDC,,,,inpatient,1,EA,374.6,224.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,303.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,318.41,percent of total billed charges,,,85,,318.41,percent of total billed charges,,,49,,183.55,percent of total billed charges,,,90,,337.14,percent of total billed charges,,,,,,,no IP contract,,80,,299.68,percent of total billed charges,,,,,,,no IP contract,,50,,187.3,percent of total billed charges,,,,,,no IP contract,,,78,,292.19,percent of total billed charges,,,70,,262.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,183.55,3324,
00003-2560-16 - aztreonam 1 gm Injection,00003-2560-16,NDC,,,,inpatient,10,ML,302.7,181.62,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,245.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,257.3,percent of total billed charges,,,85,,257.3,percent of total billed charges,,,49,,148.32,percent of total billed charges,,,90,,272.43,percent of total billed charges,,,,,,,no IP contract,,80,,242.16,percent of total billed charges,,,,,,,no IP contract,,50,,151.35,percent of total billed charges,,,,,,no IP contract,,,78,,236.11,percent of total billed charges,,,70,,211.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,148.32,3324,
00003-5194-10 - pravastatin 40 mg Tab,00003-5194-10,NDC,,,,inpatient,1,EA,46.2,27.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,37.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,39.27,percent of total billed charges,,,85,,39.27,percent of total billed charges,,,49,,22.64,percent of total billed charges,,,90,,41.58,percent of total billed charges,,,,,,,no IP contract,,80,,36.96,percent of total billed charges,,,,,,,no IP contract,,50,,23.1,percent of total billed charges,,,,,,no IP contract,,,78,,36.04,percent of total billed charges,,,70,,32.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.64,3324,
00003-6336-17 - hydroxyurea 300 mg Cap,00003-6336-17,NDC,,,,inpatient,1,EA,11.4,6.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.69,percent of total billed charges,,,85,,9.69,percent of total billed charges,,,49,,5.59,percent of total billed charges,,,90,,10.26,percent of total billed charges,,,,,,,no IP contract,,80,,9.12,percent of total billed charges,,,,,,,no IP contract,,50,,5.7,percent of total billed charges,,,,,,no IP contract,,,78,,8.89,percent of total billed charges,,,70,,7.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.59,3324,
00004-0039-09 - valganciclovir 50 mg/mL REC P,00004-0039-09,NDC,,,,inpatient,1,ML,87.4,52.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,70.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,74.29,percent of total billed charges,,,85,,74.29,percent of total billed charges,,,49,,42.83,percent of total billed charges,,,90,,78.66,percent of total billed charges,,,,,,,no IP contract,,80,,69.92,percent of total billed charges,,,,,,,no IP contract,,50,,43.7,percent of total billed charges,,,,,,no IP contract,,,78,,68.17,percent of total billed charges,,,70,,61.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,42.83,3324,
00004-0183-01 - niCARdipine 20 mg Cap,00004-0183-01,NDC,,,,inpatient,1,EA,9.95,5.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.46,percent of total billed charges,,,85,,8.46,percent of total billed charges,,,49,,4.88,percent of total billed charges,,,90,,8.96,percent of total billed charges,,,,,,,no IP contract,,80,,7.96,percent of total billed charges,,,,,,,no IP contract,,50,,4.98,percent of total billed charges,,,,,,no IP contract,,,78,,7.76,percent of total billed charges,,,70,,6.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.88,3324,
00004-0263-01 - torsemide 10 mg Tab,00004-0263-01,NDC,,,,inpatient,1,EA,12.1,7.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.29,percent of total billed charges,,,85,,10.29,percent of total billed charges,,,49,,5.93,percent of total billed charges,,,90,,10.89,percent of total billed charges,,,,,,,no IP contract,,80,,9.68,percent of total billed charges,,,,,,,no IP contract,,50,,6.05,percent of total billed charges,,,,,,no IP contract,,,78,,9.44,percent of total billed charges,,,70,,8.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.93,3324,
00004-0264-01 - torsemide 20 mg Tab,00004-0264-01,NDC,,,,inpatient,1,EA,13.5,8.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.48,percent of total billed charges,,,85,,11.48,percent of total billed charges,,,49,,6.62,percent of total billed charges,,,90,,12.15,percent of total billed charges,,,,,,,no IP contract,,80,,10.8,percent of total billed charges,,,,,,,no IP contract,,50,,6.75,percent of total billed charges,,,,,,no IP contract,,,78,,10.53,percent of total billed charges,,,70,,9.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.62,3324,
00004-0265-01 - torsemide 100 mg Tab,00004-0265-01,NDC,,,,inpatient,1,EA,39.6,23.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.66,percent of total billed charges,,,85,,33.66,percent of total billed charges,,,49,,19.4,percent of total billed charges,,,90,,35.64,percent of total billed charges,,,,,,,no IP contract,,80,,31.68,percent of total billed charges,,,,,,,no IP contract,,50,,19.8,percent of total billed charges,,,,,,no IP contract,,,78,,30.89,percent of total billed charges,,,70,,27.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.4,3324,
00004-0273-01 - ketorolac 10 mg Tab,00004-0273-01,NDC,,,,inpatient,1,EA,14.3,8.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.16,percent of total billed charges,,,85,,12.16,percent of total billed charges,,,49,,7.01,percent of total billed charges,,,90,,12.87,percent of total billed charges,,,,,,,no IP contract,,80,,11.44,percent of total billed charges,,,,,,,no IP contract,,50,,7.15,percent of total billed charges,,,,,,no IP contract,,,78,,11.15,percent of total billed charges,,,70,,10.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.01,3324,
00004-0800-85 - oseltamivir 75 mg Cap,00004-0800-85,NDC,,,,inpatient,1,EA,70.75,42.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,57.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,60.14,percent of total billed charges,,,85,,60.14,percent of total billed charges,,,49,,34.67,percent of total billed charges,,,90,,63.68,percent of total billed charges,,,,,,,no IP contract,,80,,56.6,percent of total billed charges,,,,,,,no IP contract,,50,,35.38,percent of total billed charges,,,,,,no IP contract,,,78,,55.19,percent of total billed charges,,,70,,49.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,34.67,3324,
00005-0100-05 - meningococcal group B vaccine fully recombinant Susp,00005-0100-05,NDC,,,,inpatient,0.5,ML,1524.35,914.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1234.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1295.7,percent of total billed charges,,,85,,1295.7,percent of total billed charges,,,49,,746.93,percent of total billed charges,,,90,,1371.92,percent of total billed charges,,,,,,,no IP contract,,80,,1219.48,percent of total billed charges,,,,,,,no IP contract,,50,,762.18,percent of total billed charges,,,,,,no IP contract,,,78,,1188.99,percent of total billed charges,,,70,,1067.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,746.93,3324,
pneumococcal 13-valent conjugate vaccine - Susp,00005-1971-05,NDC,,,,inpatient,1,EA,1708.5,1025.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1383.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1452.23,percent of total billed charges,,,85,,1452.23,percent of total billed charges,,,49,,837.17,percent of total billed charges,,,90,,1537.65,percent of total billed charges,,,,,,,no IP contract,,80,,1366.8,percent of total billed charges,,,,,,,no IP contract,,50,,854.25,percent of total billed charges,,,,,,no IP contract,,,78,,1332.63,percent of total billed charges,,,70,,1195.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,837.17,3324,
pneumococcal 20-valent conjugate vaccine - Susp,00005-2000-02,NDC,,,,inpatient,1,EA,2736.95,1642.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2216.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2326.41,percent of total billed charges,,,85,,2326.41,percent of total billed charges,,,49,,1341.11,percent of total billed charges,,,90,,2463.26,percent of total billed charges,,,,,,,no IP contract,,80,,2189.56,percent of total billed charges,,,,,,,no IP contract,,50,,1368.48,percent of total billed charges,,,,,,no IP contract,,,78,,2134.82,percent of total billed charges,,,70,,1915.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
00005-4451-71 - multivitamin with minerals Therapeutic Multiple Vitamins with Minerals Tab,00005-4451-71,NDC,,,,inpatient,1,EA,4.4,2.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.74,percent of total billed charges,,,85,,3.74,percent of total billed charges,,,49,,2.16,percent of total billed charges,,,90,,3.96,percent of total billed charges,,,,,,,no IP contract,,80,,3.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.2,percent of total billed charges,,,,,,no IP contract,,,78,,3.43,percent of total billed charges,,,70,,3.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.16,3324,
00005-5509-19 - calcium-vitamin D 600 mg-400 intl units Tab,00005-5509-19,NDC,,,,inpatient,1,EA,4.8,2.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.08,percent of total billed charges,,,85,,4.08,percent of total billed charges,,,49,,2.35,percent of total billed charges,,,90,,4.32,percent of total billed charges,,,,,,,no IP contract,,80,,3.84,percent of total billed charges,,,,,,,no IP contract,,50,,2.4,percent of total billed charges,,,,,,no IP contract,,,78,,3.74,percent of total billed charges,,,70,,3.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.35,3324,
00005-5509-24 - calcium-vitamin D 600 mg-20 mcg Tab,00005-5509-24,NDC,,,,inpatient,1,EA,4.7,2.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4,percent of total billed charges,,,85,,4,percent of total billed charges,,,49,,2.3,percent of total billed charges,,,90,,4.23,percent of total billed charges,,,,,,,no IP contract,,80,,3.76,percent of total billed charges,,,,,,,no IP contract,,50,,2.35,percent of total billed charges,,,,,,no IP contract,,,78,,3.67,percent of total billed charges,,,70,,3.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.3,3324,
00005-5509-25 - calcium-vitamin D 600 mg-20 mcg Tab,00005-5509-25,NDC,,,,inpatient,1,EA,4.45,2.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.78,percent of total billed charges,,,85,,3.78,percent of total billed charges,,,49,,2.18,percent of total billed charges,,,90,,4.01,percent of total billed charges,,,,,,,no IP contract,,80,,3.56,percent of total billed charges,,,,,,,no IP contract,,50,,2.23,percent of total billed charges,,,,,,no IP contract,,,78,,3.47,percent of total billed charges,,,70,,3.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.18,3324,
00006-0014-94 - enalapril 2.5 mg Tab,00006-0014-94,NDC,,,,inpatient,1,EA,11.3,6.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.61,percent of total billed charges,,,85,,9.61,percent of total billed charges,,,49,,5.54,percent of total billed charges,,,90,,10.17,percent of total billed charges,,,,,,,no IP contract,,80,,9.04,percent of total billed charges,,,,,,,no IP contract,,50,,5.65,percent of total billed charges,,,,,,no IP contract,,,78,,8.81,percent of total billed charges,,,70,,7.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.54,3324,
00006-0033-30 - suvorexant 10 mg Tab,00006-0033-30,NDC,,,,inpatient,1,EA,138.4,83.04,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,112.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,117.64,percent of total billed charges,,,85,,117.64,percent of total billed charges,,,49,,67.82,percent of total billed charges,,,90,,124.56,percent of total billed charges,,,,,,,no IP contract,,80,,110.72,percent of total billed charges,,,,,,,no IP contract,,50,,69.2,percent of total billed charges,,,,,,no IP contract,,,78,,107.95,percent of total billed charges,,,70,,96.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,67.82,3324,
00006-0041-68 - dexamethasone 0.5 mg Tab,00006-0041-68,NDC,,,,inpatient,1,EA,9,5.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.65,percent of total billed charges,,,85,,7.65,percent of total billed charges,,,49,,4.41,percent of total billed charges,,,90,,8.1,percent of total billed charges,,,,,,,no IP contract,,80,,7.2,percent of total billed charges,,,,,,,no IP contract,,50,,4.5,percent of total billed charges,,,,,,no IP contract,,,78,,7.02,percent of total billed charges,,,70,,6.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.41,3324,
00006-0043-68 - phytonadione 5 mg Tab,00006-0043-68,NDC,,,,inpatient,1,EA,9,5.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.65,percent of total billed charges,,,85,,7.65,percent of total billed charges,,,49,,4.41,percent of total billed charges,,,90,,8.1,percent of total billed charges,,,,,,,no IP contract,,80,,7.2,percent of total billed charges,,,,,,,no IP contract,,50,,4.5,percent of total billed charges,,,,,,no IP contract,,,78,,7.02,percent of total billed charges,,,70,,6.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.41,3324,
00006-0065-68 - ethacrynic acid 25 mg Tab,00006-0065-68,NDC,,,,inpatient,1,EA,6.75,4.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.74,percent of total billed charges,,,85,,5.74,percent of total billed charges,,,49,,3.31,percent of total billed charges,,,90,,6.08,percent of total billed charges,,,,,,,no IP contract,,80,,5.4,percent of total billed charges,,,,,,,no IP contract,,50,,3.38,percent of total billed charges,,,,,,no IP contract,,,78,,5.27,percent of total billed charges,,,70,,4.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.31,3324,
00006-0071-31 - finasteride 1 mg Tab,00006-0071-31,NDC,,,,inpatient,1,EA,27.75,16.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.59,percent of total billed charges,,,85,,23.59,percent of total billed charges,,,49,,13.6,percent of total billed charges,,,90,,24.98,percent of total billed charges,,,,,,,no IP contract,,80,,22.2,percent of total billed charges,,,,,,,no IP contract,,50,,13.88,percent of total billed charges,,,,,,no IP contract,,,78,,21.65,percent of total billed charges,,,70,,19.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.6,3324,
00006-0077-44 - alendronate 35 mg Tab,00006-0077-44,NDC,,,,inpatient,1,EA,171.35,102.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,138.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,145.65,percent of total billed charges,,,85,,145.65,percent of total billed charges,,,49,,83.96,percent of total billed charges,,,90,,154.22,percent of total billed charges,,,,,,,no IP contract,,80,,137.08,percent of total billed charges,,,,,,,no IP contract,,50,,85.68,percent of total billed charges,,,,,,no IP contract,,,78,,133.65,percent of total billed charges,,,70,,119.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,83.96,3324,
00006-0097-50 - dexamethasone 4 mg Tab,00006-0097-50,NDC,,,,inpatient,1,EA,22.5,13.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.13,percent of total billed charges,,,85,,19.13,percent of total billed charges,,,49,,11.03,percent of total billed charges,,,90,,20.25,percent of total billed charges,,,,,,,no IP contract,,80,,18,percent of total billed charges,,,,,,,no IP contract,,50,,11.25,percent of total billed charges,,,,,,no IP contract,,,78,,17.55,percent of total billed charges,,,70,,15.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.03,3324,
00006-0221-28 - sitagliptin 25 mg Tab,00006-0221-28,NDC,,,,inpatient,1,EA,56.95,34.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,46.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,48.41,percent of total billed charges,,,85,,48.41,percent of total billed charges,,,49,,27.91,percent of total billed charges,,,90,,51.26,percent of total billed charges,,,,,,,no IP contract,,80,,45.56,percent of total billed charges,,,,,,,no IP contract,,50,,28.48,percent of total billed charges,,,,,,no IP contract,,,78,,44.42,percent of total billed charges,,,70,,39.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.91,3324,
00006-0221-31 - sitagliptin 25 mg Tab,00006-0221-31,NDC,,,,inpatient,1,EA,52.15,31.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,42.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,44.33,percent of total billed charges,,,85,,44.33,percent of total billed charges,,,49,,25.55,percent of total billed charges,,,90,,46.94,percent of total billed charges,,,,,,,no IP contract,,80,,41.72,percent of total billed charges,,,,,,,no IP contract,,50,,26.08,percent of total billed charges,,,,,,no IP contract,,,78,,40.68,percent of total billed charges,,,70,,36.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.55,3324,
00006-0277-28 - sitagliptin 100 mg Tab,00006-0277-28,NDC,,,,inpatient,1,EA,42.45,25.47,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36.08,percent of total billed charges,,,85,,36.08,percent of total billed charges,,,49,,20.8,percent of total billed charges,,,90,,38.21,percent of total billed charges,,,,,,,no IP contract,,80,,33.96,percent of total billed charges,,,,,,,no IP contract,,50,,21.23,percent of total billed charges,,,,,,no IP contract,,,78,,33.11,percent of total billed charges,,,70,,29.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.8,3324,
00006-0277-31 - sitagliptin 100 mg Tab,00006-0277-31,NDC,,,,inpatient,1,EA,52.15,31.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,42.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,44.33,percent of total billed charges,,,85,,44.33,percent of total billed charges,,,49,,25.55,percent of total billed charges,,,90,,46.94,percent of total billed charges,,,,,,,no IP contract,,80,,41.72,percent of total billed charges,,,,,,,no IP contract,,50,,26.08,percent of total billed charges,,,,,,no IP contract,,,78,,40.68,percent of total billed charges,,,70,,36.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.55,3324,
00006-0735-31 - simvastatin 10 mg Tab,00006-0735-31,NDC,,,,inpatient,1,EA,28.7,17.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.4,percent of total billed charges,,,85,,24.4,percent of total billed charges,,,49,,14.06,percent of total billed charges,,,90,,25.83,percent of total billed charges,,,,,,,no IP contract,,80,,22.96,percent of total billed charges,,,,,,,no IP contract,,50,,14.35,percent of total billed charges,,,,,,no IP contract,,,78,,22.39,percent of total billed charges,,,70,,20.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.06,3324,
00006-0951-28 - losartan 25 mg Tab,00006-0951-28,NDC,,,,inpatient,1,EA,19.35,11.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.45,percent of total billed charges,,,85,,16.45,percent of total billed charges,,,49,,9.48,percent of total billed charges,,,90,,17.42,percent of total billed charges,,,,,,,no IP contract,,80,,15.48,percent of total billed charges,,,,,,,no IP contract,,50,,9.68,percent of total billed charges,,,,,,no IP contract,,,78,,15.09,percent of total billed charges,,,70,,13.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.48,3324,
00006-3275-16 - benztropine 1 mg/mL Soln,00006-3275-16,NDC,,,,inpatient,2,ML,78.6,47.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,63.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,66.81,percent of total billed charges,,,85,,66.81,percent of total billed charges,,,49,,38.51,percent of total billed charges,,,90,,70.74,percent of total billed charges,,,,,,,no IP contract,,80,,62.88,percent of total billed charges,,,,,,,no IP contract,,50,,39.3,percent of total billed charges,,,,,,no IP contract,,,78,,61.31,percent of total billed charges,,,70,,55.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,38.51,3324,
00006-3539-04 - famotidine 10 mg/mL Soln,00006-3539-04,NDC,,,,inpatient,1,ML,29.3,17.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.91,percent of total billed charges,,,85,,24.91,percent of total billed charges,,,49,,14.36,percent of total billed charges,,,90,,26.37,percent of total billed charges,,,,,,,no IP contract,,80,,23.44,percent of total billed charges,,,,,,,no IP contract,,50,,14.65,percent of total billed charges,,,,,,no IP contract,,,78,,22.85,percent of total billed charges,,,70,,20.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.36,3324,
00006-3843-71 - ertapenem 1 g REC I,00006-3843-71,NDC,,,,inpatient,10,ML,893.55,536.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,723.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,759.52,percent of total billed charges,,,85,,759.52,percent of total billed charges,,,49,,437.84,percent of total billed charges,,,90,,804.2,percent of total billed charges,,,,,,,no IP contract,,80,,714.84,percent of total billed charges,,,,,,,no IP contract,,50,,446.78,percent of total billed charges,,,,,,no IP contract,,,78,,696.97,percent of total billed charges,,,70,,625.49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,437.84,3324,
00006-3856-02 - imipenem/cilastatin/relebactam 1.25 g REC I,00006-3856-02,NDC,,,,inpatient,1,EA,3053.85,1832.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2473.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2595.77,percent of total billed charges,,,85,,2595.77,percent of total billed charges,,,49,,1496.39,percent of total billed charges,,,90,,2748.47,percent of total billed charges,,,,,,,no IP contract,,80,,2443.08,percent of total billed charges,,,,,,,no IP contract,,50,,1526.93,percent of total billed charges,,,,,,no IP contract,,,78,,2382,percent of total billed charges,,,70,,2137.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
00006-4681-00 - measles/mumps/rubella virus vaccine - REC I,00006-4681-00,NDC,,,,inpatient,0.5,ML,513.35,308.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,415.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,436.35,percent of total billed charges,,,85,,436.35,percent of total billed charges,,,49,,251.54,percent of total billed charges,,,90,,462.02,percent of total billed charges,,,,,,,no IP contract,,80,,410.68,percent of total billed charges,,,,,,,no IP contract,,50,,256.68,percent of total billed charges,,,,,,no IP contract,,,78,,400.41,percent of total billed charges,,,70,,359.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,251.54,3324,
varicella virus vaccine - REC I,00006-4827-00,NDC,,,,inpatient,1,EA,882.85,529.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,715.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,750.42,percent of total billed charges,,,85,,750.42,percent of total billed charges,,,49,,432.6,percent of total billed charges,,,90,,794.57,percent of total billed charges,,,,,,,no IP contract,,80,,706.28,percent of total billed charges,,,,,,,no IP contract,,50,,441.43,percent of total billed charges,,,,,,no IP contract,,,78,,688.62,percent of total billed charges,,,70,,618,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,432.6,3324,
00006-4897-00 - haemophilus b conjugate (PRP-OMP) vaccine 7.5 mcg-125 mcg/0.5 mL Susp,00006-4897-00,NDC,,,,inpatient,0.5,ML,273.3,163.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,221.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,232.31,percent of total billed charges,,,85,,232.31,percent of total billed charges,,,49,,133.92,percent of total billed charges,,,90,,245.97,percent of total billed charges,,,,,,,no IP contract,,80,,218.64,percent of total billed charges,,,,,,,no IP contract,,50,,136.65,percent of total billed charges,,,,,,no IP contract,,,78,,213.17,percent of total billed charges,,,70,,191.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,133.92,3324,
pneumococcal 23-valent vaccine - Soln,00006-4943-00,NDC,,,,inpatient,1,EA,317.8,190.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,257.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,270.13,percent of total billed charges,,,85,,270.13,percent of total billed charges,,,49,,155.72,percent of total billed charges,,,90,,286.02,percent of total billed charges,,,,,,,no IP contract,,80,,254.24,percent of total billed charges,,,,,,,no IP contract,,50,,158.9,percent of total billed charges,,,,,,no IP contract,,,78,,247.88,percent of total billed charges,,,70,,222.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,155.72,3324,
00007-4892-20 - ropinirole 1 mg Tab,00007-4892-20,NDC,,,,inpatient,1,EA,20.6,12.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.51,percent of total billed charges,,,85,,17.51,percent of total billed charges,,,49,,10.09,percent of total billed charges,,,90,,18.54,percent of total billed charges,,,,,,,no IP contract,,80,,16.48,percent of total billed charges,,,,,,,no IP contract,,50,,10.3,percent of total billed charges,,,,,,no IP contract,,,78,,16.07,percent of total billed charges,,,70,,14.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.09,3324,
00007-4896-20 - ropinirole 4 mg Tab,00007-4896-20,NDC,,,,inpatient,1,EA,24.25,14.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.61,percent of total billed charges,,,85,,20.61,percent of total billed charges,,,49,,11.88,percent of total billed charges,,,90,,21.83,percent of total billed charges,,,,,,,no IP contract,,80,,19.4,percent of total billed charges,,,,,,,no IP contract,,50,,12.13,percent of total billed charges,,,,,,no IP contract,,,78,,18.92,percent of total billed charges,,,70,,16.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.88,3324,
00008-0701-01 - venlafaxine 25 mg Tab,00008-0701-01,NDC,,,,inpatient,1,EA,20.1,12.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.09,percent of total billed charges,,,85,,17.09,percent of total billed charges,,,49,,9.85,percent of total billed charges,,,90,,18.09,percent of total billed charges,,,,,,,no IP contract,,80,,16.08,percent of total billed charges,,,,,,,no IP contract,,50,,10.05,percent of total billed charges,,,,,,no IP contract,,,78,,15.68,percent of total billed charges,,,70,,14.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.85,3324,
00008-0701-08 - venlafaxine 25 mg Tab,00008-0701-08,NDC,,,,inpatient,1,EA,23.7,14.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.15,percent of total billed charges,,,85,,20.15,percent of total billed charges,,,49,,11.61,percent of total billed charges,,,90,,21.33,percent of total billed charges,,,,,,,no IP contract,,80,,18.96,percent of total billed charges,,,,,,,no IP contract,,50,,11.85,percent of total billed charges,,,,,,no IP contract,,,78,,18.49,percent of total billed charges,,,70,,16.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.61,3324,
00008-0781-01 - venlafaxine 37.5 mg Tab,00008-0781-01,NDC,,,,inpatient,1,EA,20.6,12.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.51,percent of total billed charges,,,85,,17.51,percent of total billed charges,,,49,,10.09,percent of total billed charges,,,90,,18.54,percent of total billed charges,,,,,,,no IP contract,,80,,16.48,percent of total billed charges,,,,,,,no IP contract,,50,,10.3,percent of total billed charges,,,,,,no IP contract,,,78,,16.07,percent of total billed charges,,,70,,14.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.09,3324,
00008-0844-02 - pantoprazole 40 mg REC G,00008-0844-02,NDC,,,,inpatient,1,UN,80.55,48.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,65.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,68.47,percent of total billed charges,,,85,,68.47,percent of total billed charges,,,49,,39.47,percent of total billed charges,,,90,,72.5,percent of total billed charges,,,,,,,no IP contract,,80,,64.44,percent of total billed charges,,,,,,,no IP contract,,50,,40.28,percent of total billed charges,,,,,,no IP contract,,,78,,62.83,percent of total billed charges,,,70,,56.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,39.47,3324,
00008-0844-02 - pantoprazole 40 mg REC G,00008-0844-02,NDC,,,,inpatient,1,UN,80.55,48.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,65.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,68.47,percent of total billed charges,,,85,,68.47,percent of total billed charges,,,49,,39.47,percent of total billed charges,,,90,,72.5,percent of total billed charges,,,,,,,no IP contract,,80,,64.44,percent of total billed charges,,,,,,,no IP contract,,50,,40.28,percent of total billed charges,,,,,,no IP contract,,,78,,62.83,percent of total billed charges,,,70,,56.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,39.47,3324,
00008-0923-55 - pantoprazole 40 mg REC I,00008-0923-55,NDC,,,,inpatient,10,ML,59.9,35.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,48.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,50.92,percent of total billed charges,,,85,,50.92,percent of total billed charges,,,49,,29.35,percent of total billed charges,,,90,,53.91,percent of total billed charges,,,,,,,no IP contract,,80,,47.92,percent of total billed charges,,,,,,,no IP contract,,50,,29.95,percent of total billed charges,,,,,,no IP contract,,,78,,46.72,percent of total billed charges,,,70,,41.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,29.35,3324,
00008-0925-81 - zaleplon 5 mg Cap,00008-0925-81,NDC,,,,inpatient,1,EA,31.75,19.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,25.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.99,percent of total billed charges,,,85,,26.99,percent of total billed charges,,,49,,15.56,percent of total billed charges,,,90,,28.58,percent of total billed charges,,,,,,,no IP contract,,80,,25.4,percent of total billed charges,,,,,,,no IP contract,,50,,15.88,percent of total billed charges,,,,,,no IP contract,,,78,,24.77,percent of total billed charges,,,70,,22.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.56,3324,
00008-1030-06 - sirolimus 1 mg/mL Soln,00008-1030-06,NDC,,,,inpatient,1,ML,185.6,111.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,150.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,157.76,percent of total billed charges,,,85,,157.76,percent of total billed charges,,,49,,90.94,percent of total billed charges,,,90,,167.04,percent of total billed charges,,,,,,,no IP contract,,80,,148.48,percent of total billed charges,,,,,,,no IP contract,,50,,92.8,percent of total billed charges,,,,,,no IP contract,,,78,,144.77,percent of total billed charges,,,70,,129.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,90.94,3324,
00008-1031-05 - sirolimus 1 mg Tab,00008-1031-05,NDC,,,,inpatient,1,EA,73.45,44.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,59.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,62.43,percent of total billed charges,,,85,,62.43,percent of total billed charges,,,49,,35.99,percent of total billed charges,,,90,,66.11,percent of total billed charges,,,,,,,no IP contract,,80,,58.76,percent of total billed charges,,,,,,,no IP contract,,50,,36.73,percent of total billed charges,,,,,,no IP contract,,,78,,57.29,percent of total billed charges,,,70,,51.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,35.99,3324,
00008-1040-05 - sirolimus 0.5 mg Tab,00008-1040-05,NDC,,,,inpatient,1,EA,56.85,34.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,46.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,48.32,percent of total billed charges,,,85,,48.32,percent of total billed charges,,,49,,27.86,percent of total billed charges,,,90,,51.17,percent of total billed charges,,,,,,,no IP contract,,80,,45.48,percent of total billed charges,,,,,,,no IP contract,,50,,28.43,percent of total billed charges,,,,,,no IP contract,,,78,,44.34,percent of total billed charges,,,70,,39.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.86,3324,
00008-1041-05 - sirolimus 1 mg Tab,00008-1041-05,NDC,,,,inpatient,1,EA,76.25,45.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,61.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,64.81,percent of total billed charges,,,85,,64.81,percent of total billed charges,,,49,,37.36,percent of total billed charges,,,90,,68.63,percent of total billed charges,,,,,,,no IP contract,,80,,61,percent of total billed charges,,,,,,,no IP contract,,50,,38.13,percent of total billed charges,,,,,,no IP contract,,,78,,59.48,percent of total billed charges,,,70,,53.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,37.36,3324,
00008-1041-10 - sirolimus 1 mg Tab,00008-1041-10,NDC,,,,inpatient,1,EA,109.9,65.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,89.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,93.42,percent of total billed charges,,,85,,93.42,percent of total billed charges,,,49,,53.85,percent of total billed charges,,,90,,98.91,percent of total billed charges,,,,,,,no IP contract,,80,,87.92,percent of total billed charges,,,,,,,no IP contract,,50,,54.95,percent of total billed charges,,,,,,no IP contract,,,78,,85.72,percent of total billed charges,,,70,,76.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,53.85,3324,
00008-1211-30 - desvenlafaxine 50 mg ER Ta,00008-1211-30,NDC,,,,inpatient,1,EA,46.85,28.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,37.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,39.82,percent of total billed charges,,,85,,39.82,percent of total billed charges,,,49,,22.96,percent of total billed charges,,,90,,42.17,percent of total billed charges,,,,,,,no IP contract,,80,,37.48,percent of total billed charges,,,,,,,no IP contract,,50,,23.43,percent of total billed charges,,,,,,no IP contract,,,78,,36.54,percent of total billed charges,,,70,,32.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.96,3324,
00008-4990-02 - tigecycline 50 mg REC I,00008-4990-02,NDC,,,,inpatient,5,ML,637.9,382.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,516.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,542.22,percent of total billed charges,,,85,,542.22,percent of total billed charges,,,49,,312.57,percent of total billed charges,,,90,,574.11,percent of total billed charges,,,,,,,no IP contract,,80,,510.32,percent of total billed charges,,,,,,,no IP contract,,50,,318.95,percent of total billed charges,,,,,,no IP contract,,,78,,497.56,percent of total billed charges,,,70,,446.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,312.57,3324,
00008-4990-20 - tigecycline 50 mg REC Injection,00008-4990-20,NDC,,,,inpatient,5,ML,687.3,412.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,556.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,584.21,percent of total billed charges,,,85,,584.21,percent of total billed charges,,,49,,336.78,percent of total billed charges,,,90,,618.57,percent of total billed charges,,,,,,,no IP contract,,80,,549.84,percent of total billed charges,,,,,,,no IP contract,,50,,343.65,percent of total billed charges,,,,,,no IP contract,,,78,,536.09,percent of total billed charges,,,70,,481.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,336.78,3324,
00008-5360-02 - tigecycline 50 mg REC Inj,00008-5360-02,NDC,,,,inpatient,5,ML,546.1,327.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,442.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,464.19,percent of total billed charges,,,85,,464.19,percent of total billed charges,,,49,,267.59,percent of total billed charges,,,90,,491.49,percent of total billed charges,,,,,,,no IP contract,,80,,436.88,percent of total billed charges,,,,,,,no IP contract,,50,,273.05,percent of total billed charges,,,,,,no IP contract,,,78,,425.96,percent of total billed charges,,,70,,382.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,267.59,3324,
hydrocortisone 100 mg preservative-free REC I,00009-0011-03,NDC,,,,inpatient,1,EA,78.55,47.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,63.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,66.77,percent of total billed charges,,,85,,66.77,percent of total billed charges,,,49,,38.49,percent of total billed charges,,,90,,70.7,percent of total billed charges,,,,,,,no IP contract,,80,,62.84,percent of total billed charges,,,,,,,no IP contract,,50,,39.28,percent of total billed charges,,,,,,no IP contract,,,78,,61.27,percent of total billed charges,,,70,,54.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,38.49,3324,
00009-0018-20 - methylPREDNISolone 1 g preservative-free REC I,00009-0018-20,NDC,,,,inpatient,1,ML,90.75,54.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,73.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,77.14,percent of total billed charges,,,85,,77.14,percent of total billed charges,,,49,,44.47,percent of total billed charges,,,90,,81.68,percent of total billed charges,,,,,,,no IP contract,,80,,72.6,percent of total billed charges,,,,,,,no IP contract,,50,,45.38,percent of total billed charges,,,,,,no IP contract,,,78,,70.79,percent of total billed charges,,,70,,63.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,44.47,3324,
00009-0031-01 - hydrocortisone 10 mg Tab,00009-0031-01,NDC,,,,inpatient,1,EA,7.5,4.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.38,percent of total billed charges,,,85,,6.38,percent of total billed charges,,,49,,3.68,percent of total billed charges,,,90,,6.75,percent of total billed charges,,,,,,,no IP contract,,80,,6,percent of total billed charges,,,,,,,no IP contract,,50,,3.75,percent of total billed charges,,,,,,no IP contract,,,78,,5.85,percent of total billed charges,,,70,,5.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.68,3324,
00009-0039-28 - methylPREDNISolone 40 mg preservative-free REC I,00009-0039-28,NDC,,,,inpatient,1,ML,39.75,23.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.79,percent of total billed charges,,,85,,33.79,percent of total billed charges,,,49,,19.48,percent of total billed charges,,,90,,35.78,percent of total billed charges,,,,,,,no IP contract,,80,,31.8,percent of total billed charges,,,,,,,no IP contract,,50,,19.88,percent of total billed charges,,,,,,no IP contract,,,78,,31.01,percent of total billed charges,,,70,,27.83,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.48,3324,
00009-0039-32 - methylPREDNISolone 40 mg preservative-free REC I,00009-0039-32,NDC,,,,inpatient,1,ML,39.75,23.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.79,percent of total billed charges,,,85,,33.79,percent of total billed charges,,,49,,19.48,percent of total billed charges,,,90,,35.78,percent of total billed charges,,,,,,,no IP contract,,80,,31.8,percent of total billed charges,,,,,,,no IP contract,,50,,19.88,percent of total billed charges,,,,,,no IP contract,,,78,,31.01,percent of total billed charges,,,70,,27.83,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.48,3324,
00009-0047-26 - methylPREDNISolone 125 mg preservative-free REC I,00009-0047-26,NDC,,,,inpatient,1,ML,58.35,35.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,47.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,49.6,percent of total billed charges,,,85,,49.6,percent of total billed charges,,,49,,28.59,percent of total billed charges,,,90,,52.52,percent of total billed charges,,,,,,,no IP contract,,80,,46.68,percent of total billed charges,,,,,,,no IP contract,,50,,29.18,percent of total billed charges,,,,,,no IP contract,,,78,,45.51,percent of total billed charges,,,70,,40.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,28.59,3324,
00009-0056-02 - methylPREDNISolone 4 mg Tab,00009-0056-02,NDC,,,,inpatient,1,EA,14.25,8.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.11,percent of total billed charges,,,85,,12.11,percent of total billed charges,,,49,,6.98,percent of total billed charges,,,90,,12.83,percent of total billed charges,,,,,,,no IP contract,,80,,11.4,percent of total billed charges,,,,,,,no IP contract,,50,,7.13,percent of total billed charges,,,,,,no IP contract,,,78,,11.12,percent of total billed charges,,,70,,9.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.98,3324,
00009-0056-02 - methylPREDNISolone 4 mg Tab,00009-0056-02,NDC,,,,inpatient,1,EA,14.25,8.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.11,percent of total billed charges,,,85,,12.11,percent of total billed charges,,,49,,6.98,percent of total billed charges,,,90,,12.83,percent of total billed charges,,,,,,,no IP contract,,80,,11.4,percent of total billed charges,,,,,,,no IP contract,,50,,7.13,percent of total billed charges,,,,,,no IP contract,,,78,,11.12,percent of total billed charges,,,70,,9.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.98,3324,
00009-0064-04 - medroxyPROGESTERone 2.5 mg Tab,00009-0064-04,NDC,,,,inpatient,1,EA,10.2,6.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.67,percent of total billed charges,,,85,,8.67,percent of total billed charges,,,49,,5,percent of total billed charges,,,90,,9.18,percent of total billed charges,,,,,,,no IP contract,,80,,8.16,percent of total billed charges,,,,,,,no IP contract,,50,,5.1,percent of total billed charges,,,,,,no IP contract,,,78,,7.96,percent of total billed charges,,,70,,7.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5,3324,
00009-0073-01 - methylPREDNISolone 16 mg Tab,00009-0073-01,NDC,,,,inpatient,1,EA,26.4,15.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.44,percent of total billed charges,,,85,,22.44,percent of total billed charges,,,49,,12.94,percent of total billed charges,,,90,,23.76,percent of total billed charges,,,,,,,no IP contract,,80,,21.12,percent of total billed charges,,,,,,,no IP contract,,50,,13.2,percent of total billed charges,,,,,,no IP contract,,,78,,20.59,percent of total billed charges,,,70,,18.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.94,3324,
00009-0225-03 - clindamycin 150 mg Cap,00009-0225-03,NDC,,,,inpatient,1,EA,28.8,17.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.48,percent of total billed charges,,,85,,24.48,percent of total billed charges,,,49,,14.11,percent of total billed charges,,,90,,25.92,percent of total billed charges,,,,,,,no IP contract,,80,,23.04,percent of total billed charges,,,,,,,no IP contract,,50,,14.4,percent of total billed charges,,,,,,no IP contract,,,78,,22.46,percent of total billed charges,,,70,,20.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.11,3324,
00009-0388-01 - predniSONE 50 mg Tab,00009-0388-01,NDC,,,,inpatient,1,EA,6.05,3.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.14,percent of total billed charges,,,85,,5.14,percent of total billed charges,,,49,,2.96,percent of total billed charges,,,90,,5.45,percent of total billed charges,,,,,,,no IP contract,,80,,4.84,percent of total billed charges,,,,,,,no IP contract,,50,,3.03,percent of total billed charges,,,,,,no IP contract,,,78,,4.72,percent of total billed charges,,,70,,4.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.96,3324,
00009-0450-03 - colestipol 1 g Tab,00009-0450-03,NDC,,,,inpatient,1,EA,9.4,5.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.99,percent of total billed charges,,,85,,7.99,percent of total billed charges,,,49,,4.61,percent of total billed charges,,,90,,8.46,percent of total billed charges,,,,,,,no IP contract,,80,,7.52,percent of total billed charges,,,,,,,no IP contract,,50,,4.7,percent of total billed charges,,,,,,no IP contract,,,78,,7.33,percent of total billed charges,,,70,,6.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.61,3324,
00009-0746-30 - medroxyPROGESTERone 150 mg/mL Susp,00009-0746-30,NDC,,,,inpatient,1,ML,561.85,337.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,455.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,477.57,percent of total billed charges,,,85,,477.57,percent of total billed charges,,,49,,275.31,percent of total billed charges,,,90,,505.67,percent of total billed charges,,,,,,,no IP contract,,80,,449.48,percent of total billed charges,,,,,,,no IP contract,,50,,280.93,percent of total billed charges,,,,,,no IP contract,,,78,,438.24,percent of total billed charges,,,70,,393.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,275.31,3324,
00009-0775-26 - clindamycin 150 mg/mL Soln,00009-0775-26,NDC,,,,inpatient,1,ML,28.7,17.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.4,percent of total billed charges,,,85,,24.4,percent of total billed charges,,,49,,14.06,percent of total billed charges,,,90,,25.83,percent of total billed charges,,,,,,,no IP contract,,80,,22.96,percent of total billed charges,,,,,,,no IP contract,,50,,14.35,percent of total billed charges,,,,,,no IP contract,,,78,,22.39,percent of total billed charges,,,70,,20.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.06,3324,
clindamycin 150 mg/mL Soln,00009-0902-18,NDC,,,,inpatient,1,mL,26.25,15.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.31,percent of total billed charges,,,85,,22.31,percent of total billed charges,,,49,,12.86,percent of total billed charges,,,90,,23.63,percent of total billed charges,,,,,,,no IP contract,,80,,21,percent of total billed charges,,,,,,,no IP contract,,50,,13.13,percent of total billed charges,,,,,,no IP contract,,,78,,20.48,percent of total billed charges,,,70,,18.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.86,3324,
00009-3073-01 - methylPREDNISolone 40 mg/mL Susp,00009-3073-01,NDC,,,,inpatient,1,ML,85.55,51.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,69.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,72.72,percent of total billed charges,,,85,,72.72,percent of total billed charges,,,49,,41.92,percent of total billed charges,,,90,,77,percent of total billed charges,,,,,,,no IP contract,,80,,68.44,percent of total billed charges,,,,,,,no IP contract,,50,,42.78,percent of total billed charges,,,,,,no IP contract,,,78,,66.73,percent of total billed charges,,,70,,59.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,41.92,3324,
00009-3329-01 - clindamycin topical 1% Lotio,00009-3329-01,NDC,,,,inpatient,1,UN,708.95,425.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,574.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,602.61,percent of total billed charges,,,85,,602.61,percent of total billed charges,,,49,,347.39,percent of total billed charges,,,90,,638.06,percent of total billed charges,,,,,,,no IP contract,,80,,567.16,percent of total billed charges,,,,,,,no IP contract,,50,,354.48,percent of total billed charges,,,,,,no IP contract,,,78,,552.98,percent of total billed charges,,,70,,496.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,347.39,3324,
methylPREDNISolone 80 mg/mL Susp,00009-3475-01,NDC,,,,inpatient,1,EA,141.4,84.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,114.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,120.19,percent of total billed charges,,,85,,120.19,percent of total billed charges,,,49,,69.29,percent of total billed charges,,,90,,127.26,percent of total billed charges,,,,,,,no IP contract,,80,,113.12,percent of total billed charges,,,,,,,no IP contract,,50,,70.7,percent of total billed charges,,,,,,no IP contract,,,78,,110.29,percent of total billed charges,,,70,,98.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,69.29,3324,
alprostadil 20 mcg REC I,00009-3701-05,NDC,,,,inpatient,1,EA,589.2,353.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,477.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,500.82,percent of total billed charges,,,85,,500.82,percent of total billed charges,,,49,,288.71,percent of total billed charges,,,90,,530.28,percent of total billed charges,,,,,,,no IP contract,,80,,471.36,percent of total billed charges,,,,,,,no IP contract,,50,,294.6,percent of total billed charges,,,,,,no IP contract,,,78,,459.58,percent of total billed charges,,,70,,412.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,288.71,3324,
00009-4541-02 - tolterodine 1 mg Tab,00009-4541-02,NDC,,,,inpatient,1,EA,20.1,12.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.09,percent of total billed charges,,,85,,17.09,percent of total billed charges,,,49,,9.85,percent of total billed charges,,,90,,18.09,percent of total billed charges,,,,,,,no IP contract,,80,,16.08,percent of total billed charges,,,,,,,no IP contract,,50,,10.05,percent of total billed charges,,,,,,no IP contract,,,78,,15.68,percent of total billed charges,,,70,,14.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.85,3324,
00009-5136-01 - linezolid 100 mg/5 mL REC Powder,00009-5136-01,NDC,,,,inpatient,1,ML,51.8,31.08,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,41.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,44.03,percent of total billed charges,,,85,,44.03,percent of total billed charges,,,49,,25.38,percent of total billed charges,,,90,,46.62,percent of total billed charges,,,,,,,no IP contract,,80,,41.44,percent of total billed charges,,,,,,,no IP contract,,50,,25.9,percent of total billed charges,,,,,,no IP contract,,,78,,40.4,percent of total billed charges,,,70,,36.26,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.38,3324,
00009-5140-01 - linezolid 2 mg/mL Soln,00009-5140-01,NDC,,,,inpatient,300,ML,1172.65,703.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,949.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,996.75,percent of total billed charges,,,85,,996.75,percent of total billed charges,,,49,,574.6,percent of total billed charges,,,90,,1055.39,percent of total billed charges,,,,,,,no IP contract,,80,,938.12,percent of total billed charges,,,,,,,no IP contract,,50,,586.33,percent of total billed charges,,,,,,no IP contract,,,78,,914.67,percent of total billed charges,,,70,,820.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,574.6,3324,
00009-5140-04 - linezolid Pre-mixed IVPB 600 mg / 300 mL Injection,00009-5140-04,NDC,,,,inpatient,300,ML,413.95,248.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,335.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,351.86,percent of total billed charges,,,85,,351.86,percent of total billed charges,,,49,,202.84,percent of total billed charges,,,90,,372.56,percent of total billed charges,,,,,,,no IP contract,,80,,331.16,percent of total billed charges,,,,,,,no IP contract,,50,,206.98,percent of total billed charges,,,,,,no IP contract,,,78,,322.88,percent of total billed charges,,,70,,289.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,202.84,3324,
00009-5181-01 - alprostadil 10 mcg REC I,00009-5181-01,NDC,,,,inpatient,0.5,ML,789,473.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,639.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,670.65,percent of total billed charges,,,85,,670.65,percent of total billed charges,,,49,,386.61,percent of total billed charges,,,90,,710.1,percent of total billed charges,,,,,,,no IP contract,,80,,631.2,percent of total billed charges,,,,,,,no IP contract,,50,,394.5,percent of total billed charges,,,,,,no IP contract,,,78,,615.42,percent of total billed charges,,,70,,552.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,386.61,3324,
alprostadil 20 mcg REC I,00009-5182-01,NDC,,,,inpatient,1,EA,560.55,336.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,454.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,476.47,percent of total billed charges,,,85,,476.47,percent of total billed charges,,,49,,274.67,percent of total billed charges,,,90,,504.5,percent of total billed charges,,,,,,,no IP contract,,80,,448.44,percent of total billed charges,,,,,,,no IP contract,,50,,280.28,percent of total billed charges,,,,,,no IP contract,,,78,,437.23,percent of total billed charges,,,70,,392.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,274.67,3324,
alprostadil 20 mcg REC I,00009-5182-01,NDC,,,,inpatient,1,EA,560.55,336.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,454.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,476.47,percent of total billed charges,,,85,,476.47,percent of total billed charges,,,49,,274.67,percent of total billed charges,,,90,,504.5,percent of total billed charges,,,,,,,no IP contract,,80,,448.44,percent of total billed charges,,,,,,,no IP contract,,50,,280.28,percent of total billed charges,,,,,,no IP contract,,,78,,437.23,percent of total billed charges,,,70,,392.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,274.67,3324,
00013-0101-11 - sulfasalazine 500 mg Tab,00013-0101-11,NDC,,,,inpatient,1,EA,6.35,3.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.4,percent of total billed charges,,,85,,5.4,percent of total billed charges,,,49,,3.11,percent of total billed charges,,,90,,5.72,percent of total billed charges,,,,,,,no IP contract,,80,,5.08,percent of total billed charges,,,,,,,no IP contract,,50,,3.18,percent of total billed charges,,,,,,no IP contract,,,78,,4.95,percent of total billed charges,,,70,,4.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.11,3324,
00013-0102-01 - sulfasalazine 500 mg EC Tab,00013-0102-01,NDC,,,,inpatient,1,EA,8.3,4.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.06,percent of total billed charges,,,85,,7.06,percent of total billed charges,,,49,,4.07,percent of total billed charges,,,90,,7.47,percent of total billed charges,,,,,,,no IP contract,,80,,6.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.15,percent of total billed charges,,,,,,no IP contract,,,78,,6.47,percent of total billed charges,,,70,,5.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.07,3324,
00013-0102-50 - sulfaSALAzine 500 mg EC Ta,00013-0102-50,NDC,,,,inpatient,1,EA,22.75,13.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.34,percent of total billed charges,,,85,,19.34,percent of total billed charges,,,49,,11.15,percent of total billed charges,,,90,,20.48,percent of total billed charges,,,,,,,no IP contract,,80,,18.2,percent of total billed charges,,,,,,,no IP contract,,50,,11.38,percent of total billed charges,,,,,,no IP contract,,,78,,17.75,percent of total billed charges,,,70,,15.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.15,3324,
amphotericin B 50 mg REC I,00013-1405-44,NDC,,,,inpatient,1,EA,366.25,219.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,296.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,311.31,percent of total billed charges,,,85,,311.31,percent of total billed charges,,,49,,179.46,percent of total billed charges,,,90,,329.63,percent of total billed charges,,,,,,,no IP contract,,80,,293,percent of total billed charges,,,,,,,no IP contract,,50,,183.13,percent of total billed charges,,,,,,no IP contract,,,78,,285.68,percent of total billed charges,,,70,,256.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,179.46,3324,
00013-5301-17 - rifabutin 150 mg Cap,00013-5301-17,NDC,,,,inpatient,1,EA,66.85,40.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,54.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.82,percent of total billed charges,,,85,,56.82,percent of total billed charges,,,49,,32.76,percent of total billed charges,,,90,,60.17,percent of total billed charges,,,,,,,no IP contract,,80,,53.48,percent of total billed charges,,,,,,,no IP contract,,50,,33.43,percent of total billed charges,,,,,,no IP contract,,,78,,52.14,percent of total billed charges,,,70,,46.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.76,3324,
00015-7981-20 - oxacillin 1 g REC I,00015-7981-20,NDC,,,,inpatient,1,EA,298.35,179.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,241.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,253.6,percent of total billed charges,,,85,,253.6,percent of total billed charges,,,49,,146.19,percent of total billed charges,,,90,,268.52,percent of total billed charges,,,,,,,no IP contract,,80,,238.68,percent of total billed charges,,,,,,,no IP contract,,50,,149.18,percent of total billed charges,,,,,,no IP contract,,,78,,232.71,percent of total billed charges,,,70,,208.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,146.19,3324,
00023-0240-04 - ocular lubricant - Ointm,00023-0240-04,NDC,,,,inpatient,1,UN,88.25,52.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,71.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,75.01,percent of total billed charges,,,85,,75.01,percent of total billed charges,,,49,,43.24,percent of total billed charges,,,90,,79.43,percent of total billed charges,,,,,,,no IP contract,,80,,70.6,percent of total billed charges,,,,,,,no IP contract,,50,,44.13,percent of total billed charges,,,,,,no IP contract,,,78,,68.84,percent of total billed charges,,,70,,61.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,43.24,3324,
00023-0506-01 - ocular lubricant - Soln,00023-0506-01,NDC,,,,inpatient,1,UN,11.9,7.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.12,percent of total billed charges,,,85,,10.12,percent of total billed charges,,,49,,5.83,percent of total billed charges,,,90,,10.71,percent of total billed charges,,,,,,,no IP contract,,80,,9.52,percent of total billed charges,,,,,,,no IP contract,,50,,5.95,percent of total billed charges,,,,,,no IP contract,,,78,,9.28,percent of total billed charges,,,70,,8.33,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.83,3324,
00023-0506-50 - ocular lubricant - Soln,00023-0506-50,NDC,,,,inpatient,1,UN,11.65,6.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.9,percent of total billed charges,,,85,,9.9,percent of total billed charges,,,49,,5.71,percent of total billed charges,,,90,,10.49,percent of total billed charges,,,,,,,no IP contract,,80,,9.32,percent of total billed charges,,,,,,,no IP contract,,50,,5.83,percent of total billed charges,,,,,,no IP contract,,,78,,9.09,percent of total billed charges,,,70,,8.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.71,3324,
ONAbotulinum toxin type A 100 units REC I,00023-1145-01,NDC,,,,inpatient,1,EA,2473.75,1484.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2003.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2102.69,percent of total billed charges,,,85,,2102.69,percent of total billed charges,,,49,,1212.14,percent of total billed charges,,,90,,2226.38,percent of total billed charges,,,,,,,no IP contract,,80,,1979,percent of total billed charges,,,,,,,no IP contract,,50,,1236.88,percent of total billed charges,,,,,,no IP contract,,,78,,1929.53,percent of total billed charges,,,70,,1731.63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
00023-3205-03 - bimatoprost ophthalmic 0.01% Soln,00023-3205-03,NDC,,,,inpatient,1,UN,1163.15,697.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,942.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,988.68,percent of total billed charges,,,85,,988.68,percent of total billed charges,,,49,,569.94,percent of total billed charges,,,90,,1046.84,percent of total billed charges,,,,,,,no IP contract,,80,,930.52,percent of total billed charges,,,,,,,no IP contract,,50,,581.58,percent of total billed charges,,,,,,no IP contract,,,78,,907.26,percent of total billed charges,,,70,,814.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,569.94,3324,
00023-3507-30 - ketorolac ophthalmic 0.45% Soln,00023-3507-30,NDC,,,,inpatient,1,UN,74.1,44.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,62.99,percent of total billed charges,,,85,,62.99,percent of total billed charges,,,49,,36.31,percent of total billed charges,,,90,,66.69,percent of total billed charges,,,,,,,no IP contract,,80,,59.28,percent of total billed charges,,,,,,,no IP contract,,50,,37.05,percent of total billed charges,,,,,,no IP contract,,,78,,57.8,percent of total billed charges,,,70,,51.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.31,3324,
00023-3513-60 - trospium 20 mg Tab,00023-3513-60,NDC,,,,inpatient,1,EA,20.5,12.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.43,percent of total billed charges,,,85,,17.43,percent of total billed charges,,,49,,10.05,percent of total billed charges,,,90,,18.45,percent of total billed charges,,,,,,,no IP contract,,80,,16.4,percent of total billed charges,,,,,,,no IP contract,,50,,10.25,percent of total billed charges,,,,,,no IP contract,,,78,,15.99,percent of total billed charges,,,70,,14.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.05,3324,
00023-4554-30 - ocular lubricant - Soln,00023-4554-30,NDC,,,,inpatient,1,UN,12.3,7.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.46,percent of total billed charges,,,85,,10.46,percent of total billed charges,,,49,,6.03,percent of total billed charges,,,90,,11.07,percent of total billed charges,,,,,,,no IP contract,,80,,9.84,percent of total billed charges,,,,,,,no IP contract,,50,,6.15,percent of total billed charges,,,,,,no IP contract,,,78,,9.59,percent of total billed charges,,,70,,8.61,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.03,3324,
00023-5853-18 - mesalamine DR [Delzicol] 400 mg DR Capsule,00023-5853-18,NDC,,,,inpatient,1,EA,34.65,20.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.45,percent of total billed charges,,,85,,29.45,percent of total billed charges,,,49,,16.98,percent of total billed charges,,,90,,31.19,percent of total billed charges,,,,,,,no IP contract,,80,,27.72,percent of total billed charges,,,,,,,no IP contract,,50,,17.33,percent of total billed charges,,,,,,no IP contract,,,78,,27.03,percent of total billed charges,,,70,,24.26,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.98,3324,
00023-5879-01 - vit. B Complex with C/folic acid/Biotin (nephro-vite Rx) - Tab,00023-5879-01,NDC,,,,inpatient,1,EA,6.95,4.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.91,percent of total billed charges,,,85,,5.91,percent of total billed charges,,,49,,3.41,percent of total billed charges,,,90,,6.26,percent of total billed charges,,,,,,,no IP contract,,80,,5.56,percent of total billed charges,,,,,,,no IP contract,,50,,3.48,percent of total billed charges,,,,,,no IP contract,,,78,,5.42,percent of total billed charges,,,70,,4.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.41,3324,
00023-9163-30 - cycloSPORINE 0.05% ophthal 1 drop(s) Drops,00023-9163-30,NDC,,,,inpatient,1,UN,63.95,38.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,51.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,54.36,percent of total billed charges,,,85,,54.36,percent of total billed charges,,,49,,31.34,percent of total billed charges,,,90,,57.56,percent of total billed charges,,,,,,,no IP contract,,80,,51.16,percent of total billed charges,,,,,,,no IP contract,,50,,31.98,percent of total billed charges,,,,,,no IP contract,,,78,,49.88,percent of total billed charges,,,70,,44.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.34,3324,
00023-9211-05 - brimonidine-timolol ophthalmic 0.2%-0.5% Soln,00023-9211-05,NDC,,,,inpatient,1,UN,1042.15,625.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,844.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,885.83,percent of total billed charges,,,85,,885.83,percent of total billed charges,,,49,,510.65,percent of total billed charges,,,90,,937.94,percent of total billed charges,,,,,,,no IP contract,,80,,833.72,percent of total billed charges,,,,,,,no IP contract,,50,,521.08,percent of total billed charges,,,,,,no IP contract,,,78,,812.88,percent of total billed charges,,,70,,729.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,510.65,3324,
00023-9321-10 - brimonidine ophthalmic 0.1% Soln,00023-9321-10,NDC,,,,inpatient,1,UN,945.95,567.57,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,766.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,804.06,percent of total billed charges,,,85,,804.06,percent of total billed charges,,,49,,463.52,percent of total billed charges,,,90,,851.36,percent of total billed charges,,,,,,,no IP contract,,80,,756.76,percent of total billed charges,,,,,,,no IP contract,,50,,472.98,percent of total billed charges,,,,,,no IP contract,,,78,,737.84,percent of total billed charges,,,70,,662.17,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,463.52,3324,
00024-4142-10 - dronedarone 400 mg Tab,00024-4142-10,NDC,,,,inpatient,1,EA,45.4,27.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,38.59,percent of total billed charges,,,85,,38.59,percent of total billed charges,,,49,,22.25,percent of total billed charges,,,90,,40.86,percent of total billed charges,,,,,,,no IP contract,,80,,36.32,percent of total billed charges,,,,,,,no IP contract,,50,,22.7,percent of total billed charges,,,,,,no IP contract,,,78,,35.41,percent of total billed charges,,,70,,31.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.25,3324,
00024-4142-60 - dronedarone 400 mg Tab,00024-4142-60,NDC,,,,inpatient,1,EA,45.4,27.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,38.59,percent of total billed charges,,,85,,38.59,percent of total billed charges,,,49,,22.25,percent of total billed charges,,,90,,40.86,percent of total billed charges,,,,,,,no IP contract,,80,,36.32,percent of total billed charges,,,,,,,no IP contract,,50,,22.7,percent of total billed charges,,,,,,no IP contract,,,78,,35.41,percent of total billed charges,,,70,,31.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.25,3324,
00024-5851-30 - irbesartan 150 mg Tab,00024-5851-30,NDC,,,,inpatient,1,EA,58.1,34.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,47.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,49.39,percent of total billed charges,,,85,,49.39,percent of total billed charges,,,49,,28.47,percent of total billed charges,,,90,,52.29,percent of total billed charges,,,,,,,no IP contract,,80,,46.48,percent of total billed charges,,,,,,,no IP contract,,50,,29.05,percent of total billed charges,,,,,,no IP contract,,,78,,45.32,percent of total billed charges,,,70,,40.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,28.47,3324,
00024-5926-05 - insulin lispro 100 units/mL Soln,00024-5926-05,NDC,,,,inpatient,1,ML,200.7,120.42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,162.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,170.6,percent of total billed charges,,,85,,170.6,percent of total billed charges,,,49,,98.34,percent of total billed charges,,,90,,180.63,percent of total billed charges,,,,,,,no IP contract,,80,,160.56,percent of total billed charges,,,,,,,no IP contract,,50,,100.35,percent of total billed charges,,,,,,no IP contract,,,78,,156.55,percent of total billed charges,,,70,,140.49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,98.34,3324,
00029-1526-11 - mupirocin topical 2% Ointm,00029-1526-11,NDC,,,,inpatient,1,EA,129.6,77.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,104.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,110.16,percent of total billed charges,,,85,,110.16,percent of total billed charges,,,49,,63.5,percent of total billed charges,,,90,,116.64,percent of total billed charges,,,,,,,no IP contract,,80,,103.68,percent of total billed charges,,,,,,,no IP contract,,50,,64.8,percent of total billed charges,,,,,,no IP contract,,,78,,101.09,percent of total billed charges,,,70,,90.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,63.5,3324,
00029-1527-25 - mupirocin Topical 2% Cream,00029-1527-25,NDC,,,,inpatient,1,UN,1208.75,725.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,979.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1027.44,percent of total billed charges,,,85,,1027.44,percent of total billed charges,,,49,,592.29,percent of total billed charges,,,90,,1087.88,percent of total billed charges,,,,,,,no IP contract,,80,,967,percent of total billed charges,,,,,,,no IP contract,,50,,604.38,percent of total billed charges,,,,,,no IP contract,,,78,,942.83,percent of total billed charges,,,70,,846.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,592.29,3324,
00029-6075-27 - amoxicillin-clavulanate 250 mg-125 mg Tab,00029-6075-27,NDC,,,,inpatient,1,EA,32.85,19.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,26.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,27.92,percent of total billed charges,,,85,,27.92,percent of total billed charges,,,49,,16.1,percent of total billed charges,,,90,,29.57,percent of total billed charges,,,,,,,no IP contract,,80,,26.28,percent of total billed charges,,,,,,,no IP contract,,50,,16.43,percent of total billed charges,,,,,,no IP contract,,,78,,25.62,percent of total billed charges,,,70,,23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.1,3324,
00029-6075-31 - amoxicillin-clavulanate 250 mg-125 mg Tab,00029-6075-31,NDC,,,,inpatient,1,EA,38.15,22.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.43,percent of total billed charges,,,85,,32.43,percent of total billed charges,,,49,,18.69,percent of total billed charges,,,90,,34.34,percent of total billed charges,,,,,,,no IP contract,,80,,30.52,percent of total billed charges,,,,,,,no IP contract,,50,,19.08,percent of total billed charges,,,,,,no IP contract,,,78,,29.76,percent of total billed charges,,,70,,26.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.69,3324,
"pancrelipase 60,000 units-12,000 units DR Capsule",00032-0047-70,NDC,,,,inpatient,1,EA,43.4,26.04,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,35.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36.89,percent of total billed charges,,,85,,36.89,percent of total billed charges,,,49,,21.27,percent of total billed charges,,,90,,39.06,percent of total billed charges,,,,,,,no IP contract,,80,,34.72,percent of total billed charges,,,,,,,no IP contract,,50,,21.7,percent of total billed charges,,,,,,no IP contract,,,78,,33.85,percent of total billed charges,,,70,,30.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.27,3324,
"00032-1206-01 - pancrelipase 6000 units-19,000 units-30,000 units DR Ca",00032-1206-01,NDC,,,,inpatient,1,EA,14.55,8.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.37,percent of total billed charges,,,85,,12.37,percent of total billed charges,,,49,,7.13,percent of total billed charges,,,90,,13.1,percent of total billed charges,,,,,,,no IP contract,,80,,11.64,percent of total billed charges,,,,,,,no IP contract,,50,,7.28,percent of total billed charges,,,,,,no IP contract,,,78,,11.35,percent of total billed charges,,,70,,10.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.13,3324,
"00032-1212-01 - pancrelipase 60,000 units-12,000 units-38,000 units DRC",00032-1212-01,NDC,,,,inpatient,1,EA,24.75,14.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.04,percent of total billed charges,,,85,,21.04,percent of total billed charges,,,49,,12.13,percent of total billed charges,,,90,,22.28,percent of total billed charges,,,,,,,no IP contract,,80,,19.8,percent of total billed charges,,,,,,,no IP contract,,50,,12.38,percent of total billed charges,,,,,,no IP contract,,,78,,19.31,percent of total billed charges,,,70,,17.33,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.13,3324,
"00032-1224-01 - pancrelipase 120,000 units-24,000 units-76,000 units DRC",00032-1224-01,NDC,,,,inpatient,1,EA,34.1,20.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.99,percent of total billed charges,,,85,,28.99,percent of total billed charges,,,49,,16.71,percent of total billed charges,,,90,,30.69,percent of total billed charges,,,,,,,no IP contract,,80,,27.28,percent of total billed charges,,,,,,,no IP contract,,50,,17.05,percent of total billed charges,,,,,,no IP contract,,,78,,26.6,percent of total billed charges,,,70,,23.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.71,3324,
00032-1924-82 - mesalamine 4 g/60 mL Enema,00032-1924-82,NDC,,,,inpatient,60,ML,161.25,96.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,130.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,137.06,percent of total billed charges,,,85,,137.06,percent of total billed charges,,,49,,79.01,percent of total billed charges,,,90,,145.13,percent of total billed charges,,,,,,,no IP contract,,80,,129,percent of total billed charges,,,,,,,no IP contract,,50,,80.63,percent of total billed charges,,,,,,no IP contract,,,78,,125.78,percent of total billed charges,,,70,,112.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,79.01,3324,
pancrelipase 24-76-120K units Cap,00032-2636-01,NDC,,,,inpatient,1,EA,82.35,49.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,66.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,70,percent of total billed charges,,,85,,70,percent of total billed charges,,,49,,40.35,percent of total billed charges,,,90,,74.12,percent of total billed charges,,,,,,,no IP contract,,80,,65.88,percent of total billed charges,,,,,,,no IP contract,,50,,41.18,percent of total billed charges,,,,,,no IP contract,,,78,,64.23,percent of total billed charges,,,70,,57.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,40.35,3324,
00037-0430-01 - felbamate 400 mg Tab,00037-0430-01,NDC,,,,inpatient,1,EA,48.1,28.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,38.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,40.89,percent of total billed charges,,,85,,40.89,percent of total billed charges,,,49,,23.57,percent of total billed charges,,,90,,43.29,percent of total billed charges,,,,,,,no IP contract,,80,,38.48,percent of total billed charges,,,,,,,no IP contract,,50,,24.05,percent of total billed charges,,,,,,no IP contract,,,78,,37.52,percent of total billed charges,,,70,,33.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.57,3324,
00037-6822-10 - hydrocortisone-pramoxine topical 1%-1% Foam,00037-6822-10,NDC,,,,inpatient,1,UN,930.8,558.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,753.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,791.18,percent of total billed charges,,,85,,791.18,percent of total billed charges,,,49,,456.09,percent of total billed charges,,,90,,837.72,percent of total billed charges,,,,,,,no IP contract,,80,,744.64,percent of total billed charges,,,,,,,no IP contract,,50,,465.4,percent of total billed charges,,,,,,no IP contract,,,78,,726.02,percent of total billed charges,,,70,,651.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,456.09,3324,
00037-6830-15 - hydrocortisone 10% Foam,00037-6830-15,NDC,,,,inpatient,1,UN,3640.95,2184.57,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2949.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3094.81,percent of total billed charges,,,85,,3094.81,percent of total billed charges,,,49,,1784.07,percent of total billed charges,,,90,,3276.86,percent of total billed charges,,,,,,,no IP contract,,80,,2912.76,percent of total billed charges,,,,,,,no IP contract,,50,,1820.48,percent of total billed charges,,,,,,no IP contract,,,78,,2839.94,percent of total billed charges,,,70,,2548.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
00039-0222-10 - glimepiride 2 mg Tab,00039-0222-10,NDC,,,,inpatient,1,EA,10.1,6.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.59,percent of total billed charges,,,85,,8.59,percent of total billed charges,,,49,,4.95,percent of total billed charges,,,90,,9.09,percent of total billed charges,,,,,,,no IP contract,,80,,8.08,percent of total billed charges,,,,,,,no IP contract,,50,,5.05,percent of total billed charges,,,,,,no IP contract,,,78,,7.88,percent of total billed charges,,,70,,7.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.95,3324,
00039-0223-10 - glimepiride 4 mg Tab,00039-0223-10,NDC,,,,inpatient,1,EA,15.6,9.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.26,percent of total billed charges,,,85,,13.26,percent of total billed charges,,,49,,7.64,percent of total billed charges,,,90,,14.04,percent of total billed charges,,,,,,,no IP contract,,80,,12.48,percent of total billed charges,,,,,,,no IP contract,,50,,7.8,percent of total billed charges,,,,,,no IP contract,,,78,,12.17,percent of total billed charges,,,70,,10.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.64,3324,
00045-0080-02 - lactase 3000 units Tab,00045-0080-02,NDC,,,,inpatient,1,EA,4.6,2.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.91,percent of total billed charges,,,85,,3.91,percent of total billed charges,,,49,,2.25,percent of total billed charges,,,90,,4.14,percent of total billed charges,,,,,,,no IP contract,,80,,3.68,percent of total billed charges,,,,,,,no IP contract,,50,,2.3,percent of total billed charges,,,,,,no IP contract,,,78,,3.59,percent of total billed charges,,,70,,3.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.25,3324,
00045-0485-32 - acetaminophen 80 mg Chew,00045-0485-32,NDC,,,,inpatient,1,EA,4.6,2.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.91,percent of total billed charges,,,85,,3.91,percent of total billed charges,,,49,,2.25,percent of total billed charges,,,90,,4.14,percent of total billed charges,,,,,,,no IP contract,,80,,3.68,percent of total billed charges,,,,,,,no IP contract,,50,,2.3,percent of total billed charges,,,,,,no IP contract,,,78,,3.59,percent of total billed charges,,,70,,3.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.25,3324,
00045-0641-65 - topiramate 100 mg Tab,00045-0641-65,NDC,,,,inpatient,1,EA,46.75,28.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,37.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,39.74,percent of total billed charges,,,85,,39.74,percent of total billed charges,,,49,,22.91,percent of total billed charges,,,90,,42.08,percent of total billed charges,,,,,,,no IP contract,,80,,37.4,percent of total billed charges,,,,,,,no IP contract,,50,,23.38,percent of total billed charges,,,,,,no IP contract,,,78,,36.47,percent of total billed charges,,,70,,32.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.91,3324,
00045-0645-65 - topiramate 25 mg Cap,00045-0645-65,NDC,,,,inpatient,1,EA,21.8,13.08,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.53,percent of total billed charges,,,85,,18.53,percent of total billed charges,,,49,,10.68,percent of total billed charges,,,90,,19.62,percent of total billed charges,,,,,,,no IP contract,,80,,17.44,percent of total billed charges,,,,,,,no IP contract,,50,,10.9,percent of total billed charges,,,,,,no IP contract,,,78,,17,percent of total billed charges,,,70,,15.26,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.68,3324,
00045-6321-01 - memantine 10 mg Tab,00045-6321-01,NDC,,,,inpatient,1,EA,26.65,15.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.65,percent of total billed charges,,,85,,22.65,percent of total billed charges,,,49,,13.06,percent of total billed charges,,,90,,23.99,percent of total billed charges,,,,,,,no IP contract,,80,,21.32,percent of total billed charges,,,,,,,no IP contract,,50,,13.33,percent of total billed charges,,,,,,no IP contract,,,78,,20.79,percent of total billed charges,,,70,,18.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.06,3324,
00046-0872-21 - conjugated estrogens topical 0.625 mg/g Cream,00046-0872-21,NDC,,,,inpatient,1,UN,1344.2,806.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1088.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1142.57,percent of total billed charges,,,85,,1142.57,percent of total billed charges,,,49,,658.66,percent of total billed charges,,,90,,1209.78,percent of total billed charges,,,,,,,no IP contract,,80,,1075.36,percent of total billed charges,,,,,,,no IP contract,,50,,672.1,percent of total billed charges,,,,,,no IP contract,,,78,,1048.48,percent of total billed charges,,,70,,940.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,658.66,3324,
"00049-0530-22 - penicillin G potassium 20,000,000 units REC I",00049-0530-22,NDC,,,,inpatient,20,ML,583.75,350.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,472.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,496.19,percent of total billed charges,,,85,,496.19,percent of total billed charges,,,49,,286.04,percent of total billed charges,,,90,,525.38,percent of total billed charges,,,,,,,no IP contract,,80,,467,percent of total billed charges,,,,,,,no IP contract,,50,,291.88,percent of total billed charges,,,,,,no IP contract,,,78,,455.33,percent of total billed charges,,,70,,408.63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,286.04,3324,
00049-1550-66 - glipiZIDE 5 mg ER Ta,00049-1550-66,NDC,,,,inpatient,1,EA,8.1,4.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.89,percent of total billed charges,,,85,,6.89,percent of total billed charges,,,49,,3.97,percent of total billed charges,,,90,,7.29,percent of total billed charges,,,,,,,no IP contract,,80,,6.48,percent of total billed charges,,,,,,,no IP contract,,50,,4.05,percent of total billed charges,,,,,,no IP contract,,,78,,6.32,percent of total billed charges,,,70,,5.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.97,3324,
00049-1620-30 - glipiZIDE 2.5 mg ER Tab,00049-1620-30,NDC,,,,inpatient,1,EA,8.1,4.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.89,percent of total billed charges,,,85,,6.89,percent of total billed charges,,,49,,3.97,percent of total billed charges,,,90,,7.29,percent of total billed charges,,,,,,,no IP contract,,80,,6.48,percent of total billed charges,,,,,,,no IP contract,,50,,4.05,percent of total billed charges,,,,,,no IP contract,,,78,,6.32,percent of total billed charges,,,70,,5.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.97,3324,
00049-2770-66 - doxazosin 4 mg Tab,00049-2770-66,NDC,,,,inpatient,1,EA,15.45,9.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.13,percent of total billed charges,,,85,,13.13,percent of total billed charges,,,49,,7.57,percent of total billed charges,,,90,,13.91,percent of total billed charges,,,,,,,no IP contract,,80,,12.36,percent of total billed charges,,,,,,,no IP contract,,50,,7.73,percent of total billed charges,,,,,,no IP contract,,,78,,12.05,percent of total billed charges,,,70,,10.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.57,3324,
00049-3160-44 - voriconazole 40 mg/mL REC P,00049-3160-44,NDC,,,,inpatient,1,ML,163.05,97.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,132.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,138.59,percent of total billed charges,,,85,,138.59,percent of total billed charges,,,49,,79.89,percent of total billed charges,,,90,,146.75,percent of total billed charges,,,,,,,no IP contract,,80,,130.44,percent of total billed charges,,,,,,,no IP contract,,50,,81.53,percent of total billed charges,,,,,,no IP contract,,,78,,127.18,percent of total billed charges,,,70,,114.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,79.89,3324,
fluconazole 40 mg/mL REC P,00049-3450-19,NDC,,,,inpatient,1,mL,13.4,8.04,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.39,percent of total billed charges,,,85,,11.39,percent of total billed charges,,,49,,6.57,percent of total billed charges,,,90,,12.06,percent of total billed charges,,,,,,,no IP contract,,80,,10.72,percent of total billed charges,,,,,,,no IP contract,,50,,6.7,percent of total billed charges,,,,,,no IP contract,,,78,,10.45,percent of total billed charges,,,70,,9.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.57,3324,
00049-3500-79 - fluconazole 150 mg Tab,00049-3500-79,NDC,,,,inpatient,1,EA,128.55,77.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,104.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,109.27,percent of total billed charges,,,85,,109.27,percent of total billed charges,,,49,,62.99,percent of total billed charges,,,90,,115.7,percent of total billed charges,,,,,,,no IP contract,,80,,102.84,percent of total billed charges,,,,,,,no IP contract,,50,,64.28,percent of total billed charges,,,,,,no IP contract,,,78,,100.27,percent of total billed charges,,,70,,89.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,62.99,3324,
00049-4120-66 - glipiZIDE 10 mg Tab,00049-4120-66,NDC,,,,inpatient,1,EA,11.85,7.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.07,percent of total billed charges,,,85,,10.07,percent of total billed charges,,,49,,5.81,percent of total billed charges,,,90,,10.67,percent of total billed charges,,,,,,,no IP contract,,80,,9.48,percent of total billed charges,,,,,,,no IP contract,,50,,5.93,percent of total billed charges,,,,,,no IP contract,,,78,,9.24,percent of total billed charges,,,70,,8.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.81,3324,
00049-4960-30 - sertraline 25 mg Tab,00049-4960-30,NDC,,,,inpatient,1,EA,27.85,16.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.67,percent of total billed charges,,,85,,23.67,percent of total billed charges,,,49,,13.65,percent of total billed charges,,,90,,25.07,percent of total billed charges,,,,,,,no IP contract,,80,,22.28,percent of total billed charges,,,,,,,no IP contract,,50,,13.93,percent of total billed charges,,,,,,no IP contract,,,78,,21.72,percent of total billed charges,,,70,,19.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.65,3324,
00051-0022-11 - dronabinol 5 mg Cap,00051-0022-11,NDC,,,,inpatient,1,EA,109.55,65.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,88.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,93.12,percent of total billed charges,,,85,,93.12,percent of total billed charges,,,49,,53.68,percent of total billed charges,,,90,,98.6,percent of total billed charges,,,,,,,no IP contract,,80,,87.64,percent of total billed charges,,,,,,,no IP contract,,50,,54.78,percent of total billed charges,,,,,,no IP contract,,,78,,85.45,percent of total billed charges,,,70,,76.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,53.68,3324,
00051-0022-21 - dronabinol 5 mg Cap,00051-0022-21,NDC,,,,inpatient,1,EA,118.95,71.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,96.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,101.11,percent of total billed charges,,,85,,101.11,percent of total billed charges,,,49,,58.29,percent of total billed charges,,,90,,107.06,percent of total billed charges,,,,,,,no IP contract,,80,,95.16,percent of total billed charges,,,,,,,no IP contract,,50,,59.48,percent of total billed charges,,,,,,no IP contract,,,78,,92.78,percent of total billed charges,,,70,,83.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.29,3324,
00054-0002-85 - fluconazole 10 mg/mL REC P,00054-0002-85,NDC,,,,inpatient,1,ML,14,8.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.9,percent of total billed charges,,,85,,11.9,percent of total billed charges,,,49,,6.86,percent of total billed charges,,,90,,12.6,percent of total billed charges,,,,,,,no IP contract,,80,,11.2,percent of total billed charges,,,,,,,no IP contract,,50,,7,percent of total billed charges,,,,,,no IP contract,,,78,,10.92,percent of total billed charges,,,70,,9.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.86,3324,
00054-0011-25 - flecainide 100 mg Tab,00054-0011-25,NDC,,,,inpatient,1,EA,25.55,15.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.72,percent of total billed charges,,,85,,21.72,percent of total billed charges,,,49,,12.52,percent of total billed charges,,,90,,23,percent of total billed charges,,,,,,,no IP contract,,80,,20.44,percent of total billed charges,,,,,,,no IP contract,,50,,12.78,percent of total billed charges,,,,,,no IP contract,,,78,,19.93,percent of total billed charges,,,70,,17.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.52,3324,
00054-0017-20 - predniSONE 10 mg Tab,00054-0017-20,NDC,,,,inpatient,1,EA,4.85,2.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.12,percent of total billed charges,,,85,,4.12,percent of total billed charges,,,49,,2.38,percent of total billed charges,,,90,,4.37,percent of total billed charges,,,,,,,no IP contract,,80,,3.88,percent of total billed charges,,,,,,,no IP contract,,50,,2.43,percent of total billed charges,,,,,,no IP contract,,,78,,3.78,percent of total billed charges,,,70,,3.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.38,3324,
00054-0017-25 - predniSONE 10 mg Tab,00054-0017-25,NDC,,,,inpatient,1,EA,4.3,2.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.66,percent of total billed charges,,,85,,3.66,percent of total billed charges,,,49,,2.11,percent of total billed charges,,,90,,3.87,percent of total billed charges,,,,,,,no IP contract,,80,,3.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.15,percent of total billed charges,,,,,,no IP contract,,,78,,3.35,percent of total billed charges,,,70,,3.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.11,3324,
00054-0018-20 - predniSONE 20 mg Tab,00054-0018-20,NDC,,,,inpatient,1,EA,5.2,3.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.42,percent of total billed charges,,,85,,4.42,percent of total billed charges,,,49,,2.55,percent of total billed charges,,,90,,4.68,percent of total billed charges,,,,,,,no IP contract,,80,,4.16,percent of total billed charges,,,,,,,no IP contract,,50,,2.6,percent of total billed charges,,,,,,no IP contract,,,78,,4.06,percent of total billed charges,,,70,,3.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.55,3324,
00054-0019-20 - predniSONE 50 mg Tab,00054-0019-20,NDC,,,,inpatient,1,EA,6.55,3.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.57,percent of total billed charges,,,85,,5.57,percent of total billed charges,,,49,,3.21,percent of total billed charges,,,90,,5.9,percent of total billed charges,,,,,,,no IP contract,,80,,5.24,percent of total billed charges,,,,,,,no IP contract,,50,,3.28,percent of total billed charges,,,,,,no IP contract,,,78,,5.11,percent of total billed charges,,,70,,4.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.21,3324,
00054-0019-25 - predniSONE 50 mg Tab,00054-0019-25,NDC,,,,inpatient,1,EA,6.3,3.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.36,percent of total billed charges,,,85,,5.36,percent of total billed charges,,,49,,3.09,percent of total billed charges,,,90,,5.67,percent of total billed charges,,,,,,,no IP contract,,80,,5.04,percent of total billed charges,,,,,,,no IP contract,,50,,3.15,percent of total billed charges,,,,,,no IP contract,,,78,,4.91,percent of total billed charges,,,70,,4.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.09,3324,
00054-0021-25 - lithium 300 mg ER Ta,00054-0021-25,NDC,,,,inpatient,1,EA,7.55,4.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.42,percent of total billed charges,,,85,,6.42,percent of total billed charges,,,49,,3.7,percent of total billed charges,,,90,,6.8,percent of total billed charges,,,,,,,no IP contract,,80,,6.04,percent of total billed charges,,,,,,,no IP contract,,50,,3.78,percent of total billed charges,,,,,,no IP contract,,,78,,5.89,percent of total billed charges,,,70,,5.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.7,3324,
00054-0044-21 - cilostazol 100 mg Tab,00054-0044-21,NDC,,,,inpatient,1,EA,18.3,10.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.56,percent of total billed charges,,,85,,15.56,percent of total billed charges,,,49,,8.97,percent of total billed charges,,,90,,16.47,percent of total billed charges,,,,,,,no IP contract,,80,,14.64,percent of total billed charges,,,,,,,no IP contract,,50,,9.15,percent of total billed charges,,,,,,no IP contract,,,78,,14.27,percent of total billed charges,,,70,,12.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.97,3324,
00054-0046-41 - ipratropium nasal 0.06% Spray,00054-0046-41,NDC,,,,inpatient,1,UN,379.1,227.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,307.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,322.24,percent of total billed charges,,,85,,322.24,percent of total billed charges,,,49,,185.76,percent of total billed charges,,,90,,341.19,percent of total billed charges,,,,,,,no IP contract,,80,,303.28,percent of total billed charges,,,,,,,no IP contract,,50,,189.55,percent of total billed charges,,,,,,no IP contract,,,78,,295.7,percent of total billed charges,,,70,,265.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,185.76,3324,
00054-0056-25 - pilocarpine 5 mg Tab,00054-0056-25,NDC,,,,inpatient,1,EA,15.9,9.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.52,percent of total billed charges,,,85,,13.52,percent of total billed charges,,,49,,7.79,percent of total billed charges,,,90,,14.31,percent of total billed charges,,,,,,,no IP contract,,80,,12.72,percent of total billed charges,,,,,,,no IP contract,,50,,7.95,percent of total billed charges,,,,,,no IP contract,,,78,,12.4,percent of total billed charges,,,70,,11.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.79,3324,
00054-0057-46 - digoxin 50 mcg/mL (0.05 mg/mL) Elixi,00054-0057-46,NDC,,,,inpatient,1,ML,11.85,7.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.07,percent of total billed charges,,,85,,10.07,percent of total billed charges,,,49,,5.81,percent of total billed charges,,,90,,10.67,percent of total billed charges,,,,,,,no IP contract,,80,,9.48,percent of total billed charges,,,,,,,no IP contract,,50,,5.93,percent of total billed charges,,,,,,no IP contract,,,78,,9.24,percent of total billed charges,,,70,,8.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.81,3324,
00054-0062-58 - citalopram 10 mg/5 mL Soln,00054-0062-58,NDC,,,,inpatient,1,ML,13.6,8.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.56,percent of total billed charges,,,85,,11.56,percent of total billed charges,,,49,,6.66,percent of total billed charges,,,90,,12.24,percent of total billed charges,,,,,,,no IP contract,,80,,10.88,percent of total billed charges,,,,,,,no IP contract,,50,,6.8,percent of total billed charges,,,,,,no IP contract,,,78,,10.61,percent of total billed charges,,,70,,9.52,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.66,3324,
00054-0063-44 - risperidone 1 mg/mL Soln,00054-0063-44,NDC,,,,inpatient,1,ML,52,31.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,42.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,44.2,percent of total billed charges,,,85,,44.2,percent of total billed charges,,,49,,25.48,percent of total billed charges,,,90,,46.8,percent of total billed charges,,,,,,,no IP contract,,80,,41.6,percent of total billed charges,,,,,,,no IP contract,,50,,26,percent of total billed charges,,,,,,no IP contract,,,78,,40.56,percent of total billed charges,,,70,,36.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.48,3324,
00054-0077-25 - torsemide 20 mg Tab,00054-0077-25,NDC,,,,inpatient,1,EA,10.8,6.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.18,percent of total billed charges,,,85,,9.18,percent of total billed charges,,,49,,5.29,percent of total billed charges,,,90,,9.72,percent of total billed charges,,,,,,,no IP contract,,80,,8.64,percent of total billed charges,,,,,,,no IP contract,,50,,5.4,percent of total billed charges,,,,,,no IP contract,,,78,,8.42,percent of total billed charges,,,70,,7.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.29,3324,
00054-0080-13 - exemestane 25 mg Tab,00054-0080-13,NDC,,,,inpatient,1,EA,164.65,98.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,133.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,139.95,percent of total billed charges,,,85,,139.95,percent of total billed charges,,,49,,80.68,percent of total billed charges,,,90,,148.19,percent of total billed charges,,,,,,,no IP contract,,80,,131.72,percent of total billed charges,,,,,,,no IP contract,,50,,82.33,percent of total billed charges,,,,,,no IP contract,,,78,,128.43,percent of total billed charges,,,70,,115.26,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,80.68,3324,
00054-0084-25 - zaleplon 5 mg Cap,00054-0084-25,NDC,,,,inpatient,1,EA,36.15,21.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.73,percent of total billed charges,,,85,,30.73,percent of total billed charges,,,49,,17.71,percent of total billed charges,,,90,,32.54,percent of total billed charges,,,,,,,no IP contract,,80,,28.92,percent of total billed charges,,,,,,,no IP contract,,50,,18.08,percent of total billed charges,,,,,,no IP contract,,,78,,28.2,percent of total billed charges,,,70,,25.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.71,3324,
00054-0088-26 - calcium acetate 667 mg Cap,00054-0088-26,NDC,,,,inpatient,1,EA,10.1,6.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.59,percent of total billed charges,,,85,,8.59,percent of total billed charges,,,49,,4.95,percent of total billed charges,,,90,,9.09,percent of total billed charges,,,,,,,no IP contract,,80,,8.08,percent of total billed charges,,,,,,,no IP contract,,50,,5.05,percent of total billed charges,,,,,,no IP contract,,,78,,7.88,percent of total billed charges,,,70,,7.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.95,3324,
00054-0107-20 - ramipril 2.5 mg Cap,00054-0107-20,NDC,,,,inpatient,1,EA,18.2,10.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.47,percent of total billed charges,,,85,,15.47,percent of total billed charges,,,49,,8.92,percent of total billed charges,,,90,,16.38,percent of total billed charges,,,,,,,no IP contract,,80,,14.56,percent of total billed charges,,,,,,,no IP contract,,50,,9.1,percent of total billed charges,,,,,,no IP contract,,,78,,14.2,percent of total billed charges,,,70,,12.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.92,3324,
00054-0108-20 - ramipril 5 mg Cap,00054-0108-20,NDC,,,,inpatient,1,EA,18.85,11.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.02,percent of total billed charges,,,85,,16.02,percent of total billed charges,,,49,,9.24,percent of total billed charges,,,90,,16.97,percent of total billed charges,,,,,,,no IP contract,,80,,15.08,percent of total billed charges,,,,,,,no IP contract,,50,,9.43,percent of total billed charges,,,,,,no IP contract,,,78,,14.7,percent of total billed charges,,,70,,13.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.24,3324,
00054-0235-24 - morphine sulfate 15 mg Tab,00054-0235-24,NDC,,,,inpatient,1,EA,8.1,4.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.89,percent of total billed charges,,,85,,6.89,percent of total billed charges,,,49,,3.97,percent of total billed charges,,,90,,7.29,percent of total billed charges,,,,,,,no IP contract,,80,,6.48,percent of total billed charges,,,,,,,no IP contract,,50,,4.05,percent of total billed charges,,,,,,no IP contract,,,78,,6.32,percent of total billed charges,,,70,,5.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.97,3324,
00054-0235-25 - morphine 15 mg Tab,00054-0235-25,NDC,,,,inpatient,1,EA,6.9,4.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.87,percent of total billed charges,,,85,,5.87,percent of total billed charges,,,49,,3.38,percent of total billed charges,,,90,,6.21,percent of total billed charges,,,,,,,no IP contract,,80,,5.52,percent of total billed charges,,,,,,,no IP contract,,50,,3.45,percent of total billed charges,,,,,,no IP contract,,,78,,5.38,percent of total billed charges,,,70,,4.83,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.38,3324,
00054-0237-63 - morphine 10 mg/5 ml Soln,00054-0237-63,NDC,,,,inpatient,1,ML,326.65,195.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,264.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,277.65,percent of total billed charges,,,85,,277.65,percent of total billed charges,,,49,,160.06,percent of total billed charges,,,90,,293.99,percent of total billed charges,,,,,,,no IP contract,,80,,261.32,percent of total billed charges,,,,,,,no IP contract,,50,,163.33,percent of total billed charges,,,,,,no IP contract,,,78,,254.79,percent of total billed charges,,,70,,228.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,160.06,3324,
00054-0244-25 - codeine sulfate 30 mg Tab,00054-0244-25,NDC,,,,inpatient,1,EA,9.35,5.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.95,percent of total billed charges,,,85,,7.95,percent of total billed charges,,,49,,4.58,percent of total billed charges,,,90,,8.42,percent of total billed charges,,,,,,,no IP contract,,80,,7.48,percent of total billed charges,,,,,,,no IP contract,,50,,4.68,percent of total billed charges,,,,,,no IP contract,,,78,,7.29,percent of total billed charges,,,70,,6.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.58,3324,
00054-0283-25 - oxymorphone 5 mg Tab,00054-0283-25,NDC,,,,inpatient,1,EA,30,18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.5,percent of total billed charges,,,85,,25.5,percent of total billed charges,,,49,,14.7,percent of total billed charges,,,90,,27,percent of total billed charges,,,,,,,no IP contract,,80,,24,percent of total billed charges,,,,,,,no IP contract,,50,,15,percent of total billed charges,,,,,,no IP contract,,,78,,23.4,percent of total billed charges,,,70,,21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.7,3324,
00054-0327-56 - fluticasone-salmeterol 250 mcg-50 mcg Powde,00054-0327-56,NDC,,,,inpatient,1,UN,881.55,528.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,714.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,749.32,percent of total billed charges,,,85,,749.32,percent of total billed charges,,,49,,431.96,percent of total billed charges,,,90,,793.4,percent of total billed charges,,,,,,,no IP contract,,80,,705.24,percent of total billed charges,,,,,,,no IP contract,,50,,440.78,percent of total billed charges,,,,,,no IP contract,,,78,,687.61,percent of total billed charges,,,70,,617.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,431.96,3324,
00054-0334-25 - cevimeline 30 mg Cap,00054-0334-25,NDC,,,,inpatient,1,EA,28.45,17.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.18,percent of total billed charges,,,85,,24.18,percent of total billed charges,,,49,,13.94,percent of total billed charges,,,90,,25.61,percent of total billed charges,,,,,,,no IP contract,,80,,22.76,percent of total billed charges,,,,,,,no IP contract,,50,,14.23,percent of total billed charges,,,,,,no IP contract,,,78,,22.19,percent of total billed charges,,,70,,19.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.94,3324,
00054-0379-51 - sodium polystyrene sulfonate 15 g/60 mL Susp,00054-0379-51,NDC,,,,inpatient,60,ML,75.4,45.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,61.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,64.09,percent of total billed charges,,,85,,64.09,percent of total billed charges,,,49,,36.95,percent of total billed charges,,,90,,67.86,percent of total billed charges,,,,,,,no IP contract,,80,,60.32,percent of total billed charges,,,,,,,no IP contract,,50,,37.7,percent of total billed charges,,,,,,no IP contract,,,78,,58.81,percent of total billed charges,,,70,,52.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.95,3324,
oxyCODONE 5 mg/5 mL Soln,00054-0390-63,NDC,,,,inpatient,1,mL,7.85,4.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.67,percent of total billed charges,,,85,,6.67,percent of total billed charges,,,49,,3.85,percent of total billed charges,,,90,,7.07,percent of total billed charges,,,,,,,no IP contract,,80,,6.28,percent of total billed charges,,,,,,,no IP contract,,50,,3.93,percent of total billed charges,,,,,,no IP contract,,,78,,6.12,percent of total billed charges,,,70,,5.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.85,3324,
00054-0400-13 - desvenlafaxine 50 mg ER Ta,00054-0400-13,NDC,,,,inpatient,1,EA,98.85,59.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,80.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,84.02,percent of total billed charges,,,85,,84.02,percent of total billed charges,,,49,,48.44,percent of total billed charges,,,90,,88.97,percent of total billed charges,,,,,,,no IP contract,,80,,79.08,percent of total billed charges,,,,,,,no IP contract,,50,,49.43,percent of total billed charges,,,,,,no IP contract,,,78,,77.1,percent of total billed charges,,,70,,69.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,48.44,3324,
00054-0404-44 - Morphine sulfate 100 mg / 5 mL Soln,00054-0404-44,NDC,,,,inpatient,0.1,ML,12.4,7.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.54,percent of total billed charges,,,85,,10.54,percent of total billed charges,,,49,,6.08,percent of total billed charges,,,90,,11.16,percent of total billed charges,,,,,,,no IP contract,,80,,9.92,percent of total billed charges,,,,,,,no IP contract,,50,,6.2,percent of total billed charges,,,,,,no IP contract,,,78,,9.67,percent of total billed charges,,,70,,8.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.08,3324,
00054-0407-13 - ritonavir 100 mg Tab,00054-0407-13,NDC,,,,inpatient,1,EA,77.45,46.47,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,62.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,65.83,percent of total billed charges,,,85,,65.83,percent of total billed charges,,,49,,37.95,percent of total billed charges,,,90,,69.71,percent of total billed charges,,,,,,,no IP contract,,80,,61.96,percent of total billed charges,,,,,,,no IP contract,,50,,38.73,percent of total billed charges,,,,,,no IP contract,,,78,,60.41,percent of total billed charges,,,70,,54.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,37.95,3324,
00054-0517-44 - morphine 20 mg/mL Conc,00054-0517-44,NDC,,,,inpatient,0.1,ML,12.4,7.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.54,percent of total billed charges,,,85,,10.54,percent of total billed charges,,,49,,6.08,percent of total billed charges,,,90,,11.16,percent of total billed charges,,,,,,,no IP contract,,80,,9.92,percent of total billed charges,,,,,,,no IP contract,,50,,6.2,percent of total billed charges,,,,,,no IP contract,,,78,,9.67,percent of total billed charges,,,70,,8.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.08,3324,
00054-0710-20 - methadone 10 mg Tab,00054-0710-20,NDC,,,,inpatient,1,EA,9.1,5.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.74,percent of total billed charges,,,85,,7.74,percent of total billed charges,,,49,,4.46,percent of total billed charges,,,90,,8.19,percent of total billed charges,,,,,,,no IP contract,,80,,7.28,percent of total billed charges,,,,,,,no IP contract,,50,,4.55,percent of total billed charges,,,,,,no IP contract,,,78,,7.1,percent of total billed charges,,,70,,6.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.46,3324,
00054-2526-25 - lithium 150 mg Cap,00054-2526-25,NDC,,,,inpatient,1,EA,4.95,2.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.21,percent of total billed charges,,,85,,4.21,percent of total billed charges,,,49,,2.43,percent of total billed charges,,,90,,4.46,percent of total billed charges,,,,,,,no IP contract,,80,,3.96,percent of total billed charges,,,,,,,no IP contract,,50,,2.48,percent of total billed charges,,,,,,no IP contract,,,78,,3.86,percent of total billed charges,,,70,,3.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.43,3324,
00054-3117-63 - calcium carbonate 1250 mg/5 mL Susp,00054-3117-63,NDC,,,,inpatient,1,ML,5.6,3.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.76,percent of total billed charges,,,85,,4.76,percent of total billed charges,,,49,,2.74,percent of total billed charges,,,90,,5.04,percent of total billed charges,,,,,,,no IP contract,,80,,4.48,percent of total billed charges,,,,,,,no IP contract,,50,,2.8,percent of total billed charges,,,,,,no IP contract,,,78,,4.37,percent of total billed charges,,,70,,3.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.74,3324,
00054-3120-41 - calcitriol 1 mcg/mL LIQ,00054-3120-41,NDC,,,,inpatient,1,ML,105.15,63.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,85.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,89.38,percent of total billed charges,,,85,,89.38,percent of total billed charges,,,49,,51.52,percent of total billed charges,,,90,,94.64,percent of total billed charges,,,,,,,no IP contract,,80,,84.12,percent of total billed charges,,,,,,,no IP contract,,50,,52.58,percent of total billed charges,,,,,,no IP contract,,,78,,82.02,percent of total billed charges,,,70,,73.61,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,51.52,3324,
00054-3176-44 - dexamethasone 1 mg/mL Conc,00054-3176-44,NDC,,,,inpatient,1,ML,12.65,7.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.75,percent of total billed charges,,,85,,10.75,percent of total billed charges,,,49,,6.2,percent of total billed charges,,,90,,11.39,percent of total billed charges,,,,,,,no IP contract,,80,,10.12,percent of total billed charges,,,,,,,no IP contract,,50,,6.33,percent of total billed charges,,,,,,no IP contract,,,78,,9.87,percent of total billed charges,,,70,,8.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.2,3324,
00054-3177-63 - dexamethasone 0.5 mg/5 mL LIQ,00054-3177-63,NDC,,,,inpatient,1,ML,5.85,3.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.97,percent of total billed charges,,,85,,4.97,percent of total billed charges,,,49,,2.87,percent of total billed charges,,,90,,5.27,percent of total billed charges,,,,,,,no IP contract,,80,,4.68,percent of total billed charges,,,,,,,no IP contract,,50,,2.93,percent of total billed charges,,,,,,no IP contract,,,78,,4.56,percent of total billed charges,,,70,,4.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.87,3324,
00054-3188-63 - diazepam 5 mg/5 mL Soln,00054-3188-63,NDC,,,,inpatient,1,ML,6.25,3.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.31,percent of total billed charges,,,85,,5.31,percent of total billed charges,,,49,,3.06,percent of total billed charges,,,90,,5.63,percent of total billed charges,,,,,,,no IP contract,,80,,5,percent of total billed charges,,,,,,,no IP contract,,50,,3.13,percent of total billed charges,,,,,,no IP contract,,,78,,4.88,percent of total billed charges,,,70,,4.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.06,3324,
00054-3270-99 - fluticasone nasal 0.05 mg/inh Spray,00054-3270-99,NDC,,,,inpatient,1,UN,635.65,381.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,514.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,540.3,percent of total billed charges,,,85,,540.3,percent of total billed charges,,,49,,311.47,percent of total billed charges,,,90,,572.09,percent of total billed charges,,,,,,,no IP contract,,80,,508.52,percent of total billed charges,,,,,,,no IP contract,,50,,317.83,percent of total billed charges,,,,,,no IP contract,,,78,,495.81,percent of total billed charges,,,70,,444.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,311.47,3324,
00054-3294-50 - furosemide 10 mg/mL LIQ,00054-3294-50,NDC,,,,inpatient,1,ML,6.85,4.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.82,percent of total billed charges,,,85,,5.82,percent of total billed charges,,,49,,3.36,percent of total billed charges,,,90,,6.17,percent of total billed charges,,,,,,,no IP contract,,80,,5.48,percent of total billed charges,,,,,,,no IP contract,,50,,3.43,percent of total billed charges,,,,,,no IP contract,,,78,,5.34,percent of total billed charges,,,70,,4.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.36,3324,
00054-3500-49 - lidocaine topical 2% Soln,00054-3500-49,NDC,,,,inpatient,15,ML,34.2,20.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.07,percent of total billed charges,,,85,,29.07,percent of total billed charges,,,49,,16.76,percent of total billed charges,,,90,,30.78,percent of total billed charges,,,,,,,no IP contract,,80,,27.36,percent of total billed charges,,,,,,,no IP contract,,50,,17.1,percent of total billed charges,,,,,,no IP contract,,,78,,26.68,percent of total billed charges,,,70,,23.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.76,3324,
00054-3532-44 - lorazepam 2 mg/mL Conc,00054-3532-44,NDC,,,,inpatient,1,ML,18.35,11.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.6,percent of total billed charges,,,85,,15.6,percent of total billed charges,,,49,,8.99,percent of total billed charges,,,90,,16.52,percent of total billed charges,,,,,,,no IP contract,,80,,14.68,percent of total billed charges,,,,,,,no IP contract,,50,,9.18,percent of total billed charges,,,,,,no IP contract,,,78,,14.31,percent of total billed charges,,,70,,12.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.99,3324,
00054-3542-58 - megestrol 40 mg/mL Susp,00054-3542-58,NDC,,,,inpatient,1,ML,10.4,6.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.84,percent of total billed charges,,,85,,8.84,percent of total billed charges,,,49,,5.1,percent of total billed charges,,,90,,9.36,percent of total billed charges,,,,,,,no IP contract,,80,,8.32,percent of total billed charges,,,,,,,no IP contract,,50,,5.2,percent of total billed charges,,,,,,no IP contract,,,78,,8.11,percent of total billed charges,,,70,,7.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.1,3324,
00054-3553-44 - methadone 10 mg/mL Conc,00054-3553-44,NDC,,,,inpatient,1,ML,12.5,7.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.63,percent of total billed charges,,,85,,10.63,percent of total billed charges,,,49,,6.13,percent of total billed charges,,,90,,11.25,percent of total billed charges,,,,,,,no IP contract,,80,,10,percent of total billed charges,,,,,,,no IP contract,,50,,6.25,percent of total billed charges,,,,,,no IP contract,,,78,,9.75,percent of total billed charges,,,70,,8.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.13,3324,
00054-3555-63 - methadone 5 mg/5 mL Soln,00054-3555-63,NDC,,,,inpatient,1,ML,6.1,3.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.19,percent of total billed charges,,,85,,5.19,percent of total billed charges,,,49,,2.99,percent of total billed charges,,,90,,5.49,percent of total billed charges,,,,,,,no IP contract,,80,,4.88,percent of total billed charges,,,,,,,no IP contract,,50,,3.05,percent of total billed charges,,,,,,no IP contract,,,78,,4.76,percent of total billed charges,,,70,,4.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.99,3324,
00054-3556-63 - methadone 10 mg/5 mL Soln,00054-3556-63,NDC,,,,inpatient,5,ML,6.5,3.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.53,percent of total billed charges,,,85,,5.53,percent of total billed charges,,,49,,3.19,percent of total billed charges,,,90,,5.85,percent of total billed charges,,,,,,,no IP contract,,80,,5.2,percent of total billed charges,,,,,,,no IP contract,,50,,3.25,percent of total billed charges,,,,,,no IP contract,,,78,,5.07,percent of total billed charges,,,70,,4.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.19,3324,
00054-3722-50 - predniSONE 5 mg/5 mL Soln,00054-3722-50,NDC,,,,inpatient,1,ML,7.25,4.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.16,percent of total billed charges,,,85,,6.16,percent of total billed charges,,,49,,3.55,percent of total billed charges,,,90,,6.53,percent of total billed charges,,,,,,,no IP contract,,80,,5.8,percent of total billed charges,,,,,,,no IP contract,,50,,3.63,percent of total billed charges,,,,,,no IP contract,,,78,,5.66,percent of total billed charges,,,70,,5.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.55,3324,
00054-3722-63 - predniSONE 5 mg/5 mL Soln,00054-3722-63,NDC,,,,inpatient,1,ML,7.25,4.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.16,percent of total billed charges,,,85,,6.16,percent of total billed charges,,,49,,3.55,percent of total billed charges,,,90,,6.53,percent of total billed charges,,,,,,,no IP contract,,80,,5.8,percent of total billed charges,,,,,,,no IP contract,,50,,3.63,percent of total billed charges,,,,,,no IP contract,,,78,,5.66,percent of total billed charges,,,70,,5.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.55,3324,
00054-3727-63 - propranolol 20 mg/5 mL Soln,00054-3727-63,NDC,,,,inpatient,1,ML,6.35,3.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.4,percent of total billed charges,,,85,,5.4,percent of total billed charges,,,49,,3.11,percent of total billed charges,,,90,,5.72,percent of total billed charges,,,,,,,no IP contract,,80,,5.08,percent of total billed charges,,,,,,,no IP contract,,50,,3.18,percent of total billed charges,,,,,,no IP contract,,,78,,4.95,percent of total billed charges,,,70,,4.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.11,3324,
00054-3785-63 - morphine 10 mg/5 mL Soln,00054-3785-63,NDC,,,,inpatient,1,ML,6.1,3.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.19,percent of total billed charges,,,85,,5.19,percent of total billed charges,,,49,,2.99,percent of total billed charges,,,90,,5.49,percent of total billed charges,,,,,,,no IP contract,,80,,4.88,percent of total billed charges,,,,,,,no IP contract,,50,,3.05,percent of total billed charges,,,,,,no IP contract,,,78,,4.76,percent of total billed charges,,,70,,4.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.99,3324,
00054-4146-22 - clotrimazole 10 mg Lozen,00054-4146-22,NDC,,,,inpatient,1,UN,16.6,9.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.11,percent of total billed charges,,,85,,14.11,percent of total billed charges,,,49,,8.13,percent of total billed charges,,,90,,14.94,percent of total billed charges,,,,,,,no IP contract,,80,,13.28,percent of total billed charges,,,,,,,no IP contract,,50,,8.3,percent of total billed charges,,,,,,no IP contract,,,78,,12.95,percent of total billed charges,,,70,,11.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.13,3324,
00054-4146-23 - clotrimazole 10 mg Lozen,00054-4146-23,NDC,,,,inpatient,1,UN,27.05,16.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.99,percent of total billed charges,,,85,,22.99,percent of total billed charges,,,49,,13.25,percent of total billed charges,,,90,,24.35,percent of total billed charges,,,,,,,no IP contract,,80,,21.64,percent of total billed charges,,,,,,,no IP contract,,50,,13.53,percent of total billed charges,,,,,,no IP contract,,,78,,21.1,percent of total billed charges,,,70,,18.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.25,3324,
00054-4179-25 - dexamethasone 0.5 mg Tab,00054-4179-25,NDC,,,,inpatient,1,EA,5.35,3.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.55,percent of total billed charges,,,85,,4.55,percent of total billed charges,,,49,,2.62,percent of total billed charges,,,90,,4.82,percent of total billed charges,,,,,,,no IP contract,,80,,4.28,percent of total billed charges,,,,,,,no IP contract,,50,,2.68,percent of total billed charges,,,,,,no IP contract,,,78,,4.17,percent of total billed charges,,,70,,3.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.62,3324,
00054-4181-25 - dexamethasone 1 mg Tab,00054-4181-25,NDC,,,,inpatient,1,EA,6.35,3.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.4,percent of total billed charges,,,85,,5.4,percent of total billed charges,,,49,,3.11,percent of total billed charges,,,90,,5.72,percent of total billed charges,,,,,,,no IP contract,,80,,5.08,percent of total billed charges,,,,,,,no IP contract,,50,,3.18,percent of total billed charges,,,,,,no IP contract,,,78,,4.95,percent of total billed charges,,,70,,4.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.11,3324,
00054-4182-25 - dexamethasone 1.5 mg Tab,00054-4182-25,NDC,,,,inpatient,1,EA,5.95,3.57,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.06,percent of total billed charges,,,85,,5.06,percent of total billed charges,,,49,,2.92,percent of total billed charges,,,90,,5.36,percent of total billed charges,,,,,,,no IP contract,,80,,4.76,percent of total billed charges,,,,,,,no IP contract,,50,,2.98,percent of total billed charges,,,,,,no IP contract,,,78,,4.64,percent of total billed charges,,,70,,4.17,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.92,3324,
furosemide 20 mg Tab,00054-4297-25,NDC,,,,inpatient,1,EA,7.25,4.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.16,percent of total billed charges,,,85,,6.16,percent of total billed charges,,,49,,3.55,percent of total billed charges,,,90,,6.53,percent of total billed charges,,,,,,,no IP contract,,80,,5.8,percent of total billed charges,,,,,,,no IP contract,,50,,3.63,percent of total billed charges,,,,,,no IP contract,,,78,,5.66,percent of total billed charges,,,70,,5.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.55,3324,
00054-4496-13 - leucovorin 5 mg Tab,00054-4496-13,NDC,,,,inpatient,1,EA,20.1,12.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.09,percent of total billed charges,,,85,,17.09,percent of total billed charges,,,49,,9.85,percent of total billed charges,,,90,,18.09,percent of total billed charges,,,,,,,no IP contract,,80,,16.08,percent of total billed charges,,,,,,,no IP contract,,50,,10.05,percent of total billed charges,,,,,,no IP contract,,,78,,15.68,percent of total billed charges,,,70,,14.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.85,3324,
00054-4496-25 - leucovorin 5 mg Tab,00054-4496-25,NDC,,,,inpatient,1,EA,19.95,11.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.96,percent of total billed charges,,,85,,16.96,percent of total billed charges,,,49,,9.78,percent of total billed charges,,,90,,17.96,percent of total billed charges,,,,,,,no IP contract,,80,,15.96,percent of total billed charges,,,,,,,no IP contract,,50,,9.98,percent of total billed charges,,,,,,no IP contract,,,78,,15.56,percent of total billed charges,,,70,,13.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.78,3324,
00054-4499-11 - leucovorin 25 mg Tab,00054-4499-11,NDC,,,,inpatient,1,EA,200.45,120.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,162.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,170.38,percent of total billed charges,,,85,,170.38,percent of total billed charges,,,49,,98.22,percent of total billed charges,,,90,,180.41,percent of total billed charges,,,,,,,no IP contract,,80,,160.36,percent of total billed charges,,,,,,,no IP contract,,50,,100.23,percent of total billed charges,,,,,,no IP contract,,,78,,156.35,percent of total billed charges,,,70,,140.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,98.22,3324,
00054-4581-11 - mercaptopurine 50 mg Tab,00054-4581-11,NDC,,,,inpatient,1,EA,34.05,20.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.94,percent of total billed charges,,,85,,28.94,percent of total billed charges,,,49,,16.68,percent of total billed charges,,,90,,30.65,percent of total billed charges,,,,,,,no IP contract,,80,,27.24,percent of total billed charges,,,,,,,no IP contract,,50,,17.03,percent of total billed charges,,,,,,no IP contract,,,78,,26.56,percent of total billed charges,,,70,,23.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.68,3324,
00054-4741-25 - predniSONE 1 mg Tab,00054-4741-25,NDC,,,,inpatient,1,EA,5.35,3.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.55,percent of total billed charges,,,85,,4.55,percent of total billed charges,,,49,,2.62,percent of total billed charges,,,90,,4.82,percent of total billed charges,,,,,,,no IP contract,,80,,4.28,percent of total billed charges,,,,,,,no IP contract,,50,,2.68,percent of total billed charges,,,,,,no IP contract,,,78,,4.17,percent of total billed charges,,,70,,3.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.62,3324,
00054-4859-25 - triazolam 0.25 mg Tab,00054-4859-25,NDC,,,,inpatient,1,EA,51.85,31.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,44.07,percent of total billed charges,,,85,,44.07,percent of total billed charges,,,49,,25.41,percent of total billed charges,,,90,,46.67,percent of total billed charges,,,,,,,no IP contract,,80,,41.48,percent of total billed charges,,,,,,,no IP contract,,50,,25.93,percent of total billed charges,,,,,,no IP contract,,,78,,40.44,percent of total billed charges,,,70,,36.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.41,3324,
00054-8084-25 - azathioprine 50 mg Tab,00054-8084-25,NDC,,,,inpatient,1,EA,15.25,9.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.96,percent of total billed charges,,,85,,12.96,percent of total billed charges,,,49,,7.47,percent of total billed charges,,,90,,13.73,percent of total billed charges,,,,,,,no IP contract,,80,,12.2,percent of total billed charges,,,,,,,no IP contract,,50,,7.63,percent of total billed charges,,,,,,no IP contract,,,78,,11.9,percent of total billed charges,,,70,,10.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.47,3324,
00054-8120-25 - calcium carbonate 1250 mg Tab,00054-8120-25,NDC,,,,inpatient,1,EA,6.85,4.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.82,percent of total billed charges,,,85,,5.82,percent of total billed charges,,,49,,3.36,percent of total billed charges,,,90,,6.17,percent of total billed charges,,,,,,,no IP contract,,80,,5.48,percent of total billed charges,,,,,,,no IP contract,,50,,3.43,percent of total billed charges,,,,,,no IP contract,,,78,,5.34,percent of total billed charges,,,70,,4.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.36,3324,
00054-8120-25 - calcium carbonate 1250 mg Tab,00054-8120-25,NDC,,,,inpatient,1,EA,6.85,4.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.82,percent of total billed charges,,,85,,5.82,percent of total billed charges,,,49,,3.36,percent of total billed charges,,,90,,6.17,percent of total billed charges,,,,,,,no IP contract,,80,,5.48,percent of total billed charges,,,,,,,no IP contract,,50,,3.43,percent of total billed charges,,,,,,no IP contract,,,78,,5.34,percent of total billed charges,,,70,,4.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.36,3324,
00054-8146-22 - clotrimazole 10 mg Lozen,00054-8146-22,NDC,,,,inpatient,1,UN,31.15,18.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,25.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.48,percent of total billed charges,,,85,,26.48,percent of total billed charges,,,49,,15.26,percent of total billed charges,,,90,,28.04,percent of total billed charges,,,,,,,no IP contract,,80,,24.92,percent of total billed charges,,,,,,,no IP contract,,50,,15.58,percent of total billed charges,,,,,,no IP contract,,,78,,24.3,percent of total billed charges,,,70,,21.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.26,3324,
00054-8156-24 - codeine sulfate 30 mg Tab,00054-8156-24,NDC,,,,inpatient,1,EA,9.75,5.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.29,percent of total billed charges,,,85,,8.29,percent of total billed charges,,,49,,4.78,percent of total billed charges,,,90,,8.78,percent of total billed charges,,,,,,,no IP contract,,80,,7.8,percent of total billed charges,,,,,,,no IP contract,,50,,4.88,percent of total billed charges,,,,,,no IP contract,,,78,,7.61,percent of total billed charges,,,70,,6.83,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.78,3324,
00054-8174-25 - dexamethasone 1 mg Tab,00054-8174-25,NDC,,,,inpatient,1,EA,6.55,3.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.57,percent of total billed charges,,,85,,5.57,percent of total billed charges,,,49,,3.21,percent of total billed charges,,,90,,5.9,percent of total billed charges,,,,,,,no IP contract,,80,,5.24,percent of total billed charges,,,,,,,no IP contract,,50,,3.28,percent of total billed charges,,,,,,no IP contract,,,78,,5.11,percent of total billed charges,,,70,,4.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.21,3324,
00054-8175-25 - dexamethasone 4 mg Tab,00054-8175-25,NDC,,,,inpatient,1,EA,8.75,5.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.44,percent of total billed charges,,,85,,7.44,percent of total billed charges,,,49,,4.29,percent of total billed charges,,,90,,7.88,percent of total billed charges,,,,,,,no IP contract,,80,,7,percent of total billed charges,,,,,,,no IP contract,,50,,4.38,percent of total billed charges,,,,,,no IP contract,,,78,,6.83,percent of total billed charges,,,70,,6.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.29,3324,
00054-8176-25 - dexamethasone 2 mg Tab,00054-8176-25,NDC,,,,inpatient,1,EA,9,5.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.65,percent of total billed charges,,,85,,7.65,percent of total billed charges,,,49,,4.41,percent of total billed charges,,,90,,8.1,percent of total billed charges,,,,,,,no IP contract,,80,,7.2,percent of total billed charges,,,,,,,no IP contract,,50,,4.5,percent of total billed charges,,,,,,no IP contract,,,78,,7.02,percent of total billed charges,,,70,,6.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.41,3324,
00054-8179-25 - dexamethasone 0.5 mg Tab,00054-8179-25,NDC,,,,inpatient,1,EA,5.75,3.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.89,percent of total billed charges,,,85,,4.89,percent of total billed charges,,,49,,2.82,percent of total billed charges,,,90,,5.18,percent of total billed charges,,,,,,,no IP contract,,80,,4.6,percent of total billed charges,,,,,,,no IP contract,,50,,2.88,percent of total billed charges,,,,,,no IP contract,,,78,,4.49,percent of total billed charges,,,70,,4.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.82,3324,
00054-8181-25 - dexamethasone 1.5 mg Tab,00054-8181-25,NDC,,,,inpatient,1,EA,6.35,3.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.4,percent of total billed charges,,,85,,5.4,percent of total billed charges,,,49,,3.11,percent of total billed charges,,,90,,5.72,percent of total billed charges,,,,,,,no IP contract,,80,,5.08,percent of total billed charges,,,,,,,no IP contract,,50,,3.18,percent of total billed charges,,,,,,no IP contract,,,78,,4.95,percent of total billed charges,,,70,,4.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.11,3324,
00054-8299-25 - furosemide 40 mg Tab,00054-8299-25,NDC,,,,inpatient,1,EA,5.4,3.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.59,percent of total billed charges,,,85,,4.59,percent of total billed charges,,,49,,2.65,percent of total billed charges,,,90,,4.86,percent of total billed charges,,,,,,,no IP contract,,80,,4.32,percent of total billed charges,,,,,,,no IP contract,,50,,2.7,percent of total billed charges,,,,,,no IP contract,,,78,,4.21,percent of total billed charges,,,70,,3.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.65,3324,
00054-8496-19 - leucovorin 5 mg Tab,00054-8496-19,NDC,,,,inpatient,1,EA,26.1,15.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.19,percent of total billed charges,,,85,,22.19,percent of total billed charges,,,49,,12.79,percent of total billed charges,,,90,,23.49,percent of total billed charges,,,,,,,no IP contract,,80,,20.88,percent of total billed charges,,,,,,,no IP contract,,50,,13.05,percent of total billed charges,,,,,,no IP contract,,,78,,20.36,percent of total billed charges,,,70,,18.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.79,3324,
00054-8526-25 - lithium 150 mg Cap,00054-8526-25,NDC,,,,inpatient,1,EA,5.35,3.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.55,percent of total billed charges,,,85,,4.55,percent of total billed charges,,,49,,2.62,percent of total billed charges,,,90,,4.82,percent of total billed charges,,,,,,,no IP contract,,80,,4.28,percent of total billed charges,,,,,,,no IP contract,,50,,2.68,percent of total billed charges,,,,,,no IP contract,,,78,,4.17,percent of total billed charges,,,70,,3.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.62,3324,
00054-8527-25 - lithium 300 mg Cap,00054-8527-25,NDC,,,,inpatient,1,EA,5.5,3.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.68,percent of total billed charges,,,85,,4.68,percent of total billed charges,,,49,,2.7,percent of total billed charges,,,90,,4.95,percent of total billed charges,,,,,,,no IP contract,,80,,4.4,percent of total billed charges,,,,,,,no IP contract,,50,,2.75,percent of total billed charges,,,,,,no IP contract,,,78,,4.29,percent of total billed charges,,,70,,3.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.7,3324,
00054-8550-25 - methotrexate 2.5 mg Tab,00054-8550-25,NDC,,,,inpatient,1,EA,31.95,19.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,25.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,27.16,percent of total billed charges,,,85,,27.16,percent of total billed charges,,,49,,15.66,percent of total billed charges,,,90,,28.76,percent of total billed charges,,,,,,,no IP contract,,80,,25.56,percent of total billed charges,,,,,,,no IP contract,,50,,15.98,percent of total billed charges,,,,,,no IP contract,,,78,,24.92,percent of total billed charges,,,70,,22.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.66,3324,
00054-8724-25 - predniSONE 5 mg Tab,00054-8724-25,NDC,,,,inpatient,1,EA,4.8,2.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.08,percent of total billed charges,,,85,,4.08,percent of total billed charges,,,49,,2.35,percent of total billed charges,,,90,,4.32,percent of total billed charges,,,,,,,no IP contract,,80,,3.84,percent of total billed charges,,,,,,,no IP contract,,50,,2.4,percent of total billed charges,,,,,,no IP contract,,,78,,3.74,percent of total billed charges,,,70,,3.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.35,3324,
00054-8739-25 - predniSONE 1 mg Tab,00054-8739-25,NDC,,,,inpatient,1,EA,5.65,3.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.8,percent of total billed charges,,,85,,4.8,percent of total billed charges,,,49,,2.77,percent of total billed charges,,,90,,5.09,percent of total billed charges,,,,,,,no IP contract,,80,,4.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.83,percent of total billed charges,,,,,,no IP contract,,,78,,4.41,percent of total billed charges,,,70,,3.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.77,3324,
00056-0168-75 - warfarin 4 mg Tab,00056-0168-75,NDC,,,,inpatient,1,EA,12.15,7.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.33,percent of total billed charges,,,85,,10.33,percent of total billed charges,,,49,,5.95,percent of total billed charges,,,90,,10.94,percent of total billed charges,,,,,,,no IP contract,,80,,9.72,percent of total billed charges,,,,,,,no IP contract,,50,,6.08,percent of total billed charges,,,,,,no IP contract,,,78,,9.48,percent of total billed charges,,,70,,8.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.95,3324,
00056-0169-01 - warfarin 1 mg Tab,00056-0169-01,NDC,,,,inpatient,1,EA,11.55,6.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.82,percent of total billed charges,,,85,,9.82,percent of total billed charges,,,49,,5.66,percent of total billed charges,,,90,,10.4,percent of total billed charges,,,,,,,no IP contract,,80,,9.24,percent of total billed charges,,,,,,,no IP contract,,50,,5.78,percent of total billed charges,,,,,,no IP contract,,,78,,9.01,percent of total billed charges,,,70,,8.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.66,3324,
00056-0169-70 - warfarin 1 mg Tab,00056-0169-70,NDC,,,,inpatient,1,EA,10.6,6.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.01,percent of total billed charges,,,85,,9.01,percent of total billed charges,,,49,,5.19,percent of total billed charges,,,90,,9.54,percent of total billed charges,,,,,,,no IP contract,,80,,8.48,percent of total billed charges,,,,,,,no IP contract,,50,,5.3,percent of total billed charges,,,,,,no IP contract,,,78,,8.27,percent of total billed charges,,,70,,7.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.19,3324,
00056-0169-75 - warfarin 1 mg Tab,00056-0169-75,NDC,,,,inpatient,1,EA,11.05,6.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.39,percent of total billed charges,,,85,,9.39,percent of total billed charges,,,49,,5.41,percent of total billed charges,,,90,,9.95,percent of total billed charges,,,,,,,no IP contract,,80,,8.84,percent of total billed charges,,,,,,,no IP contract,,50,,5.53,percent of total billed charges,,,,,,no IP contract,,,78,,8.62,percent of total billed charges,,,70,,7.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.41,3324,
00056-0172-01 - warfarin 5 mg Tab,00056-0172-01,NDC,,,,inpatient,1,EA,11.95,7.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.16,percent of total billed charges,,,85,,10.16,percent of total billed charges,,,49,,5.86,percent of total billed charges,,,90,,10.76,percent of total billed charges,,,,,,,no IP contract,,80,,9.56,percent of total billed charges,,,,,,,no IP contract,,50,,5.98,percent of total billed charges,,,,,,no IP contract,,,78,,9.32,percent of total billed charges,,,70,,8.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.86,3324,
00056-0172-70 - warfarin 5 mg Tab,00056-0172-70,NDC,,,,inpatient,1,EA,11.45,6.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.73,percent of total billed charges,,,85,,9.73,percent of total billed charges,,,49,,5.61,percent of total billed charges,,,90,,10.31,percent of total billed charges,,,,,,,no IP contract,,80,,9.16,percent of total billed charges,,,,,,,no IP contract,,50,,5.73,percent of total billed charges,,,,,,no IP contract,,,78,,8.93,percent of total billed charges,,,70,,8.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.61,3324,
00056-0172-75 - warfarin 5 mg Tab,00056-0172-75,NDC,,,,inpatient,1,EA,11.95,7.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.16,percent of total billed charges,,,85,,10.16,percent of total billed charges,,,49,,5.86,percent of total billed charges,,,90,,10.76,percent of total billed charges,,,,,,,no IP contract,,80,,9.56,percent of total billed charges,,,,,,,no IP contract,,50,,5.98,percent of total billed charges,,,,,,no IP contract,,,78,,9.32,percent of total billed charges,,,70,,8.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.86,3324,
00056-0173-70 - warfarin 7.5 mg Tab,00056-0173-70,NDC,,,,inpatient,1,EA,13.9,8.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.82,percent of total billed charges,,,85,,11.82,percent of total billed charges,,,49,,6.81,percent of total billed charges,,,90,,12.51,percent of total billed charges,,,,,,,no IP contract,,80,,11.12,percent of total billed charges,,,,,,,no IP contract,,50,,6.95,percent of total billed charges,,,,,,no IP contract,,,78,,10.84,percent of total billed charges,,,70,,9.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.81,3324,
00056-0173-75 - warfarin 7.5 mg Tab,00056-0173-75,NDC,,,,inpatient,1,EA,13.6,8.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.56,percent of total billed charges,,,85,,11.56,percent of total billed charges,,,49,,6.66,percent of total billed charges,,,90,,12.24,percent of total billed charges,,,,,,,no IP contract,,80,,10.88,percent of total billed charges,,,,,,,no IP contract,,50,,6.8,percent of total billed charges,,,,,,no IP contract,,,78,,10.61,percent of total billed charges,,,70,,9.52,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.66,3324,
00056-0174-70 - warfarin 10 mg Tab,00056-0174-70,NDC,,,,inpatient,1,EA,14.3,8.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.16,percent of total billed charges,,,85,,12.16,percent of total billed charges,,,49,,7.01,percent of total billed charges,,,90,,12.87,percent of total billed charges,,,,,,,no IP contract,,80,,11.44,percent of total billed charges,,,,,,,no IP contract,,50,,7.15,percent of total billed charges,,,,,,no IP contract,,,78,,11.15,percent of total billed charges,,,70,,10.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.01,3324,
00056-0174-75 - warfarin 10 mg Tab,00056-0174-75,NDC,,,,inpatient,1,EA,18.6,11.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.81,percent of total billed charges,,,85,,15.81,percent of total billed charges,,,49,,9.11,percent of total billed charges,,,90,,16.74,percent of total billed charges,,,,,,,no IP contract,,80,,14.88,percent of total billed charges,,,,,,,no IP contract,,50,,9.3,percent of total billed charges,,,,,,no IP contract,,,78,,14.51,percent of total billed charges,,,70,,13.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.11,3324,
00056-0510-30 - efavirenz 600 mg Tab,00056-0510-30,NDC,,,,inpatient,1,EA,141.45,84.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,114.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,120.23,percent of total billed charges,,,85,,120.23,percent of total billed charges,,,49,,69.31,percent of total billed charges,,,90,,127.31,percent of total billed charges,,,,,,,no IP contract,,80,,113.16,percent of total billed charges,,,,,,,no IP contract,,50,,70.73,percent of total billed charges,,,,,,no IP contract,,,78,,110.33,percent of total billed charges,,,70,,99.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,69.31,3324,
00056-0511-68 - carbidopa 25 mg Tab,00056-0511-68,NDC,,,,inpatient,1,EA,9.15,5.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.78,percent of total billed charges,,,85,,7.78,percent of total billed charges,,,49,,4.48,percent of total billed charges,,,90,,8.24,percent of total billed charges,,,,,,,no IP contract,,80,,7.32,percent of total billed charges,,,,,,,no IP contract,,50,,4.58,percent of total billed charges,,,,,,no IP contract,,,78,,7.14,percent of total billed charges,,,70,,6.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.48,3324,
00056-0601-68 - carbidopa-levodopa 25 mg-100 mg ER Tab,00056-0601-68,NDC,,,,inpatient,1,EA,12.5,7.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.63,percent of total billed charges,,,85,,10.63,percent of total billed charges,,,49,,6.13,percent of total billed charges,,,90,,11.25,percent of total billed charges,,,,,,,no IP contract,,80,,10,percent of total billed charges,,,,,,,no IP contract,,50,,6.25,percent of total billed charges,,,,,,no IP contract,,,78,,9.75,percent of total billed charges,,,70,,8.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.13,3324,
00056-0647-68 - carbidopa-levodopa 10 mg-100 mg Tab,00056-0647-68,NDC,,,,inpatient,1,EA,10.65,6.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.05,percent of total billed charges,,,85,,9.05,percent of total billed charges,,,49,,5.22,percent of total billed charges,,,90,,9.59,percent of total billed charges,,,,,,,no IP contract,,80,,8.52,percent of total billed charges,,,,,,,no IP contract,,50,,5.33,percent of total billed charges,,,,,,no IP contract,,,78,,8.31,percent of total billed charges,,,70,,7.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.22,3324,
00056-0654-68 - carbidopa-levodopa 25 mg-250 mg Tab,00056-0654-68,NDC,,,,inpatient,1,EA,13.7,8.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.65,percent of total billed charges,,,85,,11.65,percent of total billed charges,,,49,,6.71,percent of total billed charges,,,90,,12.33,percent of total billed charges,,,,,,,no IP contract,,80,,10.96,percent of total billed charges,,,,,,,no IP contract,,50,,6.85,percent of total billed charges,,,,,,no IP contract,,,78,,10.69,percent of total billed charges,,,70,,9.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.71,3324,
00062-5351-01 - terconazole topical 80 mg Supp,00062-5351-01,NDC,,,,inpatient,1,UN,441,264.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,357.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,374.85,percent of total billed charges,,,85,,374.85,percent of total billed charges,,,49,,216.09,percent of total billed charges,,,90,,396.9,percent of total billed charges,,,,,,,no IP contract,,80,,352.8,percent of total billed charges,,,,,,,no IP contract,,50,,220.5,percent of total billed charges,,,,,,no IP contract,,,78,,343.98,percent of total billed charges,,,70,,308.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,216.09,3324,
"00064-1000-01 - papain-urea Topical 830,000 units/g-10% Ointm",00064-1000-01,NDC,,,,inpatient,1,UN,464.05,278.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,375.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,394.44,percent of total billed charges,,,85,,394.44,percent of total billed charges,,,49,,227.38,percent of total billed charges,,,90,,417.65,percent of total billed charges,,,,,,,no IP contract,,80,,371.24,percent of total billed charges,,,,,,,no IP contract,,50,,232.03,percent of total billed charges,,,,,,no IP contract,,,78,,361.96,percent of total billed charges,,,70,,324.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,227.38,3324,
"00064-1000-07 - papain-urea Topical 830,000 units/g-10% Ointm",00064-1000-07,NDC,,,,inpatient,1,UN,131.2,78.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,106.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,111.52,percent of total billed charges,,,85,,111.52,percent of total billed charges,,,49,,64.29,percent of total billed charges,,,90,,118.08,percent of total billed charges,,,,,,,no IP contract,,80,,104.96,percent of total billed charges,,,,,,,no IP contract,,50,,65.6,percent of total billed charges,,,,,,no IP contract,,,78,,102.34,percent of total billed charges,,,70,,91.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,64.29,3324,
00064-1001-33 - papain-urea Topical 10%-10% Spray,00064-1001-33,NDC,,,,inpatient,1,UN,462.8,277.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,374.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,393.38,percent of total billed charges,,,85,,393.38,percent of total billed charges,,,49,,226.77,percent of total billed charges,,,90,,416.52,percent of total billed charges,,,,,,,no IP contract,,80,,370.24,percent of total billed charges,,,,,,,no IP contract,,50,,231.4,percent of total billed charges,,,,,,no IP contract,,,78,,360.98,percent of total billed charges,,,70,,323.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,226.77,3324,
00064-3510-33 - papain-urea Topical 0.5%-10%-10% Spray,00064-3510-33,NDC,,,,inpatient,1,UN,743.2,445.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,601.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,631.72,percent of total billed charges,,,85,,631.72,percent of total billed charges,,,49,,364.17,percent of total billed charges,,,90,,668.88,percent of total billed charges,,,,,,,no IP contract,,80,,594.56,percent of total billed charges,,,,,,,no IP contract,,50,,371.6,percent of total billed charges,,,,,,no IP contract,,,78,,579.7,percent of total billed charges,,,70,,520.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,364.17,3324,
00064-5010-30 - collagenase topical 250 units/g Ointm,00064-5010-30,NDC,,,,inpatient,1,UN,937.6,562.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,759.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,796.96,percent of total billed charges,,,85,,796.96,percent of total billed charges,,,49,,459.42,percent of total billed charges,,,90,,843.84,percent of total billed charges,,,,,,,no IP contract,,80,,750.08,percent of total billed charges,,,,,,,no IP contract,,50,,468.8,percent of total billed charges,,,,,,no IP contract,,,78,,731.33,percent of total billed charges,,,70,,656.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,459.42,3324,
00065-0275-10 - brinzolamide ophthalmic 1% Susp,00065-0275-10,NDC,,,,inpatient,1,UN,1608.6,965.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1302.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1367.31,percent of total billed charges,,,85,,1367.31,percent of total billed charges,,,49,,788.21,percent of total billed charges,,,90,,1447.74,percent of total billed charges,,,,,,,no IP contract,,80,,1286.88,percent of total billed charges,,,,,,,no IP contract,,50,,804.3,percent of total billed charges,,,,,,no IP contract,,,78,,1254.71,percent of total billed charges,,,70,,1126.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,788.21,3324,
00065-0303-55 - atropine ophthalmic 1% Soln,00065-0303-55,NDC,,,,inpatient,1,UN,476.1,285.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,385.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,404.69,percent of total billed charges,,,85,,404.69,percent of total billed charges,,,49,,233.29,percent of total billed charges,,,90,,428.49,percent of total billed charges,,,,,,,no IP contract,,80,,380.88,percent of total billed charges,,,,,,,no IP contract,,50,,238.05,percent of total billed charges,,,,,,no IP contract,,,78,,371.36,percent of total billed charges,,,70,,333.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,233.29,3324,
00065-0418-15 - ocular lubricant preserved Soln,00065-0418-15,NDC,,,,inpatient,1,UN,139.15,83.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,112.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,118.28,percent of total billed charges,,,85,,118.28,percent of total billed charges,,,49,,68.18,percent of total billed charges,,,90,,125.24,percent of total billed charges,,,,,,,no IP contract,,80,,111.32,percent of total billed charges,,,,,,,no IP contract,,50,,69.58,percent of total billed charges,,,,,,no IP contract,,,78,,108.54,percent of total billed charges,,,70,,97.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,68.18,3324,
00065-0426-36 - ocular lubricant preserved Soln,00065-0426-36,NDC,,,,inpatient,1,UN,69.2,41.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,56.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,58.82,percent of total billed charges,,,85,,58.82,percent of total billed charges,,,49,,33.91,percent of total billed charges,,,90,,62.28,percent of total billed charges,,,,,,,no IP contract,,80,,55.36,percent of total billed charges,,,,,,,no IP contract,,50,,34.6,percent of total billed charges,,,,,,no IP contract,,,78,,53.98,percent of total billed charges,,,70,,48.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,33.91,3324,
00065-0426-37 - ocular lubricant preserved Soln,00065-0426-37,NDC,,,,inpatient,1,UN,65.45,39.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,53.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,55.63,percent of total billed charges,,,85,,55.63,percent of total billed charges,,,49,,32.07,percent of total billed charges,,,90,,58.91,percent of total billed charges,,,,,,,no IP contract,,80,,52.36,percent of total billed charges,,,,,,,no IP contract,,50,,32.73,percent of total billed charges,,,,,,no IP contract,,,78,,51.05,percent of total billed charges,,,70,,45.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.07,3324,
00065-0474-01 - ocular lubricant - Gel,00065-0474-01,NDC,,,,inpatient,1,UN,99.2,59.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,80.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,84.32,percent of total billed charges,,,85,,84.32,percent of total billed charges,,,49,,48.61,percent of total billed charges,,,90,,89.28,percent of total billed charges,,,,,,,no IP contract,,80,,79.36,percent of total billed charges,,,,,,,no IP contract,,50,,49.6,percent of total billed charges,,,,,,no IP contract,,,78,,77.38,percent of total billed charges,,,70,,69.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,48.61,3324,
00065-0644-35 - tobramycin ophthalmic 0.3% Ointm,00065-0644-35,NDC,,,,inpatient,1,UN,873.65,524.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,707.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,742.6,percent of total billed charges,,,85,,742.6,percent of total billed charges,,,49,,428.09,percent of total billed charges,,,90,,786.29,percent of total billed charges,,,,,,,no IP contract,,80,,698.92,percent of total billed charges,,,,,,,no IP contract,,50,,436.83,percent of total billed charges,,,,,,no IP contract,,,78,,681.45,percent of total billed charges,,,70,,611.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,428.09,3324,
00065-0648-35 - dexamethasone-tobramycin ophthalmic 0.1%-0.3% Ointm,00065-0648-35,NDC,,,,inpatient,1,UN,676.6,405.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,548.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,575.11,percent of total billed charges,,,85,,575.11,percent of total billed charges,,,49,,331.53,percent of total billed charges,,,90,,608.94,percent of total billed charges,,,,,,,no IP contract,,80,,541.28,percent of total billed charges,,,,,,,no IP contract,,50,,338.3,percent of total billed charges,,,,,,no IP contract,,,78,,527.75,percent of total billed charges,,,70,,473.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,331.53,3324,
00065-0654-35 - ciprofloxacin ophthalmic 0.3% Ointm,00065-0654-35,NDC,,,,inpatient,1,UN,1331.1,798.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1078.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1131.44,percent of total billed charges,,,85,,1131.44,percent of total billed charges,,,49,,652.24,percent of total billed charges,,,90,,1197.99,percent of total billed charges,,,,,,,no IP contract,,80,,1064.88,percent of total billed charges,,,,,,,no IP contract,,50,,665.55,percent of total billed charges,,,,,,no IP contract,,,78,,1038.26,percent of total billed charges,,,70,,931.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,652.24,3324,
00065-0656-05 - ciprofloxacin ophthalmic 0.3% Soln,00065-0656-05,NDC,,,,inpatient,1,UN,485.3,291.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,393.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,412.51,percent of total billed charges,,,85,,412.51,percent of total billed charges,,,49,,237.8,percent of total billed charges,,,90,,436.77,percent of total billed charges,,,,,,,no IP contract,,80,,388.24,percent of total billed charges,,,,,,,no IP contract,,50,,242.65,percent of total billed charges,,,,,,no IP contract,,,78,,378.53,percent of total billed charges,,,70,,339.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,237.8,3324,
00065-0817-01 - atropine ophthalmic 1% Soln,00065-0817-01,NDC,,,,inpatient,1,UN,516.5,309.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,418.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,439.03,percent of total billed charges,,,85,,439.03,percent of total billed charges,,,49,,253.09,percent of total billed charges,,,90,,464.85,percent of total billed charges,,,,,,,no IP contract,,80,,413.2,percent of total billed charges,,,,,,,no IP contract,,50,,258.25,percent of total billed charges,,,,,,no IP contract,,,78,,402.87,percent of total billed charges,,,70,,361.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,253.09,3324,
00065-8064-01 - ocular lubricant - Gel,00065-8064-01,NDC,,,,inpatient,1,UN,74.2,44.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63.07,percent of total billed charges,,,85,,63.07,percent of total billed charges,,,49,,36.36,percent of total billed charges,,,90,,66.78,percent of total billed charges,,,,,,,no IP contract,,80,,59.36,percent of total billed charges,,,,,,,no IP contract,,50,,37.1,percent of total billed charges,,,,,,no IP contract,,,78,,57.88,percent of total billed charges,,,70,,51.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.36,3324,
00065-8533-02 - ciprofloxacin-dexamethasone otic 0.3%-0.1% Susp,00065-8533-02,NDC,,,,inpatient,1,UN,1600.45,960.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1296.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1360.38,percent of total billed charges,,,85,,1360.38,percent of total billed charges,,,49,,784.22,percent of total billed charges,,,90,,1440.41,percent of total billed charges,,,,,,,no IP contract,,80,,1280.36,percent of total billed charges,,,,,,,no IP contract,,50,,800.23,percent of total billed charges,,,,,,no IP contract,,,78,,1248.35,percent of total billed charges,,,70,,1120.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,784.22,3324,
00066-8008-02 - ciclopirox topical 8% Soln,00066-8008-02,NDC,,,,inpatient,1,UN,1456.8,874.08,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1180.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1238.28,percent of total billed charges,,,85,,1238.28,percent of total billed charges,,,49,,713.83,percent of total billed charges,,,90,,1311.12,percent of total billed charges,,,,,,,no IP contract,,80,,1165.44,percent of total billed charges,,,,,,,no IP contract,,50,,728.4,percent of total billed charges,,,,,,no IP contract,,,78,,1136.3,percent of total billed charges,,,70,,1019.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,713.83,3324,
00067-0042-48 -,00067-0042-48,NDC,,,,inpatient,1,UN,37.4,22.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.79,percent of total billed charges,,,85,,31.79,percent of total billed charges,,,49,,18.33,percent of total billed charges,,,90,,33.66,percent of total billed charges,,,,,,,no IP contract,,80,,29.92,percent of total billed charges,,,,,,,no IP contract,,50,,18.7,percent of total billed charges,,,,,,no IP contract,,,78,,29.17,percent of total billed charges,,,70,,26.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.33,3324,
wheat dextrin 100% REC P,00067-0044-38,NDC,,,,inpatient,1,GM,4.2,2.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.57,percent of total billed charges,,,85,,3.57,percent of total billed charges,,,49,,2.06,percent of total billed charges,,,90,,3.78,percent of total billed charges,,,,,,,no IP contract,,80,,3.36,percent of total billed charges,,,,,,,no IP contract,,50,,2.1,percent of total billed charges,,,,,,no IP contract,,,78,,3.28,percent of total billed charges,,,70,,2.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.06,3324,
00067-0047-36 -,00067-0047-36,NDC,,,,inpatient,1,EA,5,3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.25,percent of total billed charges,,,85,,4.25,percent of total billed charges,,,49,,2.45,percent of total billed charges,,,90,,4.5,percent of total billed charges,,,,,,,no IP contract,,80,,4,percent of total billed charges,,,,,,,no IP contract,,50,,2.5,percent of total billed charges,,,,,,no IP contract,,,78,,3.9,percent of total billed charges,,,70,,3.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.45,3324,
00067-3998-30 - terbinafine 1 app Cream,00067-3998-30,NDC,,,,inpatient,1,UN,93.25,55.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,75.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,79.26,percent of total billed charges,,,85,,79.26,percent of total billed charges,,,49,,45.69,percent of total billed charges,,,90,,83.93,percent of total billed charges,,,,,,,no IP contract,,80,,74.6,percent of total billed charges,,,,,,,no IP contract,,50,,46.63,percent of total billed charges,,,,,,no IP contract,,,78,,72.74,percent of total billed charges,,,70,,65.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,45.69,3324,
00068-0007-01 - desipramine 10 mg Tab,00068-0007-01,NDC,,,,inpatient,1,EA,9.65,5.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.2,percent of total billed charges,,,85,,8.2,percent of total billed charges,,,49,,4.73,percent of total billed charges,,,90,,8.69,percent of total billed charges,,,,,,,no IP contract,,80,,7.72,percent of total billed charges,,,,,,,no IP contract,,50,,4.83,percent of total billed charges,,,,,,no IP contract,,,78,,7.53,percent of total billed charges,,,70,,6.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.73,3324,
00068-0011-01 - desipramine 25 mg Tab,00068-0011-01,NDC,,,,inpatient,1,EA,10.8,6.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.18,percent of total billed charges,,,85,,9.18,percent of total billed charges,,,49,,5.29,percent of total billed charges,,,90,,9.72,percent of total billed charges,,,,,,,no IP contract,,80,,8.64,percent of total billed charges,,,,,,,no IP contract,,50,,5.4,percent of total billed charges,,,,,,no IP contract,,,78,,8.42,percent of total billed charges,,,70,,7.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.29,3324,
00068-0277-61 - methenamine hippurate 1 g Tab,00068-0277-61,NDC,,,,inpatient,1,EA,17.6,10.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.96,percent of total billed charges,,,85,,14.96,percent of total billed charges,,,49,,8.62,percent of total billed charges,,,90,,15.84,percent of total billed charges,,,,,,,no IP contract,,80,,14.08,percent of total billed charges,,,,,,,no IP contract,,50,,8.8,percent of total billed charges,,,,,,no IP contract,,,78,,13.73,percent of total billed charges,,,70,,12.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.62,3324,
00068-0510-30 - rifampin 150 mg Cap,00068-0510-30,NDC,,,,inpatient,1,EA,19,11.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.15,percent of total billed charges,,,85,,16.15,percent of total billed charges,,,49,,9.31,percent of total billed charges,,,90,,17.1,percent of total billed charges,,,,,,,no IP contract,,80,,15.2,percent of total billed charges,,,,,,,no IP contract,,50,,9.5,percent of total billed charges,,,,,,no IP contract,,,78,,14.82,percent of total billed charges,,,70,,13.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.31,3324,
00068-0597-01 - rifampin 600 mg REC Inj,00068-0597-01,NDC,,,,inpatient,10,ML,1782.75,1069.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1444.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1515.34,percent of total billed charges,,,85,,1515.34,percent of total billed charges,,,49,,873.55,percent of total billed charges,,,90,,1604.48,percent of total billed charges,,,,,,,no IP contract,,80,,1426.2,percent of total billed charges,,,,,,,no IP contract,,50,,891.38,percent of total billed charges,,,,,,no IP contract,,,78,,1390.55,percent of total billed charges,,,70,,1247.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,873.55,3324,
00068-0599-01 - rifAMPin 600 mg REC I,00068-0599-01,NDC,,,,inpatient,10,ML,1815.6,1089.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1470.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1543.26,percent of total billed charges,,,85,,1543.26,percent of total billed charges,,,49,,889.64,percent of total billed charges,,,90,,1634.04,percent of total billed charges,,,,,,,no IP contract,,80,,1452.48,percent of total billed charges,,,,,,,no IP contract,,50,,907.8,percent of total billed charges,,,,,,no IP contract,,,78,,1416.17,percent of total billed charges,,,70,,1270.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,889.64,3324,
"00069-0050-19 - insulin inhalation, rapid acting 1 mg and 3 mg Powde",00069-0050-19,NDC,,,,inpatient,1,EA,10.05,6.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.54,percent of total billed charges,,,85,,8.54,percent of total billed charges,,,49,,4.92,percent of total billed charges,,,90,,9.05,percent of total billed charges,,,,,,,no IP contract,,80,,8.04,percent of total billed charges,,,,,,,no IP contract,,50,,5.03,percent of total billed charges,,,,,,no IP contract,,,78,,7.84,percent of total billed charges,,,70,,7.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.92,3324,
"00069-0050-53 - insulin inhalation, rapid acting 1 mg and 3 mg Powde",00069-0050-53,NDC,,,,inpatient,1,EA,9,5.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.65,percent of total billed charges,,,85,,7.65,percent of total billed charges,,,49,,4.41,percent of total billed charges,,,90,,8.1,percent of total billed charges,,,,,,,no IP contract,,80,,7.2,percent of total billed charges,,,,,,,no IP contract,,50,,4.5,percent of total billed charges,,,,,,no IP contract,,,78,,7.02,percent of total billed charges,,,70,,6.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.41,3324,
00069-0058-01 - heparin 1000 units/mL Soln,00069-0058-01,NDC,,,,inpatient,10,ML,43.05,25.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36.59,percent of total billed charges,,,85,,36.59,percent of total billed charges,,,49,,21.09,percent of total billed charges,,,90,,38.75,percent of total billed charges,,,,,,,no IP contract,,80,,34.44,percent of total billed charges,,,,,,,no IP contract,,50,,21.53,percent of total billed charges,,,,,,no IP contract,,,78,,33.58,percent of total billed charges,,,70,,30.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.09,3324,
00069-0059-03 - heparin 5000 units/mL Soln,00069-0059-03,NDC,,,,inpatient,1,ML,45.75,27.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,37.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,38.89,percent of total billed charges,,,85,,38.89,percent of total billed charges,,,49,,22.42,percent of total billed charges,,,90,,41.18,percent of total billed charges,,,,,,,no IP contract,,80,,36.6,percent of total billed charges,,,,,,,no IP contract,,50,,22.88,percent of total billed charges,,,,,,no IP contract,,,78,,35.69,percent of total billed charges,,,70,,32.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.42,3324,
00069-0469-56 - varenicline 1 mg Tab,00069-0469-56,NDC,,,,inpatient,1,EA,18.45,11.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.68,percent of total billed charges,,,85,,15.68,percent of total billed charges,,,49,,9.04,percent of total billed charges,,,90,,16.61,percent of total billed charges,,,,,,,no IP contract,,80,,14.76,percent of total billed charges,,,,,,,no IP contract,,50,,9.23,percent of total billed charges,,,,,,no IP contract,,,78,,14.39,percent of total billed charges,,,70,,12.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.04,3324,
00069-1305-10 - epoetin alfa epbx 2000 units/mL preservative-free Soln,00069-1305-10,NDC,,,,inpatient,1,ML,232.45,139.47,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,188.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,197.58,percent of total billed charges,,,85,,197.58,percent of total billed charges,,,49,,113.9,percent of total billed charges,,,90,,209.21,percent of total billed charges,,,,,,,no IP contract,,80,,185.96,percent of total billed charges,,,,,,,no IP contract,,50,,116.23,percent of total billed charges,,,,,,no IP contract,,,78,,181.31,percent of total billed charges,,,70,,162.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,113.9,3324,
00069-1306-10 - epoetin alfa epbx 3000 units/mL preservative-free Soln,00069-1306-10,NDC,,,,inpatient,1,ML,344.1,206.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,278.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,292.49,percent of total billed charges,,,85,,292.49,percent of total billed charges,,,49,,168.61,percent of total billed charges,,,90,,309.69,percent of total billed charges,,,,,,,no IP contract,,80,,275.28,percent of total billed charges,,,,,,,no IP contract,,50,,172.05,percent of total billed charges,,,,,,no IP contract,,,78,,268.4,percent of total billed charges,,,70,,240.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,168.61,3324,
00069-1307-10 - epoetin alfa epbx 4000 units/mL preservative-free Soln,00069-1307-10,NDC,,,,inpatient,1,ML,455.6,273.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,369.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,387.26,percent of total billed charges,,,85,,387.26,percent of total billed charges,,,49,,223.24,percent of total billed charges,,,90,,410.04,percent of total billed charges,,,,,,,no IP contract,,80,,364.48,percent of total billed charges,,,,,,,no IP contract,,50,,227.8,percent of total billed charges,,,,,,no IP contract,,,78,,355.37,percent of total billed charges,,,70,,318.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,223.24,3324,
"00069-1308-10 - epoetin alfa epbx 10,000 units/mL preservative-free Soln",00069-1308-10,NDC,,,,inpatient,1,ML,1125.1,675.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,911.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,956.34,percent of total billed charges,,,85,,956.34,percent of total billed charges,,,49,,551.3,percent of total billed charges,,,90,,1012.59,percent of total billed charges,,,,,,,no IP contract,,80,,900.08,percent of total billed charges,,,,,,,no IP contract,,50,,562.55,percent of total billed charges,,,,,,no IP contract,,,78,,877.58,percent of total billed charges,,,70,,787.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,551.3,3324,
"00069-1309-04 - epoetin alfa epbx 40,000 units/mL preservative-free Soln",00069-1309-04,NDC,,,,inpatient,1,ML,4472.5,2683.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3622.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3801.63,percent of total billed charges,,,85,,3801.63,percent of total billed charges,,,49,,2191.53,percent of total billed charges,,,90,,4025.25,percent of total billed charges,,,,,,,no IP contract,,80,,3578,percent of total billed charges,,,,,,,no IP contract,,50,,2236.25,percent of total billed charges,,,,,,no IP contract,,,78,,3488.55,percent of total billed charges,,,70,,3130.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4025.25,
"epoetin alfa epbx 20,000 units/mL Soln",00069-1311-10,NDC,,,,inpatient,1,EA,2240.9,1344.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1815.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1904.77,percent of total billed charges,,,85,,1904.77,percent of total billed charges,,,49,,1098.04,percent of total billed charges,,,90,,2016.81,percent of total billed charges,,,,,,,no IP contract,,80,,1792.72,percent of total billed charges,,,,,,,no IP contract,,50,,1120.45,percent of total billed charges,,,,,,no IP contract,,,78,,1747.9,percent of total billed charges,,,70,,1568.63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
00071-0007-24 - phenytoin 50 mg Chew Tab,00071-0007-24,NDC,,,,inpatient,1,EA,6.45,3.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.48,percent of total billed charges,,,85,,5.48,percent of total billed charges,,,49,,3.16,percent of total billed charges,,,90,,5.81,percent of total billed charges,,,,,,,no IP contract,,80,,5.16,percent of total billed charges,,,,,,,no IP contract,,50,,3.23,percent of total billed charges,,,,,,no IP contract,,,78,,5.03,percent of total billed charges,,,70,,4.52,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.16,3324,
00071-0007-40 - phenytoin 50 mg Chew,00071-0007-40,NDC,,,,inpatient,1,EA,7.7,4.62,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.55,percent of total billed charges,,,85,,6.55,percent of total billed charges,,,49,,3.77,percent of total billed charges,,,90,,6.93,percent of total billed charges,,,,,,,no IP contract,,80,,6.16,percent of total billed charges,,,,,,,no IP contract,,50,,3.85,percent of total billed charges,,,,,,no IP contract,,,78,,6.01,percent of total billed charges,,,70,,5.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.77,3324,
00071-0362-40 - phenytoin 100 mg ER Cap,00071-0362-40,NDC,,,,inpatient,1,EA,7.1,4.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.04,percent of total billed charges,,,85,,6.04,percent of total billed charges,,,49,,3.48,percent of total billed charges,,,90,,6.39,percent of total billed charges,,,,,,,no IP contract,,80,,5.68,percent of total billed charges,,,,,,,no IP contract,,50,,3.55,percent of total billed charges,,,,,,no IP contract,,,78,,5.54,percent of total billed charges,,,70,,4.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.48,3324,
00071-0365-24 - phenytoin 30 mg ER Cap,00071-0365-24,NDC,,,,inpatient,1,EA,6.35,3.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.4,percent of total billed charges,,,85,,5.4,percent of total billed charges,,,49,,3.11,percent of total billed charges,,,90,,5.72,percent of total billed charges,,,,,,,no IP contract,,80,,5.08,percent of total billed charges,,,,,,,no IP contract,,50,,3.18,percent of total billed charges,,,,,,no IP contract,,,78,,4.95,percent of total billed charges,,,70,,4.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.11,3324,
00071-0418-13 - nitroglycerin 0.4 mg Tab,00071-0418-13,NDC,,,,inpatient,1,EA,57.5,34.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,46.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,48.88,percent of total billed charges,,,85,,48.88,percent of total billed charges,,,49,,28.18,percent of total billed charges,,,90,,51.75,percent of total billed charges,,,,,,,no IP contract,,80,,46,percent of total billed charges,,,,,,,no IP contract,,50,,28.75,percent of total billed charges,,,,,,no IP contract,,,78,,44.85,percent of total billed charges,,,70,,40.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,28.18,3324,
00071-0418-24 - nitroglycerin 0.4 mg Tab,00071-0418-24,NDC,,,,inpatient,1,EA,51.5,30.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,41.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,43.78,percent of total billed charges,,,85,,43.78,percent of total billed charges,,,49,,25.24,percent of total billed charges,,,90,,46.35,percent of total billed charges,,,,,,,no IP contract,,80,,41.2,percent of total billed charges,,,,,,,no IP contract,,50,,25.75,percent of total billed charges,,,,,,no IP contract,,,78,,40.17,percent of total billed charges,,,70,,36.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.24,3324,
00071-1012-68 - pregabalin 25 mg Cap,00071-1012-68,NDC,,,,inpatient,1,EA,49.5,29.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,40.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,42.08,percent of total billed charges,,,85,,42.08,percent of total billed charges,,,49,,24.26,percent of total billed charges,,,90,,44.55,percent of total billed charges,,,,,,,no IP contract,,80,,39.6,percent of total billed charges,,,,,,,no IP contract,,50,,24.75,percent of total billed charges,,,,,,no IP contract,,,78,,38.61,percent of total billed charges,,,70,,34.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.26,3324,
00071-1013-41 - pregabalin 50 mg Cap,00071-1013-41,NDC,,,,inpatient,1,EA,53.8,32.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,43.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,45.73,percent of total billed charges,,,85,,45.73,percent of total billed charges,,,49,,26.36,percent of total billed charges,,,90,,48.42,percent of total billed charges,,,,,,,no IP contract,,80,,43.04,percent of total billed charges,,,,,,,no IP contract,,50,,26.9,percent of total billed charges,,,,,,no IP contract,,,78,,41.96,percent of total billed charges,,,70,,37.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.36,3324,
00071-1014-41 - pregabalin 75 mg Cap,00071-1014-41,NDC,,,,inpatient,1,EA,50,30,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,40.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,42.5,percent of total billed charges,,,85,,42.5,percent of total billed charges,,,49,,24.5,percent of total billed charges,,,90,,45,percent of total billed charges,,,,,,,no IP contract,,80,,40,percent of total billed charges,,,,,,,no IP contract,,50,,25,percent of total billed charges,,,,,,no IP contract,,,78,,39,percent of total billed charges,,,70,,35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.5,3324,
00071-1014-68 - pregabalin 75 mg Cap,00071-1014-68,NDC,,,,inpatient,1,EA,45.9,27.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,37.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,39.02,percent of total billed charges,,,85,,39.02,percent of total billed charges,,,49,,22.49,percent of total billed charges,,,90,,41.31,percent of total billed charges,,,,,,,no IP contract,,80,,36.72,percent of total billed charges,,,,,,,no IP contract,,50,,22.95,percent of total billed charges,,,,,,no IP contract,,,78,,35.8,percent of total billed charges,,,70,,32.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.49,3324,
00071-1015-41 - pregabalin 100 mg Cap,00071-1015-41,NDC,,,,inpatient,1,EA,53.8,32.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,43.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,45.73,percent of total billed charges,,,85,,45.73,percent of total billed charges,,,49,,26.36,percent of total billed charges,,,90,,48.42,percent of total billed charges,,,,,,,no IP contract,,80,,43.04,percent of total billed charges,,,,,,,no IP contract,,50,,26.9,percent of total billed charges,,,,,,no IP contract,,,78,,41.96,percent of total billed charges,,,70,,37.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.36,3324,
00071-1015-68 - pregabalin 100 mg Cap,00071-1015-68,NDC,,,,inpatient,1,EA,49.5,29.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,40.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,42.08,percent of total billed charges,,,85,,42.08,percent of total billed charges,,,49,,24.26,percent of total billed charges,,,90,,44.55,percent of total billed charges,,,,,,,no IP contract,,80,,39.6,percent of total billed charges,,,,,,,no IP contract,,50,,24.75,percent of total billed charges,,,,,,no IP contract,,,78,,38.61,percent of total billed charges,,,70,,34.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.26,3324,
00071-1020-01 - pregabalin 20 mg/mL Soln,00071-1020-01,NDC,,,,inpatient,0.1,ML,18.15,10.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.43,percent of total billed charges,,,85,,15.43,percent of total billed charges,,,49,,8.89,percent of total billed charges,,,90,,16.34,percent of total billed charges,,,,,,,no IP contract,,80,,14.52,percent of total billed charges,,,,,,,no IP contract,,50,,9.08,percent of total billed charges,,,,,,no IP contract,,,78,,14.16,percent of total billed charges,,,70,,12.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.89,3324,
00071-3740-66 - phenytoin 30 mg ER Capsule,00071-3740-66,NDC,,,,inpatient,1,EA,7.7,4.62,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.55,percent of total billed charges,,,85,,6.55,percent of total billed charges,,,49,,3.77,percent of total billed charges,,,90,,6.93,percent of total billed charges,,,,,,,no IP contract,,80,,6.16,percent of total billed charges,,,,,,,no IP contract,,50,,3.85,percent of total billed charges,,,,,,no IP contract,,,78,,6.01,percent of total billed charges,,,70,,5.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.77,3324,
00072-2600-07 - salicylic acid-sulfur Topical 2%-2% Shamp,00072-2600-07,NDC,,,,inpatient,1,UN,92.5,55.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,74.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,78.63,percent of total billed charges,,,85,,78.63,percent of total billed charges,,,49,,45.33,percent of total billed charges,,,90,,83.25,percent of total billed charges,,,,,,,no IP contract,,80,,74,percent of total billed charges,,,,,,,no IP contract,,50,,46.25,percent of total billed charges,,,,,,no IP contract,,,78,,72.15,percent of total billed charges,,,70,,64.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,45.33,3324,
00074-1658-01 - paricalcitol 5 mcg/mL Soln,00074-1658-01,NDC,,,,inpatient,1,ML,255.5,153.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,206.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,217.18,percent of total billed charges,,,85,,217.18,percent of total billed charges,,,49,,125.2,percent of total billed charges,,,90,,229.95,percent of total billed charges,,,,,,,no IP contract,,80,,204.4,percent of total billed charges,,,,,,,no IP contract,,50,,127.75,percent of total billed charges,,,,,,no IP contract,,,78,,199.29,percent of total billed charges,,,70,,178.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,125.2,3324,
00074-3080-90 - niacin 1000 mg ER Ta,00074-3080-90,NDC,,,,inpatient,1,EA,37.2,22.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.62,percent of total billed charges,,,85,,31.62,percent of total billed charges,,,49,,18.23,percent of total billed charges,,,90,,33.48,percent of total billed charges,,,,,,,no IP contract,,80,,29.76,percent of total billed charges,,,,,,,no IP contract,,50,,18.6,percent of total billed charges,,,,,,no IP contract,,,78,,29.02,percent of total billed charges,,,70,,26.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.23,3324,
00074-3109-32 - cyclosporine (modified) [GenGRAF] 100 mg Cap,00074-3109-32,NDC,,,,inpatient,1,EA,70.55,42.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,57.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,59.97,percent of total billed charges,,,85,,59.97,percent of total billed charges,,,49,,34.57,percent of total billed charges,,,90,,63.5,percent of total billed charges,,,,,,,no IP contract,,80,,56.44,percent of total billed charges,,,,,,,no IP contract,,50,,35.28,percent of total billed charges,,,,,,no IP contract,,,78,,55.03,percent of total billed charges,,,70,,49.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,34.57,3324,
00074-3188-13 - clarithromycin 250 mg/5 mL REC Powder,00074-3188-13,NDC,,,,inpatient,1,ML,12.6,7.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.71,percent of total billed charges,,,85,,10.71,percent of total billed charges,,,49,,6.17,percent of total billed charges,,,90,,11.34,percent of total billed charges,,,,,,,no IP contract,,80,,10.08,percent of total billed charges,,,,,,,no IP contract,,50,,6.3,percent of total billed charges,,,,,,no IP contract,,,78,,9.83,percent of total billed charges,,,70,,8.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.17,3324,
00074-3333-30 - ritonavir 100 mg Tab,00074-3333-30,NDC,,,,inpatient,1,EA,85.65,51.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,69.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,72.8,percent of total billed charges,,,85,,72.8,percent of total billed charges,,,49,,41.97,percent of total billed charges,,,90,,77.09,percent of total billed charges,,,,,,,no IP contract,,80,,68.52,percent of total billed charges,,,,,,,no IP contract,,50,,42.83,percent of total billed charges,,,,,,no IP contract,,,78,,66.81,percent of total billed charges,,,70,,59.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,41.97,3324,
00074-3611-01 - potassium chloride 20 mEq REC P,00074-3611-01,NDC,,,,inpatient,1,UN,18.15,10.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.43,percent of total billed charges,,,85,,15.43,percent of total billed charges,,,49,,8.89,percent of total billed charges,,,90,,16.34,percent of total billed charges,,,,,,,no IP contract,,80,,14.52,percent of total billed charges,,,,,,,no IP contract,,50,,9.08,percent of total billed charges,,,,,,no IP contract,,,78,,14.16,percent of total billed charges,,,70,,12.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.89,3324,
00074-3795-01 - ketorolac 30 mg/mL Soln,00074-3795-01,NDC,,,,inpatient,1,ML,25.75,15.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.89,percent of total billed charges,,,85,,21.89,percent of total billed charges,,,49,,12.62,percent of total billed charges,,,90,,23.18,percent of total billed charges,,,,,,,no IP contract,,80,,20.6,percent of total billed charges,,,,,,,no IP contract,,50,,12.88,percent of total billed charges,,,,,,no IP contract,,,78,,20.09,percent of total billed charges,,,70,,18.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.62,3324,
00074-3959-77 - lopinavir-ritonavir 133.3 mg-33.3 mg Cap,00074-3959-77,NDC,,,,inpatient,1,EA,38.95,23.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.11,percent of total billed charges,,,85,,33.11,percent of total billed charges,,,49,,19.09,percent of total billed charges,,,90,,35.06,percent of total billed charges,,,,,,,no IP contract,,80,,31.16,percent of total billed charges,,,,,,,no IP contract,,50,,19.48,percent of total billed charges,,,,,,no IP contract,,,78,,30.38,percent of total billed charges,,,70,,27.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.09,3324,
00074-4552-90 - levothyroxine 50 mcg (0.05 mg) Tab,00074-4552-90,NDC,,,,inpatient,1,EA,13.2,7.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.22,percent of total billed charges,,,85,,11.22,percent of total billed charges,,,49,,6.47,percent of total billed charges,,,90,,11.88,percent of total billed charges,,,,,,,no IP contract,,80,,10.56,percent of total billed charges,,,,,,,no IP contract,,50,,6.6,percent of total billed charges,,,,,,no IP contract,,,78,,10.3,percent of total billed charges,,,70,,9.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.47,3324,
00074-6123-90 - fenofibrate 145 mg Tab,00074-6123-90,NDC,,,,inpatient,1,EA,51.6,30.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,41.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,43.86,percent of total billed charges,,,85,,43.86,percent of total billed charges,,,49,,25.28,percent of total billed charges,,,90,,46.44,percent of total billed charges,,,,,,,no IP contract,,80,,41.28,percent of total billed charges,,,,,,,no IP contract,,50,,25.8,percent of total billed charges,,,,,,no IP contract,,,78,,40.25,percent of total billed charges,,,70,,36.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.28,3324,
00074-6463-32 - cycloSPORINE modified 25 mg Cap,00074-6463-32,NDC,,,,inpatient,1,EA,15.35,9.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.05,percent of total billed charges,,,85,,13.05,percent of total billed charges,,,49,,7.52,percent of total billed charges,,,90,,13.82,percent of total billed charges,,,,,,,no IP contract,,80,,12.28,percent of total billed charges,,,,,,,no IP contract,,50,,7.68,percent of total billed charges,,,,,,no IP contract,,,78,,11.97,percent of total billed charges,,,70,,10.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.52,3324,
00074-6594-90 - levothyroxine 88 mcg (0.088 mg) Tab,00074-6594-90,NDC,,,,inpatient,1,EA,12,7.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.2,percent of total billed charges,,,85,,10.2,percent of total billed charges,,,49,,5.88,percent of total billed charges,,,90,,10.8,percent of total billed charges,,,,,,,no IP contract,,80,,9.6,percent of total billed charges,,,,,,,no IP contract,,50,,6,percent of total billed charges,,,,,,no IP contract,,,78,,9.36,percent of total billed charges,,,70,,8.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.88,3324,
00074-6624-11 - levothyroxine 100 mcg (0.1 mg) Tab,00074-6624-11,NDC,,,,inpatient,1,EA,8.65,5.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.35,percent of total billed charges,,,85,,7.35,percent of total billed charges,,,49,,4.24,percent of total billed charges,,,90,,7.79,percent of total billed charges,,,,,,,no IP contract,,80,,6.92,percent of total billed charges,,,,,,,no IP contract,,50,,4.33,percent of total billed charges,,,,,,no IP contract,,,78,,6.75,percent of total billed charges,,,70,,6.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.24,3324,
00074-6799-22 - lopinavir-ritonavir 200 mg-50 mg Tab,00074-6799-22,NDC,,,,inpatient,1,EA,61.55,36.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,49.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,52.32,percent of total billed charges,,,85,,52.32,percent of total billed charges,,,49,,30.16,percent of total billed charges,,,90,,55.4,percent of total billed charges,,,,,,,no IP contract,,80,,49.24,percent of total billed charges,,,,,,,no IP contract,,50,,30.78,percent of total billed charges,,,,,,no IP contract,,,78,,48.01,percent of total billed charges,,,70,,43.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,30.16,3324,
00074-7068-11 - levothyroxine 125 mcg (0.125 mg) Tab,00074-7068-11,NDC,,,,inpatient,1,EA,15.35,9.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.05,percent of total billed charges,,,85,,13.05,percent of total billed charges,,,49,,7.52,percent of total billed charges,,,90,,13.82,percent of total billed charges,,,,,,,no IP contract,,80,,12.28,percent of total billed charges,,,,,,,no IP contract,,50,,7.68,percent of total billed charges,,,,,,no IP contract,,,78,,11.97,percent of total billed charges,,,70,,10.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.52,3324,
00074-7148-11 - levothyroxine 200 mcg (0.2 mg) Tab,00074-7148-11,NDC,,,,inpatient,1,EA,10.05,6.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.54,percent of total billed charges,,,85,,8.54,percent of total billed charges,,,49,,4.92,percent of total billed charges,,,90,,9.05,percent of total billed charges,,,,,,,no IP contract,,80,,8.04,percent of total billed charges,,,,,,,no IP contract,,50,,5.03,percent of total billed charges,,,,,,no IP contract,,,78,,7.84,percent of total billed charges,,,70,,7.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.92,3324,
00074-7362-01 - carbamide peroxide otic 6.5% Soln,00074-7362-01,NDC,,,,inpatient,5,UN,59.2,35.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,47.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,50.32,percent of total billed charges,,,85,,50.32,percent of total billed charges,,,49,,29.01,percent of total billed charges,,,90,,53.28,percent of total billed charges,,,,,,,no IP contract,,80,,47.36,percent of total billed charges,,,,,,,no IP contract,,50,,29.6,percent of total billed charges,,,,,,no IP contract,,,78,,46.18,percent of total billed charges,,,70,,41.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,29.01,3324,
00074-7362-03 - carbamide peroxide otic 6.5% Soln,00074-7362-03,NDC,,,,inpatient,5,UN,54.2,32.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,43.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,46.07,percent of total billed charges,,,85,,46.07,percent of total billed charges,,,49,,26.56,percent of total billed charges,,,90,,48.78,percent of total billed charges,,,,,,,no IP contract,,80,,43.36,percent of total billed charges,,,,,,,no IP contract,,50,,27.1,percent of total billed charges,,,,,,no IP contract,,,78,,42.28,percent of total billed charges,,,70,,37.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.56,3324,
00075-0620-40 - enoxaparin 40 mg/0.4 mL Soln,00075-0620-40,NDC,,,,inpatient,0.4,ML,343.9,206.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,278.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,292.32,percent of total billed charges,,,85,,292.32,percent of total billed charges,,,49,,168.51,percent of total billed charges,,,90,,309.51,percent of total billed charges,,,,,,,no IP contract,,80,,275.12,percent of total billed charges,,,,,,,no IP contract,,50,,171.95,percent of total billed charges,,,,,,no IP contract,,,78,,268.24,percent of total billed charges,,,70,,240.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,168.51,3324,
00075-0621-60 - enoxaparin 60 mg/0.6 mL Soln,00075-0621-60,NDC,,,,inpatient,0.6,ML,511.85,307.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,414.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,435.07,percent of total billed charges,,,85,,435.07,percent of total billed charges,,,49,,250.81,percent of total billed charges,,,90,,460.67,percent of total billed charges,,,,,,,no IP contract,,80,,409.48,percent of total billed charges,,,,,,,no IP contract,,50,,255.93,percent of total billed charges,,,,,,no IP contract,,,78,,399.24,percent of total billed charges,,,70,,358.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,250.81,3324,
00075-0622-80 - enoxaparin 80 mg/0.8 mL Soln,00075-0622-80,NDC,,,,inpatient,0.8,ML,679.35,407.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,550.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,577.45,percent of total billed charges,,,85,,577.45,percent of total billed charges,,,49,,332.88,percent of total billed charges,,,90,,611.42,percent of total billed charges,,,,,,,no IP contract,,80,,543.48,percent of total billed charges,,,,,,,no IP contract,,50,,339.68,percent of total billed charges,,,,,,no IP contract,,,78,,529.89,percent of total billed charges,,,70,,475.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,332.88,3324,
enoxaparin 100 mg/mL Soln,00075-0623-00,NDC,,,,inpatient,1,EA,846.75,508.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,685.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,719.74,percent of total billed charges,,,85,,719.74,percent of total billed charges,,,49,,414.91,percent of total billed charges,,,90,,762.08,percent of total billed charges,,,,,,,no IP contract,,80,,677.4,percent of total billed charges,,,,,,,no IP contract,,50,,423.38,percent of total billed charges,,,,,,no IP contract,,,78,,660.47,percent of total billed charges,,,70,,592.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,414.91,3324,
00075-0626-03 - enoxaparin 100 mg/mL Soln,00075-0626-03,NDC,,,,inpatient,0.01,ML,17.7,10.62,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.05,percent of total billed charges,,,85,,15.05,percent of total billed charges,,,49,,8.67,percent of total billed charges,,,90,,15.93,percent of total billed charges,,,,,,,no IP contract,,80,,14.16,percent of total billed charges,,,,,,,no IP contract,,50,,8.85,percent of total billed charges,,,,,,no IP contract,,,78,,13.81,percent of total billed charges,,,70,,12.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.67,3324,
enoxaparin 150 mg/mL Soln,00075-2915-01,NDC,,,,inpatient,1,EA,1266.15,759.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1025.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1076.23,percent of total billed charges,,,85,,1076.23,percent of total billed charges,,,49,,620.41,percent of total billed charges,,,90,,1139.54,percent of total billed charges,,,,,,,no IP contract,,80,,1012.92,percent of total billed charges,,,,,,,no IP contract,,50,,633.08,percent of total billed charges,,,,,,no IP contract,,,78,,987.6,percent of total billed charges,,,70,,886.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,620.41,3324,
00078-0180-01 - octreotide 50 mcg/mL Soln,00078-0180-01,NDC,,,,inpatient,1,ML,113.95,68.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,92.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,96.86,percent of total billed charges,,,85,,96.86,percent of total billed charges,,,49,,55.84,percent of total billed charges,,,90,,102.56,percent of total billed charges,,,,,,,no IP contract,,80,,91.16,percent of total billed charges,,,,,,,no IP contract,,50,,56.98,percent of total billed charges,,,,,,no IP contract,,,78,,88.88,percent of total billed charges,,,70,,79.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,55.84,3324,
00078-0246-15 - cycloSPORINE microemulsion 25 mg Cap,00078-0246-15,NDC,,,,inpatient,1,EA,16,9.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.6,percent of total billed charges,,,85,,13.6,percent of total billed charges,,,49,,7.84,percent of total billed charges,,,90,,14.4,percent of total billed charges,,,,,,,no IP contract,,80,,12.8,percent of total billed charges,,,,,,,no IP contract,,50,,8,percent of total billed charges,,,,,,no IP contract,,,78,,12.48,percent of total billed charges,,,70,,11.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.84,3324,
00078-0246-61 - cycloSPORINE 25 mg Cap,00078-0246-61,NDC,,,,inpatient,1,EA,368.4,221.04,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,298.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,313.14,percent of total billed charges,,,85,,313.14,percent of total billed charges,,,49,,180.52,percent of total billed charges,,,90,,331.56,percent of total billed charges,,,,,,,no IP contract,,80,,294.72,percent of total billed charges,,,,,,,no IP contract,,50,,184.2,percent of total billed charges,,,,,,no IP contract,,,78,,287.35,percent of total billed charges,,,70,,257.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,180.52,3324,
cycloSPORINE modified 100 mg Cap,00078-0248-15,NDC,,,,inpatient,1,EA,52.4,31.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,42.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,44.54,percent of total billed charges,,,85,,44.54,percent of total billed charges,,,49,,25.68,percent of total billed charges,,,90,,47.16,percent of total billed charges,,,,,,,no IP contract,,80,,41.92,percent of total billed charges,,,,,,,no IP contract,,50,,26.2,percent of total billed charges,,,,,,no IP contract,,,78,,40.87,percent of total billed charges,,,70,,36.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.68,3324,
00078-0274-22 - cycloSPORINE microemulsion 100 mg/mL LIQ,00078-0274-22,NDC,,,,inpatient,1,ML,72.9,43.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,59.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,61.97,percent of total billed charges,,,85,,61.97,percent of total billed charges,,,49,,35.72,percent of total billed charges,,,90,,65.61,percent of total billed charges,,,,,,,no IP contract,,80,,58.32,percent of total billed charges,,,,,,,no IP contract,,50,,36.45,percent of total billed charges,,,,,,no IP contract,,,78,,56.86,percent of total billed charges,,,70,,51.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,35.72,3324,
00078-0320-05 - potassium chloride 8 mEq ER Tab,00078-0320-05,NDC,,,,inpatient,1,EA,5.8,3.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.93,percent of total billed charges,,,85,,4.93,percent of total billed charges,,,49,,2.84,percent of total billed charges,,,90,,5.22,percent of total billed charges,,,,,,,no IP contract,,80,,4.64,percent of total billed charges,,,,,,,no IP contract,,50,,2.9,percent of total billed charges,,,,,,no IP contract,,,78,,4.52,percent of total billed charges,,,70,,4.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.84,3324,
00078-0336-05 - oxcarbazepine 150 mg Tab,00078-0336-05,NDC,,,,inpatient,1,EA,14.95,8.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.71,percent of total billed charges,,,85,,12.71,percent of total billed charges,,,49,,7.33,percent of total billed charges,,,90,,13.46,percent of total billed charges,,,,,,,no IP contract,,80,,11.96,percent of total billed charges,,,,,,,no IP contract,,50,,7.48,percent of total billed charges,,,,,,no IP contract,,,78,,11.66,percent of total billed charges,,,70,,10.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.33,3324,
00078-0339-31 - rivastigmine 2 mg/mL Soln,00078-0339-31,NDC,,,,inpatient,1,ML,37.25,22.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.66,percent of total billed charges,,,85,,31.66,percent of total billed charges,,,49,,18.25,percent of total billed charges,,,90,,33.53,percent of total billed charges,,,,,,,no IP contract,,80,,29.8,percent of total billed charges,,,,,,,no IP contract,,50,,18.63,percent of total billed charges,,,,,,no IP contract,,,78,,29.06,percent of total billed charges,,,70,,26.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.25,3324,
00078-0347-51 - deferoxamine 2 g REC Inj,00078-0347-51,NDC,,,,inpatient,20,ML,763.05,457.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,618.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,648.59,percent of total billed charges,,,85,,648.59,percent of total billed charges,,,49,,373.89,percent of total billed charges,,,90,,686.75,percent of total billed charges,,,,,,,no IP contract,,80,,610.44,percent of total billed charges,,,,,,,no IP contract,,50,,381.53,percent of total billed charges,,,,,,no IP contract,,,78,,595.18,percent of total billed charges,,,70,,534.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,373.89,3324,
00078-0356-80 - tegaserod 6 mg Tab,00078-0356-80,NDC,,,,inpatient,1,EA,27.2,16.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.12,percent of total billed charges,,,85,,23.12,percent of total billed charges,,,49,,13.33,percent of total billed charges,,,90,,24.48,percent of total billed charges,,,,,,,no IP contract,,80,,21.76,percent of total billed charges,,,,,,,no IP contract,,50,,13.6,percent of total billed charges,,,,,,no IP contract,,,78,,21.22,percent of total billed charges,,,70,,19.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.33,3324,
00078-0358-06 - valsartan 80 mg Tab,00078-0358-06,NDC,,,,inpatient,1,EA,33.3,19.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,26.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.31,percent of total billed charges,,,85,,28.31,percent of total billed charges,,,49,,16.32,percent of total billed charges,,,90,,29.97,percent of total billed charges,,,,,,,no IP contract,,80,,26.64,percent of total billed charges,,,,,,,no IP contract,,50,,16.65,percent of total billed charges,,,,,,no IP contract,,,78,,25.97,percent of total billed charges,,,70,,23.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.32,3324,
00078-0358-34 - valsartan 80 mg Tab,00078-0358-34,NDC,,,,inpatient,1,EA,19.8,11.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.83,percent of total billed charges,,,85,,16.83,percent of total billed charges,,,49,,9.7,percent of total billed charges,,,90,,17.82,percent of total billed charges,,,,,,,no IP contract,,80,,15.84,percent of total billed charges,,,,,,,no IP contract,,50,,9.9,percent of total billed charges,,,,,,no IP contract,,,78,,15.44,percent of total billed charges,,,70,,13.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.7,3324,
00078-0359-06 - valsartan 160 mg Tab,00078-0359-06,NDC,,,,inpatient,1,EA,35.55,21.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.22,percent of total billed charges,,,85,,30.22,percent of total billed charges,,,49,,17.42,percent of total billed charges,,,90,,32,percent of total billed charges,,,,,,,no IP contract,,80,,28.44,percent of total billed charges,,,,,,,no IP contract,,50,,17.78,percent of total billed charges,,,,,,no IP contract,,,78,,27.73,percent of total billed charges,,,70,,24.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.42,3324,
00078-0359-34 - valsartan 160 mg Tab,00078-0359-34,NDC,,,,inpatient,1,EA,35.55,21.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.22,percent of total billed charges,,,85,,30.22,percent of total billed charges,,,49,,17.42,percent of total billed charges,,,90,,32,percent of total billed charges,,,,,,,no IP contract,,80,,28.44,percent of total billed charges,,,,,,,no IP contract,,50,,17.78,percent of total billed charges,,,,,,no IP contract,,,78,,27.73,percent of total billed charges,,,70,,24.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.42,3324,
00078-0370-05 - methylphenidate 20 mg/24 hr ER Ca,00078-0370-05,NDC,,,,inpatient,1,EA,31.15,18.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,25.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.48,percent of total billed charges,,,85,,26.48,percent of total billed charges,,,49,,15.26,percent of total billed charges,,,90,,28.04,percent of total billed charges,,,,,,,no IP contract,,80,,24.92,percent of total billed charges,,,,,,,no IP contract,,50,,15.58,percent of total billed charges,,,,,,no IP contract,,,78,,24.3,percent of total billed charges,,,70,,21.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.26,3324,
00078-0407-05 - carbidopa/entacapone/levodopa 12.5 mg-200 mg-50 mg Tab,00078-0407-05,NDC,,,,inpatient,1,EA,23.7,14.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.15,percent of total billed charges,,,85,,20.15,percent of total billed charges,,,49,,11.61,percent of total billed charges,,,90,,21.33,percent of total billed charges,,,,,,,no IP contract,,80,,18.96,percent of total billed charges,,,,,,,no IP contract,,50,,11.85,percent of total billed charges,,,,,,no IP contract,,,78,,18.49,percent of total billed charges,,,70,,16.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.61,3324,
00078-0408-05 - carbidopa/entacapone/levodopa 25 mg-200 mg-100 mg Tab,00078-0408-05,NDC,,,,inpatient,1,EA,3.2,1.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2.72,percent of total billed charges,,,85,,2.72,percent of total billed charges,,,49,,1.57,percent of total billed charges,,,90,,2.88,percent of total billed charges,,,,,,,no IP contract,,80,,2.56,percent of total billed charges,,,,,,,no IP contract,,50,,1.6,percent of total billed charges,,,,,,no IP contract,,,78,,2.5,percent of total billed charges,,,70,,2.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.57,3324,
00078-0409-05 - carbidopa/entacapone/levodopa 37.5 mg-200 mg-150 mg Tab,00078-0409-05,NDC,,,,inpatient,1,EA,23.7,14.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.15,percent of total billed charges,,,85,,20.15,percent of total billed charges,,,49,,11.61,percent of total billed charges,,,90,,21.33,percent of total billed charges,,,,,,,no IP contract,,80,,18.96,percent of total billed charges,,,,,,,no IP contract,,50,,11.85,percent of total billed charges,,,,,,no IP contract,,,78,,18.49,percent of total billed charges,,,70,,16.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.61,3324,
00078-0415-20 - everolimus 0.75 mg Tab,00078-0415-20,NDC,,,,inpatient,1,EA,173,103.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,140.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,147.05,percent of total billed charges,,,85,,147.05,percent of total billed charges,,,49,,84.77,percent of total billed charges,,,90,,155.7,percent of total billed charges,,,,,,,no IP contract,,80,,138.4,percent of total billed charges,,,,,,,no IP contract,,50,,86.5,percent of total billed charges,,,,,,no IP contract,,,78,,134.94,percent of total billed charges,,,70,,121.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,84.77,3324,
00078-0417-20 - everolimus 0.25 mg Tab,00078-0417-20,NDC,,,,inpatient,1,EA,55.5,33.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,44.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,47.18,percent of total billed charges,,,85,,47.18,percent of total billed charges,,,49,,27.2,percent of total billed charges,,,90,,49.95,percent of total billed charges,,,,,,,no IP contract,,80,,44.4,percent of total billed charges,,,,,,,no IP contract,,50,,27.75,percent of total billed charges,,,,,,no IP contract,,,78,,43.29,percent of total billed charges,,,70,,38.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.2,3324,
00078-0423-15 - valsartan 40 mg Tab,00078-0423-15,NDC,,,,inpatient,1,EA,17.2,10.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.62,percent of total billed charges,,,85,,14.62,percent of total billed charges,,,49,,8.43,percent of total billed charges,,,90,,15.48,percent of total billed charges,,,,,,,no IP contract,,80,,13.76,percent of total billed charges,,,,,,,no IP contract,,50,,8.6,percent of total billed charges,,,,,,no IP contract,,,78,,13.42,percent of total billed charges,,,70,,12.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.43,3324,
00078-0426-20 - tegaserod 6 mg Tab,00078-0426-20,NDC,,,,inpatient,1,EA,33.3,19.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,26.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.31,percent of total billed charges,,,85,,28.31,percent of total billed charges,,,49,,16.32,percent of total billed charges,,,90,,29.97,percent of total billed charges,,,,,,,no IP contract,,80,,26.64,percent of total billed charges,,,,,,,no IP contract,,50,,16.65,percent of total billed charges,,,,,,no IP contract,,,78,,25.97,percent of total billed charges,,,70,,23.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.32,3324,
00078-0429-47 - ocular lubricant - Gel,00078-0429-47,NDC,,,,inpatient,1,UN,70.05,42.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,56.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,59.54,percent of total billed charges,,,85,,59.54,percent of total billed charges,,,49,,34.32,percent of total billed charges,,,90,,63.05,percent of total billed charges,,,,,,,no IP contract,,80,,56.04,percent of total billed charges,,,,,,,no IP contract,,50,,35.03,percent of total billed charges,,,,,,no IP contract,,,78,,54.64,percent of total billed charges,,,70,,49.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,34.32,3324,
00078-0473-97 - ocular lubricant - Ointm,00078-0473-97,NDC,,,,inpatient,1,UN,70.45,42.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,57.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,59.88,percent of total billed charges,,,85,,59.88,percent of total billed charges,,,49,,34.52,percent of total billed charges,,,90,,63.41,percent of total billed charges,,,,,,,no IP contract,,80,,56.36,percent of total billed charges,,,,,,,no IP contract,,50,,35.23,percent of total billed charges,,,,,,no IP contract,,,78,,54.95,percent of total billed charges,,,70,,49.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,34.52,3324,
00078-0492-35 - carbamazepine 100 mg Chew,00078-0492-35,NDC,,,,inpatient,1,EA,7.4,4.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.29,percent of total billed charges,,,85,,6.29,percent of total billed charges,,,49,,3.63,percent of total billed charges,,,90,,6.66,percent of total billed charges,,,,,,,no IP contract,,80,,5.92,percent of total billed charges,,,,,,,no IP contract,,50,,3.7,percent of total billed charges,,,,,,no IP contract,,,78,,5.77,percent of total billed charges,,,70,,5.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.63,3324,
00078-0501-15 - rivastigmine 4.6 mg/24 hr ER Fi,00078-0501-15,NDC,,,,inpatient,1,UN,70.8,42.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,57.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,60.18,percent of total billed charges,,,85,,60.18,percent of total billed charges,,,49,,34.69,percent of total billed charges,,,90,,63.72,percent of total billed charges,,,,,,,no IP contract,,80,,56.64,percent of total billed charges,,,,,,,no IP contract,,50,,35.4,percent of total billed charges,,,,,,no IP contract,,,78,,55.22,percent of total billed charges,,,70,,49.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,34.69,3324,
00078-0501-61 - rivastigmine 4.6 mg/24 hr ER Fi,00078-0501-61,NDC,,,,inpatient,1,UN,71.6,42.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,60.86,percent of total billed charges,,,85,,60.86,percent of total billed charges,,,49,,35.08,percent of total billed charges,,,90,,64.44,percent of total billed charges,,,,,,,no IP contract,,80,,57.28,percent of total billed charges,,,,,,,no IP contract,,50,,35.8,percent of total billed charges,,,,,,no IP contract,,,78,,55.85,percent of total billed charges,,,70,,50.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,35.08,3324,
00078-0502-15 - rivastigmine 9.5 mg/24 hr ER Fi,00078-0502-15,NDC,,,,inpatient,1,UN,196.25,117.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,158.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,166.81,percent of total billed charges,,,85,,166.81,percent of total billed charges,,,49,,96.16,percent of total billed charges,,,90,,176.63,percent of total billed charges,,,,,,,no IP contract,,80,,157,percent of total billed charges,,,,,,,no IP contract,,50,,98.13,percent of total billed charges,,,,,,no IP contract,,,78,,153.08,percent of total billed charges,,,70,,137.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,96.16,3324,
00078-0510-05 - carbamazepine XR 100 mg ER Tablet,00078-0510-05,NDC,,,,inpatient,1,EA,13.2,7.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.22,percent of total billed charges,,,85,,11.22,percent of total billed charges,,,49,,6.47,percent of total billed charges,,,90,,11.88,percent of total billed charges,,,,,,,no IP contract,,80,,10.56,percent of total billed charges,,,,,,,no IP contract,,50,,6.6,percent of total billed charges,,,,,,no IP contract,,,78,,10.3,percent of total billed charges,,,70,,9.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.47,3324,
00078-0511-05 - carbamazepine ER Tab 200 mg ER Tablet,00078-0511-05,NDC,,,,inpatient,1,EA,13.45,8.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.43,percent of total billed charges,,,85,,11.43,percent of total billed charges,,,49,,6.59,percent of total billed charges,,,90,,12.11,percent of total billed charges,,,,,,,no IP contract,,80,,10.76,percent of total billed charges,,,,,,,no IP contract,,50,,6.73,percent of total billed charges,,,,,,no IP contract,,,78,,10.49,percent of total billed charges,,,70,,9.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.59,3324,
00078-0527-05 - carbidopa/entacapone/levodopa 50 mg-200 mg-200 mg Tab,00078-0527-05,NDC,,,,inpatient,1,EA,29.2,17.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.82,percent of total billed charges,,,85,,24.82,percent of total billed charges,,,49,,14.31,percent of total billed charges,,,90,,26.28,percent of total billed charges,,,,,,,no IP contract,,80,,23.36,percent of total billed charges,,,,,,,no IP contract,,50,,14.6,percent of total billed charges,,,,,,no IP contract,,,78,,22.78,percent of total billed charges,,,70,,20.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.31,3324,
00078-0544-05 - carbidopa/entacapone/levodopa 18.75 mg-200 mg-75 mg Tab,00078-0544-05,NDC,,,,inpatient,1,EA,37,22.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.45,percent of total billed charges,,,85,,31.45,percent of total billed charges,,,49,,18.13,percent of total billed charges,,,90,,33.3,percent of total billed charges,,,,,,,no IP contract,,80,,29.6,percent of total billed charges,,,,,,,no IP contract,,50,,18.5,percent of total billed charges,,,,,,no IP contract,,,78,,28.86,percent of total billed charges,,,70,,25.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.13,3324,
00078-0607-15 - fingolimod 0.5 mg Cap,00078-0607-15,NDC,,,,inpatient,1,EA,2148.2,1288.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1740.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1825.97,percent of total billed charges,,,85,,1825.97,percent of total billed charges,,,49,,1052.62,percent of total billed charges,,,90,,1933.38,percent of total billed charges,,,,,,,no IP contract,,80,,1718.56,percent of total billed charges,,,,,,,no IP contract,,50,,1074.1,percent of total billed charges,,,,,,no IP contract,,,78,,1675.6,percent of total billed charges,,,70,,1503.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
00078-0607-51 - fingolimod 0.5 mg Cap,00078-0607-51,NDC,,,,inpatient,1,EA,1372.4,823.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1111.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1166.54,percent of total billed charges,,,85,,1166.54,percent of total billed charges,,,49,,672.48,percent of total billed charges,,,90,,1235.16,percent of total billed charges,,,,,,,no IP contract,,80,,1097.92,percent of total billed charges,,,,,,,no IP contract,,50,,686.2,percent of total billed charges,,,,,,no IP contract,,,78,,1070.47,percent of total billed charges,,,70,,960.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,672.48,3324,
00078-0659-20 - sacubitril-valsartan 24 mg-26 mg Tab,00078-0659-20,NDC,,,,inpatient,1,EA,84.75,50.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,68.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,72.04,percent of total billed charges,,,85,,72.04,percent of total billed charges,,,49,,41.53,percent of total billed charges,,,90,,76.28,percent of total billed charges,,,,,,,no IP contract,,80,,67.8,percent of total billed charges,,,,,,,no IP contract,,50,,42.38,percent of total billed charges,,,,,,no IP contract,,,78,,66.11,percent of total billed charges,,,70,,59.33,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,41.53,3324,
00078-0696-20 - sacubitril-valsartan 97 mg-103 mg Tab,00078-0696-20,NDC,,,,inpatient,1,EA,84.75,50.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,68.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,72.04,percent of total billed charges,,,85,,72.04,percent of total billed charges,,,49,,41.53,percent of total billed charges,,,90,,76.28,percent of total billed charges,,,,,,,no IP contract,,80,,67.8,percent of total billed charges,,,,,,,no IP contract,,50,,42.38,percent of total billed charges,,,,,,no IP contract,,,78,,66.11,percent of total billed charges,,,70,,59.33,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,41.53,3324,
00078-0777-20 - sacubitril-valsartan 49 mg-51 mg Tab,00078-0777-20,NDC,,,,inpatient,1,EA,84.75,50.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,68.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,72.04,percent of total billed charges,,,85,,72.04,percent of total billed charges,,,49,,41.53,percent of total billed charges,,,90,,76.28,percent of total billed charges,,,,,,,no IP contract,,80,,67.8,percent of total billed charges,,,,,,,no IP contract,,50,,42.38,percent of total billed charges,,,,,,no IP contract,,,78,,66.11,percent of total billed charges,,,70,,59.33,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,41.53,3324,
00078-0799-75 - ciprofloxacin-dexamethasone otic 0.3%-0.1% Susp,00078-0799-75,NDC,,,,inpatient,1,UN,2498.85,1499.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2024.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2124.02,percent of total billed charges,,,85,,2124.02,percent of total billed charges,,,49,,1224.44,percent of total billed charges,,,90,,2248.97,percent of total billed charges,,,,,,,no IP contract,,80,,1999.08,percent of total billed charges,,,,,,,no IP contract,,50,,1249.43,percent of total billed charges,,,,,,no IP contract,,,78,,1949.1,percent of total billed charges,,,70,,1749.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
00081-0728-69 - gramicidin/neomycin/polymyxin B ophthalmic 0.025 mg-1.75 mg-10000 units/mL Soln,00081-0728-69,NDC,,,,inpatient,1,UN,9.2,5.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.82,percent of total billed charges,,,85,,7.82,percent of total billed charges,,,49,,4.51,percent of total billed charges,,,90,,8.28,percent of total billed charges,,,,,,,no IP contract,,80,,7.36,percent of total billed charges,,,,,,,no IP contract,,50,,4.6,percent of total billed charges,,,,,,no IP contract,,,78,,7.18,percent of total billed charges,,,70,,6.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.51,3324,
00081-0798-87 - bacitracin-polymyxin B Topical 500 units-10000 units/g Ointm,00081-0798-87,NDC,,,,inpatient,1,UN,64.2,38.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,54.57,percent of total billed charges,,,85,,54.57,percent of total billed charges,,,49,,31.46,percent of total billed charges,,,90,,57.78,percent of total billed charges,,,,,,,no IP contract,,80,,51.36,percent of total billed charges,,,,,,,no IP contract,,50,,32.1,percent of total billed charges,,,,,,no IP contract,,,78,,50.08,percent of total billed charges,,,70,,44.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.46,3324,
00085-1244-01 - temozolomide 20 mg Cap,00085-1244-01,NDC,,,,inpatient,1,EA,286.45,171.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,232.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,243.48,percent of total billed charges,,,85,,243.48,percent of total billed charges,,,49,,140.36,percent of total billed charges,,,90,,257.81,percent of total billed charges,,,,,,,no IP contract,,80,,229.16,percent of total billed charges,,,,,,,no IP contract,,50,,143.23,percent of total billed charges,,,,,,no IP contract,,,78,,223.43,percent of total billed charges,,,70,,200.52,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,140.36,3324,
00085-1288-01 - mometasone nasal 50 mcg/inh Spray,00085-1288-01,NDC,,,,inpatient,1,UN,1868.55,1121.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1513.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1588.27,percent of total billed charges,,,85,,1588.27,percent of total billed charges,,,49,,915.59,percent of total billed charges,,,90,,1681.7,percent of total billed charges,,,,,,,no IP contract,,80,,1494.84,percent of total billed charges,,,,,,,no IP contract,,50,,934.28,percent of total billed charges,,,,,,no IP contract,,,78,,1457.47,percent of total billed charges,,,70,,1307.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,915.59,3324,
00085-1328-01 - posaconazole 40 mg/mL Susp,00085-1328-01,NDC,,,,inpatient,1,ML,91.05,54.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,73.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,77.39,percent of total billed charges,,,85,,77.39,percent of total billed charges,,,49,,44.61,percent of total billed charges,,,90,,81.95,percent of total billed charges,,,,,,,no IP contract,,80,,72.84,percent of total billed charges,,,,,,,no IP contract,,50,,45.53,percent of total billed charges,,,,,,no IP contract,,,78,,71.02,percent of total billed charges,,,70,,63.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,44.61,3324,
00085-1336-04 - temozolomide 20 mg Cap,00085-1336-04,NDC,,,,inpatient,1,EA,379.2,227.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,307.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,322.32,percent of total billed charges,,,85,,322.32,percent of total billed charges,,,49,,185.81,percent of total billed charges,,,90,,341.28,percent of total billed charges,,,,,,,no IP contract,,80,,303.36,percent of total billed charges,,,,,,,no IP contract,,50,,189.6,percent of total billed charges,,,,,,no IP contract,,,78,,295.78,percent of total billed charges,,,70,,265.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,185.81,3324,
00085-1341-06 - mometasone 220 mcg/inh Aeros,00085-1341-06,NDC,,,,inpatient,1,UN,748.5,449.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,606.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,636.23,percent of total billed charges,,,85,,636.23,percent of total billed charges,,,49,,366.77,percent of total billed charges,,,90,,673.65,percent of total billed charges,,,,,,,no IP contract,,80,,598.8,percent of total billed charges,,,,,,,no IP contract,,50,,374.25,percent of total billed charges,,,,,,no IP contract,,,78,,583.83,percent of total billed charges,,,70,,523.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,366.77,3324,
00085-1366-05 - temozolamide 20 mg Cap,00085-1366-05,NDC,,,,inpatient,1,EA,379.2,227.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,307.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,322.32,percent of total billed charges,,,85,,322.32,percent of total billed charges,,,49,,185.81,percent of total billed charges,,,90,,341.28,percent of total billed charges,,,,,,,no IP contract,,80,,303.36,percent of total billed charges,,,,,,,no IP contract,,50,,189.6,percent of total billed charges,,,,,,no IP contract,,,78,,295.78,percent of total billed charges,,,70,,265.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,185.81,3324,
00085-1519-01 - temozolomide 20 mg Cap,00085-1519-01,NDC,,,,inpatient,1,EA,379.2,227.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,307.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,322.32,percent of total billed charges,,,85,,322.32,percent of total billed charges,,,49,,185.81,percent of total billed charges,,,90,,341.28,percent of total billed charges,,,,,,,no IP contract,,80,,303.36,percent of total billed charges,,,,,,,no IP contract,,50,,189.6,percent of total billed charges,,,,,,no IP contract,,,78,,295.78,percent of total billed charges,,,70,,265.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,185.81,3324,
00085-1519-02 - temozolomide 20 mg Cap,00085-1519-02,NDC,,,,inpatient,1,EA,332.1,199.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,269,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,282.29,percent of total billed charges,,,85,,282.29,percent of total billed charges,,,49,,162.73,percent of total billed charges,,,90,,298.89,percent of total billed charges,,,,,,,no IP contract,,80,,265.68,percent of total billed charges,,,,,,,no IP contract,,50,,166.05,percent of total billed charges,,,,,,no IP contract,,,78,,259.04,percent of total billed charges,,,70,,232.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,162.73,3324,
00085-3004-01 - temozolomide 5 mg Cap,00085-3004-01,NDC,,,,inpatient,1,EA,98.1,58.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,79.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,83.39,percent of total billed charges,,,85,,83.39,percent of total billed charges,,,49,,48.07,percent of total billed charges,,,90,,88.29,percent of total billed charges,,,,,,,no IP contract,,80,,78.48,percent of total billed charges,,,,,,,no IP contract,,50,,49.05,percent of total billed charges,,,,,,no IP contract,,,78,,76.52,percent of total billed charges,,,70,,68.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,48.07,3324,
00085-3004-04 - temozolomide 5 mg Cap,00085-3004-04,NDC,,,,inpatient,1,EA,107.8,64.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,87.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,91.63,percent of total billed charges,,,85,,91.63,percent of total billed charges,,,49,,52.82,percent of total billed charges,,,90,,97.02,percent of total billed charges,,,,,,,no IP contract,,80,,86.24,percent of total billed charges,,,,,,,no IP contract,,50,,53.9,percent of total billed charges,,,,,,no IP contract,,,78,,84.08,percent of total billed charges,,,70,,75.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,52.82,3324,
00085-4110-03 - isosorbide mononitrate 60 mg ER Tab,00085-4110-03,NDC,,,,inpatient,1,EA,21.8,13.08,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.53,percent of total billed charges,,,85,,18.53,percent of total billed charges,,,49,,10.68,percent of total billed charges,,,90,,19.62,percent of total billed charges,,,,,,,no IP contract,,80,,17.44,percent of total billed charges,,,,,,,no IP contract,,50,,10.9,percent of total billed charges,,,,,,no IP contract,,,78,,17,percent of total billed charges,,,70,,15.26,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.68,3324,
00085-4324-02 - posaconazole 100 mg EC Ta,00085-4324-02,NDC,,,,inpatient,1,EA,478.3,286.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,387.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,406.56,percent of total billed charges,,,85,,406.56,percent of total billed charges,,,49,,234.37,percent of total billed charges,,,90,,430.47,percent of total billed charges,,,,,,,no IP contract,,80,,382.64,percent of total billed charges,,,,,,,no IP contract,,50,,239.15,percent of total billed charges,,,,,,no IP contract,,,78,,373.07,percent of total billed charges,,,70,,334.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,234.37,3324,
00087-0365-03 - medium chain triglycerides 100% Oil,00087-0365-03,NDC,,,,inpatient,1,ML,5.9,3.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.02,percent of total billed charges,,,85,,5.02,percent of total billed charges,,,49,,2.89,percent of total billed charges,,,90,,5.31,percent of total billed charges,,,,,,,no IP contract,,80,,4.72,percent of total billed charges,,,,,,,no IP contract,,50,,2.95,percent of total billed charges,,,,,,no IP contract,,,78,,4.6,percent of total billed charges,,,70,,4.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.89,3324,
00087-0402-03 - multivitamin Pediatric Multiple Vitamins LIQ,00087-0402-03,NDC,,,,inpatient,1,ML,6.65,3.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.65,percent of total billed charges,,,85,,5.65,percent of total billed charges,,,49,,3.26,percent of total billed charges,,,90,,5.99,percent of total billed charges,,,,,,,no IP contract,,80,,5.32,percent of total billed charges,,,,,,,no IP contract,,50,,3.33,percent of total billed charges,,,,,,no IP contract,,,78,,5.19,percent of total billed charges,,,70,,4.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.26,3324,
00087-0818-41 - busPIRone 5 mg Tab,00087-0818-41,NDC,,,,inpatient,1,EA,11.6,6.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.86,percent of total billed charges,,,85,,9.86,percent of total billed charges,,,49,,5.68,percent of total billed charges,,,90,,10.44,percent of total billed charges,,,,,,,no IP contract,,80,,9.28,percent of total billed charges,,,,,,,no IP contract,,50,,5.8,percent of total billed charges,,,,,,no IP contract,,,78,,9.05,percent of total billed charges,,,70,,8.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.68,3324,
00088-1095-47 - fexofenadine-pseudoephedrine 180 mg-240 mg ER Ta,00088-1095-47,NDC,,,,inpatient,1,EA,34.6,20.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.41,percent of total billed charges,,,85,,29.41,percent of total billed charges,,,49,,16.95,percent of total billed charges,,,90,,31.14,percent of total billed charges,,,,,,,no IP contract,,80,,27.68,percent of total billed charges,,,,,,,no IP contract,,50,,17.3,percent of total billed charges,,,,,,no IP contract,,,78,,26.99,percent of total billed charges,,,70,,24.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.95,3324,
00088-2220-33 - insulin glargine 100 units/mL Soln,00088-2220-33,NDC,,,,inpatient,0.01,ML,73.1,43.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,59.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,62.14,percent of total billed charges,,,85,,62.14,percent of total billed charges,,,49,,35.82,percent of total billed charges,,,90,,65.79,percent of total billed charges,,,,,,,no IP contract,,80,,58.48,percent of total billed charges,,,,,,,no IP contract,,50,,36.55,percent of total billed charges,,,,,,no IP contract,,,78,,57.02,percent of total billed charges,,,70,,51.17,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,35.82,3324,
00088-5021-01 - insulin GLARgine  100 unit(s) / 1 mL Soln,00088-5021-01,NDC,,,,inpatient,0.01,ML,73.15,43.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,59.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,62.18,percent of total billed charges,,,85,,62.18,percent of total billed charges,,,49,,35.84,percent of total billed charges,,,90,,65.84,percent of total billed charges,,,,,,,no IP contract,,80,,58.52,percent of total billed charges,,,,,,,no IP contract,,50,,36.58,percent of total billed charges,,,,,,no IP contract,,,78,,57.06,percent of total billed charges,,,70,,51.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,35.84,3324,
00091-0695-20 - hydrocortisone 10% Foam,00091-0695-20,NDC,,,,inpatient,1,UN,854.1,512.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,691.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,725.99,percent of total billed charges,,,85,,725.99,percent of total billed charges,,,49,,418.51,percent of total billed charges,,,90,,768.69,percent of total billed charges,,,,,,,no IP contract,,80,,683.28,percent of total billed charges,,,,,,,no IP contract,,50,,427.05,percent of total billed charges,,,,,,no IP contract,,,78,,666.2,percent of total billed charges,,,70,,597.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,418.51,3324,
00091-1120-20 - alprostadil 20 mcg REC I,00091-1120-20,NDC,,,,inpatient,1,ML,369.55,221.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,299.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,314.12,percent of total billed charges,,,85,,314.12,percent of total billed charges,,,49,,181.08,percent of total billed charges,,,90,,332.6,percent of total billed charges,,,,,,,no IP contract,,80,,295.64,percent of total billed charges,,,,,,,no IP contract,,50,,184.78,percent of total billed charges,,,,,,no IP contract,,,78,,288.25,percent of total billed charges,,,70,,258.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,181.08,3324,
00093-0010-06 - tolterodine 1 mg Tab,00093-0010-06,NDC,,,,inpatient,1,EA,30.15,18.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.63,percent of total billed charges,,,85,,25.63,percent of total billed charges,,,49,,14.77,percent of total billed charges,,,90,,27.14,percent of total billed charges,,,,,,,no IP contract,,80,,24.12,percent of total billed charges,,,,,,,no IP contract,,50,,15.08,percent of total billed charges,,,,,,no IP contract,,,78,,23.52,percent of total billed charges,,,70,,21.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.77,3324,
00093-0018-06 - tolterodine 2 mg Tab,00093-0018-06,NDC,,,,inpatient,1,EA,30.85,18.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.22,percent of total billed charges,,,85,,26.22,percent of total billed charges,,,49,,15.12,percent of total billed charges,,,90,,27.77,percent of total billed charges,,,,,,,no IP contract,,80,,24.68,percent of total billed charges,,,,,,,no IP contract,,50,,15.43,percent of total billed charges,,,,,,no IP contract,,,78,,24.06,percent of total billed charges,,,70,,21.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.12,3324,
00093-0039-01 - lamotrigine 25 mg Tab,00093-0039-01,NDC,,,,inpatient,1,EA,36.9,22.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.37,percent of total billed charges,,,85,,31.37,percent of total billed charges,,,49,,18.08,percent of total billed charges,,,90,,33.21,percent of total billed charges,,,,,,,no IP contract,,80,,29.52,percent of total billed charges,,,,,,,no IP contract,,50,,18.45,percent of total billed charges,,,,,,no IP contract,,,78,,28.78,percent of total billed charges,,,70,,25.83,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.08,3324,
00093-0051-01 - carvedilol 3.125 mg Tab,00093-0051-01,NDC,,,,inpatient,1,EA,4.4,2.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.74,percent of total billed charges,,,85,,3.74,percent of total billed charges,,,49,,2.16,percent of total billed charges,,,90,,3.96,percent of total billed charges,,,,,,,no IP contract,,80,,3.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.2,percent of total billed charges,,,,,,no IP contract,,,78,,3.43,percent of total billed charges,,,70,,3.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.16,3324,
00093-0054-01 - busPIRone 10 mg Tab,00093-0054-01,NDC,,,,inpatient,1,EA,14.5,8.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.33,percent of total billed charges,,,85,,12.33,percent of total billed charges,,,49,,7.11,percent of total billed charges,,,90,,13.05,percent of total billed charges,,,,,,,no IP contract,,80,,11.6,percent of total billed charges,,,,,,,no IP contract,,50,,7.25,percent of total billed charges,,,,,,no IP contract,,,78,,11.31,percent of total billed charges,,,70,,10.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.11,3324,
00093-0199-01 - venlafaxine 25 mg Tab,00093-0199-01,NDC,,,,inpatient,1,EA,19.25,11.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.36,percent of total billed charges,,,85,,16.36,percent of total billed charges,,,49,,9.43,percent of total billed charges,,,90,,17.33,percent of total billed charges,,,,,,,no IP contract,,80,,15.4,percent of total billed charges,,,,,,,no IP contract,,50,,9.63,percent of total billed charges,,,,,,no IP contract,,,78,,15.02,percent of total billed charges,,,70,,13.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.43,3324,
00093-0262-30 - fluocinonide topical 0.05% Cream,00093-0262-30,NDC,,,,inpatient,1,UN,768.9,461.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,622.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,653.57,percent of total billed charges,,,85,,653.57,percent of total billed charges,,,49,,376.76,percent of total billed charges,,,90,,692.01,percent of total billed charges,,,,,,,no IP contract,,80,,615.12,percent of total billed charges,,,,,,,no IP contract,,50,,384.45,percent of total billed charges,,,,,,no IP contract,,,78,,599.74,percent of total billed charges,,,70,,538.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,376.76,3324,
00093-0314-01 - ketorolac 10 mg Tab,00093-0314-01,NDC,,,,inpatient,1,EA,11.2,6.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.52,percent of total billed charges,,,85,,9.52,percent of total billed charges,,,49,,5.49,percent of total billed charges,,,90,,10.08,percent of total billed charges,,,,,,,no IP contract,,80,,8.96,percent of total billed charges,,,,,,,no IP contract,,50,,5.6,percent of total billed charges,,,,,,no IP contract,,,78,,8.74,percent of total billed charges,,,70,,7.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.49,3324,
00093-0319-01 - dilTIAZem 60 mg Tab,00093-0319-01,NDC,,,,inpatient,1,EA,16.3,9.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.86,percent of total billed charges,,,85,,13.86,percent of total billed charges,,,49,,7.99,percent of total billed charges,,,90,,14.67,percent of total billed charges,,,,,,,no IP contract,,80,,13.04,percent of total billed charges,,,,,,,no IP contract,,50,,8.15,percent of total billed charges,,,,,,no IP contract,,,78,,12.71,percent of total billed charges,,,70,,11.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.99,3324,
00093-0793-01 - niCARdipine 20 mg Cap,00093-0793-01,NDC,,,,inpatient,1,EA,7.5,4.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.38,percent of total billed charges,,,85,,6.38,percent of total billed charges,,,49,,3.68,percent of total billed charges,,,90,,6.75,percent of total billed charges,,,,,,,no IP contract,,80,,6,percent of total billed charges,,,,,,,no IP contract,,50,,3.75,percent of total billed charges,,,,,,no IP contract,,,78,,5.85,percent of total billed charges,,,70,,5.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.68,3324,
mupirocin topical 2% Ointm,00093-1010-42,NDC,,,,inpatient,1,EA,722.1,433.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,584.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,613.79,percent of total billed charges,,,85,,613.79,percent of total billed charges,,,49,,353.83,percent of total billed charges,,,90,,649.89,percent of total billed charges,,,,,,,no IP contract,,80,,577.68,percent of total billed charges,,,,,,,no IP contract,,50,,361.05,percent of total billed charges,,,,,,no IP contract,,,78,,563.24,percent of total billed charges,,,70,,505.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,353.83,3324,
00093-1061-01 - sotalol 80 mg Tab,00093-1061-01,NDC,,,,inpatient,1,EA,22.5,13.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.13,percent of total billed charges,,,85,,19.13,percent of total billed charges,,,49,,11.03,percent of total billed charges,,,90,,20.25,percent of total billed charges,,,,,,,no IP contract,,80,,18,percent of total billed charges,,,,,,,no IP contract,,50,,11.25,percent of total billed charges,,,,,,no IP contract,,,78,,17.55,percent of total billed charges,,,70,,15.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.03,3324,
00093-1716-01 - warfarin 4 mg Tab,00093-1716-01,NDC,,,,inpatient,1,EA,9.05,5.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.69,percent of total billed charges,,,85,,7.69,percent of total billed charges,,,49,,4.43,percent of total billed charges,,,90,,8.15,percent of total billed charges,,,,,,,no IP contract,,80,,7.24,percent of total billed charges,,,,,,,no IP contract,,50,,4.53,percent of total billed charges,,,,,,no IP contract,,,78,,7.06,percent of total billed charges,,,70,,6.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.43,3324,
00093-1718-01 - warfarin 6 mg Tab,00093-1718-01,NDC,,,,inpatient,1,EA,11.4,6.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.69,percent of total billed charges,,,85,,9.69,percent of total billed charges,,,49,,5.59,percent of total billed charges,,,90,,10.26,percent of total billed charges,,,,,,,no IP contract,,80,,9.12,percent of total billed charges,,,,,,,no IP contract,,50,,5.7,percent of total billed charges,,,,,,no IP contract,,,78,,8.89,percent of total billed charges,,,70,,7.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.59,3324,
00093-2027-23 - azithromycin 100 mg/5 mL REC P,00093-2027-23,NDC,,,,inpatient,1,ML,24.85,14.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.12,percent of total billed charges,,,85,,21.12,percent of total billed charges,,,49,,12.18,percent of total billed charges,,,90,,22.37,percent of total billed charges,,,,,,,no IP contract,,80,,19.88,percent of total billed charges,,,,,,,no IP contract,,50,,12.43,percent of total billed charges,,,,,,no IP contract,,,78,,19.38,percent of total billed charges,,,70,,17.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.18,3324,
00093-2064-06 - cilostazol 100 mg Tab,00093-2064-06,NDC,,,,inpatient,1,EA,18.3,10.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.56,percent of total billed charges,,,85,,15.56,percent of total billed charges,,,49,,8.97,percent of total billed charges,,,90,,16.47,percent of total billed charges,,,,,,,no IP contract,,80,,14.64,percent of total billed charges,,,,,,,no IP contract,,50,,9.15,percent of total billed charges,,,,,,no IP contract,,,78,,14.27,percent of total billed charges,,,70,,12.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.97,3324,
00093-2203-01 - metoclopramide 10 mg Tab,00093-2203-01,NDC,,,,inpatient,1,EA,4.6,2.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.91,percent of total billed charges,,,85,,3.91,percent of total billed charges,,,49,,2.25,percent of total billed charges,,,90,,4.14,percent of total billed charges,,,,,,,no IP contract,,80,,3.68,percent of total billed charges,,,,,,,no IP contract,,50,,2.3,percent of total billed charges,,,,,,no IP contract,,,78,,3.59,percent of total billed charges,,,70,,3.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.25,3324,
00093-2274-34 - amoxicillin-clavulanate 500 mg-125 mg Tab,00093-2274-34,NDC,,,,inpatient,1,EA,33.9,20.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.82,percent of total billed charges,,,85,,28.82,percent of total billed charges,,,49,,16.61,percent of total billed charges,,,90,,30.51,percent of total billed charges,,,,,,,no IP contract,,80,,27.12,percent of total billed charges,,,,,,,no IP contract,,50,,16.95,percent of total billed charges,,,,,,no IP contract,,,78,,26.44,percent of total billed charges,,,70,,23.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.61,3324,
00093-2275-34 - amoxicillin-clavulanate 875 mg-125 mg Tab,00093-2275-34,NDC,,,,inpatient,1,EA,19.95,11.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.96,percent of total billed charges,,,85,,16.96,percent of total billed charges,,,49,,9.78,percent of total billed charges,,,90,,17.96,percent of total billed charges,,,,,,,no IP contract,,80,,15.96,percent of total billed charges,,,,,,,no IP contract,,50,,9.98,percent of total billed charges,,,,,,no IP contract,,,78,,15.56,percent of total billed charges,,,70,,13.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.78,3324,
00093-3060-56 - rasagiline 0.5 mg Tab,00093-3060-56,NDC,,,,inpatient,1,EA,202.55,121.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,164.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,172.17,percent of total billed charges,,,85,,172.17,percent of total billed charges,,,49,,99.25,percent of total billed charges,,,90,,182.3,percent of total billed charges,,,,,,,no IP contract,,80,,162.04,percent of total billed charges,,,,,,,no IP contract,,50,,101.28,percent of total billed charges,,,,,,no IP contract,,,78,,157.99,percent of total billed charges,,,70,,141.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,99.25,3324,
00093-3061-56 - rasagiline 1 mg Tab,00093-3061-56,NDC,,,,inpatient,1,EA,202.55,121.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,164.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,172.17,percent of total billed charges,,,85,,172.17,percent of total billed charges,,,49,,99.25,percent of total billed charges,,,90,,182.3,percent of total billed charges,,,,,,,no IP contract,,80,,162.04,percent of total billed charges,,,,,,,no IP contract,,50,,101.28,percent of total billed charges,,,,,,no IP contract,,,78,,157.99,percent of total billed charges,,,70,,141.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,99.25,3324,
00093-3090-56 - armodafinil 50 mg Tab,00093-3090-56,NDC,,,,inpatient,1,EA,65.9,39.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,53.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.02,percent of total billed charges,,,85,,56.02,percent of total billed charges,,,49,,32.29,percent of total billed charges,,,90,,59.31,percent of total billed charges,,,,,,,no IP contract,,80,,52.72,percent of total billed charges,,,,,,,no IP contract,,50,,32.95,percent of total billed charges,,,,,,no IP contract,,,78,,51.4,percent of total billed charges,,,70,,46.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.29,3324,
00093-3107-93 - amoxicillin 250 mg Cap,00093-3107-93,NDC,,,,inpatient,1,EA,5.9,3.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.02,percent of total billed charges,,,85,,5.02,percent of total billed charges,,,49,,2.89,percent of total billed charges,,,90,,5.31,percent of total billed charges,,,,,,,no IP contract,,80,,4.72,percent of total billed charges,,,,,,,no IP contract,,50,,2.95,percent of total billed charges,,,,,,no IP contract,,,78,,4.6,percent of total billed charges,,,70,,4.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.89,3324,
00093-3109-93 - amoxicillin 500 mg Cap,00093-3109-93,NDC,,,,inpatient,1,EA,7.7,4.62,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.55,percent of total billed charges,,,85,,6.55,percent of total billed charges,,,49,,3.77,percent of total billed charges,,,90,,6.93,percent of total billed charges,,,,,,,no IP contract,,80,,6.16,percent of total billed charges,,,,,,,no IP contract,,50,,3.85,percent of total billed charges,,,,,,no IP contract,,,78,,6.01,percent of total billed charges,,,70,,5.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.77,3324,
00093-3123-01 - dicloxacillin 250 mg Cap,00093-3123-01,NDC,,,,inpatient,1,EA,9.05,5.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.69,percent of total billed charges,,,85,,7.69,percent of total billed charges,,,49,,4.43,percent of total billed charges,,,90,,8.15,percent of total billed charges,,,,,,,no IP contract,,80,,7.24,percent of total billed charges,,,,,,,no IP contract,,50,,4.53,percent of total billed charges,,,,,,no IP contract,,,78,,7.06,percent of total billed charges,,,70,,6.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.43,3324,
00093-3125-01 - dicloxacillin 500 mg Cap,00093-3125-01,NDC,,,,inpatient,1,EA,13.35,8.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.35,percent of total billed charges,,,85,,11.35,percent of total billed charges,,,49,,6.54,percent of total billed charges,,,90,,12.02,percent of total billed charges,,,,,,,no IP contract,,80,,10.68,percent of total billed charges,,,,,,,no IP contract,,50,,6.68,percent of total billed charges,,,,,,no IP contract,,,78,,10.41,percent of total billed charges,,,70,,9.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.54,3324,
00093-3145-01 - cephalexin 250 mg Cap,00093-3145-01,NDC,,,,inpatient,1,EA,9.3,5.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.91,percent of total billed charges,,,85,,7.91,percent of total billed charges,,,49,,4.56,percent of total billed charges,,,90,,8.37,percent of total billed charges,,,,,,,no IP contract,,80,,7.44,percent of total billed charges,,,,,,,no IP contract,,50,,4.65,percent of total billed charges,,,,,,no IP contract,,,78,,7.25,percent of total billed charges,,,70,,6.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.56,3324,
00093-3147-01 - cephalexin 500 mg Cap,00093-3147-01,NDC,,,,inpatient,1,EA,5.9,3.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.02,percent of total billed charges,,,85,,5.02,percent of total billed charges,,,49,,2.89,percent of total billed charges,,,90,,5.31,percent of total billed charges,,,,,,,no IP contract,,80,,4.72,percent of total billed charges,,,,,,,no IP contract,,50,,2.95,percent of total billed charges,,,,,,no IP contract,,,78,,4.6,percent of total billed charges,,,70,,4.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.89,3324,
00093-3160-06 - cefdinir 300 mg Cap,00093-3160-06,NDC,,,,inpatient,1,EA,44.45,26.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,37.78,percent of total billed charges,,,85,,37.78,percent of total billed charges,,,49,,21.78,percent of total billed charges,,,90,,40.01,percent of total billed charges,,,,,,,no IP contract,,80,,35.56,percent of total billed charges,,,,,,,no IP contract,,50,,22.23,percent of total billed charges,,,,,,no IP contract,,,78,,34.67,percent of total billed charges,,,70,,31.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.78,3324,
00093-3195-01 - ketoprofen 75 mg Cap,00093-3195-01,NDC,,,,inpatient,1,EA,12.35,7.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.5,percent of total billed charges,,,85,,10.5,percent of total billed charges,,,49,,6.05,percent of total billed charges,,,90,,11.12,percent of total billed charges,,,,,,,no IP contract,,80,,9.88,percent of total billed charges,,,,,,,no IP contract,,50,,6.18,percent of total billed charges,,,,,,no IP contract,,,78,,9.63,percent of total billed charges,,,70,,8.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.05,3324,
00093-3196-01 - cefadroxil 500 mg Cap,00093-3196-01,NDC,,,,inpatient,1,EA,32.45,19.47,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,26.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,27.58,percent of total billed charges,,,85,,27.58,percent of total billed charges,,,49,,15.9,percent of total billed charges,,,90,,29.21,percent of total billed charges,,,,,,,no IP contract,,80,,25.96,percent of total billed charges,,,,,,,no IP contract,,50,,16.23,percent of total billed charges,,,,,,no IP contract,,,78,,25.31,percent of total billed charges,,,70,,22.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.9,3324,
00093-3196-53 - cefadroxil 500 mg Cap,00093-3196-53,NDC,,,,inpatient,1,EA,33.4,20.04,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.39,percent of total billed charges,,,85,,28.39,percent of total billed charges,,,49,,16.37,percent of total billed charges,,,90,,30.06,percent of total billed charges,,,,,,,no IP contract,,80,,26.72,percent of total billed charges,,,,,,,no IP contract,,50,,16.7,percent of total billed charges,,,,,,no IP contract,,,78,,26.05,percent of total billed charges,,,70,,23.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.37,3324,
00093-3212-01 - clonazePAM 1 mg Tab,00093-3212-01,NDC,,,,inpatient,1,EA,12.6,7.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.71,percent of total billed charges,,,85,,10.71,percent of total billed charges,,,49,,6.17,percent of total billed charges,,,90,,11.34,percent of total billed charges,,,,,,,no IP contract,,80,,10.08,percent of total billed charges,,,,,,,no IP contract,,50,,6.3,percent of total billed charges,,,,,,no IP contract,,,78,,9.83,percent of total billed charges,,,70,,8.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.17,3324,
00093-3225-55 - diclofenac epolamine 1.3% Patch,00093-3225-55,NDC,,,,inpatient,1,UN,60.85,36.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,49.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,51.72,percent of total billed charges,,,85,,51.72,percent of total billed charges,,,49,,29.82,percent of total billed charges,,,90,,54.77,percent of total billed charges,,,,,,,no IP contract,,80,,48.68,percent of total billed charges,,,,,,,no IP contract,,50,,30.43,percent of total billed charges,,,,,,no IP contract,,,78,,47.46,percent of total billed charges,,,70,,42.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,29.82,3324,
00093-3230-01 - methylphenidate 20 mg/24 hr ER Capsule,00093-3230-01,NDC,,,,inpatient,1,EA,95.55,57.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,77.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,81.22,percent of total billed charges,,,85,,81.22,percent of total billed charges,,,49,,46.82,percent of total billed charges,,,90,,86,percent of total billed charges,,,,,,,no IP contract,,80,,76.44,percent of total billed charges,,,,,,,no IP contract,,50,,47.78,percent of total billed charges,,,,,,no IP contract,,,78,,74.53,percent of total billed charges,,,70,,66.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,46.82,3324,
cyclobenzaprine 10 mg Tab,00093-3422-01,NDC,,,,inpatient,1,EA,12.95,7.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.01,percent of total billed charges,,,85,,11.01,percent of total billed charges,,,49,,6.35,percent of total billed charges,,,90,,11.66,percent of total billed charges,,,,,,,no IP contract,,80,,10.36,percent of total billed charges,,,,,,,no IP contract,,50,,6.48,percent of total billed charges,,,,,,no IP contract,,,78,,10.1,percent of total billed charges,,,70,,9.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.35,3324,
00093-3426-01 - LORazepam 1 mg Tab,00093-3426-01,NDC,,,,inpatient,1,EA,12.75,7.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.84,percent of total billed charges,,,85,,10.84,percent of total billed charges,,,49,,6.25,percent of total billed charges,,,90,,11.48,percent of total billed charges,,,,,,,no IP contract,,80,,10.2,percent of total billed charges,,,,,,,no IP contract,,50,,6.38,percent of total billed charges,,,,,,no IP contract,,,78,,9.95,percent of total billed charges,,,70,,8.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.25,3324,
00093-3542-56 - atomoxetine 10 mg Cap,00093-3542-56,NDC,,,,inpatient,1,EA,116.95,70.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,94.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,99.41,percent of total billed charges,,,85,,99.41,percent of total billed charges,,,49,,57.31,percent of total billed charges,,,90,,105.26,percent of total billed charges,,,,,,,no IP contract,,80,,93.56,percent of total billed charges,,,,,,,no IP contract,,50,,58.48,percent of total billed charges,,,,,,no IP contract,,,78,,91.22,percent of total billed charges,,,70,,81.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,57.31,3324,
00093-4067-01 - prazosin 1 mg Cap,00093-4067-01,NDC,,,,inpatient,1,EA,7,4.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.95,percent of total billed charges,,,85,,5.95,percent of total billed charges,,,49,,3.43,percent of total billed charges,,,90,,6.3,percent of total billed charges,,,,,,,no IP contract,,80,,5.6,percent of total billed charges,,,,,,,no IP contract,,50,,3.5,percent of total billed charges,,,,,,no IP contract,,,78,,5.46,percent of total billed charges,,,70,,4.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.43,3324,
00093-4127-74 - penicillin V potassium 250 mg/5 mL REC P,00093-4127-74,NDC,,,,inpatient,1,ML,5.65,3.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.8,percent of total billed charges,,,85,,4.8,percent of total billed charges,,,49,,2.77,percent of total billed charges,,,90,,5.09,percent of total billed charges,,,,,,,no IP contract,,80,,4.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.83,percent of total billed charges,,,,,,no IP contract,,,78,,4.41,percent of total billed charges,,,70,,3.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.77,3324,
levalbuterol 0.63 mg/3 mL Soln,00093-4146-56,NDC,,,,inpatient,1,EA,65.2,39.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,52.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,55.42,percent of total billed charges,,,85,,55.42,percent of total billed charges,,,49,,31.95,percent of total billed charges,,,90,,58.68,percent of total billed charges,,,,,,,no IP contract,,80,,52.16,percent of total billed charges,,,,,,,no IP contract,,50,,32.6,percent of total billed charges,,,,,,no IP contract,,,78,,50.86,percent of total billed charges,,,70,,45.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.95,3324,
00093-4146-64 - levalbuterol 0.63 mg/3 mL Soln,00093-4146-64,NDC,,,,inpatient,3,ML,65.2,39.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,52.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,55.42,percent of total billed charges,,,85,,55.42,percent of total billed charges,,,49,,31.95,percent of total billed charges,,,90,,58.68,percent of total billed charges,,,,,,,no IP contract,,80,,52.16,percent of total billed charges,,,,,,,no IP contract,,50,,32.6,percent of total billed charges,,,,,,no IP contract,,,78,,50.86,percent of total billed charges,,,70,,45.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.95,3324,
00093-4148-64 - levalbuterol 1.25 mg/3 mL Soln,00093-4148-64,NDC,,,,inpatient,3,ML,65.2,39.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,52.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,55.42,percent of total billed charges,,,85,,55.42,percent of total billed charges,,,49,,31.95,percent of total billed charges,,,90,,58.68,percent of total billed charges,,,,,,,no IP contract,,80,,52.16,percent of total billed charges,,,,,,,no IP contract,,50,,32.6,percent of total billed charges,,,,,,no IP contract,,,78,,50.86,percent of total billed charges,,,70,,45.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.95,3324,
00093-4177-73 - cephalexin 250 mg/5 mL REC P,00093-4177-73,NDC,,,,inpatient,1,ML,7,4.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.95,percent of total billed charges,,,85,,5.95,percent of total billed charges,,,49,,3.43,percent of total billed charges,,,90,,6.3,percent of total billed charges,,,,,,,no IP contract,,80,,5.6,percent of total billed charges,,,,,,,no IP contract,,50,,3.5,percent of total billed charges,,,,,,no IP contract,,,78,,5.46,percent of total billed charges,,,70,,4.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.43,3324,
00093-4740-01 - citalopram 10 mg Tab,00093-4740-01,NDC,,,,inpatient,1,EA,22.35,13.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19,percent of total billed charges,,,85,,19,percent of total billed charges,,,49,,10.95,percent of total billed charges,,,90,,20.12,percent of total billed charges,,,,,,,no IP contract,,80,,17.88,percent of total billed charges,,,,,,,no IP contract,,50,,11.18,percent of total billed charges,,,,,,no IP contract,,,78,,17.43,percent of total billed charges,,,70,,15.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.95,3324,
00093-4740-93 - citalopram 10 mg Tab,00093-4740-93,NDC,,,,inpatient,1,EA,22.5,13.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.13,percent of total billed charges,,,85,,19.13,percent of total billed charges,,,49,,11.03,percent of total billed charges,,,90,,20.25,percent of total billed charges,,,,,,,no IP contract,,80,,18,percent of total billed charges,,,,,,,no IP contract,,50,,11.25,percent of total billed charges,,,,,,no IP contract,,,78,,17.55,percent of total billed charges,,,70,,15.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.03,3324,
00093-5058-98 - atorvastatin 40 mg Tab,00093-5058-98,NDC,,,,inpatient,1,EA,88.9,53.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,72.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,75.57,percent of total billed charges,,,85,,75.57,percent of total billed charges,,,49,,43.56,percent of total billed charges,,,90,,80.01,percent of total billed charges,,,,,,,no IP contract,,80,,71.12,percent of total billed charges,,,,,,,no IP contract,,50,,44.45,percent of total billed charges,,,,,,no IP contract,,,78,,69.34,percent of total billed charges,,,70,,62.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,43.56,3324,
00093-5060-01 - hydrOXYzine hydrochloride 10 mg Tab,00093-5060-01,NDC,,,,inpatient,1,EA,9,5.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.65,percent of total billed charges,,,85,,7.65,percent of total billed charges,,,49,,4.41,percent of total billed charges,,,90,,8.1,percent of total billed charges,,,,,,,no IP contract,,80,,7.2,percent of total billed charges,,,,,,,no IP contract,,50,,4.5,percent of total billed charges,,,,,,no IP contract,,,78,,7.02,percent of total billed charges,,,70,,6.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.41,3324,
00093-5172-44 - alendronate 35 mg Tab,00093-5172-44,NDC,,,,inpatient,1,EA,166.7,100.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,135.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,141.7,percent of total billed charges,,,85,,141.7,percent of total billed charges,,,49,,81.68,percent of total billed charges,,,90,,150.03,percent of total billed charges,,,,,,,no IP contract,,80,,133.36,percent of total billed charges,,,,,,,no IP contract,,50,,83.35,percent of total billed charges,,,,,,no IP contract,,,78,,130.03,percent of total billed charges,,,70,,116.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,81.68,3324,
00093-5207-01 - oxybutynin 10 mg/24 hr ER Ta,00093-5207-01,NDC,,,,inpatient,1,EA,30,18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.5,percent of total billed charges,,,85,,25.5,percent of total billed charges,,,49,,14.7,percent of total billed charges,,,90,,27,percent of total billed charges,,,,,,,no IP contract,,80,,24,percent of total billed charges,,,,,,,no IP contract,,50,,15,percent of total billed charges,,,,,,no IP contract,,,78,,23.4,percent of total billed charges,,,70,,21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.7,3324,
00093-5268-01 - zaleplon 5 mg Cap,00093-5268-01,NDC,,,,inpatient,1,EA,36.15,21.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.73,percent of total billed charges,,,85,,30.73,percent of total billed charges,,,49,,17.71,percent of total billed charges,,,90,,32.54,percent of total billed charges,,,,,,,no IP contract,,80,,28.92,percent of total billed charges,,,,,,,no IP contract,,50,,18.08,percent of total billed charges,,,,,,no IP contract,,,78,,28.2,percent of total billed charges,,,70,,25.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.71,3324,
00093-5275-01 - dexmethylphenidate 2.5 mg Tab,00093-5275-01,NDC,,,,inpatient,1,EA,11.1,6.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.44,percent of total billed charges,,,85,,9.44,percent of total billed charges,,,49,,5.44,percent of total billed charges,,,90,,9.99,percent of total billed charges,,,,,,,no IP contract,,80,,8.88,percent of total billed charges,,,,,,,no IP contract,,50,,5.55,percent of total billed charges,,,,,,no IP contract,,,78,,8.66,percent of total billed charges,,,70,,7.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.44,3324,
00093-5354-01 - progesterone 200 mg Cap,00093-5354-01,NDC,,,,inpatient,1,EA,36,21.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.6,percent of total billed charges,,,85,,30.6,percent of total billed charges,,,49,,17.64,percent of total billed charges,,,90,,32.4,percent of total billed charges,,,,,,,no IP contract,,80,,28.8,percent of total billed charges,,,,,,,no IP contract,,50,,18,percent of total billed charges,,,,,,no IP contract,,,78,,28.08,percent of total billed charges,,,70,,25.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.64,3324,
00093-5401-89 - omega-3 polyunsaturated fatty acids ethyl esters 1000 mg Cap,00093-5401-89,NDC,,,,inpatient,1,EA,20.3,12.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.26,percent of total billed charges,,,85,,17.26,percent of total billed charges,,,49,,9.95,percent of total billed charges,,,90,,18.27,percent of total billed charges,,,,,,,no IP contract,,80,,16.24,percent of total billed charges,,,,,,,no IP contract,,50,,10.15,percent of total billed charges,,,,,,no IP contract,,,78,,15.83,percent of total billed charges,,,70,,14.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.95,3324,
00093-5420-88 - cabergoline 0.5 mg Tab,00093-5420-88,NDC,,,,inpatient,1,EA,295.25,177.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,239.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,250.96,percent of total billed charges,,,85,,250.96,percent of total billed charges,,,49,,144.67,percent of total billed charges,,,90,,265.73,percent of total billed charges,,,,,,,no IP contract,,80,,236.2,percent of total billed charges,,,,,,,no IP contract,,50,,147.63,percent of total billed charges,,,,,,no IP contract,,,78,,230.3,percent of total billed charges,,,70,,206.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,144.67,3324,
00093-5537-56 - eszopiclone 1 mg Tab,00093-5537-56,NDC,,,,inpatient,1,EA,102.65,61.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,83.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,87.25,percent of total billed charges,,,85,,87.25,percent of total billed charges,,,49,,50.3,percent of total billed charges,,,90,,92.39,percent of total billed charges,,,,,,,no IP contract,,80,,82.12,percent of total billed charges,,,,,,,no IP contract,,50,,51.33,percent of total billed charges,,,,,,no IP contract,,,78,,80.07,percent of total billed charges,,,70,,71.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,50.3,3324,
00093-5740-65 - cycloSPORINE modified 25 mg Cap,00093-5740-65,NDC,,,,inpatient,1,EA,14.8,8.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.58,percent of total billed charges,,,85,,12.58,percent of total billed charges,,,49,,7.25,percent of total billed charges,,,90,,13.32,percent of total billed charges,,,,,,,no IP contract,,80,,11.84,percent of total billed charges,,,,,,,no IP contract,,50,,7.4,percent of total billed charges,,,,,,no IP contract,,,78,,11.54,percent of total billed charges,,,70,,10.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.25,3324,
00093-5768-56 - OLANZapine 5 mg Tab,00093-5768-56,NDC,,,,inpatient,1,EA,108.9,65.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,88.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,92.57,percent of total billed charges,,,85,,92.57,percent of total billed charges,,,49,,53.36,percent of total billed charges,,,90,,98.01,percent of total billed charges,,,,,,,no IP contract,,80,,87.12,percent of total billed charges,,,,,,,no IP contract,,50,,54.45,percent of total billed charges,,,,,,no IP contract,,,78,,84.94,percent of total billed charges,,,70,,76.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,53.36,3324,
00093-5786-56 - entecavir 0.5 mg Tab,00093-5786-56,NDC,,,,inpatient,1,EA,357.1,214.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,289.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,303.54,percent of total billed charges,,,85,,303.54,percent of total billed charges,,,49,,174.98,percent of total billed charges,,,90,,321.39,percent of total billed charges,,,,,,,no IP contract,,80,,285.68,percent of total billed charges,,,,,,,no IP contract,,50,,178.55,percent of total billed charges,,,,,,no IP contract,,,78,,278.54,percent of total billed charges,,,70,,249.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,174.98,3324,
00093-5907-86 - mesalamine 400 mg DR Ca,00093-5907-86,NDC,,,,inpatient,1,EA,38.95,23.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.11,percent of total billed charges,,,85,,33.11,percent of total billed charges,,,49,,19.09,percent of total billed charges,,,90,,35.06,percent of total billed charges,,,,,,,no IP contract,,80,,31.16,percent of total billed charges,,,,,,,no IP contract,,50,,19.48,percent of total billed charges,,,,,,no IP contract,,,78,,30.38,percent of total billed charges,,,70,,27.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.09,3324,
00093-6137-32 - diazepam 2.5 mg Kit,00093-6137-32,NDC,,,,inpatient,1,EA,2351.05,1410.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1904.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1998.39,percent of total billed charges,,,85,,1998.39,percent of total billed charges,,,49,,1152.01,percent of total billed charges,,,90,,2115.95,percent of total billed charges,,,,,,,no IP contract,,80,,1880.84,percent of total billed charges,,,,,,,no IP contract,,50,,1175.53,percent of total billed charges,,,,,,no IP contract,,,78,,1833.82,percent of total billed charges,,,70,,1645.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
00093-6138-32 - diazepam 10 mg Kit,00093-6138-32,NDC,,,,inpatient,1,EA,2676.7,1606.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2168.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2275.2,percent of total billed charges,,,85,,2275.2,percent of total billed charges,,,49,,1311.58,percent of total billed charges,,,90,,2409.03,percent of total billed charges,,,,,,,no IP contract,,80,,2141.36,percent of total billed charges,,,,,,,no IP contract,,50,,1338.35,percent of total billed charges,,,,,,no IP contract,,,78,,2087.83,percent of total billed charges,,,70,,1873.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
00093-6139-32 - diazepam 20 mg Kit,00093-6139-32,NDC,,,,inpatient,1,EA,2676.7,1606.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2168.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2275.2,percent of total billed charges,,,85,,2275.2,percent of total billed charges,,,49,,1311.58,percent of total billed charges,,,90,,2409.03,percent of total billed charges,,,,,,,no IP contract,,80,,2141.36,percent of total billed charges,,,,,,,no IP contract,,50,,1338.35,percent of total billed charges,,,,,,no IP contract,,,78,,2087.83,percent of total billed charges,,,70,,1873.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
00093-6816-73 - budesonide 0.5 mg/2 mL Susp,00093-6816-73,NDC,,,,inpatient,2,ML,101.5,60.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,82.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,86.28,percent of total billed charges,,,85,,86.28,percent of total billed charges,,,49,,49.74,percent of total billed charges,,,90,,91.35,percent of total billed charges,,,,,,,no IP contract,,80,,81.2,percent of total billed charges,,,,,,,no IP contract,,50,,50.75,percent of total billed charges,,,,,,no IP contract,,,78,,79.17,percent of total billed charges,,,70,,71.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,49.74,3324,
00093-7128-01 - torsemide 10 mg Tab,00093-7128-01,NDC,,,,inpatient,1,EA,9.4,5.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.99,percent of total billed charges,,,85,,7.99,percent of total billed charges,,,49,,4.61,percent of total billed charges,,,90,,8.46,percent of total billed charges,,,,,,,no IP contract,,80,,7.52,percent of total billed charges,,,,,,,no IP contract,,50,,4.7,percent of total billed charges,,,,,,no IP contract,,,78,,7.33,percent of total billed charges,,,70,,6.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.61,3324,
00093-7164-56 - tolterodine 4 mg ER Ca,00093-7164-56,NDC,,,,inpatient,1,EA,67.75,40.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,54.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,57.59,percent of total billed charges,,,85,,57.59,percent of total billed charges,,,49,,33.2,percent of total billed charges,,,90,,60.98,percent of total billed charges,,,,,,,no IP contract,,80,,54.2,percent of total billed charges,,,,,,,no IP contract,,50,,33.88,percent of total billed charges,,,,,,no IP contract,,,78,,52.85,percent of total billed charges,,,70,,47.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,33.2,3324,
00093-7254-01 - glimepiride 1 mg Tab,00093-7254-01,NDC,,,,inpatient,1,EA,7,4.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.95,percent of total billed charges,,,85,,5.95,percent of total billed charges,,,49,,3.43,percent of total billed charges,,,90,,6.3,percent of total billed charges,,,,,,,no IP contract,,80,,5.6,percent of total billed charges,,,,,,,no IP contract,,50,,3.5,percent of total billed charges,,,,,,no IP contract,,,78,,5.46,percent of total billed charges,,,70,,4.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.43,3324,
00093-7273-98 - pioglitazone 45 mg Tab,00093-7273-98,NDC,,,,inpatient,1,EA,96.3,57.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,81.86,percent of total billed charges,,,85,,81.86,percent of total billed charges,,,49,,47.19,percent of total billed charges,,,90,,86.67,percent of total billed charges,,,,,,,no IP contract,,80,,77.04,percent of total billed charges,,,,,,,no IP contract,,50,,48.15,percent of total billed charges,,,,,,no IP contract,,,78,,75.11,percent of total billed charges,,,70,,67.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,47.19,3324,
00093-7334-01 - mycophenolate mofetil 250 mg Cap,00093-7334-01,NDC,,,,inpatient,1,EA,35.4,21.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.09,percent of total billed charges,,,85,,30.09,percent of total billed charges,,,49,,17.35,percent of total billed charges,,,90,,31.86,percent of total billed charges,,,,,,,no IP contract,,80,,28.32,percent of total billed charges,,,,,,,no IP contract,,50,,17.7,percent of total billed charges,,,,,,no IP contract,,,78,,27.61,percent of total billed charges,,,70,,24.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.35,3324,
00093-7336-06 - topiramate 25 mg Cap,00093-7336-06,NDC,,,,inpatient,1,EA,27.05,16.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.99,percent of total billed charges,,,85,,22.99,percent of total billed charges,,,49,,13.25,percent of total billed charges,,,90,,24.35,percent of total billed charges,,,,,,,no IP contract,,80,,21.64,percent of total billed charges,,,,,,,no IP contract,,50,,13.53,percent of total billed charges,,,,,,no IP contract,,,78,,21.1,percent of total billed charges,,,70,,18.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.25,3324,
00093-7385-98 - venlafaxine 75 mg ER Capsule,00093-7385-98,NDC,,,,inpatient,1,EA,40.95,24.57,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34.81,percent of total billed charges,,,85,,34.81,percent of total billed charges,,,49,,20.07,percent of total billed charges,,,90,,36.86,percent of total billed charges,,,,,,,no IP contract,,80,,32.76,percent of total billed charges,,,,,,,no IP contract,,50,,20.48,percent of total billed charges,,,,,,no IP contract,,,78,,31.94,percent of total billed charges,,,70,,28.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.07,3324,
00093-7392-98 - niacin 500 mg ER Ta,00093-7392-98,NDC,,,,inpatient,1,EA,37.55,22.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.92,percent of total billed charges,,,85,,31.92,percent of total billed charges,,,49,,18.4,percent of total billed charges,,,90,,33.8,percent of total billed charges,,,,,,,no IP contract,,80,,30.04,percent of total billed charges,,,,,,,no IP contract,,50,,18.78,percent of total billed charges,,,,,,no IP contract,,,78,,29.29,percent of total billed charges,,,70,,26.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.4,3324,
00093-7424-98 - montelukast 4 mg Chew,00093-7424-98,NDC,,,,inpatient,1,EA,48.8,29.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,39.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,41.48,percent of total billed charges,,,85,,41.48,percent of total billed charges,,,49,,23.91,percent of total billed charges,,,90,,43.92,percent of total billed charges,,,,,,,no IP contract,,80,,39.04,percent of total billed charges,,,,,,,no IP contract,,50,,24.4,percent of total billed charges,,,,,,no IP contract,,,78,,38.06,percent of total billed charges,,,70,,34.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.91,3324,
00093-7425-56 - montelukast 5 mg Chew,00093-7425-56,NDC,,,,inpatient,1,EA,48.8,29.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,39.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,41.48,percent of total billed charges,,,85,,41.48,percent of total billed charges,,,49,,23.91,percent of total billed charges,,,90,,43.92,percent of total billed charges,,,,,,,no IP contract,,80,,39.04,percent of total billed charges,,,,,,,no IP contract,,50,,24.4,percent of total billed charges,,,,,,no IP contract,,,78,,38.06,percent of total billed charges,,,70,,34.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.91,3324,
00093-7425-98 - montelukast 5 mg Chew,00093-7425-98,NDC,,,,inpatient,1,EA,48.8,29.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,39.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,41.48,percent of total billed charges,,,85,,41.48,percent of total billed charges,,,49,,23.91,percent of total billed charges,,,90,,43.92,percent of total billed charges,,,,,,,no IP contract,,80,,39.04,percent of total billed charges,,,,,,,no IP contract,,50,,24.4,percent of total billed charges,,,,,,no IP contract,,,78,,38.06,percent of total billed charges,,,70,,34.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.91,3324,
00093-7439-01 - divalproex sodium 125 mg EC Ta,00093-7439-01,NDC,,,,inpatient,1,EA,11,6.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.35,percent of total billed charges,,,85,,9.35,percent of total billed charges,,,49,,5.39,percent of total billed charges,,,90,,9.9,percent of total billed charges,,,,,,,no IP contract,,80,,8.8,percent of total billed charges,,,,,,,no IP contract,,50,,5.5,percent of total billed charges,,,,,,no IP contract,,,78,,8.58,percent of total billed charges,,,70,,7.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.39,3324,
00093-7440-01 - divalproex sodium 250 mg EC Ta,00093-7440-01,NDC,,,,inpatient,1,EA,17.8,10.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.13,percent of total billed charges,,,85,,15.13,percent of total billed charges,,,49,,8.72,percent of total billed charges,,,90,,16.02,percent of total billed charges,,,,,,,no IP contract,,80,,14.24,percent of total billed charges,,,,,,,no IP contract,,50,,8.9,percent of total billed charges,,,,,,no IP contract,,,78,,13.88,percent of total billed charges,,,70,,12.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.72,3324,
00093-7572-98 - rosuvastatin 20 mg Tab,00093-7572-98,NDC,,,,inpatient,1,EA,74.9,44.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63.67,percent of total billed charges,,,85,,63.67,percent of total billed charges,,,49,,36.7,percent of total billed charges,,,90,,67.41,percent of total billed charges,,,,,,,no IP contract,,80,,59.92,percent of total billed charges,,,,,,,no IP contract,,50,,37.45,percent of total billed charges,,,,,,no IP contract,,,78,,58.42,percent of total billed charges,,,70,,52.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.7,3324,
00093-7599-41 - temozolomide 5 mg Cap,00093-7599-41,NDC,,,,inpatient,1,EA,100.75,60.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,81.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,85.64,percent of total billed charges,,,85,,85.64,percent of total billed charges,,,49,,49.37,percent of total billed charges,,,90,,90.68,percent of total billed charges,,,,,,,no IP contract,,80,,80.6,percent of total billed charges,,,,,,,no IP contract,,50,,50.38,percent of total billed charges,,,,,,no IP contract,,,78,,78.59,percent of total billed charges,,,70,,70.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,49.37,3324,
00093-7601-41 - temozolomide 100 mg Cap,00093-7601-41,NDC,,,,inpatient,1,EA,1931.55,1158.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1564.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1641.82,percent of total billed charges,,,85,,1641.82,percent of total billed charges,,,49,,946.46,percent of total billed charges,,,90,,1738.4,percent of total billed charges,,,,,,,no IP contract,,80,,1545.24,percent of total billed charges,,,,,,,no IP contract,,50,,965.78,percent of total billed charges,,,,,,no IP contract,,,78,,1506.61,percent of total billed charges,,,70,,1352.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,946.46,3324,
00093-7620-56 - letrozole 2.5 mg Tab,00093-7620-56,NDC,,,,inpatient,1,EA,147.95,88.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,119.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,125.76,percent of total billed charges,,,85,,125.76,percent of total billed charges,,,49,,72.5,percent of total billed charges,,,90,,133.16,percent of total billed charges,,,,,,,no IP contract,,80,,118.36,percent of total billed charges,,,,,,,no IP contract,,50,,73.98,percent of total billed charges,,,,,,no IP contract,,,78,,115.4,percent of total billed charges,,,70,,103.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,72.5,3324,
00093-7704-56 - emtricitabine-tenofovir 200 mg-300 mg Tab,00093-7704-56,NDC,,,,inpatient,1,EA,560.4,336.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,453.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,476.34,percent of total billed charges,,,85,,476.34,percent of total billed charges,,,49,,274.6,percent of total billed charges,,,90,,504.36,percent of total billed charges,,,,,,,no IP contract,,80,,448.32,percent of total billed charges,,,,,,,no IP contract,,50,,280.2,percent of total billed charges,,,,,,no IP contract,,,78,,437.11,percent of total billed charges,,,70,,392.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,274.6,3324,
00093-7772-93 - clozapine 100 mg Tab,00093-7772-93,NDC,,,,inpatient,1,EA,31.1,18.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,25.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.44,percent of total billed charges,,,85,,26.44,percent of total billed charges,,,49,,15.24,percent of total billed charges,,,90,,27.99,percent of total billed charges,,,,,,,no IP contract,,80,,24.88,percent of total billed charges,,,,,,,no IP contract,,50,,15.55,percent of total billed charges,,,,,,no IP contract,,,78,,24.26,percent of total billed charges,,,70,,21.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.24,3324,
00093-8035-01 - glyBURIDE micronized 3 mg Tab,00093-8035-01,NDC,,,,inpatient,1,EA,8.6,5.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.31,percent of total billed charges,,,85,,7.31,percent of total billed charges,,,49,,4.21,percent of total billed charges,,,90,,7.74,percent of total billed charges,,,,,,,no IP contract,,80,,6.88,percent of total billed charges,,,,,,,no IP contract,,50,,4.3,percent of total billed charges,,,,,,no IP contract,,,78,,6.71,percent of total billed charges,,,70,,6.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.21,3324,
00093-8123-01 - doxazosin 8 mg Tab,00093-8123-01,NDC,,,,inpatient,1,EA,11.95,7.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.16,percent of total billed charges,,,85,,10.16,percent of total billed charges,,,49,,5.86,percent of total billed charges,,,90,,10.76,percent of total billed charges,,,,,,,no IP contract,,80,,9.56,percent of total billed charges,,,,,,,no IP contract,,50,,5.98,percent of total billed charges,,,,,,no IP contract,,,78,,9.32,percent of total billed charges,,,70,,8.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.86,3324,
00093-8343-01 - glyBURIDE 2.5 mg Tab,00093-8343-01,NDC,,,,inpatient,1,EA,7.5,4.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.38,percent of total billed charges,,,85,,6.38,percent of total billed charges,,,49,,3.68,percent of total billed charges,,,90,,6.75,percent of total billed charges,,,,,,,no IP contract,,80,,6,percent of total billed charges,,,,,,,no IP contract,,50,,3.75,percent of total billed charges,,,,,,no IP contract,,,78,,5.85,percent of total billed charges,,,70,,5.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.68,3324,
00093-8739-01 - mexiletine 150 mg Cap,00093-8739-01,NDC,,,,inpatient,1,EA,11,6.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.35,percent of total billed charges,,,85,,9.35,percent of total billed charges,,,49,,5.39,percent of total billed charges,,,90,,9.9,percent of total billed charges,,,,,,,no IP contract,,80,,8.8,percent of total billed charges,,,,,,,no IP contract,,50,,5.5,percent of total billed charges,,,,,,no IP contract,,,78,,8.58,percent of total billed charges,,,70,,7.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.39,3324,
00093-8740-01 - mexiletine 200 mg Cap,00093-8740-01,NDC,,,,inpatient,1,EA,16.45,9.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.98,percent of total billed charges,,,85,,13.98,percent of total billed charges,,,49,,8.06,percent of total billed charges,,,90,,14.81,percent of total billed charges,,,,,,,no IP contract,,80,,13.16,percent of total billed charges,,,,,,,no IP contract,,50,,8.23,percent of total billed charges,,,,,,no IP contract,,,78,,12.83,percent of total billed charges,,,70,,11.52,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.06,3324,
00093-8947-01 - acyclovir 800 mg Tab,00093-8947-01,NDC,,,,inpatient,1,EA,33,19.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,26.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.05,percent of total billed charges,,,85,,28.05,percent of total billed charges,,,49,,16.17,percent of total billed charges,,,90,,29.7,percent of total billed charges,,,,,,,no IP contract,,80,,26.4,percent of total billed charges,,,,,,,no IP contract,,50,,16.5,percent of total billed charges,,,,,,no IP contract,,,78,,25.74,percent of total billed charges,,,70,,23.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.17,3324,
00093-8947-05 - acyclovir 800 mg Tab,00093-8947-05,NDC,,,,inpatient,1,EA,31.65,18.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,25.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.9,percent of total billed charges,,,85,,26.9,percent of total billed charges,,,49,,15.51,percent of total billed charges,,,90,,28.49,percent of total billed charges,,,,,,,no IP contract,,80,,25.32,percent of total billed charges,,,,,,,no IP contract,,50,,15.83,percent of total billed charges,,,,,,no IP contract,,,78,,24.69,percent of total billed charges,,,70,,22.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.51,3324,
00093-9018-65 - cycloSPORINE modified 25 mg Cap,00093-9018-65,NDC,,,,inpatient,1,EA,14.8,8.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.58,percent of total billed charges,,,85,,12.58,percent of total billed charges,,,49,,7.25,percent of total billed charges,,,90,,13.32,percent of total billed charges,,,,,,,no IP contract,,80,,11.84,percent of total billed charges,,,,,,,no IP contract,,50,,7.4,percent of total billed charges,,,,,,no IP contract,,,78,,11.54,percent of total billed charges,,,70,,10.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.25,3324,
00093-9020-65 - cycloSPORINE  100 mg Cap,00093-9020-65,NDC,,,,inpatient,1,EA,47.55,28.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,38.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,40.42,percent of total billed charges,,,85,,40.42,percent of total billed charges,,,49,,23.3,percent of total billed charges,,,90,,42.8,percent of total billed charges,,,,,,,no IP contract,,80,,38.04,percent of total billed charges,,,,,,,no IP contract,,50,,23.78,percent of total billed charges,,,,,,no IP contract,,,78,,37.09,percent of total billed charges,,,70,,33.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.3,3324,
venlafaxine 37.5 mg Tab,00093-9148-01,NDC,,,,inpatient,1,EA,19.7,11.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.75,percent of total billed charges,,,85,,16.75,percent of total billed charges,,,49,,9.65,percent of total billed charges,,,90,,17.73,percent of total billed charges,,,,,,,no IP contract,,80,,15.76,percent of total billed charges,,,,,,,no IP contract,,50,,9.85,percent of total billed charges,,,,,,no IP contract,,,78,,15.37,percent of total billed charges,,,70,,13.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.65,3324,
00093-9292-67 - clonazePAM 0.5 mg DIS T,00093-9292-67,NDC,,,,inpatient,1,EA,16.25,9.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.81,percent of total billed charges,,,85,,13.81,percent of total billed charges,,,49,,7.96,percent of total billed charges,,,90,,14.63,percent of total billed charges,,,,,,,no IP contract,,80,,13,percent of total billed charges,,,,,,,no IP contract,,50,,8.13,percent of total billed charges,,,,,,no IP contract,,,78,,12.68,percent of total billed charges,,,70,,11.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.96,3324,
00093-9643-01 - prochlorperazine 5 mg Tab,00093-9643-01,NDC,,,,inpatient,1,EA,8.35,5.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.1,percent of total billed charges,,,85,,7.1,percent of total billed charges,,,49,,4.09,percent of total billed charges,,,90,,7.52,percent of total billed charges,,,,,,,no IP contract,,80,,6.68,percent of total billed charges,,,,,,,no IP contract,,50,,4.18,percent of total billed charges,,,,,,no IP contract,,,78,,6.51,percent of total billed charges,,,70,,5.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.09,3324,
00093-9701-01 - carbidopa-levodopa 10 mg-100 mg Tab,00093-9701-01,NDC,,,,inpatient,1,EA,9.95,5.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.46,percent of total billed charges,,,85,,8.46,percent of total billed charges,,,49,,4.88,percent of total billed charges,,,90,,8.96,percent of total billed charges,,,,,,,no IP contract,,80,,7.96,percent of total billed charges,,,,,,,no IP contract,,50,,4.98,percent of total billed charges,,,,,,no IP contract,,,78,,7.76,percent of total billed charges,,,70,,6.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.88,3324,
00093-9702-01 - carbidopa-levodopa 25 mg-100 mg Tab,00093-9702-01,NDC,,,,inpatient,1,EA,10.75,6.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.14,percent of total billed charges,,,85,,9.14,percent of total billed charges,,,49,,5.27,percent of total billed charges,,,90,,9.68,percent of total billed charges,,,,,,,no IP contract,,80,,8.6,percent of total billed charges,,,,,,,no IP contract,,50,,5.38,percent of total billed charges,,,,,,no IP contract,,,78,,8.39,percent of total billed charges,,,70,,7.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.27,3324,
00115-1232-01 - oxymorphone 10 mg ER Ta,00115-1232-01,NDC,,,,inpatient,1,EA,34.4,20.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.24,percent of total billed charges,,,85,,29.24,percent of total billed charges,,,49,,16.86,percent of total billed charges,,,90,,30.96,percent of total billed charges,,,,,,,no IP contract,,80,,27.52,percent of total billed charges,,,,,,,no IP contract,,50,,17.2,percent of total billed charges,,,,,,no IP contract,,,78,,26.83,percent of total billed charges,,,70,,24.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.86,3324,
00115-1315-01 - oxymorphone 7.5 mg ER Ta,00115-1315-01,NDC,,,,inpatient,1,EA,27.5,16.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.38,percent of total billed charges,,,85,,23.38,percent of total billed charges,,,49,,13.48,percent of total billed charges,,,90,,24.75,percent of total billed charges,,,,,,,no IP contract,,80,,22,percent of total billed charges,,,,,,,no IP contract,,50,,13.75,percent of total billed charges,,,,,,no IP contract,,,78,,21.45,percent of total billed charges,,,70,,19.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.48,3324,
00115-1315-13 - oxyMORphone 7.5 mg ER Ta,00115-1315-13,NDC,,,,inpatient,1,EA,35.75,21.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.39,percent of total billed charges,,,85,,30.39,percent of total billed charges,,,49,,17.52,percent of total billed charges,,,90,,32.18,percent of total billed charges,,,,,,,no IP contract,,80,,28.6,percent of total billed charges,,,,,,,no IP contract,,50,,17.88,percent of total billed charges,,,,,,no IP contract,,,78,,27.89,percent of total billed charges,,,70,,25.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.52,3324,
00115-1366-29 - sevelamer carbonate 2.4 g REC P,00115-1366-29,NDC,,,,inpatient,60,ML,156.85,94.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,127.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,133.32,percent of total billed charges,,,85,,133.32,percent of total billed charges,,,49,,76.86,percent of total billed charges,,,90,,141.17,percent of total billed charges,,,,,,,no IP contract,,80,,125.48,percent of total billed charges,,,,,,,no IP contract,,50,,78.43,percent of total billed charges,,,,,,no IP contract,,,78,,122.34,percent of total billed charges,,,70,,109.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,76.86,3324,
00115-1468-45 - lidocaine-prilocaine topical 2.5%-2.5% Cream,00115-1468-45,NDC,,,,inpatient,1,UN,394.05,236.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,319.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,334.94,percent of total billed charges,,,85,,334.94,percent of total billed charges,,,49,,193.08,percent of total billed charges,,,90,,354.65,percent of total billed charges,,,,,,,no IP contract,,80,,315.24,percent of total billed charges,,,,,,,no IP contract,,50,,197.03,percent of total billed charges,,,,,,no IP contract,,,78,,307.36,percent of total billed charges,,,70,,275.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,193.08,3324,
00115-1659-01 - propranolol 10 mg Tab,00115-1659-01,NDC,,,,inpatient,1,EA,7.1,4.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.04,percent of total billed charges,,,85,,6.04,percent of total billed charges,,,49,,3.48,percent of total billed charges,,,90,,6.39,percent of total billed charges,,,,,,,no IP contract,,80,,5.68,percent of total billed charges,,,,,,,no IP contract,,50,,3.55,percent of total billed charges,,,,,,no IP contract,,,78,,5.54,percent of total billed charges,,,70,,4.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.48,3324,
00115-1660-01 - propranolol 20 mg Tab,00115-1660-01,NDC,,,,inpatient,1,EA,7.9,4.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.72,percent of total billed charges,,,85,,6.72,percent of total billed charges,,,49,,3.87,percent of total billed charges,,,90,,7.11,percent of total billed charges,,,,,,,no IP contract,,80,,6.32,percent of total billed charges,,,,,,,no IP contract,,50,,3.95,percent of total billed charges,,,,,,no IP contract,,,78,,6.16,percent of total billed charges,,,70,,5.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.87,3324,
00115-1687-74 - budesonide 0.25 mg/2 mL Susp,00115-1687-74,NDC,,,,inpatient,2,ML,87.7,52.62,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,71.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,74.55,percent of total billed charges,,,85,,74.55,percent of total billed charges,,,49,,42.97,percent of total billed charges,,,90,,78.93,percent of total billed charges,,,,,,,no IP contract,,80,,70.16,percent of total billed charges,,,,,,,no IP contract,,50,,43.85,percent of total billed charges,,,,,,no IP contract,,,78,,68.41,percent of total billed charges,,,70,,61.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,42.97,3324,
00115-1694-49 - EPINEPHrine 0.3 mg Kit,00115-1694-49,NDC,,,,inpatient,1,EA,2121.4,1272.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1718.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1803.19,percent of total billed charges,,,85,,1803.19,percent of total billed charges,,,49,,1039.49,percent of total billed charges,,,90,,1909.26,percent of total billed charges,,,,,,,no IP contract,,80,,1697.12,percent of total billed charges,,,,,,,no IP contract,,50,,1060.7,percent of total billed charges,,,,,,no IP contract,,,78,,1654.69,percent of total billed charges,,,70,,1484.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
00115-1697-01 - hydrocortisone 10 mg Tab,00115-1697-01,NDC,,,,inpatient,1,EA,8.35,5.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.1,percent of total billed charges,,,85,,7.1,percent of total billed charges,,,49,,4.09,percent of total billed charges,,,90,,7.52,percent of total billed charges,,,,,,,no IP contract,,80,,6.68,percent of total billed charges,,,,,,,no IP contract,,50,,4.18,percent of total billed charges,,,,,,no IP contract,,,78,,6.51,percent of total billed charges,,,70,,5.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.09,3324,
00115-2622-01 - terbutaline 5 mg Tab,00115-2622-01,NDC,,,,inpatient,1,EA,8.75,5.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.44,percent of total billed charges,,,85,,7.44,percent of total billed charges,,,49,,4.29,percent of total billed charges,,,90,,7.88,percent of total billed charges,,,,,,,no IP contract,,80,,7,percent of total billed charges,,,,,,,no IP contract,,50,,4.38,percent of total billed charges,,,,,,no IP contract,,,78,,6.83,percent of total billed charges,,,70,,6.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.29,3324,
00115-4411-01 - dantrolene 25 mg Cap,00115-4411-01,NDC,,,,inpatient,1,EA,12.35,7.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.5,percent of total billed charges,,,85,,10.5,percent of total billed charges,,,49,,6.05,percent of total billed charges,,,90,,11.12,percent of total billed charges,,,,,,,no IP contract,,80,,9.88,percent of total billed charges,,,,,,,no IP contract,,50,,6.18,percent of total billed charges,,,,,,no IP contract,,,78,,9.63,percent of total billed charges,,,70,,8.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.05,3324,
00115-4422-01 - dantrolene 50 mg Cap,00115-4422-01,NDC,,,,inpatient,1,EA,16.55,9.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.07,percent of total billed charges,,,85,,14.07,percent of total billed charges,,,49,,8.11,percent of total billed charges,,,90,,14.9,percent of total billed charges,,,,,,,no IP contract,,80,,13.24,percent of total billed charges,,,,,,,no IP contract,,50,,8.28,percent of total billed charges,,,,,,no IP contract,,,78,,12.91,percent of total billed charges,,,70,,11.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.11,3324,
00115-4433-01 - dantrolene 100 mg Cap,00115-4433-01,NDC,,,,inpatient,1,EA,21.1,12.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.94,percent of total billed charges,,,85,,17.94,percent of total billed charges,,,49,,10.34,percent of total billed charges,,,90,,18.99,percent of total billed charges,,,,,,,no IP contract,,80,,16.88,percent of total billed charges,,,,,,,no IP contract,,50,,10.55,percent of total billed charges,,,,,,no IP contract,,,78,,16.46,percent of total billed charges,,,70,,14.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.34,3324,
00121-0431-30 - magnesium hydroxide 8% Susp,00121-0431-30,NDC,,,,inpatient,30,ML,12.9,7.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.97,percent of total billed charges,,,85,,10.97,percent of total billed charges,,,49,,6.32,percent of total billed charges,,,90,,11.61,percent of total billed charges,,,,,,,no IP contract,,80,,10.32,percent of total billed charges,,,,,,,no IP contract,,50,,6.45,percent of total billed charges,,,,,,no IP contract,,,78,,10.06,percent of total billed charges,,,70,,9.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.32,3324,
00121-0489-10 - diphenhydrAMINE 12.5 mg/5 mL LIQ,00121-0489-10,NDC,,,,inpatient,10,ML,12.9,7.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.97,percent of total billed charges,,,85,,10.97,percent of total billed charges,,,49,,6.32,percent of total billed charges,,,90,,11.61,percent of total billed charges,,,,,,,no IP contract,,80,,10.32,percent of total billed charges,,,,,,,no IP contract,,50,,6.45,percent of total billed charges,,,,,,no IP contract,,,78,,10.06,percent of total billed charges,,,70,,9.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.32,3324,
00121-0504-05 - acetaminophen-codeine 120 mg-12 mg/5 mL LIQ,00121-0504-05,NDC,,,,inpatient,5,ML,11.25,6.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.56,percent of total billed charges,,,85,,9.56,percent of total billed charges,,,49,,5.51,percent of total billed charges,,,90,,10.13,percent of total billed charges,,,,,,,no IP contract,,80,,9,percent of total billed charges,,,,,,,no IP contract,,50,,5.63,percent of total billed charges,,,,,,no IP contract,,,78,,8.78,percent of total billed charges,,,70,,7.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.51,3324,
00121-0504-05 - acetaminophen-codeine 120 mg-12 mg/5 mL LIQ,00121-0504-05,NDC,,,,inpatient,5,ML,11.25,6.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.56,percent of total billed charges,,,85,,9.56,percent of total billed charges,,,49,,5.51,percent of total billed charges,,,90,,10.13,percent of total billed charges,,,,,,,no IP contract,,80,,9,percent of total billed charges,,,,,,,no IP contract,,50,,5.63,percent of total billed charges,,,,,,no IP contract,,,78,,8.78,percent of total billed charges,,,70,,7.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.51,3324,
00121-0504-05 - acetaminophen-codeine 120 mg-12 mg/5 mL LIQ,00121-0504-05,NDC,,,,inpatient,5,ML,11.25,6.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.56,percent of total billed charges,,,85,,9.56,percent of total billed charges,,,49,,5.51,percent of total billed charges,,,90,,10.13,percent of total billed charges,,,,,,,no IP contract,,80,,9,percent of total billed charges,,,,,,,no IP contract,,50,,5.63,percent of total billed charges,,,,,,no IP contract,,,78,,8.78,percent of total billed charges,,,70,,7.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.51,3324,
00121-0530-05 - ferrous sulfate 300 mg/5 mL LIQ,00121-0530-05,NDC,,,,inpatient,5,ML,10.4,6.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.84,percent of total billed charges,,,85,,8.84,percent of total billed charges,,,49,,5.1,percent of total billed charges,,,90,,9.36,percent of total billed charges,,,,,,,no IP contract,,80,,8.32,percent of total billed charges,,,,,,,no IP contract,,50,,5.2,percent of total billed charges,,,,,,no IP contract,,,78,,8.11,percent of total billed charges,,,70,,7.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.1,3324,
00121-0576-16 - metoclopramide 5 mg/5 mL Syrup,00121-0576-16,NDC,,,,inpatient,1,ML,5.75,3.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.89,percent of total billed charges,,,85,,4.89,percent of total billed charges,,,49,,2.82,percent of total billed charges,,,90,,5.18,percent of total billed charges,,,,,,,no IP contract,,80,,4.6,percent of total billed charges,,,,,,,no IP contract,,50,,2.88,percent of total billed charges,,,,,,no IP contract,,,78,,4.49,percent of total billed charges,,,70,,4.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.82,3324,
00121-0576-16 - metoclopramide 5 mg/5 mL Syrup,00121-0576-16,NDC,,,,inpatient,1,ML,5.75,3.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.89,percent of total billed charges,,,85,,4.89,percent of total billed charges,,,49,,2.82,percent of total billed charges,,,90,,5.18,percent of total billed charges,,,,,,,no IP contract,,80,,4.6,percent of total billed charges,,,,,,,no IP contract,,50,,2.88,percent of total billed charges,,,,,,no IP contract,,,78,,4.49,percent of total billed charges,,,70,,4.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.82,3324,
00121-0577-08 - lactulose 10 g/15 mL Syrup,00121-0577-08,NDC,,,,inpatient,1.5,ML,5.65,3.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.8,percent of total billed charges,,,85,,4.8,percent of total billed charges,,,49,,2.77,percent of total billed charges,,,90,,5.09,percent of total billed charges,,,,,,,no IP contract,,80,,4.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.83,percent of total billed charges,,,,,,no IP contract,,,78,,4.41,percent of total billed charges,,,70,,3.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.77,3324,
00121-0595-15 - citric acid-sodium citrate 334 mg-500 mg/5 mL Soln,00121-0595-15,NDC,,,,inpatient,1,ML,5.65,3.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.8,percent of total billed charges,,,85,,4.8,percent of total billed charges,,,49,,2.77,percent of total billed charges,,,90,,5.09,percent of total billed charges,,,,,,,no IP contract,,80,,4.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.83,percent of total billed charges,,,,,,no IP contract,,,78,,4.41,percent of total billed charges,,,70,,3.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.77,3324,
00121-0595-16 - citric acid-sodium citrate 334 mg-500 mg/5 mL Soln,00121-0595-16,NDC,,,,inpatient,1,ML,5.65,3.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.8,percent of total billed charges,,,85,,4.8,percent of total billed charges,,,49,,2.77,percent of total billed charges,,,90,,5.09,percent of total billed charges,,,,,,,no IP contract,,80,,4.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.83,percent of total billed charges,,,,,,no IP contract,,,78,,4.41,percent of total billed charges,,,70,,3.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.77,3324,
00121-0595-30 - citric acid-sodium citrate 334 mg-500 mg/5 mL Soln,00121-0595-30,NDC,,,,inpatient,1,ML,5.6,3.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.76,percent of total billed charges,,,85,,4.76,percent of total billed charges,,,49,,2.74,percent of total billed charges,,,90,,5.04,percent of total billed charges,,,,,,,no IP contract,,80,,4.48,percent of total billed charges,,,,,,,no IP contract,,50,,2.8,percent of total billed charges,,,,,,no IP contract,,,78,,4.37,percent of total billed charges,,,70,,3.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.74,3324,
00121-0646-10 - amantadine 50 mg/5 mL Syrup,00121-0646-10,NDC,,,,inpatient,10,ML,27.1,16.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.04,percent of total billed charges,,,85,,23.04,percent of total billed charges,,,49,,13.28,percent of total billed charges,,,90,,24.39,percent of total billed charges,,,,,,,no IP contract,,80,,21.68,percent of total billed charges,,,,,,,no IP contract,,50,,13.55,percent of total billed charges,,,,,,no IP contract,,,78,,21.14,percent of total billed charges,,,70,,18.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.28,3324,
00121-0646-16 - amantadine 50 mg/5 mL Syrup,00121-0646-16,NDC,,,,inpatient,10,ML,17.9,10.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.22,percent of total billed charges,,,85,,15.22,percent of total billed charges,,,49,,8.77,percent of total billed charges,,,90,,16.11,percent of total billed charges,,,,,,,no IP contract,,80,,14.32,percent of total billed charges,,,,,,,no IP contract,,50,,8.95,percent of total billed charges,,,,,,no IP contract,,,78,,13.96,percent of total billed charges,,,70,,12.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.77,3324,
00121-0657-21 - acetaminophen 160 mg/5 mL LIQ,00121-0657-21,NDC,,,,inpatient,20.3,ML,12.1,7.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.29,percent of total billed charges,,,85,,10.29,percent of total billed charges,,,49,,5.93,percent of total billed charges,,,90,,10.89,percent of total billed charges,,,,,,,no IP contract,,80,,9.68,percent of total billed charges,,,,,,,no IP contract,,50,,6.05,percent of total billed charges,,,,,,no IP contract,,,78,,9.44,percent of total billed charges,,,70,,8.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.93,3324,
00121-0658-16 - trihexyphenidyl 2 mg/5 mL Elixi,00121-0658-16,NDC,,,,inpatient,1,ML,5.9,3.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.02,percent of total billed charges,,,85,,5.02,percent of total billed charges,,,49,,2.89,percent of total billed charges,,,90,,5.31,percent of total billed charges,,,,,,,no IP contract,,80,,4.72,percent of total billed charges,,,,,,,no IP contract,,50,,2.95,percent of total billed charges,,,,,,no IP contract,,,78,,4.6,percent of total billed charges,,,70,,4.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.89,3324,
00121-0670-16 - ethosuximide 250 mg/5 mL Syrup,00121-0670-16,NDC,,,,inpatient,1,ML,7.25,4.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.16,percent of total billed charges,,,85,,6.16,percent of total billed charges,,,49,,3.55,percent of total billed charges,,,90,,6.53,percent of total billed charges,,,,,,,no IP contract,,80,,5.8,percent of total billed charges,,,,,,,no IP contract,,50,,3.63,percent of total billed charges,,,,,,no IP contract,,,78,,5.66,percent of total billed charges,,,70,,5.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.55,3324,
00121-0675-16 - valproic acid 250 mg/5 mL Syrup,00121-0675-16,NDC,,,,inpatient,1,ML,6.65,3.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.65,percent of total billed charges,,,85,,5.65,percent of total billed charges,,,49,,3.26,percent of total billed charges,,,90,,5.99,percent of total billed charges,,,,,,,no IP contract,,80,,5.32,percent of total billed charges,,,,,,,no IP contract,,50,,3.33,percent of total billed charges,,,,,,no IP contract,,,78,,5.19,percent of total billed charges,,,70,,4.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.26,3324,
00121-0721-04 - fluoxetine 20 mg/5 mL Soln,00121-0721-04,NDC,,,,inpatient,1,ML,6.25,3.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.31,percent of total billed charges,,,85,,5.31,percent of total billed charges,,,49,,3.06,percent of total billed charges,,,90,,5.63,percent of total billed charges,,,,,,,no IP contract,,80,,5,percent of total billed charges,,,,,,,no IP contract,,50,,3.13,percent of total billed charges,,,,,,no IP contract,,,78,,4.88,percent of total billed charges,,,70,,4.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.06,3324,
00121-0766-16 - calcium carbonate 1250 mg/5 mL Susp,00121-0766-16,NDC,,,,inpatient,1,ML,5.6,3.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.76,percent of total billed charges,,,85,,4.76,percent of total billed charges,,,49,,2.74,percent of total billed charges,,,90,,5.04,percent of total billed charges,,,,,,,no IP contract,,80,,4.48,percent of total billed charges,,,,,,,no IP contract,,50,,2.8,percent of total billed charges,,,,,,no IP contract,,,78,,4.37,percent of total billed charges,,,70,,3.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.74,3324,
LORazepam 2 mg Soln,00121-0770-01,NDC,,,,inpatient,1,mL,16.5,9.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.03,percent of total billed charges,,,85,,14.03,percent of total billed charges,,,49,,8.09,percent of total billed charges,,,90,,14.85,percent of total billed charges,,,,,,,no IP contract,,80,,13.2,percent of total billed charges,,,,,,,no IP contract,,50,,8.25,percent of total billed charges,,,,,,no IP contract,,,78,,12.87,percent of total billed charges,,,70,,11.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.09,3324,
00121-0826-01 - oxyCODONE 20 mg/mL Conc,00121-0826-01,NDC,,,,inpatient,0.1,ML,66.15,39.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,53.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.23,percent of total billed charges,,,85,,56.23,percent of total billed charges,,,49,,32.41,percent of total billed charges,,,90,,59.54,percent of total billed charges,,,,,,,no IP contract,,80,,52.92,percent of total billed charges,,,,,,,no IP contract,,50,,33.08,percent of total billed charges,,,,,,no IP contract,,,78,,51.6,percent of total billed charges,,,70,,46.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.41,3324,
00121-0867-20 - vancomycin 125 mg Cap,00121-0867-20,NDC,,,,inpatient,1,EA,252.75,151.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,204.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,214.84,percent of total billed charges,,,85,,214.84,percent of total billed charges,,,49,,123.85,percent of total billed charges,,,90,,227.48,percent of total billed charges,,,,,,,no IP contract,,80,,202.2,percent of total billed charges,,,,,,,no IP contract,,50,,126.38,percent of total billed charges,,,,,,no IP contract,,,78,,197.15,percent of total billed charges,,,70,,176.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,123.85,3324,
00121-0868-50 - nystatin 100000 units/mL Susp,00121-0868-50,NDC,,,,inpatient,5,ML,19.6,11.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.66,percent of total billed charges,,,85,,16.66,percent of total billed charges,,,49,,9.6,percent of total billed charges,,,90,,17.64,percent of total billed charges,,,,,,,no IP contract,,80,,15.68,percent of total billed charges,,,,,,,no IP contract,,50,,9.8,percent of total billed charges,,,,,,no IP contract,,,78,,15.29,percent of total billed charges,,,70,,13.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.6,3324,
00121-0890-20 - vancomycin 250 mg Cap,00121-0890-20,NDC,,,,inpatient,1,EA,462.7,277.62,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,374.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,393.3,percent of total billed charges,,,85,,393.3,percent of total billed charges,,,49,,226.72,percent of total billed charges,,,90,,416.43,percent of total billed charges,,,,,,,no IP contract,,80,,370.16,percent of total billed charges,,,,,,,no IP contract,,50,,231.35,percent of total billed charges,,,,,,no IP contract,,,78,,360.91,percent of total billed charges,,,70,,323.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,226.72,3324,
00121-0978-10 - diphenhydrAMINE 12.5 mg/5 mL LIQ,00121-0978-10,NDC,,,,inpatient,10,ML,28.75,17.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.44,percent of total billed charges,,,85,,24.44,percent of total billed charges,,,49,,14.09,percent of total billed charges,,,90,,25.88,percent of total billed charges,,,,,,,no IP contract,,80,,23,percent of total billed charges,,,,,,,no IP contract,,50,,14.38,percent of total billed charges,,,,,,no IP contract,,,78,,22.43,percent of total billed charges,,,70,,20.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.09,3324,
00121-1154-30 - lactulose 10 g/15 mL Syrup,00121-1154-30,NDC,,,,inpatient,30,ML,12.9,7.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.97,percent of total billed charges,,,85,,10.97,percent of total billed charges,,,49,,6.32,percent of total billed charges,,,90,,11.61,percent of total billed charges,,,,,,,no IP contract,,80,,10.32,percent of total billed charges,,,,,,,no IP contract,,50,,6.45,percent of total billed charges,,,,,,no IP contract,,,78,,10.06,percent of total billed charges,,,70,,9.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.32,3324,
00121-1488-00 - guaiFENesin 100 mg/5 mL LIQ,00121-1488-00,NDC,,,,inpatient,10,ML,10.4,6.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.84,percent of total billed charges,,,85,,8.84,percent of total billed charges,,,49,,5.1,percent of total billed charges,,,90,,9.36,percent of total billed charges,,,,,,,no IP contract,,80,,8.32,percent of total billed charges,,,,,,,no IP contract,,50,,5.2,percent of total billed charges,,,,,,no IP contract,,,78,,8.11,percent of total billed charges,,,70,,7.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.1,3324,
00121-1576-10 - metoclopramide 5 mg/5 mL Syrup,00121-1576-10,NDC,,,,inpatient,10,ML,10.4,6.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.84,percent of total billed charges,,,85,,8.84,percent of total billed charges,,,49,,5.1,percent of total billed charges,,,90,,9.36,percent of total billed charges,,,,,,,no IP contract,,80,,8.32,percent of total billed charges,,,,,,,no IP contract,,50,,5.2,percent of total billed charges,,,,,,no IP contract,,,78,,8.11,percent of total billed charges,,,70,,7.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.1,3324,
00121-1683-05 - codeine-guaifenesin 10 mg-100 mg/5 mL Syrup,00121-1683-05,NDC,,,,inpatient,5,ML,9.6,5.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.16,percent of total billed charges,,,85,,8.16,percent of total billed charges,,,49,,4.7,percent of total billed charges,,,90,,8.64,percent of total billed charges,,,,,,,no IP contract,,80,,7.68,percent of total billed charges,,,,,,,no IP contract,,50,,4.8,percent of total billed charges,,,,,,no IP contract,,,78,,7.49,percent of total billed charges,,,70,,6.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.7,3324,
00121-1760-30 - aluminum hydroxide-magnesium hydroxide 225 mg-200 mg/5 mL Susp,00121-1760-30,NDC,,,,inpatient,30,ML,10.4,6.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.84,percent of total billed charges,,,85,,8.84,percent of total billed charges,,,49,,5.1,percent of total billed charges,,,90,,9.36,percent of total billed charges,,,,,,,no IP contract,,80,,8.32,percent of total billed charges,,,,,,,no IP contract,,50,,5.2,percent of total billed charges,,,,,,no IP contract,,,78,,8.11,percent of total billed charges,,,70,,7.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.1,3324,
00121-1775-05 - codeine-guaifenesin 10 mg-100 mg/5 mL Syrup,00121-1775-05,NDC,,,,inpatient,5,ML,10.85,6.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.22,percent of total billed charges,,,85,,9.22,percent of total billed charges,,,49,,5.32,percent of total billed charges,,,90,,9.77,percent of total billed charges,,,,,,,no IP contract,,80,,8.68,percent of total billed charges,,,,,,,no IP contract,,50,,5.43,percent of total billed charges,,,,,,no IP contract,,,78,,8.46,percent of total billed charges,,,70,,7.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.32,3324,
00121-1870-00 - docusate 10 mg/mL LIQ,00121-1870-00,NDC,,,,inpatient,10,ML,11.25,6.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.56,percent of total billed charges,,,85,,9.56,percent of total billed charges,,,49,,5.51,percent of total billed charges,,,90,,10.13,percent of total billed charges,,,,,,,no IP contract,,80,,9,percent of total billed charges,,,,,,,no IP contract,,50,,5.63,percent of total billed charges,,,,,,no IP contract,,,78,,8.78,percent of total billed charges,,,70,,7.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.51,3324,
00121-1971-00 - acetaminophen 650 mg / 20.3 mL Soln,00121-1971-00,NDC,,,,inpatient,20.3,ML,18.75,11.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.94,percent of total billed charges,,,85,,15.94,percent of total billed charges,,,49,,9.19,percent of total billed charges,,,90,,16.88,percent of total billed charges,,,,,,,no IP contract,,80,,15,percent of total billed charges,,,,,,,no IP contract,,50,,9.38,percent of total billed charges,,,,,,no IP contract,,,78,,14.63,percent of total billed charges,,,70,,13.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.19,3324,
00121-4655-15 - acetaminophen-hydrocodone 500 mg-7.5 mg/15 mL Elixi,00121-4655-15,NDC,,,,inpatient,15,ML,37.9,22.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.22,percent of total billed charges,,,85,,32.22,percent of total billed charges,,,49,,18.57,percent of total billed charges,,,90,,34.11,percent of total billed charges,,,,,,,no IP contract,,80,,30.32,percent of total billed charges,,,,,,,no IP contract,,50,,18.95,percent of total billed charges,,,,,,no IP contract,,,78,,29.56,percent of total billed charges,,,70,,26.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.57,3324,
00121-4655-15 - acetaminophen-hydrocodone 500 mg-7.5 mg/15 mL Elixi,00121-4655-15,NDC,,,,inpatient,15,ML,37.9,22.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.22,percent of total billed charges,,,85,,32.22,percent of total billed charges,,,49,,18.57,percent of total billed charges,,,90,,34.11,percent of total billed charges,,,,,,,no IP contract,,80,,30.32,percent of total billed charges,,,,,,,no IP contract,,50,,18.95,percent of total billed charges,,,,,,no IP contract,,,78,,29.56,percent of total billed charges,,,70,,26.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.57,3324,
00121-4675-05 - valproic acid 250 mg/5 mL Syrup,00121-4675-05,NDC,,,,inpatient,5,ML,23.35,14.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.85,percent of total billed charges,,,85,,19.85,percent of total billed charges,,,49,,11.44,percent of total billed charges,,,90,,21.02,percent of total billed charges,,,,,,,no IP contract,,80,,18.68,percent of total billed charges,,,,,,,no IP contract,,50,,11.68,percent of total billed charges,,,,,,no IP contract,,,78,,18.21,percent of total billed charges,,,70,,16.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.44,3324,
00121-4675-55 - valproic acid 250 mg/5 mL Syrup,00121-4675-55,NDC,,,,inpatient,5,ML,10,6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.5,percent of total billed charges,,,85,,8.5,percent of total billed charges,,,49,,4.9,percent of total billed charges,,,90,,9,percent of total billed charges,,,,,,,no IP contract,,80,,8,percent of total billed charges,,,,,,,no IP contract,,50,,5,percent of total billed charges,,,,,,no IP contract,,,78,,7.8,percent of total billed charges,,,70,,7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.9,3324,
00121-4772-15 - acetaminophen-HYDROcodone 325 mg-7.5 mg/15 mL Soln,00121-4772-15,NDC,,,,inpatient,15,ML,46.65,27.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,37.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,39.65,percent of total billed charges,,,85,,39.65,percent of total billed charges,,,49,,22.86,percent of total billed charges,,,90,,41.99,percent of total billed charges,,,,,,,no IP contract,,80,,37.32,percent of total billed charges,,,,,,,no IP contract,,50,,23.33,percent of total billed charges,,,,,,no IP contract,,,78,,36.39,percent of total billed charges,,,70,,32.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.86,3324,
00121-4776-10 - megestrol 40 mg/mL Susp,00121-4776-10,NDC,,,,inpatient,10,ML,86.25,51.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,69.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,73.31,percent of total billed charges,,,85,,73.31,percent of total billed charges,,,49,,42.26,percent of total billed charges,,,90,,77.63,percent of total billed charges,,,,,,,no IP contract,,80,,69,percent of total billed charges,,,,,,,no IP contract,,50,,43.13,percent of total billed charges,,,,,,no IP contract,,,78,,67.28,percent of total billed charges,,,70,,60.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,42.26,3324,
00121-4776-35 - megestrol 40 mg/mL Susp,00121-4776-35,NDC,,,,inpatient,10,ML,41.25,24.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,35.06,percent of total billed charges,,,85,,35.06,percent of total billed charges,,,49,,20.21,percent of total billed charges,,,90,,37.13,percent of total billed charges,,,,,,,no IP contract,,80,,33,percent of total billed charges,,,,,,,no IP contract,,50,,20.63,percent of total billed charges,,,,,,no IP contract,,,78,,32.18,percent of total billed charges,,,70,,28.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.21,3324,
00121-4799-05 - levetiracetam UD cup 500 mg / 5 mL Soln,00121-4799-05,NDC,,,,inpatient,5,ML,41.25,24.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,35.06,percent of total billed charges,,,85,,35.06,percent of total billed charges,,,49,,20.21,percent of total billed charges,,,90,,37.13,percent of total billed charges,,,,,,,no IP contract,,80,,33,percent of total billed charges,,,,,,,no IP contract,,50,,20.63,percent of total billed charges,,,,,,no IP contract,,,78,,32.18,percent of total billed charges,,,70,,28.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.21,3324,
oxyCODONE 5 mg/5 mL Soln,00121-4827-40,NDC,,,,inpatient,1,EA,67.5,40.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,54.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,57.38,percent of total billed charges,,,85,,57.38,percent of total billed charges,,,49,,33.08,percent of total billed charges,,,90,,60.75,percent of total billed charges,,,,,,,no IP contract,,80,,54,percent of total billed charges,,,,,,,no IP contract,,50,,33.75,percent of total billed charges,,,,,,no IP contract,,,78,,52.65,percent of total billed charges,,,70,,47.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,33.08,3324,
00131-2477-60 - lacosamide 50 mg Tab,00131-2477-60,NDC,,,,inpatient,1,EA,73.25,43.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,59.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,62.26,percent of total billed charges,,,85,,62.26,percent of total billed charges,,,49,,35.89,percent of total billed charges,,,90,,65.93,percent of total billed charges,,,,,,,no IP contract,,80,,58.6,percent of total billed charges,,,,,,,no IP contract,,50,,36.63,percent of total billed charges,,,,,,no IP contract,,,78,,57.14,percent of total billed charges,,,70,,51.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,35.89,3324,
00131-2478-35 - lacosamide 100 mg Tab,00131-2478-35,NDC,,,,inpatient,1,EA,101.9,61.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,82.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,86.62,percent of total billed charges,,,85,,86.62,percent of total billed charges,,,49,,49.93,percent of total billed charges,,,90,,91.71,percent of total billed charges,,,,,,,no IP contract,,80,,81.52,percent of total billed charges,,,,,,,no IP contract,,50,,50.95,percent of total billed charges,,,,,,no IP contract,,,78,,79.48,percent of total billed charges,,,70,,71.33,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,49.93,3324,
00131-2478-60 - lacosamide 100 mg Tab,00131-2478-60,NDC,,,,inpatient,1,EA,111.45,66.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,90.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,94.73,percent of total billed charges,,,85,,94.73,percent of total billed charges,,,49,,54.61,percent of total billed charges,,,90,,100.31,percent of total billed charges,,,,,,,no IP contract,,80,,89.16,percent of total billed charges,,,,,,,no IP contract,,50,,55.73,percent of total billed charges,,,,,,no IP contract,,,78,,86.93,percent of total billed charges,,,70,,78.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,54.61,3324,
00131-2479-60 - lacosamide 150 mg Tab,00131-2479-60,NDC,,,,inpatient,1,EA,176.8,106.08,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,143.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,150.28,percent of total billed charges,,,85,,150.28,percent of total billed charges,,,49,,86.63,percent of total billed charges,,,90,,159.12,percent of total billed charges,,,,,,,no IP contract,,80,,141.44,percent of total billed charges,,,,,,,no IP contract,,50,,88.4,percent of total billed charges,,,,,,no IP contract,,,78,,137.9,percent of total billed charges,,,70,,123.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,86.63,3324,
00131-2480-60 - lacosamide 200 mg Tab,00131-2480-60,NDC,,,,inpatient,1,EA,176.9,106.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,143.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,150.37,percent of total billed charges,,,85,,150.37,percent of total billed charges,,,49,,86.68,percent of total billed charges,,,90,,159.21,percent of total billed charges,,,,,,,no IP contract,,80,,141.52,percent of total billed charges,,,,,,,no IP contract,,50,,88.45,percent of total billed charges,,,,,,no IP contract,,,78,,137.98,percent of total billed charges,,,70,,123.83,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,86.68,3324,
00131-5410-71 - lacosamide 10 mg/mL Soln,00131-5410-71,NDC,,,,inpatient,1,ML,17.4,10.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.79,percent of total billed charges,,,85,,14.79,percent of total billed charges,,,49,,8.53,percent of total billed charges,,,90,,15.66,percent of total billed charges,,,,,,,no IP contract,,80,,13.92,percent of total billed charges,,,,,,,no IP contract,,50,,8.7,percent of total billed charges,,,,,,no IP contract,,,78,,13.57,percent of total billed charges,,,70,,12.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.53,3324,
glycerin adult Supp,00132-0079-12,NDC,,,,inpatient,12,EA,4.6,2.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.91,percent of total billed charges,,,85,,3.91,percent of total billed charges,,,49,,2.25,percent of total billed charges,,,90,,4.14,percent of total billed charges,,,,,,,no IP contract,,80,,3.68,percent of total billed charges,,,,,,,no IP contract,,50,,2.3,percent of total billed charges,,,,,,no IP contract,,,78,,3.59,percent of total billed charges,,,70,,3.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.25,3324,
00132-0079-24 - glycerin adult Supp,00132-0079-24,NDC,,,,inpatient,1,UN,4.55,2.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.87,percent of total billed charges,,,85,,3.87,percent of total billed charges,,,49,,2.23,percent of total billed charges,,,90,,4.1,percent of total billed charges,,,,,,,no IP contract,,80,,3.64,percent of total billed charges,,,,,,,no IP contract,,50,,2.28,percent of total billed charges,,,,,,no IP contract,,,78,,3.55,percent of total billed charges,,,70,,3.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.23,3324,
00132-0107-01 - sodium biphosphate-sodium phosphate 48%-18% Soln,00132-0107-01,NDC,,,,inpatient,5,ML,57.9,34.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,46.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,49.22,percent of total billed charges,,,85,,49.22,percent of total billed charges,,,49,,28.37,percent of total billed charges,,,90,,52.11,percent of total billed charges,,,,,,,no IP contract,,80,,46.32,percent of total billed charges,,,,,,,no IP contract,,50,,28.95,percent of total billed charges,,,,,,no IP contract,,,78,,45.16,percent of total billed charges,,,70,,40.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,28.37,3324,
00132-0108-03 - sodium biphosphate-sodium phosphate 48%-18% Soln,00132-0108-03,NDC,,,,inpatient,5,ML,35.4,21.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.09,percent of total billed charges,,,85,,30.09,percent of total billed charges,,,49,,17.35,percent of total billed charges,,,90,,31.86,percent of total billed charges,,,,,,,no IP contract,,80,,28.32,percent of total billed charges,,,,,,,no IP contract,,50,,17.7,percent of total billed charges,,,,,,no IP contract,,,78,,27.61,percent of total billed charges,,,70,,24.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.35,3324,
00132-0109-15 - sodium biphosphate-sodium phosphate 48%-18% Soln,00132-0109-15,NDC,,,,inpatient,5,ML,57.9,34.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,46.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,49.22,percent of total billed charges,,,85,,49.22,percent of total billed charges,,,49,,28.37,percent of total billed charges,,,90,,52.11,percent of total billed charges,,,,,,,no IP contract,,80,,46.32,percent of total billed charges,,,,,,,no IP contract,,50,,28.95,percent of total billed charges,,,,,,no IP contract,,,78,,45.16,percent of total billed charges,,,70,,40.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,28.37,3324,
glycerin infant Enema,00132-0190-12,NDC,,,,inpatient,1,EA,14.3,8.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.16,percent of total billed charges,,,85,,12.16,percent of total billed charges,,,49,,7.01,percent of total billed charges,,,90,,12.87,percent of total billed charges,,,,,,,no IP contract,,80,,11.44,percent of total billed charges,,,,,,,no IP contract,,50,,7.15,percent of total billed charges,,,,,,no IP contract,,,78,,11.15,percent of total billed charges,,,70,,10.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.01,3324,
00132-0301-40 - mineral oil 100% Enema,00132-0301-40,NDC,,,,inpatient,133,ML,14.4,8.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.24,percent of total billed charges,,,85,,12.24,percent of total billed charges,,,49,,7.06,percent of total billed charges,,,90,,12.96,percent of total billed charges,,,,,,,no IP contract,,80,,11.52,percent of total billed charges,,,,,,,no IP contract,,50,,7.2,percent of total billed charges,,,,,,no IP contract,,,78,,11.23,percent of total billed charges,,,70,,10.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.06,3324,
00132-0703-36 - bisacodyl 10 mg Soln,00132-0703-36,NDC,,,,inpatient,37,ML,21.45,12.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.23,percent of total billed charges,,,85,,18.23,percent of total billed charges,,,49,,10.51,percent of total billed charges,,,90,,19.31,percent of total billed charges,,,,,,,no IP contract,,80,,17.16,percent of total billed charges,,,,,,,no IP contract,,50,,10.73,percent of total billed charges,,,,,,no IP contract,,,78,,16.73,percent of total billed charges,,,70,,15.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.51,3324,
00135-0200-01 - docosanol topical 10% Cream,00135-0200-01,NDC,,,,inpatient,1,UN,156.5,93.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,126.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,133.03,percent of total billed charges,,,85,,133.03,percent of total billed charges,,,49,,76.69,percent of total billed charges,,,90,,140.85,percent of total billed charges,,,,,,,no IP contract,,80,,125.2,percent of total billed charges,,,,,,,no IP contract,,50,,78.25,percent of total billed charges,,,,,,no IP contract,,,78,,122.07,percent of total billed charges,,,70,,109.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,76.69,3324,
docosanol 10% Cream,00135-0300-01,NDC,,,,inpatient,1,EA,186.15,111.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,150.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,158.23,percent of total billed charges,,,85,,158.23,percent of total billed charges,,,49,,91.21,percent of total billed charges,,,90,,167.54,percent of total billed charges,,,,,,,no IP contract,,80,,148.92,percent of total billed charges,,,,,,,no IP contract,,50,,93.08,percent of total billed charges,,,,,,no IP contract,,,78,,145.2,percent of total billed charges,,,70,,130.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,91.21,3324,
00143-1172-01 - captopril 25 mg Tab,00143-1172-01,NDC,,,,inpatient,1,EA,9.25,5.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.86,percent of total billed charges,,,85,,7.86,percent of total billed charges,,,49,,4.53,percent of total billed charges,,,90,,8.33,percent of total billed charges,,,,,,,no IP contract,,80,,7.4,percent of total billed charges,,,,,,,no IP contract,,50,,4.63,percent of total billed charges,,,,,,no IP contract,,,78,,7.22,percent of total billed charges,,,70,,6.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.53,3324,
00143-1172-01 - captopril 25 mg Tab,00143-1172-01,NDC,,,,inpatient,1,EA,9.25,5.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.86,percent of total billed charges,,,85,,7.86,percent of total billed charges,,,49,,4.53,percent of total billed charges,,,90,,8.33,percent of total billed charges,,,,,,,no IP contract,,80,,7.4,percent of total billed charges,,,,,,,no IP contract,,50,,4.63,percent of total billed charges,,,,,,no IP contract,,,78,,7.22,percent of total billed charges,,,70,,6.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.53,3324,
00143-1202-01 - cortisone 25 mg Tab,00143-1202-01,NDC,,,,inpatient,1,EA,7.5,4.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.38,percent of total billed charges,,,85,,6.38,percent of total billed charges,,,49,,3.68,percent of total billed charges,,,90,,6.75,percent of total billed charges,,,,,,,no IP contract,,80,,6,percent of total billed charges,,,,,,,no IP contract,,50,,3.75,percent of total billed charges,,,,,,no IP contract,,,78,,5.85,percent of total billed charges,,,70,,5.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.68,3324,
00143-1241-01 - digoxin 250 mcg (0.25 mg) Tab,00143-1241-01,NDC,,,,inpatient,1,EA,22.1,13.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.79,percent of total billed charges,,,85,,18.79,percent of total billed charges,,,49,,10.83,percent of total billed charges,,,90,,19.89,percent of total billed charges,,,,,,,no IP contract,,80,,17.68,percent of total billed charges,,,,,,,no IP contract,,50,,11.05,percent of total billed charges,,,,,,no IP contract,,,78,,17.24,percent of total billed charges,,,70,,15.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.83,3324,
00143-1445-05 - PHENobarbital 15 mg Tab,00143-1445-05,NDC,,,,inpatient,1,EA,6.85,4.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.82,percent of total billed charges,,,85,,5.82,percent of total billed charges,,,49,,3.36,percent of total billed charges,,,90,,6.17,percent of total billed charges,,,,,,,no IP contract,,80,,5.48,percent of total billed charges,,,,,,,no IP contract,,50,,3.43,percent of total billed charges,,,,,,no IP contract,,,78,,5.34,percent of total billed charges,,,70,,4.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.36,3324,
00143-1458-01 - phenobarbital 100 mg Tab,00143-1458-01,NDC,,,,inpatient,1,EA,7.4,4.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.29,percent of total billed charges,,,85,,6.29,percent of total billed charges,,,49,,3.63,percent of total billed charges,,,90,,6.66,percent of total billed charges,,,,,,,no IP contract,,80,,5.92,percent of total billed charges,,,,,,,no IP contract,,50,,3.7,percent of total billed charges,,,,,,no IP contract,,,78,,5.77,percent of total billed charges,,,70,,5.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.63,3324,
00143-1458-05 - PHENobarbital 100 mg Tab,00143-1458-05,NDC,,,,inpatient,1,EA,8.5,5.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.23,percent of total billed charges,,,85,,7.23,percent of total billed charges,,,49,,4.17,percent of total billed charges,,,90,,7.65,percent of total billed charges,,,,,,,no IP contract,,80,,6.8,percent of total billed charges,,,,,,,no IP contract,,50,,4.25,percent of total billed charges,,,,,,no IP contract,,,78,,6.63,percent of total billed charges,,,70,,5.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.17,3324,
00143-1473-01 - predniSONE 10 mg Tab,00143-1473-01,NDC,,,,inpatient,1,EA,4.45,2.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.78,percent of total billed charges,,,85,,3.78,percent of total billed charges,,,49,,2.18,percent of total billed charges,,,90,,4.01,percent of total billed charges,,,,,,,no IP contract,,80,,3.56,percent of total billed charges,,,,,,,no IP contract,,50,,2.23,percent of total billed charges,,,,,,no IP contract,,,78,,3.47,percent of total billed charges,,,70,,3.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.18,3324,
00143-1473-10 - predniSONE 10 mg Tab,00143-1473-10,NDC,,,,inpatient,1,EA,4.3,2.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.66,percent of total billed charges,,,85,,3.66,percent of total billed charges,,,49,,2.11,percent of total billed charges,,,90,,3.87,percent of total billed charges,,,,,,,no IP contract,,80,,3.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.15,percent of total billed charges,,,,,,no IP contract,,,78,,3.35,percent of total billed charges,,,70,,3.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.11,3324,
PHENobarbital 15 mg Tab,00143-1495-01,NDC,,,,inpatient,1,EA,8.25,4.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.01,percent of total billed charges,,,85,,7.01,percent of total billed charges,,,49,,4.04,percent of total billed charges,,,90,,7.43,percent of total billed charges,,,,,,,no IP contract,,80,,6.6,percent of total billed charges,,,,,,,no IP contract,,50,,4.13,percent of total billed charges,,,,,,no IP contract,,,78,,6.44,percent of total billed charges,,,70,,5.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.04,3324,
00143-1772-01 - isosorbide dinitrate 20 mg Tab,00143-1772-01,NDC,,,,inpatient,1,EA,5.4,3.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.59,percent of total billed charges,,,85,,4.59,percent of total billed charges,,,49,,2.65,percent of total billed charges,,,90,,4.86,percent of total billed charges,,,,,,,no IP contract,,80,,4.32,percent of total billed charges,,,,,,,no IP contract,,50,,2.7,percent of total billed charges,,,,,,no IP contract,,,78,,4.21,percent of total billed charges,,,70,,3.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.65,3324,
00143-1773-01 - isosorbide dinitrate 30 mg Tab,00143-1773-01,NDC,,,,inpatient,1,EA,8.05,4.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.84,percent of total billed charges,,,85,,6.84,percent of total billed charges,,,49,,3.94,percent of total billed charges,,,90,,7.25,percent of total billed charges,,,,,,,no IP contract,,80,,6.44,percent of total billed charges,,,,,,,no IP contract,,50,,4.03,percent of total billed charges,,,,,,no IP contract,,,78,,6.28,percent of total billed charges,,,70,,5.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.94,3324,
00143-3126-01 - dicyclomine 10 mg Cap,00143-3126-01,NDC,,,,inpatient,1,EA,8.1,4.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.89,percent of total billed charges,,,85,,6.89,percent of total billed charges,,,49,,3.97,percent of total billed charges,,,90,,7.29,percent of total billed charges,,,,,,,no IP contract,,80,,6.48,percent of total billed charges,,,,,,,no IP contract,,50,,4.05,percent of total billed charges,,,,,,no IP contract,,,78,,6.32,percent of total billed charges,,,70,,5.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.97,3324,
00143-3141-50 - doxycycline hyclate 50 mg Cap,00143-3141-50,NDC,,,,inpatient,1,EA,9.65,5.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.2,percent of total billed charges,,,85,,8.2,percent of total billed charges,,,49,,4.73,percent of total billed charges,,,90,,8.69,percent of total billed charges,,,,,,,no IP contract,,80,,7.72,percent of total billed charges,,,,,,,no IP contract,,50,,4.83,percent of total billed charges,,,,,,no IP contract,,,78,,7.53,percent of total billed charges,,,70,,6.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.73,3324,
00143-3142-50 - doxycycline hyclate 100 mg Cap,00143-3142-50,NDC,,,,inpatient,1,EA,47.8,28.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,38.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,40.63,percent of total billed charges,,,85,,40.63,percent of total billed charges,,,49,,23.42,percent of total billed charges,,,90,,43.02,percent of total billed charges,,,,,,,no IP contract,,80,,38.24,percent of total billed charges,,,,,,,no IP contract,,50,,23.9,percent of total billed charges,,,,,,no IP contract,,,78,,37.28,percent of total billed charges,,,70,,33.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.42,3324,
00143-9262-25 - ceFAZolin 1 g REC I,00143-9262-25,NDC,,,,inpatient,1,EA,45.9,27.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,37.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,39.02,percent of total billed charges,,,85,,39.02,percent of total billed charges,,,49,,22.49,percent of total billed charges,,,90,,41.31,percent of total billed charges,,,,,,,no IP contract,,80,,36.72,percent of total billed charges,,,,,,,no IP contract,,50,,22.95,percent of total billed charges,,,,,,no IP contract,,,78,,35.8,percent of total billed charges,,,70,,32.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.49,3324,
00143-9595-25 - lidocaine 1% preservative-free Soln,00143-9595-25,NDC,,,,inpatient,5,ML,34.2,20.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.07,percent of total billed charges,,,85,,29.07,percent of total billed charges,,,49,,16.76,percent of total billed charges,,,90,,30.78,percent of total billed charges,,,,,,,no IP contract,,80,,27.36,percent of total billed charges,,,,,,,no IP contract,,50,,17.1,percent of total billed charges,,,,,,no IP contract,,,78,,26.68,percent of total billed charges,,,70,,23.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.76,3324,
00143-9684-10 - flumazenil 0.1 mg/mL Soln,00143-9684-10,NDC,,,,inpatient,1,ML,22.5,13.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.13,percent of total billed charges,,,85,,19.13,percent of total billed charges,,,49,,11.03,percent of total billed charges,,,90,,20.25,percent of total billed charges,,,,,,,no IP contract,,80,,18,percent of total billed charges,,,,,,,no IP contract,,50,,11.25,percent of total billed charges,,,,,,no IP contract,,,78,,17.55,percent of total billed charges,,,70,,15.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.03,3324,
00143-9719-10 - milrinone 200 mcg/mL-D5% Soln,00143-9719-10,NDC,,,,inpatient,1,EA,161.05,96.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,130.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,136.89,percent of total billed charges,,,85,,136.89,percent of total billed charges,,,49,,78.91,percent of total billed charges,,,90,,144.95,percent of total billed charges,,,,,,,no IP contract,,80,,128.84,percent of total billed charges,,,,,,,no IP contract,,50,,80.53,percent of total billed charges,,,,,,no IP contract,,,78,,125.62,percent of total billed charges,,,70,,112.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,78.91,3324,
00143-9719-10 - milrinone 200 mcg/mL-D5% Soln,00143-9719-10,NDC,,,,inpatient,1,EA,161.05,96.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,130.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,136.89,percent of total billed charges,,,85,,136.89,percent of total billed charges,,,49,,78.91,percent of total billed charges,,,90,,144.95,percent of total billed charges,,,,,,,no IP contract,,80,,128.84,percent of total billed charges,,,,,,,no IP contract,,50,,80.53,percent of total billed charges,,,,,,no IP contract,,,78,,125.62,percent of total billed charges,,,70,,112.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,78.91,3324,
00143-9720-24 - levoFLOXacin 750 mg/150 mL Soln,00143-9720-24,NDC,,,,inpatient,150,ML,120.9,72.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,97.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,102.77,percent of total billed charges,,,85,,102.77,percent of total billed charges,,,49,,59.24,percent of total billed charges,,,90,,108.81,percent of total billed charges,,,,,,,no IP contract,,80,,96.72,percent of total billed charges,,,,,,,no IP contract,,50,,60.45,percent of total billed charges,,,,,,no IP contract,,,78,,94.3,percent of total billed charges,,,70,,84.63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,59.24,3324,
00143-9803-50 - doxycycline hyclate 100 mg Cap,00143-9803-50,NDC,,,,inpatient,1,EA,18.15,10.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.43,percent of total billed charges,,,85,,15.43,percent of total billed charges,,,49,,8.89,percent of total billed charges,,,90,,16.34,percent of total billed charges,,,,,,,no IP contract,,80,,14.52,percent of total billed charges,,,,,,,no IP contract,,50,,9.08,percent of total billed charges,,,,,,no IP contract,,,78,,14.16,percent of total billed charges,,,70,,12.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.89,3324,
00143-9856-25 - cefTRIAXone 2 g REC I,00143-9856-25,NDC,,,,inpatient,1,EA,272.75,163.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,220.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,231.84,percent of total billed charges,,,85,,231.84,percent of total billed charges,,,49,,133.65,percent of total billed charges,,,90,,245.48,percent of total billed charges,,,,,,,no IP contract,,80,,218.2,percent of total billed charges,,,,,,,no IP contract,,50,,136.38,percent of total billed charges,,,,,,no IP contract,,,78,,212.75,percent of total billed charges,,,70,,190.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,133.65,3324,
00143-9873-01 - metoprolol 1 mg/mL Soln,00143-9873-01,NDC,,,,inpatient,5,ML,430.8,258.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,348.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,366.18,percent of total billed charges,,,85,,366.18,percent of total billed charges,,,49,,211.09,percent of total billed charges,,,90,,387.72,percent of total billed charges,,,,,,,no IP contract,,80,,344.64,percent of total billed charges,,,,,,,no IP contract,,50,,215.4,percent of total billed charges,,,,,,no IP contract,,,78,,336.02,percent of total billed charges,,,70,,301.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,211.09,3324,
00143-9875-10 - amiodarone 50 mg/mL Soln,00143-9875-10,NDC,,,,inpatient,1,ML,16.3,9.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.86,percent of total billed charges,,,85,,13.86,percent of total billed charges,,,49,,7.99,percent of total billed charges,,,90,,14.67,percent of total billed charges,,,,,,,no IP contract,,80,,13.04,percent of total billed charges,,,,,,,no IP contract,,50,,8.15,percent of total billed charges,,,,,,no IP contract,,,78,,12.71,percent of total billed charges,,,70,,11.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.99,3324,
00143-9889-01 - amoxicillin 250 mg/5 mL REC P,00143-9889-01,NDC,,,,inpatient,1,ML,5.9,3.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.02,percent of total billed charges,,,85,,5.02,percent of total billed charges,,,49,,2.89,percent of total billed charges,,,90,,5.31,percent of total billed charges,,,,,,,no IP contract,,80,,4.72,percent of total billed charges,,,,,,,no IP contract,,50,,2.95,percent of total billed charges,,,,,,no IP contract,,,78,,4.6,percent of total billed charges,,,70,,4.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.89,3324,
00143-9889-15 - amoxicillin 250 mg/5 mL REC P,00143-9889-15,NDC,,,,inpatient,1,ML,5.85,3.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.97,percent of total billed charges,,,85,,4.97,percent of total billed charges,,,49,,2.87,percent of total billed charges,,,90,,5.27,percent of total billed charges,,,,,,,no IP contract,,80,,4.68,percent of total billed charges,,,,,,,no IP contract,,50,,2.93,percent of total billed charges,,,,,,no IP contract,,,78,,4.56,percent of total billed charges,,,70,,4.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.87,3324,
00143-9928-01 - ciprofloxacin 500 mg Tab,00143-9928-01,NDC,,,,inpatient,1,EA,46.5,27.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,37.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,39.53,percent of total billed charges,,,85,,39.53,percent of total billed charges,,,49,,22.79,percent of total billed charges,,,90,,41.85,percent of total billed charges,,,,,,,no IP contract,,80,,37.2,percent of total billed charges,,,,,,,no IP contract,,50,,23.25,percent of total billed charges,,,,,,no IP contract,,,78,,36.27,percent of total billed charges,,,70,,32.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.79,3324,
00143-9929-50 - ciprofloxacin 750 mg Tab,00143-9929-50,NDC,,,,inpatient,1,EA,48.75,29.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,39.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,41.44,percent of total billed charges,,,85,,41.44,percent of total billed charges,,,49,,23.89,percent of total billed charges,,,90,,43.88,percent of total billed charges,,,,,,,no IP contract,,80,,39,percent of total billed charges,,,,,,,no IP contract,,50,,24.38,percent of total billed charges,,,,,,no IP contract,,,78,,38.03,percent of total billed charges,,,70,,34.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.89,3324,
CeFAZolin 10 g REC I,00143-9983-03,NDC,,,,inpatient,1,EA,95.1,57.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,77.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,80.84,percent of total billed charges,,,85,,80.84,percent of total billed charges,,,49,,46.6,percent of total billed charges,,,90,,85.59,percent of total billed charges,,,,,,,no IP contract,,80,,76.08,percent of total billed charges,,,,,,,no IP contract,,50,,47.55,percent of total billed charges,,,,,,no IP contract,,,78,,74.18,percent of total billed charges,,,70,,66.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,46.6,3324,
00149-0007-05 - nitrofurantoin macrocrystals 25 mg Cap,00149-0007-05,NDC,,,,inpatient,1,EA,17.75,10.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.09,percent of total billed charges,,,85,,15.09,percent of total billed charges,,,49,,8.7,percent of total billed charges,,,90,,15.98,percent of total billed charges,,,,,,,no IP contract,,80,,14.2,percent of total billed charges,,,,,,,no IP contract,,50,,8.88,percent of total billed charges,,,,,,no IP contract,,,78,,13.85,percent of total billed charges,,,70,,12.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.7,3324,
00149-0030-77 - dantrolene 25 mg Cap,00149-0030-77,NDC,,,,inpatient,1,EA,11.95,7.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.16,percent of total billed charges,,,85,,10.16,percent of total billed charges,,,49,,5.86,percent of total billed charges,,,90,,10.76,percent of total billed charges,,,,,,,no IP contract,,80,,9.56,percent of total billed charges,,,,,,,no IP contract,,50,,5.98,percent of total billed charges,,,,,,no IP contract,,,78,,9.32,percent of total billed charges,,,70,,8.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.86,3324,
00149-0031-05 - dantrolene 50 mg Cap,00149-0031-05,NDC,,,,inpatient,1,EA,18.85,11.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.02,percent of total billed charges,,,85,,16.02,percent of total billed charges,,,49,,9.24,percent of total billed charges,,,90,,16.97,percent of total billed charges,,,,,,,no IP contract,,80,,15.08,percent of total billed charges,,,,,,,no IP contract,,50,,9.43,percent of total billed charges,,,,,,no IP contract,,,78,,14.7,percent of total billed charges,,,70,,13.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.24,3324,
00168-0002-15 - triamcinolone topical 0.5% Cream,00168-0002-15,NDC,,,,inpatient,1,UN,101.7,61.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,82.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,86.45,percent of total billed charges,,,85,,86.45,percent of total billed charges,,,49,,49.83,percent of total billed charges,,,90,,91.53,percent of total billed charges,,,,,,,no IP contract,,80,,81.36,percent of total billed charges,,,,,,,no IP contract,,50,,50.85,percent of total billed charges,,,,,,no IP contract,,,78,,79.33,percent of total billed charges,,,70,,71.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,49.83,3324,
00168-0003-80 - triamcinolone Topical 0.025% Cream,00168-0003-80,NDC,,,,inpatient,1,UN,102.5,61.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,83.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,87.13,percent of total billed charges,,,85,,87.13,percent of total billed charges,,,49,,50.23,percent of total billed charges,,,90,,92.25,percent of total billed charges,,,,,,,no IP contract,,80,,82,percent of total billed charges,,,,,,,no IP contract,,50,,51.25,percent of total billed charges,,,,,,no IP contract,,,78,,79.95,percent of total billed charges,,,70,,71.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,50.23,3324,
00168-0004-15 - triamcinolone topical 0.1% Cream,00168-0004-15,NDC,,,,inpatient,1,UN,55.45,33.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,44.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,47.13,percent of total billed charges,,,85,,47.13,percent of total billed charges,,,49,,27.17,percent of total billed charges,,,90,,49.91,percent of total billed charges,,,,,,,no IP contract,,80,,44.36,percent of total billed charges,,,,,,,no IP contract,,50,,27.73,percent of total billed charges,,,,,,no IP contract,,,78,,43.25,percent of total billed charges,,,70,,38.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.17,3324,
00168-0004-16 - triamcinolone topical 0.1% Cream,00168-0004-16,NDC,,,,inpatient,1,UN,273.95,164.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,221.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,232.86,percent of total billed charges,,,85,,232.86,percent of total billed charges,,,49,,134.24,percent of total billed charges,,,90,,246.56,percent of total billed charges,,,,,,,no IP contract,,80,,219.16,percent of total billed charges,,,,,,,no IP contract,,50,,136.98,percent of total billed charges,,,,,,no IP contract,,,78,,213.68,percent of total billed charges,,,70,,191.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,134.24,3324,
00168-0005-80 - triamcinolone Topical 0.025% Ointm,00168-0005-80,NDC,,,,inpatient,1,UN,102.5,61.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,83.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,87.13,percent of total billed charges,,,85,,87.13,percent of total billed charges,,,49,,50.23,percent of total billed charges,,,90,,92.25,percent of total billed charges,,,,,,,no IP contract,,80,,82,percent of total billed charges,,,,,,,no IP contract,,50,,51.25,percent of total billed charges,,,,,,no IP contract,,,78,,79.95,percent of total billed charges,,,70,,71.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,50.23,3324,
00168-0006-15 - triamcinolone topical 0.1% Ointm,00168-0006-15,NDC,,,,inpatient,1,UN,55.45,33.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,44.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,47.13,percent of total billed charges,,,85,,47.13,percent of total billed charges,,,49,,27.17,percent of total billed charges,,,90,,49.91,percent of total billed charges,,,,,,,no IP contract,,80,,44.36,percent of total billed charges,,,,,,,no IP contract,,50,,27.73,percent of total billed charges,,,,,,no IP contract,,,78,,43.25,percent of total billed charges,,,70,,38.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.17,3324,
00168-0015-31 - hydrocortisone topical 1% Cream,00168-0015-31,NDC,,,,inpatient,1,UN,71.7,43.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,58.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,60.95,percent of total billed charges,,,85,,60.95,percent of total billed charges,,,49,,35.13,percent of total billed charges,,,90,,64.53,percent of total billed charges,,,,,,,no IP contract,,80,,57.36,percent of total billed charges,,,,,,,no IP contract,,50,,35.85,percent of total billed charges,,,,,,no IP contract,,,78,,55.93,percent of total billed charges,,,70,,50.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,35.13,3324,
hydrocortisone Topical 1% Ointm,00168-0020-31,NDC,,,,inpatient,1,EA,39.55,23.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.62,percent of total billed charges,,,85,,33.62,percent of total billed charges,,,49,,19.38,percent of total billed charges,,,90,,35.6,percent of total billed charges,,,,,,,no IP contract,,80,,31.64,percent of total billed charges,,,,,,,no IP contract,,50,,19.78,percent of total billed charges,,,,,,no IP contract,,,78,,30.85,percent of total billed charges,,,70,,27.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.38,3324,
00168-0029-38 - bacitracin/HC/neomycin/polymyxin B ophthalmic 400 units-10 mg-3.5 mg-10000 units/g O,00168-0029-38,NDC,,,,inpatient,1,UN,145.4,87.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,117.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,123.59,percent of total billed charges,,,85,,123.59,percent of total billed charges,,,49,,71.25,percent of total billed charges,,,90,,130.86,percent of total billed charges,,,,,,,no IP contract,,80,,116.32,percent of total billed charges,,,,,,,no IP contract,,50,,72.7,percent of total billed charges,,,,,,no IP contract,,,78,,113.41,percent of total billed charges,,,70,,101.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,71.25,3324,
00168-0053-21 - petrolatum Topical 100% Ointm,00168-0053-21,NDC,,,,inpatient,1,UN,30.5,18.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.93,percent of total billed charges,,,85,,25.93,percent of total billed charges,,,49,,14.95,percent of total billed charges,,,90,,27.45,percent of total billed charges,,,,,,,no IP contract,,80,,24.4,percent of total billed charges,,,,,,,no IP contract,,50,,15.25,percent of total billed charges,,,,,,no IP contract,,,78,,23.79,percent of total billed charges,,,70,,21.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.95,3324,
00168-0059-60 - fluocinolone topical 0.01% Soln,00168-0059-60,NDC,,,,inpatient,1,UN,99.2,59.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,80.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,84.32,percent of total billed charges,,,85,,84.32,percent of total billed charges,,,49,,48.61,percent of total billed charges,,,90,,89.28,percent of total billed charges,,,,,,,no IP contract,,80,,79.36,percent of total billed charges,,,,,,,no IP contract,,50,,49.6,percent of total billed charges,,,,,,no IP contract,,,78,,77.38,percent of total billed charges,,,70,,69.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,48.61,3324,
00168-0062-02 - zinc oxide topical 20% Ointm,00168-0062-02,NDC,,,,inpatient,1,UN,49.2,29.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,39.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,41.82,percent of total billed charges,,,85,,41.82,percent of total billed charges,,,49,,24.11,percent of total billed charges,,,90,,44.28,percent of total billed charges,,,,,,,no IP contract,,80,,39.36,percent of total billed charges,,,,,,,no IP contract,,50,,24.6,percent of total billed charges,,,,,,no IP contract,,,78,,38.38,percent of total billed charges,,,70,,34.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.11,3324,
00168-0080-31 - hydrocortisone topical 2.5% Cream,00168-0080-31,NDC,,,,inpatient,1,UN,101.7,61.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,82.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,86.45,percent of total billed charges,,,85,,86.45,percent of total billed charges,,,49,,49.83,percent of total billed charges,,,90,,91.53,percent of total billed charges,,,,,,,no IP contract,,80,,81.36,percent of total billed charges,,,,,,,no IP contract,,50,,50.85,percent of total billed charges,,,,,,no IP contract,,,78,,79.33,percent of total billed charges,,,70,,71.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,49.83,3324,
00168-0099-30 - ketoconazole topical 2% Cream,00168-0099-30,NDC,,,,inpatient,1,UN,444.05,266.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,359.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,377.44,percent of total billed charges,,,85,,377.44,percent of total billed charges,,,49,,217.58,percent of total billed charges,,,90,,399.65,percent of total billed charges,,,,,,,no IP contract,,80,,355.24,percent of total billed charges,,,,,,,no IP contract,,50,,222.03,percent of total billed charges,,,,,,no IP contract,,,78,,346.36,percent of total billed charges,,,70,,310.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,217.58,3324,
00168-0134-60 - fluocinonide topical 0.05% Soln,00168-0134-60,NDC,,,,inpatient,1,UN,234.15,140.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,189.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,199.03,percent of total billed charges,,,85,,199.03,percent of total billed charges,,,49,,114.73,percent of total billed charges,,,90,,210.74,percent of total billed charges,,,,,,,no IP contract,,80,,187.32,percent of total billed charges,,,,,,,no IP contract,,50,,117.08,percent of total billed charges,,,,,,no IP contract,,,78,,182.64,percent of total billed charges,,,70,,163.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,114.73,3324,
00168-0146-30 - hydrocortisone topical 2.5% Ointm,00168-0146-30,NDC,,,,inpatient,1,UN,74.2,44.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63.07,percent of total billed charges,,,85,,63.07,percent of total billed charges,,,49,,36.36,percent of total billed charges,,,90,,66.78,percent of total billed charges,,,,,,,no IP contract,,80,,59.36,percent of total billed charges,,,,,,,no IP contract,,50,,37.1,percent of total billed charges,,,,,,no IP contract,,,78,,57.88,percent of total billed charges,,,70,,51.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.36,3324,
00168-0162-30 - clobetasol topical 0.05% Ointm,00168-0162-30,NDC,,,,inpatient,1,UN,2173.35,1304.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1760.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1847.35,percent of total billed charges,,,85,,1847.35,percent of total billed charges,,,49,,1064.94,percent of total billed charges,,,90,,1956.02,percent of total billed charges,,,,,,,no IP contract,,80,,1738.68,percent of total billed charges,,,,,,,no IP contract,,50,,1086.68,percent of total billed charges,,,,,,no IP contract,,,78,,1695.21,percent of total billed charges,,,70,,1521.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
00168-0163-15 - clobetasol topical 0.05% Cream,00168-0163-15,NDC,,,,inpatient,1,UN,215.4,129.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,174.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,183.09,percent of total billed charges,,,85,,183.09,percent of total billed charges,,,49,,105.55,percent of total billed charges,,,90,,193.86,percent of total billed charges,,,,,,,no IP contract,,80,,172.32,percent of total billed charges,,,,,,,no IP contract,,50,,107.7,percent of total billed charges,,,,,,no IP contract,,,78,,168.01,percent of total billed charges,,,70,,150.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,105.55,3324,
00168-0201-60 - clindamycin topical 1% Soln,00168-0201-60,NDC,,,,inpatient,1,UN,663.95,398.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,537.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,564.36,percent of total billed charges,,,85,,564.36,percent of total billed charges,,,49,,325.34,percent of total billed charges,,,90,,597.56,percent of total billed charges,,,,,,,no IP contract,,80,,531.16,percent of total billed charges,,,,,,,no IP contract,,50,,331.98,percent of total billed charges,,,,,,no IP contract,,,78,,517.88,percent of total billed charges,,,70,,464.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,325.34,3324,
00168-0203-60 - clindamycin topical 1% Lotio,00168-0203-60,NDC,,,,inpatient,1,UN,1008.8,605.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,817.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,857.48,percent of total billed charges,,,85,,857.48,percent of total billed charges,,,49,,494.31,percent of total billed charges,,,90,,907.92,percent of total billed charges,,,,,,,no IP contract,,80,,807.04,percent of total billed charges,,,,,,,no IP contract,,50,,504.4,percent of total billed charges,,,,,,no IP contract,,,78,,786.86,percent of total billed charges,,,70,,706.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,494.31,3324,
00168-0258-46 - betamethasone-clotrimazole topical 0.05%-1% Cream,00168-0258-46,NDC,,,,inpatient,1,UN,541.5,324.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,438.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,460.28,percent of total billed charges,,,85,,460.28,percent of total billed charges,,,49,,265.34,percent of total billed charges,,,90,,487.35,percent of total billed charges,,,,,,,no IP contract,,80,,433.2,percent of total billed charges,,,,,,,no IP contract,,50,,270.75,percent of total billed charges,,,,,,no IP contract,,,78,,422.37,percent of total billed charges,,,70,,379.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,265.34,3324,
00168-0264-15 - alclometasone topical 0.05% Ointm,00168-0264-15,NDC,,,,inpatient,1,UN,673.95,404.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,545.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,572.86,percent of total billed charges,,,85,,572.86,percent of total billed charges,,,49,,330.24,percent of total billed charges,,,90,,606.56,percent of total billed charges,,,,,,,no IP contract,,80,,539.16,percent of total billed charges,,,,,,,no IP contract,,50,,336.98,percent of total billed charges,,,,,,no IP contract,,,78,,525.68,percent of total billed charges,,,70,,471.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,330.24,3324,
00168-0310-02 - desonide topical 0.05% Lotio,00168-0310-02,NDC,,,,inpatient,1,UN,2518.2,1510.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2039.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2140.47,percent of total billed charges,,,85,,2140.47,percent of total billed charges,,,49,,1233.92,percent of total billed charges,,,90,,2266.38,percent of total billed charges,,,,,,,no IP contract,,80,,2014.56,percent of total billed charges,,,,,,,no IP contract,,50,,1259.1,percent of total billed charges,,,,,,no IP contract,,,78,,1964.2,percent of total billed charges,,,70,,1762.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
00168-0313-90 - ciclopirox topical 0.77% Cream,00168-0313-90,NDC,,,,inpatient,1,UN,1043.8,626.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,845.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,887.23,percent of total billed charges,,,85,,887.23,percent of total billed charges,,,49,,511.46,percent of total billed charges,,,90,,939.42,percent of total billed charges,,,,,,,no IP contract,,80,,835.04,percent of total billed charges,,,,,,,no IP contract,,50,,521.9,percent of total billed charges,,,,,,no IP contract,,,78,,814.16,percent of total billed charges,,,70,,730.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,511.46,3324,
00168-0357-30 - lidocaine-prilocaine topical 2.5%-2.5% Cream,00168-0357-30,NDC,,,,inpatient,1,UN,434.05,260.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,351.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,368.94,percent of total billed charges,,,85,,368.94,percent of total billed charges,,,49,,212.68,percent of total billed charges,,,90,,390.65,percent of total billed charges,,,,,,,no IP contract,,80,,347.24,percent of total billed charges,,,,,,,no IP contract,,50,,217.03,percent of total billed charges,,,,,,no IP contract,,,78,,338.56,percent of total billed charges,,,70,,303.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,212.68,3324,
00168-0416-30 - tacrolimus topical 0.1% Ointm,00168-0416-30,NDC,,,,inpatient,1,UN,1363.7,818.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1104.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1159.15,percent of total billed charges,,,85,,1159.15,percent of total billed charges,,,49,,668.21,percent of total billed charges,,,90,,1227.33,percent of total billed charges,,,,,,,no IP contract,,80,,1090.96,percent of total billed charges,,,,,,,no IP contract,,50,,681.85,percent of total billed charges,,,,,,no IP contract,,,78,,1063.69,percent of total billed charges,,,70,,954.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,668.21,3324,
00168-0432-24 - imiquimod topical 5% Cream,00168-0432-24,NDC,,,,inpatient,1,EA,285.55,171.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,231.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,242.72,percent of total billed charges,,,85,,242.72,percent of total billed charges,,,49,,139.92,percent of total billed charges,,,90,,257,percent of total billed charges,,,,,,,no IP contract,,80,,228.44,percent of total billed charges,,,,,,,no IP contract,,50,,142.78,percent of total billed charges,,,,,,no IP contract,,,78,,222.73,percent of total billed charges,,,70,,199.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,139.92,3324,
00169-0084-81 - repaglinide 2 mg Tab,00169-0084-81,NDC,,,,inpatient,1,EA,14.9,8.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.67,percent of total billed charges,,,85,,12.67,percent of total billed charges,,,49,,7.3,percent of total billed charges,,,90,,13.41,percent of total billed charges,,,,,,,no IP contract,,80,,11.92,percent of total billed charges,,,,,,,no IP contract,,50,,7.45,percent of total billed charges,,,,,,no IP contract,,,78,,11.62,percent of total billed charges,,,70,,10.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.3,3324,
00169-3687-12 - insulin detemir 100 units/mL Soln,00169-3687-12,NDC,,,,inpatient,1,ML,451.8,271.08,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,365.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,384.03,percent of total billed charges,,,85,,384.03,percent of total billed charges,,,49,,221.38,percent of total billed charges,,,90,,406.62,percent of total billed charges,,,,,,,no IP contract,,80,,361.44,percent of total billed charges,,,,,,,no IP contract,,50,,225.9,percent of total billed charges,,,,,,no IP contract,,,78,,352.4,percent of total billed charges,,,70,,316.26,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,221.38,3324,
00169-4060-12 - liraglutide 18 mg/3 mL Soln,00169-4060-12,NDC,,,,inpatient,3,ML,425.5,255.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,344.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,361.68,percent of total billed charges,,,85,,361.68,percent of total billed charges,,,49,,208.5,percent of total billed charges,,,90,,382.95,percent of total billed charges,,,,,,,no IP contract,,80,,340.4,percent of total billed charges,,,,,,,no IP contract,,50,,212.75,percent of total billed charges,,,,,,no IP contract,,,78,,331.89,percent of total billed charges,,,70,,297.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,208.5,3324,
00172-2083-10 - hydrochlorothiazide 25 mg Tab,00172-2083-10,NDC,,,,inpatient,1,EA,5,3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.25,percent of total billed charges,,,85,,4.25,percent of total billed charges,,,49,,2.45,percent of total billed charges,,,90,,4.5,percent of total billed charges,,,,,,,no IP contract,,80,,4,percent of total billed charges,,,,,,,no IP contract,,50,,2.5,percent of total billed charges,,,,,,no IP contract,,,78,,3.9,percent of total billed charges,,,70,,3.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.45,3324,
00172-2345-60 - procainamide 250 mg Cap,00172-2345-60,NDC,,,,inpatient,1,EA,9.25,5.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.86,percent of total billed charges,,,85,,7.86,percent of total billed charges,,,49,,4.53,percent of total billed charges,,,90,,8.33,percent of total billed charges,,,,,,,no IP contract,,80,,7.4,percent of total billed charges,,,,,,,no IP contract,,50,,4.63,percent of total billed charges,,,,,,no IP contract,,,78,,7.22,percent of total billed charges,,,70,,6.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.53,3324,
00172-3925-60 - diazepam 2 mg Tab,00172-3925-60,NDC,,,,inpatient,1,EA,6.4,3.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.44,percent of total billed charges,,,85,,5.44,percent of total billed charges,,,49,,3.14,percent of total billed charges,,,90,,5.76,percent of total billed charges,,,,,,,no IP contract,,80,,5.12,percent of total billed charges,,,,,,,no IP contract,,50,,3.2,percent of total billed charges,,,,,,no IP contract,,,78,,4.99,percent of total billed charges,,,70,,4.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.14,3324,
00172-3926-60 - diazePAM 5 mg Tab,00172-3926-60,NDC,,,,inpatient,1,EA,7.1,4.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.04,percent of total billed charges,,,85,,6.04,percent of total billed charges,,,49,,3.48,percent of total billed charges,,,90,,6.39,percent of total billed charges,,,,,,,no IP contract,,80,,5.68,percent of total billed charges,,,,,,,no IP contract,,50,,3.55,percent of total billed charges,,,,,,no IP contract,,,78,,5.54,percent of total billed charges,,,70,,4.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.48,3324,
00172-4029-60 - indomethacin 25 mg Cap,00172-4029-60,NDC,,,,inpatient,1,EA,6.85,4.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.82,percent of total billed charges,,,85,,5.82,percent of total billed charges,,,49,,3.36,percent of total billed charges,,,90,,6.17,percent of total billed charges,,,,,,,no IP contract,,80,,5.48,percent of total billed charges,,,,,,,no IP contract,,50,,3.43,percent of total billed charges,,,,,,no IP contract,,,78,,5.34,percent of total billed charges,,,70,,4.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.36,3324,
00172-4058-60 - cefadroxil 500 mg Cap,00172-4058-60,NDC,,,,inpatient,1,EA,36.8,22.08,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.28,percent of total billed charges,,,85,,31.28,percent of total billed charges,,,49,,18.03,percent of total billed charges,,,90,,33.12,percent of total billed charges,,,,,,,no IP contract,,80,,29.44,percent of total billed charges,,,,,,,no IP contract,,50,,18.4,percent of total billed charges,,,,,,no IP contract,,,78,,28.7,percent of total billed charges,,,70,,25.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.03,3324,
00172-4096-60 - baclofen 10 mg Tab,00172-4096-60,NDC,,,,inpatient,1,EA,23.45,14.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.93,percent of total billed charges,,,85,,19.93,percent of total billed charges,,,49,,11.49,percent of total billed charges,,,90,,21.11,percent of total billed charges,,,,,,,no IP contract,,80,,18.76,percent of total billed charges,,,,,,,no IP contract,,50,,11.73,percent of total billed charges,,,,,,no IP contract,,,78,,18.29,percent of total billed charges,,,70,,16.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.49,3324,
00172-4236-60 - nadolol 40 mg Tab,00172-4236-60,NDC,,,,inpatient,1,EA,11.85,7.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.07,percent of total billed charges,,,85,,10.07,percent of total billed charges,,,49,,5.81,percent of total billed charges,,,90,,10.67,percent of total billed charges,,,,,,,no IP contract,,80,,9.48,percent of total billed charges,,,,,,,no IP contract,,50,,5.93,percent of total billed charges,,,,,,no IP contract,,,78,,9.24,percent of total billed charges,,,70,,8.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.81,3324,
00172-4285-10 - verapamil 120 mg/12 hours ER Ta,00172-4285-10,NDC,,,,inpatient,1,EA,12.35,7.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.5,percent of total billed charges,,,85,,10.5,percent of total billed charges,,,49,,6.05,percent of total billed charges,,,90,,11.12,percent of total billed charges,,,,,,,no IP contract,,80,,9.88,percent of total billed charges,,,,,,,no IP contract,,50,,6.18,percent of total billed charges,,,,,,no IP contract,,,78,,9.63,percent of total billed charges,,,70,,8.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.05,3324,
00172-4366-60 - labetalol 300 mg Tab,00172-4366-60,NDC,,,,inpatient,1,EA,12.25,7.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.41,percent of total billed charges,,,85,,10.41,percent of total billed charges,,,49,,6,percent of total billed charges,,,90,,11.03,percent of total billed charges,,,,,,,no IP contract,,80,,9.8,percent of total billed charges,,,,,,,no IP contract,,50,,6.13,percent of total billed charges,,,,,,no IP contract,,,78,,9.56,percent of total billed charges,,,70,,8.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6,3324,
00172-5411-46 - fluconazole 100 mg Tab,00172-5411-46,NDC,,,,inpatient,1,EA,73.4,44.04,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,59.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,62.39,percent of total billed charges,,,85,,62.39,percent of total billed charges,,,49,,35.97,percent of total billed charges,,,90,,66.06,percent of total billed charges,,,,,,,no IP contract,,80,,58.72,percent of total billed charges,,,,,,,no IP contract,,50,,36.7,percent of total billed charges,,,,,,no IP contract,,,78,,57.25,percent of total billed charges,,,70,,51.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,35.97,3324,
00172-5412-11 - fluconazole 150 mg Tab,00172-5412-11,NDC,,,,inpatient,1,EA,114.55,68.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,92.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,97.37,percent of total billed charges,,,85,,97.37,percent of total billed charges,,,49,,56.13,percent of total billed charges,,,90,,103.1,percent of total billed charges,,,,,,,no IP contract,,80,,91.64,percent of total billed charges,,,,,,,no IP contract,,50,,57.28,percent of total billed charges,,,,,,no IP contract,,,78,,89.35,percent of total billed charges,,,70,,80.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,56.13,3324,
00172-7313-20 - cycloSPORINE modified 100 mg/mL LIQ,00172-7313-20,NDC,,,,inpatient,1,ML,54.65,32.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,44.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,46.45,percent of total billed charges,,,85,,46.45,percent of total billed charges,,,49,,26.78,percent of total billed charges,,,90,,49.19,percent of total billed charges,,,,,,,no IP contract,,80,,43.72,percent of total billed charges,,,,,,,no IP contract,,50,,27.33,percent of total billed charges,,,,,,no IP contract,,,78,,42.63,percent of total billed charges,,,70,,38.26,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.78,3324,
00173-0178-55 - buPROPion 100 mg Tab,00173-0178-55,NDC,,,,inpatient,1,EA,21.65,12.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.4,percent of total billed charges,,,85,,18.4,percent of total billed charges,,,49,,10.61,percent of total billed charges,,,90,,19.49,percent of total billed charges,,,,,,,no IP contract,,80,,17.32,percent of total billed charges,,,,,,,no IP contract,,50,,10.83,percent of total billed charges,,,,,,no IP contract,,,78,,16.89,percent of total billed charges,,,70,,15.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.61,3324,
00173-0430-01 - fluticasone Topical 0.05% Cream,00173-0430-01,NDC,,,,inpatient,1,UN,361.6,216.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,292.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,307.36,percent of total billed charges,,,85,,307.36,percent of total billed charges,,,49,,177.18,percent of total billed charges,,,90,,325.44,percent of total billed charges,,,,,,,no IP contract,,80,,289.28,percent of total billed charges,,,,,,,no IP contract,,50,,180.8,percent of total billed charges,,,,,,no IP contract,,,78,,282.05,percent of total billed charges,,,70,,253.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,177.18,3324,
00173-0449-02 - sumatriptan 6 mg/0.5 mL Soln,00173-0449-02,NDC,,,,inpatient,0.5,ML,786.8,472.08,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,637.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,668.78,percent of total billed charges,,,85,,668.78,percent of total billed charges,,,49,,385.53,percent of total billed charges,,,90,,708.12,percent of total billed charges,,,,,,,no IP contract,,80,,629.44,percent of total billed charges,,,,,,,no IP contract,,50,,393.4,percent of total billed charges,,,,,,no IP contract,,,78,,613.7,percent of total billed charges,,,70,,550.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,385.53,3324,
00173-0460-02 - sumatriptan 25 mg Tab,00173-0460-02,NDC,,,,inpatient,1,EA,163.4,98.04,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,132.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,138.89,percent of total billed charges,,,85,,138.89,percent of total billed charges,,,49,,80.07,percent of total billed charges,,,90,,147.06,percent of total billed charges,,,,,,,no IP contract,,80,,130.72,percent of total billed charges,,,,,,,no IP contract,,50,,81.7,percent of total billed charges,,,,,,no IP contract,,,78,,127.45,percent of total billed charges,,,70,,114.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,80.07,3324,
00173-0491-00 - fluticasone 44 mcg/inh Aeros,00173-0491-00,NDC,,,,inpatient,1,UN,603.75,362.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,489.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,513.19,percent of total billed charges,,,85,,513.19,percent of total billed charges,,,49,,295.84,percent of total billed charges,,,90,,543.38,percent of total billed charges,,,,,,,no IP contract,,80,,483,percent of total billed charges,,,,,,,no IP contract,,50,,301.88,percent of total billed charges,,,,,,no IP contract,,,78,,470.93,percent of total billed charges,,,70,,422.63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,295.84,3324,
00173-0662-00 - lamivudine 100 mg Tab,00173-0662-00,NDC,,,,inpatient,1,EA,75.55,45.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,61.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,64.22,percent of total billed charges,,,85,,64.22,percent of total billed charges,,,49,,37.02,percent of total billed charges,,,90,,68,percent of total billed charges,,,,,,,no IP contract,,80,,60.44,percent of total billed charges,,,,,,,no IP contract,,50,,37.78,percent of total billed charges,,,,,,no IP contract,,,78,,58.93,percent of total billed charges,,,70,,52.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,37.02,3324,
00173-0672-00 - amprenavir 150 mg Cap,00173-0672-00,NDC,,,,inpatient,1,EA,16.6,9.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.11,percent of total billed charges,,,85,,14.11,percent of total billed charges,,,49,,8.13,percent of total billed charges,,,90,,14.94,percent of total billed charges,,,,,,,no IP contract,,80,,13.28,percent of total billed charges,,,,,,,no IP contract,,50,,8.3,percent of total billed charges,,,,,,no IP contract,,,78,,12.95,percent of total billed charges,,,70,,11.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.13,3324,
00173-0682-21 - albuterol CFC free 90 mcg/inh Aeros,00173-0682-21,NDC,,,,inpatient,1,UN,172.1,103.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,139.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,146.29,percent of total billed charges,,,85,,146.29,percent of total billed charges,,,49,,84.33,percent of total billed charges,,,90,,154.89,percent of total billed charges,,,,,,,no IP contract,,80,,137.68,percent of total billed charges,,,,,,,no IP contract,,50,,86.05,percent of total billed charges,,,,,,no IP contract,,,78,,134.24,percent of total billed charges,,,70,,120.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,84.33,3324,
00173-0682-24 - albuterol CFC free 90 mcg/inh Aeros,00173-0682-24,NDC,,,,inpatient,1,UN,172.1,103.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,139.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,146.29,percent of total billed charges,,,85,,146.29,percent of total billed charges,,,49,,84.33,percent of total billed charges,,,90,,154.89,percent of total billed charges,,,,,,,no IP contract,,80,,137.68,percent of total billed charges,,,,,,,no IP contract,,50,,86.05,percent of total billed charges,,,,,,no IP contract,,,78,,134.24,percent of total billed charges,,,70,,120.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,84.33,3324,
00173-0695-04 - fluticasone-salmeterol 100 mcg-50 mcg Powde,00173-0695-04,NDC,,,,inpatient,1,UN,1114.8,668.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,902.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,947.58,percent of total billed charges,,,85,,947.58,percent of total billed charges,,,49,,546.25,percent of total billed charges,,,90,,1003.32,percent of total billed charges,,,,,,,no IP contract,,80,,891.84,percent of total billed charges,,,,,,,no IP contract,,50,,557.4,percent of total billed charges,,,,,,no IP contract,,,78,,869.54,percent of total billed charges,,,70,,780.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,546.25,3324,
00173-0696-04 - fluticasone-salmeterol 1 INH Inhaler,00173-0696-04,NDC,,,,inpatient,1,UN,1114.8,668.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,902.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,947.58,percent of total billed charges,,,85,,947.58,percent of total billed charges,,,49,,546.25,percent of total billed charges,,,90,,1003.32,percent of total billed charges,,,,,,,no IP contract,,80,,891.84,percent of total billed charges,,,,,,,no IP contract,,50,,557.4,percent of total billed charges,,,,,,no IP contract,,,78,,869.54,percent of total billed charges,,,70,,780.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,546.25,3324,
00173-0697-04 - fluticasone-salmeterol 1 INH Inhaler,00173-0697-04,NDC,,,,inpatient,1,UN,1811,1086.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1466.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1539.35,percent of total billed charges,,,85,,1539.35,percent of total billed charges,,,49,,887.39,percent of total billed charges,,,90,,1629.9,percent of total billed charges,,,,,,,no IP contract,,80,,1448.8,percent of total billed charges,,,,,,,no IP contract,,50,,905.5,percent of total billed charges,,,,,,no IP contract,,,78,,1412.58,percent of total billed charges,,,70,,1267.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,887.39,3324,
00173-0712-04 - dutasteride 0.5 mg Cap,00173-0712-04,NDC,,,,inpatient,1,EA,40.15,24.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34.13,percent of total billed charges,,,85,,34.13,percent of total billed charges,,,49,,19.67,percent of total billed charges,,,90,,36.14,percent of total billed charges,,,,,,,no IP contract,,80,,32.12,percent of total billed charges,,,,,,,no IP contract,,50,,20.08,percent of total billed charges,,,,,,no IP contract,,,78,,31.32,percent of total billed charges,,,70,,28.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.67,3324,
00173-0717-20 - fluticasone-salmeterol CFC free 230 mcg-21 mcg/inh Aeros,00173-0717-20,NDC,,,,inpatient,1,UN,2774.1,1664.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2247.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2357.99,percent of total billed charges,,,85,,2357.99,percent of total billed charges,,,49,,1359.31,percent of total billed charges,,,90,,2496.69,percent of total billed charges,,,,,,,no IP contract,,80,,2219.28,percent of total billed charges,,,,,,,no IP contract,,50,,1387.05,percent of total billed charges,,,,,,no IP contract,,,78,,2163.8,percent of total billed charges,,,70,,1941.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
00173-0718-20 - fluticasone CFC free 44 mcg/inh Aeros,00173-0718-20,NDC,,,,inpatient,1,UN,829.5,497.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,671.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,705.08,percent of total billed charges,,,85,,705.08,percent of total billed charges,,,49,,406.46,percent of total billed charges,,,90,,746.55,percent of total billed charges,,,,,,,no IP contract,,80,,663.6,percent of total billed charges,,,,,,,no IP contract,,50,,414.75,percent of total billed charges,,,,,,no IP contract,,,78,,647.01,percent of total billed charges,,,70,,580.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,406.46,3324,
00173-0719-20 - fluticasone CFC free 110 mcg/inh Aeros,00173-0719-20,NDC,,,,inpatient,1,UN,1856.5,1113.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1503.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1578.03,percent of total billed charges,,,85,,1578.03,percent of total billed charges,,,49,,909.69,percent of total billed charges,,,90,,1670.85,percent of total billed charges,,,,,,,no IP contract,,80,,1485.2,percent of total billed charges,,,,,,,no IP contract,,50,,928.25,percent of total billed charges,,,,,,no IP contract,,,78,,1448.07,percent of total billed charges,,,70,,1299.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,909.69,3324,
00173-0720-20 - fluticasone CFC free 220 mcg/inh Aeros,00173-0720-20,NDC,,,,inpatient,1,UN,2879.1,1727.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2332.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2447.24,percent of total billed charges,,,85,,2447.24,percent of total billed charges,,,49,,1410.76,percent of total billed charges,,,90,,2591.19,percent of total billed charges,,,,,,,no IP contract,,80,,2303.28,percent of total billed charges,,,,,,,no IP contract,,50,,1439.55,percent of total billed charges,,,,,,no IP contract,,,78,,2245.7,percent of total billed charges,,,70,,2015.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
00173-0735-00 - sumatriptan 25 mg Tab,00173-0735-00,NDC,,,,inpatient,1,EA,222.2,133.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,179.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,188.87,percent of total billed charges,,,85,,188.87,percent of total billed charges,,,49,,108.88,percent of total billed charges,,,90,,199.98,percent of total billed charges,,,,,,,no IP contract,,80,,177.76,percent of total billed charges,,,,,,,no IP contract,,50,,111.1,percent of total billed charges,,,,,,no IP contract,,,78,,173.32,percent of total billed charges,,,70,,155.54,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,108.88,3324,
00173-0757-00 - lamotrigine 200 mg ER Ta,00173-0757-00,NDC,,,,inpatient,1,EA,100.25,60.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,81.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,85.21,percent of total billed charges,,,85,,85.21,percent of total billed charges,,,49,,49.12,percent of total billed charges,,,90,,90.23,percent of total billed charges,,,,,,,no IP contract,,80,,80.2,percent of total billed charges,,,,,,,no IP contract,,50,,50.13,percent of total billed charges,,,,,,no IP contract,,,78,,78.2,percent of total billed charges,,,70,,70.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,49.12,3324,
00173-0859-14 - fluticasone-vilanterol 100 mcg-25 mcg/inh Powde,00173-0859-14,NDC,,,,inpatient,1,UN,1203.4,722.04,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,974.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1022.89,percent of total billed charges,,,85,,1022.89,percent of total billed charges,,,49,,589.67,percent of total billed charges,,,90,,1083.06,percent of total billed charges,,,,,,,no IP contract,,80,,962.72,percent of total billed charges,,,,,,,no IP contract,,50,,601.7,percent of total billed charges,,,,,,no IP contract,,,78,,938.65,percent of total billed charges,,,70,,842.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,589.67,3324,
00173-0869-06 - umeclidinium-vilanterol 62.5 mcg-25 mcg/inh Powde,00173-0869-06,NDC,,,,inpatient,1,UN,133.35,80.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,108.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,113.35,percent of total billed charges,,,85,,113.35,percent of total billed charges,,,49,,65.34,percent of total billed charges,,,90,,120.02,percent of total billed charges,,,,,,,no IP contract,,80,,106.68,percent of total billed charges,,,,,,,no IP contract,,50,,66.68,percent of total billed charges,,,,,,no IP contract,,,78,,104.01,percent of total billed charges,,,70,,93.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,65.34,3324,
00173-0873-06 - umeclidinium 62.5 mcg (0.0625 mg)/inh Powde,00173-0873-06,NDC,,,,inpatient,1,UN,98.35,59.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,79.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,83.6,percent of total billed charges,,,85,,83.6,percent of total billed charges,,,49,,48.19,percent of total billed charges,,,90,,88.52,percent of total billed charges,,,,,,,no IP contract,,80,,78.68,percent of total billed charges,,,,,,,no IP contract,,50,,49.18,percent of total billed charges,,,,,,no IP contract,,,78,,76.71,percent of total billed charges,,,70,,68.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,48.19,3324,
00173-0874-14 - fluticasone furoate 100 mcg Powde,00173-0874-14,NDC,,,,inpatient,1,UN,60.3,36.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,48.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,51.26,percent of total billed charges,,,85,,51.26,percent of total billed charges,,,49,,29.55,percent of total billed charges,,,90,,54.27,percent of total billed charges,,,,,,,no IP contract,,80,,48.24,percent of total billed charges,,,,,,,no IP contract,,50,,30.15,percent of total billed charges,,,,,,no IP contract,,,78,,47.03,percent of total billed charges,,,70,,42.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,29.55,3324,
00173-0876-14 - fluticasone furoate 200 mcg Powde,00173-0876-14,NDC,,,,inpatient,1,UN,965.5,579.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,782.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,820.68,percent of total billed charges,,,85,,820.68,percent of total billed charges,,,49,,473.1,percent of total billed charges,,,90,,868.95,percent of total billed charges,,,,,,,no IP contract,,80,,772.4,percent of total billed charges,,,,,,,no IP contract,,50,,482.75,percent of total billed charges,,,,,,no IP contract,,,78,,753.09,percent of total billed charges,,,70,,675.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,473.1,3324,
00173-0882-14 - fluticasone-vilanterol 200 mcg-25 mcg/inh Powde,00173-0882-14,NDC,,,,inpatient,1,UN,1203.4,722.04,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,974.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1022.89,percent of total billed charges,,,85,,1022.89,percent of total billed charges,,,49,,589.67,percent of total billed charges,,,90,,1083.06,percent of total billed charges,,,,,,,no IP contract,,80,,962.72,percent of total billed charges,,,,,,,no IP contract,,50,,601.7,percent of total billed charges,,,,,,no IP contract,,,78,,938.65,percent of total billed charges,,,70,,842.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,589.67,3324,
00173-0945-55 - acyclovir 800 mg Tab,00173-0945-55,NDC,,,,inpatient,1,EA,68.8,41.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,55.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,58.48,percent of total billed charges,,,85,,58.48,percent of total billed charges,,,49,,33.71,percent of total billed charges,,,90,,61.92,percent of total billed charges,,,,,,,no IP contract,,80,,55.04,percent of total billed charges,,,,,,,no IP contract,,50,,34.4,percent of total billed charges,,,,,,no IP contract,,,78,,53.66,percent of total billed charges,,,70,,48.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,33.71,3324,
00178-0610-01 - potassium citrate 10 mEq ER Ta,00178-0610-01,NDC,,,,inpatient,1,EA,8.45,5.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.18,percent of total billed charges,,,85,,7.18,percent of total billed charges,,,49,,4.14,percent of total billed charges,,,90,,7.61,percent of total billed charges,,,,,,,no IP contract,,80,,6.76,percent of total billed charges,,,,,,,no IP contract,,50,,4.23,percent of total billed charges,,,,,,no IP contract,,,78,,6.59,percent of total billed charges,,,70,,5.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.14,3324,
00182-0001-01 - niacin 100 mg Tab,00182-0001-01,NDC,,,,inpatient,1,EA,4,2.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.4,percent of total billed charges,,,85,,3.4,percent of total billed charges,,,49,,1.96,percent of total billed charges,,,90,,3.6,percent of total billed charges,,,,,,,no IP contract,,80,,3.2,percent of total billed charges,,,,,,,no IP contract,,50,,2,percent of total billed charges,,,,,,no IP contract,,,78,,3.12,percent of total billed charges,,,70,,2.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.96,3324,
00182-0833-39 - magnesium hydroxide 8% Susp,00182-0833-39,NDC,,,,inpatient,30,ML,7.9,4.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.72,percent of total billed charges,,,85,,6.72,percent of total billed charges,,,49,,3.87,percent of total billed charges,,,90,,7.11,percent of total billed charges,,,,,,,no IP contract,,80,,6.32,percent of total billed charges,,,,,,,no IP contract,,50,,3.95,percent of total billed charges,,,,,,no IP contract,,,78,,6.16,percent of total billed charges,,,70,,5.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.87,3324,
00182-0833-40 - magnesium hydroxide 8% Susp,00182-0833-40,NDC,,,,inpatient,30,ML,7.9,4.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.72,percent of total billed charges,,,85,,6.72,percent of total billed charges,,,49,,3.87,percent of total billed charges,,,90,,7.11,percent of total billed charges,,,,,,,no IP contract,,80,,6.32,percent of total billed charges,,,,,,,no IP contract,,50,,3.95,percent of total billed charges,,,,,,no IP contract,,,78,,6.16,percent of total billed charges,,,70,,5.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.87,3324,
00182-1035-00 - doxyclycline 100 mg Cap,00182-1035-00,NDC,,,,inpatient,1,EA,482,289.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,390.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,409.7,percent of total billed charges,,,85,,409.7,percent of total billed charges,,,49,,236.18,percent of total billed charges,,,90,,433.8,percent of total billed charges,,,,,,,no IP contract,,80,,385.6,percent of total billed charges,,,,,,,no IP contract,,50,,241,percent of total billed charges,,,,,,no IP contract,,,78,,375.96,percent of total billed charges,,,70,,337.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,236.18,3324,
00182-1138-01 - selenium 50 mcg Tab,00182-1138-01,NDC,,,,inpatient,1,EA,4.05,2.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.44,percent of total billed charges,,,85,,3.44,percent of total billed charges,,,49,,1.98,percent of total billed charges,,,90,,3.65,percent of total billed charges,,,,,,,no IP contract,,80,,3.24,percent of total billed charges,,,,,,,no IP contract,,50,,2.03,percent of total billed charges,,,,,,no IP contract,,,78,,3.16,percent of total billed charges,,,70,,2.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.98,3324,
00182-1334-00 - predniSONE 10 mg Tab,00182-1334-00,NDC,,,,inpatient,1,EA,4.55,2.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.87,percent of total billed charges,,,85,,3.87,percent of total billed charges,,,49,,2.23,percent of total billed charges,,,90,,4.1,percent of total billed charges,,,,,,,no IP contract,,80,,3.64,percent of total billed charges,,,,,,,no IP contract,,50,,2.28,percent of total billed charges,,,,,,no IP contract,,,78,,3.55,percent of total billed charges,,,70,,3.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.23,3324,
00182-6084-39 - magnesium hydroxide 8% Susp,00182-6084-39,NDC,,,,inpatient,30,ML,7.9,4.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.72,percent of total billed charges,,,85,,6.72,percent of total billed charges,,,49,,3.87,percent of total billed charges,,,90,,7.11,percent of total billed charges,,,,,,,no IP contract,,80,,6.32,percent of total billed charges,,,,,,,no IP contract,,50,,3.95,percent of total billed charges,,,,,,no IP contract,,,78,,6.16,percent of total billed charges,,,70,,5.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.87,3324,
00182-8643-89 - simethicone 80 mg Chew,00182-8643-89,NDC,,,,inpatient,1,EA,5.1,3.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.34,percent of total billed charges,,,85,,4.34,percent of total billed charges,,,49,,2.5,percent of total billed charges,,,90,,4.59,percent of total billed charges,,,,,,,no IP contract,,80,,4.08,percent of total billed charges,,,,,,,no IP contract,,50,,2.55,percent of total billed charges,,,,,,no IP contract,,,78,,3.98,percent of total billed charges,,,70,,3.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.5,3324,
00182-8643-89 - simethicone 80 mg Chew Tab,00182-8643-89,NDC,,,,inpatient,1,EA,5.1,3.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.34,percent of total billed charges,,,85,,4.34,percent of total billed charges,,,49,,2.5,percent of total billed charges,,,90,,4.59,percent of total billed charges,,,,,,,no IP contract,,80,,4.08,percent of total billed charges,,,,,,,no IP contract,,50,,2.55,percent of total billed charges,,,,,,no IP contract,,,78,,3.98,percent of total billed charges,,,70,,3.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.5,3324,
00185-0063-01 - clonazePAM 0.5 mg Tab,00185-0063-01,NDC,,,,inpatient,1,EA,11.35,6.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.65,percent of total billed charges,,,85,,9.65,percent of total billed charges,,,49,,5.56,percent of total billed charges,,,90,,10.22,percent of total billed charges,,,,,,,no IP contract,,80,,9.08,percent of total billed charges,,,,,,,no IP contract,,50,,5.68,percent of total billed charges,,,,,,no IP contract,,,78,,8.85,percent of total billed charges,,,70,,7.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.56,3324,
00185-0128-01 - bumetanide 0.5 mg Tab,00185-0128-01,NDC,,,,inpatient,1,EA,8.3,4.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.06,percent of total billed charges,,,85,,7.06,percent of total billed charges,,,49,,4.07,percent of total billed charges,,,90,,7.47,percent of total billed charges,,,,,,,no IP contract,,80,,6.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.15,percent of total billed charges,,,,,,no IP contract,,,78,,6.47,percent of total billed charges,,,70,,5.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.07,3324,
00185-0129-01 - bumetanide 1 mg Tab,00185-0129-01,NDC,,,,inpatient,1,EA,10.2,6.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.67,percent of total billed charges,,,85,,8.67,percent of total billed charges,,,49,,5,percent of total billed charges,,,90,,9.18,percent of total billed charges,,,,,,,no IP contract,,80,,8.16,percent of total billed charges,,,,,,,no IP contract,,50,,5.1,percent of total billed charges,,,,,,no IP contract,,,78,,7.96,percent of total billed charges,,,70,,7.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5,3324,
00185-0130-01 - bumetanide 2 mg Tab,00185-0130-01,NDC,,,,inpatient,1,EA,14.5,8.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.33,percent of total billed charges,,,85,,12.33,percent of total billed charges,,,49,,7.11,percent of total billed charges,,,90,,13.05,percent of total billed charges,,,,,,,no IP contract,,80,,11.6,percent of total billed charges,,,,,,,no IP contract,,50,,7.25,percent of total billed charges,,,,,,no IP contract,,,78,,11.31,percent of total billed charges,,,70,,10.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.11,3324,
00185-0144-60 - amiodarone 200 mg Tab,00185-0144-60,NDC,,,,inpatient,1,EA,30.7,18.42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.1,percent of total billed charges,,,85,,26.1,percent of total billed charges,,,49,,15.04,percent of total billed charges,,,90,,27.63,percent of total billed charges,,,,,,,no IP contract,,80,,24.56,percent of total billed charges,,,,,,,no IP contract,,50,,15.35,percent of total billed charges,,,,,,no IP contract,,,78,,23.95,percent of total billed charges,,,70,,21.49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.04,3324,
00185-0550-30 - itraconazole 100 mg Cap,00185-0550-30,NDC,,,,inpatient,1,EA,77.6,46.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,62.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,65.96,percent of total billed charges,,,85,,65.96,percent of total billed charges,,,49,,38.02,percent of total billed charges,,,90,,69.84,percent of total billed charges,,,,,,,no IP contract,,80,,62.08,percent of total billed charges,,,,,,,no IP contract,,50,,38.8,percent of total billed charges,,,,,,no IP contract,,,78,,60.53,percent of total billed charges,,,70,,54.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,38.02,3324,
00185-0674-01 - hydrOXYzine pamoate 25 mg Cap,00185-0674-01,NDC,,,,inpatient,1,EA,6.2,3.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.27,percent of total billed charges,,,85,,5.27,percent of total billed charges,,,49,,3.04,percent of total billed charges,,,90,,5.58,percent of total billed charges,,,,,,,no IP contract,,80,,4.96,percent of total billed charges,,,,,,,no IP contract,,50,,3.1,percent of total billed charges,,,,,,no IP contract,,,78,,4.84,percent of total billed charges,,,70,,4.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.04,3324,
00185-0720-01 - indomethacin 75 mg ER Cap,00185-0720-01,NDC,,,,inpatient,1,EA,20.85,12.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.72,percent of total billed charges,,,85,,17.72,percent of total billed charges,,,49,,10.22,percent of total billed charges,,,90,,18.77,percent of total billed charges,,,,,,,no IP contract,,80,,16.68,percent of total billed charges,,,,,,,no IP contract,,50,,10.43,percent of total billed charges,,,,,,no IP contract,,,78,,16.26,percent of total billed charges,,,70,,14.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.22,3324,
00185-0757-01 - sulfADIAZINE 500 mg Tab,00185-0757-01,NDC,,,,inpatient,1,EA,15.25,9.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.96,percent of total billed charges,,,85,,12.96,percent of total billed charges,,,49,,7.47,percent of total billed charges,,,90,,13.73,percent of total billed charges,,,,,,,no IP contract,,80,,12.2,percent of total billed charges,,,,,,,no IP contract,,50,,7.63,percent of total billed charges,,,,,,no IP contract,,,78,,11.9,percent of total billed charges,,,70,,10.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.47,3324,
00185-0801-30 - rifampin 150 mg Cap,00185-0801-30,NDC,,,,inpatient,1,EA,14.5,8.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.33,percent of total billed charges,,,85,,12.33,percent of total billed charges,,,49,,7.11,percent of total billed charges,,,90,,13.05,percent of total billed charges,,,,,,,no IP contract,,80,,11.6,percent of total billed charges,,,,,,,no IP contract,,50,,7.25,percent of total billed charges,,,,,,no IP contract,,,78,,11.31,percent of total billed charges,,,70,,10.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.11,3324,
00185-0831-01 - amphetamine-dextroamphetamine 5 mg Tab,00185-0831-01,NDC,,,,inpatient,1,EA,19.65,11.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.7,percent of total billed charges,,,85,,16.7,percent of total billed charges,,,49,,9.63,percent of total billed charges,,,90,,17.69,percent of total billed charges,,,,,,,no IP contract,,80,,15.72,percent of total billed charges,,,,,,,no IP contract,,50,,9.83,percent of total billed charges,,,,,,no IP contract,,,78,,15.33,percent of total billed charges,,,70,,13.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.63,3324,
00185-0853-01 - amphetamine-dextroamphetamine 20 mg Tab,00185-0853-01,NDC,,,,inpatient,1,EA,9.15,5.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.78,percent of total billed charges,,,85,,7.78,percent of total billed charges,,,49,,4.48,percent of total billed charges,,,90,,8.24,percent of total billed charges,,,,,,,no IP contract,,80,,7.32,percent of total billed charges,,,,,,,no IP contract,,50,,4.58,percent of total billed charges,,,,,,no IP contract,,,78,,7.14,percent of total billed charges,,,70,,6.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.48,3324,
00185-0940-98 - cholestyramine 4 g/9 g REC P,00185-0940-98,NDC,,,,inpatient,1,UN,30.6,18.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.01,percent of total billed charges,,,85,,26.01,percent of total billed charges,,,49,,14.99,percent of total billed charges,,,90,,27.54,percent of total billed charges,,,,,,,no IP contract,,80,,24.48,percent of total billed charges,,,,,,,no IP contract,,50,,15.3,percent of total billed charges,,,,,,no IP contract,,,78,,23.87,percent of total billed charges,,,70,,21.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.99,3324,
00185-4350-30 - isoniazid 300 mg Tab,00185-4350-30,NDC,,,,inpatient,1,EA,6.2,3.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.27,percent of total billed charges,,,85,,5.27,percent of total billed charges,,,49,,3.04,percent of total billed charges,,,90,,5.58,percent of total billed charges,,,,,,,no IP contract,,80,,4.96,percent of total billed charges,,,,,,,no IP contract,,50,,3.1,percent of total billed charges,,,,,,no IP contract,,,78,,4.84,percent of total billed charges,,,70,,4.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.04,3324,
00185-5050-01 - metOLazone 2.5 mg Tab,00185-5050-01,NDC,,,,inpatient,1,EA,20.3,12.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.26,percent of total billed charges,,,85,,17.26,percent of total billed charges,,,49,,9.95,percent of total billed charges,,,90,,18.27,percent of total billed charges,,,,,,,no IP contract,,80,,16.24,percent of total billed charges,,,,,,,no IP contract,,50,,10.15,percent of total billed charges,,,,,,no IP contract,,,78,,15.83,percent of total billed charges,,,70,,14.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.95,3324,
00186-0370-28 - budesonide-formoterol 160 mcg-4.5 mcg/inh Aeros,00186-0370-28,NDC,,,,inpatient,1,UN,1737.05,1042.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1407.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1476.49,percent of total billed charges,,,85,,1476.49,percent of total billed charges,,,49,,851.15,percent of total billed charges,,,90,,1563.35,percent of total billed charges,,,,,,,no IP contract,,80,,1389.64,percent of total billed charges,,,,,,,no IP contract,,50,,868.53,percent of total billed charges,,,,,,no IP contract,,,78,,1354.9,percent of total billed charges,,,70,,1215.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,851.15,3324,
00186-0372-20 - budesonide 80 mcg/fomoterol fumarate 4.5 mcg 80/4.5 Inhaler,00186-0372-20,NDC,,,,inpatient,1,UN,15357.9,9214.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12439.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13054.22,percent of total billed charges,,,85,,13054.22,percent of total billed charges,,,49,,7525.37,percent of total billed charges,,,90,,13822.11,percent of total billed charges,,,,,,,no IP contract,,80,,12286.32,percent of total billed charges,,,,,,,no IP contract,,50,,7678.95,percent of total billed charges,,,,,,no IP contract,,,78,,11979.16,percent of total billed charges,,,70,,10750.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,13822.11,
00186-0450-31 - felodipine 2.5 mg ER Tab,00186-0450-31,NDC,,,,inpatient,1,EA,13.5,8.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.48,percent of total billed charges,,,85,,11.48,percent of total billed charges,,,49,,6.62,percent of total billed charges,,,90,,12.15,percent of total billed charges,,,,,,,no IP contract,,80,,10.8,percent of total billed charges,,,,,,,no IP contract,,50,,6.75,percent of total billed charges,,,,,,no IP contract,,,78,,10.53,percent of total billed charges,,,70,,9.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.62,3324,
00186-0450-58 - felodipine 2.5 mg ER Ta,00186-0450-58,NDC,,,,inpatient,1,EA,16.3,9.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.86,percent of total billed charges,,,85,,13.86,percent of total billed charges,,,49,,7.99,percent of total billed charges,,,90,,14.67,percent of total billed charges,,,,,,,no IP contract,,80,,13.04,percent of total billed charges,,,,,,,no IP contract,,50,,8.15,percent of total billed charges,,,,,,no IP contract,,,78,,12.71,percent of total billed charges,,,70,,11.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.99,3324,
00186-0776-60 - ticagrelor 60 mg Tab,00186-0776-60,NDC,,,,inpatient,1,EA,68.2,40.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,55.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,57.97,percent of total billed charges,,,85,,57.97,percent of total billed charges,,,49,,33.42,percent of total billed charges,,,90,,61.38,percent of total billed charges,,,,,,,no IP contract,,80,,54.56,percent of total billed charges,,,,,,,no IP contract,,50,,34.1,percent of total billed charges,,,,,,no IP contract,,,78,,53.2,percent of total billed charges,,,70,,47.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,33.42,3324,
00186-0777-39 - ticagrelor 90 mg Tab,00186-0777-39,NDC,,,,inpatient,1,EA,41.6,24.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,35.36,percent of total billed charges,,,85,,35.36,percent of total billed charges,,,49,,20.38,percent of total billed charges,,,90,,37.44,percent of total billed charges,,,,,,,no IP contract,,80,,33.28,percent of total billed charges,,,,,,,no IP contract,,50,,20.8,percent of total billed charges,,,,,,no IP contract,,,78,,32.45,percent of total billed charges,,,70,,29.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.38,3324,
00186-0916-12 - budesonide 180 mcg/inh Powde,00186-0916-12,NDC,,,,inpatient,1,UN,1710.2,1026.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1385.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1453.67,percent of total billed charges,,,85,,1453.67,percent of total billed charges,,,49,,838,percent of total billed charges,,,90,,1539.18,percent of total billed charges,,,,,,,no IP contract,,80,,1368.16,percent of total billed charges,,,,,,,no IP contract,,50,,855.1,percent of total billed charges,,,,,,no IP contract,,,78,,1333.96,percent of total billed charges,,,70,,1197.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,838,3324,
00186-1092-05 - metoprolol 100 mg ER Tab,00186-1092-05,NDC,,,,inpatient,1,EA,15.35,9.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.05,percent of total billed charges,,,85,,13.05,percent of total billed charges,,,49,,7.52,percent of total billed charges,,,90,,13.82,percent of total billed charges,,,,,,,no IP contract,,80,,12.28,percent of total billed charges,,,,,,,no IP contract,,50,,7.68,percent of total billed charges,,,,,,no IP contract,,,78,,11.97,percent of total billed charges,,,70,,10.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.52,3324,
00186-1988-04 - budesonide 0.25 mg/2 mL Susp,00186-1988-04,NDC,,,,inpatient,2,ML,96.35,57.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,78.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,81.9,percent of total billed charges,,,85,,81.9,percent of total billed charges,,,49,,47.21,percent of total billed charges,,,90,,86.72,percent of total billed charges,,,,,,,no IP contract,,80,,77.08,percent of total billed charges,,,,,,,no IP contract,,50,,48.18,percent of total billed charges,,,,,,no IP contract,,,78,,75.15,percent of total billed charges,,,70,,67.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,47.21,3324,
00187-0658-20 - diazepam 10 mg Kit,00187-0658-20,NDC,,,,inpatient,1,EA,2815.95,1689.57,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2280.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2393.56,percent of total billed charges,,,85,,2393.56,percent of total billed charges,,,49,,1379.82,percent of total billed charges,,,90,,2534.36,percent of total billed charges,,,,,,,no IP contract,,80,,2252.76,percent of total billed charges,,,,,,,no IP contract,,50,,1407.98,percent of total billed charges,,,,,,no IP contract,,,78,,2196.44,percent of total billed charges,,,70,,1971.17,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
00187-0659-20 - diazepam 20 mg Kit,00187-0659-20,NDC,,,,inpatient,1,EA,3394.05,2036.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2749.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2884.94,percent of total billed charges,,,85,,2884.94,percent of total billed charges,,,49,,1663.08,percent of total billed charges,,,90,,3054.65,percent of total billed charges,,,,,,,no IP contract,,80,,2715.24,percent of total billed charges,,,,,,,no IP contract,,50,,1697.03,percent of total billed charges,,,,,,no IP contract,,,78,,2647.36,percent of total billed charges,,,70,,2375.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
00187-0799-42 - diltiazem 360 mg/24 hours ER Ca,00187-0799-42,NDC,,,,inpatient,1,EA,99.8,59.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,80.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,84.83,percent of total billed charges,,,85,,84.83,percent of total billed charges,,,49,,48.9,percent of total billed charges,,,90,,89.82,percent of total billed charges,,,,,,,no IP contract,,80,,79.84,percent of total billed charges,,,,,,,no IP contract,,50,,49.9,percent of total billed charges,,,,,,no IP contract,,,78,,77.84,percent of total billed charges,,,70,,69.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,48.9,3324,
00187-5100-01 - pimecrolimus topical 1% Cream,00187-5100-01,NDC,,,,inpatient,1,UN,2165.85,1299.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1754.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1840.97,percent of total billed charges,,,85,,1840.97,percent of total billed charges,,,49,,1061.27,percent of total billed charges,,,90,,1949.27,percent of total billed charges,,,,,,,no IP contract,,80,,1732.68,percent of total billed charges,,,,,,,no IP contract,,50,,1082.93,percent of total billed charges,,,,,,no IP contract,,,78,,1689.36,percent of total billed charges,,,70,,1516.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
00187-5160-20 - tretinoin topical 0.025% Cream,00187-5160-20,NDC,,,,inpatient,1,UN,800.55,480.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,648.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,680.47,percent of total billed charges,,,85,,680.47,percent of total billed charges,,,49,,392.27,percent of total billed charges,,,90,,720.5,percent of total billed charges,,,,,,,no IP contract,,80,,640.44,percent of total billed charges,,,,,,,no IP contract,,50,,400.28,percent of total billed charges,,,,,,no IP contract,,,78,,624.43,percent of total billed charges,,,70,,560.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,392.27,3324,
00187-5162-20 - tretinoin topical 0.05% Cream,00187-5162-20,NDC,,,,inpatient,1,UN,800.55,480.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,648.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,680.47,percent of total billed charges,,,85,,680.47,percent of total billed charges,,,49,,392.27,percent of total billed charges,,,90,,720.5,percent of total billed charges,,,,,,,no IP contract,,80,,640.44,percent of total billed charges,,,,,,,no IP contract,,50,,400.28,percent of total billed charges,,,,,,no IP contract,,,78,,624.43,percent of total billed charges,,,70,,560.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,392.27,3324,
00187-5267-01 - magnesium carbonate 54 mg/5 mL LIQ,00187-5267-01,NDC,,,,inpatient,1,ML,5.65,3.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.8,percent of total billed charges,,,85,,4.8,percent of total billed charges,,,49,,2.77,percent of total billed charges,,,90,,5.09,percent of total billed charges,,,,,,,no IP contract,,80,,4.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.83,percent of total billed charges,,,,,,no IP contract,,,78,,4.41,percent of total billed charges,,,70,,3.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.77,3324,
00223-1760-01 - sodium chloride 1 g Tab,00223-1760-01,NDC,,,,inpatient,1,EA,4.3,2.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.66,percent of total billed charges,,,85,,3.66,percent of total billed charges,,,49,,2.11,percent of total billed charges,,,90,,3.87,percent of total billed charges,,,,,,,no IP contract,,80,,3.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.15,percent of total billed charges,,,,,,no IP contract,,,78,,3.35,percent of total billed charges,,,70,,3.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.11,3324,
trolamine salicylate topical 10% Cream,00225-0360-35,NDC,,,,inpatient,1,EA,109.2,65.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,88.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,92.82,percent of total billed charges,,,85,,92.82,percent of total billed charges,,,49,,53.51,percent of total billed charges,,,90,,98.28,percent of total billed charges,,,,,,,no IP contract,,80,,87.36,percent of total billed charges,,,,,,,no IP contract,,50,,54.6,percent of total billed charges,,,,,,no IP contract,,,78,,85.18,percent of total billed charges,,,70,,76.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,53.51,3324,
00225-0805-47 - phenylephrine nasal 0.5% Spray,00225-0805-47,NDC,,,,inpatient,1,UN,40.45,24.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34.38,percent of total billed charges,,,85,,34.38,percent of total billed charges,,,49,,19.82,percent of total billed charges,,,90,,36.41,percent of total billed charges,,,,,,,no IP contract,,80,,32.36,percent of total billed charges,,,,,,,no IP contract,,50,,20.23,percent of total billed charges,,,,,,no IP contract,,,78,,31.55,percent of total billed charges,,,70,,28.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.82,3324,
00228-2027-10 - ALPRAZolam 0.25 mg Tab,00228-2027-10,NDC,,,,inpatient,1,EA,11.25,6.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.56,percent of total billed charges,,,85,,9.56,percent of total billed charges,,,49,,5.51,percent of total billed charges,,,90,,10.13,percent of total billed charges,,,,,,,no IP contract,,80,,9,percent of total billed charges,,,,,,,no IP contract,,50,,5.63,percent of total billed charges,,,,,,no IP contract,,,78,,8.78,percent of total billed charges,,,70,,7.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.51,3324,
00228-2029-10 - ALPRAZolam 0.5 mg Tab,00228-2029-10,NDC,,,,inpatient,1,EA,13.15,7.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.18,percent of total billed charges,,,85,,11.18,percent of total billed charges,,,49,,6.44,percent of total billed charges,,,90,,11.84,percent of total billed charges,,,,,,,no IP contract,,80,,10.52,percent of total billed charges,,,,,,,no IP contract,,50,,6.58,percent of total billed charges,,,,,,no IP contract,,,78,,10.26,percent of total billed charges,,,70,,9.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.44,3324,
00228-2076-10 - temazepam 15 mg Cap,00228-2076-10,NDC,,,,inpatient,1,EA,11.5,6.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.78,percent of total billed charges,,,85,,9.78,percent of total billed charges,,,49,,5.64,percent of total billed charges,,,90,,10.35,percent of total billed charges,,,,,,,no IP contract,,80,,9.2,percent of total billed charges,,,,,,,no IP contract,,50,,5.75,percent of total billed charges,,,,,,no IP contract,,,78,,8.97,percent of total billed charges,,,70,,8.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.64,3324,
00228-2127-10 - cloNIDine 0.1 mg Tab,00228-2127-10,NDC,,,,inpatient,1,EA,5.9,3.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.02,percent of total billed charges,,,85,,5.02,percent of total billed charges,,,49,,2.89,percent of total billed charges,,,90,,5.31,percent of total billed charges,,,,,,,no IP contract,,80,,4.72,percent of total billed charges,,,,,,,no IP contract,,50,,2.95,percent of total billed charges,,,,,,no IP contract,,,78,,4.6,percent of total billed charges,,,70,,4.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.89,3324,
00228-2129-10 - cloNIDine 0.3 mg Tab,00228-2129-10,NDC,,,,inpatient,1,EA,7.95,4.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.76,percent of total billed charges,,,85,,6.76,percent of total billed charges,,,49,,3.9,percent of total billed charges,,,90,,7.16,percent of total billed charges,,,,,,,no IP contract,,80,,6.36,percent of total billed charges,,,,,,,no IP contract,,50,,3.98,percent of total billed charges,,,,,,no IP contract,,,78,,6.2,percent of total billed charges,,,70,,5.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.9,3324,
00228-2348-10 - propylthiouracil 50 mg Tab,00228-2348-10,NDC,,,,inpatient,1,EA,5.1,3.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.34,percent of total billed charges,,,85,,4.34,percent of total billed charges,,,49,,2.5,percent of total billed charges,,,90,,4.59,percent of total billed charges,,,,,,,no IP contract,,80,,4.08,percent of total billed charges,,,,,,,no IP contract,,50,,2.55,percent of total billed charges,,,,,,no IP contract,,,78,,3.98,percent of total billed charges,,,70,,3.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.5,3324,
00228-2538-10 - carbidopa-levodopa 10 mg-100 mg Tab,00228-2538-10,NDC,,,,inpatient,1,EA,9.95,5.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.46,percent of total billed charges,,,85,,8.46,percent of total billed charges,,,49,,4.88,percent of total billed charges,,,90,,8.96,percent of total billed charges,,,,,,,no IP contract,,80,,7.96,percent of total billed charges,,,,,,,no IP contract,,50,,4.98,percent of total billed charges,,,,,,no IP contract,,,78,,7.76,percent of total billed charges,,,70,,6.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.88,3324,
00228-2550-06 - diclofenac sodium 50 mg EC Ta,00228-2550-06,NDC,,,,inpatient,1,EA,11.4,6.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.69,percent of total billed charges,,,85,,9.69,percent of total billed charges,,,49,,5.59,percent of total billed charges,,,90,,10.26,percent of total billed charges,,,,,,,no IP contract,,80,,9.12,percent of total billed charges,,,,,,,no IP contract,,50,,5.7,percent of total billed charges,,,,,,no IP contract,,,78,,8.89,percent of total billed charges,,,70,,7.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.59,3324,
00228-2571-11 - indapamide 2.5 mg Tab,00228-2571-11,NDC,,,,inpatient,1,EA,10.4,6.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.84,percent of total billed charges,,,85,,8.84,percent of total billed charges,,,49,,5.1,percent of total billed charges,,,90,,9.36,percent of total billed charges,,,,,,,no IP contract,,80,,8.32,percent of total billed charges,,,,,,,no IP contract,,50,,5.2,percent of total billed charges,,,,,,no IP contract,,,78,,8.11,percent of total billed charges,,,70,,7.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.1,3324,
00228-2620-11 - isosorbide mononitrate 20 mg Tab,00228-2620-11,NDC,,,,inpatient,1,EA,9.8,5.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.33,percent of total billed charges,,,85,,8.33,percent of total billed charges,,,49,,4.8,percent of total billed charges,,,90,,8.82,percent of total billed charges,,,,,,,no IP contract,,80,,7.84,percent of total billed charges,,,,,,,no IP contract,,50,,4.9,percent of total billed charges,,,,,,no IP contract,,,78,,7.64,percent of total billed charges,,,70,,6.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.8,3324,
00228-2801-11 - pilocarpine 5 mg Tab,00228-2801-11,NDC,,,,inpatient,1,EA,15.9,9.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.52,percent of total billed charges,,,85,,13.52,percent of total billed charges,,,49,,7.79,percent of total billed charges,,,90,,14.31,percent of total billed charges,,,,,,,no IP contract,,80,,12.72,percent of total billed charges,,,,,,,no IP contract,,50,,7.95,percent of total billed charges,,,,,,no IP contract,,,78,,12.4,percent of total billed charges,,,70,,11.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.79,3324,
00228-2918-09 - diltiazem 360 mg/24 hours ER Ca,00228-2918-09,NDC,,,,inpatient,1,EA,85.15,51.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,68.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,72.38,percent of total billed charges,,,85,,72.38,percent of total billed charges,,,49,,41.72,percent of total billed charges,,,90,,76.64,percent of total billed charges,,,,,,,no IP contract,,80,,68.12,percent of total billed charges,,,,,,,no IP contract,,50,,42.58,percent of total billed charges,,,,,,no IP contract,,,78,,66.42,percent of total billed charges,,,70,,59.61,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,41.72,3324,
00228-2975-06 - levETIRAcetam 750 mg ER Ta,00228-2975-06,NDC,,,,inpatient,1,EA,56.85,34.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,46.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,48.32,percent of total billed charges,,,85,,48.32,percent of total billed charges,,,49,,27.86,percent of total billed charges,,,90,,51.17,percent of total billed charges,,,,,,,no IP contract,,80,,45.48,percent of total billed charges,,,,,,,no IP contract,,50,,28.43,percent of total billed charges,,,,,,no IP contract,,,78,,44.34,percent of total billed charges,,,70,,39.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.86,3324,
00228-2996-11 - tamsulosin 0.4 mg Cap,00228-2996-11,NDC,,,,inpatient,1,EA,37.3,22.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.71,percent of total billed charges,,,85,,31.71,percent of total billed charges,,,49,,18.28,percent of total billed charges,,,90,,33.57,percent of total billed charges,,,,,,,no IP contract,,80,,29.84,percent of total billed charges,,,,,,,no IP contract,,50,,18.65,percent of total billed charges,,,,,,no IP contract,,,78,,29.09,percent of total billed charges,,,70,,26.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.28,3324,
00228-3003-11 - clonazePAM 0.5 mg Tab,00228-3003-11,NDC,,,,inpatient,1,EA,11.65,6.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.9,percent of total billed charges,,,85,,9.9,percent of total billed charges,,,49,,5.71,percent of total billed charges,,,90,,10.49,percent of total billed charges,,,,,,,no IP contract,,80,,9.32,percent of total billed charges,,,,,,,no IP contract,,50,,5.83,percent of total billed charges,,,,,,no IP contract,,,78,,9.09,percent of total billed charges,,,70,,8.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.71,3324,
00228-3004-11 - clonazePAM 1 mg Tab,00228-3004-11,NDC,,,,inpatient,1,EA,12.6,7.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.71,percent of total billed charges,,,85,,10.71,percent of total billed charges,,,49,,6.17,percent of total billed charges,,,90,,11.34,percent of total billed charges,,,,,,,no IP contract,,80,,10.08,percent of total billed charges,,,,,,,no IP contract,,50,,6.3,percent of total billed charges,,,,,,no IP contract,,,78,,9.83,percent of total billed charges,,,70,,8.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.17,3324,
00228-3501-06 - morphine 10 mg/12 to 24 hr ER Ca,00228-3501-06,NDC,,,,inpatient,1,EA,41.45,24.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,35.23,percent of total billed charges,,,85,,35.23,percent of total billed charges,,,49,,20.31,percent of total billed charges,,,90,,37.31,percent of total billed charges,,,,,,,no IP contract,,80,,33.16,percent of total billed charges,,,,,,,no IP contract,,50,,20.73,percent of total billed charges,,,,,,no IP contract,,,78,,32.33,percent of total billed charges,,,70,,29.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.31,3324,
00245-0035-01 - potassium chloride 20 mEq REC P,00245-0035-01,NDC,,,,inpatient,1,UN,50.1,30.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,40.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,42.59,percent of total billed charges,,,85,,42.59,percent of total billed charges,,,49,,24.55,percent of total billed charges,,,90,,45.09,percent of total billed charges,,,,,,,no IP contract,,80,,40.08,percent of total billed charges,,,,,,,no IP contract,,50,,25.05,percent of total billed charges,,,,,,no IP contract,,,78,,39.08,percent of total billed charges,,,70,,35.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.55,3324,
00245-0035-30 - potassium chloride 20 mEq REC P,00245-0035-30,NDC,,,,inpatient,1,UN,50.1,30.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,40.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,42.59,percent of total billed charges,,,85,,42.59,percent of total billed charges,,,49,,24.55,percent of total billed charges,,,90,,45.09,percent of total billed charges,,,,,,,no IP contract,,80,,40.08,percent of total billed charges,,,,,,,no IP contract,,50,,25.05,percent of total billed charges,,,,,,no IP contract,,,78,,39.08,percent of total billed charges,,,70,,35.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.55,3324,
00245-0035-89 - potassium 20 mEq Packet,00245-0035-89,NDC,,,,inpatient,1,UN,50.1,30.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,40.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,42.59,percent of total billed charges,,,85,,42.59,percent of total billed charges,,,49,,24.55,percent of total billed charges,,,90,,45.09,percent of total billed charges,,,,,,,no IP contract,,80,,40.08,percent of total billed charges,,,,,,,no IP contract,,50,,25.05,percent of total billed charges,,,,,,no IP contract,,,78,,39.08,percent of total billed charges,,,70,,35.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.55,3324,
00245-0061-01 - ferrous gluconate 300 mg Tab,00245-0061-01,NDC,,,,inpatient,1,EA,4.6,2.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.91,percent of total billed charges,,,85,,3.91,percent of total billed charges,,,49,,2.25,percent of total billed charges,,,90,,4.14,percent of total billed charges,,,,,,,no IP contract,,80,,3.68,percent of total billed charges,,,,,,,no IP contract,,50,,2.3,percent of total billed charges,,,,,,no IP contract,,,78,,3.59,percent of total billed charges,,,70,,3.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.25,3324,
00245-0061-11 - ferrous gluconate 300 mg Tab,00245-0061-11,NDC,,,,inpatient,1,EA,4,2.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.4,percent of total billed charges,,,85,,3.4,percent of total billed charges,,,49,,1.96,percent of total billed charges,,,90,,3.6,percent of total billed charges,,,,,,,no IP contract,,80,,3.2,percent of total billed charges,,,,,,,no IP contract,,50,,2,percent of total billed charges,,,,,,no IP contract,,,78,,3.12,percent of total billed charges,,,70,,2.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.96,3324,
00245-0071-11 - potassium citrate 10 mEq ER Ta,00245-0071-11,NDC,,,,inpatient,1,EA,7.95,4.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.76,percent of total billed charges,,,85,,6.76,percent of total billed charges,,,49,,3.9,percent of total billed charges,,,90,,7.16,percent of total billed charges,,,,,,,no IP contract,,80,,6.36,percent of total billed charges,,,,,,,no IP contract,,50,,3.98,percent of total billed charges,,,,,,no IP contract,,,78,,6.2,percent of total billed charges,,,70,,5.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.9,3324,
00245-0080-11 - zinc sulfate 220 mg Cap,00245-0080-11,NDC,,,,inpatient,1,EA,4.85,2.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.12,percent of total billed charges,,,85,,4.12,percent of total billed charges,,,49,,2.38,percent of total billed charges,,,90,,4.37,percent of total billed charges,,,,,,,no IP contract,,80,,3.88,percent of total billed charges,,,,,,,no IP contract,,50,,2.43,percent of total billed charges,,,,,,no IP contract,,,78,,3.78,percent of total billed charges,,,70,,3.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.38,3324,
00245-0147-01 - amiodarone 200 mg Tab,00245-0147-01,NDC,,,,inpatient,1,EA,66.95,40.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,54.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.91,percent of total billed charges,,,85,,56.91,percent of total billed charges,,,49,,32.81,percent of total billed charges,,,90,,60.26,percent of total billed charges,,,,,,,no IP contract,,80,,53.56,percent of total billed charges,,,,,,,no IP contract,,50,,33.48,percent of total billed charges,,,,,,no IP contract,,,78,,52.22,percent of total billed charges,,,70,,46.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.81,3324,
00245-0180-01 - divalproex sodium 125 mg EC Ta,00245-0180-01,NDC,,,,inpatient,1,EA,11.4,6.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.69,percent of total billed charges,,,85,,9.69,percent of total billed charges,,,49,,5.59,percent of total billed charges,,,90,,10.26,percent of total billed charges,,,,,,,no IP contract,,80,,9.12,percent of total billed charges,,,,,,,no IP contract,,50,,5.7,percent of total billed charges,,,,,,no IP contract,,,78,,8.89,percent of total billed charges,,,70,,7.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.59,3324,
00245-0181-01 - divalproex sodium 250 mg EC Ta,00245-0181-01,NDC,,,,inpatient,1,EA,18.45,11.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.68,percent of total billed charges,,,85,,15.68,percent of total billed charges,,,49,,9.04,percent of total billed charges,,,90,,16.61,percent of total billed charges,,,,,,,no IP contract,,80,,14.76,percent of total billed charges,,,,,,,no IP contract,,50,,9.23,percent of total billed charges,,,,,,no IP contract,,,78,,14.39,percent of total billed charges,,,70,,12.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.04,3324,
00245-0211-11 - midodrine 2.5 mg Tab,00245-0211-11,NDC,,,,inpatient,1,EA,13.45,8.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.43,percent of total billed charges,,,85,,11.43,percent of total billed charges,,,49,,6.59,percent of total billed charges,,,90,,12.11,percent of total billed charges,,,,,,,no IP contract,,80,,10.76,percent of total billed charges,,,,,,,no IP contract,,50,,6.73,percent of total billed charges,,,,,,no IP contract,,,78,,10.49,percent of total billed charges,,,70,,9.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.59,3324,
00245-0212-11 - midodrine 5 mg Tab,00245-0212-11,NDC,,,,inpatient,1,EA,36.9,22.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.37,percent of total billed charges,,,85,,31.37,percent of total billed charges,,,49,,18.08,percent of total billed charges,,,90,,33.21,percent of total billed charges,,,,,,,no IP contract,,80,,29.52,percent of total billed charges,,,,,,,no IP contract,,50,,18.45,percent of total billed charges,,,,,,no IP contract,,,78,,28.78,percent of total billed charges,,,70,,25.83,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.08,3324,
00245-0213-11 - midodrine 10 mg Tab,00245-0213-11,NDC,,,,inpatient,1,EA,81.1,48.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,65.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,68.94,percent of total billed charges,,,85,,68.94,percent of total billed charges,,,49,,39.74,percent of total billed charges,,,90,,72.99,percent of total billed charges,,,,,,,no IP contract,,80,,64.88,percent of total billed charges,,,,,,,no IP contract,,50,,40.55,percent of total billed charges,,,,,,no IP contract,,,78,,63.26,percent of total billed charges,,,70,,56.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,39.74,3324,
00245-0360-30 - potassium chloride 20 mEq REC P,00245-0360-30,NDC,,,,inpatient,1,UN,89.2,53.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,72.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,75.82,percent of total billed charges,,,85,,75.82,percent of total billed charges,,,49,,43.71,percent of total billed charges,,,90,,80.28,percent of total billed charges,,,,,,,no IP contract,,80,,71.36,percent of total billed charges,,,,,,,no IP contract,,50,,44.6,percent of total billed charges,,,,,,no IP contract,,,78,,69.58,percent of total billed charges,,,70,,62.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,43.71,3324,
00245-5316-01 - potassium chloride 10 mEq ER Ta,00245-5316-01,NDC,,,,inpatient,1,EA,9,5.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.65,percent of total billed charges,,,85,,7.65,percent of total billed charges,,,49,,4.41,percent of total billed charges,,,90,,8.1,percent of total billed charges,,,,,,,no IP contract,,80,,7.2,percent of total billed charges,,,,,,,no IP contract,,50,,4.5,percent of total billed charges,,,,,,no IP contract,,,78,,7.02,percent of total billed charges,,,70,,6.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.41,3324,
00247-0176-02 - guaifenesin-pseudoephedrine 600 mg-120 mg ER Tab,00247-0176-02,NDC,,,,inpatient,1,EA,25.55,15.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.72,percent of total billed charges,,,85,,21.72,percent of total billed charges,,,49,,12.52,percent of total billed charges,,,90,,23,percent of total billed charges,,,,,,,no IP contract,,80,,20.44,percent of total billed charges,,,,,,,no IP contract,,50,,12.78,percent of total billed charges,,,,,,no IP contract,,,78,,19.93,percent of total billed charges,,,70,,17.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.52,3324,
00254-2008-01 - colchicine 0.6 mg Tab,00254-2008-01,NDC,,,,inpatient,1,EA,44.2,26.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,35.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,37.57,percent of total billed charges,,,85,,37.57,percent of total billed charges,,,49,,21.66,percent of total billed charges,,,90,,39.78,percent of total billed charges,,,,,,,no IP contract,,80,,35.36,percent of total billed charges,,,,,,,no IP contract,,50,,22.1,percent of total billed charges,,,,,,no IP contract,,,78,,34.48,percent of total billed charges,,,70,,30.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.66,3324,
00254-3029-02 - lubiprostone 24 mcg Cap,00254-3029-02,NDC,,,,inpatient,1,EA,56.95,34.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,46.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,48.41,percent of total billed charges,,,85,,48.41,percent of total billed charges,,,49,,27.91,percent of total billed charges,,,90,,51.26,percent of total billed charges,,,,,,,no IP contract,,80,,45.56,percent of total billed charges,,,,,,,no IP contract,,50,,28.48,percent of total billed charges,,,,,,no IP contract,,,78,,44.42,percent of total billed charges,,,70,,39.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.91,3324,
00259-0303-50 -,00259-0303-50,NDC,,,,inpatient,1,UN,102.5,61.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,83.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,87.13,percent of total billed charges,,,85,,87.13,percent of total billed charges,,,49,,50.23,percent of total billed charges,,,90,,92.25,percent of total billed charges,,,,,,,no IP contract,,80,,82,percent of total billed charges,,,,,,,no IP contract,,50,,51.25,percent of total billed charges,,,,,,no IP contract,,,78,,79.95,percent of total billed charges,,,70,,71.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,50.23,3324,
00259-0501-16 - glycopyrrolate 1 mg/5 mL Soln,00259-0501-16,NDC,,,,inpatient,1,ML,15.35,9.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.05,percent of total billed charges,,,85,,13.05,percent of total billed charges,,,49,,7.52,percent of total billed charges,,,90,,13.82,percent of total billed charges,,,,,,,no IP contract,,80,,12.28,percent of total billed charges,,,,,,,no IP contract,,50,,7.68,percent of total billed charges,,,,,,no IP contract,,,78,,11.97,percent of total billed charges,,,70,,10.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.52,3324,
incobotulinumtoxinA 50 units REC I,00259-1605-01,NDC,,,,inpatient,1,EA,1041.35,624.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,843.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,885.15,percent of total billed charges,,,85,,885.15,percent of total billed charges,,,49,,510.26,percent of total billed charges,,,90,,937.22,percent of total billed charges,,,,,,,no IP contract,,80,,833.08,percent of total billed charges,,,,,,,no IP contract,,50,,520.68,percent of total billed charges,,,,,,no IP contract,,,78,,812.25,percent of total billed charges,,,70,,728.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,510.26,3324,
incobotulinumtoxinA 100 units REC I,00259-1610-01,NDC,,,,inpatient,1,EA,1983.95,1190.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1607,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1686.36,percent of total billed charges,,,85,,1686.36,percent of total billed charges,,,49,,972.14,percent of total billed charges,,,90,,1785.56,percent of total billed charges,,,,,,,no IP contract,,80,,1587.16,percent of total billed charges,,,,,,,no IP contract,,50,,991.98,percent of total billed charges,,,,,,no IP contract,,,78,,1547.48,percent of total billed charges,,,70,,1388.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,972.14,3324,
00264-1800-31 - LVP solution Sodium Chloride 0.9% Soln,00264-1800-31,NDC,,,,inpatient,50,ML,81.25,48.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,65.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,69.06,percent of total billed charges,,,85,,69.06,percent of total billed charges,,,49,,39.81,percent of total billed charges,,,90,,73.13,percent of total billed charges,,,,,,,no IP contract,,80,,65,percent of total billed charges,,,,,,,no IP contract,,50,,40.63,percent of total billed charges,,,,,,no IP contract,,,78,,63.38,percent of total billed charges,,,70,,56.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,39.81,3324,
00264-1800-32 - LVP solution Sodium Chloride 0.9% Soln,00264-1800-32,NDC,,,,inpatient,100,ML,118.7,71.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,96.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,100.9,percent of total billed charges,,,85,,100.9,percent of total billed charges,,,49,,58.16,percent of total billed charges,,,90,,106.83,percent of total billed charges,,,,,,,no IP contract,,80,,94.96,percent of total billed charges,,,,,,,no IP contract,,50,,59.35,percent of total billed charges,,,,,,no IP contract,,,78,,92.59,percent of total billed charges,,,70,,83.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.16,3324,
00264-2201-00 - sodium chloride 0.9% Soln,00264-2201-00,NDC,,,,inpatient,1000,ML,175.8,105.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,142.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,149.43,percent of total billed charges,,,85,,149.43,percent of total billed charges,,,49,,86.14,percent of total billed charges,,,90,,158.22,percent of total billed charges,,,,,,,no IP contract,,80,,140.64,percent of total billed charges,,,,,,,no IP contract,,50,,87.9,percent of total billed charges,,,,,,no IP contract,,,78,,137.12,percent of total billed charges,,,70,,123.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,86.14,3324,
00264-2304-00 - acetic acid Topical 0.25% Soln,00264-2304-00,NDC,,,,inpatient,1,UN,92.5,55.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,74.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,78.63,percent of total billed charges,,,85,,78.63,percent of total billed charges,,,49,,45.33,percent of total billed charges,,,90,,83.25,percent of total billed charges,,,,,,,no IP contract,,80,,74,percent of total billed charges,,,,,,,no IP contract,,50,,46.25,percent of total billed charges,,,,,,no IP contract,,,78,,72.15,percent of total billed charges,,,70,,64.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,45.33,3324,
00264-7510-00 - LVP solution Dextrose 5% in Water Soln,00264-7510-00,NDC,,,,inpatient,1000,ML,35.4,21.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.09,percent of total billed charges,,,85,,30.09,percent of total billed charges,,,49,,17.35,percent of total billed charges,,,90,,31.86,percent of total billed charges,,,,,,,no IP contract,,80,,28.32,percent of total billed charges,,,,,,,no IP contract,,50,,17.7,percent of total billed charges,,,,,,no IP contract,,,78,,27.61,percent of total billed charges,,,70,,24.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.35,3324,
00264-7520-00 - parenteral nutrition solution Dextrose 10% in Water Soln,00264-7520-00,NDC,,,,inpatient,1000,ML,285.3,171.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,231.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,242.51,percent of total billed charges,,,85,,242.51,percent of total billed charges,,,49,,139.8,percent of total billed charges,,,90,,256.77,percent of total billed charges,,,,,,,no IP contract,,80,,228.24,percent of total billed charges,,,,,,,no IP contract,,50,,142.65,percent of total billed charges,,,,,,no IP contract,,,78,,222.53,percent of total billed charges,,,70,,199.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,139.8,3324,
00264-7610-00 - LVP solution Dextrose 5% with 0.9% NaCl Soln,00264-7610-00,NDC,,,,inpatient,1000,ML,118.7,71.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,96.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,100.9,percent of total billed charges,,,85,,100.9,percent of total billed charges,,,49,,58.16,percent of total billed charges,,,90,,106.83,percent of total billed charges,,,,,,,no IP contract,,80,,94.96,percent of total billed charges,,,,,,,no IP contract,,50,,59.35,percent of total billed charges,,,,,,no IP contract,,,78,,92.59,percent of total billed charges,,,70,,83.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.16,3324,
00264-7612-00 - LVP solution Dextrose 5% with 0.45% NaCl Soln,00264-7612-00,NDC,,,,inpatient,1000,ML,118.7,71.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,96.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,100.9,percent of total billed charges,,,85,,100.9,percent of total billed charges,,,49,,58.16,percent of total billed charges,,,90,,106.83,percent of total billed charges,,,,,,,no IP contract,,80,,94.96,percent of total billed charges,,,,,,,no IP contract,,50,,59.35,percent of total billed charges,,,,,,no IP contract,,,78,,92.59,percent of total billed charges,,,70,,83.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.16,3324,
00264-7750-00 - LVP solution Lactated Ringers Injection Soln,00264-7750-00,NDC,,,,inpatient,1000,ML,35.4,21.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.09,percent of total billed charges,,,85,,30.09,percent of total billed charges,,,49,,17.35,percent of total billed charges,,,90,,31.86,percent of total billed charges,,,,,,,no IP contract,,80,,28.32,percent of total billed charges,,,,,,,no IP contract,,50,,17.7,percent of total billed charges,,,,,,no IP contract,,,78,,27.61,percent of total billed charges,,,70,,24.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.35,3324,
00264-7800-00 - LVP solution Sodium Chloride 0.9% Soln,00264-7800-00,NDC,,,,inpatient,1000,ML,118.7,71.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,96.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,100.9,percent of total billed charges,,,85,,100.9,percent of total billed charges,,,49,,58.16,percent of total billed charges,,,90,,106.83,percent of total billed charges,,,,,,,no IP contract,,80,,94.96,percent of total billed charges,,,,,,,no IP contract,,50,,59.35,percent of total billed charges,,,,,,no IP contract,,,78,,92.59,percent of total billed charges,,,70,,83.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.16,3324,
00264-7800-09 - LVP solution Sodium Chloride 0.9% Soln,00264-7800-09,NDC,,,,inpatient,1000,ML,35.4,21.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.09,percent of total billed charges,,,85,,30.09,percent of total billed charges,,,49,,17.35,percent of total billed charges,,,90,,31.86,percent of total billed charges,,,,,,,no IP contract,,80,,28.32,percent of total billed charges,,,,,,,no IP contract,,50,,17.7,percent of total billed charges,,,,,,no IP contract,,,78,,27.61,percent of total billed charges,,,70,,24.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.35,3324,
00264-7800-10 - LVP solution Sodium Chloride 0.9% Soln,00264-7800-10,NDC,,,,inpatient,500,ML,118.7,71.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,96.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,100.9,percent of total billed charges,,,85,,100.9,percent of total billed charges,,,49,,58.16,percent of total billed charges,,,90,,106.83,percent of total billed charges,,,,,,,no IP contract,,80,,94.96,percent of total billed charges,,,,,,,no IP contract,,50,,59.35,percent of total billed charges,,,,,,no IP contract,,,78,,92.59,percent of total billed charges,,,70,,83.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.16,3324,
00264-7800-20 - LVP solution Sodium Chloride 0.9% Soln,00264-7800-20,NDC,,,,inpatient,250,ML,118.7,71.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,96.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,100.9,percent of total billed charges,,,85,,100.9,percent of total billed charges,,,49,,58.16,percent of total billed charges,,,90,,106.83,percent of total billed charges,,,,,,,no IP contract,,80,,94.96,percent of total billed charges,,,,,,,no IP contract,,50,,59.35,percent of total billed charges,,,,,,no IP contract,,,78,,92.59,percent of total billed charges,,,70,,83.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.16,3324,
00264-7802-00 - LVP solution Sodium Chloride 0.45% Soln,00264-7802-00,NDC,,,,inpatient,1000,ML,118.7,71.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,96.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,100.9,percent of total billed charges,,,85,,100.9,percent of total billed charges,,,49,,58.16,percent of total billed charges,,,90,,106.83,percent of total billed charges,,,,,,,no IP contract,,80,,94.96,percent of total billed charges,,,,,,,no IP contract,,50,,59.35,percent of total billed charges,,,,,,no IP contract,,,78,,92.59,percent of total billed charges,,,70,,83.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.16,3324,
diatrizoate 66%-10% Soln,00270-0445-35,NDC,,,,inpatient,1,EA,225.35,135.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,182.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,191.55,percent of total billed charges,,,85,,191.55,percent of total billed charges,,,49,,110.42,percent of total billed charges,,,90,,202.82,percent of total billed charges,,,,,,,no IP contract,,80,,180.28,percent of total billed charges,,,,,,,no IP contract,,50,,112.68,percent of total billed charges,,,,,,no IP contract,,,78,,175.77,percent of total billed charges,,,70,,157.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,110.42,3324,
iopamidol 61% Soln,00270-1315-47,NDC,,,,inpatient,1,EA,749.05,449.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,606.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,636.69,percent of total billed charges,,,85,,636.69,percent of total billed charges,,,49,,367.03,percent of total billed charges,,,90,,674.15,percent of total billed charges,,,,,,,no IP contract,,80,,599.24,percent of total billed charges,,,,,,,no IP contract,,50,,374.53,percent of total billed charges,,,,,,no IP contract,,,78,,584.26,percent of total billed charges,,,70,,524.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,367.03,3324,
iopamidol 76% Soln,00270-1316-04,NDC,,,,inpatient,1,EA,1179,707.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,954.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1002.15,percent of total billed charges,,,85,,1002.15,percent of total billed charges,,,49,,577.71,percent of total billed charges,,,90,,1061.1,percent of total billed charges,,,,,,,no IP contract,,80,,943.2,percent of total billed charges,,,,,,,no IP contract,,50,,589.5,percent of total billed charges,,,,,,no IP contract,,,78,,919.62,percent of total billed charges,,,70,,825.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,577.71,3324,
iopamidol 76% Soln,00270-1316-52,NDC,,,,inpatient,1,EA,755.4,453.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,611.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,642.09,percent of total billed charges,,,85,,642.09,percent of total billed charges,,,49,,370.15,percent of total billed charges,,,90,,679.86,percent of total billed charges,,,,,,,no IP contract,,80,,604.32,percent of total billed charges,,,,,,,no IP contract,,50,,377.7,percent of total billed charges,,,,,,no IP contract,,,78,,589.21,percent of total billed charges,,,70,,528.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,370.15,3324,
iopamidol 61% Soln,00270-1412-15,NDC,,,,inpatient,1,EA,878.05,526.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,711.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,746.34,percent of total billed charges,,,85,,746.34,percent of total billed charges,,,49,,430.24,percent of total billed charges,,,90,,790.25,percent of total billed charges,,,,,,,no IP contract,,80,,702.44,percent of total billed charges,,,,,,,no IP contract,,50,,439.03,percent of total billed charges,,,,,,no IP contract,,,78,,684.88,percent of total billed charges,,,70,,614.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,430.24,3324,
gadobenate dimeglumine 529 mg/mL Soln,00270-5164-13,NDC,,,,inpatient,1,EA,597.75,358.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,484.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,508.09,percent of total billed charges,,,85,,508.09,percent of total billed charges,,,49,,292.9,percent of total billed charges,,,90,,537.98,percent of total billed charges,,,,,,,no IP contract,,80,,478.2,percent of total billed charges,,,,,,,no IP contract,,50,,298.88,percent of total billed charges,,,,,,no IP contract,,,78,,466.25,percent of total billed charges,,,70,,418.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,292.9,3324,
gadobenate dimeglumine 529 mg/mL Soln,00270-5164-14,NDC,,,,inpatient,1,EA,870.45,522.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,705.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,739.88,percent of total billed charges,,,85,,739.88,percent of total billed charges,,,49,,426.52,percent of total billed charges,,,90,,783.41,percent of total billed charges,,,,,,,no IP contract,,80,,696.36,percent of total billed charges,,,,,,,no IP contract,,50,,435.23,percent of total billed charges,,,,,,no IP contract,,,78,,678.95,percent of total billed charges,,,70,,609.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,426.52,3324,
00281-0326-08 - nitroglycerin 2% Ointm,00281-0326-08,NDC,,,,inpatient,1,UN,30.15,18.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.63,percent of total billed charges,,,85,,25.63,percent of total billed charges,,,49,,14.77,percent of total billed charges,,,90,,27.14,percent of total billed charges,,,,,,,no IP contract,,80,,24.12,percent of total billed charges,,,,,,,no IP contract,,50,,15.08,percent of total billed charges,,,,,,no IP contract,,,78,,23.52,percent of total billed charges,,,70,,21.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.77,3324,
00299-3820-60 - metronidazole topical 1% Gel,00299-3820-60,NDC,,,,inpatient,1,UN,1698.55,1019.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1375.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1443.77,percent of total billed charges,,,85,,1443.77,percent of total billed charges,,,49,,832.29,percent of total billed charges,,,90,,1528.7,percent of total billed charges,,,,,,,no IP contract,,80,,1358.84,percent of total billed charges,,,,,,,no IP contract,,50,,849.28,percent of total billed charges,,,,,,no IP contract,,,78,,1324.87,percent of total billed charges,,,70,,1188.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,832.29,3324,
00300-7309-30 - lansoprazole 15 mg REC Granules,00300-7309-30,NDC,,,,inpatient,1,UN,53.25,31.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,43.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,45.26,percent of total billed charges,,,85,,45.26,percent of total billed charges,,,49,,26.09,percent of total billed charges,,,90,,47.93,percent of total billed charges,,,,,,,no IP contract,,80,,42.6,percent of total billed charges,,,,,,,no IP contract,,50,,26.63,percent of total billed charges,,,,,,no IP contract,,,78,,41.54,percent of total billed charges,,,70,,37.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.09,3324,
00300-7311-30 - lansoprazole 30 mg REC GRANULES,00300-7311-30,NDC,,,,inpatient,1,UN,46.05,27.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,37.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,39.14,percent of total billed charges,,,85,,39.14,percent of total billed charges,,,49,,22.56,percent of total billed charges,,,90,,41.45,percent of total billed charges,,,,,,,no IP contract,,80,,36.84,percent of total billed charges,,,,,,,no IP contract,,50,,23.03,percent of total billed charges,,,,,,no IP contract,,,78,,35.92,percent of total billed charges,,,70,,32.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.56,3324,
00310-0040-10 - amitriptyline 10 mg Tab,00310-0040-10,NDC,,,,inpatient,1,EA,6.05,3.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.14,percent of total billed charges,,,85,,5.14,percent of total billed charges,,,49,,2.96,percent of total billed charges,,,90,,5.45,percent of total billed charges,,,,,,,no IP contract,,80,,4.84,percent of total billed charges,,,,,,,no IP contract,,50,,3.03,percent of total billed charges,,,,,,no IP contract,,,78,,4.72,percent of total billed charges,,,70,,4.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.96,3324,
00310-0041-39 - amitriptyline 50 mg Tab,00310-0041-39,NDC,,,,inpatient,1,EA,9.8,5.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.33,percent of total billed charges,,,85,,8.33,percent of total billed charges,,,49,,4.8,percent of total billed charges,,,90,,8.82,percent of total billed charges,,,,,,,no IP contract,,80,,7.84,percent of total billed charges,,,,,,,no IP contract,,50,,4.9,percent of total billed charges,,,,,,no IP contract,,,78,,7.64,percent of total billed charges,,,70,,6.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.8,3324,
00310-0042-10 - amitriptyline 75 mg Tab,00310-0042-10,NDC,,,,inpatient,1,EA,14.5,8.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.33,percent of total billed charges,,,85,,12.33,percent of total billed charges,,,49,,7.11,percent of total billed charges,,,90,,13.05,percent of total billed charges,,,,,,,no IP contract,,80,,11.6,percent of total billed charges,,,,,,,no IP contract,,50,,7.25,percent of total billed charges,,,,,,no IP contract,,,78,,11.31,percent of total billed charges,,,70,,10.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.11,3324,
00310-0043-10 - amitriptyline 100 mg Tab,00310-0043-10,NDC,,,,inpatient,1,EA,17.35,10.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.75,percent of total billed charges,,,85,,14.75,percent of total billed charges,,,49,,8.5,percent of total billed charges,,,90,,15.62,percent of total billed charges,,,,,,,no IP contract,,80,,13.88,percent of total billed charges,,,,,,,no IP contract,,50,,8.68,percent of total billed charges,,,,,,no IP contract,,,78,,13.53,percent of total billed charges,,,70,,12.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.5,3324,
00310-0105-39 - atenolol 50 mg Tab,00310-0105-39,NDC,,,,inpatient,1,EA,12.55,7.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.67,percent of total billed charges,,,85,,10.67,percent of total billed charges,,,49,,6.15,percent of total billed charges,,,90,,11.3,percent of total billed charges,,,,,,,no IP contract,,80,,10.04,percent of total billed charges,,,,,,,no IP contract,,50,,6.28,percent of total billed charges,,,,,,no IP contract,,,78,,9.79,percent of total billed charges,,,70,,8.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.15,3324,
00310-0201-30 - anastrozole 1 mg Tab,00310-0201-30,NDC,,,,inpatient,1,EA,76.25,45.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,61.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,64.81,percent of total billed charges,,,85,,64.81,percent of total billed charges,,,49,,37.36,percent of total billed charges,,,90,,68.63,percent of total billed charges,,,,,,,no IP contract,,80,,61,percent of total billed charges,,,,,,,no IP contract,,50,,38.13,percent of total billed charges,,,,,,no IP contract,,,78,,59.48,percent of total billed charges,,,70,,53.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,37.36,3324,
00310-1105-30 - sodium zirconium cyclosilicate 5 g REC P,00310-1105-30,NDC,,,,inpatient,1,UN,218.4,131.04,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,176.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,185.64,percent of total billed charges,,,85,,185.64,percent of total billed charges,,,49,,107.02,percent of total billed charges,,,90,,196.56,percent of total billed charges,,,,,,,no IP contract,,80,,174.72,percent of total billed charges,,,,,,,no IP contract,,50,,109.2,percent of total billed charges,,,,,,no IP contract,,,78,,170.35,percent of total billed charges,,,70,,152.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,107.02,3324,
00310-1110-30 - sodium zirconium cyclosilicate 10 g REC P,00310-1110-30,NDC,,,,inpatient,1,UN,218.4,131.04,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,176.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,185.64,percent of total billed charges,,,85,,185.64,percent of total billed charges,,,49,,107.02,percent of total billed charges,,,90,,196.56,percent of total billed charges,,,,,,,no IP contract,,80,,174.72,percent of total billed charges,,,,,,,no IP contract,,50,,109.2,percent of total billed charges,,,,,,no IP contract,,,78,,170.35,percent of total billed charges,,,70,,152.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,107.02,3324,
00310-6210-30 - dapagliflozin 10 mg Tab,00310-6210-30,NDC,,,,inpatient,1,EA,173.25,103.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,140.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,147.26,percent of total billed charges,,,85,,147.26,percent of total billed charges,,,49,,84.89,percent of total billed charges,,,90,,155.93,percent of total billed charges,,,,,,,no IP contract,,80,,138.6,percent of total billed charges,,,,,,,no IP contract,,50,,86.63,percent of total billed charges,,,,,,no IP contract,,,78,,135.14,percent of total billed charges,,,70,,121.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,84.89,3324,
00310-6512-01 - exenatide 5 mcg / 0.02 mL Injection,00310-6512-01,NDC,,,,inpatient,0.02,ML,882.65,529.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,714.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,750.25,percent of total billed charges,,,85,,750.25,percent of total billed charges,,,49,,432.5,percent of total billed charges,,,90,,794.39,percent of total billed charges,,,,,,,no IP contract,,80,,706.12,percent of total billed charges,,,,,,,no IP contract,,50,,441.33,percent of total billed charges,,,,,,no IP contract,,,78,,688.47,percent of total billed charges,,,70,,617.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,432.5,3324,
00310-7372-20 - budesonide-formoterol 80 mcg-4.5 mcg/inh Aeros,00310-7372-20,NDC,,,,inpatient,1,UN,1995.65,1197.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1616.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1696.3,percent of total billed charges,,,85,,1696.3,percent of total billed charges,,,49,,977.87,percent of total billed charges,,,90,,1796.09,percent of total billed charges,,,,,,,no IP contract,,80,,1596.52,percent of total billed charges,,,,,,,no IP contract,,50,,997.83,percent of total billed charges,,,,,,no IP contract,,,78,,1556.61,percent of total billed charges,,,70,,1396.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
00338-0003-44 - sterile water - Soln,00338-0003-44,NDC,,,,inpatient,1000,ML,35.5,21.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.18,percent of total billed charges,,,85,,30.18,percent of total billed charges,,,49,,17.4,percent of total billed charges,,,90,,31.95,percent of total billed charges,,,,,,,no IP contract,,80,,28.4,percent of total billed charges,,,,,,,no IP contract,,50,,17.75,percent of total billed charges,,,,,,no IP contract,,,78,,27.69,percent of total billed charges,,,70,,24.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.4,3324,
00338-0004-04 - sterile water - Soln,00338-0004-04,NDC,,,,inpatient,1000,ML,35.5,21.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.18,percent of total billed charges,,,85,,30.18,percent of total billed charges,,,49,,17.4,percent of total billed charges,,,90,,31.95,percent of total billed charges,,,,,,,no IP contract,,80,,28.4,percent of total billed charges,,,,,,,no IP contract,,50,,17.75,percent of total billed charges,,,,,,no IP contract,,,78,,27.69,percent of total billed charges,,,70,,24.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.4,3324,
00338-0017-02 - LVP solution Dextrose 5% in Water Soln,00338-0017-02,NDC,,,,inpatient,250,ML,56.25,33.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,45.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,47.81,percent of total billed charges,,,85,,47.81,percent of total billed charges,,,49,,27.56,percent of total billed charges,,,90,,50.63,percent of total billed charges,,,,,,,no IP contract,,80,,45,percent of total billed charges,,,,,,,no IP contract,,50,,28.13,percent of total billed charges,,,,,,no IP contract,,,78,,43.88,percent of total billed charges,,,70,,39.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.56,3324,
00338-0017-03 - LVP solution Dextrose 5% in Water Soln,00338-0017-03,NDC,,,,inpatient,500,ML,118.7,71.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,96.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,100.9,percent of total billed charges,,,85,,100.9,percent of total billed charges,,,49,,58.16,percent of total billed charges,,,90,,106.83,percent of total billed charges,,,,,,,no IP contract,,80,,94.96,percent of total billed charges,,,,,,,no IP contract,,50,,59.35,percent of total billed charges,,,,,,no IP contract,,,78,,92.59,percent of total billed charges,,,70,,83.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.16,3324,
00338-0017-04 - LVP solution Dextrose 5% in Water Soln,00338-0017-04,NDC,,,,inpatient,1000,ML,35.4,21.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.09,percent of total billed charges,,,85,,30.09,percent of total billed charges,,,49,,17.35,percent of total billed charges,,,90,,31.86,percent of total billed charges,,,,,,,no IP contract,,80,,28.32,percent of total billed charges,,,,,,,no IP contract,,50,,17.7,percent of total billed charges,,,,,,no IP contract,,,78,,27.61,percent of total billed charges,,,70,,24.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.35,3324,
00338-0017-31 - LVP solution Dextrose 5% in Water Soln,00338-0017-31,NDC,,,,inpatient,50,ML,114.55,68.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,92.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,97.37,percent of total billed charges,,,85,,97.37,percent of total billed charges,,,49,,56.13,percent of total billed charges,,,90,,103.1,percent of total billed charges,,,,,,,no IP contract,,80,,91.64,percent of total billed charges,,,,,,,no IP contract,,50,,57.28,percent of total billed charges,,,,,,no IP contract,,,78,,89.35,percent of total billed charges,,,70,,80.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,56.13,3324,
00338-0017-38 - LVP solution Dextrose 5% in Water Soln,00338-0017-38,NDC,,,,inpatient,100,ML,35.6,21.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.26,percent of total billed charges,,,85,,30.26,percent of total billed charges,,,49,,17.44,percent of total billed charges,,,90,,32.04,percent of total billed charges,,,,,,,no IP contract,,80,,28.48,percent of total billed charges,,,,,,,no IP contract,,50,,17.8,percent of total billed charges,,,,,,no IP contract,,,78,,27.77,percent of total billed charges,,,70,,24.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.44,3324,
00338-0043-04 - LVP solution Sodium Chloride 0.45% Soln,00338-0043-04,NDC,,,,inpatient,1000,ML,35.4,21.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.09,percent of total billed charges,,,85,,30.09,percent of total billed charges,,,49,,17.35,percent of total billed charges,,,90,,31.86,percent of total billed charges,,,,,,,no IP contract,,80,,28.32,percent of total billed charges,,,,,,,no IP contract,,50,,17.7,percent of total billed charges,,,,,,no IP contract,,,78,,27.61,percent of total billed charges,,,70,,24.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.35,3324,
00338-0049-02 - LVP solution Sodium Chloride 0.9% Soln,00338-0049-02,NDC,,,,inpatient,250,ML,56.25,33.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,45.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,47.81,percent of total billed charges,,,85,,47.81,percent of total billed charges,,,49,,27.56,percent of total billed charges,,,90,,50.63,percent of total billed charges,,,,,,,no IP contract,,80,,45,percent of total billed charges,,,,,,,no IP contract,,50,,28.13,percent of total billed charges,,,,,,no IP contract,,,78,,43.88,percent of total billed charges,,,70,,39.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.56,3324,
00338-0049-03 - LVP solution Sodium Chloride 0.9% Soln,00338-0049-03,NDC,,,,inpatient,500,ML,77.05,46.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,62.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,65.49,percent of total billed charges,,,85,,65.49,percent of total billed charges,,,49,,37.75,percent of total billed charges,,,90,,69.35,percent of total billed charges,,,,,,,no IP contract,,80,,61.64,percent of total billed charges,,,,,,,no IP contract,,50,,38.53,percent of total billed charges,,,,,,no IP contract,,,78,,60.1,percent of total billed charges,,,70,,53.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,37.75,3324,
00338-0049-04 - LVP solution Sodium Chloride 0.9% Soln,00338-0049-04,NDC,,,,inpatient,1000,ML,35.4,21.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.09,percent of total billed charges,,,85,,30.09,percent of total billed charges,,,49,,17.35,percent of total billed charges,,,90,,31.86,percent of total billed charges,,,,,,,no IP contract,,80,,28.32,percent of total billed charges,,,,,,,no IP contract,,50,,17.7,percent of total billed charges,,,,,,no IP contract,,,78,,27.61,percent of total billed charges,,,70,,24.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.35,3324,
00338-0049-31 - LVP solution Sodium Chloride 0.9% Soln,00338-0049-31,NDC,,,,inpatient,50,ML,52.1,31.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,42.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,44.29,percent of total billed charges,,,85,,44.29,percent of total billed charges,,,49,,25.53,percent of total billed charges,,,90,,46.89,percent of total billed charges,,,,,,,no IP contract,,80,,41.68,percent of total billed charges,,,,,,,no IP contract,,50,,26.05,percent of total billed charges,,,,,,no IP contract,,,78,,40.64,percent of total billed charges,,,70,,36.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.53,3324,
00338-0049-48 - LVP solution Sodium Chloride 0.9% Soln,00338-0049-48,NDC,,,,inpatient,100,ML,118.7,71.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,96.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,100.9,percent of total billed charges,,,85,,100.9,percent of total billed charges,,,49,,58.16,percent of total billed charges,,,90,,106.83,percent of total billed charges,,,,,,,no IP contract,,80,,94.96,percent of total billed charges,,,,,,,no IP contract,,50,,59.35,percent of total billed charges,,,,,,no IP contract,,,78,,92.59,percent of total billed charges,,,70,,83.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.16,3324,
00338-0085-03 - LVP solution Dextrose 5% with 0.45% NaCl Soln,00338-0085-03,NDC,,,,inpatient,500,ML,118.7,71.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,96.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,100.9,percent of total billed charges,,,85,,100.9,percent of total billed charges,,,49,,58.16,percent of total billed charges,,,90,,106.83,percent of total billed charges,,,,,,,no IP contract,,80,,94.96,percent of total billed charges,,,,,,,no IP contract,,50,,59.35,percent of total billed charges,,,,,,no IP contract,,,78,,92.59,percent of total billed charges,,,70,,83.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.16,3324,
00338-0085-04 - LVP solution Dextrose 5% with 0.45% NaCl Soln,00338-0085-04,NDC,,,,inpatient,1000,ML,35.4,21.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.09,percent of total billed charges,,,85,,30.09,percent of total billed charges,,,49,,17.35,percent of total billed charges,,,90,,31.86,percent of total billed charges,,,,,,,no IP contract,,80,,28.32,percent of total billed charges,,,,,,,no IP contract,,50,,17.7,percent of total billed charges,,,,,,no IP contract,,,78,,27.61,percent of total billed charges,,,70,,24.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.35,3324,
00338-0089-04 - LVP solution Dextrose 5% with 0.9% NaCl Soln,00338-0089-04,NDC,,,,inpatient,1000,ML,118.7,71.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,96.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,100.9,percent of total billed charges,,,85,,100.9,percent of total billed charges,,,49,,58.16,percent of total billed charges,,,90,,106.83,percent of total billed charges,,,,,,,no IP contract,,80,,94.96,percent of total billed charges,,,,,,,no IP contract,,50,,59.35,percent of total billed charges,,,,,,no IP contract,,,78,,92.59,percent of total billed charges,,,70,,83.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.16,3324,
00338-0117-04 - LVP solution Lactated Ringers Injection Soln,00338-0117-04,NDC,,,,inpatient,1000,ML,35.4,21.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.09,percent of total billed charges,,,85,,30.09,percent of total billed charges,,,49,,17.35,percent of total billed charges,,,90,,31.86,percent of total billed charges,,,,,,,no IP contract,,80,,28.32,percent of total billed charges,,,,,,,no IP contract,,50,,17.7,percent of total billed charges,,,,,,no IP contract,,,78,,27.61,percent of total billed charges,,,70,,24.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.35,3324,
"00338-0519-02 - fat emulsion, intravenous 20% Emuls",00338-0519-02,NDC,,,,inpatient,250,ML,162.55,97.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,131.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,138.17,percent of total billed charges,,,85,,138.17,percent of total billed charges,,,49,,79.65,percent of total billed charges,,,90,,146.3,percent of total billed charges,,,,,,,no IP contract,,80,,130.04,percent of total billed charges,,,,,,,no IP contract,,50,,81.28,percent of total billed charges,,,,,,no IP contract,,,78,,126.79,percent of total billed charges,,,70,,113.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,79.65,3324,
"00338-0519-03 - fat emulsion, intravenous 20% Emuls",00338-0519-03,NDC,,,,inpatient,500,ML,743.45,446.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,602.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,631.93,percent of total billed charges,,,85,,631.93,percent of total billed charges,,,49,,364.29,percent of total billed charges,,,90,,669.11,percent of total billed charges,,,,,,,no IP contract,,80,,594.76,percent of total billed charges,,,,,,,no IP contract,,50,,371.73,percent of total billed charges,,,,,,no IP contract,,,78,,579.89,percent of total billed charges,,,70,,520.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,364.29,3324,
"00338-0519-09 - fat emulsion, intravenous 20% EMULS",00338-0519-09,NDC,,,,inpatient,250,ML,474.9,284.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,384.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,403.67,percent of total billed charges,,,85,,403.67,percent of total billed charges,,,49,,232.7,percent of total billed charges,,,90,,427.41,percent of total billed charges,,,,,,,no IP contract,,80,,379.92,percent of total billed charges,,,,,,,no IP contract,,50,,237.45,percent of total billed charges,,,,,,no IP contract,,,78,,370.42,percent of total billed charges,,,70,,332.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,232.7,3324,
"00338-0519-48 - fat emulsion, intravenous 20% Emuls",00338-0519-48,NDC,,,,inpatient,100,ML,110.4,66.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,89.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,93.84,percent of total billed charges,,,85,,93.84,percent of total billed charges,,,49,,54.1,percent of total billed charges,,,90,,99.36,percent of total billed charges,,,,,,,no IP contract,,80,,88.32,percent of total billed charges,,,,,,,no IP contract,,50,,55.2,percent of total billed charges,,,,,,no IP contract,,,78,,86.11,percent of total billed charges,,,70,,77.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,54.1,3324,
"00338-0519-58 - fat emulsion, IV 20% (100 mL) 20% Emulsion",00338-0519-58,NDC,,,,inpatient,100,ML,110.4,66.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,89.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,93.84,percent of total billed charges,,,85,,93.84,percent of total billed charges,,,49,,54.1,percent of total billed charges,,,90,,99.36,percent of total billed charges,,,,,,,no IP contract,,80,,88.32,percent of total billed charges,,,,,,,no IP contract,,50,,55.2,percent of total billed charges,,,,,,no IP contract,,,78,,86.11,percent of total billed charges,,,70,,77.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,54.1,3324,
00338-0553-18 - LVP solution Sodium Chloride 0.9% Soln,00338-0553-18,NDC,,,,inpatient,100,ML,93.75,56.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,75.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,79.69,percent of total billed charges,,,85,,79.69,percent of total billed charges,,,49,,45.94,percent of total billed charges,,,90,,84.38,percent of total billed charges,,,,,,,no IP contract,,80,,75,percent of total billed charges,,,,,,,no IP contract,,50,,46.88,percent of total billed charges,,,,,,no IP contract,,,78,,73.13,percent of total billed charges,,,70,,65.63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,45.94,3324,
00338-0656-04 - acetic acid topical 0.25% Soln,00338-0656-04,NDC,,,,inpatient,1,UN,9.2,5.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.82,percent of total billed charges,,,85,,7.82,percent of total billed charges,,,49,,4.51,percent of total billed charges,,,90,,8.28,percent of total billed charges,,,,,,,no IP contract,,80,,7.36,percent of total billed charges,,,,,,,no IP contract,,50,,4.6,percent of total billed charges,,,,,,no IP contract,,,78,,7.18,percent of total billed charges,,,70,,6.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.51,3324,
00338-0705-48 - potassium chloride 20 mEq/100 mL Soln,00338-0705-48,NDC,,,,inpatient,100,ML,83.4,50.04,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,67.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,70.89,percent of total billed charges,,,85,,70.89,percent of total billed charges,,,49,,40.87,percent of total billed charges,,,90,,75.06,percent of total billed charges,,,,,,,no IP contract,,80,,66.72,percent of total billed charges,,,,,,,no IP contract,,50,,41.7,percent of total billed charges,,,,,,no IP contract,,,78,,65.05,percent of total billed charges,,,70,,58.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,40.87,3324,
00338-5003-41 - cefTRIAXone 2 g/50 mL Soln,00338-5003-41,NDC,,,,inpatient,50,ML,749.8,449.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,607.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,637.33,percent of total billed charges,,,85,,637.33,percent of total billed charges,,,49,,367.4,percent of total billed charges,,,90,,674.82,percent of total billed charges,,,,,,,no IP contract,,80,,599.84,percent of total billed charges,,,,,,,no IP contract,,50,,374.9,percent of total billed charges,,,,,,no IP contract,,,78,,584.84,percent of total billed charges,,,70,,524.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,367.4,3324,
"00338-9540-06 - fat emulsion, intravenous 20% EMULS",00338-9540-06,NDC,,,,inpatient,250,ML,537.4,322.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,435.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,456.79,percent of total billed charges,,,85,,456.79,percent of total billed charges,,,49,,263.33,percent of total billed charges,,,90,,483.66,percent of total billed charges,,,,,,,no IP contract,,80,,429.92,percent of total billed charges,,,,,,,no IP contract,,50,,268.7,percent of total billed charges,,,,,,no IP contract,,,78,,419.17,percent of total billed charges,,,70,,376.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,263.33,3324,
"00338-9540-07 - fat emulsion, intravenous 20% EMULS",00338-9540-07,NDC,,,,inpatient,500,ML,474.9,284.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,384.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,403.67,percent of total billed charges,,,85,,403.67,percent of total billed charges,,,49,,232.7,percent of total billed charges,,,90,,427.41,percent of total billed charges,,,,,,,no IP contract,,80,,379.92,percent of total billed charges,,,,,,,no IP contract,,50,,237.45,percent of total billed charges,,,,,,no IP contract,,,78,,370.42,percent of total billed charges,,,70,,332.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,232.7,3324,
00378-0023-01 - diltiazem 30 mg Tab,00378-0023-01,NDC,,,,inpatient,1,EA,7.55,4.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.42,percent of total billed charges,,,85,,6.42,percent of total billed charges,,,49,,3.7,percent of total billed charges,,,90,,6.8,percent of total billed charges,,,,,,,no IP contract,,80,,6.04,percent of total billed charges,,,,,,,no IP contract,,50,,3.78,percent of total billed charges,,,,,,no IP contract,,,78,,5.89,percent of total billed charges,,,70,,5.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.7,3324,
00378-0045-01 - diltiazem 60 mg Tab,00378-0045-01,NDC,,,,inpatient,1,EA,10.35,6.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.8,percent of total billed charges,,,85,,8.8,percent of total billed charges,,,49,,5.07,percent of total billed charges,,,90,,9.32,percent of total billed charges,,,,,,,no IP contract,,80,,8.28,percent of total billed charges,,,,,,,no IP contract,,50,,5.18,percent of total billed charges,,,,,,no IP contract,,,78,,8.07,percent of total billed charges,,,70,,7.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.07,3324,
00378-0047-01 - metoprolol 100 mg Tab,00378-0047-01,NDC,,,,inpatient,1,EA,10.2,6.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.67,percent of total billed charges,,,85,,8.67,percent of total billed charges,,,49,,5,percent of total billed charges,,,90,,9.18,percent of total billed charges,,,,,,,no IP contract,,80,,8.16,percent of total billed charges,,,,,,,no IP contract,,50,,5.1,percent of total billed charges,,,,,,no IP contract,,,78,,7.96,percent of total billed charges,,,70,,7.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5,3324,
00378-0085-01 - carbidopa-levodopa 25 mg-100 mg Tab,00378-0085-01,NDC,,,,inpatient,1,EA,10.75,6.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.14,percent of total billed charges,,,85,,9.14,percent of total billed charges,,,49,,5.27,percent of total billed charges,,,90,,9.68,percent of total billed charges,,,,,,,no IP contract,,80,,8.6,percent of total billed charges,,,,,,,no IP contract,,50,,5.38,percent of total billed charges,,,,,,no IP contract,,,78,,8.39,percent of total billed charges,,,70,,7.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.27,3324,
00378-0088-01 - carbidopa-levodopa 25 mg-100 mg ER Ta,00378-0088-01,NDC,,,,inpatient,1,EA,11.7,7.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.95,percent of total billed charges,,,85,,9.95,percent of total billed charges,,,49,,5.73,percent of total billed charges,,,90,,10.53,percent of total billed charges,,,,,,,no IP contract,,80,,9.36,percent of total billed charges,,,,,,,no IP contract,,50,,5.85,percent of total billed charges,,,,,,no IP contract,,,78,,9.13,percent of total billed charges,,,70,,8.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.73,3324,
00378-0094-01 - carbidopa-levodopa 50 mg-200 mg ER Ta,00378-0094-01,NDC,,,,inpatient,1,EA,18.2,10.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.47,percent of total billed charges,,,85,,15.47,percent of total billed charges,,,49,,8.92,percent of total billed charges,,,90,,16.38,percent of total billed charges,,,,,,,no IP contract,,80,,14.56,percent of total billed charges,,,,,,,no IP contract,,50,,9.1,percent of total billed charges,,,,,,no IP contract,,,78,,14.2,percent of total billed charges,,,70,,12.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.92,3324,
00378-0137-01 - allopurinol 100 mg Tab,00378-0137-01,NDC,,,,inpatient,1,EA,7.65,4.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.5,percent of total billed charges,,,85,,6.5,percent of total billed charges,,,49,,3.75,percent of total billed charges,,,90,,6.89,percent of total billed charges,,,,,,,no IP contract,,80,,6.12,percent of total billed charges,,,,,,,no IP contract,,50,,3.83,percent of total billed charges,,,,,,no IP contract,,,78,,5.97,percent of total billed charges,,,70,,5.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.75,3324,
00378-0147-01 - indomethacin 50 mg Cap,00378-0147-01,NDC,,,,inpatient,1,EA,8.9,5.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.57,percent of total billed charges,,,85,,7.57,percent of total billed charges,,,49,,4.36,percent of total billed charges,,,90,,8.01,percent of total billed charges,,,,,,,no IP contract,,80,,7.12,percent of total billed charges,,,,,,,no IP contract,,50,,4.45,percent of total billed charges,,,,,,no IP contract,,,78,,6.94,percent of total billed charges,,,70,,6.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.36,3324,
00378-0183-01 - propranolol 20 mg Tab,00378-0183-01,NDC,,,,inpatient,1,EA,7.9,4.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.72,percent of total billed charges,,,85,,6.72,percent of total billed charges,,,49,,3.87,percent of total billed charges,,,90,,7.11,percent of total billed charges,,,,,,,no IP contract,,80,,6.32,percent of total billed charges,,,,,,,no IP contract,,50,,3.95,percent of total billed charges,,,,,,no IP contract,,,78,,6.16,percent of total billed charges,,,70,,5.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.87,3324,
00378-0184-01 - propranolol 40 mg Tab,00378-0184-01,NDC,,,,inpatient,1,EA,9.55,5.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.12,percent of total billed charges,,,85,,8.12,percent of total billed charges,,,49,,4.68,percent of total billed charges,,,90,,8.6,percent of total billed charges,,,,,,,no IP contract,,80,,7.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.78,percent of total billed charges,,,,,,no IP contract,,,78,,7.45,percent of total billed charges,,,70,,6.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.68,3324,
00378-0208-01 - furosemide 20 mg Tab,00378-0208-01,NDC,,,,inpatient,1,EA,4.95,2.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.21,percent of total billed charges,,,85,,4.21,percent of total billed charges,,,49,,2.43,percent of total billed charges,,,90,,4.46,percent of total billed charges,,,,,,,no IP contract,,80,,3.96,percent of total billed charges,,,,,,,no IP contract,,50,,2.48,percent of total billed charges,,,,,,no IP contract,,,78,,3.86,percent of total billed charges,,,70,,3.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.43,3324,
00378-0213-01 - chlorthalidone 50 mg Tab,00378-0213-01,NDC,,,,inpatient,1,EA,5.8,3.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.93,percent of total billed charges,,,85,,4.93,percent of total billed charges,,,49,,2.84,percent of total billed charges,,,90,,5.22,percent of total billed charges,,,,,,,no IP contract,,80,,4.64,percent of total billed charges,,,,,,,no IP contract,,50,,2.9,percent of total billed charges,,,,,,no IP contract,,,78,,4.52,percent of total billed charges,,,70,,4.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.84,3324,
00378-0257-01 - haloperidol 1 mg Tab,00378-0257-01,NDC,,,,inpatient,1,EA,7.5,4.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.38,percent of total billed charges,,,85,,6.38,percent of total billed charges,,,49,,3.68,percent of total billed charges,,,90,,6.75,percent of total billed charges,,,,,,,no IP contract,,80,,6,percent of total billed charges,,,,,,,no IP contract,,50,,3.75,percent of total billed charges,,,,,,no IP contract,,,78,,5.85,percent of total billed charges,,,70,,5.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.68,3324,
00378-0271-01 - diazepam 2 mg Tab,00378-0271-01,NDC,,,,inpatient,1,EA,6.25,3.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.31,percent of total billed charges,,,85,,5.31,percent of total billed charges,,,49,,3.06,percent of total billed charges,,,90,,5.63,percent of total billed charges,,,,,,,no IP contract,,80,,5,percent of total billed charges,,,,,,,no IP contract,,50,,3.13,percent of total billed charges,,,,,,no IP contract,,,78,,4.88,percent of total billed charges,,,70,,4.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.06,3324,
00378-0345-01 - diazePAM 5 mg Tab,00378-0345-01,NDC,,,,inpatient,1,EA,6.75,4.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.74,percent of total billed charges,,,85,,5.74,percent of total billed charges,,,49,,3.31,percent of total billed charges,,,90,,6.08,percent of total billed charges,,,,,,,no IP contract,,80,,5.4,percent of total billed charges,,,,,,,no IP contract,,50,,3.38,percent of total billed charges,,,,,,no IP contract,,,78,,5.27,percent of total billed charges,,,70,,4.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.31,3324,
00378-0415-01 - atropine-diphenoxylate 0.025 mg-2.5 mg Tab,00378-0415-01,NDC,,,,inpatient,1,EA,9.4,5.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.99,percent of total billed charges,,,85,,7.99,percent of total billed charges,,,49,,4.61,percent of total billed charges,,,90,,8.46,percent of total billed charges,,,,,,,no IP contract,,80,,7.52,percent of total billed charges,,,,,,,no IP contract,,50,,4.7,percent of total billed charges,,,,,,no IP contract,,,78,,7.33,percent of total billed charges,,,70,,6.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.61,3324,
00378-0616-01 - thioridazine 50 mg Tab,00378-0616-01,NDC,,,,inpatient,1,EA,8.45,5.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.18,percent of total billed charges,,,85,,7.18,percent of total billed charges,,,49,,4.14,percent of total billed charges,,,90,,7.61,percent of total billed charges,,,,,,,no IP contract,,80,,6.76,percent of total billed charges,,,,,,,no IP contract,,50,,4.23,percent of total billed charges,,,,,,no IP contract,,,78,,6.59,percent of total billed charges,,,70,,5.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.14,3324,
00378-0772-01 - verapamil 120 mg Tab,00378-0772-01,NDC,,,,inpatient,1,EA,6.95,4.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.91,percent of total billed charges,,,85,,5.91,percent of total billed charges,,,49,,3.41,percent of total billed charges,,,90,,6.26,percent of total billed charges,,,,,,,no IP contract,,80,,5.56,percent of total billed charges,,,,,,,no IP contract,,50,,3.48,percent of total billed charges,,,,,,no IP contract,,,78,,5.42,percent of total billed charges,,,70,,4.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.41,3324,
00378-0782-93 - fexofenadine 180 mg Tab,00378-0782-93,NDC,,,,inpatient,1,EA,23.15,13.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.68,percent of total billed charges,,,85,,19.68,percent of total billed charges,,,49,,11.34,percent of total billed charges,,,90,,20.84,percent of total billed charges,,,,,,,no IP contract,,80,,18.52,percent of total billed charges,,,,,,,no IP contract,,50,,11.58,percent of total billed charges,,,,,,no IP contract,,,78,,18.06,percent of total billed charges,,,70,,16.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.34,3324,
00378-0825-01 - cloZAPine 25 mg Tab,00378-0825-01,NDC,,,,inpatient,1,EA,14.3,8.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.16,percent of total billed charges,,,85,,12.16,percent of total billed charges,,,49,,7.01,percent of total billed charges,,,90,,12.87,percent of total billed charges,,,,,,,no IP contract,,80,,11.44,percent of total billed charges,,,,,,,no IP contract,,50,,7.15,percent of total billed charges,,,,,,no IP contract,,,78,,11.15,percent of total billed charges,,,70,,10.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.01,3324,
00378-0871-16 - clonidine 0.1 mg/24 hr ER Patch,00378-0871-16,NDC,,,,inpatient,1,UN,285.1,171.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,230.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,242.34,percent of total billed charges,,,85,,242.34,percent of total billed charges,,,49,,139.7,percent of total billed charges,,,90,,256.59,percent of total billed charges,,,,,,,no IP contract,,80,,228.08,percent of total billed charges,,,,,,,no IP contract,,50,,142.55,percent of total billed charges,,,,,,no IP contract,,,78,,222.38,percent of total billed charges,,,70,,199.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,139.7,3324,
00378-1020-77 - niCARdipine 20 mg Cap,00378-1020-77,NDC,,,,inpatient,1,EA,7.5,4.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.38,percent of total billed charges,,,85,,6.38,percent of total billed charges,,,49,,3.68,percent of total billed charges,,,90,,6.75,percent of total billed charges,,,,,,,no IP contract,,80,,6,percent of total billed charges,,,,,,,no IP contract,,50,,3.75,percent of total billed charges,,,,,,no IP contract,,,78,,5.85,percent of total billed charges,,,70,,5.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.68,3324,
00378-1086-93 - colchicine 0.6 mg Tab,00378-1086-93,NDC,,,,inpatient,1,EA,39.75,23.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.79,percent of total billed charges,,,85,,33.79,percent of total billed charges,,,49,,19.48,percent of total billed charges,,,90,,35.78,percent of total billed charges,,,,,,,no IP contract,,80,,31.8,percent of total billed charges,,,,,,,no IP contract,,50,,19.88,percent of total billed charges,,,,,,no IP contract,,,78,,31.01,percent of total billed charges,,,70,,27.83,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.48,3324,
00378-1134-01 - ketorolac 10 mg Tab,00378-1134-01,NDC,,,,inpatient,1,EA,11.95,7.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.16,percent of total billed charges,,,85,,10.16,percent of total billed charges,,,49,,5.86,percent of total billed charges,,,90,,10.76,percent of total billed charges,,,,,,,no IP contract,,80,,9.56,percent of total billed charges,,,,,,,no IP contract,,50,,5.98,percent of total billed charges,,,,,,no IP contract,,,78,,9.32,percent of total billed charges,,,70,,8.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.86,3324,
00378-1171-01 - nadolol 40 mg Tab,00378-1171-01,NDC,,,,inpatient,1,EA,12.15,7.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.33,percent of total billed charges,,,85,,10.33,percent of total billed charges,,,49,,5.95,percent of total billed charges,,,90,,10.94,percent of total billed charges,,,,,,,no IP contract,,80,,9.72,percent of total billed charges,,,,,,,no IP contract,,50,,6.08,percent of total billed charges,,,,,,no IP contract,,,78,,9.48,percent of total billed charges,,,70,,8.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.95,3324,
00378-1190-01 - guanfacine 2 mg Tab,00378-1190-01,NDC,,,,inpatient,1,EA,13.2,7.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.22,percent of total billed charges,,,85,,11.22,percent of total billed charges,,,49,,6.47,percent of total billed charges,,,90,,11.88,percent of total billed charges,,,,,,,no IP contract,,80,,10.56,percent of total billed charges,,,,,,,no IP contract,,50,,6.6,percent of total billed charges,,,,,,no IP contract,,,78,,10.3,percent of total billed charges,,,70,,9.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.47,3324,
00378-1270-93 - rasagiline 0.5 mg Tab,00378-1270-93,NDC,,,,inpatient,1,EA,202.55,121.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,164.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,172.17,percent of total billed charges,,,85,,172.17,percent of total billed charges,,,49,,99.25,percent of total billed charges,,,90,,182.3,percent of total billed charges,,,,,,,no IP contract,,80,,162.04,percent of total billed charges,,,,,,,no IP contract,,50,,101.28,percent of total billed charges,,,,,,no IP contract,,,78,,157.99,percent of total billed charges,,,70,,141.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,99.25,3324,
00378-1271-93 - rasagiline 1 mg Tab,00378-1271-93,NDC,,,,inpatient,1,EA,202.55,121.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,164.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,172.17,percent of total billed charges,,,85,,172.17,percent of total billed charges,,,49,,99.25,percent of total billed charges,,,90,,182.3,percent of total billed charges,,,,,,,no IP contract,,80,,162.04,percent of total billed charges,,,,,,,no IP contract,,50,,101.28,percent of total billed charges,,,,,,no IP contract,,,78,,157.99,percent of total billed charges,,,70,,141.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,99.25,3324,
00378-1805-77 - levothyroxine 75 mcg (0.075 mg) Tab,00378-1805-77,NDC,,,,inpatient,1,EA,8.2,4.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.97,percent of total billed charges,,,85,,6.97,percent of total billed charges,,,49,,4.02,percent of total billed charges,,,90,,7.38,percent of total billed charges,,,,,,,no IP contract,,80,,6.56,percent of total billed charges,,,,,,,no IP contract,,50,,4.1,percent of total billed charges,,,,,,no IP contract,,,78,,6.4,percent of total billed charges,,,70,,5.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.02,3324,
00378-1813-77 - levothyroxine 125 mcg (0.125 mg) Tab,00378-1813-77,NDC,,,,inpatient,1,EA,9.05,5.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.69,percent of total billed charges,,,85,,7.69,percent of total billed charges,,,49,,4.43,percent of total billed charges,,,90,,8.15,percent of total billed charges,,,,,,,no IP contract,,80,,7.24,percent of total billed charges,,,,,,,no IP contract,,50,,4.53,percent of total billed charges,,,,,,no IP contract,,,78,,7.06,percent of total billed charges,,,70,,6.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.43,3324,
00378-1902-01 - midodrine 5 mg Tab,00378-1902-01,NDC,,,,inpatient,1,EA,23.05,13.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.59,percent of total billed charges,,,85,,19.59,percent of total billed charges,,,49,,11.29,percent of total billed charges,,,90,,20.75,percent of total billed charges,,,,,,,no IP contract,,80,,18.44,percent of total billed charges,,,,,,,no IP contract,,50,,11.53,percent of total billed charges,,,,,,no IP contract,,,78,,17.98,percent of total billed charges,,,70,,16.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.29,3324,
00378-1910-01 - clonazePAM 0.5 mg Tab,00378-1910-01,NDC,,,,inpatient,1,EA,11.65,6.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.9,percent of total billed charges,,,85,,9.9,percent of total billed charges,,,49,,5.71,percent of total billed charges,,,90,,10.49,percent of total billed charges,,,,,,,no IP contract,,80,,9.32,percent of total billed charges,,,,,,,no IP contract,,50,,5.83,percent of total billed charges,,,,,,no IP contract,,,78,,9.09,percent of total billed charges,,,70,,8.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.71,3324,
00378-1930-93 - emtricitabine-tenofovir  200 mg-300 mg Tab,00378-1930-93,NDC,,,,inpatient,1,EA,59.45,35.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,48.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,50.53,percent of total billed charges,,,85,,50.53,percent of total billed charges,,,49,,29.13,percent of total billed charges,,,90,,53.51,percent of total billed charges,,,,,,,no IP contract,,80,,47.56,percent of total billed charges,,,,,,,no IP contract,,50,,29.73,percent of total billed charges,,,,,,no IP contract,,,78,,46.37,percent of total billed charges,,,70,,41.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,29.13,3324,
00378-2003-93 - paroxetine 12.5 mg ER Ta,00378-2003-93,NDC,,,,inpatient,1,EA,31,18.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,25.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.35,percent of total billed charges,,,85,,26.35,percent of total billed charges,,,49,,15.19,percent of total billed charges,,,90,,27.9,percent of total billed charges,,,,,,,no IP contract,,80,,24.8,percent of total billed charges,,,,,,,no IP contract,,50,,15.5,percent of total billed charges,,,,,,no IP contract,,,78,,24.18,percent of total billed charges,,,70,,21.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.19,3324,
00378-2004-93 - paroxetine 25 mg ER Ta,00378-2004-93,NDC,,,,inpatient,1,EA,32.2,19.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,26.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,27.37,percent of total billed charges,,,85,,27.37,percent of total billed charges,,,49,,15.78,percent of total billed charges,,,90,,28.98,percent of total billed charges,,,,,,,no IP contract,,80,,25.76,percent of total billed charges,,,,,,,no IP contract,,50,,16.1,percent of total billed charges,,,,,,no IP contract,,,78,,25.12,percent of total billed charges,,,70,,22.54,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.78,3324,
00378-2042-01 - bromocriptine 2.5 mg Tab,00378-2042-01,NDC,,,,inpatient,1,EA,21.15,12.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.98,percent of total billed charges,,,85,,17.98,percent of total billed charges,,,49,,10.36,percent of total billed charges,,,90,,19.04,percent of total billed charges,,,,,,,no IP contract,,80,,16.92,percent of total billed charges,,,,,,,no IP contract,,50,,10.58,percent of total billed charges,,,,,,no IP contract,,,78,,16.5,percent of total billed charges,,,70,,14.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.36,3324,
00378-2045-01 - tacrolimus 0.5 mg Cap,00378-2045-01,NDC,,,,inpatient,1,EA,21.55,12.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.32,percent of total billed charges,,,85,,18.32,percent of total billed charges,,,49,,10.56,percent of total billed charges,,,90,,19.4,percent of total billed charges,,,,,,,no IP contract,,80,,17.24,percent of total billed charges,,,,,,,no IP contract,,50,,10.78,percent of total billed charges,,,,,,no IP contract,,,78,,16.81,percent of total billed charges,,,70,,15.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.56,3324,
00378-2046-01 - tacrolimus 1 mg Cap,00378-2046-01,NDC,,,,inpatient,1,EA,39.3,23.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.41,percent of total billed charges,,,85,,33.41,percent of total billed charges,,,49,,19.26,percent of total billed charges,,,90,,35.37,percent of total billed charges,,,,,,,no IP contract,,80,,31.44,percent of total billed charges,,,,,,,no IP contract,,50,,19.65,percent of total billed charges,,,,,,no IP contract,,,78,,30.65,percent of total billed charges,,,70,,27.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.26,3324,
00378-2233-93 - efavirenz 600 mg Tab,00378-2233-93,NDC,,,,inpatient,1,EA,300.05,180.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,243.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,255.04,percent of total billed charges,,,85,,255.04,percent of total billed charges,,,49,,147.02,percent of total billed charges,,,90,,270.05,percent of total billed charges,,,,,,,no IP contract,,80,,240.04,percent of total billed charges,,,,,,,no IP contract,,50,,150.03,percent of total billed charges,,,,,,no IP contract,,,78,,234.04,percent of total billed charges,,,70,,210.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,147.02,3324,
00378-3065-77 - fenofibrate 48 mg Tab,00378-3065-77,NDC,,,,inpatient,1,EA,19,11.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.15,percent of total billed charges,,,85,,16.15,percent of total billed charges,,,49,,9.31,percent of total billed charges,,,90,,17.1,percent of total billed charges,,,,,,,no IP contract,,80,,15.2,percent of total billed charges,,,,,,,no IP contract,,50,,9.5,percent of total billed charges,,,,,,no IP contract,,,78,,14.82,percent of total billed charges,,,70,,13.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.31,3324,
00378-3066-77 - fenofibrate 145 mg Tab,00378-3066-77,NDC,,,,inpatient,1,EA,49.4,29.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,40.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,41.99,percent of total billed charges,,,85,,41.99,percent of total billed charges,,,49,,24.21,percent of total billed charges,,,90,,44.46,percent of total billed charges,,,,,,,no IP contract,,80,,39.52,percent of total billed charges,,,,,,,no IP contract,,50,,24.7,percent of total billed charges,,,,,,no IP contract,,,78,,38.53,percent of total billed charges,,,70,,34.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.21,3324,
00378-3225-93 - candesartan 8 mg Tab,00378-3225-93,NDC,,,,inpatient,1,EA,28.15,16.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.93,percent of total billed charges,,,85,,23.93,percent of total billed charges,,,49,,13.79,percent of total billed charges,,,90,,25.34,percent of total billed charges,,,,,,,no IP contract,,80,,22.52,percent of total billed charges,,,,,,,no IP contract,,50,,14.08,percent of total billed charges,,,,,,no IP contract,,,78,,21.96,percent of total billed charges,,,70,,19.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.79,3324,
00378-3232-93 - candesartan 32 mg Tab,00378-3232-93,NDC,,,,inpatient,1,EA,37,22.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.45,percent of total billed charges,,,85,,31.45,percent of total billed charges,,,49,,18.13,percent of total billed charges,,,90,,33.3,percent of total billed charges,,,,,,,no IP contract,,80,,29.6,percent of total billed charges,,,,,,,no IP contract,,50,,18.5,percent of total billed charges,,,,,,no IP contract,,,78,,28.86,percent of total billed charges,,,70,,25.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.13,3324,
00378-3431-93 - armodafinil 50 mg Tab,00378-3431-93,NDC,,,,inpatient,1,EA,65.9,39.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,53.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.02,percent of total billed charges,,,85,,56.02,percent of total billed charges,,,49,,32.29,percent of total billed charges,,,90,,59.31,percent of total billed charges,,,,,,,no IP contract,,80,,52.72,percent of total billed charges,,,,,,,no IP contract,,50,,32.95,percent of total billed charges,,,,,,no IP contract,,,78,,51.4,percent of total billed charges,,,70,,46.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.29,3324,
00378-3547-52 - mercaptopurine 50 mg Tab,00378-3547-52,NDC,,,,inpatient,1,EA,36.35,21.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.9,percent of total billed charges,,,85,,30.9,percent of total billed charges,,,49,,17.81,percent of total billed charges,,,90,,32.72,percent of total billed charges,,,,,,,no IP contract,,80,,29.08,percent of total billed charges,,,,,,,no IP contract,,50,,18.18,percent of total billed charges,,,,,,no IP contract,,,78,,28.35,percent of total billed charges,,,70,,25.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.81,3324,
00378-3635-01 - cetirizine 5 mg Tab,00378-3635-01,NDC,,,,inpatient,1,EA,23.6,14.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.06,percent of total billed charges,,,85,,20.06,percent of total billed charges,,,49,,11.56,percent of total billed charges,,,90,,21.24,percent of total billed charges,,,,,,,no IP contract,,80,,18.88,percent of total billed charges,,,,,,,no IP contract,,50,,11.8,percent of total billed charges,,,,,,no IP contract,,,78,,18.41,percent of total billed charges,,,70,,16.52,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.56,3324,
00378-3637-01 - cetirizine 10 mg Tab,00378-3637-01,NDC,,,,inpatient,1,EA,23.6,14.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.06,percent of total billed charges,,,85,,20.06,percent of total billed charges,,,49,,11.56,percent of total billed charges,,,90,,21.24,percent of total billed charges,,,,,,,no IP contract,,80,,18.88,percent of total billed charges,,,,,,,no IP contract,,50,,11.8,percent of total billed charges,,,,,,no IP contract,,,78,,18.41,percent of total billed charges,,,70,,16.52,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.56,3324,
00378-4010-01 - temazepam 15 mg Cap,00378-4010-01,NDC,,,,inpatient,1,EA,11.5,6.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.78,percent of total billed charges,,,85,,9.78,percent of total billed charges,,,49,,5.64,percent of total billed charges,,,90,,10.35,percent of total billed charges,,,,,,,no IP contract,,80,,9.2,percent of total billed charges,,,,,,,no IP contract,,50,,5.75,percent of total billed charges,,,,,,no IP contract,,,78,,8.97,percent of total billed charges,,,70,,8.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.64,3324,
00378-4105-91 - abacavir 300 mg Tab,00378-4105-91,NDC,,,,inpatient,1,EA,83.65,50.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,67.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,71.1,percent of total billed charges,,,85,,71.1,percent of total billed charges,,,49,,40.99,percent of total billed charges,,,90,,75.29,percent of total billed charges,,,,,,,no IP contract,,80,,66.92,percent of total billed charges,,,,,,,no IP contract,,50,,41.83,percent of total billed charges,,,,,,no IP contract,,,78,,65.25,percent of total billed charges,,,70,,58.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,40.99,3324,
00378-4250-01 - doxepin 50 mg Cap,00378-4250-01,NDC,,,,inpatient,1,EA,8.2,4.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.97,percent of total billed charges,,,85,,6.97,percent of total billed charges,,,49,,4.02,percent of total billed charges,,,90,,7.38,percent of total billed charges,,,,,,,no IP contract,,80,,6.56,percent of total billed charges,,,,,,,no IP contract,,50,,4.1,percent of total billed charges,,,,,,no IP contract,,,78,,6.4,percent of total billed charges,,,70,,5.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.02,3324,
00378-4275-77 - valACYclovir 500 mg Tab,00378-4275-77,NDC,,,,inpatient,1,EA,61.2,36.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,49.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,52.02,percent of total billed charges,,,85,,52.02,percent of total billed charges,,,49,,29.99,percent of total billed charges,,,90,,55.08,percent of total billed charges,,,,,,,no IP contract,,80,,48.96,percent of total billed charges,,,,,,,no IP contract,,50,,30.6,percent of total billed charges,,,,,,no IP contract,,,78,,47.74,percent of total billed charges,,,70,,42.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,29.99,3324,
00378-4276-77 - valACYclovir 1 g Tab,00378-4276-77,NDC,,,,inpatient,1,EA,104.3,62.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,84.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,88.66,percent of total billed charges,,,85,,88.66,percent of total billed charges,,,49,,51.11,percent of total billed charges,,,90,,93.87,percent of total billed charges,,,,,,,no IP contract,,80,,83.44,percent of total billed charges,,,,,,,no IP contract,,50,,52.15,percent of total billed charges,,,,,,no IP contract,,,78,,81.35,percent of total billed charges,,,70,,73.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,51.11,3324,
00378-4472-01 - mycophenolate mofetil 500 mg Tab,00378-4472-01,NDC,,,,inpatient,1,EA,66.85,40.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,54.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.82,percent of total billed charges,,,85,,56.82,percent of total billed charges,,,49,,32.76,percent of total billed charges,,,90,,60.17,percent of total billed charges,,,,,,,no IP contract,,80,,53.48,percent of total billed charges,,,,,,,no IP contract,,50,,33.43,percent of total billed charges,,,,,,no IP contract,,,78,,52.14,percent of total billed charges,,,70,,46.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.76,3324,
00378-4561-77 - potassium chloride 10 mEq ER Ta,00378-4561-77,NDC,,,,inpatient,1,EA,8.3,4.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.06,percent of total billed charges,,,85,,7.06,percent of total billed charges,,,49,,4.07,percent of total billed charges,,,90,,7.47,percent of total billed charges,,,,,,,no IP contract,,80,,6.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.15,percent of total billed charges,,,,,,no IP contract,,,78,,6.47,percent of total billed charges,,,70,,5.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.07,3324,
00378-5220-01 - diltiazem 120 mg/24 hours ER Ca,00378-5220-01,NDC,,,,inpatient,1,EA,11.05,6.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.39,percent of total billed charges,,,85,,9.39,percent of total billed charges,,,49,,5.41,percent of total billed charges,,,90,,9.95,percent of total billed charges,,,,,,,no IP contract,,80,,8.84,percent of total billed charges,,,,,,,no IP contract,,50,,5.53,percent of total billed charges,,,,,,no IP contract,,,78,,8.62,percent of total billed charges,,,70,,7.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.41,3324,
00378-5220-01 - diltiazem 120 mg/24 hours ER Cap,00378-5220-01,NDC,,,,inpatient,1,EA,11.05,6.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.39,percent of total billed charges,,,85,,9.39,percent of total billed charges,,,49,,5.41,percent of total billed charges,,,90,,9.95,percent of total billed charges,,,,,,,no IP contract,,80,,8.84,percent of total billed charges,,,,,,,no IP contract,,50,,5.53,percent of total billed charges,,,,,,no IP contract,,,78,,8.62,percent of total billed charges,,,70,,7.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.41,3324,
00378-5615-05 - levETIRAcetam 500 mg Tab,00378-5615-05,NDC,,,,inpatient,1,EA,31.75,19.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,25.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.99,percent of total billed charges,,,85,,26.99,percent of total billed charges,,,49,,15.56,percent of total billed charges,,,90,,28.58,percent of total billed charges,,,,,,,no IP contract,,80,,25.4,percent of total billed charges,,,,,,,no IP contract,,50,,15.88,percent of total billed charges,,,,,,no IP contract,,,78,,24.77,percent of total billed charges,,,70,,22.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.56,3324,
levETIRAcetam 500 mg Tab,00378-5615-78,NDC,,,,inpatient,1,EA,31.75,19.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,25.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.99,percent of total billed charges,,,85,,26.99,percent of total billed charges,,,49,,15.56,percent of total billed charges,,,90,,28.58,percent of total billed charges,,,,,,,no IP contract,,80,,25.4,percent of total billed charges,,,,,,,no IP contract,,50,,15.88,percent of total billed charges,,,,,,no IP contract,,,78,,24.77,percent of total billed charges,,,70,,22.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.56,3324,
00378-5813-77 - valsartan 80 mg Tab,00378-5813-77,NDC,,,,inpatient,1,EA,42.4,25.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36.04,percent of total billed charges,,,85,,36.04,percent of total billed charges,,,49,,20.78,percent of total billed charges,,,90,,38.16,percent of total billed charges,,,,,,,no IP contract,,80,,33.92,percent of total billed charges,,,,,,,no IP contract,,50,,21.2,percent of total billed charges,,,,,,no IP contract,,,78,,33.07,percent of total billed charges,,,70,,29.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.78,3324,
00378-6106-91 - zidovudine 300 mg Tab,00378-6106-91,NDC,,,,inpatient,1,EA,52.15,31.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,42.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,44.33,percent of total billed charges,,,85,,44.33,percent of total billed charges,,,49,,25.55,percent of total billed charges,,,90,,46.94,percent of total billed charges,,,,,,,no IP contract,,80,,41.72,percent of total billed charges,,,,,,,no IP contract,,50,,26.08,percent of total billed charges,,,,,,no IP contract,,,78,,40.68,percent of total billed charges,,,70,,36.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.55,3324,
00378-6270-45 - voriconazole 40 mg/mL REC P,00378-6270-45,NDC,,,,inpatient,1,ML,122.95,73.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,99.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,104.51,percent of total billed charges,,,85,,104.51,percent of total billed charges,,,49,,60.25,percent of total billed charges,,,90,,110.66,percent of total billed charges,,,,,,,no IP contract,,80,,98.36,percent of total billed charges,,,,,,,no IP contract,,50,,61.48,percent of total billed charges,,,,,,no IP contract,,,78,,95.9,percent of total billed charges,,,70,,86.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,60.25,3324,
00378-6470-99 - scopolamine 1 mg/72 hr ER Fi,00378-6470-99,NDC,,,,inpatient,1,UN,177.5,106.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,143.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,150.88,percent of total billed charges,,,85,,150.88,percent of total billed charges,,,49,,86.98,percent of total billed charges,,,90,,159.75,percent of total billed charges,,,,,,,no IP contract,,80,,142,percent of total billed charges,,,,,,,no IP contract,,50,,88.75,percent of total billed charges,,,,,,no IP contract,,,78,,138.45,percent of total billed charges,,,70,,124.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,86.98,3324,
00378-6669-40 - polyethylene glycol 3350 with electrolytes - REC P,00378-6669-40,NDC,,,,inpatient,4000,ML,5.4,3.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.59,percent of total billed charges,,,85,,4.59,percent of total billed charges,,,49,,2.65,percent of total billed charges,,,90,,4.86,percent of total billed charges,,,,,,,no IP contract,,80,,4.32,percent of total billed charges,,,,,,,no IP contract,,50,,2.7,percent of total billed charges,,,,,,no IP contract,,,78,,4.21,percent of total billed charges,,,70,,3.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.65,3324,
00378-6726-01 - zonisamide 50 mg Cap,00378-6726-01,NDC,,,,inpatient,1,EA,12.55,7.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.67,percent of total billed charges,,,85,,10.67,percent of total billed charges,,,49,,6.15,percent of total billed charges,,,90,,11.3,percent of total billed charges,,,,,,,no IP contract,,80,,10.04,percent of total billed charges,,,,,,,no IP contract,,50,,6.28,percent of total billed charges,,,,,,no IP contract,,,78,,9.79,percent of total billed charges,,,70,,8.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.15,3324,
00378-7096-01 - bromocriptine 5 mg Cap,00378-7096-01,NDC,,,,inpatient,1,EA,43.65,26.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,35.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,37.1,percent of total billed charges,,,85,,37.1,percent of total billed charges,,,49,,21.39,percent of total billed charges,,,90,,39.29,percent of total billed charges,,,,,,,no IP contract,,80,,34.92,percent of total billed charges,,,,,,,no IP contract,,50,,21.83,percent of total billed charges,,,,,,no IP contract,,,78,,34.05,percent of total billed charges,,,70,,30.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.39,3324,
00378-7096-93 - bromocriptine 5 mg Cap,00378-7096-93,NDC,,,,inpatient,1,EA,77.85,46.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,63.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,66.17,percent of total billed charges,,,85,,66.17,percent of total billed charges,,,49,,38.15,percent of total billed charges,,,90,,70.07,percent of total billed charges,,,,,,,no IP contract,,80,,62.28,percent of total billed charges,,,,,,,no IP contract,,50,,38.93,percent of total billed charges,,,,,,no IP contract,,,78,,60.72,percent of total billed charges,,,70,,54.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,38.15,3324,
00378-7732-93 - ondansetron 4 mg DIS T,00378-7732-93,NDC,,,,inpatient,1,EA,181.05,108.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,146.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,153.89,percent of total billed charges,,,85,,153.89,percent of total billed charges,,,49,,88.71,percent of total billed charges,,,90,,162.95,percent of total billed charges,,,,,,,no IP contract,,80,,144.84,percent of total billed charges,,,,,,,no IP contract,,50,,90.53,percent of total billed charges,,,,,,no IP contract,,,78,,141.22,percent of total billed charges,,,70,,126.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,88.71,3324,
00378-7970-55 - ipratropium 500 mcg/2.5 mL Soln,00378-7970-55,NDC,,,,inpatient,2.5,ML,27.75,16.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.59,percent of total billed charges,,,85,,23.59,percent of total billed charges,,,49,,13.6,percent of total billed charges,,,90,,24.98,percent of total billed charges,,,,,,,no IP contract,,80,,22.2,percent of total billed charges,,,,,,,no IP contract,,50,,13.88,percent of total billed charges,,,,,,no IP contract,,,78,,21.65,percent of total billed charges,,,70,,19.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.6,3324,
00378-8082-20 - tretinoin topical 0.025% Cream,00378-8082-20,NDC,,,,inpatient,1,UN,1072.15,643.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,868.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,911.33,percent of total billed charges,,,85,,911.33,percent of total billed charges,,,49,,525.35,percent of total billed charges,,,90,,964.94,percent of total billed charges,,,,,,,no IP contract,,80,,857.72,percent of total billed charges,,,,,,,no IP contract,,50,,536.08,percent of total billed charges,,,,,,no IP contract,,,78,,836.28,percent of total billed charges,,,70,,750.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,525.35,3324,
00378-8117-45 - doxepin topical 5% Cream,00378-8117-45,NDC,,,,inpatient,1,UN,6025.55,3615.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4880.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5121.72,percent of total billed charges,,,85,,5121.72,percent of total billed charges,,,49,,2952.52,percent of total billed charges,,,90,,5423,percent of total billed charges,,,,,,,no IP contract,,80,,4820.44,percent of total billed charges,,,,,,,no IP contract,,50,,3012.78,percent of total billed charges,,,,,,no IP contract,,,78,,4699.93,percent of total billed charges,,,70,,4217.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,5423,
00378-8270-55 - albuterol 2.5 mg/3 mL (0.083%) Soln,00378-8270-55,NDC,,,,inpatient,3,ML,22.2,13.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.87,percent of total billed charges,,,85,,18.87,percent of total billed charges,,,49,,10.88,percent of total billed charges,,,90,,19.98,percent of total billed charges,,,,,,,no IP contract,,80,,17.76,percent of total billed charges,,,,,,,no IP contract,,50,,11.1,percent of total billed charges,,,,,,no IP contract,,,78,,17.32,percent of total billed charges,,,70,,15.54,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.88,3324,
00378-9102-16 - nitroglycerin 0.1 mg/hr Patch,00378-9102-16,NDC,,,,inpatient,1,UN,22.4,13.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.04,percent of total billed charges,,,85,,19.04,percent of total billed charges,,,49,,10.98,percent of total billed charges,,,90,,20.16,percent of total billed charges,,,,,,,no IP contract,,80,,17.92,percent of total billed charges,,,,,,,no IP contract,,50,,11.2,percent of total billed charges,,,,,,no IP contract,,,78,,17.47,percent of total billed charges,,,70,,15.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.98,3324,
00378-9102-93 - nitroglycerin 0.1 mg/hr ER Patch,00378-9102-93,NDC,,,,inpatient,1,UN,22.4,13.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.04,percent of total billed charges,,,85,,19.04,percent of total billed charges,,,49,,10.98,percent of total billed charges,,,90,,20.16,percent of total billed charges,,,,,,,no IP contract,,80,,17.92,percent of total billed charges,,,,,,,no IP contract,,50,,11.2,percent of total billed charges,,,,,,no IP contract,,,78,,17.47,percent of total billed charges,,,70,,15.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.98,3324,
00378-9104-93 - nitroglycerin 0.2 mg/hr ER Fi,00378-9104-93,NDC,,,,inpatient,1,EA,22.7,13.62,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.3,percent of total billed charges,,,85,,19.3,percent of total billed charges,,,49,,11.12,percent of total billed charges,,,90,,20.43,percent of total billed charges,,,,,,,no IP contract,,80,,18.16,percent of total billed charges,,,,,,,no IP contract,,50,,11.35,percent of total billed charges,,,,,,no IP contract,,,78,,17.71,percent of total billed charges,,,70,,15.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.12,3324,
00378-9112-93 - nitroglycerin 0.4 mg/hr ER Patch,00378-9112-93,NDC,,,,inpatient,1,UN,24.65,14.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.95,percent of total billed charges,,,85,,20.95,percent of total billed charges,,,49,,12.08,percent of total billed charges,,,90,,22.19,percent of total billed charges,,,,,,,no IP contract,,80,,19.72,percent of total billed charges,,,,,,,no IP contract,,50,,12.33,percent of total billed charges,,,,,,no IP contract,,,78,,19.23,percent of total billed charges,,,70,,17.26,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.08,3324,
00378-9119-98 - fentanyl 12 mcg/hr ER Fi,00378-9119-98,NDC,,,,inpatient,1,UN,174.5,104.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,141.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,148.33,percent of total billed charges,,,85,,148.33,percent of total billed charges,,,49,,85.51,percent of total billed charges,,,90,,157.05,percent of total billed charges,,,,,,,no IP contract,,80,,139.6,percent of total billed charges,,,,,,,no IP contract,,50,,87.25,percent of total billed charges,,,,,,no IP contract,,,78,,136.11,percent of total billed charges,,,70,,122.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,85.51,3324,
00378-9121-98 - fentanyl 25 mcg/hr ER Fi,00378-9121-98,NDC,,,,inpatient,1,UN,125.15,75.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,101.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,106.38,percent of total billed charges,,,85,,106.38,percent of total billed charges,,,49,,61.32,percent of total billed charges,,,90,,112.64,percent of total billed charges,,,,,,,no IP contract,,80,,100.12,percent of total billed charges,,,,,,,no IP contract,,50,,62.58,percent of total billed charges,,,,,,no IP contract,,,78,,97.62,percent of total billed charges,,,70,,87.61,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,61.32,3324,
00378-9122-98 - fentanyl 50 mcg/hr ER Fi,00378-9122-98,NDC,,,,inpatient,1,UN,225,135,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,182.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,191.25,percent of total billed charges,,,85,,191.25,percent of total billed charges,,,49,,110.25,percent of total billed charges,,,90,,202.5,percent of total billed charges,,,,,,,no IP contract,,80,,180,percent of total billed charges,,,,,,,no IP contract,,50,,112.5,percent of total billed charges,,,,,,no IP contract,,,78,,175.5,percent of total billed charges,,,70,,157.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,110.25,3324,
00378-9123-98 - fentanyl 75 mcg/hr ER Fi,00378-9123-98,NDC,,,,inpatient,1,UN,339.05,203.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,274.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,288.19,percent of total billed charges,,,85,,288.19,percent of total billed charges,,,49,,166.13,percent of total billed charges,,,90,,305.15,percent of total billed charges,,,,,,,no IP contract,,80,,271.24,percent of total billed charges,,,,,,,no IP contract,,50,,169.53,percent of total billed charges,,,,,,no IP contract,,,78,,264.46,percent of total billed charges,,,70,,237.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,166.13,3324,
00378-9124-98 - fentanyl 100 mcg/hr ER Fi,00378-9124-98,NDC,,,,inpatient,1,UN,449.9,269.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,364.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,382.42,percent of total billed charges,,,85,,382.42,percent of total billed charges,,,49,,220.45,percent of total billed charges,,,90,,404.91,percent of total billed charges,,,,,,,no IP contract,,80,,359.92,percent of total billed charges,,,,,,,no IP contract,,50,,224.95,percent of total billed charges,,,,,,no IP contract,,,78,,350.92,percent of total billed charges,,,70,,314.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,220.45,3324,
00378-9125-98 - fentaNYL 37.5 mcg/hr ER Fi,00378-9125-98,NDC,,,,inpatient,1,EA,549.45,329.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,445.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,467.03,percent of total billed charges,,,85,,467.03,percent of total billed charges,,,49,,269.23,percent of total billed charges,,,90,,494.51,percent of total billed charges,,,,,,,no IP contract,,80,,439.56,percent of total billed charges,,,,,,,no IP contract,,50,,274.73,percent of total billed charges,,,,,,no IP contract,,,78,,428.57,percent of total billed charges,,,70,,384.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,269.23,3324,
00378-9671-93 - albuterol-ipratropium 2.5 mg-0.5 mg/3 mL Soln,00378-9671-93,NDC,,,,inpatient,3,ML,28.45,17.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.18,percent of total billed charges,,,85,,24.18,percent of total billed charges,,,49,,13.94,percent of total billed charges,,,90,,25.61,percent of total billed charges,,,,,,,no IP contract,,80,,22.76,percent of total billed charges,,,,,,,no IP contract,,50,,14.23,percent of total billed charges,,,,,,no IP contract,,,78,,22.19,percent of total billed charges,,,70,,19.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.94,3324,
00378-9681-44 - levalbuterol 0.63 mg/3 mL Soln,00378-9681-44,NDC,,,,inpatient,3,ML,65.2,39.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,52.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,55.42,percent of total billed charges,,,85,,55.42,percent of total billed charges,,,49,,31.95,percent of total billed charges,,,90,,58.68,percent of total billed charges,,,,,,,no IP contract,,80,,52.16,percent of total billed charges,,,,,,,no IP contract,,50,,32.6,percent of total billed charges,,,,,,no IP contract,,,78,,50.86,percent of total billed charges,,,70,,45.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.95,3324,
00378-9682-44 - levalbuterol 1.25 mg/3 mL Soln,00378-9682-44,NDC,,,,inpatient,3,ML,65.2,39.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,52.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,55.42,percent of total billed charges,,,85,,55.42,percent of total billed charges,,,49,,31.95,percent of total billed charges,,,90,,58.68,percent of total billed charges,,,,,,,no IP contract,,80,,52.16,percent of total billed charges,,,,,,,no IP contract,,50,,32.6,percent of total billed charges,,,,,,no IP contract,,,78,,50.86,percent of total billed charges,,,70,,45.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.95,3324,
00386-0001-03 - ethyl chloride Topical 100% Spray,00386-0001-03,NDC,,,,inpatient,1,UN,280.35,168.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,227.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,238.3,percent of total billed charges,,,85,,238.3,percent of total billed charges,,,49,,137.37,percent of total billed charges,,,90,,252.32,percent of total billed charges,,,,,,,no IP contract,,80,,224.28,percent of total billed charges,,,,,,,no IP contract,,50,,140.18,percent of total billed charges,,,,,,no IP contract,,,78,,218.67,percent of total billed charges,,,70,,196.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,137.37,3324,
00386-0009-75 - saliva substitutes - Spray,00386-0009-75,NDC,,,,inpatient,1,UN,90.45,54.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,73.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,76.88,percent of total billed charges,,,85,,76.88,percent of total billed charges,,,49,,44.32,percent of total billed charges,,,90,,81.41,percent of total billed charges,,,,,,,no IP contract,,80,,72.36,percent of total billed charges,,,,,,,no IP contract,,50,,45.23,percent of total billed charges,,,,,,no IP contract,,,78,,70.55,percent of total billed charges,,,70,,63.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,44.32,3324,
00394-0499-02 - zinc sulfate 220 mg Cap,00394-0499-02,NDC,,,,inpatient,1,EA,4.4,2.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.74,percent of total billed charges,,,85,,3.74,percent of total billed charges,,,49,,2.16,percent of total billed charges,,,90,,3.96,percent of total billed charges,,,,,,,no IP contract,,80,,3.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.2,percent of total billed charges,,,,,,no IP contract,,,78,,3.43,percent of total billed charges,,,70,,3.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.16,3324,
00406-0123-01 - acetaminophen-hydrocodone 325 mg-5 mg Tab,00406-0123-01,NDC,,,,inpatient,1,EA,11.15,6.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.48,percent of total billed charges,,,85,,9.48,percent of total billed charges,,,49,,5.46,percent of total billed charges,,,90,,10.04,percent of total billed charges,,,,,,,no IP contract,,80,,8.92,percent of total billed charges,,,,,,,no IP contract,,50,,5.58,percent of total billed charges,,,,,,no IP contract,,,78,,8.7,percent of total billed charges,,,70,,7.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.46,3324,
00406-0123-62 - acetaminophen-hydrocodone 1 tab(s) Tab,00406-0123-62,NDC,,,,inpatient,1,EA,12.1,7.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.29,percent of total billed charges,,,85,,10.29,percent of total billed charges,,,49,,5.93,percent of total billed charges,,,90,,10.89,percent of total billed charges,,,,,,,no IP contract,,80,,9.68,percent of total billed charges,,,,,,,no IP contract,,50,,6.05,percent of total billed charges,,,,,,no IP contract,,,78,,9.44,percent of total billed charges,,,70,,8.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.93,3324,
00406-0125-05 - acetaminophen-hydrocodone 325 mg-10 mg Tab,00406-0125-05,NDC,,,,inpatient,1,EA,13.6,8.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.56,percent of total billed charges,,,85,,11.56,percent of total billed charges,,,49,,6.66,percent of total billed charges,,,90,,12.24,percent of total billed charges,,,,,,,no IP contract,,80,,10.88,percent of total billed charges,,,,,,,no IP contract,,50,,6.8,percent of total billed charges,,,,,,no IP contract,,,78,,10.61,percent of total billed charges,,,70,,9.52,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.66,3324,
00406-0125-62 - APAP-HYDROcodone 325 mg-10 mg Tab,00406-0125-62,NDC,,,,inpatient,1,EA,15.5,9.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.18,percent of total billed charges,,,85,,13.18,percent of total billed charges,,,49,,7.6,percent of total billed charges,,,90,,13.95,percent of total billed charges,,,,,,,no IP contract,,80,,12.4,percent of total billed charges,,,,,,,no IP contract,,50,,7.75,percent of total billed charges,,,,,,no IP contract,,,78,,12.09,percent of total billed charges,,,70,,10.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.6,3324,
00406-0484-62 - acetaminophen-codeine 300 mg-30 mg Tab,00406-0484-62,NDC,,,,inpatient,1,EA,35.5,21.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.18,percent of total billed charges,,,85,,30.18,percent of total billed charges,,,49,,17.4,percent of total billed charges,,,90,,31.95,percent of total billed charges,,,,,,,no IP contract,,80,,28.4,percent of total billed charges,,,,,,,no IP contract,,50,,17.75,percent of total billed charges,,,,,,no IP contract,,,78,,27.69,percent of total billed charges,,,70,,24.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.4,3324,
00406-0512-01 - acetaminophen-oxycodone 325 mg-5 mg Tab,00406-0512-01,NDC,,,,inpatient,1,EA,8,4.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.8,percent of total billed charges,,,85,,6.8,percent of total billed charges,,,49,,3.92,percent of total billed charges,,,90,,7.2,percent of total billed charges,,,,,,,no IP contract,,80,,6.4,percent of total billed charges,,,,,,,no IP contract,,50,,4,percent of total billed charges,,,,,,no IP contract,,,78,,6.24,percent of total billed charges,,,70,,5.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.92,3324,
00406-0512-23 - acetaminophen-oxycodone 325 mg-5 mg Tab,00406-0512-23,NDC,,,,inpatient,1,EA,8.15,4.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.93,percent of total billed charges,,,85,,6.93,percent of total billed charges,,,49,,3.99,percent of total billed charges,,,90,,7.34,percent of total billed charges,,,,,,,no IP contract,,80,,6.52,percent of total billed charges,,,,,,,no IP contract,,50,,4.08,percent of total billed charges,,,,,,no IP contract,,,78,,6.36,percent of total billed charges,,,70,,5.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.99,3324,
00406-0512-62 - acetaminophen-oxycodone 325 mg-5 mg Tab,00406-0512-62,NDC,,,,inpatient,1,EA,8.15,4.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.93,percent of total billed charges,,,85,,6.93,percent of total billed charges,,,49,,3.99,percent of total billed charges,,,90,,7.34,percent of total billed charges,,,,,,,no IP contract,,80,,6.52,percent of total billed charges,,,,,,,no IP contract,,50,,4.08,percent of total billed charges,,,,,,no IP contract,,,78,,6.36,percent of total billed charges,,,70,,5.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.99,3324,
00406-0552-01 - oxycodone 5 mg Tab,00406-0552-01,NDC,,,,inpatient,1,EA,9.4,5.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.99,percent of total billed charges,,,85,,7.99,percent of total billed charges,,,49,,4.61,percent of total billed charges,,,90,,8.46,percent of total billed charges,,,,,,,no IP contract,,80,,7.52,percent of total billed charges,,,,,,,no IP contract,,50,,4.7,percent of total billed charges,,,,,,no IP contract,,,78,,7.33,percent of total billed charges,,,70,,6.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.61,3324,
00406-0552-62 - oxycodone 5 mg Tab,00406-0552-62,NDC,,,,inpatient,1,EA,9.9,5.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.42,percent of total billed charges,,,85,,8.42,percent of total billed charges,,,49,,4.85,percent of total billed charges,,,90,,8.91,percent of total billed charges,,,,,,,no IP contract,,80,,7.92,percent of total billed charges,,,,,,,no IP contract,,50,,4.95,percent of total billed charges,,,,,,no IP contract,,,78,,7.72,percent of total billed charges,,,70,,6.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.85,3324,
00406-0830-12 - morphine 20 mg/mL Conc,00406-0830-12,NDC,,,,inpatient,0.1,ML,10.25,6.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.71,percent of total billed charges,,,85,,8.71,percent of total billed charges,,,49,,5.02,percent of total billed charges,,,90,,9.23,percent of total billed charges,,,,,,,no IP contract,,80,,8.2,percent of total billed charges,,,,,,,no IP contract,,50,,5.13,percent of total billed charges,,,,,,no IP contract,,,78,,8,percent of total billed charges,,,70,,7.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.02,3324,
00406-1009-01 - oxymorphone 5 mg Tab,00406-1009-01,NDC,,,,inpatient,1,EA,32.5,19.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,26.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,27.63,percent of total billed charges,,,85,,27.63,percent of total billed charges,,,49,,15.93,percent of total billed charges,,,90,,29.25,percent of total billed charges,,,,,,,no IP contract,,80,,26,percent of total billed charges,,,,,,,no IP contract,,50,,16.25,percent of total billed charges,,,,,,no IP contract,,,78,,25.35,percent of total billed charges,,,70,,22.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.93,3324,
00406-1142-01 - methylphenidate 5 mg Tab,00406-1142-01,NDC,,,,inpatient,1,EA,11.5,6.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.78,percent of total billed charges,,,85,,9.78,percent of total billed charges,,,49,,5.64,percent of total billed charges,,,90,,10.35,percent of total billed charges,,,,,,,no IP contract,,80,,9.2,percent of total billed charges,,,,,,,no IP contract,,50,,5.75,percent of total billed charges,,,,,,no IP contract,,,78,,8.97,percent of total billed charges,,,70,,8.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.64,3324,
00406-1236-01 - atropine-diphenoxylate 0.025 mg-2.5 mg Tab,00406-1236-01,NDC,,,,inpatient,1,EA,11.25,6.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.56,percent of total billed charges,,,85,,9.56,percent of total billed charges,,,49,,5.51,percent of total billed charges,,,90,,10.13,percent of total billed charges,,,,,,,no IP contract,,80,,9,percent of total billed charges,,,,,,,no IP contract,,50,,5.63,percent of total billed charges,,,,,,no IP contract,,,78,,8.78,percent of total billed charges,,,70,,7.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.51,3324,
00406-3243-01 - hydromorphone 2 mg Tab,00406-3243-01,NDC,,,,inpatient,1,EA,8.5,5.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.23,percent of total billed charges,,,85,,7.23,percent of total billed charges,,,49,,4.17,percent of total billed charges,,,90,,7.65,percent of total billed charges,,,,,,,no IP contract,,80,,6.8,percent of total billed charges,,,,,,,no IP contract,,50,,4.25,percent of total billed charges,,,,,,no IP contract,,,78,,6.63,percent of total billed charges,,,70,,5.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.17,3324,
00406-3244-01 - hydromorphone 4 mg Tab,00406-3244-01,NDC,,,,inpatient,1,EA,10.5,6.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.93,percent of total billed charges,,,85,,8.93,percent of total billed charges,,,49,,5.15,percent of total billed charges,,,90,,9.45,percent of total billed charges,,,,,,,no IP contract,,80,,8.4,percent of total billed charges,,,,,,,no IP contract,,50,,5.25,percent of total billed charges,,,,,,no IP contract,,,78,,8.19,percent of total billed charges,,,70,,7.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.15,3324,
00406-3249-01 - hydromorphone 8 mg Tab,00406-3249-01,NDC,,,,inpatient,1,EA,14.8,8.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.58,percent of total billed charges,,,85,,12.58,percent of total billed charges,,,49,,7.25,percent of total billed charges,,,90,,13.32,percent of total billed charges,,,,,,,no IP contract,,80,,11.84,percent of total billed charges,,,,,,,no IP contract,,50,,7.4,percent of total billed charges,,,,,,no IP contract,,,78,,11.54,percent of total billed charges,,,70,,10.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.25,3324,
00406-5771-62 - methadone 10 mg Tab,00406-5771-62,NDC,,,,inpatient,1,EA,9.75,5.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.29,percent of total billed charges,,,85,,8.29,percent of total billed charges,,,49,,4.78,percent of total billed charges,,,90,,8.78,percent of total billed charges,,,,,,,no IP contract,,80,,7.8,percent of total billed charges,,,,,,,no IP contract,,50,,4.88,percent of total billed charges,,,,,,no IP contract,,,78,,7.61,percent of total billed charges,,,70,,6.83,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.78,3324,
00406-8003-30 - morphine 20 mg/mL Conc,00406-8003-30,NDC,,,,inpatient,0.1,ML,11.65,6.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.9,percent of total billed charges,,,85,,9.9,percent of total billed charges,,,49,,5.71,percent of total billed charges,,,90,,10.49,percent of total billed charges,,,,,,,no IP contract,,80,,9.32,percent of total billed charges,,,,,,,no IP contract,,50,,5.83,percent of total billed charges,,,,,,no IP contract,,,78,,9.09,percent of total billed charges,,,70,,8.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.71,3324,
00406-8315-62 - morphine 15 mg ER Ta,00406-8315-62,NDC,,,,inpatient,1,EA,21,12.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.85,percent of total billed charges,,,85,,17.85,percent of total billed charges,,,49,,10.29,percent of total billed charges,,,90,,18.9,percent of total billed charges,,,,,,,no IP contract,,80,,16.8,percent of total billed charges,,,,,,,no IP contract,,50,,10.5,percent of total billed charges,,,,,,no IP contract,,,78,,16.38,percent of total billed charges,,,70,,14.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.29,3324,
00406-8315-62 - morphine 15 mg/8 hr ER Ta,00406-8315-62,NDC,,,,inpatient,1,EA,21,12.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.85,percent of total billed charges,,,85,,17.85,percent of total billed charges,,,49,,10.29,percent of total billed charges,,,90,,18.9,percent of total billed charges,,,,,,,no IP contract,,80,,16.8,percent of total billed charges,,,,,,,no IP contract,,50,,10.5,percent of total billed charges,,,,,,no IP contract,,,78,,16.38,percent of total billed charges,,,70,,14.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.29,3324,
00406-8330-62 - morphine 30 mg ER Ta,00406-8330-62,NDC,,,,inpatient,1,EA,33.6,20.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.56,percent of total billed charges,,,85,,28.56,percent of total billed charges,,,49,,16.46,percent of total billed charges,,,90,,30.24,percent of total billed charges,,,,,,,no IP contract,,80,,26.88,percent of total billed charges,,,,,,,no IP contract,,50,,16.8,percent of total billed charges,,,,,,no IP contract,,,78,,26.21,percent of total billed charges,,,70,,23.52,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.46,3324,
00406-8390-62 - morphine 100 mg/12 hours ER Ta,00406-8390-62,NDC,,,,inpatient,1,EA,46.35,27.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,37.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,39.4,percent of total billed charges,,,85,,39.4,percent of total billed charges,,,49,,22.71,percent of total billed charges,,,90,,41.72,percent of total billed charges,,,,,,,no IP contract,,80,,37.08,percent of total billed charges,,,,,,,no IP contract,,50,,23.18,percent of total billed charges,,,,,,no IP contract,,,78,,36.15,percent of total billed charges,,,70,,32.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.71,3324,
00406-8515-01 - oxycodone 15 mg Tab,00406-8515-01,NDC,,,,inpatient,1,EA,11.75,7.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.99,percent of total billed charges,,,85,,9.99,percent of total billed charges,,,49,,5.76,percent of total billed charges,,,90,,10.58,percent of total billed charges,,,,,,,no IP contract,,80,,9.4,percent of total billed charges,,,,,,,no IP contract,,50,,5.88,percent of total billed charges,,,,,,no IP contract,,,78,,9.17,percent of total billed charges,,,70,,8.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.76,3324,
oxyCODONE 15 mg Tab,00406-8515-62,NDC,,,,inpatient,1,EA,25.15,15.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.38,percent of total billed charges,,,85,,21.38,percent of total billed charges,,,49,,12.32,percent of total billed charges,,,90,,22.64,percent of total billed charges,,,,,,,no IP contract,,80,,20.12,percent of total billed charges,,,,,,,no IP contract,,50,,12.58,percent of total billed charges,,,,,,no IP contract,,,78,,19.62,percent of total billed charges,,,70,,17.61,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.32,3324,
00406-8556-05 - oxyCODONE 5 mg/5 mL Soln,00406-8556-05,NDC,,,,inpatient,1,ML,7.85,4.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.67,percent of total billed charges,,,85,,6.67,percent of total billed charges,,,49,,3.85,percent of total billed charges,,,90,,7.07,percent of total billed charges,,,,,,,no IP contract,,80,,6.28,percent of total billed charges,,,,,,,no IP contract,,50,,3.93,percent of total billed charges,,,,,,no IP contract,,,78,,6.12,percent of total billed charges,,,70,,5.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.85,3324,
00406-8891-01 - amphetamine-dextroamphetamine 5 mg Tab,00406-8891-01,NDC,,,,inpatient,1,EA,19.65,11.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.7,percent of total billed charges,,,85,,16.7,percent of total billed charges,,,49,,9.63,percent of total billed charges,,,90,,17.69,percent of total billed charges,,,,,,,no IP contract,,80,,15.72,percent of total billed charges,,,,,,,no IP contract,,50,,9.83,percent of total billed charges,,,,,,no IP contract,,,78,,15.33,percent of total billed charges,,,70,,13.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.63,3324,
00406-8952-01 - amphetamine-dextroamphetamine 10 mg ER Ca,00406-8952-01,NDC,,,,inpatient,1,EA,56.5,33.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,45.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,48.03,percent of total billed charges,,,85,,48.03,percent of total billed charges,,,49,,27.69,percent of total billed charges,,,90,,50.85,percent of total billed charges,,,,,,,no IP contract,,80,,45.2,percent of total billed charges,,,,,,,no IP contract,,50,,28.25,percent of total billed charges,,,,,,no IP contract,,,78,,44.07,percent of total billed charges,,,70,,39.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.69,3324,
00406-8958-01 - dextroamphetamine 5 mg Tab,00406-8958-01,NDC,,,,inpatient,1,EA,7.75,4.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.59,percent of total billed charges,,,85,,6.59,percent of total billed charges,,,49,,3.8,percent of total billed charges,,,90,,6.98,percent of total billed charges,,,,,,,no IP contract,,80,,6.2,percent of total billed charges,,,,,,,no IP contract,,50,,3.88,percent of total billed charges,,,,,,no IP contract,,,78,,6.05,percent of total billed charges,,,70,,5.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.8,3324,
00406-9000-76 - fentaNYL 100 mcg/hr ER Fi,00406-9000-76,NDC,,,,inpatient,1,UN,449.9,269.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,364.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,382.42,percent of total billed charges,,,85,,382.42,percent of total billed charges,,,49,,220.45,percent of total billed charges,,,90,,404.91,percent of total billed charges,,,,,,,no IP contract,,80,,359.92,percent of total billed charges,,,,,,,no IP contract,,50,,224.95,percent of total billed charges,,,,,,no IP contract,,,78,,350.92,percent of total billed charges,,,70,,314.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,220.45,3324,
00406-9012-76 - fentaNYL 12 mcg/hr ER Fi,00406-9012-76,NDC,,,,inpatient,1,UN,176.95,106.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,143.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,150.41,percent of total billed charges,,,85,,150.41,percent of total billed charges,,,49,,86.71,percent of total billed charges,,,90,,159.26,percent of total billed charges,,,,,,,no IP contract,,80,,141.56,percent of total billed charges,,,,,,,no IP contract,,50,,88.48,percent of total billed charges,,,,,,no IP contract,,,78,,138.02,percent of total billed charges,,,70,,123.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,86.71,3324,
00406-9025-76 - fentanyl 25 mcg/hr ER Fi,00406-9025-76,NDC,,,,inpatient,1,UN,125.55,75.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,101.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,106.72,percent of total billed charges,,,85,,106.72,percent of total billed charges,,,49,,61.52,percent of total billed charges,,,90,,113,percent of total billed charges,,,,,,,no IP contract,,80,,100.44,percent of total billed charges,,,,,,,no IP contract,,50,,62.78,percent of total billed charges,,,,,,no IP contract,,,78,,97.93,percent of total billed charges,,,70,,87.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,61.52,3324,
00406-9050-76 - fentanyl 50 mcg/hr ER Fi,00406-9050-76,NDC,,,,inpatient,1,UN,216.4,129.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,175.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,183.94,percent of total billed charges,,,85,,183.94,percent of total billed charges,,,49,,106.04,percent of total billed charges,,,90,,194.76,percent of total billed charges,,,,,,,no IP contract,,80,,173.12,percent of total billed charges,,,,,,,no IP contract,,50,,108.2,percent of total billed charges,,,,,,no IP contract,,,78,,168.79,percent of total billed charges,,,70,,151.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,106.04,3324,
00406-9100-76 - fentaNYL 100 mcg/hr ER Fi,00406-9100-76,NDC,,,,inpatient,1,UN,449.9,269.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,364.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,382.42,percent of total billed charges,,,85,,382.42,percent of total billed charges,,,49,,220.45,percent of total billed charges,,,90,,404.91,percent of total billed charges,,,,,,,no IP contract,,80,,359.92,percent of total billed charges,,,,,,,no IP contract,,50,,224.95,percent of total billed charges,,,,,,no IP contract,,,78,,350.92,percent of total billed charges,,,70,,314.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,220.45,3324,
00406-9112-76 - fentaNYL 12 mcg/hr ER Fi,00406-9112-76,NDC,,,,inpatient,1,UN,174.5,104.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,141.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,148.33,percent of total billed charges,,,85,,148.33,percent of total billed charges,,,49,,85.51,percent of total billed charges,,,90,,157.05,percent of total billed charges,,,,,,,no IP contract,,80,,139.6,percent of total billed charges,,,,,,,no IP contract,,50,,87.25,percent of total billed charges,,,,,,no IP contract,,,78,,136.11,percent of total billed charges,,,70,,122.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,85.51,3324,
00406-9125-76 - fentaNYL 25 mcg/hr ER Fi,00406-9125-76,NDC,,,,inpatient,1,UN,125.55,75.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,101.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,106.72,percent of total billed charges,,,85,,106.72,percent of total billed charges,,,49,,61.52,percent of total billed charges,,,90,,113,percent of total billed charges,,,,,,,no IP contract,,80,,100.44,percent of total billed charges,,,,,,,no IP contract,,50,,62.78,percent of total billed charges,,,,,,no IP contract,,,78,,97.93,percent of total billed charges,,,70,,87.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,61.52,3324,
00406-9150-76 - fentaNYL 50 mcg/hr ER Fi,00406-9150-76,NDC,,,,inpatient,1,UN,225,135,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,182.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,191.25,percent of total billed charges,,,85,,191.25,percent of total billed charges,,,49,,110.25,percent of total billed charges,,,90,,202.5,percent of total billed charges,,,,,,,no IP contract,,80,,180,percent of total billed charges,,,,,,,no IP contract,,50,,112.5,percent of total billed charges,,,,,,no IP contract,,,78,,175.5,percent of total billed charges,,,70,,157.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,110.25,3324,
00406-9175-76 - fentaNYL  75 mcg/hr Patch,00406-9175-76,NDC,,,,inpatient,1,UN,340.35,204.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,275.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,289.3,percent of total billed charges,,,85,,289.3,percent of total billed charges,,,49,,166.77,percent of total billed charges,,,90,,306.32,percent of total billed charges,,,,,,,no IP contract,,80,,272.28,percent of total billed charges,,,,,,,no IP contract,,50,,170.18,percent of total billed charges,,,,,,no IP contract,,,78,,265.47,percent of total billed charges,,,70,,238.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,166.77,3324,
00406-9920-01 - imipramine 10 mg Tab,00406-9920-01,NDC,,,,inpatient,1,EA,18.95,11.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.11,percent of total billed charges,,,85,,16.11,percent of total billed charges,,,49,,9.29,percent of total billed charges,,,90,,17.06,percent of total billed charges,,,,,,,no IP contract,,80,,15.16,percent of total billed charges,,,,,,,no IP contract,,50,,9.48,percent of total billed charges,,,,,,no IP contract,,,78,,14.78,percent of total billed charges,,,70,,13.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.29,3324,
00406-9960-01 - temazepam 7.5 mg Cap,00406-9960-01,NDC,,,,inpatient,1,EA,13.9,8.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.82,percent of total billed charges,,,85,,11.82,percent of total billed charges,,,49,,6.81,percent of total billed charges,,,90,,12.51,percent of total billed charges,,,,,,,no IP contract,,80,,11.12,percent of total billed charges,,,,,,,no IP contract,,50,,6.95,percent of total billed charges,,,,,,no IP contract,,,78,,10.84,percent of total billed charges,,,70,,9.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.81,3324,
temazepam 15 mg Cap,00406-9961-01,NDC,,,,inpatient,1,EA,11.65,6.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.9,percent of total billed charges,,,85,,9.9,percent of total billed charges,,,49,,5.71,percent of total billed charges,,,90,,10.49,percent of total billed charges,,,,,,,no IP contract,,80,,9.32,percent of total billed charges,,,,,,,no IP contract,,50,,5.83,percent of total billed charges,,,,,,no IP contract,,,78,,9.09,percent of total billed charges,,,70,,8.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.71,3324,
iohexol 240 mg/mL Soln,00407-1412-30,NDC,,,,inpatient,1,EA,405.55,243.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,328.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,344.72,percent of total billed charges,,,85,,344.72,percent of total billed charges,,,49,,198.72,percent of total billed charges,,,90,,365,percent of total billed charges,,,,,,,no IP contract,,80,,324.44,percent of total billed charges,,,,,,,no IP contract,,50,,202.78,percent of total billed charges,,,,,,no IP contract,,,78,,316.33,percent of total billed charges,,,70,,283.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,198.72,3324,
iohexol 300 mg/mL Soln,00407-1413-10,NDC,,,,inpatient,1,EA,483.1,289.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,391.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,410.64,percent of total billed charges,,,85,,410.64,percent of total billed charges,,,49,,236.72,percent of total billed charges,,,90,,434.79,percent of total billed charges,,,,,,,no IP contract,,80,,386.48,percent of total billed charges,,,,,,,no IP contract,,50,,241.55,percent of total billed charges,,,,,,no IP contract,,,78,,376.82,percent of total billed charges,,,70,,338.17,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,236.72,3324,
iohexol 350 mg/mL Soln,00407-1414-76,NDC,,,,inpatient,1,EA,1105.2,663.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,895.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,939.42,percent of total billed charges,,,85,,939.42,percent of total billed charges,,,49,,541.55,percent of total billed charges,,,90,,994.68,percent of total billed charges,,,,,,,no IP contract,,80,,884.16,percent of total billed charges,,,,,,,no IP contract,,50,,552.6,percent of total billed charges,,,,,,no IP contract,,,78,,862.06,percent of total billed charges,,,70,,773.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,541.55,3324,
00409-0144-11 - azithromycin 500 mg REC I,00409-0144-11,NDC,,,,inpatient,5,ML,78.85,47.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,63.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,67.02,percent of total billed charges,,,85,,67.02,percent of total billed charges,,,49,,38.64,percent of total billed charges,,,90,,70.97,percent of total billed charges,,,,,,,no IP contract,,80,,63.08,percent of total billed charges,,,,,,,no IP contract,,50,,39.43,percent of total billed charges,,,,,,no IP contract,,,78,,61.5,percent of total billed charges,,,70,,55.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,38.64,3324,
00409-0217-01 - cefepime 1 g REC I,00409-0217-01,NDC,,,,inpatient,1,EA,66.5,39.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,53.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.53,percent of total billed charges,,,85,,56.53,percent of total billed charges,,,49,,32.59,percent of total billed charges,,,90,,59.85,percent of total billed charges,,,,,,,no IP contract,,80,,53.2,percent of total billed charges,,,,,,,no IP contract,,50,,33.25,percent of total billed charges,,,,,,no IP contract,,,78,,51.87,percent of total billed charges,,,70,,46.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.59,3324,
00409-0218-01 - cefepime 2 g REC I,00409-0218-01,NDC,,,,inpatient,1,EA,169.5,101.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,137.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,144.08,percent of total billed charges,,,85,,144.08,percent of total billed charges,,,49,,83.06,percent of total billed charges,,,90,,152.55,percent of total billed charges,,,,,,,no IP contract,,80,,135.6,percent of total billed charges,,,,,,,no IP contract,,50,,84.75,percent of total billed charges,,,,,,no IP contract,,,78,,132.21,percent of total billed charges,,,70,,118.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,83.06,3324,
00409-0220-01 - cefepime 2 g REC I,00409-0220-01,NDC,,,,inpatient,1,EA,160.1,96.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,129.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,136.09,percent of total billed charges,,,85,,136.09,percent of total billed charges,,,49,,78.45,percent of total billed charges,,,90,,144.09,percent of total billed charges,,,,,,,no IP contract,,80,,128.08,percent of total billed charges,,,,,,,no IP contract,,50,,80.05,percent of total billed charges,,,,,,no IP contract,,,78,,124.88,percent of total billed charges,,,70,,112.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,78.45,3324,
00409-1151-70 - heparin 10 units/mL Soln,00409-1151-70,NDC,,,,inpatient,30,ML,21.95,13.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.66,percent of total billed charges,,,85,,18.66,percent of total billed charges,,,49,,10.76,percent of total billed charges,,,90,,19.76,percent of total billed charges,,,,,,,no IP contract,,80,,17.56,percent of total billed charges,,,,,,,no IP contract,,50,,10.98,percent of total billed charges,,,,,,no IP contract,,,78,,17.12,percent of total billed charges,,,70,,15.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.76,3324,
bupivacaine 0.25% preservative-free Soln,00409-1159-01,NDC,,,,inpatient,1,EA,28.7,17.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.4,percent of total billed charges,,,85,,24.4,percent of total billed charges,,,49,,14.06,percent of total billed charges,,,90,,25.83,percent of total billed charges,,,,,,,no IP contract,,80,,22.96,percent of total billed charges,,,,,,,no IP contract,,50,,14.35,percent of total billed charges,,,,,,no IP contract,,,78,,22.39,percent of total billed charges,,,70,,20.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.06,3324,
bupivacaine 0.25% preservative-free Soln,00409-1159-02,NDC,,,,inpatient,1,EA,21.95,13.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.66,percent of total billed charges,,,85,,18.66,percent of total billed charges,,,49,,10.76,percent of total billed charges,,,90,,19.76,percent of total billed charges,,,,,,,no IP contract,,80,,17.56,percent of total billed charges,,,,,,,no IP contract,,50,,10.98,percent of total billed charges,,,,,,no IP contract,,,78,,17.12,percent of total billed charges,,,70,,15.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.76,3324,
bupivacaine 0.25% preservative-free Soln,00409-1159-10,NDC,,,,inpatient,1,EA,24.5,14.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.83,percent of total billed charges,,,85,,20.83,percent of total billed charges,,,49,,12.01,percent of total billed charges,,,90,,22.05,percent of total billed charges,,,,,,,no IP contract,,80,,19.6,percent of total billed charges,,,,,,,no IP contract,,50,,12.25,percent of total billed charges,,,,,,no IP contract,,,78,,19.11,percent of total billed charges,,,70,,17.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.01,3324,
bupivacaine 0.5% preservative-free Soln,00409-1162-01,NDC,,,,inpatient,1,EA,32.1,19.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,27.29,percent of total billed charges,,,85,,27.29,percent of total billed charges,,,49,,15.73,percent of total billed charges,,,90,,28.89,percent of total billed charges,,,,,,,no IP contract,,80,,25.68,percent of total billed charges,,,,,,,no IP contract,,50,,16.05,percent of total billed charges,,,,,,no IP contract,,,78,,25.04,percent of total billed charges,,,70,,22.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.73,3324,
bupivacaine 0.5% preservative-free Soln,00409-1162-02,NDC,,,,inpatient,1,ML,16.9,10.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.37,percent of total billed charges,,,85,,14.37,percent of total billed charges,,,49,,8.28,percent of total billed charges,,,90,,15.21,percent of total billed charges,,,,,,,no IP contract,,80,,13.52,percent of total billed charges,,,,,,,no IP contract,,50,,8.45,percent of total billed charges,,,,,,no IP contract,,,78,,13.18,percent of total billed charges,,,70,,11.83,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.28,3324,
bupivacaine 0.5% preservative-free Soln,00409-1162-02,NDC,,,,inpatient,1,EA,16.9,10.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.37,percent of total billed charges,,,85,,14.37,percent of total billed charges,,,49,,8.28,percent of total billed charges,,,90,,15.21,percent of total billed charges,,,,,,,no IP contract,,80,,13.52,percent of total billed charges,,,,,,,no IP contract,,50,,8.45,percent of total billed charges,,,,,,no IP contract,,,78,,13.18,percent of total billed charges,,,70,,11.83,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.28,3324,
BUPivacaine 0.5% preservative-free Soln,00409-1162-10,NDC,,,,inpatient,1,EA,29.55,17.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.12,percent of total billed charges,,,85,,25.12,percent of total billed charges,,,49,,14.48,percent of total billed charges,,,90,,26.6,percent of total billed charges,,,,,,,no IP contract,,80,,23.64,percent of total billed charges,,,,,,,no IP contract,,50,,14.78,percent of total billed charges,,,,,,no IP contract,,,78,,23.05,percent of total billed charges,,,70,,20.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.48,3324,
00409-1207-03 - gentamicin 40 mg/mL Soln,00409-1207-03,NDC,,,,inpatient,1,ML,81.45,48.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,65.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,69.23,percent of total billed charges,,,85,,69.23,percent of total billed charges,,,49,,39.91,percent of total billed charges,,,90,,73.31,percent of total billed charges,,,,,,,no IP contract,,80,,65.16,percent of total billed charges,,,,,,,no IP contract,,50,,40.73,percent of total billed charges,,,,,,no IP contract,,,78,,63.53,percent of total billed charges,,,70,,57.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,39.91,3324,
00409-1207-25 - gentamicin 40 mg/mL Soln,00409-1207-25,NDC,,,,inpatient,1,ML,81.45,48.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,65.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,69.23,percent of total billed charges,,,85,,69.23,percent of total billed charges,,,49,,39.91,percent of total billed charges,,,90,,73.31,percent of total billed charges,,,,,,,no IP contract,,80,,65.16,percent of total billed charges,,,,,,,no IP contract,,50,,40.73,percent of total billed charges,,,,,,no IP contract,,,78,,63.53,percent of total billed charges,,,70,,57.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,39.91,3324,
00409-1215-01 - naloxone 0.4 mg/mL Soln,00409-1215-01,NDC,,,,inpatient,1,ML,162.75,97.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,131.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,138.34,percent of total billed charges,,,85,,138.34,percent of total billed charges,,,49,,79.75,percent of total billed charges,,,90,,146.48,percent of total billed charges,,,,,,,no IP contract,,80,,130.2,percent of total billed charges,,,,,,,no IP contract,,50,,81.38,percent of total billed charges,,,,,,no IP contract,,,78,,126.95,percent of total billed charges,,,70,,113.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,79.75,3324,
00409-1323-05 - lidocaine 2% preservative-free Soln,00409-1323-05,NDC,,,,inpatient,1,ML,40.5,24.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34.43,percent of total billed charges,,,85,,34.43,percent of total billed charges,,,49,,19.85,percent of total billed charges,,,90,,36.45,percent of total billed charges,,,,,,,no IP contract,,80,,32.4,percent of total billed charges,,,,,,,no IP contract,,50,,20.25,percent of total billed charges,,,,,,no IP contract,,,78,,31.59,percent of total billed charges,,,70,,28.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.85,3324,
00409-1330-01 - doxercalciferol 2 mcg/mL Soln,00409-1330-01,NDC,,,,inpatient,2,ML,49.8,29.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,40.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,42.33,percent of total billed charges,,,85,,42.33,percent of total billed charges,,,49,,24.4,percent of total billed charges,,,90,,44.82,percent of total billed charges,,,,,,,no IP contract,,80,,39.84,percent of total billed charges,,,,,,,no IP contract,,50,,24.9,percent of total billed charges,,,,,,no IP contract,,,78,,38.84,percent of total billed charges,,,70,,34.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.4,3324,
00409-1391-22 - meropenem 1000 mg REC I,00409-1391-22,NDC,,,,inpatient,1,EA,282.15,169.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,228.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,239.83,percent of total billed charges,,,85,,239.83,percent of total billed charges,,,49,,138.25,percent of total billed charges,,,90,,253.94,percent of total billed charges,,,,,,,no IP contract,,80,,225.72,percent of total billed charges,,,,,,,no IP contract,,50,,141.08,percent of total billed charges,,,,,,no IP contract,,,78,,220.08,percent of total billed charges,,,70,,197.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,138.25,3324,
00409-1412-10 - bumetanide 0.25 mg/mL Soln,00409-1412-10,NDC,,,,inpatient,1,ML,48.1,28.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,38.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,40.89,percent of total billed charges,,,85,,40.89,percent of total billed charges,,,49,,23.57,percent of total billed charges,,,90,,43.29,percent of total billed charges,,,,,,,no IP contract,,80,,38.48,percent of total billed charges,,,,,,,no IP contract,,50,,24.05,percent of total billed charges,,,,,,no IP contract,,,78,,37.52,percent of total billed charges,,,70,,33.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.57,3324,
00409-1560-10 - bupivacaine 0.5% preservative-free Soln,00409-1560-10,NDC,,,,inpatient,1,UN,33.75,20.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.69,percent of total billed charges,,,85,,28.69,percent of total billed charges,,,49,,16.54,percent of total billed charges,,,90,,30.38,percent of total billed charges,,,,,,,no IP contract,,80,,27,percent of total billed charges,,,,,,,no IP contract,,50,,16.88,percent of total billed charges,,,,,,no IP contract,,,78,,26.33,percent of total billed charges,,,70,,23.63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.54,3324,
00409-1560-10 - bupivacaine 0.5% Soln,00409-1560-10,NDC,,,,inpatient,1,UN,33.75,20.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.69,percent of total billed charges,,,85,,28.69,percent of total billed charges,,,49,,16.54,percent of total billed charges,,,90,,30.38,percent of total billed charges,,,,,,,no IP contract,,80,,27,percent of total billed charges,,,,,,,no IP contract,,50,,16.88,percent of total billed charges,,,,,,no IP contract,,,78,,26.33,percent of total billed charges,,,70,,23.63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.54,3324,
00409-1631-10 - calcium chloride 100 mg/mL Soln,00409-1631-10,NDC,,,,inpatient,1,ML,11.35,6.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.65,percent of total billed charges,,,85,,9.65,percent of total billed charges,,,49,,5.56,percent of total billed charges,,,90,,10.22,percent of total billed charges,,,,,,,no IP contract,,80,,9.08,percent of total billed charges,,,,,,,no IP contract,,50,,5.68,percent of total billed charges,,,,,,no IP contract,,,78,,8.85,percent of total billed charges,,,70,,7.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.56,3324,
00409-1754-10 - magnesium sulfate 50% Soln,00409-1754-10,NDC,,,,inpatient,1,ML,12.8,7.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.88,percent of total billed charges,,,85,,10.88,percent of total billed charges,,,49,,6.27,percent of total billed charges,,,90,,11.52,percent of total billed charges,,,,,,,no IP contract,,80,,10.24,percent of total billed charges,,,,,,,no IP contract,,50,,6.4,percent of total billed charges,,,,,,no IP contract,,,78,,9.98,percent of total billed charges,,,70,,8.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.27,3324,
00409-1778-35 - metoprolol 1 mg/mL Soln,00409-1778-35,NDC,,,,inpatient,5,ML,48.1,28.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,38.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,40.89,percent of total billed charges,,,85,,40.89,percent of total billed charges,,,49,,23.57,percent of total billed charges,,,90,,43.29,percent of total billed charges,,,,,,,no IP contract,,80,,38.48,percent of total billed charges,,,,,,,no IP contract,,50,,24.05,percent of total billed charges,,,,,,no IP contract,,,78,,37.52,percent of total billed charges,,,70,,33.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.57,3324,
00409-2016-10 - metoprolol 1 mg/mL Soln,00409-2016-10,NDC,,,,inpatient,5,ML,20.3,12.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.26,percent of total billed charges,,,85,,17.26,percent of total billed charges,,,49,,9.95,percent of total billed charges,,,90,,18.27,percent of total billed charges,,,,,,,no IP contract,,80,,16.24,percent of total billed charges,,,,,,,no IP contract,,50,,10.15,percent of total billed charges,,,,,,no IP contract,,,78,,15.83,percent of total billed charges,,,70,,14.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.95,3324,
00409-2267-25 - labetalol 5 mg/mL Soln,00409-2267-25,NDC,,,,inpatient,1,ML,10.85,6.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.22,percent of total billed charges,,,85,,9.22,percent of total billed charges,,,49,,5.32,percent of total billed charges,,,90,,9.77,percent of total billed charges,,,,,,,no IP contract,,80,,8.68,percent of total billed charges,,,,,,,no IP contract,,50,,5.43,percent of total billed charges,,,,,,no IP contract,,,78,,8.46,percent of total billed charges,,,70,,7.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.32,3324,
00409-2308-01 - midazolam 5 mg/mL preservative-free Soln,00409-2308-01,NDC,,,,inpatient,1,ML,16,9.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.6,percent of total billed charges,,,85,,13.6,percent of total billed charges,,,49,,7.84,percent of total billed charges,,,90,,14.4,percent of total billed charges,,,,,,,no IP contract,,80,,12.8,percent of total billed charges,,,,,,,no IP contract,,50,,8,percent of total billed charges,,,,,,no IP contract,,,78,,12.48,percent of total billed charges,,,70,,11.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.84,3324,
00409-2308-49 - midazolam 5 mg/mL preservative-free Soln,00409-2308-49,NDC,,,,inpatient,1,ML,16,9.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.6,percent of total billed charges,,,85,,13.6,percent of total billed charges,,,49,,7.84,percent of total billed charges,,,90,,14.4,percent of total billed charges,,,,,,,no IP contract,,80,,12.8,percent of total billed charges,,,,,,,no IP contract,,50,,8,percent of total billed charges,,,,,,no IP contract,,,78,,12.48,percent of total billed charges,,,70,,11.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.84,3324,
00409-2720-02 - heparin 1000 units/mL Soln,00409-2720-02,NDC,,,,inpatient,10,ML,31.25,18.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,25.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.56,percent of total billed charges,,,85,,26.56,percent of total billed charges,,,49,,15.31,percent of total billed charges,,,90,,28.13,percent of total billed charges,,,,,,,no IP contract,,80,,25,percent of total billed charges,,,,,,,no IP contract,,50,,15.63,percent of total billed charges,,,,,,no IP contract,,,78,,24.38,percent of total billed charges,,,70,,21.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.31,3324,
00409-2723-01 - heparin 5000 units/mL Soln,00409-2723-01,NDC,,,,inpatient,1,ML,23.9,14.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.32,percent of total billed charges,,,85,,20.32,percent of total billed charges,,,49,,11.71,percent of total billed charges,,,90,,21.51,percent of total billed charges,,,,,,,no IP contract,,80,,19.12,percent of total billed charges,,,,,,,no IP contract,,50,,11.95,percent of total billed charges,,,,,,no IP contract,,,78,,18.64,percent of total billed charges,,,70,,16.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.71,3324,
00409-3307-03 - acetylcysteine 10% Soln,00409-3307-03,NDC,,,,inpatient,1,ML,11.9,7.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.12,percent of total billed charges,,,85,,10.12,percent of total billed charges,,,49,,5.83,percent of total billed charges,,,90,,10.71,percent of total billed charges,,,,,,,no IP contract,,80,,9.52,percent of total billed charges,,,,,,,no IP contract,,50,,5.95,percent of total billed charges,,,,,,no IP contract,,,78,,9.28,percent of total billed charges,,,70,,8.33,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.83,3324,
00409-3308-03 - acetylcysteine 20% Soln,00409-3308-03,NDC,,,,inpatient,1,ML,11.95,7.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.16,percent of total billed charges,,,85,,10.16,percent of total billed charges,,,49,,5.86,percent of total billed charges,,,90,,10.76,percent of total billed charges,,,,,,,no IP contract,,80,,9.56,percent of total billed charges,,,,,,,no IP contract,,50,,5.98,percent of total billed charges,,,,,,no IP contract,,,78,,9.32,percent of total billed charges,,,70,,8.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.86,3324,
00409-3378-13 - piperacillin-tazobactam 3 g-0.375 g REC I,00409-3378-13,NDC,,,,inpatient,1,EA,82.4,49.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,66.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,70.04,percent of total billed charges,,,85,,70.04,percent of total billed charges,,,49,,40.38,percent of total billed charges,,,90,,74.16,percent of total billed charges,,,,,,,no IP contract,,80,,65.92,percent of total billed charges,,,,,,,no IP contract,,50,,41.2,percent of total billed charges,,,,,,no IP contract,,,78,,64.27,percent of total billed charges,,,70,,57.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,40.38,3324,
00409-3385-13 - piperacillin-tazobactam 3.375 gm Injection,00409-3385-13,NDC,,,,inpatient,1,EA,70.85,42.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,57.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,60.22,percent of total billed charges,,,85,,60.22,percent of total billed charges,,,49,,34.72,percent of total billed charges,,,90,,63.77,percent of total billed charges,,,,,,,no IP contract,,80,,56.68,percent of total billed charges,,,,,,,no IP contract,,50,,35.43,percent of total billed charges,,,,,,no IP contract,,,78,,55.26,percent of total billed charges,,,70,,49.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,34.72,3324,
00409-3390-04 - piperacillin-tazobactam 4.5 gm Injection,00409-3390-04,NDC,,,,inpatient,1,EA,158.85,95.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,128.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,135.02,percent of total billed charges,,,85,,135.02,percent of total billed charges,,,49,,77.84,percent of total billed charges,,,90,,142.97,percent of total billed charges,,,,,,,no IP contract,,80,,127.08,percent of total billed charges,,,,,,,no IP contract,,50,,79.43,percent of total billed charges,,,,,,no IP contract,,,78,,123.9,percent of total billed charges,,,70,,111.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,77.84,3324,
00409-3414-01 - metoclopramide 5 mg/mL Soln,00409-3414-01,NDC,,,,inpatient,2,ML,17.4,10.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.79,percent of total billed charges,,,85,,14.79,percent of total billed charges,,,49,,8.53,percent of total billed charges,,,90,,15.66,percent of total billed charges,,,,,,,no IP contract,,80,,13.92,percent of total billed charges,,,,,,,no IP contract,,50,,8.7,percent of total billed charges,,,,,,no IP contract,,,78,,13.57,percent of total billed charges,,,70,,12.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.53,3324,
00409-3505-01 - meropenem 500 mg REC I,00409-3505-01,NDC,,,,inpatient,1,EA,134.2,80.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,108.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,114.07,percent of total billed charges,,,85,,114.07,percent of total billed charges,,,49,,65.76,percent of total billed charges,,,90,,120.78,percent of total billed charges,,,,,,,no IP contract,,80,,107.36,percent of total billed charges,,,,,,,no IP contract,,50,,67.1,percent of total billed charges,,,,,,no IP contract,,,78,,104.68,percent of total billed charges,,,70,,93.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,65.76,3324,
00409-3506-01 - meropenem 1 g REC I,00409-3506-01,NDC,,,,inpatient,1,EA,193.25,115.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,156.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,164.26,percent of total billed charges,,,85,,164.26,percent of total billed charges,,,49,,94.69,percent of total billed charges,,,90,,173.93,percent of total billed charges,,,,,,,no IP contract,,80,,154.6,percent of total billed charges,,,,,,,no IP contract,,50,,96.63,percent of total billed charges,,,,,,no IP contract,,,78,,150.74,percent of total billed charges,,,70,,135.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,94.69,3324,
00409-3720-01 - ampicillin 2 g REC I,00409-3720-01,NDC,,,,inpatient,1,EA,138.6,83.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,112.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,117.81,percent of total billed charges,,,85,,117.81,percent of total billed charges,,,49,,67.91,percent of total billed charges,,,90,,124.74,percent of total billed charges,,,,,,,no IP contract,,80,,110.88,percent of total billed charges,,,,,,,no IP contract,,50,,69.3,percent of total billed charges,,,,,,no IP contract,,,78,,108.11,percent of total billed charges,,,70,,97.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,67.91,3324,
00409-3795-01 - ketorolac 30 mg/mL Soln,00409-3795-01,NDC,,,,inpatient,1,ML,19.55,11.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.62,percent of total billed charges,,,85,,16.62,percent of total billed charges,,,49,,9.58,percent of total billed charges,,,90,,17.6,percent of total billed charges,,,,,,,no IP contract,,80,,15.64,percent of total billed charges,,,,,,,no IP contract,,50,,9.78,percent of total billed charges,,,,,,no IP contract,,,78,,15.25,percent of total billed charges,,,70,,13.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.58,3324,
00409-4090-01 - zinc chloride 1 mg/mL Soln,00409-4090-01,NDC,,,,inpatient,1,ML,10,6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.5,percent of total billed charges,,,85,,8.5,percent of total billed charges,,,49,,4.9,percent of total billed charges,,,90,,9,percent of total billed charges,,,,,,,no IP contract,,80,,8,percent of total billed charges,,,,,,,no IP contract,,50,,5,percent of total billed charges,,,,,,no IP contract,,,78,,7.8,percent of total billed charges,,,70,,7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.9,3324,
00409-4091-01 - manganese chloride 0.1 mg/mL Soln,00409-4091-01,NDC,,,,inpatient,1,ML,35.7,21.42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.35,percent of total billed charges,,,85,,30.35,percent of total billed charges,,,49,,17.49,percent of total billed charges,,,90,,32.13,percent of total billed charges,,,,,,,no IP contract,,80,,28.56,percent of total billed charges,,,,,,,no IP contract,,50,,17.85,percent of total billed charges,,,,,,no IP contract,,,78,,27.85,percent of total billed charges,,,70,,24.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.49,3324,
00409-4092-01 - copper chloride 1.07 mg/mL Soln,00409-4092-01,NDC,,,,inpatient,1,ML,15.75,9.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.39,percent of total billed charges,,,85,,13.39,percent of total billed charges,,,49,,7.72,percent of total billed charges,,,90,,14.18,percent of total billed charges,,,,,,,no IP contract,,80,,12.6,percent of total billed charges,,,,,,,no IP contract,,50,,7.88,percent of total billed charges,,,,,,no IP contract,,,78,,12.29,percent of total billed charges,,,70,,11.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.72,3324,
00409-4093-01 - chromic chloride hexahydrate 4 mcg/mL Soln,00409-4093-01,NDC,,,,inpatient,1,ML,10.1,6.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.59,percent of total billed charges,,,85,,8.59,percent of total billed charges,,,49,,4.95,percent of total billed charges,,,90,,9.09,percent of total billed charges,,,,,,,no IP contract,,80,,8.08,percent of total billed charges,,,,,,,no IP contract,,50,,5.05,percent of total billed charges,,,,,,no IP contract,,,78,,7.88,percent of total billed charges,,,70,,7.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.95,3324,
lidocaine 4% preservative-free Soln,00409-4283-01,NDC,,,,inpatient,1,EA,52.3,31.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,42.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,44.46,percent of total billed charges,,,85,,44.46,percent of total billed charges,,,49,,25.63,percent of total billed charges,,,90,,47.07,percent of total billed charges,,,,,,,no IP contract,,80,,41.84,percent of total billed charges,,,,,,,no IP contract,,50,,26.15,percent of total billed charges,,,,,,no IP contract,,,78,,40.79,percent of total billed charges,,,70,,36.61,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.63,3324,
00409-4332-01 - vancomycin 500 mg REC Inj,00409-4332-01,NDC,,,,inpatient,5,ML,113.2,67.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,91.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,96.22,percent of total billed charges,,,85,,96.22,percent of total billed charges,,,49,,55.47,percent of total billed charges,,,90,,101.88,percent of total billed charges,,,,,,,no IP contract,,80,,90.56,percent of total billed charges,,,,,,,no IP contract,,50,,56.6,percent of total billed charges,,,,,,no IP contract,,,78,,88.3,percent of total billed charges,,,70,,79.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,55.47,3324,
00409-4755-03 - ondansetron 2 mg/mL Soln,00409-4755-03,NDC,,,,inpatient,2,ML,22.3,13.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.96,percent of total billed charges,,,85,,18.96,percent of total billed charges,,,49,,10.93,percent of total billed charges,,,90,,20.07,percent of total billed charges,,,,,,,no IP contract,,80,,17.84,percent of total billed charges,,,,,,,no IP contract,,50,,11.15,percent of total billed charges,,,,,,no IP contract,,,78,,17.39,percent of total billed charges,,,70,,15.61,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.93,3324,
00409-4777-02 - ciprofloxacin 400 mg/200 mL-5% Soln,00409-4777-02,NDC,,,,inpatient,200,ML,91.75,55.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,74.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,77.99,percent of total billed charges,,,85,,77.99,percent of total billed charges,,,49,,44.96,percent of total billed charges,,,90,,82.58,percent of total billed charges,,,,,,,no IP contract,,80,,73.4,percent of total billed charges,,,,,,,no IP contract,,50,,45.88,percent of total billed charges,,,,,,no IP contract,,,78,,71.57,percent of total billed charges,,,70,,64.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,44.96,3324,
00409-4882-01 - linezolid 2 mg/mL Soln,00409-4882-01,NDC,,,,inpatient,300,ML,641.55,384.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,519.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,545.32,percent of total billed charges,,,85,,545.32,percent of total billed charges,,,49,,314.36,percent of total billed charges,,,90,,577.4,percent of total billed charges,,,,,,,no IP contract,,80,,513.24,percent of total billed charges,,,,,,,no IP contract,,50,,320.78,percent of total billed charges,,,,,,no IP contract,,,78,,500.41,percent of total billed charges,,,70,,449.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,314.36,3324,
00409-4887-10 - sterile water - Soln,00409-4887-10,NDC,,,,inpatient,10,ML,16.05,9.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.64,percent of total billed charges,,,85,,13.64,percent of total billed charges,,,49,,7.86,percent of total billed charges,,,90,,14.45,percent of total billed charges,,,,,,,no IP contract,,80,,12.84,percent of total billed charges,,,,,,,no IP contract,,50,,8.03,percent of total billed charges,,,,,,no IP contract,,,78,,12.52,percent of total billed charges,,,70,,11.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.86,3324,
00409-4887-20 - sterile water - Soln,00409-4887-20,NDC,,,,inpatient,20,ML,17.75,10.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.09,percent of total billed charges,,,85,,15.09,percent of total billed charges,,,49,,8.7,percent of total billed charges,,,90,,15.98,percent of total billed charges,,,,,,,no IP contract,,80,,14.2,percent of total billed charges,,,,,,,no IP contract,,50,,8.88,percent of total billed charges,,,,,,no IP contract,,,78,,13.85,percent of total billed charges,,,70,,12.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.7,3324,
00409-4887-99 - sterile water - Soln,00409-4887-99,NDC,,,,inpatient,100,ML,43.05,25.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36.59,percent of total billed charges,,,85,,36.59,percent of total billed charges,,,49,,21.09,percent of total billed charges,,,90,,38.75,percent of total billed charges,,,,,,,no IP contract,,80,,34.44,percent of total billed charges,,,,,,,no IP contract,,50,,21.53,percent of total billed charges,,,,,,no IP contract,,,78,,33.58,percent of total billed charges,,,70,,30.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.09,3324,
00409-4888-10 - sodium chloride 0.9% Soln,00409-4888-10,NDC,,,,inpatient,10,ML,16.05,9.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.64,percent of total billed charges,,,85,,13.64,percent of total billed charges,,,49,,7.86,percent of total billed charges,,,90,,14.45,percent of total billed charges,,,,,,,no IP contract,,80,,12.84,percent of total billed charges,,,,,,,no IP contract,,50,,8.03,percent of total billed charges,,,,,,no IP contract,,,78,,12.52,percent of total billed charges,,,70,,11.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.86,3324,
00409-4888-12 - sodium chloride 0.9% Soln,00409-4888-12,NDC,,,,inpatient,10,ML,21.15,12.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.98,percent of total billed charges,,,85,,17.98,percent of total billed charges,,,49,,10.36,percent of total billed charges,,,90,,19.04,percent of total billed charges,,,,,,,no IP contract,,80,,16.92,percent of total billed charges,,,,,,,no IP contract,,50,,10.58,percent of total billed charges,,,,,,no IP contract,,,78,,16.5,percent of total billed charges,,,70,,14.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.36,3324,
00409-4902-34 - glucose 50% Soln,00409-4902-34,NDC,,,,inpatient,50,ML,127.35,76.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,103.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,108.25,percent of total billed charges,,,85,,108.25,percent of total billed charges,,,49,,62.4,percent of total billed charges,,,90,,114.62,percent of total billed charges,,,,,,,no IP contract,,80,,101.88,percent of total billed charges,,,,,,,no IP contract,,50,,63.68,percent of total billed charges,,,,,,no IP contract,,,78,,99.33,percent of total billed charges,,,70,,89.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,62.4,3324,
00409-4903-34 - lidocaine 2% Soln,00409-4903-34,NDC,,,,inpatient,1,ML,40.1,24.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34.09,percent of total billed charges,,,85,,34.09,percent of total billed charges,,,49,,19.65,percent of total billed charges,,,90,,36.09,percent of total billed charges,,,,,,,no IP contract,,80,,32.08,percent of total billed charges,,,,,,,no IP contract,,50,,20.05,percent of total billed charges,,,,,,no IP contract,,,78,,31.28,percent of total billed charges,,,70,,28.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.65,3324,
atropine 0.1 mg/mL Soln,00409-4911-34,NDC,,,,inpatient,1,EA,42.2,25.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,35.87,percent of total billed charges,,,85,,35.87,percent of total billed charges,,,49,,20.68,percent of total billed charges,,,90,,37.98,percent of total billed charges,,,,,,,no IP contract,,80,,33.76,percent of total billed charges,,,,,,,no IP contract,,50,,21.1,percent of total billed charges,,,,,,no IP contract,,,78,,32.92,percent of total billed charges,,,70,,29.54,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.68,3324,
EPINEPHrine 0.1 mg/mL Soln,00409-4921-34,NDC,,,,inpatient,1,EA,31.25,18.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,25.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.56,percent of total billed charges,,,85,,26.56,percent of total billed charges,,,49,,15.31,percent of total billed charges,,,90,,28.13,percent of total billed charges,,,,,,,no IP contract,,80,,25,percent of total billed charges,,,,,,,no IP contract,,50,,15.63,percent of total billed charges,,,,,,no IP contract,,,78,,24.38,percent of total billed charges,,,70,,21.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.31,3324,
00409-5084-11 - ceftazidime 2 g REC I,00409-5084-11,NDC,,,,inpatient,1,EA,101.8,61.08,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,82.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,86.53,percent of total billed charges,,,85,,86.53,percent of total billed charges,,,49,,49.88,percent of total billed charges,,,90,,91.62,percent of total billed charges,,,,,,,no IP contract,,80,,81.44,percent of total billed charges,,,,,,,no IP contract,,50,,50.9,percent of total billed charges,,,,,,no IP contract,,,78,,79.4,percent of total billed charges,,,70,,71.26,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,49.88,3324,
00409-5092-16 - ceftazidime 1 g REC I,00409-5092-16,NDC,,,,inpatient,1,EA,83.35,50.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,67.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,70.85,percent of total billed charges,,,85,,70.85,percent of total billed charges,,,49,,40.84,percent of total billed charges,,,90,,75.02,percent of total billed charges,,,,,,,no IP contract,,80,,66.68,percent of total billed charges,,,,,,,no IP contract,,50,,41.68,percent of total billed charges,,,,,,no IP contract,,,78,,65.01,percent of total billed charges,,,70,,58.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,40.84,3324,
00409-5093-11 - ceftazidime 2 g REC I,00409-5093-11,NDC,,,,inpatient,1,EA,196.4,117.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,159.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,166.94,percent of total billed charges,,,85,,166.94,percent of total billed charges,,,49,,96.24,percent of total billed charges,,,90,,176.76,percent of total billed charges,,,,,,,no IP contract,,80,,157.12,percent of total billed charges,,,,,,,no IP contract,,50,,98.2,percent of total billed charges,,,,,,no IP contract,,,78,,153.19,percent of total billed charges,,,70,,137.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,96.24,3324,
00409-6102-02 - furosemide 10 mg/mL Soln,00409-6102-02,NDC,,,,inpatient,2,ML,13.9,8.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.82,percent of total billed charges,,,85,,11.82,percent of total billed charges,,,49,,6.81,percent of total billed charges,,,90,,12.51,percent of total billed charges,,,,,,,no IP contract,,80,,11.12,percent of total billed charges,,,,,,,no IP contract,,50,,6.95,percent of total billed charges,,,,,,no IP contract,,,78,,10.84,percent of total billed charges,,,70,,9.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.81,3324,
00409-6102-04 - furosemide 10 mg/mL Soln,00409-6102-04,NDC,,,,inpatient,4,ML,43.4,26.04,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,35.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36.89,percent of total billed charges,,,85,,36.89,percent of total billed charges,,,49,,21.27,percent of total billed charges,,,90,,39.06,percent of total billed charges,,,,,,,no IP contract,,80,,34.72,percent of total billed charges,,,,,,,no IP contract,,50,,21.7,percent of total billed charges,,,,,,no IP contract,,,78,,33.85,percent of total billed charges,,,70,,30.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.27,3324,
00409-6102-25 - furosemide 10 mg/mL Soln,00409-6102-25,NDC,,,,inpatient,2,ML,43.9,26.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,35.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,37.32,percent of total billed charges,,,85,,37.32,percent of total billed charges,,,49,,21.51,percent of total billed charges,,,90,,39.51,percent of total billed charges,,,,,,,no IP contract,,80,,35.12,percent of total billed charges,,,,,,,no IP contract,,50,,21.95,percent of total billed charges,,,,,,no IP contract,,,78,,34.24,percent of total billed charges,,,70,,30.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.51,3324,
00409-6102-26 - furosemide 10 mg/mL Soln,00409-6102-26,NDC,,,,inpatient,4,ML,37.65,22.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32,percent of total billed charges,,,85,,32,percent of total billed charges,,,49,,18.45,percent of total billed charges,,,90,,33.89,percent of total billed charges,,,,,,,no IP contract,,80,,30.12,percent of total billed charges,,,,,,,no IP contract,,50,,18.83,percent of total billed charges,,,,,,no IP contract,,,78,,29.37,percent of total billed charges,,,70,,26.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.45,3324,
00409-6510-01 - vancomycin 10 g REC I,00409-6510-01,NDC,,,,inpatient,100,ML,2208.4,1325.04,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1788.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1877.14,percent of total billed charges,,,85,,1877.14,percent of total billed charges,,,49,,1082.12,percent of total billed charges,,,90,,1987.56,percent of total billed charges,,,,,,,no IP contract,,80,,1766.72,percent of total billed charges,,,,,,,no IP contract,,50,,1104.2,percent of total billed charges,,,,,,no IP contract,,,78,,1722.55,percent of total billed charges,,,70,,1545.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
00409-6531-01 - vancomycin 750 mg REC I,00409-6531-01,NDC,,,,inpatient,7.5,ML,168.05,100.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,136.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,142.84,percent of total billed charges,,,85,,142.84,percent of total billed charges,,,49,,82.34,percent of total billed charges,,,90,,151.25,percent of total billed charges,,,,,,,no IP contract,,80,,134.44,percent of total billed charges,,,,,,,no IP contract,,50,,84.03,percent of total billed charges,,,,,,no IP contract,,,78,,131.08,percent of total billed charges,,,70,,117.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,82.34,3324,
00409-6533-01 - vancomycin 1 g REC I,00409-6533-01,NDC,,,,inpatient,10,ML,136.25,81.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,110.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,115.81,percent of total billed charges,,,85,,115.81,percent of total billed charges,,,49,,66.76,percent of total billed charges,,,90,,122.63,percent of total billed charges,,,,,,,no IP contract,,80,,109,percent of total billed charges,,,,,,,no IP contract,,50,,68.13,percent of total billed charges,,,,,,no IP contract,,,78,,106.28,percent of total billed charges,,,70,,95.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,66.76,3324,
00409-6534-01 - vancomycin 500 mg REC I,00409-6534-01,NDC,,,,inpatient,5,ML,112.3,67.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,90.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,95.46,percent of total billed charges,,,85,,95.46,percent of total billed charges,,,49,,55.03,percent of total billed charges,,,90,,101.07,percent of total billed charges,,,,,,,no IP contract,,80,,89.84,percent of total billed charges,,,,,,,no IP contract,,50,,56.15,percent of total billed charges,,,,,,no IP contract,,,78,,87.59,percent of total billed charges,,,70,,78.61,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,55.03,3324,
00409-6535-01 - vancomycin 1 g REC I,00409-6535-01,NDC,,,,inpatient,10,ML,142.45,85.47,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,115.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,121.08,percent of total billed charges,,,85,,121.08,percent of total billed charges,,,49,,69.8,percent of total billed charges,,,90,,128.21,percent of total billed charges,,,,,,,no IP contract,,80,,113.96,percent of total billed charges,,,,,,,no IP contract,,50,,71.23,percent of total billed charges,,,,,,no IP contract,,,78,,111.11,percent of total billed charges,,,70,,99.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,69.8,3324,
00409-6625-02 - sodium bicarbonate 8.4% Soln,00409-6625-02,NDC,,,,inpatient,1,ML,10.85,6.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.22,percent of total billed charges,,,85,,9.22,percent of total billed charges,,,49,,5.32,percent of total billed charges,,,90,,9.77,percent of total billed charges,,,,,,,no IP contract,,80,,8.68,percent of total billed charges,,,,,,,no IP contract,,50,,5.43,percent of total billed charges,,,,,,no IP contract,,,78,,8.46,percent of total billed charges,,,70,,7.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.32,3324,
00409-6651-06 - potassium chloride 2 mEq/mL Soln,00409-6651-06,NDC,,,,inpatient,10,ML,21.95,13.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.66,percent of total billed charges,,,85,,18.66,percent of total billed charges,,,49,,10.76,percent of total billed charges,,,90,,19.76,percent of total billed charges,,,,,,,no IP contract,,80,,17.56,percent of total billed charges,,,,,,,no IP contract,,50,,10.98,percent of total billed charges,,,,,,no IP contract,,,78,,17.12,percent of total billed charges,,,70,,15.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.76,3324,
00409-6729-24 - magnesium sulfate 2 g/50 mL-sterile water Soln,00409-6729-24,NDC,,,,inpatient,50,ML,204.2,122.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,165.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,173.57,percent of total billed charges,,,85,,173.57,percent of total billed charges,,,49,,100.06,percent of total billed charges,,,90,,183.78,percent of total billed charges,,,,,,,no IP contract,,80,,163.36,percent of total billed charges,,,,,,,no IP contract,,50,,102.1,percent of total billed charges,,,,,,no IP contract,,,78,,159.28,percent of total billed charges,,,70,,142.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,100.06,3324,
00409-6729-24 - magnesium sulfate 40 mg/mL Soln,00409-6729-24,NDC,,,,inpatient,50,ML,204.2,122.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,165.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,173.57,percent of total billed charges,,,85,,173.57,percent of total billed charges,,,49,,100.06,percent of total billed charges,,,90,,183.78,percent of total billed charges,,,,,,,no IP contract,,80,,163.36,percent of total billed charges,,,,,,,no IP contract,,50,,102.1,percent of total billed charges,,,,,,no IP contract,,,78,,159.28,percent of total billed charges,,,70,,142.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,100.06,3324,
00409-6778-02 - LORazepam 2 mg/mL Soln,00409-6778-02,NDC,,,,inpatient,1,ML,16.1,9.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.69,percent of total billed charges,,,85,,13.69,percent of total billed charges,,,49,,7.89,percent of total billed charges,,,90,,14.49,percent of total billed charges,,,,,,,no IP contract,,80,,12.88,percent of total billed charges,,,,,,,no IP contract,,50,,8.05,percent of total billed charges,,,,,,no IP contract,,,78,,12.56,percent of total billed charges,,,70,,11.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.89,3324,
00409-7075-26 - potassium chloride 20 mEq/100 mL Soln,00409-7075-26,NDC,,,,inpatient,100,ML,91.75,55.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,74.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,77.99,percent of total billed charges,,,85,,77.99,percent of total billed charges,,,49,,44.96,percent of total billed charges,,,90,,82.58,percent of total billed charges,,,,,,,no IP contract,,80,,73.4,percent of total billed charges,,,,,,,no IP contract,,50,,45.88,percent of total billed charges,,,,,,no IP contract,,,78,,71.57,percent of total billed charges,,,70,,64.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,44.96,3324,
00409-7100-67 - LVP solution Dextrose 5% in Water Soln,00409-7100-67,NDC,,,,inpatient,100,ML,35.6,21.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.26,percent of total billed charges,,,85,,30.26,percent of total billed charges,,,49,,17.44,percent of total billed charges,,,90,,32.04,percent of total billed charges,,,,,,,no IP contract,,80,,28.48,percent of total billed charges,,,,,,,no IP contract,,50,,17.8,percent of total billed charges,,,,,,no IP contract,,,78,,27.77,percent of total billed charges,,,70,,24.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.44,3324,
00409-7101-02 - LVP solution Sodium Chloride 0.9% Soln,00409-7101-02,NDC,,,,inpatient,250,ML,56.25,33.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,45.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,47.81,percent of total billed charges,,,85,,47.81,percent of total billed charges,,,49,,27.56,percent of total billed charges,,,90,,50.63,percent of total billed charges,,,,,,,no IP contract,,80,,45,percent of total billed charges,,,,,,,no IP contract,,50,,28.13,percent of total billed charges,,,,,,no IP contract,,,78,,43.88,percent of total billed charges,,,70,,39.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.56,3324,
00409-7101-67 - LVP solution Sodium Chloride 0.9% Soln,00409-7101-67,NDC,,,,inpatient,100,ML,52.1,31.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,42.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,44.29,percent of total billed charges,,,85,,44.29,percent of total billed charges,,,49,,25.53,percent of total billed charges,,,90,,46.89,percent of total billed charges,,,,,,,no IP contract,,80,,41.68,percent of total billed charges,,,,,,,no IP contract,,50,,26.05,percent of total billed charges,,,,,,no IP contract,,,78,,40.64,percent of total billed charges,,,70,,36.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.53,3324,
00409-7120-07 - parenteral nutrition solution Dextrose 70% in Water Soln,00409-7120-07,NDC,,,,inpatient,1,ML,1224.5,734.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,991.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1040.83,percent of total billed charges,,,85,,1040.83,percent of total billed charges,,,49,,600.01,percent of total billed charges,,,90,,1102.05,percent of total billed charges,,,,,,,no IP contract,,80,,979.6,percent of total billed charges,,,,,,,no IP contract,,50,,612.25,percent of total billed charges,,,,,,no IP contract,,,78,,955.11,percent of total billed charges,,,70,,857.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,600.01,3324,
00409-7120-07 - parenteral nutrition solution Dextrose 70% in Water Soln,00409-7120-07,NDC,,,,inpatient,1,ML,1224.5,734.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,991.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1040.83,percent of total billed charges,,,85,,1040.83,percent of total billed charges,,,49,,600.01,percent of total billed charges,,,90,,1102.05,percent of total billed charges,,,,,,,no IP contract,,80,,979.6,percent of total billed charges,,,,,,,no IP contract,,50,,612.25,percent of total billed charges,,,,,,no IP contract,,,78,,955.11,percent of total billed charges,,,70,,857.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,600.01,3324,
00409-7139-09 - sterile water - Soln,00409-7139-09,NDC,,,,inpatient,1000,ML,35.4,21.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.09,percent of total billed charges,,,85,,30.09,percent of total billed charges,,,49,,17.35,percent of total billed charges,,,90,,31.86,percent of total billed charges,,,,,,,no IP contract,,80,,28.32,percent of total billed charges,,,,,,,no IP contract,,50,,17.7,percent of total billed charges,,,,,,no IP contract,,,78,,27.61,percent of total billed charges,,,70,,24.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.35,3324,
00409-7299-25 - sodium acetate 2 mEq/mL Soln,00409-7299-25,NDC,,,,inpatient,1,ML,10.85,6.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.22,percent of total billed charges,,,85,,9.22,percent of total billed charges,,,49,,5.32,percent of total billed charges,,,90,,9.77,percent of total billed charges,,,,,,,no IP contract,,80,,8.68,percent of total billed charges,,,,,,,no IP contract,,50,,5.43,percent of total billed charges,,,,,,no IP contract,,,78,,8.46,percent of total billed charges,,,70,,7.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.32,3324,
00409-7299-73 - sodium acetate 2 mEq/mL Soln,00409-7299-73,NDC,,,,inpatient,1,ML,10.25,6.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.71,percent of total billed charges,,,85,,8.71,percent of total billed charges,,,49,,5.02,percent of total billed charges,,,90,,9.23,percent of total billed charges,,,,,,,no IP contract,,80,,8.2,percent of total billed charges,,,,,,,no IP contract,,50,,5.13,percent of total billed charges,,,,,,no IP contract,,,78,,8,percent of total billed charges,,,70,,7.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.02,3324,
00409-7332-01 - ceftriaxone 1 g REC I,00409-7332-01,NDC,,,,inpatient,1,EA,90.1,54.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,72.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,76.59,percent of total billed charges,,,85,,76.59,percent of total billed charges,,,49,,44.15,percent of total billed charges,,,90,,81.09,percent of total billed charges,,,,,,,no IP contract,,80,,72.08,percent of total billed charges,,,,,,,no IP contract,,50,,45.05,percent of total billed charges,,,,,,no IP contract,,,78,,70.28,percent of total billed charges,,,70,,63.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,44.15,3324,
00409-7332-20 - cefTRIAXone 1 g REC I,00409-7332-20,NDC,,,,inpatient,1,EA,90.1,54.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,72.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,76.59,percent of total billed charges,,,85,,76.59,percent of total billed charges,,,49,,44.15,percent of total billed charges,,,90,,81.09,percent of total billed charges,,,,,,,no IP contract,,80,,72.08,percent of total billed charges,,,,,,,no IP contract,,50,,45.05,percent of total billed charges,,,,,,no IP contract,,,78,,70.28,percent of total billed charges,,,70,,63.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,44.15,3324,
00409-7333-04 - ceftriaxone 1 g REC I,00409-7333-04,NDC,,,,inpatient,1,EA,196,117.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,158.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,166.6,percent of total billed charges,,,85,,166.6,percent of total billed charges,,,49,,96.04,percent of total billed charges,,,90,,176.4,percent of total billed charges,,,,,,,no IP contract,,80,,156.8,percent of total billed charges,,,,,,,no IP contract,,50,,98,percent of total billed charges,,,,,,no IP contract,,,78,,152.88,percent of total billed charges,,,70,,137.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,96.04,3324,
00409-7333-49 - cefTRIAXone 1 g REC I,00409-7333-49,NDC,,,,inpatient,1,EA,114.55,68.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,92.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,97.37,percent of total billed charges,,,85,,97.37,percent of total billed charges,,,49,,56.13,percent of total billed charges,,,90,,103.1,percent of total billed charges,,,,,,,no IP contract,,80,,91.64,percent of total billed charges,,,,,,,no IP contract,,50,,57.28,percent of total billed charges,,,,,,no IP contract,,,78,,89.35,percent of total billed charges,,,70,,80.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,56.13,3324,
00409-7335-03 - ceftriaxone 2 g REC I,00409-7335-03,NDC,,,,inpatient,1,EA,38.4,23.04,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.64,percent of total billed charges,,,85,,32.64,percent of total billed charges,,,49,,18.82,percent of total billed charges,,,90,,34.56,percent of total billed charges,,,,,,,no IP contract,,80,,30.72,percent of total billed charges,,,,,,,no IP contract,,50,,19.2,percent of total billed charges,,,,,,no IP contract,,,78,,29.95,percent of total billed charges,,,70,,26.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.82,3324,
00409-7335-20 - cefTRIAXone 2 g REC I,00409-7335-20,NDC,,,,inpatient,1,EA,38.15,22.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.43,percent of total billed charges,,,85,,32.43,percent of total billed charges,,,49,,18.69,percent of total billed charges,,,90,,34.34,percent of total billed charges,,,,,,,no IP contract,,80,,30.52,percent of total billed charges,,,,,,,no IP contract,,50,,19.08,percent of total billed charges,,,,,,no IP contract,,,78,,29.76,percent of total billed charges,,,70,,26.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.69,3324,
00409-7336-04 - ceftriaxone 2 g REC I,00409-7336-04,NDC,,,,inpatient,1,EA,89.75,53.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,72.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,76.29,percent of total billed charges,,,85,,76.29,percent of total billed charges,,,49,,43.98,percent of total billed charges,,,90,,80.78,percent of total billed charges,,,,,,,no IP contract,,80,,71.8,percent of total billed charges,,,,,,,no IP contract,,50,,44.88,percent of total billed charges,,,,,,no IP contract,,,78,,70.01,percent of total billed charges,,,70,,62.83,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,43.98,3324,
00409-7391-72 - sodium phosphate 3 mmol/mL Soln,00409-7391-72,NDC,,,,inpatient,1,ML,12.85,7.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.92,percent of total billed charges,,,85,,10.92,percent of total billed charges,,,49,,6.3,percent of total billed charges,,,90,,11.57,percent of total billed charges,,,,,,,no IP contract,,80,,10.28,percent of total billed charges,,,,,,,no IP contract,,50,,6.43,percent of total billed charges,,,,,,no IP contract,,,78,,10.02,percent of total billed charges,,,70,,9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.3,3324,
00409-7517-16 - glucose 50% Soln,00409-7517-16,NDC,,,,inpatient,50,ML,34.6,20.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.41,percent of total billed charges,,,85,,29.41,percent of total billed charges,,,49,,16.95,percent of total billed charges,,,90,,31.14,percent of total billed charges,,,,,,,no IP contract,,80,,27.68,percent of total billed charges,,,,,,,no IP contract,,50,,17.3,percent of total billed charges,,,,,,no IP contract,,,78,,26.99,percent of total billed charges,,,70,,24.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.95,3324,
00409-7811-24 - metronidazole 500 mg/100 mL Soln,00409-7811-24,NDC,,,,inpatient,100,ML,83.4,50.04,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,67.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,70.89,percent of total billed charges,,,85,,70.89,percent of total billed charges,,,49,,40.87,percent of total billed charges,,,90,,75.06,percent of total billed charges,,,,,,,no IP contract,,80,,66.72,percent of total billed charges,,,,,,,no IP contract,,50,,41.7,percent of total billed charges,,,,,,no IP contract,,,78,,65.05,percent of total billed charges,,,70,,58.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,40.87,3324,
00409-7922-03 - LVP solution Dextrose 5% in Water Soln,00409-7922-03,NDC,,,,inpatient,500,ML,35.4,21.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.09,percent of total billed charges,,,85,,30.09,percent of total billed charges,,,49,,17.35,percent of total billed charges,,,90,,31.86,percent of total billed charges,,,,,,,no IP contract,,80,,28.32,percent of total billed charges,,,,,,,no IP contract,,50,,17.7,percent of total billed charges,,,,,,no IP contract,,,78,,27.61,percent of total billed charges,,,70,,24.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.35,3324,
00409-7922-25 - dextrose 5% water 250 mL Injection,00409-7922-25,NDC,,,,inpatient,250,ML,77.05,46.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,62.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,65.49,percent of total billed charges,,,85,,65.49,percent of total billed charges,,,49,,37.75,percent of total billed charges,,,90,,69.35,percent of total billed charges,,,,,,,no IP contract,,80,,61.64,percent of total billed charges,,,,,,,no IP contract,,50,,38.53,percent of total billed charges,,,,,,no IP contract,,,78,,60.1,percent of total billed charges,,,70,,53.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,37.75,3324,
00409-7923-37 - LVP solution Dextrose 5% in Water Soln,00409-7923-37,NDC,,,,inpatient,100,ML,35.6,21.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.26,percent of total billed charges,,,85,,30.26,percent of total billed charges,,,49,,17.44,percent of total billed charges,,,90,,32.04,percent of total billed charges,,,,,,,no IP contract,,80,,28.48,percent of total billed charges,,,,,,,no IP contract,,50,,17.8,percent of total billed charges,,,,,,no IP contract,,,78,,27.77,percent of total billed charges,,,70,,24.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.44,3324,
00409-7926-03 - LVP solution Dextrose 5% with 0.45% NaCl Soln,00409-7926-03,NDC,,,,inpatient,500,ML,77.05,46.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,62.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,65.49,percent of total billed charges,,,85,,65.49,percent of total billed charges,,,49,,37.75,percent of total billed charges,,,90,,69.35,percent of total billed charges,,,,,,,no IP contract,,80,,61.64,percent of total billed charges,,,,,,,no IP contract,,50,,38.53,percent of total billed charges,,,,,,no IP contract,,,78,,60.1,percent of total billed charges,,,70,,53.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,37.75,3324,
00409-7941-09 - LVP solution Dextrose 5% with 0.9% NaCl Soln,00409-7941-09,NDC,,,,inpatient,1000,ML,35.4,21.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.09,percent of total billed charges,,,85,,30.09,percent of total billed charges,,,49,,17.35,percent of total billed charges,,,90,,31.86,percent of total billed charges,,,,,,,no IP contract,,80,,28.32,percent of total billed charges,,,,,,,no IP contract,,50,,17.7,percent of total billed charges,,,,,,no IP contract,,,78,,27.61,percent of total billed charges,,,70,,24.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.35,3324,
00409-7983-03 - LVP solution Sodium Chloride 0.9% Soln,00409-7983-03,NDC,,,,inpatient,500,ML,77.05,46.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,62.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,65.49,percent of total billed charges,,,85,,65.49,percent of total billed charges,,,49,,37.75,percent of total billed charges,,,90,,69.35,percent of total billed charges,,,,,,,no IP contract,,80,,61.64,percent of total billed charges,,,,,,,no IP contract,,50,,38.53,percent of total billed charges,,,,,,no IP contract,,,78,,60.1,percent of total billed charges,,,70,,53.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,37.75,3324,
00409-7984-36 - LVP solution Sodium Chloride 0.9% Soln,00409-7984-36,NDC,,,,inpatient,50,ML,52.1,31.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,42.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,44.29,percent of total billed charges,,,85,,44.29,percent of total billed charges,,,49,,25.53,percent of total billed charges,,,90,,46.89,percent of total billed charges,,,,,,,no IP contract,,80,,41.68,percent of total billed charges,,,,,,,no IP contract,,50,,26.05,percent of total billed charges,,,,,,no IP contract,,,78,,40.64,percent of total billed charges,,,70,,36.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.53,3324,
00409-7984-37 - LVP solution Sodium Chloride 0.9% Soln,00409-7984-37,NDC,,,,inpatient,100,ML,60.4,36.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,48.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,51.34,percent of total billed charges,,,85,,51.34,percent of total billed charges,,,49,,29.6,percent of total billed charges,,,90,,54.36,percent of total billed charges,,,,,,,no IP contract,,80,,48.32,percent of total billed charges,,,,,,,no IP contract,,50,,30.2,percent of total billed charges,,,,,,no IP contract,,,78,,47.11,percent of total billed charges,,,70,,42.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,29.6,3324,
00409-7985-03 - LVP solution Sodium Chloride 0.45% Soln,00409-7985-03,NDC,,,,inpatient,500,ML,77.05,46.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,62.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,65.49,percent of total billed charges,,,85,,65.49,percent of total billed charges,,,49,,37.75,percent of total billed charges,,,90,,69.35,percent of total billed charges,,,,,,,no IP contract,,80,,61.64,percent of total billed charges,,,,,,,no IP contract,,50,,38.53,percent of total billed charges,,,,,,no IP contract,,,78,,60.1,percent of total billed charges,,,70,,53.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,37.75,3324,
00409-7985-09 - LVP solution Sodium Chloride 0.45% Soln,00409-7985-09,NDC,,,,inpatient,1000,ML,118.7,71.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,96.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,100.9,percent of total billed charges,,,85,,100.9,percent of total billed charges,,,49,,58.16,percent of total billed charges,,,90,,106.83,percent of total billed charges,,,,,,,no IP contract,,80,,94.96,percent of total billed charges,,,,,,,no IP contract,,50,,59.35,percent of total billed charges,,,,,,no IP contract,,,78,,92.59,percent of total billed charges,,,70,,83.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.16,3324,
00409-8183-01 - potassium acetate 2 mEq/mL Soln,00409-8183-01,NDC,,,,inpatient,1,ML,10.35,6.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.8,percent of total billed charges,,,85,,8.8,percent of total billed charges,,,49,,5.07,percent of total billed charges,,,90,,9.32,percent of total billed charges,,,,,,,no IP contract,,80,,8.28,percent of total billed charges,,,,,,,no IP contract,,50,,5.18,percent of total billed charges,,,,,,no IP contract,,,78,,8.07,percent of total billed charges,,,70,,7.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.07,3324,
00409-8183-25 - potassium acetate 2 mEq/mL Soln,00409-8183-25,NDC,,,,inpatient,1,ML,11,6.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.35,percent of total billed charges,,,85,,9.35,percent of total billed charges,,,49,,5.39,percent of total billed charges,,,90,,9.9,percent of total billed charges,,,,,,,no IP contract,,80,,8.8,percent of total billed charges,,,,,,,no IP contract,,50,,5.5,percent of total billed charges,,,,,,no IP contract,,,78,,8.58,percent of total billed charges,,,70,,7.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.39,3324,
00409-9158-01 - phytonadione 10 mg/mL Soln,00409-9158-01,NDC,,,,inpatient,1,ML,67.75,40.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,54.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,57.59,percent of total billed charges,,,85,,57.59,percent of total billed charges,,,49,,33.2,percent of total billed charges,,,90,,60.98,percent of total billed charges,,,,,,,no IP contract,,80,,54.2,percent of total billed charges,,,,,,,no IP contract,,50,,33.88,percent of total billed charges,,,,,,no IP contract,,,78,,52.85,percent of total billed charges,,,70,,47.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,33.2,3324,
00409-9158-25 - phytonadione 10 mg/mL Soln,00409-9158-25,NDC,,,,inpatient,1,ML,477.2,286.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,386.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,405.62,percent of total billed charges,,,85,,405.62,percent of total billed charges,,,49,,233.83,percent of total billed charges,,,90,,429.48,percent of total billed charges,,,,,,,no IP contract,,80,,381.76,percent of total billed charges,,,,,,,no IP contract,,50,,238.6,percent of total billed charges,,,,,,no IP contract,,,78,,372.22,percent of total billed charges,,,70,,334.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,233.83,3324,
00409-9301-30 - ropivacaine 0.5% Soln,00409-9301-30,NDC,,,,inpatient,30,ML,75.1,45.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63.84,percent of total billed charges,,,85,,63.84,percent of total billed charges,,,49,,36.8,percent of total billed charges,,,90,,67.59,percent of total billed charges,,,,,,,no IP contract,,80,,60.08,percent of total billed charges,,,,,,,no IP contract,,50,,37.55,percent of total billed charges,,,,,,no IP contract,,,78,,58.58,percent of total billed charges,,,70,,52.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.8,3324,
00409-9735-10 - cefepime 2 g REC I,00409-9735-10,NDC,,,,inpatient,1,EA,174.6,104.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,141.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,148.41,percent of total billed charges,,,85,,148.41,percent of total billed charges,,,49,,85.55,percent of total billed charges,,,90,,157.14,percent of total billed charges,,,,,,,no IP contract,,80,,139.68,percent of total billed charges,,,,,,,no IP contract,,50,,87.3,percent of total billed charges,,,,,,no IP contract,,,78,,136.19,percent of total billed charges,,,70,,122.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,85.55,3324,
00430-0166-24 - methenamine mandelate 0.5 g Tab,00430-0166-24,NDC,,,,inpatient,1,EA,8.1,4.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.89,percent of total billed charges,,,85,,6.89,percent of total billed charges,,,49,,3.97,percent of total billed charges,,,90,,7.29,percent of total billed charges,,,,,,,no IP contract,,80,,6.48,percent of total billed charges,,,,,,,no IP contract,,50,,4.05,percent of total billed charges,,,,,,no IP contract,,,78,,6.32,percent of total billed charges,,,70,,5.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.97,3324,
00436-0672-16 - sodium hypochlorite topical 0.125% Soln,00436-0672-16,NDC,,,,inpatient,1,UN,39.4,23.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.49,percent of total billed charges,,,85,,33.49,percent of total billed charges,,,49,,19.31,percent of total billed charges,,,90,,35.46,percent of total billed charges,,,,,,,no IP contract,,80,,31.52,percent of total billed charges,,,,,,,no IP contract,,50,,19.7,percent of total billed charges,,,,,,no IP contract,,,78,,30.73,percent of total billed charges,,,70,,27.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.31,3324,
00436-0936-16 - sodium hypochlorite topical 0.25% Soln,00436-0936-16,NDC,,,,inpatient,1,UN,39.4,23.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.49,percent of total billed charges,,,85,,33.49,percent of total billed charges,,,49,,19.31,percent of total billed charges,,,90,,35.46,percent of total billed charges,,,,,,,no IP contract,,80,,31.52,percent of total billed charges,,,,,,,no IP contract,,50,,19.7,percent of total billed charges,,,,,,no IP contract,,,78,,30.73,percent of total billed charges,,,70,,27.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.31,3324,
00436-0946-16 - sodium hypochlorite topical 0.5% Soln,00436-0946-16,NDC,,,,inpatient,1,UN,39.4,23.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.49,percent of total billed charges,,,85,,33.49,percent of total billed charges,,,49,,19.31,percent of total billed charges,,,90,,35.46,percent of total billed charges,,,,,,,no IP contract,,80,,31.52,percent of total billed charges,,,,,,,no IP contract,,50,,19.7,percent of total billed charges,,,,,,no IP contract,,,78,,30.73,percent of total billed charges,,,70,,27.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.31,3324,
00451-2201-04 - prednisoLONE 5 mg/5 mL LIQ,00451-2201-04,NDC,,,,inpatient,5,ML,6.9,4.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.87,percent of total billed charges,,,85,,5.87,percent of total billed charges,,,49,,3.38,percent of total billed charges,,,90,,6.21,percent of total billed charges,,,,,,,no IP contract,,80,,5.52,percent of total billed charges,,,,,,,no IP contract,,50,,3.45,percent of total billed charges,,,,,,no IP contract,,,78,,5.38,percent of total billed charges,,,70,,4.83,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.38,3324,
00456-0400-10 - ceftaroline 400 mg REC I,00456-0400-10,NDC,,,,inpatient,20,ML,1338.1,802.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1083.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1137.39,percent of total billed charges,,,85,,1137.39,percent of total billed charges,,,49,,655.67,percent of total billed charges,,,90,,1204.29,percent of total billed charges,,,,,,,no IP contract,,80,,1070.48,percent of total billed charges,,,,,,,no IP contract,,50,,669.05,percent of total billed charges,,,,,,no IP contract,,,78,,1043.72,percent of total billed charges,,,70,,936.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,655.67,3324,
00456-0459-01 - thyroid desiccated 60 mg Tab,00456-0459-01,NDC,,,,inpatient,1,EA,5.1,3.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.34,percent of total billed charges,,,85,,4.34,percent of total billed charges,,,49,,2.5,percent of total billed charges,,,90,,4.59,percent of total billed charges,,,,,,,no IP contract,,80,,4.08,percent of total billed charges,,,,,,,no IP contract,,50,,2.55,percent of total billed charges,,,,,,no IP contract,,,78,,3.98,percent of total billed charges,,,70,,3.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.5,3324,
00456-0600-10 - ceftaroline 600 mg REC I,00456-0600-10,NDC,,,,inpatient,20,ML,1338.1,802.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1083.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1137.39,percent of total billed charges,,,85,,1137.39,percent of total billed charges,,,49,,655.67,percent of total billed charges,,,90,,1204.29,percent of total billed charges,,,,,,,no IP contract,,80,,1070.48,percent of total billed charges,,,,,,,no IP contract,,50,,669.05,percent of total billed charges,,,,,,no IP contract,,,78,,1043.72,percent of total billed charges,,,70,,936.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,655.67,3324,
00456-0644-16 - theophylline 80 mg/15 mL Elixi,00456-0644-16,NDC,,,,inpatient,1,ML,7.1,4.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.04,percent of total billed charges,,,85,,6.04,percent of total billed charges,,,49,,3.48,percent of total billed charges,,,90,,6.39,percent of total billed charges,,,,,,,no IP contract,,80,,5.68,percent of total billed charges,,,,,,,no IP contract,,50,,3.55,percent of total billed charges,,,,,,no IP contract,,,78,,5.54,percent of total billed charges,,,70,,4.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.48,3324,
00456-0662-71 - potassium chloride 20 mEq REC P,00456-0662-71,NDC,,,,inpatient,1,UN,15.1,9.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.84,percent of total billed charges,,,85,,12.84,percent of total billed charges,,,49,,7.4,percent of total billed charges,,,90,,13.59,percent of total billed charges,,,,,,,no IP contract,,80,,12.08,percent of total billed charges,,,,,,,no IP contract,,50,,7.55,percent of total billed charges,,,,,,no IP contract,,,78,,11.78,percent of total billed charges,,,70,,10.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.4,3324,
vilazodone 20 mg Tab,00456-1120-30,NDC,,,,inpatient,1,EA,44.55,26.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,37.87,percent of total billed charges,,,85,,37.87,percent of total billed charges,,,49,,21.83,percent of total billed charges,,,90,,40.1,percent of total billed charges,,,,,,,no IP contract,,80,,35.64,percent of total billed charges,,,,,,,no IP contract,,50,,22.28,percent of total billed charges,,,,,,no IP contract,,,78,,34.75,percent of total billed charges,,,70,,31.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.83,3324,
00456-1405-30 - nebivolol 5 mg Tab,00456-1405-30,NDC,,,,inpatient,1,EA,21.85,13.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.57,percent of total billed charges,,,85,,18.57,percent of total billed charges,,,49,,10.71,percent of total billed charges,,,90,,19.67,percent of total billed charges,,,,,,,no IP contract,,80,,17.48,percent of total billed charges,,,,,,,no IP contract,,50,,10.93,percent of total billed charges,,,,,,no IP contract,,,78,,17.04,percent of total billed charges,,,70,,15.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.71,3324,
00456-1405-63 - nebivolol 5 mg Tab,00456-1405-63,NDC,,,,inpatient,1,EA,22.25,13.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.91,percent of total billed charges,,,85,,18.91,percent of total billed charges,,,49,,10.9,percent of total billed charges,,,90,,20.03,percent of total billed charges,,,,,,,no IP contract,,80,,17.8,percent of total billed charges,,,,,,,no IP contract,,50,,11.13,percent of total billed charges,,,,,,no IP contract,,,78,,17.36,percent of total billed charges,,,70,,15.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.9,3324,
00456-2700-10 - avibactam-ceftazidime 0.5 g-2 g REC I,00456-2700-10,NDC,,,,inpatient,12,ML,2665,1599,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2158.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2265.25,percent of total billed charges,,,85,,2265.25,percent of total billed charges,,,49,,1305.85,percent of total billed charges,,,90,,2398.5,percent of total billed charges,,,,,,,no IP contract,,80,,2132,percent of total billed charges,,,,,,,no IP contract,,50,,1332.5,percent of total billed charges,,,,,,no IP contract,,,78,,2078.7,percent of total billed charges,,,70,,1865.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
00456-3202-12 - memantine 2 mg/mL Soln,00456-3202-12,NDC,,,,inpatient,1,ML,14.9,8.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.67,percent of total billed charges,,,85,,12.67,percent of total billed charges,,,49,,7.3,percent of total billed charges,,,90,,13.41,percent of total billed charges,,,,,,,no IP contract,,80,,11.92,percent of total billed charges,,,,,,,no IP contract,,50,,7.45,percent of total billed charges,,,,,,no IP contract,,,78,,11.62,percent of total billed charges,,,70,,10.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.3,3324,
00456-3205-60 - memantine 5 mg Tab,00456-3205-60,NDC,,,,inpatient,1,EA,24.35,14.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.7,percent of total billed charges,,,85,,20.7,percent of total billed charges,,,49,,11.93,percent of total billed charges,,,90,,21.92,percent of total billed charges,,,,,,,no IP contract,,80,,19.48,percent of total billed charges,,,,,,,no IP contract,,50,,12.18,percent of total billed charges,,,,,,no IP contract,,,78,,18.99,percent of total billed charges,,,70,,17.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.93,3324,
00456-3210-11 - memantine 10 mg Tab,00456-3210-11,NDC,,,,inpatient,1,EA,26.65,15.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.65,percent of total billed charges,,,85,,22.65,percent of total billed charges,,,49,,13.06,percent of total billed charges,,,90,,23.99,percent of total billed charges,,,,,,,no IP contract,,80,,21.32,percent of total billed charges,,,,,,,no IP contract,,50,,13.33,percent of total billed charges,,,,,,no IP contract,,,78,,20.79,percent of total billed charges,,,70,,18.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.06,3324,
00456-3210-60 - memantine 10 mg Tab,00456-3210-60,NDC,,,,inpatient,1,EA,24.35,14.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.7,percent of total billed charges,,,85,,20.7,percent of total billed charges,,,49,,11.93,percent of total billed charges,,,90,,21.92,percent of total billed charges,,,,,,,no IP contract,,80,,19.48,percent of total billed charges,,,,,,,no IP contract,,50,,12.18,percent of total billed charges,,,,,,no IP contract,,,78,,18.99,percent of total billed charges,,,70,,17.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.93,3324,
00456-3210-63 - memantine 10 mg Tab,00456-3210-63,NDC,,,,inpatient,1,EA,25.35,15.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.55,percent of total billed charges,,,85,,21.55,percent of total billed charges,,,49,,12.42,percent of total billed charges,,,90,,22.82,percent of total billed charges,,,,,,,no IP contract,,80,,20.28,percent of total billed charges,,,,,,,no IP contract,,50,,12.68,percent of total billed charges,,,,,,no IP contract,,,78,,19.77,percent of total billed charges,,,70,,17.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.42,3324,
00456-4040-01 - citalopram 40 mg Tab,00456-4040-01,NDC,,,,inpatient,1,EA,29.35,17.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.95,percent of total billed charges,,,85,,24.95,percent of total billed charges,,,49,,14.38,percent of total billed charges,,,90,,26.42,percent of total billed charges,,,,,,,no IP contract,,80,,23.48,percent of total billed charges,,,,,,,no IP contract,,50,,14.68,percent of total billed charges,,,,,,no IP contract,,,78,,22.89,percent of total billed charges,,,70,,20.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.38,3324,
00469-0420-99 - isavuconazonium 372 mg REC I,00469-0420-99,NDC,,,,inpatient,5,ML,2803.7,1682.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2271,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2383.15,percent of total billed charges,,,85,,2383.15,percent of total billed charges,,,49,,1373.81,percent of total billed charges,,,90,,2523.33,percent of total billed charges,,,,,,,no IP contract,,80,,2242.96,percent of total billed charges,,,,,,,no IP contract,,50,,1401.85,percent of total billed charges,,,,,,no IP contract,,,78,,2186.89,percent of total billed charges,,,70,,1962.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
00469-0520-14 - isavuconazonium 186 mg Cap,00469-0520-14,NDC,,,,inpatient,1,EA,194.85,116.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,157.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,165.62,percent of total billed charges,,,85,,165.62,percent of total billed charges,,,49,,95.48,percent of total billed charges,,,90,,175.37,percent of total billed charges,,,,,,,no IP contract,,80,,155.88,percent of total billed charges,,,,,,,no IP contract,,50,,97.43,percent of total billed charges,,,,,,no IP contract,,,78,,151.98,percent of total billed charges,,,70,,136.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,95.48,3324,
00469-0607-67 - tacrolimus 0.5 mg Cap,00469-0607-67,NDC,,,,inpatient,1,EA,19.35,11.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.45,percent of total billed charges,,,85,,16.45,percent of total billed charges,,,49,,9.48,percent of total billed charges,,,90,,17.42,percent of total billed charges,,,,,,,no IP contract,,80,,15.48,percent of total billed charges,,,,,,,no IP contract,,50,,9.68,percent of total billed charges,,,,,,no IP contract,,,78,,15.09,percent of total billed charges,,,70,,13.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.48,3324,
00469-0607-73 - tacrolimus 0.5 mg Cap,00469-0607-73,NDC,,,,inpatient,1,EA,21.85,13.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.57,percent of total billed charges,,,85,,18.57,percent of total billed charges,,,49,,10.71,percent of total billed charges,,,90,,19.67,percent of total billed charges,,,,,,,no IP contract,,80,,17.48,percent of total billed charges,,,,,,,no IP contract,,50,,10.93,percent of total billed charges,,,,,,no IP contract,,,78,,17.04,percent of total billed charges,,,70,,15.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.71,3324,
00469-0617-73 - tacrolimus 1 mg Cap,00469-0617-73,NDC,,,,inpatient,1,EA,37.85,22.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.17,percent of total billed charges,,,85,,32.17,percent of total billed charges,,,49,,18.55,percent of total billed charges,,,90,,34.07,percent of total billed charges,,,,,,,no IP contract,,80,,30.28,percent of total billed charges,,,,,,,no IP contract,,50,,18.93,percent of total billed charges,,,,,,no IP contract,,,78,,29.52,percent of total billed charges,,,70,,26.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.55,3324,
00469-2601-30 - mirabegron 25 mg ER Ta,00469-2601-30,NDC,,,,inpatient,1,EA,70.15,42.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,56.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,59.63,percent of total billed charges,,,85,,59.63,percent of total billed charges,,,49,,34.37,percent of total billed charges,,,90,,63.14,percent of total billed charges,,,,,,,no IP contract,,80,,56.12,percent of total billed charges,,,,,,,no IP contract,,50,,35.08,percent of total billed charges,,,,,,no IP contract,,,78,,54.72,percent of total billed charges,,,70,,49.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,34.37,3324,
00469-2602-30 - mirabegron 50 mg ER Ta,00469-2602-30,NDC,,,,inpatient,1,EA,70.15,42.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,56.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,59.63,percent of total billed charges,,,85,,59.63,percent of total billed charges,,,49,,34.37,percent of total billed charges,,,90,,63.14,percent of total billed charges,,,,,,,no IP contract,,80,,56.12,percent of total billed charges,,,,,,,no IP contract,,50,,35.08,percent of total billed charges,,,,,,no IP contract,,,78,,54.72,percent of total billed charges,,,70,,49.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,34.37,3324,
00469-3051-30 - amphotericin B liposomal 50 mg REC I,00469-3051-30,NDC,,,,inpatient,12.5,ML,1644,986.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1331.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1397.4,percent of total billed charges,,,85,,1397.4,percent of total billed charges,,,49,,805.56,percent of total billed charges,,,90,,1479.6,percent of total billed charges,,,,,,,no IP contract,,80,,1315.2,percent of total billed charges,,,,,,,no IP contract,,50,,822,percent of total billed charges,,,,,,no IP contract,,,78,,1282.32,percent of total billed charges,,,70,,1150.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,805.56,3324,
micafungin 100 mg REC I,00469-3211-10,NDC,,,,inpatient,1,EA,1944.4,1166.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1574.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1652.74,percent of total billed charges,,,85,,1652.74,percent of total billed charges,,,49,,952.76,percent of total billed charges,,,90,,1749.96,percent of total billed charges,,,,,,,no IP contract,,80,,1555.52,percent of total billed charges,,,,,,,no IP contract,,50,,972.2,percent of total billed charges,,,,,,no IP contract,,,78,,1516.63,percent of total billed charges,,,70,,1361.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,952.76,3324,
00469-3211-99 - micafungin 100 mg REC I,00469-3211-99,NDC,,,,inpatient,5,ML,1944.4,1166.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1574.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1652.74,percent of total billed charges,,,85,,1652.74,percent of total billed charges,,,49,,952.76,percent of total billed charges,,,90,,1749.96,percent of total billed charges,,,,,,,no IP contract,,80,,1555.52,percent of total billed charges,,,,,,,no IP contract,,50,,972.2,percent of total billed charges,,,,,,no IP contract,,,78,,1516.63,percent of total billed charges,,,70,,1361.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,952.76,3324,
micafungin 50 mg REC I,00469-3250-10,NDC,,,,inpatient,1,EA,1032.05,619.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,835.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,877.24,percent of total billed charges,,,85,,877.24,percent of total billed charges,,,49,,505.7,percent of total billed charges,,,90,,928.85,percent of total billed charges,,,,,,,no IP contract,,80,,825.64,percent of total billed charges,,,,,,,no IP contract,,50,,516.03,percent of total billed charges,,,,,,no IP contract,,,78,,805,percent of total billed charges,,,70,,722.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,505.7,3324,
00472-0082-16 - acyclovir 200 mg/5 mL Susp,00472-0082-16,NDC,,,,inpatient,1,ML,13.25,7.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.26,percent of total billed charges,,,85,,11.26,percent of total billed charges,,,49,,6.49,percent of total billed charges,,,90,,11.93,percent of total billed charges,,,,,,,no IP contract,,80,,10.6,percent of total billed charges,,,,,,,no IP contract,,50,,6.63,percent of total billed charges,,,,,,no IP contract,,,78,,10.34,percent of total billed charges,,,70,,9.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.49,3324,
00472-0117-20 - tretinoin topical 0.025% Cream,00472-0117-20,NDC,,,,inpatient,1,UN,1072.15,643.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,868.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,911.33,percent of total billed charges,,,85,,911.33,percent of total billed charges,,,49,,525.35,percent of total billed charges,,,90,,964.94,percent of total billed charges,,,,,,,no IP contract,,80,,857.72,percent of total billed charges,,,,,,,no IP contract,,50,,536.08,percent of total billed charges,,,,,,no IP contract,,,78,,836.28,percent of total billed charges,,,70,,750.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,525.35,3324,
00472-0150-30 - nystatin-triamcinolone topical 100000 units/g-0.1% Cream,00472-0150-30,NDC,,,,inpatient,1,UN,64.2,38.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,54.57,percent of total billed charges,,,85,,54.57,percent of total billed charges,,,49,,31.46,percent of total billed charges,,,90,,57.78,percent of total billed charges,,,,,,,no IP contract,,80,,51.36,percent of total billed charges,,,,,,,no IP contract,,50,,32.1,percent of total billed charges,,,,,,no IP contract,,,78,,50.08,percent of total billed charges,,,70,,44.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.46,3324,
00472-0163-30 - nystatin topical 100000 units/g Cream,00472-0163-30,NDC,,,,inpatient,1,UN,229.15,137.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,185.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,194.78,percent of total billed charges,,,85,,194.78,percent of total billed charges,,,49,,112.28,percent of total billed charges,,,90,,206.24,percent of total billed charges,,,,,,,no IP contract,,80,,183.32,percent of total billed charges,,,,,,,no IP contract,,50,,114.58,percent of total billed charges,,,,,,no IP contract,,,78,,178.74,percent of total billed charges,,,70,,160.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,112.28,3324,
00472-0166-30 - nystatin topical 100000 units/g Ointm,00472-0166-30,NDC,,,,inpatient,1,UN,229.15,137.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,185.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,194.78,percent of total billed charges,,,85,,194.78,percent of total billed charges,,,49,,112.28,percent of total billed charges,,,90,,206.24,percent of total billed charges,,,,,,,no IP contract,,80,,183.32,percent of total billed charges,,,,,,,no IP contract,,50,,114.58,percent of total billed charges,,,,,,no IP contract,,,78,,178.74,percent of total billed charges,,,70,,160.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,112.28,3324,
00472-0179-16 - bacitracin/neomycin/polymyxin B Topical 400 units-3.5 mg-5000 units/g Ointm,00472-0179-16,NDC,,,,inpatient,1,UN,160.5,96.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,130.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,136.43,percent of total billed charges,,,85,,136.43,percent of total billed charges,,,49,,78.65,percent of total billed charges,,,90,,144.45,percent of total billed charges,,,,,,,no IP contract,,80,,128.4,percent of total billed charges,,,,,,,no IP contract,,50,,80.25,percent of total billed charges,,,,,,no IP contract,,,78,,125.19,percent of total billed charges,,,70,,112.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,78.65,3324,
00472-0220-41 - clotrimazole topical 1% Cream,00472-0220-41,NDC,,,,inpatient,1,UN,110.45,66.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,89.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,93.88,percent of total billed charges,,,85,,93.88,percent of total billed charges,,,49,,54.12,percent of total billed charges,,,90,,99.41,percent of total billed charges,,,,,,,no IP contract,,80,,88.36,percent of total billed charges,,,,,,,no IP contract,,50,,55.23,percent of total billed charges,,,,,,no IP contract,,,78,,86.15,percent of total billed charges,,,70,,77.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,54.12,3324,
00472-0235-16 - levetiracetam 100 mg/mL Soln,00472-0235-16,NDC,,,,inpatient,1,ML,10.85,6.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.22,percent of total billed charges,,,85,,9.22,percent of total billed charges,,,49,,5.32,percent of total billed charges,,,90,,9.77,percent of total billed charges,,,,,,,no IP contract,,80,,8.68,percent of total billed charges,,,,,,,no IP contract,,50,,5.43,percent of total billed charges,,,,,,no IP contract,,,78,,8.46,percent of total billed charges,,,70,,7.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.32,3324,
00472-0242-60 - permethrin topical 5% Cream,00472-0242-60,NDC,,,,inpatient,1,UN,1038.8,623.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,841.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,882.98,percent of total billed charges,,,85,,882.98,percent of total billed charges,,,49,,509.01,percent of total billed charges,,,90,,934.92,percent of total billed charges,,,,,,,no IP contract,,80,,831.04,percent of total billed charges,,,,,,,no IP contract,,50,,519.4,percent of total billed charges,,,,,,no IP contract,,,78,,810.26,percent of total billed charges,,,70,,727.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,509.01,3324,
00472-0345-56 - hydrocortisone topical 1% Ointm,00472-0345-56,NDC,,,,inpatient,1,UN,37.2,22.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.62,percent of total billed charges,,,85,,31.62,percent of total billed charges,,,49,,18.23,percent of total billed charges,,,90,,33.48,percent of total billed charges,,,,,,,no IP contract,,80,,29.76,percent of total billed charges,,,,,,,no IP contract,,50,,18.6,percent of total billed charges,,,,,,no IP contract,,,78,,29.02,percent of total billed charges,,,70,,26.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.23,3324,
00472-0381-15 - betamethasone topical dipropionate 0.05% Ointm,00472-0381-15,NDC,,,,inpatient,1,UN,71.7,43.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,58.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,60.95,percent of total billed charges,,,85,,60.95,percent of total billed charges,,,49,,35.13,percent of total billed charges,,,90,,64.53,percent of total billed charges,,,,,,,no IP contract,,80,,57.36,percent of total billed charges,,,,,,,no IP contract,,50,,35.85,percent of total billed charges,,,,,,no IP contract,,,78,,55.93,percent of total billed charges,,,70,,50.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,35.13,3324,
00472-0570-02 - lindane Topical 1% Lotio,00472-0570-02,NDC,,,,inpatient,1,UN,264.8,158.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,214.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,225.08,percent of total billed charges,,,85,,225.08,percent of total billed charges,,,49,,129.75,percent of total billed charges,,,90,,238.32,percent of total billed charges,,,,,,,no IP contract,,80,,211.84,percent of total billed charges,,,,,,,no IP contract,,50,,132.4,percent of total billed charges,,,,,,no IP contract,,,78,,206.54,percent of total billed charges,,,70,,185.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,129.75,3324,
00472-0735-56 - miconazole topical 2% Cream,00472-0735-56,NDC,,,,inpatient,1,UN,37.6,22.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.96,percent of total billed charges,,,85,,31.96,percent of total billed charges,,,49,,18.42,percent of total billed charges,,,90,,33.84,percent of total billed charges,,,,,,,no IP contract,,80,,30.08,percent of total billed charges,,,,,,,no IP contract,,50,,18.8,percent of total billed charges,,,,,,no IP contract,,,78,,29.33,percent of total billed charges,,,70,,26.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.42,3324,
00472-0803-02 - desonide topical 0.05% Lotio,00472-0803-02,NDC,,,,inpatient,1,UN,2518.2,1510.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2039.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2140.47,percent of total billed charges,,,85,,2140.47,percent of total billed charges,,,49,,1233.92,percent of total billed charges,,,90,,2266.38,percent of total billed charges,,,,,,,no IP contract,,80,,2014.56,percent of total billed charges,,,,,,,no IP contract,,50,,1259.1,percent of total billed charges,,,,,,no IP contract,,,78,,1964.2,percent of total billed charges,,,70,,1762.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
00472-0804-60 - desonide topical 0.05% Cream,00472-0804-60,NDC,,,,inpatient,1,UN,2683.15,1609.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2173.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2280.68,percent of total billed charges,,,85,,2280.68,percent of total billed charges,,,49,,1314.74,percent of total billed charges,,,90,,2414.84,percent of total billed charges,,,,,,,no IP contract,,80,,2146.52,percent of total billed charges,,,,,,,no IP contract,,50,,1341.58,percent of total billed charges,,,,,,no IP contract,,,78,,2092.86,percent of total billed charges,,,70,,1878.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
00472-1270-94 - ibuprofen 100 mg/5 mL Susp,00472-1270-94,NDC,,,,inpatient,1,ML,95.4,57.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,77.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,81.09,percent of total billed charges,,,85,,81.09,percent of total billed charges,,,49,,46.75,percent of total billed charges,,,90,,85.86,percent of total billed charges,,,,,,,no IP contract,,80,,76.32,percent of total billed charges,,,,,,,no IP contract,,50,,47.7,percent of total billed charges,,,,,,no IP contract,,,78,,74.41,percent of total billed charges,,,70,,66.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,46.75,3324,
00472-1444-16 - theophylline 80 mg/15 mL Elixi,00472-1444-16,NDC,,,,inpatient,1,ML,5.5,3.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.68,percent of total billed charges,,,85,,4.68,percent of total billed charges,,,49,,2.7,percent of total billed charges,,,90,,4.95,percent of total billed charges,,,,,,,no IP contract,,80,,4.4,percent of total billed charges,,,,,,,no IP contract,,50,,2.75,percent of total billed charges,,,,,,no IP contract,,,78,,4.29,percent of total billed charges,,,70,,3.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.7,3324,
00472-1736-07 - miconazole topical 100 mg Supp,00472-1736-07,NDC,,,,inpatient,1,UN,95.65,57.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,77.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,81.3,percent of total billed charges,,,85,,81.3,percent of total billed charges,,,49,,46.87,percent of total billed charges,,,90,,86.09,percent of total billed charges,,,,,,,no IP contract,,80,,76.52,percent of total billed charges,,,,,,,no IP contract,,50,,47.83,percent of total billed charges,,,,,,no IP contract,,,78,,74.61,percent of total billed charges,,,70,,66.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,46.87,3324,
00486-1111-01 - potassium acid phosphate 500 mg Tab,00486-1111-01,NDC,,,,inpatient,1,EA,5,3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.25,percent of total billed charges,,,85,,4.25,percent of total billed charges,,,49,,2.45,percent of total billed charges,,,90,,4.5,percent of total billed charges,,,,,,,no IP contract,,80,,4,percent of total billed charges,,,,,,,no IP contract,,50,,2.5,percent of total billed charges,,,,,,no IP contract,,,78,,3.9,percent of total billed charges,,,70,,3.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.45,3324,
00486-1111-05 - potassium acid phosphate 500 mg Tab,00486-1111-05,NDC,,,,inpatient,1,EA,8.2,4.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.97,percent of total billed charges,,,85,,6.97,percent of total billed charges,,,49,,4.02,percent of total billed charges,,,90,,7.38,percent of total billed charges,,,,,,,no IP contract,,80,,6.56,percent of total billed charges,,,,,,,no IP contract,,50,,4.1,percent of total billed charges,,,,,,no IP contract,,,78,,6.4,percent of total billed charges,,,70,,5.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.02,3324,
potassium phosphate-sodium phosphate 250 mg-45 mg-298 mg Tab,00486-1125-01,NDC,,,,inpatient,1,EA,5.25,3.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.46,percent of total billed charges,,,85,,4.46,percent of total billed charges,,,49,,2.57,percent of total billed charges,,,90,,4.73,percent of total billed charges,,,,,,,no IP contract,,80,,4.2,percent of total billed charges,,,,,,,no IP contract,,50,,2.63,percent of total billed charges,,,,,,no IP contract,,,78,,4.1,percent of total billed charges,,,70,,3.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.57,3324,
00487-0201-01 - albuterol-ipratropium 2.5 mg-0.5 mg/3 mL Soln,00487-0201-01,NDC,,,,inpatient,3,ML,27.7,16.62,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.55,percent of total billed charges,,,85,,23.55,percent of total billed charges,,,49,,13.57,percent of total billed charges,,,90,,24.93,percent of total billed charges,,,,,,,no IP contract,,80,,22.16,percent of total billed charges,,,,,,,no IP contract,,50,,13.85,percent of total billed charges,,,,,,no IP contract,,,78,,21.61,percent of total billed charges,,,70,,19.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.57,3324,
00487-0201-03 - albuterol-ipratropium 2.5 mg-0.5 mg/3 mL Soln,00487-0201-03,NDC,,,,inpatient,3,ML,27.45,16.47,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.33,percent of total billed charges,,,85,,23.33,percent of total billed charges,,,49,,13.45,percent of total billed charges,,,90,,24.71,percent of total billed charges,,,,,,,no IP contract,,80,,21.96,percent of total billed charges,,,,,,,no IP contract,,50,,13.73,percent of total billed charges,,,,,,no IP contract,,,78,,21.41,percent of total billed charges,,,70,,19.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.45,3324,
00487-2784-01 - racepinephrine 2.25% Soln,00487-2784-01,NDC,,,,inpatient,1,UN,17.55,10.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.92,percent of total billed charges,,,85,,14.92,percent of total billed charges,,,49,,8.6,percent of total billed charges,,,90,,15.8,percent of total billed charges,,,,,,,no IP contract,,80,,14.04,percent of total billed charges,,,,,,,no IP contract,,50,,8.78,percent of total billed charges,,,,,,no IP contract,,,78,,13.69,percent of total billed charges,,,70,,12.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.6,3324,
00487-5901-99 - epinephrine 2.25% Soln,00487-5901-99,NDC,,,,inpatient,1,UN,20.15,12.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.13,percent of total billed charges,,,85,,17.13,percent of total billed charges,,,49,,9.87,percent of total billed charges,,,90,,18.14,percent of total billed charges,,,,,,,no IP contract,,80,,16.12,percent of total billed charges,,,,,,,no IP contract,,50,,10.08,percent of total billed charges,,,,,,no IP contract,,,78,,15.72,percent of total billed charges,,,70,,14.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.87,3324,
00487-9003-60 - sodium chloride 3% Soln,00487-9003-60,NDC,,,,inpatient,4,ML,12.55,7.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.67,percent of total billed charges,,,85,,10.67,percent of total billed charges,,,49,,6.15,percent of total billed charges,,,90,,11.3,percent of total billed charges,,,,,,,no IP contract,,80,,10.04,percent of total billed charges,,,,,,,no IP contract,,50,,6.28,percent of total billed charges,,,,,,no IP contract,,,78,,9.79,percent of total billed charges,,,70,,8.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.15,3324,
00487-9301-03 - sodium chloride 0.9% Soln,00487-9301-03,NDC,,,,inpatient,3,ML,10.2,6.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.67,percent of total billed charges,,,85,,8.67,percent of total billed charges,,,49,,5,percent of total billed charges,,,90,,9.18,percent of total billed charges,,,,,,,no IP contract,,80,,8.16,percent of total billed charges,,,,,,,no IP contract,,50,,5.1,percent of total billed charges,,,,,,no IP contract,,,78,,7.96,percent of total billed charges,,,70,,7.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5,3324,
00487-9501-01 - albuterol 0.083% Soln,00487-9501-01,NDC,,,,inpatient,3,ML,15.95,9.57,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.56,percent of total billed charges,,,85,,13.56,percent of total billed charges,,,49,,7.82,percent of total billed charges,,,90,,14.36,percent of total billed charges,,,,,,,no IP contract,,80,,12.76,percent of total billed charges,,,,,,,no IP contract,,50,,7.98,percent of total billed charges,,,,,,no IP contract,,,78,,12.44,percent of total billed charges,,,70,,11.17,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.82,3324,
00487-9601-01 - budesonide 0.25 mg/2 mL Susp,00487-9601-01,NDC,,,,inpatient,2,ML,88.2,52.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,71.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,74.97,percent of total billed charges,,,85,,74.97,percent of total billed charges,,,49,,43.22,percent of total billed charges,,,90,,79.38,percent of total billed charges,,,,,,,no IP contract,,80,,70.56,percent of total billed charges,,,,,,,no IP contract,,50,,44.1,percent of total billed charges,,,,,,no IP contract,,,78,,68.8,percent of total billed charges,,,70,,61.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,43.22,3324,
00487-9601-30 - budesonide 0.25 mg/2 mL Susp,00487-9601-30,NDC,,,,inpatient,2,ML,58.85,35.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,47.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,50.02,percent of total billed charges,,,85,,50.02,percent of total billed charges,,,49,,28.84,percent of total billed charges,,,90,,52.97,percent of total billed charges,,,,,,,no IP contract,,80,,47.08,percent of total billed charges,,,,,,,no IP contract,,50,,29.43,percent of total billed charges,,,,,,no IP contract,,,78,,45.9,percent of total billed charges,,,70,,41.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,28.84,3324,
00487-9801-01 - ipratropium 0.02% Soln,00487-9801-01,NDC,,,,inpatient,2.5,ML,20.25,12.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.21,percent of total billed charges,,,85,,17.21,percent of total billed charges,,,49,,9.92,percent of total billed charges,,,90,,18.23,percent of total billed charges,,,,,,,no IP contract,,80,,16.2,percent of total billed charges,,,,,,,no IP contract,,50,,10.13,percent of total billed charges,,,,,,no IP contract,,,78,,15.8,percent of total billed charges,,,70,,14.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.92,3324,
00496-0882-06 - lidocaine topical 4% Cream,00496-0882-06,NDC,,,,inpatient,1,UN,439.05,263.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,355.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,373.19,percent of total billed charges,,,85,,373.19,percent of total billed charges,,,49,,215.13,percent of total billed charges,,,90,,395.15,percent of total billed charges,,,,,,,no IP contract,,80,,351.24,percent of total billed charges,,,,,,,no IP contract,,50,,219.53,percent of total billed charges,,,,,,no IP contract,,,78,,342.46,percent of total billed charges,,,70,,307.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,215.13,3324,
00496-0883-30 - lidocaine Topical 5% Cream,00496-0883-30,NDC,,,,inpatient,1,UN,501.55,300.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,406.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,426.32,percent of total billed charges,,,85,,426.32,percent of total billed charges,,,49,,245.76,percent of total billed charges,,,90,,451.4,percent of total billed charges,,,,,,,no IP contract,,80,,401.24,percent of total billed charges,,,,,,,no IP contract,,50,,250.78,percent of total billed charges,,,,,,no IP contract,,,78,,391.21,percent of total billed charges,,,70,,351.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,245.76,3324,
00496-0892-30 - lidocaine topical 5% Cream,00496-0892-30,NDC,,,,inpatient,1,UN,189.15,113.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,153.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,160.78,percent of total billed charges,,,85,,160.78,percent of total billed charges,,,49,,92.68,percent of total billed charges,,,90,,170.24,percent of total billed charges,,,,,,,no IP contract,,80,,151.32,percent of total billed charges,,,,,,,no IP contract,,50,,94.58,percent of total billed charges,,,,,,no IP contract,,,78,,147.54,percent of total billed charges,,,70,,132.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,92.68,3324,
00501-3798-01 - bacitracin-polymyxin B topical 500 units-10000 units/g Ointm,00501-3798-01,NDC,,,,inpatient,1,UN,81.7,49.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,66.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,69.45,percent of total billed charges,,,85,,69.45,percent of total billed charges,,,49,,40.03,percent of total billed charges,,,90,,73.53,percent of total billed charges,,,,,,,no IP contract,,80,,65.36,percent of total billed charges,,,,,,,no IP contract,,50,,40.85,percent of total billed charges,,,,,,no IP contract,,,78,,63.73,percent of total billed charges,,,70,,57.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,40.03,3324,
00517-0031-25 - cyanocobalamin 1000 mcg/mL Soln,00517-0031-25,NDC,,,,inpatient,1,ML,35.05,21.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.79,percent of total billed charges,,,85,,29.79,percent of total billed charges,,,49,,17.17,percent of total billed charges,,,90,,31.55,percent of total billed charges,,,,,,,no IP contract,,80,,28.04,percent of total billed charges,,,,,,,no IP contract,,50,,17.53,percent of total billed charges,,,,,,no IP contract,,,78,,27.34,percent of total billed charges,,,70,,24.54,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.17,3324,
betamethasone acetate- betamet NA PH 6 mg/mL Susp,00517-0720-01,NDC,,,,inpatient,1,EA,346.5,207.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,280.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,294.53,percent of total billed charges,,,85,,294.53,percent of total billed charges,,,49,,169.79,percent of total billed charges,,,90,,311.85,percent of total billed charges,,,,,,,no IP contract,,80,,277.2,percent of total billed charges,,,,,,,no IP contract,,50,,173.25,percent of total billed charges,,,,,,no IP contract,,,78,,270.27,percent of total billed charges,,,70,,242.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,169.79,3324,
00517-0955-01 - OLANZapine 10 mg REC I,00517-0955-01,NDC,,,,inpatient,2,ML,357.05,214.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,289.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,303.49,percent of total billed charges,,,85,,303.49,percent of total billed charges,,,49,,174.95,percent of total billed charges,,,90,,321.35,percent of total billed charges,,,,,,,no IP contract,,80,,285.64,percent of total billed charges,,,,,,,no IP contract,,50,,178.53,percent of total billed charges,,,,,,no IP contract,,,78,,278.5,percent of total billed charges,,,70,,249.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,174.95,3324,
levOCARNitine 200 mg/mL Soln,00517-1045-05,NDC,,,,inpatient,1,mL,81.5,48.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,66.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,69.28,percent of total billed charges,,,85,,69.28,percent of total billed charges,,,49,,39.94,percent of total billed charges,,,90,,73.35,percent of total billed charges,,,,,,,no IP contract,,80,,65.2,percent of total billed charges,,,,,,,no IP contract,,50,,40.75,percent of total billed charges,,,,,,no IP contract,,,78,,63.57,percent of total billed charges,,,70,,57.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,39.94,3324,
levOCARNitine 200 mg/mL Soln,00517-1075-01,NDC,,,,inpatient,1,mL,81.5,48.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,66.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,69.28,percent of total billed charges,,,85,,69.28,percent of total billed charges,,,49,,39.94,percent of total billed charges,,,90,,73.35,percent of total billed charges,,,,,,,no IP contract,,80,,65.2,percent of total billed charges,,,,,,,no IP contract,,50,,40.75,percent of total billed charges,,,,,,no IP contract,,,78,,63.57,percent of total billed charges,,,70,,57.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,39.94,3324,
00517-2340-10 - iron sucrose 20 mg/mL Soln,00517-2340-10,NDC,,,,inpatient,5,ML,515.1,309.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,417.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,437.84,percent of total billed charges,,,85,,437.84,percent of total billed charges,,,49,,252.4,percent of total billed charges,,,90,,463.59,percent of total billed charges,,,,,,,no IP contract,,80,,412.08,percent of total billed charges,,,,,,,no IP contract,,50,,257.55,percent of total billed charges,,,,,,no IP contract,,,78,,401.78,percent of total billed charges,,,70,,360.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,252.4,3324,
00517-3020-25 - sterile water - Soln,00517-3020-25,NDC,,,,inpatient,20,ML,21.15,12.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.98,percent of total billed charges,,,85,,17.98,percent of total billed charges,,,49,,10.36,percent of total billed charges,,,90,,19.04,percent of total billed charges,,,,,,,no IP contract,,80,,16.92,percent of total billed charges,,,,,,,no IP contract,,50,,10.58,percent of total billed charges,,,,,,no IP contract,,,78,,16.5,percent of total billed charges,,,70,,14.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.36,3324,
00517-5710-25 - furosemide 10 mg/mL Soln,00517-5710-25,NDC,,,,inpatient,2,ML,13.2,7.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.22,percent of total billed charges,,,85,,11.22,percent of total billed charges,,,49,,6.47,percent of total billed charges,,,90,,11.88,percent of total billed charges,,,,,,,no IP contract,,80,,10.56,percent of total billed charges,,,,,,,no IP contract,,50,,6.6,percent of total billed charges,,,,,,no IP contract,,,78,,10.3,percent of total billed charges,,,70,,9.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.47,3324,
00517-6110-25 - zinc sulfate 1 mg/mL Soln,00517-6110-25,NDC,,,,inpatient,1,ML,26.95,16.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.91,percent of total billed charges,,,85,,22.91,percent of total billed charges,,,49,,13.21,percent of total billed charges,,,90,,24.26,percent of total billed charges,,,,,,,no IP contract,,80,,21.56,percent of total billed charges,,,,,,,no IP contract,,50,,13.48,percent of total billed charges,,,,,,no IP contract,,,78,,21.02,percent of total billed charges,,,70,,18.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.21,3324,
00517-6410-25 - manganese sulfate 0.1 mg/mL Soln,00517-6410-25,NDC,,,,inpatient,1,ML,36.2,21.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.77,percent of total billed charges,,,85,,30.77,percent of total billed charges,,,49,,17.74,percent of total billed charges,,,90,,32.58,percent of total billed charges,,,,,,,no IP contract,,80,,28.96,percent of total billed charges,,,,,,,no IP contract,,50,,18.1,percent of total billed charges,,,,,,no IP contract,,,78,,28.24,percent of total billed charges,,,70,,25.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.74,3324,
00517-6510-25 - selenium 40 mcg/mL Soln,00517-6510-25,NDC,,,,inpatient,1,ML,13.55,8.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.52,percent of total billed charges,,,85,,11.52,percent of total billed charges,,,49,,6.64,percent of total billed charges,,,90,,12.2,percent of total billed charges,,,,,,,no IP contract,,80,,10.84,percent of total billed charges,,,,,,,no IP contract,,50,,6.78,percent of total billed charges,,,,,,no IP contract,,,78,,10.57,percent of total billed charges,,,70,,9.49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.64,3324,
00517-6710-10 - calcium chloride 100 mg/mL Soln,00517-6710-10,NDC,,,,inpatient,1,ML,29.8,17.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.33,percent of total billed charges,,,85,,25.33,percent of total billed charges,,,49,,14.6,percent of total billed charges,,,90,,26.82,percent of total billed charges,,,,,,,no IP contract,,80,,23.84,percent of total billed charges,,,,,,,no IP contract,,50,,14.9,percent of total billed charges,,,,,,no IP contract,,,78,,23.24,percent of total billed charges,,,70,,20.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.6,3324,
00517-7201-25 - trace elements 4.0 mcg-0.4 mg-0.1 mg-1.0 mg/mL Soln,00517-7201-25,NDC,,,,inpatient,1,ML,16.05,9.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.64,percent of total billed charges,,,85,,13.64,percent of total billed charges,,,49,,7.86,percent of total billed charges,,,90,,14.45,percent of total billed charges,,,,,,,no IP contract,,80,,12.84,percent of total billed charges,,,,,,,no IP contract,,50,,8.03,percent of total billed charges,,,,,,no IP contract,,,78,,12.52,percent of total billed charges,,,70,,11.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.86,3324,
00517-7410-25 - trace elements 4.0 mcg-0.4 mg-0.1 mg-1.0 mg/mL Soln,00517-7410-25,NDC,,,,inpatient,1,ML,13.8,8.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.73,percent of total billed charges,,,85,,11.73,percent of total billed charges,,,49,,6.76,percent of total billed charges,,,90,,12.42,percent of total billed charges,,,,,,,no IP contract,,80,,11.04,percent of total billed charges,,,,,,,no IP contract,,50,,6.9,percent of total billed charges,,,,,,no IP contract,,,78,,10.76,percent of total billed charges,,,70,,9.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.76,3324,
00517-8201-25 - trace elements with selenium 4 mcg-0.4 mg-0.1 mg-20 mcg-1 mg/mL Soln,00517-8201-25,NDC,,,,inpatient,1,ML,93.6,56.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,75.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,79.56,percent of total billed charges,,,85,,79.56,percent of total billed charges,,,49,,45.86,percent of total billed charges,,,90,,84.24,percent of total billed charges,,,,,,,no IP contract,,80,,74.88,percent of total billed charges,,,,,,,no IP contract,,50,,46.8,percent of total billed charges,,,,,,no IP contract,,,78,,73.01,percent of total billed charges,,,70,,65.52,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,45.86,3324,
00517-9203-25 - trace elements 1 mcg-0.1 mg-0.025 mg-1.0 mg/mL Soln,00517-9203-25,NDC,,,,inpatient,1,ML,12.85,7.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.92,percent of total billed charges,,,85,,10.92,percent of total billed charges,,,49,,6.3,percent of total billed charges,,,90,,11.57,percent of total billed charges,,,,,,,no IP contract,,80,,10.28,percent of total billed charges,,,,,,,no IP contract,,50,,6.43,percent of total billed charges,,,,,,no IP contract,,,78,,10.02,percent of total billed charges,,,70,,9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.3,3324,
00525-0906-90 - multivitamin Vitamin B Complex with Folic Acid Tab,00525-0906-90,NDC,,,,inpatient,1,EA,9.45,5.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.03,percent of total billed charges,,,85,,8.03,percent of total billed charges,,,49,,4.63,percent of total billed charges,,,90,,8.51,percent of total billed charges,,,,,,,no IP contract,,80,,7.56,percent of total billed charges,,,,,,,no IP contract,,50,,4.73,percent of total billed charges,,,,,,no IP contract,,,78,,7.37,percent of total billed charges,,,70,,6.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.63,3324,
00527-0586-01 - dicyclomine 10 mg Cap,00527-0586-01,NDC,,,,inpatient,1,EA,5.9,3.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.02,percent of total billed charges,,,85,,5.02,percent of total billed charges,,,49,,2.89,percent of total billed charges,,,90,,5.31,percent of total billed charges,,,,,,,no IP contract,,80,,4.72,percent of total billed charges,,,,,,,no IP contract,,50,,2.95,percent of total billed charges,,,,,,no IP contract,,,78,,4.6,percent of total billed charges,,,70,,4.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.89,3324,
00527-1116-10 - sodium chloride 1 g Tab,00527-1116-10,NDC,,,,inpatient,1,EA,4.4,2.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.74,percent of total billed charges,,,85,,3.74,percent of total billed charges,,,49,,2.16,percent of total billed charges,,,90,,3.96,percent of total billed charges,,,,,,,no IP contract,,80,,3.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.2,percent of total billed charges,,,,,,no IP contract,,,78,,3.43,percent of total billed charges,,,70,,3.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.16,3324,
00527-1301-01 - primidone 50 mg Tab,00527-1301-01,NDC,,,,inpatient,1,EA,7.8,4.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.63,percent of total billed charges,,,85,,6.63,percent of total billed charges,,,49,,3.82,percent of total billed charges,,,90,,7.02,percent of total billed charges,,,,,,,no IP contract,,80,,6.24,percent of total billed charges,,,,,,,no IP contract,,50,,3.9,percent of total billed charges,,,,,,no IP contract,,,78,,6.08,percent of total billed charges,,,70,,5.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.82,3324,
00527-1311-01 - terbutaline 5 mg Tab,00527-1311-01,NDC,,,,inpatient,1,EA,8.75,5.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.44,percent of total billed charges,,,85,,7.44,percent of total billed charges,,,49,,4.29,percent of total billed charges,,,90,,7.88,percent of total billed charges,,,,,,,no IP contract,,80,,7,percent of total billed charges,,,,,,,no IP contract,,50,,4.38,percent of total billed charges,,,,,,no IP contract,,,78,,6.83,percent of total billed charges,,,70,,6.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.29,3324,
00527-1313-01 - pilocarpine 5 mg Tab,00527-1313-01,NDC,,,,inpatient,1,EA,15.9,9.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.52,percent of total billed charges,,,85,,13.52,percent of total billed charges,,,49,,7.79,percent of total billed charges,,,90,,14.31,percent of total billed charges,,,,,,,no IP contract,,80,,12.72,percent of total billed charges,,,,,,,no IP contract,,50,,7.95,percent of total billed charges,,,,,,no IP contract,,,78,,12.4,percent of total billed charges,,,70,,11.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.79,3324,
00527-1332-01 - bethanechol 5 mg Tab,00527-1332-01,NDC,,,,inpatient,1,EA,10.65,6.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.05,percent of total billed charges,,,85,,9.05,percent of total billed charges,,,49,,5.22,percent of total billed charges,,,90,,9.59,percent of total billed charges,,,,,,,no IP contract,,80,,8.52,percent of total billed charges,,,,,,,no IP contract,,50,,5.33,percent of total billed charges,,,,,,no IP contract,,,78,,8.31,percent of total billed charges,,,70,,7.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.22,3324,
00527-1336-01 - doxycycline 20 mg Tab,00527-1336-01,NDC,,,,inpatient,1,EA,13.3,7.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.31,percent of total billed charges,,,85,,11.31,percent of total billed charges,,,49,,6.52,percent of total billed charges,,,90,,11.97,percent of total billed charges,,,,,,,no IP contract,,80,,10.64,percent of total billed charges,,,,,,,no IP contract,,50,,6.65,percent of total billed charges,,,,,,no IP contract,,,78,,10.37,percent of total billed charges,,,70,,9.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.52,3324,
00527-1341-01 - levothyroxine 25 mcg (0.025 mg) Tab,00527-1341-01,NDC,,,,inpatient,1,EA,5.75,3.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.89,percent of total billed charges,,,85,,4.89,percent of total billed charges,,,49,,2.82,percent of total billed charges,,,90,,5.18,percent of total billed charges,,,,,,,no IP contract,,80,,4.6,percent of total billed charges,,,,,,,no IP contract,,50,,2.88,percent of total billed charges,,,,,,no IP contract,,,78,,4.49,percent of total billed charges,,,70,,4.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.82,3324,
00527-1342-01 - levothyroxine 50 mcg (0.05 mg) Tab,00527-1342-01,NDC,,,,inpatient,1,EA,5.95,3.57,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.06,percent of total billed charges,,,85,,5.06,percent of total billed charges,,,49,,2.92,percent of total billed charges,,,90,,5.36,percent of total billed charges,,,,,,,no IP contract,,80,,4.76,percent of total billed charges,,,,,,,no IP contract,,50,,2.98,percent of total billed charges,,,,,,no IP contract,,,78,,4.64,percent of total billed charges,,,70,,4.17,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.92,3324,
00527-1344-01 - levothyroxine 88 mcg (0.088 mg) Tab,00527-1344-01,NDC,,,,inpatient,1,EA,8.3,4.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.06,percent of total billed charges,,,85,,7.06,percent of total billed charges,,,49,,4.07,percent of total billed charges,,,90,,7.47,percent of total billed charges,,,,,,,no IP contract,,80,,6.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.15,percent of total billed charges,,,,,,no IP contract,,,78,,6.47,percent of total billed charges,,,70,,5.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.07,3324,
00527-1346-01 - levothyroxine 112 mcg (0.112 mg) Tab,00527-1346-01,NDC,,,,inpatient,1,EA,6.6,3.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.61,percent of total billed charges,,,85,,5.61,percent of total billed charges,,,49,,3.23,percent of total billed charges,,,90,,5.94,percent of total billed charges,,,,,,,no IP contract,,80,,5.28,percent of total billed charges,,,,,,,no IP contract,,50,,3.3,percent of total billed charges,,,,,,no IP contract,,,78,,5.15,percent of total billed charges,,,70,,4.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.23,3324,
00527-1349-01 - levothyroxine 150 mcg (0.15 mg) Tab,00527-1349-01,NDC,,,,inpatient,1,EA,6.75,4.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.74,percent of total billed charges,,,85,,5.74,percent of total billed charges,,,49,,3.31,percent of total billed charges,,,90,,6.08,percent of total billed charges,,,,,,,no IP contract,,80,,5.4,percent of total billed charges,,,,,,,no IP contract,,50,,3.38,percent of total billed charges,,,,,,no IP contract,,,78,,5.27,percent of total billed charges,,,70,,4.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.31,3324,
00527-1352-01 - levothyroxine 300 mcg (0.3 mg) Tab,00527-1352-01,NDC,,,,inpatient,1,EA,8.6,5.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.31,percent of total billed charges,,,85,,7.31,percent of total billed charges,,,49,,4.21,percent of total billed charges,,,90,,7.74,percent of total billed charges,,,,,,,no IP contract,,80,,6.88,percent of total billed charges,,,,,,,no IP contract,,50,,4.3,percent of total billed charges,,,,,,no IP contract,,,78,,6.71,percent of total billed charges,,,70,,6.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.21,3324,
00527-1638-01 - levothyroxine 137 mcg (0.137 mg) Tab,00527-1638-01,NDC,,,,inpatient,1,EA,6.7,4.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.7,percent of total billed charges,,,85,,5.7,percent of total billed charges,,,49,,3.28,percent of total billed charges,,,90,,6.03,percent of total billed charges,,,,,,,no IP contract,,80,,5.36,percent of total billed charges,,,,,,,no IP contract,,50,,3.35,percent of total billed charges,,,,,,no IP contract,,,78,,5.23,percent of total billed charges,,,70,,4.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.28,3324,
00527-1695-01 - acetaminophen/butalbital/caffeine 325 mg-50 mg-40 mg Tab,00527-1695-01,NDC,,,,inpatient,1,EA,17.25,10.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.66,percent of total billed charges,,,85,,14.66,percent of total billed charges,,,49,,8.45,percent of total billed charges,,,90,,15.53,percent of total billed charges,,,,,,,no IP contract,,80,,13.8,percent of total billed charges,,,,,,,no IP contract,,50,,8.63,percent of total billed charges,,,,,,no IP contract,,,78,,13.46,percent of total billed charges,,,70,,12.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.45,3324,
00527-1927-36 - methadone 10 mg/mL Conc,00527-1927-36,NDC,,,,inpatient,1,ML,12.5,7.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.63,percent of total billed charges,,,85,,10.63,percent of total billed charges,,,49,,6.13,percent of total billed charges,,,90,,11.25,percent of total billed charges,,,,,,,no IP contract,,80,,10,percent of total billed charges,,,,,,,no IP contract,,50,,6.25,percent of total billed charges,,,,,,no IP contract,,,78,,9.75,percent of total billed charges,,,70,,8.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.13,3324,
00527-3219-37 - dantrolene 25 mg Cap,00527-3219-37,NDC,,,,inpatient,1,EA,12.35,7.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.5,percent of total billed charges,,,85,,10.5,percent of total billed charges,,,49,,6.05,percent of total billed charges,,,90,,11.12,percent of total billed charges,,,,,,,no IP contract,,80,,9.88,percent of total billed charges,,,,,,,no IP contract,,50,,6.18,percent of total billed charges,,,,,,no IP contract,,,78,,9.63,percent of total billed charges,,,70,,8.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.05,3324,
00527-3220-37 - dantrolene 50 mg Cap,00527-3220-37,NDC,,,,inpatient,1,EA,17.6,10.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.96,percent of total billed charges,,,85,,14.96,percent of total billed charges,,,49,,8.62,percent of total billed charges,,,90,,15.84,percent of total billed charges,,,,,,,no IP contract,,80,,14.08,percent of total billed charges,,,,,,,no IP contract,,50,,8.8,percent of total billed charges,,,,,,no IP contract,,,78,,13.73,percent of total billed charges,,,70,,12.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.62,3324,
00527-3221-37 - dantrolene 100 mg Cap,00527-3221-37,NDC,,,,inpatient,1,EA,21.1,12.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.94,percent of total billed charges,,,85,,17.94,percent of total billed charges,,,49,,10.34,percent of total billed charges,,,90,,18.99,percent of total billed charges,,,,,,,no IP contract,,80,,16.88,percent of total billed charges,,,,,,,no IP contract,,50,,10.55,percent of total billed charges,,,,,,no IP contract,,,78,,16.46,percent of total billed charges,,,70,,14.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.34,3324,
00527-3282-46 - levothyroxine 75 mcg (0.075 mg) Tab,00527-3282-46,NDC,,,,inpatient,1,EA,8.35,5.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.1,percent of total billed charges,,,85,,7.1,percent of total billed charges,,,49,,4.09,percent of total billed charges,,,90,,7.52,percent of total billed charges,,,,,,,no IP contract,,80,,6.68,percent of total billed charges,,,,,,,no IP contract,,50,,4.18,percent of total billed charges,,,,,,no IP contract,,,78,,6.51,percent of total billed charges,,,70,,5.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.09,3324,
00527-4107-37 - mexiletine 150 mg Cap,00527-4107-37,NDC,,,,inpatient,1,EA,24,14.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.4,percent of total billed charges,,,85,,20.4,percent of total billed charges,,,49,,11.76,percent of total billed charges,,,90,,21.6,percent of total billed charges,,,,,,,no IP contract,,80,,19.2,percent of total billed charges,,,,,,,no IP contract,,50,,12,percent of total billed charges,,,,,,no IP contract,,,78,,18.72,percent of total billed charges,,,70,,16.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.76,3324,
00527-4108-37 - mexiletine 200 mg Cap,00527-4108-37,NDC,,,,inpatient,1,EA,27.9,16.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.72,percent of total billed charges,,,85,,23.72,percent of total billed charges,,,49,,13.67,percent of total billed charges,,,90,,25.11,percent of total billed charges,,,,,,,no IP contract,,80,,22.32,percent of total billed charges,,,,,,,no IP contract,,50,,13.95,percent of total billed charges,,,,,,no IP contract,,,78,,21.76,percent of total billed charges,,,70,,19.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.67,3324,
00527-4117-37 - propranolol 80 mg ER Ca,00527-4117-37,NDC,,,,inpatient,1,EA,23,13.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.55,percent of total billed charges,,,85,,19.55,percent of total billed charges,,,49,,11.27,percent of total billed charges,,,90,,20.7,percent of total billed charges,,,,,,,no IP contract,,80,,18.4,percent of total billed charges,,,,,,,no IP contract,,50,,11.5,percent of total billed charges,,,,,,no IP contract,,,78,,17.94,percent of total billed charges,,,70,,16.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.27,3324,
00527-4579-37 - methylphenidate (30/70 release) 10 mg/24 hr ER Ca,00527-4579-37,NDC,,,,inpatient,1,EA,53.5,32.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,43.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,45.48,percent of total billed charges,,,85,,45.48,percent of total billed charges,,,49,,26.22,percent of total billed charges,,,90,,48.15,percent of total billed charges,,,,,,,no IP contract,,80,,42.8,percent of total billed charges,,,,,,,no IP contract,,50,,26.75,percent of total billed charges,,,,,,no IP contract,,,78,,41.73,percent of total billed charges,,,70,,37.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.22,3324,
oseltamivir 30 mg Cap,00527-4591-13,NDC,,,,inpatient,1,EA,116.55,69.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,94.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,99.07,percent of total billed charges,,,85,,99.07,percent of total billed charges,,,49,,57.11,percent of total billed charges,,,90,,104.9,percent of total billed charges,,,,,,,no IP contract,,80,,93.24,percent of total billed charges,,,,,,,no IP contract,,50,,58.28,percent of total billed charges,,,,,,no IP contract,,,78,,90.91,percent of total billed charges,,,70,,81.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,57.11,3324,
00527-6004-80 - lidocaine topical 4% Soln,00527-6004-80,NDC,,,,inpatient,50,ML,546.5,327.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,442.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,464.53,percent of total billed charges,,,85,,464.53,percent of total billed charges,,,49,,267.79,percent of total billed charges,,,90,,491.85,percent of total billed charges,,,,,,,no IP contract,,80,,437.2,percent of total billed charges,,,,,,,no IP contract,,50,,273.25,percent of total billed charges,,,,,,no IP contract,,,78,,426.27,percent of total billed charges,,,70,,382.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,267.79,3324,
00527-8106-37 - dexmethylphenidate 5 mg ER Ca,00527-8106-37,NDC,,,,inpatient,1,EA,73.15,43.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,59.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,62.18,percent of total billed charges,,,85,,62.18,percent of total billed charges,,,49,,35.84,percent of total billed charges,,,90,,65.84,percent of total billed charges,,,,,,,no IP contract,,80,,58.52,percent of total billed charges,,,,,,,no IP contract,,50,,36.58,percent of total billed charges,,,,,,no IP contract,,,78,,57.06,percent of total billed charges,,,70,,51.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,35.84,3324,
00536-1000-59 - senna 8.8 mg/5 mL Syrup,00536-1000-59,NDC,,,,inpatient,1,ML,6,3.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.1,percent of total billed charges,,,85,,5.1,percent of total billed charges,,,49,,2.94,percent of total billed charges,,,90,,5.4,percent of total billed charges,,,,,,,no IP contract,,80,,4.8,percent of total billed charges,,,,,,,no IP contract,,50,,3,percent of total billed charges,,,,,,no IP contract,,,78,,4.68,percent of total billed charges,,,70,,4.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.94,3324,
00536-1007-15 - calcium carbonate 500 mg Chew,00536-1007-15,NDC,,,,inpatient,1,EA,4,2.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.4,percent of total billed charges,,,85,,3.4,percent of total billed charges,,,49,,1.96,percent of total billed charges,,,90,,3.6,percent of total billed charges,,,,,,,no IP contract,,80,,3.2,percent of total billed charges,,,,,,,no IP contract,,50,,2,percent of total billed charges,,,,,,no IP contract,,,78,,3.12,percent of total billed charges,,,70,,2.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.96,3324,
00536-1019-01 - simethicone 80 mg Chew,00536-1019-01,NDC,,,,inpatient,1,EA,4.3,2.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.66,percent of total billed charges,,,85,,3.66,percent of total billed charges,,,49,,2.11,percent of total billed charges,,,90,,3.87,percent of total billed charges,,,,,,,no IP contract,,80,,3.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.15,percent of total billed charges,,,,,,no IP contract,,,78,,3.35,percent of total billed charges,,,70,,3.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.11,3324,
00536-1056-56 - benzoyl peroxide 10% Gel,00536-1056-56,NDC,,,,inpatient,1,UN,89.2,53.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,72.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,75.82,percent of total billed charges,,,85,,75.82,percent of total billed charges,,,49,,43.71,percent of total billed charges,,,90,,80.28,percent of total billed charges,,,,,,,no IP contract,,80,,71.36,percent of total billed charges,,,,,,,no IP contract,,50,,44.6,percent of total billed charges,,,,,,no IP contract,,,78,,69.58,percent of total billed charges,,,70,,62.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,43.71,3324,
00536-1098-08 - melatonin 5 mg Tab,00536-1098-08,NDC,,,,inpatient,1,EA,4.8,2.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.08,percent of total billed charges,,,85,,4.08,percent of total billed charges,,,49,,2.35,percent of total billed charges,,,90,,4.32,percent of total billed charges,,,,,,,no IP contract,,80,,3.84,percent of total billed charges,,,,,,,no IP contract,,50,,2.4,percent of total billed charges,,,,,,no IP contract,,,78,,3.74,percent of total billed charges,,,70,,3.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.35,3324,
00536-1109-45 - urea topical 20% Cream,00536-1109-45,NDC,,,,inpatient,1,UN,136.65,81.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,110.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,116.15,percent of total billed charges,,,85,,116.15,percent of total billed charges,,,49,,66.96,percent of total billed charges,,,90,,122.99,percent of total billed charges,,,,,,,no IP contract,,80,,109.32,percent of total billed charges,,,,,,,no IP contract,,50,,68.33,percent of total billed charges,,,,,,no IP contract,,,78,,106.59,percent of total billed charges,,,70,,95.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,66.96,3324,
00536-1186-12 - phenylephrine topical 0.25% Supp,00536-1186-12,NDC,,,,inpatient,1,UN,5.75,3.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.89,percent of total billed charges,,,85,,4.89,percent of total billed charges,,,49,,2.82,percent of total billed charges,,,90,,5.18,percent of total billed charges,,,,,,,no IP contract,,80,,4.6,percent of total billed charges,,,,,,,no IP contract,,50,,2.88,percent of total billed charges,,,,,,no IP contract,,,78,,4.49,percent of total billed charges,,,70,,4.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.82,3324,
tetrahydrozoline ophthalmic 0.05% Soln,00536-1217-94,NDC,,,,inpatient,1,EA,25.45,15.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.63,percent of total billed charges,,,85,,21.63,percent of total billed charges,,,49,,12.47,percent of total billed charges,,,90,,22.91,percent of total billed charges,,,,,,,no IP contract,,80,,20.36,percent of total billed charges,,,,,,,no IP contract,,50,,12.73,percent of total billed charges,,,,,,no IP contract,,,78,,19.85,percent of total billed charges,,,70,,17.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.47,3324,
00536-1238-01 - bisacodyl 10 mg Supp,00536-1238-01,NDC,,,,inpatient,1,UN,4.7,2.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4,percent of total billed charges,,,85,,4,percent of total billed charges,,,49,,2.3,percent of total billed charges,,,90,,4.23,percent of total billed charges,,,,,,,no IP contract,,80,,3.76,percent of total billed charges,,,,,,,no IP contract,,50,,2.35,percent of total billed charges,,,,,,no IP contract,,,78,,3.67,percent of total billed charges,,,70,,3.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.3,3324,
00536-1248-01 - docusate-senna 50 mg-8.6 mg Tab,00536-1248-01,NDC,,,,inpatient,1,EA,4.05,2.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.44,percent of total billed charges,,,85,,3.44,percent of total billed charges,,,49,,1.98,percent of total billed charges,,,90,,3.65,percent of total billed charges,,,,,,,no IP contract,,80,,3.24,percent of total billed charges,,,,,,,no IP contract,,50,,2.03,percent of total billed charges,,,,,,no IP contract,,,78,,3.16,percent of total billed charges,,,70,,2.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.98,3324,
00536-1256-28 - bacitracin topical 500 units/g Ointm,00536-1256-28,NDC,,,,inpatient,1,UN,29.2,17.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.82,percent of total billed charges,,,85,,24.82,percent of total billed charges,,,49,,14.31,percent of total billed charges,,,90,,26.28,percent of total billed charges,,,,,,,no IP contract,,80,,23.36,percent of total billed charges,,,,,,,no IP contract,,50,,14.6,percent of total billed charges,,,,,,no IP contract,,,78,,22.78,percent of total billed charges,,,70,,20.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.31,3324,
00536-1275-59 - senna 8.8 mg/5 mL Syrup,00536-1275-59,NDC,,,,inpatient,1,ML,6,3.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.1,percent of total billed charges,,,85,,5.1,percent of total billed charges,,,49,,2.94,percent of total billed charges,,,90,,5.4,percent of total billed charges,,,,,,,no IP contract,,80,,4.8,percent of total billed charges,,,,,,,no IP contract,,50,,3,percent of total billed charges,,,,,,no IP contract,,,78,,4.68,percent of total billed charges,,,70,,4.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.94,3324,
00536-1277-80 - hydrocortisone topical 1% Cream,00536-1277-80,NDC,,,,inpatient,1,UN,24.2,14.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.57,percent of total billed charges,,,85,,20.57,percent of total billed charges,,,49,,11.86,percent of total billed charges,,,90,,21.78,percent of total billed charges,,,,,,,no IP contract,,80,,19.36,percent of total billed charges,,,,,,,no IP contract,,50,,12.1,percent of total billed charges,,,,,,no IP contract,,,78,,18.88,percent of total billed charges,,,70,,16.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.86,3324,
00536-1286-36 - bismuth subsalicylate 525 mg/30 mL Susp,00536-1286-36,NDC,,,,inpatient,30,ML,22.65,13.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.25,percent of total billed charges,,,85,,19.25,percent of total billed charges,,,49,,11.1,percent of total billed charges,,,90,,20.39,percent of total billed charges,,,,,,,no IP contract,,80,,18.12,percent of total billed charges,,,,,,,no IP contract,,50,,11.33,percent of total billed charges,,,,,,no IP contract,,,78,,17.67,percent of total billed charges,,,70,,15.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.1,3324,
00536-1288-06 - phenylephrine rectal ointment [Preparation H] 0.25%-3% Ointment,00536-1288-06,NDC,,,,inpatient,1,UN,27.65,16.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.5,percent of total billed charges,,,85,,23.5,percent of total billed charges,,,49,,13.55,percent of total billed charges,,,90,,24.89,percent of total billed charges,,,,,,,no IP contract,,80,,22.12,percent of total billed charges,,,,,,,no IP contract,,50,,13.83,percent of total billed charges,,,,,,no IP contract,,,78,,21.57,percent of total billed charges,,,70,,19.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.55,3324,
diclofenac topical 1% Gel,00536-1294-34,NDC,,,,inpatient,1,EA,184.15,110.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,149.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,156.53,percent of total billed charges,,,85,,156.53,percent of total billed charges,,,49,,90.23,percent of total billed charges,,,90,,165.74,percent of total billed charges,,,,,,,no IP contract,,80,,147.32,percent of total billed charges,,,,,,,no IP contract,,50,,92.08,percent of total billed charges,,,,,,no IP contract,,,78,,143.64,percent of total billed charges,,,70,,128.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,90.23,3324,
00536-1303-75 - simethicone 40 mg/0.6 mL LIQ,00536-1303-75,NDC,,,,inpatient,0.6,ML,14.15,8.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.03,percent of total billed charges,,,85,,12.03,percent of total billed charges,,,49,,6.93,percent of total billed charges,,,90,,12.74,percent of total billed charges,,,,,,,no IP contract,,80,,11.32,percent of total billed charges,,,,,,,no IP contract,,50,,7.08,percent of total billed charges,,,,,,no IP contract,,,78,,11.04,percent of total billed charges,,,70,,9.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.93,3324,
00536-1995-53 - selenium sulfide topical 1% Shamp,00536-1995-53,NDC,,,,inpatient,10,ML,44.2,26.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,35.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,37.57,percent of total billed charges,,,85,,37.57,percent of total billed charges,,,49,,21.66,percent of total billed charges,,,90,,39.78,percent of total billed charges,,,,,,,no IP contract,,80,,35.36,percent of total billed charges,,,,,,,no IP contract,,50,,22.1,percent of total billed charges,,,,,,no IP contract,,,78,,34.48,percent of total billed charges,,,70,,30.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.66,3324,
00536-3112-01 - nicotine 2 mg Gum,00536-3112-01,NDC,,,,inpatient,1,EA,7,4.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.95,percent of total billed charges,,,85,,5.95,percent of total billed charges,,,49,,3.43,percent of total billed charges,,,90,,6.3,percent of total billed charges,,,,,,,no IP contract,,80,,5.6,percent of total billed charges,,,,,,,no IP contract,,50,,3.5,percent of total billed charges,,,,,,no IP contract,,,78,,5.46,percent of total billed charges,,,70,,4.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.43,3324,
00536-3542-01 - cyanocobalamin 100 mcg Tab,00536-3542-01,NDC,,,,inpatient,1,EA,4,2.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.4,percent of total billed charges,,,85,,3.4,percent of total billed charges,,,49,,1.96,percent of total billed charges,,,90,,3.6,percent of total billed charges,,,,,,,no IP contract,,80,,3.2,percent of total billed charges,,,,,,,no IP contract,,50,,2,percent of total billed charges,,,,,,no IP contract,,,78,,3.12,percent of total billed charges,,,70,,2.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.96,3324,
00536-3551-01 - cyanocobalamin 500 mcg Tab,00536-3551-01,NDC,,,,inpatient,1,EA,4.15,2.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.53,percent of total billed charges,,,85,,3.53,percent of total billed charges,,,49,,2.03,percent of total billed charges,,,90,,3.74,percent of total billed charges,,,,,,,no IP contract,,80,,3.32,percent of total billed charges,,,,,,,no IP contract,,50,,2.08,percent of total billed charges,,,,,,no IP contract,,,78,,3.24,percent of total billed charges,,,70,,2.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.03,3324,
00536-3556-01 - cyanocobalamin 1000 mcg Tab,00536-3556-01,NDC,,,,inpatient,1,EA,4.2,2.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.57,percent of total billed charges,,,85,,3.57,percent of total billed charges,,,49,,2.06,percent of total billed charges,,,90,,3.78,percent of total billed charges,,,,,,,no IP contract,,80,,3.36,percent of total billed charges,,,,,,,no IP contract,,50,,2.1,percent of total billed charges,,,,,,no IP contract,,,78,,3.28,percent of total billed charges,,,70,,2.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.06,3324,
00536-4076-01 - niacin 100 mg Tab,00536-4076-01,NDC,,,,inpatient,1,EA,4.05,2.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.44,percent of total billed charges,,,85,,3.44,percent of total billed charges,,,49,,1.98,percent of total billed charges,,,90,,3.65,percent of total billed charges,,,,,,,no IP contract,,80,,3.24,percent of total billed charges,,,,,,,no IP contract,,50,,2.03,percent of total billed charges,,,,,,no IP contract,,,78,,3.16,percent of total billed charges,,,70,,2.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.98,3324,
00536-4306-05 - polycarbophil 625 mg Tab,00536-4306-05,NDC,,,,inpatient,1,EA,4.55,2.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.87,percent of total billed charges,,,85,,3.87,percent of total billed charges,,,49,,2.23,percent of total billed charges,,,90,,4.1,percent of total billed charges,,,,,,,no IP contract,,80,,3.64,percent of total billed charges,,,,,,,no IP contract,,50,,2.28,percent of total billed charges,,,,,,no IP contract,,,78,,3.55,percent of total billed charges,,,70,,3.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.23,3324,
00536-4306-08 - polycarbophil 625 mg Tab,00536-4306-08,NDC,,,,inpatient,1,EA,4.7,2.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4,percent of total billed charges,,,85,,4,percent of total billed charges,,,49,,2.3,percent of total billed charges,,,90,,4.23,percent of total billed charges,,,,,,,no IP contract,,80,,3.76,percent of total billed charges,,,,,,,no IP contract,,50,,2.35,percent of total billed charges,,,,,,no IP contract,,,78,,3.67,percent of total billed charges,,,70,,3.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.3,3324,
00536-4408-01 - pyridoxine 50 mg Tab,00536-4408-01,NDC,,,,inpatient,1,EA,4.15,2.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.53,percent of total billed charges,,,85,,3.53,percent of total billed charges,,,49,,2.03,percent of total billed charges,,,90,,3.74,percent of total billed charges,,,,,,,no IP contract,,80,,3.32,percent of total billed charges,,,,,,,no IP contract,,50,,2.08,percent of total billed charges,,,,,,no IP contract,,,78,,3.24,percent of total billed charges,,,70,,2.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.03,3324,
00536-4544-10 - sodium bicarbonate 650 mg Tab,00536-4544-10,NDC,,,,inpatient,1,EA,3.9,2.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.32,percent of total billed charges,,,85,,3.32,percent of total billed charges,,,49,,1.91,percent of total billed charges,,,90,,3.51,percent of total billed charges,,,,,,,no IP contract,,80,,3.12,percent of total billed charges,,,,,,,no IP contract,,50,,1.95,percent of total billed charges,,,,,,no IP contract,,,78,,3.04,percent of total billed charges,,,70,,2.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.91,3324,
00536-5700-98 - zinc oxide topical 20% Ointm,00536-5700-98,NDC,,,,inpatient,1,UN,14.2,8.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.07,percent of total billed charges,,,85,,12.07,percent of total billed charges,,,49,,6.96,percent of total billed charges,,,90,,12.78,percent of total billed charges,,,,,,,no IP contract,,80,,11.36,percent of total billed charges,,,,,,,no IP contract,,50,,7.1,percent of total billed charges,,,,,,no IP contract,,,78,,11.08,percent of total billed charges,,,70,,9.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.96,3324,
omega-3 polyunsaturated fatty acids 1000 mg Cap,00536-7187-01,NDC,,,,inpatient,1,EA,4.95,2.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.21,percent of total billed charges,,,85,,4.21,percent of total billed charges,,,49,,2.43,percent of total billed charges,,,90,,4.46,percent of total billed charges,,,,,,,no IP contract,,80,,3.96,percent of total billed charges,,,,,,,no IP contract,,50,,2.48,percent of total billed charges,,,,,,no IP contract,,,78,,3.86,percent of total billed charges,,,70,,3.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.43,3324,
00536-7300-01 - multivitamin Vitamin B Complex with C and Folic Acid Tab,00536-7300-01,NDC,,,,inpatient,1,EA,5.2,3.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.42,percent of total billed charges,,,85,,4.42,percent of total billed charges,,,49,,2.55,percent of total billed charges,,,90,,4.68,percent of total billed charges,,,,,,,no IP contract,,80,,4.16,percent of total billed charges,,,,,,,no IP contract,,50,,2.6,percent of total billed charges,,,,,,no IP contract,,,78,,4.06,percent of total billed charges,,,70,,3.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.55,3324,
00536-7415-51 - sodium biphosphate-sodium phosphate 7 g-19 g Enema,00536-7415-51,NDC,,,,inpatient,133,ML,14.4,8.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.24,percent of total billed charges,,,85,,12.24,percent of total billed charges,,,49,,7.06,percent of total billed charges,,,90,,12.96,percent of total billed charges,,,,,,,no IP contract,,80,,11.52,percent of total billed charges,,,,,,,no IP contract,,50,,7.2,percent of total billed charges,,,,,,no IP contract,,,78,,11.23,percent of total billed charges,,,70,,10.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.06,3324,
00536-7817-08 - calcium-vitamin D 500 mg-200 intl units Tab,00536-7817-08,NDC,,,,inpatient,1,EA,4.4,2.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.74,percent of total billed charges,,,85,,3.74,percent of total billed charges,,,49,,2.16,percent of total billed charges,,,90,,3.96,percent of total billed charges,,,,,,,no IP contract,,80,,3.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.2,percent of total billed charges,,,,,,no IP contract,,,78,,3.43,percent of total billed charges,,,70,,3.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.16,3324,
00536-8400-80 - cholecalciferol 400 intl units/mL LIQ,00536-8400-80,NDC,,,,inpatient,1,ML,6.25,3.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.31,percent of total billed charges,,,85,,5.31,percent of total billed charges,,,49,,3.06,percent of total billed charges,,,90,,5.63,percent of total billed charges,,,,,,,no IP contract,,80,,5,percent of total billed charges,,,,,,,no IP contract,,50,,3.13,percent of total billed charges,,,,,,no IP contract,,,78,,4.88,percent of total billed charges,,,70,,4.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.06,3324,
00536-8450-80 - multivitamin Pediatric Multiple Vitamins LIQ,00536-8450-80,NDC,,,,inpatient,1,ML,6.25,3.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.31,percent of total billed charges,,,85,,5.31,percent of total billed charges,,,49,,3.06,percent of total billed charges,,,90,,5.63,percent of total billed charges,,,,,,,no IP contract,,80,,5,percent of total billed charges,,,,,,,no IP contract,,50,,3.13,percent of total billed charges,,,,,,no IP contract,,,78,,4.88,percent of total billed charges,,,70,,4.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.06,3324,
00536-8530-80 - multivitamin with iron Pediatric Multiple Vitamins with Iron LIQ,00536-8530-80,NDC,,,,inpatient,1,ML,6.25,3.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.31,percent of total billed charges,,,85,,5.31,percent of total billed charges,,,49,,3.06,percent of total billed charges,,,90,,5.63,percent of total billed charges,,,,,,,no IP contract,,80,,5,percent of total billed charges,,,,,,,no IP contract,,50,,3.13,percent of total billed charges,,,,,,no IP contract,,,78,,4.88,percent of total billed charges,,,70,,4.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.06,3324,
00548-3316-00 - EPINEPHrine 0.1 mg/mL Soln,00548-3316-00,NDC,,,,inpatient,1,ML,49.8,29.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,40.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,42.33,percent of total billed charges,,,85,,42.33,percent of total billed charges,,,49,,24.4,percent of total billed charges,,,90,,44.82,percent of total billed charges,,,,,,,no IP contract,,80,,39.84,percent of total billed charges,,,,,,,no IP contract,,50,,24.9,percent of total billed charges,,,,,,no IP contract,,,78,,38.84,percent of total billed charges,,,70,,34.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.4,3324,
00548-3352-00 - sodium bicarbonate 8.4% Soln,00548-3352-00,NDC,,,,inpatient,50,ML,68.35,41.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,55.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,58.1,percent of total billed charges,,,85,,58.1,percent of total billed charges,,,49,,33.49,percent of total billed charges,,,90,,61.52,percent of total billed charges,,,,,,,no IP contract,,80,,54.68,percent of total billed charges,,,,,,,no IP contract,,50,,34.18,percent of total billed charges,,,,,,no IP contract,,,78,,53.31,percent of total billed charges,,,70,,47.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,33.49,3324,
00548-5601-00 - enoxaparin 30 mg/0.3 mL Soln,00548-5601-00,NDC,,,,inpatient,0.3,ML,161.05,96.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,130.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,136.89,percent of total billed charges,,,85,,136.89,percent of total billed charges,,,49,,78.91,percent of total billed charges,,,90,,144.95,percent of total billed charges,,,,,,,no IP contract,,80,,128.84,percent of total billed charges,,,,,,,no IP contract,,50,,80.53,percent of total billed charges,,,,,,no IP contract,,,78,,125.62,percent of total billed charges,,,70,,112.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,78.91,3324,
00548-5603-00 - enoxaparin 60 mg/0.6 mL Soln,00548-5603-00,NDC,,,,inpatient,0.6,ML,161.05,96.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,130.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,136.89,percent of total billed charges,,,85,,136.89,percent of total billed charges,,,49,,78.91,percent of total billed charges,,,90,,144.95,percent of total billed charges,,,,,,,no IP contract,,80,,128.84,percent of total billed charges,,,,,,,no IP contract,,50,,80.53,percent of total billed charges,,,,,,no IP contract,,,78,,125.62,percent of total billed charges,,,70,,112.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,78.91,3324,
00548-5605-00 - enoxaparin 100 mg/mL Soln,00548-5605-00,NDC,,,,inpatient,1,ML,161.05,96.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,130.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,136.89,percent of total billed charges,,,85,,136.89,percent of total billed charges,,,49,,78.91,percent of total billed charges,,,90,,144.95,percent of total billed charges,,,,,,,no IP contract,,80,,128.84,percent of total billed charges,,,,,,,no IP contract,,50,,80.53,percent of total billed charges,,,,,,no IP contract,,,78,,125.62,percent of total billed charges,,,70,,112.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,78.91,3324,
00548-5606-00 - enoxaparin 120 mg/0.8 mL Soln,00548-5606-00,NDC,,,,inpatient,0.8,ML,236.95,142.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,191.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,201.41,percent of total billed charges,,,85,,201.41,percent of total billed charges,,,49,,116.11,percent of total billed charges,,,90,,213.26,percent of total billed charges,,,,,,,no IP contract,,80,,189.56,percent of total billed charges,,,,,,,no IP contract,,50,,118.48,percent of total billed charges,,,,,,no IP contract,,,78,,184.82,percent of total billed charges,,,70,,165.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,116.11,3324,
00548-5701-00 - medroxyPROGESTERone 150 mg/mL Susp,00548-5701-00,NDC,,,,inpatient,1,ML,565.7,339.42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,458.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,480.85,percent of total billed charges,,,85,,480.85,percent of total billed charges,,,49,,277.19,percent of total billed charges,,,90,,509.13,percent of total billed charges,,,,,,,no IP contract,,80,,452.56,percent of total billed charges,,,,,,,no IP contract,,50,,282.85,percent of total billed charges,,,,,,no IP contract,,,78,,441.25,percent of total billed charges,,,70,,395.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,277.19,3324,
00548-5900-00 - cosyntropin 0.25 mg REC Inj,00548-5900-00,NDC,,,,inpatient,1,ML,758.15,454.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,614.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,644.43,percent of total billed charges,,,85,,644.43,percent of total billed charges,,,49,,371.49,percent of total billed charges,,,90,,682.34,percent of total billed charges,,,,,,,no IP contract,,80,,606.52,percent of total billed charges,,,,,,,no IP contract,,50,,379.08,percent of total billed charges,,,,,,no IP contract,,,78,,591.36,percent of total billed charges,,,70,,530.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,371.49,3324,
00555-0066-02 - isoniazid 100 mg Tab,00555-0066-02,NDC,,,,inpatient,1,EA,5,3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.25,percent of total billed charges,,,85,,4.25,percent of total billed charges,,,49,,2.45,percent of total billed charges,,,90,,4.5,percent of total billed charges,,,,,,,no IP contract,,80,,4,percent of total billed charges,,,,,,,no IP contract,,50,,2.5,percent of total billed charges,,,,,,no IP contract,,,78,,3.9,percent of total billed charges,,,70,,3.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.45,3324,
isoniazid 300 mg Tab,00555-0071-02,NDC,,,,inpatient,1,EA,6.3,3.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.36,percent of total billed charges,,,85,,5.36,percent of total billed charges,,,49,,3.09,percent of total billed charges,,,90,,5.67,percent of total billed charges,,,,,,,no IP contract,,80,,5.04,percent of total billed charges,,,,,,,no IP contract,,50,,3.15,percent of total billed charges,,,,,,no IP contract,,,78,,4.91,percent of total billed charges,,,70,,4.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.09,3324,
00555-0094-96 - clonazepam 0.125 mg DIS T,00555-0094-96,NDC,,,,inpatient,1,EA,14.15,8.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.03,percent of total billed charges,,,85,,12.03,percent of total billed charges,,,49,,6.93,percent of total billed charges,,,90,,12.74,percent of total billed charges,,,,,,,no IP contract,,80,,11.32,percent of total billed charges,,,,,,,no IP contract,,50,,7.08,percent of total billed charges,,,,,,no IP contract,,,78,,11.04,percent of total billed charges,,,70,,9.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.93,3324,
00555-0158-02 - chlordiazePOXIDE 5 mg Cap,00555-0158-02,NDC,,,,inpatient,1,EA,8.35,5.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.1,percent of total billed charges,,,85,,7.1,percent of total billed charges,,,49,,4.09,percent of total billed charges,,,90,,7.52,percent of total billed charges,,,,,,,no IP contract,,80,,6.68,percent of total billed charges,,,,,,,no IP contract,,50,,4.18,percent of total billed charges,,,,,,no IP contract,,,78,,6.51,percent of total billed charges,,,70,,5.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.09,3324,
00555-0159-02 - chlordiazePOXIDE 25 mg Cap,00555-0159-02,NDC,,,,inpatient,1,EA,9,5.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.65,percent of total billed charges,,,85,,7.65,percent of total billed charges,,,49,,4.41,percent of total billed charges,,,90,,8.1,percent of total billed charges,,,,,,,no IP contract,,80,,7.2,percent of total billed charges,,,,,,,no IP contract,,50,,4.5,percent of total billed charges,,,,,,no IP contract,,,78,,7.02,percent of total billed charges,,,70,,6.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.41,3324,
00555-0521-02 - prochlorperazine 5 mg Tab,00555-0521-02,NDC,,,,inpatient,1,EA,8.1,4.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.89,percent of total billed charges,,,85,,6.89,percent of total billed charges,,,49,,3.97,percent of total billed charges,,,90,,7.29,percent of total billed charges,,,,,,,no IP contract,,80,,6.48,percent of total billed charges,,,,,,,no IP contract,,50,,4.05,percent of total billed charges,,,,,,no IP contract,,,78,,6.32,percent of total billed charges,,,70,,5.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.97,3324,
00555-0607-02 - megestrol 40 mg Tab,00555-0607-02,NDC,,,,inpatient,1,EA,17.4,10.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.79,percent of total billed charges,,,85,,14.79,percent of total billed charges,,,49,,8.53,percent of total billed charges,,,90,,15.66,percent of total billed charges,,,,,,,no IP contract,,80,,13.92,percent of total billed charges,,,,,,,no IP contract,,50,,8.7,percent of total billed charges,,,,,,no IP contract,,,78,,13.57,percent of total billed charges,,,70,,12.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.53,3324,
00555-0615-14 - pramipexole 1.5 mg Tab,00555-0615-14,NDC,,,,inpatient,1,EA,5.65,3.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.8,percent of total billed charges,,,85,,4.8,percent of total billed charges,,,49,,2.77,percent of total billed charges,,,90,,5.09,percent of total billed charges,,,,,,,no IP contract,,80,,4.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.83,percent of total billed charges,,,,,,no IP contract,,,78,,4.41,percent of total billed charges,,,70,,3.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.77,3324,
medroxyPROGESTERone 10 mg Tab,00555-0779-02,NDC,,,,inpatient,1,EA,7.7,4.62,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.55,percent of total billed charges,,,85,,6.55,percent of total billed charges,,,49,,3.77,percent of total billed charges,,,90,,6.93,percent of total billed charges,,,,,,,no IP contract,,80,,6.16,percent of total billed charges,,,,,,,no IP contract,,50,,3.85,percent of total billed charges,,,,,,no IP contract,,,78,,6.01,percent of total billed charges,,,70,,5.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.77,3324,
00555-0834-02 - warfarin 7.5 mg Tab,00555-0834-02,NDC,,,,inpatient,1,EA,11.6,6.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.86,percent of total billed charges,,,85,,9.86,percent of total billed charges,,,49,,5.68,percent of total billed charges,,,90,,10.44,percent of total billed charges,,,,,,,no IP contract,,80,,9.28,percent of total billed charges,,,,,,,no IP contract,,50,,5.8,percent of total billed charges,,,,,,no IP contract,,,78,,9.05,percent of total billed charges,,,70,,8.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.68,3324,
00555-0886-02 - estradiol 1 mg Tab,00555-0886-02,NDC,,,,inpatient,1,EA,6.35,3.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.4,percent of total billed charges,,,85,,5.4,percent of total billed charges,,,49,,3.11,percent of total billed charges,,,90,,5.72,percent of total billed charges,,,,,,,no IP contract,,80,,5.08,percent of total billed charges,,,,,,,no IP contract,,50,,3.18,percent of total billed charges,,,,,,no IP contract,,,78,,4.95,percent of total billed charges,,,70,,4.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.11,3324,
00555-0971-02 - amphetamine-dextroamphetamine 5 mg Tab,00555-0971-02,NDC,,,,inpatient,1,EA,16.85,10.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.32,percent of total billed charges,,,85,,14.32,percent of total billed charges,,,49,,8.26,percent of total billed charges,,,90,,15.17,percent of total billed charges,,,,,,,no IP contract,,80,,13.48,percent of total billed charges,,,,,,,no IP contract,,50,,8.43,percent of total billed charges,,,,,,no IP contract,,,78,,13.14,percent of total billed charges,,,70,,11.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.26,3324,
00555-0973-02 - amphetamine-dextroamphetamine 20 mg Tab,00555-0973-02,NDC,,,,inpatient,1,EA,19.65,11.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.7,percent of total billed charges,,,85,,16.7,percent of total billed charges,,,49,,9.63,percent of total billed charges,,,90,,17.69,percent of total billed charges,,,,,,,no IP contract,,80,,15.72,percent of total billed charges,,,,,,,no IP contract,,50,,9.83,percent of total billed charges,,,,,,no IP contract,,,78,,15.33,percent of total billed charges,,,70,,13.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.63,3324,
00555-1009-16 - clonidine 0.1 mg/24 hr ER Fi,00555-1009-16,NDC,,,,inpatient,1,UN,285.45,171.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,231.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,242.63,percent of total billed charges,,,85,,242.63,percent of total billed charges,,,49,,139.87,percent of total billed charges,,,90,,256.91,percent of total billed charges,,,,,,,no IP contract,,80,,228.36,percent of total billed charges,,,,,,,no IP contract,,50,,142.73,percent of total billed charges,,,,,,no IP contract,,,78,,222.65,percent of total billed charges,,,70,,199.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,139.87,3324,
00555-1011-16 - clonidine 0.3 mg/24 hr ER Fi,00555-1011-16,NDC,,,,inpatient,1,UN,654.4,392.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,530.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,556.24,percent of total billed charges,,,85,,556.24,percent of total billed charges,,,49,,320.66,percent of total billed charges,,,90,,588.96,percent of total billed charges,,,,,,,no IP contract,,80,,523.52,percent of total billed charges,,,,,,,no IP contract,,50,,327.2,percent of total billed charges,,,,,,no IP contract,,,78,,510.43,percent of total billed charges,,,70,,458.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,320.66,3324,
00555-1022-01 - galantamine 24 mg Cap,00555-1022-01,NDC,,,,inpatient,1,EA,29.4,17.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.99,percent of total billed charges,,,85,,24.99,percent of total billed charges,,,49,,14.41,percent of total billed charges,,,90,,26.46,percent of total billed charges,,,,,,,no IP contract,,80,,23.52,percent of total billed charges,,,,,,,no IP contract,,50,,14.7,percent of total billed charges,,,,,,no IP contract,,,78,,22.93,percent of total billed charges,,,70,,20.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.41,3324,
00573-1378-01 - phenylephrine topical 0.25%-3% Supp,00573-1378-01,NDC,,,,inpatient,1,UN,12.5,7.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.63,percent of total billed charges,,,85,,10.63,percent of total billed charges,,,49,,6.13,percent of total billed charges,,,90,,11.25,percent of total billed charges,,,,,,,no IP contract,,80,,10,percent of total billed charges,,,,,,,no IP contract,,50,,6.25,percent of total billed charges,,,,,,no IP contract,,,78,,9.75,percent of total billed charges,,,70,,8.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.13,3324,
00573-2871-20 - phenylephrine topical 0.25%-3% Ointm,00573-2871-20,NDC,,,,inpatient,1,UN,89.7,53.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,72.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,76.25,percent of total billed charges,,,85,,76.25,percent of total billed charges,,,49,,43.95,percent of total billed charges,,,90,,80.73,percent of total billed charges,,,,,,,no IP contract,,80,,71.76,percent of total billed charges,,,,,,,no IP contract,,50,,44.85,percent of total billed charges,,,,,,no IP contract,,,78,,69.97,percent of total billed charges,,,70,,62.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,43.95,3324,
00573-2883-20 - phenylephrine topical 0.25%-3% Supp,00573-2883-20,NDC,,,,inpatient,1,UN,7.95,4.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.76,percent of total billed charges,,,85,,6.76,percent of total billed charges,,,49,,3.9,percent of total billed charges,,,90,,7.16,percent of total billed charges,,,,,,,no IP contract,,80,,6.36,percent of total billed charges,,,,,,,no IP contract,,50,,3.98,percent of total billed charges,,,,,,no IP contract,,,78,,6.2,percent of total billed charges,,,70,,5.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.9,3324,
00574-0069-30 - glucose 40% Gel,00574-0069-30,NDC,,,,inpatient,1,EA,16.95,10.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.41,percent of total billed charges,,,85,,14.41,percent of total billed charges,,,49,,8.31,percent of total billed charges,,,90,,15.26,percent of total billed charges,,,,,,,no IP contract,,80,,13.56,percent of total billed charges,,,,,,,no IP contract,,50,,8.48,percent of total billed charges,,,,,,no IP contract,,,78,,13.22,percent of total billed charges,,,70,,11.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.31,3324,
00574-0106-01 - bromocriptine 2.5 mg Tab,00574-0106-01,NDC,,,,inpatient,1,EA,33.65,20.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.6,percent of total billed charges,,,85,,28.6,percent of total billed charges,,,49,,16.49,percent of total billed charges,,,90,,30.29,percent of total billed charges,,,,,,,no IP contract,,80,,26.92,percent of total billed charges,,,,,,,no IP contract,,50,,16.83,percent of total billed charges,,,,,,no IP contract,,,78,,26.25,percent of total billed charges,,,70,,23.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.49,3324,
00574-0106-03 - bromocriptine 2.5 mg Tab,00574-0106-03,NDC,,,,inpatient,1,EA,36.75,22.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.24,percent of total billed charges,,,85,,31.24,percent of total billed charges,,,49,,18.01,percent of total billed charges,,,90,,33.08,percent of total billed charges,,,,,,,no IP contract,,80,,29.4,percent of total billed charges,,,,,,,no IP contract,,50,,18.38,percent of total billed charges,,,,,,no IP contract,,,78,,28.67,percent of total billed charges,,,70,,25.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.01,3324,
00574-0107-77 - clotrimazole 10 mg Lozen,00574-0107-77,NDC,,,,inpatient,1,UN,15.2,9.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.92,percent of total billed charges,,,85,,12.92,percent of total billed charges,,,49,,7.45,percent of total billed charges,,,90,,13.68,percent of total billed charges,,,,,,,no IP contract,,80,,12.16,percent of total billed charges,,,,,,,no IP contract,,50,,7.6,percent of total billed charges,,,,,,no IP contract,,,78,,11.86,percent of total billed charges,,,70,,10.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.45,3324,
00574-0121-04 - charcoal 25 g Susp,00574-0121-04,NDC,,,,inpatient,120,ML,145.35,87.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,117.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,123.55,percent of total billed charges,,,85,,123.55,percent of total billed charges,,,49,,71.22,percent of total billed charges,,,90,,130.82,percent of total billed charges,,,,,,,no IP contract,,80,,116.28,percent of total billed charges,,,,,,,no IP contract,,50,,72.68,percent of total billed charges,,,,,,no IP contract,,,78,,113.37,percent of total billed charges,,,70,,101.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,71.22,3324,
00574-0121-08 - charcoal 50 g Susp,00574-0121-08,NDC,,,,inpatient,240,ML,205.35,123.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,166.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,174.55,percent of total billed charges,,,85,,174.55,percent of total billed charges,,,49,,100.62,percent of total billed charges,,,90,,184.82,percent of total billed charges,,,,,,,no IP contract,,80,,164.28,percent of total billed charges,,,,,,,no IP contract,,50,,102.68,percent of total billed charges,,,,,,no IP contract,,,78,,160.17,percent of total billed charges,,,70,,143.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,100.62,3324,
00574-0129-01 - clindamycin 75 mg/5 mL REC P,00574-0129-01,NDC,,,,inpatient,1,ML,10.6,6.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.01,percent of total billed charges,,,85,,9.01,percent of total billed charges,,,49,,5.19,percent of total billed charges,,,90,,9.54,percent of total billed charges,,,,,,,no IP contract,,80,,8.48,percent of total billed charges,,,,,,,no IP contract,,50,,5.3,percent of total billed charges,,,,,,no IP contract,,,78,,8.27,percent of total billed charges,,,70,,7.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.19,3324,
00574-0152-10 - caffeine citrate 20 mg/mL LIQ,00574-0152-10,NDC,,,,inpatient,1,ML,132.1,79.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,107,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,112.29,percent of total billed charges,,,85,,112.29,percent of total billed charges,,,49,,64.73,percent of total billed charges,,,90,,118.89,percent of total billed charges,,,,,,,no IP contract,,80,,105.68,percent of total billed charges,,,,,,,no IP contract,,50,,66.05,percent of total billed charges,,,,,,no IP contract,,,78,,103.04,percent of total billed charges,,,70,,92.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,64.73,3324,
00574-0178-10 - glycerin - LIQ,00574-0178-10,NDC,,,,inpatient,1,ML,5.5,3.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.68,percent of total billed charges,,,85,,4.68,percent of total billed charges,,,49,,2.7,percent of total billed charges,,,90,,4.95,percent of total billed charges,,,,,,,no IP contract,,80,,4.4,percent of total billed charges,,,,,,,no IP contract,,50,,2.75,percent of total billed charges,,,,,,no IP contract,,,78,,4.29,percent of total billed charges,,,70,,3.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.7,3324,
00574-0222-01 - liothyronine 25 mcg Tab,00574-0222-01,NDC,,,,inpatient,1,EA,12.15,7.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.33,percent of total billed charges,,,85,,10.33,percent of total billed charges,,,49,,5.95,percent of total billed charges,,,90,,10.94,percent of total billed charges,,,,,,,no IP contract,,80,,9.72,percent of total billed charges,,,,,,,no IP contract,,50,,6.08,percent of total billed charges,,,,,,no IP contract,,,78,,9.48,percent of total billed charges,,,70,,8.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.95,3324,
00574-0246-01 - hyoscyamine 0.125 mg Tab,00574-0246-01,NDC,,,,inpatient,1,EA,10.6,6.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.01,percent of total billed charges,,,85,,9.01,percent of total billed charges,,,49,,5.19,percent of total billed charges,,,90,,9.54,percent of total billed charges,,,,,,,no IP contract,,80,,8.48,percent of total billed charges,,,,,,,no IP contract,,50,,5.3,percent of total billed charges,,,,,,no IP contract,,,78,,8.27,percent of total billed charges,,,70,,7.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.19,3324,
00574-0275-11 - potassium chloride 10 mEq ER Ta,00574-0275-11,NDC,,,,inpatient,1,EA,6.95,4.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.91,percent of total billed charges,,,85,,5.91,percent of total billed charges,,,49,,3.41,percent of total billed charges,,,90,,6.26,percent of total billed charges,,,,,,,no IP contract,,80,,5.56,percent of total billed charges,,,,,,,no IP contract,,50,,3.48,percent of total billed charges,,,,,,no IP contract,,,78,,5.42,percent of total billed charges,,,70,,4.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.41,3324,
00574-0292-01 - aMILoride 5 mg Tab,00574-0292-01,NDC,,,,inpatient,1,EA,5.95,3.57,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.06,percent of total billed charges,,,85,,5.06,percent of total billed charges,,,49,,2.92,percent of total billed charges,,,90,,5.36,percent of total billed charges,,,,,,,no IP contract,,80,,4.76,percent of total billed charges,,,,,,,no IP contract,,50,,2.98,percent of total billed charges,,,,,,no IP contract,,,78,,4.64,percent of total billed charges,,,70,,4.17,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.92,3324,
00574-0303-16 -,00574-0303-16,NDC,,,,inpatient,1,ML,5.65,3.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.8,percent of total billed charges,,,85,,4.8,percent of total billed charges,,,49,,2.77,percent of total billed charges,,,90,,5.09,percent of total billed charges,,,,,,,no IP contract,,80,,4.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.83,percent of total billed charges,,,,,,no IP contract,,,78,,4.41,percent of total billed charges,,,70,,3.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.77,3324,
00574-0304-16 -,00574-0304-16,NDC,,,,inpatient,1,ML,5.65,3.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.8,percent of total billed charges,,,85,,4.8,percent of total billed charges,,,49,,2.77,percent of total billed charges,,,90,,5.09,percent of total billed charges,,,,,,,no IP contract,,80,,4.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.83,percent of total billed charges,,,,,,no IP contract,,,78,,4.41,percent of total billed charges,,,70,,3.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.77,3324,
00574-0508-10 - ferrous gluconate 324 mg Tab,00574-0508-10,NDC,,,,inpatient,1,EA,4.15,2.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.53,percent of total billed charges,,,85,,3.53,percent of total billed charges,,,49,,2.03,percent of total billed charges,,,90,,3.74,percent of total billed charges,,,,,,,no IP contract,,80,,3.32,percent of total billed charges,,,,,,,no IP contract,,50,,2.08,percent of total billed charges,,,,,,no IP contract,,,78,,3.24,percent of total billed charges,,,70,,2.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.03,3324,
00574-0508-11 - ferrous gluconate 324 mg Tab,00574-0508-11,NDC,,,,inpatient,1,EA,4.55,2.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.87,percent of total billed charges,,,85,,3.87,percent of total billed charges,,,49,,2.23,percent of total billed charges,,,90,,4.1,percent of total billed charges,,,,,,,no IP contract,,80,,3.64,percent of total billed charges,,,,,,,no IP contract,,50,,2.28,percent of total billed charges,,,,,,no IP contract,,,78,,3.55,percent of total billed charges,,,70,,3.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.23,3324,
00574-0608-01 - ferrous sulfate 324 mg EC Ta,00574-0608-01,NDC,,,,inpatient,1,EA,4.3,2.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.66,percent of total billed charges,,,85,,3.66,percent of total billed charges,,,49,,2.11,percent of total billed charges,,,90,,3.87,percent of total billed charges,,,,,,,no IP contract,,80,,3.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.15,percent of total billed charges,,,,,,no IP contract,,,78,,3.35,percent of total billed charges,,,70,,3.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.11,3324,
00574-0608-11 - ferrous sulfate 324 mg Tab,00574-0608-11,NDC,,,,inpatient,1,EA,4.7,2.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4,percent of total billed charges,,,85,,4,percent of total billed charges,,,49,,2.3,percent of total billed charges,,,90,,4.23,percent of total billed charges,,,,,,,no IP contract,,80,,3.76,percent of total billed charges,,,,,,,no IP contract,,50,,2.35,percent of total billed charges,,,,,,no IP contract,,,78,,3.67,percent of total billed charges,,,70,,3.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.3,3324,
00574-0618-16 - mineral oil 100% LIQ,00574-0618-16,NDC,,,,inpatient,1,ML,5.5,3.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.68,percent of total billed charges,,,85,,4.68,percent of total billed charges,,,49,,2.7,percent of total billed charges,,,90,,4.95,percent of total billed charges,,,,,,,no IP contract,,80,,4.4,percent of total billed charges,,,,,,,no IP contract,,50,,2.75,percent of total billed charges,,,,,,no IP contract,,,78,,4.29,percent of total billed charges,,,70,,3.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.7,3324,
00574-2008-02 - nystatin topical 100000 units/g Powde,00574-2008-02,NDC,,,,inpatient,1,UN,209.15,125.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,169.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,177.78,percent of total billed charges,,,85,,177.78,percent of total billed charges,,,49,,102.48,percent of total billed charges,,,90,,188.24,percent of total billed charges,,,,,,,no IP contract,,80,,167.32,percent of total billed charges,,,,,,,no IP contract,,50,,104.58,percent of total billed charges,,,,,,no IP contract,,,78,,163.14,percent of total billed charges,,,70,,146.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,102.48,3324,
00574-2008-15 - nystatin topical 100000 units/g Powde,00574-2008-15,NDC,,,,inpatient,1,UN,237.9,142.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,192.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,202.22,percent of total billed charges,,,85,,202.22,percent of total billed charges,,,49,,116.57,percent of total billed charges,,,90,,214.11,percent of total billed charges,,,,,,,no IP contract,,80,,190.32,percent of total billed charges,,,,,,,no IP contract,,50,,118.95,percent of total billed charges,,,,,,no IP contract,,,78,,185.56,percent of total billed charges,,,70,,166.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,116.57,3324,
00574-2008-30 - nystatin topical 100000 units/g Powde,00574-2008-30,NDC,,,,inpatient,1,UN,232.9,139.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,188.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,197.97,percent of total billed charges,,,85,,197.97,percent of total billed charges,,,49,,114.12,percent of total billed charges,,,90,,209.61,percent of total billed charges,,,,,,,no IP contract,,80,,186.32,percent of total billed charges,,,,,,,no IP contract,,50,,116.45,percent of total billed charges,,,,,,no IP contract,,,78,,181.66,percent of total billed charges,,,70,,163.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,114.12,3324,
00574-2042-30 - lidocaine-prilocaine topical 2.5%-2.5% Cream,00574-2042-30,NDC,,,,inpatient,1,UN,159.15,95.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,128.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,135.28,percent of total billed charges,,,85,,135.28,percent of total billed charges,,,49,,77.98,percent of total billed charges,,,90,,143.24,percent of total billed charges,,,,,,,no IP contract,,80,,127.32,percent of total billed charges,,,,,,,no IP contract,,50,,79.58,percent of total billed charges,,,,,,no IP contract,,,78,,124.14,percent of total billed charges,,,70,,111.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,77.98,3324,
00574-4022-35 - bacitracin ophthalmic 500 units/g Ointm,00574-4022-35,NDC,,,,inpatient,1,UN,633.15,379.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,512.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,538.18,percent of total billed charges,,,85,,538.18,percent of total billed charges,,,49,,310.24,percent of total billed charges,,,90,,569.84,percent of total billed charges,,,,,,,no IP contract,,80,,506.52,percent of total billed charges,,,,,,,no IP contract,,50,,316.58,percent of total billed charges,,,,,,no IP contract,,,78,,493.86,percent of total billed charges,,,70,,443.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,310.24,3324,
00574-4024-35 - erythromycin ophthalmic 0.5% Ointm,00574-4024-35,NDC,,,,inpatient,1,UN,158.8,95.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,128.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,134.98,percent of total billed charges,,,85,,134.98,percent of total billed charges,,,49,,77.81,percent of total billed charges,,,90,,142.92,percent of total billed charges,,,,,,,no IP contract,,80,,127.04,percent of total billed charges,,,,,,,no IP contract,,50,,79.4,percent of total billed charges,,,,,,no IP contract,,,78,,123.86,percent of total billed charges,,,70,,111.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,77.81,3324,
00574-4031-05 - dexamethasone-tobramycin ophthalmic 0.1%-0.3% Susp,00574-4031-05,NDC,,,,inpatient,1,UN,1529.45,917.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1238.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1300.03,percent of total billed charges,,,85,,1300.03,percent of total billed charges,,,49,,749.43,percent of total billed charges,,,90,,1376.51,percent of total billed charges,,,,,,,no IP contract,,80,,1223.56,percent of total billed charges,,,,,,,no IP contract,,50,,764.73,percent of total billed charges,,,,,,no IP contract,,,78,,1192.97,percent of total billed charges,,,70,,1070.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,749.43,3324,
00574-4031-10 - dexamethasone-tobramycin ophthalmic 0.1%-0.3% Susp,00574-4031-10,NDC,,,,inpatient,1,UN,1529.45,917.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1238.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1300.03,percent of total billed charges,,,85,,1300.03,percent of total billed charges,,,49,,749.43,percent of total billed charges,,,90,,1376.51,percent of total billed charges,,,,,,,no IP contract,,80,,1223.56,percent of total billed charges,,,,,,,no IP contract,,50,,764.73,percent of total billed charges,,,,,,no IP contract,,,78,,1192.97,percent of total billed charges,,,70,,1070.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,749.43,3324,
00574-4160-35 - dexamethasone/neomycin/polymyxin B ophthalmic 1 mg-3.5 mg-10000 units/g Ointm,00574-4160-35,NDC,,,,inpatient,1,UN,175.7,105.42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,142.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,149.35,percent of total billed charges,,,85,,149.35,percent of total billed charges,,,49,,86.09,percent of total billed charges,,,90,,158.13,percent of total billed charges,,,,,,,no IP contract,,80,,140.56,percent of total billed charges,,,,,,,no IP contract,,50,,87.85,percent of total billed charges,,,,,,no IP contract,,,78,,137.05,percent of total billed charges,,,70,,122.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,86.09,3324,
00574-7034-12 - aspirin 300 mg Supp,00574-7034-12,NDC,,,,inpatient,1,UN,7.8,4.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.63,percent of total billed charges,,,85,,6.63,percent of total billed charges,,,49,,3.82,percent of total billed charges,,,90,,7.02,percent of total billed charges,,,,,,,no IP contract,,80,,6.24,percent of total billed charges,,,,,,,no IP contract,,50,,3.9,percent of total billed charges,,,,,,no IP contract,,,78,,6.08,percent of total billed charges,,,70,,5.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.82,3324,
00574-7045-04 - belladonna-opium 16.2 mg-30 mg Supp,00574-7045-04,NDC,,,,inpatient,1,UN,349.3,209.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,282.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,296.91,percent of total billed charges,,,85,,296.91,percent of total billed charges,,,49,,171.16,percent of total billed charges,,,90,,314.37,percent of total billed charges,,,,,,,no IP contract,,80,,279.44,percent of total billed charges,,,,,,,no IP contract,,50,,174.65,percent of total billed charges,,,,,,no IP contract,,,78,,272.45,percent of total billed charges,,,70,,244.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,171.16,3324,
00574-7045-12 - belladonna-opium 16.2 mg-30 mg Supp,00574-7045-12,NDC,,,,inpatient,1,UN,234.65,140.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,190.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,199.45,percent of total billed charges,,,85,,199.45,percent of total billed charges,,,49,,114.98,percent of total billed charges,,,90,,211.19,percent of total billed charges,,,,,,,no IP contract,,80,,187.72,percent of total billed charges,,,,,,,no IP contract,,50,,117.33,percent of total billed charges,,,,,,no IP contract,,,78,,183.03,percent of total billed charges,,,70,,164.26,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,114.98,3324,
00574-7050-50 - bisacodyl 10 mg Supp,00574-7050-50,NDC,,,,inpatient,1,UN,5.1,3.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.34,percent of total billed charges,,,85,,4.34,percent of total billed charges,,,49,,2.5,percent of total billed charges,,,90,,4.59,percent of total billed charges,,,,,,,no IP contract,,80,,4.08,percent of total billed charges,,,,,,,no IP contract,,50,,2.55,percent of total billed charges,,,,,,no IP contract,,,78,,3.98,percent of total billed charges,,,70,,3.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.5,3324,
00574-7226-12 - prochlorperazine 25 mg Supp,00574-7226-12,NDC,,,,inpatient,1,UN,103.85,62.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,84.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,88.27,percent of total billed charges,,,85,,88.27,percent of total billed charges,,,49,,50.89,percent of total billed charges,,,90,,93.47,percent of total billed charges,,,,,,,no IP contract,,80,,83.08,percent of total billed charges,,,,,,,no IP contract,,50,,51.93,percent of total billed charges,,,,,,no IP contract,,,78,,81,percent of total billed charges,,,70,,72.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,50.89,3324,
00574-9855-10 - budesonide 3 mg DR Ca,00574-9855-10,NDC,,,,inpatient,1,EA,46.3,27.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,37.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,39.36,percent of total billed charges,,,85,,39.36,percent of total billed charges,,,49,,22.69,percent of total billed charges,,,90,,41.67,percent of total billed charges,,,,,,,no IP contract,,80,,37.04,percent of total billed charges,,,,,,,no IP contract,,50,,23.15,percent of total billed charges,,,,,,no IP contract,,,78,,36.11,percent of total billed charges,,,70,,32.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.69,3324,
00575-0225-01 - citric acid-sodium citrate 334 mg-500 mg/5 mL Soln,00575-0225-01,NDC,,,,inpatient,1,ML,5.65,3.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.8,percent of total billed charges,,,85,,4.8,percent of total billed charges,,,49,,2.77,percent of total billed charges,,,90,,5.09,percent of total billed charges,,,,,,,no IP contract,,80,,4.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.83,percent of total billed charges,,,,,,no IP contract,,,78,,4.41,percent of total billed charges,,,70,,3.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.77,3324,
00575-6200-30 - diazoxide 50 mg/mL Susp,00575-6200-30,NDC,,,,inpatient,1,ML,80.5,48.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,65.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,68.43,percent of total billed charges,,,85,,68.43,percent of total billed charges,,,49,,39.45,percent of total billed charges,,,90,,72.45,percent of total billed charges,,,,,,,no IP contract,,80,,64.4,percent of total billed charges,,,,,,,no IP contract,,50,,40.25,percent of total billed charges,,,,,,no IP contract,,,78,,62.79,percent of total billed charges,,,70,,56.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,39.45,3324,
00590-0358-10 - naloxone 0.4 mg/mL Soln,00590-0358-10,NDC,,,,inpatient,1,ML,36.7,22.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.2,percent of total billed charges,,,85,,31.2,percent of total billed charges,,,49,,17.98,percent of total billed charges,,,90,,33.03,percent of total billed charges,,,,,,,no IP contract,,80,,29.36,percent of total billed charges,,,,,,,no IP contract,,50,,18.35,percent of total billed charges,,,,,,no IP contract,,,78,,28.63,percent of total billed charges,,,70,,25.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.98,3324,
00591-0240-01 - LORazepam 0.5 mg Tab,00591-0240-01,NDC,,,,inpatient,1,EA,10.75,6.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.14,percent of total billed charges,,,85,,9.14,percent of total billed charges,,,49,,5.27,percent of total billed charges,,,90,,9.68,percent of total billed charges,,,,,,,no IP contract,,80,,8.6,percent of total billed charges,,,,,,,no IP contract,,50,,5.38,percent of total billed charges,,,,,,no IP contract,,,78,,8.39,percent of total billed charges,,,70,,7.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.27,3324,
00591-0241-01 - LORazepam 1 mg Tab,00591-0241-01,NDC,,,,inpatient,1,EA,12.75,7.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.84,percent of total billed charges,,,85,,10.84,percent of total billed charges,,,49,,6.25,percent of total billed charges,,,90,,11.48,percent of total billed charges,,,,,,,no IP contract,,80,,10.2,percent of total billed charges,,,,,,,no IP contract,,50,,6.38,percent of total billed charges,,,,,,no IP contract,,,78,,9.95,percent of total billed charges,,,70,,8.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.25,3324,
00591-0241-05 - LORazepam 1 mg Tab,00591-0241-05,NDC,,,,inpatient,1,EA,12.6,7.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.71,percent of total billed charges,,,85,,10.71,percent of total billed charges,,,49,,6.17,percent of total billed charges,,,90,,11.34,percent of total billed charges,,,,,,,no IP contract,,80,,10.08,percent of total billed charges,,,,,,,no IP contract,,50,,6.3,percent of total billed charges,,,,,,no IP contract,,,78,,9.83,percent of total billed charges,,,70,,8.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.17,3324,
00591-0343-01 - verapamil 80 mg Tab,00591-0343-01,NDC,,,,inpatient,1,EA,8.05,4.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.84,percent of total billed charges,,,85,,6.84,percent of total billed charges,,,49,,3.94,percent of total billed charges,,,90,,7.25,percent of total billed charges,,,,,,,no IP contract,,80,,6.44,percent of total billed charges,,,,,,,no IP contract,,50,,4.03,percent of total billed charges,,,,,,no IP contract,,,78,,6.28,percent of total billed charges,,,70,,5.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.94,3324,
00591-0345-01 - verapamil 120 mg Tab,00591-0345-01,NDC,,,,inpatient,1,EA,9.25,5.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.86,percent of total billed charges,,,85,,7.86,percent of total billed charges,,,49,,4.53,percent of total billed charges,,,90,,8.33,percent of total billed charges,,,,,,,no IP contract,,80,,7.4,percent of total billed charges,,,,,,,no IP contract,,50,,4.63,percent of total billed charges,,,,,,no IP contract,,,78,,7.22,percent of total billed charges,,,70,,6.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.53,3324,
00591-0347-01 - hydroCHLOROthiazide 12.5 mg Cap,00591-0347-01,NDC,,,,inpatient,1,EA,7.15,4.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.08,percent of total billed charges,,,85,,6.08,percent of total billed charges,,,49,,3.5,percent of total billed charges,,,90,,6.44,percent of total billed charges,,,,,,,no IP contract,,80,,5.72,percent of total billed charges,,,,,,,no IP contract,,50,,3.58,percent of total billed charges,,,,,,no IP contract,,,78,,5.58,percent of total billed charges,,,70,,5.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.5,3324,
00591-0404-01 - verapamil 40 mg Tab,00591-0404-01,NDC,,,,inpatient,1,EA,6.05,3.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.14,percent of total billed charges,,,85,,5.14,percent of total billed charges,,,49,,2.96,percent of total billed charges,,,90,,5.45,percent of total billed charges,,,,,,,no IP contract,,80,,4.84,percent of total billed charges,,,,,,,no IP contract,,50,,3.03,percent of total billed charges,,,,,,no IP contract,,,78,,4.72,percent of total billed charges,,,70,,4.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.96,3324,
00591-0424-01 - hydrochlorothiazide-triamterene 25 mg-37.5 mg Tab,00591-0424-01,NDC,,,,inpatient,1,EA,6.7,4.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.7,percent of total billed charges,,,85,,5.7,percent of total billed charges,,,49,,3.28,percent of total billed charges,,,90,,6.03,percent of total billed charges,,,,,,,no IP contract,,80,,5.36,percent of total billed charges,,,,,,,no IP contract,,50,,3.35,percent of total billed charges,,,,,,no IP contract,,,78,,5.23,percent of total billed charges,,,70,,4.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.28,3324,
00591-0444-01 - guanFACINE 1 mg Tab,00591-0444-01,NDC,,,,inpatient,1,EA,10.75,6.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.14,percent of total billed charges,,,85,,9.14,percent of total billed charges,,,49,,5.27,percent of total billed charges,,,90,,9.68,percent of total billed charges,,,,,,,no IP contract,,80,,8.6,percent of total billed charges,,,,,,,no IP contract,,50,,5.38,percent of total billed charges,,,,,,no IP contract,,,78,,8.39,percent of total billed charges,,,70,,7.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.27,3324,
00591-0453-01 - guanfacine 2 mg Tab,00591-0453-01,NDC,,,,inpatient,1,EA,13.2,7.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.22,percent of total billed charges,,,85,,11.22,percent of total billed charges,,,49,,6.47,percent of total billed charges,,,90,,11.88,percent of total billed charges,,,,,,,no IP contract,,80,,10.56,percent of total billed charges,,,,,,,no IP contract,,50,,6.6,percent of total billed charges,,,,,,no IP contract,,,78,,10.3,percent of total billed charges,,,70,,9.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.47,3324,
00591-0461-01 - glipiZIDE 10 mg Tab,00591-0461-01,NDC,,,,inpatient,1,EA,8.6,5.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.31,percent of total billed charges,,,85,,7.31,percent of total billed charges,,,49,,4.21,percent of total billed charges,,,90,,7.74,percent of total billed charges,,,,,,,no IP contract,,80,,6.88,percent of total billed charges,,,,,,,no IP contract,,50,,4.3,percent of total billed charges,,,,,,no IP contract,,,78,,6.71,percent of total billed charges,,,70,,6.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.21,3324,
00591-0487-01 - estradiol 1 mg Tab,00591-0487-01,NDC,,,,inpatient,1,EA,6.6,3.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.61,percent of total billed charges,,,85,,5.61,percent of total billed charges,,,49,,3.23,percent of total billed charges,,,90,,5.94,percent of total billed charges,,,,,,,no IP contract,,80,,5.28,percent of total billed charges,,,,,,,no IP contract,,50,,3.3,percent of total billed charges,,,,,,no IP contract,,,78,,5.15,percent of total billed charges,,,70,,4.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.23,3324,
00591-0794-01 - dicyclomine 10 mg Cap,00591-0794-01,NDC,,,,inpatient,1,EA,4.4,2.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.74,percent of total billed charges,,,85,,3.74,percent of total billed charges,,,49,,2.16,percent of total billed charges,,,90,,3.96,percent of total billed charges,,,,,,,no IP contract,,80,,3.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.2,percent of total billed charges,,,,,,no IP contract,,,78,,3.43,percent of total billed charges,,,70,,3.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.16,3324,
00591-0796-01 - sulfaSALAzine 500 mg Tab,00591-0796-01,NDC,,,,inpatient,1,EA,5.9,3.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.02,percent of total billed charges,,,85,,5.02,percent of total billed charges,,,49,,2.89,percent of total billed charges,,,90,,5.31,percent of total billed charges,,,,,,,no IP contract,,80,,4.72,percent of total billed charges,,,,,,,no IP contract,,50,,2.95,percent of total billed charges,,,,,,no IP contract,,,78,,4.6,percent of total billed charges,,,70,,4.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.89,3324,
00591-0810-46 - silver sulfADIAZINE topical 1% Cream,00591-0810-46,NDC,,,,inpatient,1,UN,542.35,325.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,439.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,461,percent of total billed charges,,,85,,461,percent of total billed charges,,,49,,265.75,percent of total billed charges,,,90,,488.12,percent of total billed charges,,,,,,,no IP contract,,80,,433.88,percent of total billed charges,,,,,,,no IP contract,,50,,271.18,percent of total billed charges,,,,,,no IP contract,,,78,,423.03,percent of total billed charges,,,70,,379.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,265.75,3324,
00591-0844-01 - glipiZIDE 5 mg ER Ta,00591-0844-01,NDC,,,,inpatient,1,EA,7.1,4.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.04,percent of total billed charges,,,85,,6.04,percent of total billed charges,,,49,,3.48,percent of total billed charges,,,90,,6.39,percent of total billed charges,,,,,,,no IP contract,,80,,5.68,percent of total billed charges,,,,,,,no IP contract,,50,,3.55,percent of total billed charges,,,,,,no IP contract,,,78,,5.54,percent of total billed charges,,,70,,4.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.48,3324,
00591-2159-90 - ciclopirox topical 1% Shamp,00591-2159-90,NDC,,,,inpatient,1,UN,1238.75,743.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1003.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1052.94,percent of total billed charges,,,85,,1052.94,percent of total billed charges,,,49,,606.99,percent of total billed charges,,,90,,1114.88,percent of total billed charges,,,,,,,no IP contract,,80,,991,percent of total billed charges,,,,,,,no IP contract,,50,,619.38,percent of total billed charges,,,,,,no IP contract,,,78,,966.23,percent of total billed charges,,,70,,867.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,606.99,3324,
00591-2222-15 - cycloSPORINE microemulsion 25 mg Cap,00591-2222-15,NDC,,,,inpatient,1,EA,14.8,8.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.58,percent of total billed charges,,,85,,12.58,percent of total billed charges,,,49,,7.25,percent of total billed charges,,,90,,13.32,percent of total billed charges,,,,,,,no IP contract,,80,,11.84,percent of total billed charges,,,,,,,no IP contract,,50,,7.4,percent of total billed charges,,,,,,no IP contract,,,78,,11.54,percent of total billed charges,,,70,,10.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.25,3324,
00591-2245-22 - mesalamine 1.2 g EC Ta,00591-2245-22,NDC,,,,inpatient,1,EA,88.65,53.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,71.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,75.35,percent of total billed charges,,,85,,75.35,percent of total billed charges,,,49,,43.44,percent of total billed charges,,,90,,79.79,percent of total billed charges,,,,,,,no IP contract,,80,,70.92,percent of total billed charges,,,,,,,no IP contract,,50,,44.33,percent of total billed charges,,,,,,no IP contract,,,78,,69.15,percent of total billed charges,,,70,,62.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,43.44,3324,
00591-2472-60 - tamoxifen 10 mg Tab,00591-2472-60,NDC,,,,inpatient,1,EA,18.85,11.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.02,percent of total billed charges,,,85,,16.02,percent of total billed charges,,,49,,9.24,percent of total billed charges,,,90,,16.97,percent of total billed charges,,,,,,,no IP contract,,80,,15.08,percent of total billed charges,,,,,,,no IP contract,,50,,9.43,percent of total billed charges,,,,,,no IP contract,,,78,,14.7,percent of total billed charges,,,70,,13.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.24,3324,
00591-2473-30 - tamoxifen 20 mg Tab,00591-2473-30,NDC,,,,inpatient,1,EA,33.95,20.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.86,percent of total billed charges,,,85,,28.86,percent of total billed charges,,,49,,16.64,percent of total billed charges,,,90,,30.56,percent of total billed charges,,,,,,,no IP contract,,80,,27.16,percent of total billed charges,,,,,,,no IP contract,,50,,16.98,percent of total billed charges,,,,,,no IP contract,,,78,,26.48,percent of total billed charges,,,70,,23.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.64,3324,
00591-2562-01 - colchicine 0.6 mg Tab,00591-2562-01,NDC,,,,inpatient,1,EA,69,41.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,55.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,58.65,percent of total billed charges,,,85,,58.65,percent of total billed charges,,,49,,33.81,percent of total billed charges,,,90,,62.1,percent of total billed charges,,,,,,,no IP contract,,80,,55.2,percent of total billed charges,,,,,,,no IP contract,,50,,34.5,percent of total billed charges,,,,,,no IP contract,,,78,,53.82,percent of total billed charges,,,70,,48.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,33.81,3324,
00591-2562-30 - colchicine 0.6 mg Tab,00591-2562-30,NDC,,,,inpatient,1,EA,69,41.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,55.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,58.65,percent of total billed charges,,,85,,58.65,percent of total billed charges,,,49,,33.81,percent of total billed charges,,,90,,62.1,percent of total billed charges,,,,,,,no IP contract,,80,,55.2,percent of total billed charges,,,,,,,no IP contract,,50,,34.5,percent of total billed charges,,,,,,no IP contract,,,78,,53.82,percent of total billed charges,,,70,,48.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,33.81,3324,
00591-2693-01 - oxyCODONE 40 mg ER Ta,00591-2693-01,NDC,,,,inpatient,1,EA,75.05,45.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63.79,percent of total billed charges,,,85,,63.79,percent of total billed charges,,,49,,36.77,percent of total billed charges,,,90,,67.55,percent of total billed charges,,,,,,,no IP contract,,80,,60.04,percent of total billed charges,,,,,,,no IP contract,,50,,37.53,percent of total billed charges,,,,,,no IP contract,,,78,,58.54,percent of total billed charges,,,70,,52.54,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.77,3324,
00591-2729-01 - potassium citrate 10 mEq ER Ta,00591-2729-01,NDC,,,,inpatient,1,EA,23.2,13.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.72,percent of total billed charges,,,85,,19.72,percent of total billed charges,,,49,,11.37,percent of total billed charges,,,90,,20.88,percent of total billed charges,,,,,,,no IP contract,,80,,18.56,percent of total billed charges,,,,,,,no IP contract,,50,,11.6,percent of total billed charges,,,,,,no IP contract,,,78,,18.1,percent of total billed charges,,,70,,16.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.37,3324,
00591-2880-01 - verapamil 120 mg/24 hours ER Ca,00591-2880-01,NDC,,,,inpatient,1,EA,17.75,10.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.09,percent of total billed charges,,,85,,15.09,percent of total billed charges,,,49,,8.7,percent of total billed charges,,,90,,15.98,percent of total billed charges,,,,,,,no IP contract,,80,,14.2,percent of total billed charges,,,,,,,no IP contract,,50,,8.88,percent of total billed charges,,,,,,no IP contract,,,78,,13.85,percent of total billed charges,,,70,,12.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.7,3324,
00591-2882-01 - verapamil 180 mg/24 hours ER Ca,00591-2882-01,NDC,,,,inpatient,1,EA,18.35,11.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.6,percent of total billed charges,,,85,,15.6,percent of total billed charges,,,49,,8.99,percent of total billed charges,,,90,,16.52,percent of total billed charges,,,,,,,no IP contract,,80,,14.68,percent of total billed charges,,,,,,,no IP contract,,50,,9.18,percent of total billed charges,,,,,,no IP contract,,,78,,14.31,percent of total billed charges,,,70,,12.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.99,3324,
00591-2888-30 - hydroxocobalamin 1000 mcg/mL Soln,00591-2888-30,NDC,,,,inpatient,1,ML,20.1,12.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.09,percent of total billed charges,,,85,,17.09,percent of total billed charges,,,49,,9.85,percent of total billed charges,,,90,,18.09,percent of total billed charges,,,,,,,no IP contract,,80,,16.08,percent of total billed charges,,,,,,,no IP contract,,50,,10.05,percent of total billed charges,,,,,,no IP contract,,,78,,15.68,percent of total billed charges,,,70,,14.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.85,3324,
00591-2927-54 - levalbuterol 45 mcg/inh Aeros,00591-2927-54,NDC,,,,inpatient,1,UN,622.75,373.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,504.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,529.34,percent of total billed charges,,,85,,529.34,percent of total billed charges,,,49,,305.15,percent of total billed charges,,,90,,560.48,percent of total billed charges,,,,,,,no IP contract,,80,,498.2,percent of total billed charges,,,,,,,no IP contract,,50,,311.38,percent of total billed charges,,,,,,no IP contract,,,78,,485.75,percent of total billed charges,,,70,,435.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,305.15,3324,
00591-3171-04 - alendronate 35 mg Tab,00591-3171-04,NDC,,,,inpatient,1,EA,166.7,100.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,135.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,141.7,percent of total billed charges,,,85,,141.7,percent of total billed charges,,,49,,81.68,percent of total billed charges,,,90,,150.03,percent of total billed charges,,,,,,,no IP contract,,80,,133.36,percent of total billed charges,,,,,,,no IP contract,,50,,83.35,percent of total billed charges,,,,,,no IP contract,,,78,,130.03,percent of total billed charges,,,70,,116.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,81.68,3324,
00591-3217-30 - testosterone 50 mg/5 g (1%) Gel,00591-3217-30,NDC,,,,inpatient,1,UN,130.35,78.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,105.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,110.8,percent of total billed charges,,,85,,110.8,percent of total billed charges,,,49,,63.87,percent of total billed charges,,,90,,117.32,percent of total billed charges,,,,,,,no IP contract,,80,,104.28,percent of total billed charges,,,,,,,no IP contract,,50,,65.18,percent of total billed charges,,,,,,no IP contract,,,78,,101.67,percent of total billed charges,,,70,,91.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,63.87,3324,
00591-3498-30 - galantamine 24 mg ER Ca,00591-3498-30,NDC,,,,inpatient,1,EA,54.4,32.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,44.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,46.24,percent of total billed charges,,,85,,46.24,percent of total billed charges,,,49,,26.66,percent of total billed charges,,,90,,48.96,percent of total billed charges,,,,,,,no IP contract,,80,,43.52,percent of total billed charges,,,,,,,no IP contract,,50,,27.2,percent of total billed charges,,,,,,no IP contract,,,78,,42.43,percent of total billed charges,,,70,,38.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.66,3324,
00591-3508-04 - cloNIDine 0.1 mg/24 hr ER Fi,00591-3508-04,NDC,,,,inpatient,1,UN,285.1,171.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,230.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,242.34,percent of total billed charges,,,85,,242.34,percent of total billed charges,,,49,,139.7,percent of total billed charges,,,90,,256.59,percent of total billed charges,,,,,,,no IP contract,,80,,228.08,percent of total billed charges,,,,,,,no IP contract,,50,,142.55,percent of total billed charges,,,,,,no IP contract,,,78,,222.38,percent of total billed charges,,,70,,199.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,139.7,3324,
00591-3509-04 - cloNIDine 0.2 mg/24 hr ER Fi,00591-3509-04,NDC,,,,inpatient,1,UN,473.8,284.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,383.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,402.73,percent of total billed charges,,,85,,402.73,percent of total billed charges,,,49,,232.16,percent of total billed charges,,,90,,426.42,percent of total billed charges,,,,,,,no IP contract,,80,,379.04,percent of total billed charges,,,,,,,no IP contract,,50,,236.9,percent of total billed charges,,,,,,no IP contract,,,78,,369.56,percent of total billed charges,,,70,,331.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,232.16,3324,
00591-3510-04 - cloNIDine 0.3 mg/24 hr ER Fi,00591-3510-04,NDC,,,,inpatient,1,UN,653.65,392.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,529.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,555.6,percent of total billed charges,,,85,,555.6,percent of total billed charges,,,49,,320.29,percent of total billed charges,,,90,,588.29,percent of total billed charges,,,,,,,no IP contract,,80,,522.92,percent of total billed charges,,,,,,,no IP contract,,50,,326.83,percent of total billed charges,,,,,,no IP contract,,,78,,509.85,percent of total billed charges,,,70,,457.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,320.29,3324,
00591-3592-60 - dronabinol 5 mg Cap,00591-3592-60,NDC,,,,inpatient,1,EA,107.55,64.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,87.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,91.42,percent of total billed charges,,,85,,91.42,percent of total billed charges,,,49,,52.7,percent of total billed charges,,,90,,96.8,percent of total billed charges,,,,,,,no IP contract,,80,,86.04,percent of total billed charges,,,,,,,no IP contract,,50,,53.78,percent of total billed charges,,,,,,no IP contract,,,78,,83.89,percent of total billed charges,,,70,,75.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,52.7,3324,
00591-3713-19 - ezetimibe 10 mg Tab,00591-3713-19,NDC,,,,inpatient,1,EA,93.65,56.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,75.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,79.6,percent of total billed charges,,,85,,79.6,percent of total billed charges,,,49,,45.89,percent of total billed charges,,,90,,84.29,percent of total billed charges,,,,,,,no IP contract,,80,,74.92,percent of total billed charges,,,,,,,no IP contract,,50,,46.83,percent of total billed charges,,,,,,no IP contract,,,78,,73.05,percent of total billed charges,,,70,,65.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,45.89,3324,
00591-3713-30 - ezetimbe 10 mg Tab,00591-3713-30,NDC,,,,inpatient,1,EA,93.65,56.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,75.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,79.6,percent of total billed charges,,,85,,79.6,percent of total billed charges,,,49,,45.89,percent of total billed charges,,,90,,84.29,percent of total billed charges,,,,,,,no IP contract,,80,,74.92,percent of total billed charges,,,,,,,no IP contract,,50,,46.83,percent of total billed charges,,,,,,no IP contract,,,78,,73.05,percent of total billed charges,,,70,,65.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,45.89,3324,
00591-4012-01 - valproic acid 250 mg Cap,00591-4012-01,NDC,,,,inpatient,1,EA,10.1,6.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.59,percent of total billed charges,,,85,,8.59,percent of total billed charges,,,49,,4.95,percent of total billed charges,,,90,,9.09,percent of total billed charges,,,,,,,no IP contract,,80,,8.08,percent of total billed charges,,,,,,,no IP contract,,50,,5.05,percent of total billed charges,,,,,,no IP contract,,,78,,7.88,percent of total billed charges,,,70,,7.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.95,3324,
00591-5335-01 - trihexyphenidyl 2 mg Tab,00591-5335-01,NDC,,,,inpatient,1,EA,5.25,3.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.46,percent of total billed charges,,,85,,4.46,percent of total billed charges,,,49,,2.57,percent of total billed charges,,,90,,4.73,percent of total billed charges,,,,,,,no IP contract,,80,,4.2,percent of total billed charges,,,,,,,no IP contract,,50,,2.63,percent of total billed charges,,,,,,no IP contract,,,78,,4.1,percent of total billed charges,,,70,,3.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.57,3324,
00591-5335-10 - trihexyphenidyl 2 mg Tab,00591-5335-10,NDC,,,,inpatient,1,EA,5,3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.25,percent of total billed charges,,,85,,4.25,percent of total billed charges,,,49,,2.45,percent of total billed charges,,,90,,4.5,percent of total billed charges,,,,,,,no IP contract,,80,,4,percent of total billed charges,,,,,,,no IP contract,,50,,2.5,percent of total billed charges,,,,,,no IP contract,,,78,,3.9,percent of total billed charges,,,70,,3.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.45,3324,
00591-5347-01 - probenecid 500 mg Tab,00591-5347-01,NDC,,,,inpatient,1,EA,11.6,6.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.86,percent of total billed charges,,,85,,9.86,percent of total billed charges,,,49,,5.68,percent of total billed charges,,,90,,10.44,percent of total billed charges,,,,,,,no IP contract,,80,,9.28,percent of total billed charges,,,,,,,no IP contract,,50,,5.8,percent of total billed charges,,,,,,no IP contract,,,78,,9.05,percent of total billed charges,,,70,,8.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.68,3324,
00591-5571-01 - trimethoprim 100 mg Tab,00591-5571-01,NDC,,,,inpatient,1,EA,9.25,5.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.86,percent of total billed charges,,,85,,7.86,percent of total billed charges,,,49,,4.53,percent of total billed charges,,,90,,8.33,percent of total billed charges,,,,,,,no IP contract,,80,,7.4,percent of total billed charges,,,,,,,no IP contract,,50,,4.63,percent of total billed charges,,,,,,no IP contract,,,78,,7.22,percent of total billed charges,,,70,,6.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.53,3324,
00591-5643-01 - minoxidil 10 mg Tab,00591-5643-01,NDC,,,,inpatient,1,EA,14.1,8.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.99,percent of total billed charges,,,85,,11.99,percent of total billed charges,,,49,,6.91,percent of total billed charges,,,90,,12.69,percent of total billed charges,,,,,,,no IP contract,,80,,11.28,percent of total billed charges,,,,,,,no IP contract,,50,,7.05,percent of total billed charges,,,,,,no IP contract,,,78,,11,percent of total billed charges,,,70,,9.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.91,3324,
00591-5786-01 - nortriptyline 10 mg Cap,00591-5786-01,NDC,,,,inpatient,1,EA,7.1,4.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.04,percent of total billed charges,,,85,,6.04,percent of total billed charges,,,49,,3.48,percent of total billed charges,,,90,,6.39,percent of total billed charges,,,,,,,no IP contract,,80,,5.68,percent of total billed charges,,,,,,,no IP contract,,50,,3.55,percent of total billed charges,,,,,,no IP contract,,,78,,5.54,percent of total billed charges,,,70,,4.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.48,3324,
00597-0007-61 - clonidine 0.2 mg Tab,00597-0007-61,NDC,,,,inpatient,1,EA,12.1,7.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.29,percent of total billed charges,,,85,,10.29,percent of total billed charges,,,49,,5.93,percent of total billed charges,,,90,,10.89,percent of total billed charges,,,,,,,no IP contract,,80,,9.68,percent of total billed charges,,,,,,,no IP contract,,50,,6.05,percent of total billed charges,,,,,,no IP contract,,,78,,9.44,percent of total billed charges,,,70,,8.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.93,3324,
00597-0011-01 - clonidine 0.3 mg Tab,00597-0011-01,NDC,,,,inpatient,1,EA,19.55,11.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.62,percent of total billed charges,,,85,,16.62,percent of total billed charges,,,49,,9.58,percent of total billed charges,,,90,,17.6,percent of total billed charges,,,,,,,no IP contract,,80,,15.64,percent of total billed charges,,,,,,,no IP contract,,50,,9.78,percent of total billed charges,,,,,,no IP contract,,,78,,15.25,percent of total billed charges,,,70,,13.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.58,3324,
00597-0024-02 - albuterol-ipratropium CFC free 100 mcg-20 mcg/inh Aeros,00597-0024-02,NDC,,,,inpatient,1,UN,2544.2,1526.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2060.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2162.57,percent of total billed charges,,,85,,2162.57,percent of total billed charges,,,49,,1246.66,percent of total billed charges,,,90,,2289.78,percent of total billed charges,,,,,,,no IP contract,,80,,2035.36,percent of total billed charges,,,,,,,no IP contract,,50,,1272.1,percent of total billed charges,,,,,,no IP contract,,,78,,1984.48,percent of total billed charges,,,70,,1780.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
00597-0066-01 - mexiletine 150 mg Cap,00597-0066-01,NDC,,,,inpatient,1,EA,14.15,8.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.03,percent of total billed charges,,,85,,12.03,percent of total billed charges,,,49,,6.93,percent of total billed charges,,,90,,12.74,percent of total billed charges,,,,,,,no IP contract,,80,,11.32,percent of total billed charges,,,,,,,no IP contract,,50,,7.08,percent of total billed charges,,,,,,no IP contract,,,78,,11.04,percent of total billed charges,,,70,,9.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.93,3324,
00597-0067-61 - mexiletine 200 mg Cap,00597-0067-61,NDC,,,,inpatient,1,EA,13.9,8.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.82,percent of total billed charges,,,85,,11.82,percent of total billed charges,,,49,,6.81,percent of total billed charges,,,90,,12.51,percent of total billed charges,,,,,,,no IP contract,,80,,11.12,percent of total billed charges,,,,,,,no IP contract,,50,,6.95,percent of total billed charges,,,,,,no IP contract,,,78,,10.84,percent of total billed charges,,,70,,9.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.81,3324,
00597-0071-75 - metaproterenol 5% Soln,00597-0071-75,NDC,,,,inpatient,1,ML,182.5,109.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,147.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,155.13,percent of total billed charges,,,85,,155.13,percent of total billed charges,,,49,,89.43,percent of total billed charges,,,90,,164.25,percent of total billed charges,,,,,,,no IP contract,,80,,146,percent of total billed charges,,,,,,,no IP contract,,50,,91.25,percent of total billed charges,,,,,,no IP contract,,,78,,142.35,percent of total billed charges,,,70,,127.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,89.43,3324,
00597-0075-41 - tiotropium 18 mcg Cap,00597-0075-41,NDC,,,,inpatient,1,EA,477.25,286.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,386.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,405.66,percent of total billed charges,,,85,,405.66,percent of total billed charges,,,49,,233.85,percent of total billed charges,,,90,,429.53,percent of total billed charges,,,,,,,no IP contract,,80,,381.8,percent of total billed charges,,,,,,,no IP contract,,50,,238.63,percent of total billed charges,,,,,,no IP contract,,,78,,372.26,percent of total billed charges,,,70,,334.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,233.85,3324,
00597-0075-75 - tiotropium 18 mcg Cap,00597-0075-75,NDC,,,,inpatient,1,EA,755.1,453.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,611.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,641.84,percent of total billed charges,,,85,,641.84,percent of total billed charges,,,49,,370,percent of total billed charges,,,90,,679.59,percent of total billed charges,,,,,,,no IP contract,,80,,604.08,percent of total billed charges,,,,,,,no IP contract,,50,,377.55,percent of total billed charges,,,,,,no IP contract,,,78,,588.98,percent of total billed charges,,,70,,528.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,370,3324,
00597-0083-53 - pramipexole 0.125 mg Tab,00597-0083-53,NDC,,,,inpatient,1,EA,18.6,11.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.81,percent of total billed charges,,,85,,15.81,percent of total billed charges,,,49,,9.11,percent of total billed charges,,,90,,16.74,percent of total billed charges,,,,,,,no IP contract,,80,,14.88,percent of total billed charges,,,,,,,no IP contract,,50,,9.3,percent of total billed charges,,,,,,no IP contract,,,78,,14.51,percent of total billed charges,,,70,,13.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.11,3324,
00597-0084-90 - pramipexole 0.25 mg Tab,00597-0084-90,NDC,,,,inpatient,1,EA,19.55,11.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.62,percent of total billed charges,,,85,,16.62,percent of total billed charges,,,49,,9.58,percent of total billed charges,,,90,,17.6,percent of total billed charges,,,,,,,no IP contract,,80,,15.64,percent of total billed charges,,,,,,,no IP contract,,50,,9.78,percent of total billed charges,,,,,,no IP contract,,,78,,15.25,percent of total billed charges,,,70,,13.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.58,3324,
00597-0085-90 - pramipexole 0.5 mg Tab,00597-0085-90,NDC,,,,inpatient,1,EA,23.8,14.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.23,percent of total billed charges,,,85,,20.23,percent of total billed charges,,,49,,11.66,percent of total billed charges,,,90,,21.42,percent of total billed charges,,,,,,,no IP contract,,80,,19.04,percent of total billed charges,,,,,,,no IP contract,,50,,11.9,percent of total billed charges,,,,,,no IP contract,,,78,,18.56,percent of total billed charges,,,70,,16.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.66,3324,
00597-0087-17 - ipratropium CFC free 17 mcg/inh Aeros,00597-0087-17,NDC,,,,inpatient,1,UN,2627.7,1576.62,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2128.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2233.55,percent of total billed charges,,,85,,2233.55,percent of total billed charges,,,49,,1287.57,percent of total billed charges,,,90,,2364.93,percent of total billed charges,,,,,,,no IP contract,,80,,2102.16,percent of total billed charges,,,,,,,no IP contract,,50,,1313.85,percent of total billed charges,,,,,,no IP contract,,,78,,2049.61,percent of total billed charges,,,70,,1839.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
00597-0091-61 - pramipexole 1.5 mg Tab,00597-0091-61,NDC,,,,inpatient,1,EA,21.25,12.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.06,percent of total billed charges,,,85,,18.06,percent of total billed charges,,,49,,10.41,percent of total billed charges,,,90,,19.13,percent of total billed charges,,,,,,,no IP contract,,80,,17,percent of total billed charges,,,,,,,no IP contract,,50,,10.63,percent of total billed charges,,,,,,no IP contract,,,78,,16.58,percent of total billed charges,,,70,,14.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.41,3324,
00597-0107-60 - dabigatran 75 mg Cap,00597-0107-60,NDC,,,,inpatient,1,EA,36,21.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.6,percent of total billed charges,,,85,,30.6,percent of total billed charges,,,49,,17.64,percent of total billed charges,,,90,,32.4,percent of total billed charges,,,,,,,no IP contract,,80,,28.8,percent of total billed charges,,,,,,,no IP contract,,50,,18,percent of total billed charges,,,,,,no IP contract,,,78,,28.08,percent of total billed charges,,,70,,25.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.64,3324,
00597-0135-60 - dabigatran etexilate mesylate 150 mg Cap,00597-0135-60,NDC,,,,inpatient,1,EA,36,21.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.6,percent of total billed charges,,,85,,30.6,percent of total billed charges,,,49,,17.64,percent of total billed charges,,,90,,32.4,percent of total billed charges,,,,,,,no IP contract,,80,,28.8,percent of total billed charges,,,,,,,no IP contract,,50,,18,percent of total billed charges,,,,,,no IP contract,,,78,,28.08,percent of total billed charges,,,70,,25.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.64,3324,
00597-0140-61 - linagliptin 5 mg Tab,00597-0140-61,NDC,,,,inpatient,1,EA,99.4,59.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,80.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,84.49,percent of total billed charges,,,85,,84.49,percent of total billed charges,,,49,,48.71,percent of total billed charges,,,90,,89.46,percent of total billed charges,,,,,,,no IP contract,,80,,79.52,percent of total billed charges,,,,,,,no IP contract,,50,,49.7,percent of total billed charges,,,,,,no IP contract,,,78,,77.53,percent of total billed charges,,,70,,69.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,48.71,3324,
00597-0152-37 - empagliflozin 10 mg Tab,00597-0152-37,NDC,,,,inpatient,1,EA,170,102,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,137.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,144.5,percent of total billed charges,,,85,,144.5,percent of total billed charges,,,49,,83.3,percent of total billed charges,,,90,,153,percent of total billed charges,,,,,,,no IP contract,,80,,136,percent of total billed charges,,,,,,,no IP contract,,50,,85,percent of total billed charges,,,,,,no IP contract,,,78,,132.6,percent of total billed charges,,,70,,119,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,83.3,3324,
00597-0153-37 - empagliflozin 25 mg Tab,00597-0153-37,NDC,,,,inpatient,1,EA,170,102,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,137.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,144.5,percent of total billed charges,,,85,,144.5,percent of total billed charges,,,49,,83.3,percent of total billed charges,,,90,,153,percent of total billed charges,,,,,,,no IP contract,,80,,136,percent of total billed charges,,,,,,,no IP contract,,50,,85,percent of total billed charges,,,,,,no IP contract,,,78,,132.6,percent of total billed charges,,,70,,119,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,83.3,3324,
00597-0183-90 - pramipexole 0.125 mg Tab,00597-0183-90,NDC,,,,inpatient,1,EA,23.45,14.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.93,percent of total billed charges,,,85,,19.93,percent of total billed charges,,,49,,11.49,percent of total billed charges,,,90,,21.11,percent of total billed charges,,,,,,,no IP contract,,80,,18.76,percent of total billed charges,,,,,,,no IP contract,,50,,11.73,percent of total billed charges,,,,,,no IP contract,,,78,,18.29,percent of total billed charges,,,70,,16.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.49,3324,
00597-0191-90 - pramipexole 1.5 mg Tab,00597-0191-90,NDC,,,,inpatient,1,EA,25.35,15.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.55,percent of total billed charges,,,85,,21.55,percent of total billed charges,,,49,,12.42,percent of total billed charges,,,90,,22.82,percent of total billed charges,,,,,,,no IP contract,,80,,20.28,percent of total billed charges,,,,,,,no IP contract,,50,,12.68,percent of total billed charges,,,,,,no IP contract,,,78,,19.77,percent of total billed charges,,,70,,17.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.42,3324,
00597-0355-09 - dabigatran 75 mg Cap,00597-0355-09,NDC,,,,inpatient,1,EA,61.7,37.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,49.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,52.45,percent of total billed charges,,,85,,52.45,percent of total billed charges,,,49,,30.23,percent of total billed charges,,,90,,55.53,percent of total billed charges,,,,,,,no IP contract,,80,,49.36,percent of total billed charges,,,,,,,no IP contract,,50,,30.85,percent of total billed charges,,,,,,no IP contract,,,78,,48.13,percent of total billed charges,,,70,,43.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,30.23,3324,
00597-0360-82 - dabigatran 150 mg Cap,00597-0360-82,NDC,,,,inpatient,1,EA,67.5,40.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,54.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,57.38,percent of total billed charges,,,85,,57.38,percent of total billed charges,,,49,,33.08,percent of total billed charges,,,90,,60.75,percent of total billed charges,,,,,,,no IP contract,,80,,54,percent of total billed charges,,,,,,,no IP contract,,50,,33.75,percent of total billed charges,,,,,,no IP contract,,,78,,52.65,percent of total billed charges,,,70,,47.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,33.08,3324,
00603-0168-21 - aspirin 325 mg EC Ta,00603-0168-21,NDC,,,,inpatient,1,EA,4.05,2.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.44,percent of total billed charges,,,85,,3.44,percent of total billed charges,,,49,,1.98,percent of total billed charges,,,90,,3.65,percent of total billed charges,,,,,,,no IP contract,,80,,3.24,percent of total billed charges,,,,,,,no IP contract,,50,,2.03,percent of total billed charges,,,,,,no IP contract,,,78,,3.16,percent of total billed charges,,,70,,2.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.98,3324,
00603-0179-29 - ferrous sulfate 325 mg Tab,00603-0179-29,NDC,,,,inpatient,1,EA,5.2,3.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.42,percent of total billed charges,,,85,,4.42,percent of total billed charges,,,49,,2.55,percent of total billed charges,,,90,,4.68,percent of total billed charges,,,,,,,no IP contract,,80,,4.16,percent of total billed charges,,,,,,,no IP contract,,50,,2.6,percent of total billed charges,,,,,,no IP contract,,,78,,4.06,percent of total billed charges,,,70,,3.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.55,3324,
00603-0535-50 - hydrocortisone topical 1% Cream,00603-0535-50,NDC,,,,inpatient,1,UN,31.7,19.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,25.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.95,percent of total billed charges,,,85,,26.95,percent of total billed charges,,,49,,15.53,percent of total billed charges,,,90,,28.53,percent of total billed charges,,,,,,,no IP contract,,80,,25.36,percent of total billed charges,,,,,,,no IP contract,,50,,15.85,percent of total billed charges,,,,,,no IP contract,,,78,,24.73,percent of total billed charges,,,70,,22.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.53,3324,
00603-0648-88 - capsaicin topical 0.025% Cream,00603-0648-88,NDC,,,,inpatient,1,UN,149.15,89.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,120.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,126.78,percent of total billed charges,,,85,,126.78,percent of total billed charges,,,49,,73.08,percent of total billed charges,,,90,,134.24,percent of total billed charges,,,,,,,no IP contract,,80,,119.32,percent of total billed charges,,,,,,,no IP contract,,50,,74.58,percent of total billed charges,,,,,,no IP contract,,,78,,116.34,percent of total billed charges,,,70,,104.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,73.08,3324,
00603-0823-81 - diphenhydrAMINE 12.5 mg/5 mL LIQ,00603-0823-81,NDC,,,,inpatient,1,ML,5.6,3.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.76,percent of total billed charges,,,85,,4.76,percent of total billed charges,,,49,,2.74,percent of total billed charges,,,90,,5.04,percent of total billed charges,,,,,,,no IP contract,,80,,4.48,percent of total billed charges,,,,,,,no IP contract,,50,,2.8,percent of total billed charges,,,,,,no IP contract,,,78,,4.37,percent of total billed charges,,,70,,3.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.74,3324,
00603-0855-94 - dextromethorphan-guaiFENesin 10 mg-100 mg/5 mL LIQ,00603-0855-94,NDC,,,,inpatient,10,ML,25.4,15.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.59,percent of total billed charges,,,85,,21.59,percent of total billed charges,,,49,,12.45,percent of total billed charges,,,90,,22.86,percent of total billed charges,,,,,,,no IP contract,,80,,20.32,percent of total billed charges,,,,,,,no IP contract,,50,,12.7,percent of total billed charges,,,,,,no IP contract,,,78,,19.81,percent of total billed charges,,,70,,17.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.45,3324,
00603-1161-58 - dicyclomine 10 mg/5 mL Syrup,00603-1161-58,NDC,,,,inpatient,1,ML,7.9,4.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.72,percent of total billed charges,,,85,,6.72,percent of total billed charges,,,49,,3.87,percent of total billed charges,,,90,,7.11,percent of total billed charges,,,,,,,no IP contract,,80,,6.32,percent of total billed charges,,,,,,,no IP contract,,50,,3.95,percent of total billed charges,,,,,,no IP contract,,,78,,6.16,percent of total billed charges,,,70,,5.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.87,3324,
00603-1393-64 - lidocaine topical 2% Soln,00603-1393-64,NDC,,,,inpatient,15,ML,125.85,75.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,101.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,106.97,percent of total billed charges,,,85,,106.97,percent of total billed charges,,,49,,61.67,percent of total billed charges,,,90,,113.27,percent of total billed charges,,,,,,,no IP contract,,80,,100.68,percent of total billed charges,,,,,,,no IP contract,,50,,62.93,percent of total billed charges,,,,,,no IP contract,,,78,,98.16,percent of total billed charges,,,70,,88.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,61.67,3324,
00603-1491-58 - oxybutynin 5 mg/5 mL Syrup,00603-1491-58,NDC,,,,inpatient,1,ML,6.1,3.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.19,percent of total billed charges,,,85,,5.19,percent of total billed charges,,,49,,2.99,percent of total billed charges,,,90,,5.49,percent of total billed charges,,,,,,,no IP contract,,80,,4.88,percent of total billed charges,,,,,,,no IP contract,,50,,3.05,percent of total billed charges,,,,,,no IP contract,,,78,,4.76,percent of total billed charges,,,70,,4.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.99,3324,
00603-1508-58 - PHENobarbital 20 mg/5 mL Elixi,00603-1508-58,NDC,,,,inpatient,1,ML,5.85,3.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.97,percent of total billed charges,,,85,,4.97,percent of total billed charges,,,49,,2.87,percent of total billed charges,,,90,,5.27,percent of total billed charges,,,,,,,no IP contract,,80,,4.68,percent of total billed charges,,,,,,,no IP contract,,50,,2.93,percent of total billed charges,,,,,,no IP contract,,,78,,4.56,percent of total billed charges,,,70,,4.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.87,3324,
00603-1542-58 - potassium chloride soln  20 mEq / 15 mL Soln,00603-1542-58,NDC,,,,inpatient,1,ML,12.15,7.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.33,percent of total billed charges,,,85,,10.33,percent of total billed charges,,,49,,5.95,percent of total billed charges,,,90,,10.94,percent of total billed charges,,,,,,,no IP contract,,80,,9.72,percent of total billed charges,,,,,,,no IP contract,,50,,6.08,percent of total billed charges,,,,,,no IP contract,,,78,,9.48,percent of total billed charges,,,70,,8.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.95,3324,
00603-1554-16 - potassium chloride packet(s) 20 mEq REC Powder,00603-1554-16,NDC,,,,inpatient,1,UN,89.2,53.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,72.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,75.82,percent of total billed charges,,,85,,75.82,percent of total billed charges,,,49,,43.71,percent of total billed charges,,,90,,80.28,percent of total billed charges,,,,,,,no IP contract,,80,,71.36,percent of total billed charges,,,,,,,no IP contract,,50,,44.6,percent of total billed charges,,,,,,no IP contract,,,78,,69.58,percent of total billed charges,,,70,,62.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,43.71,3324,
00603-1567-58 - prednisoLONE 15 mg/5 mL Syrup,00603-1567-58,NDC,,,,inpatient,1,ML,7.5,4.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.38,percent of total billed charges,,,85,,6.38,percent of total billed charges,,,49,,3.68,percent of total billed charges,,,90,,6.75,percent of total billed charges,,,,,,,no IP contract,,80,,6,percent of total billed charges,,,,,,,no IP contract,,50,,3.75,percent of total billed charges,,,,,,no IP contract,,,78,,5.85,percent of total billed charges,,,70,,5.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.68,3324,
00603-2213-21 - amitriptyline 25 mg Tab,00603-2213-21,NDC,,,,inpatient,1,EA,6.7,4.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.7,percent of total billed charges,,,85,,5.7,percent of total billed charges,,,49,,3.28,percent of total billed charges,,,90,,6.03,percent of total billed charges,,,,,,,no IP contract,,80,,5.36,percent of total billed charges,,,,,,,no IP contract,,50,,3.35,percent of total billed charges,,,,,,no IP contract,,,78,,5.23,percent of total billed charges,,,70,,4.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.28,3324,
00603-2434-21 - benztropine 1 mg Tab,00603-2434-21,NDC,,,,inpatient,1,EA,5.55,3.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.72,percent of total billed charges,,,85,,4.72,percent of total billed charges,,,49,,2.72,percent of total billed charges,,,90,,5,percent of total billed charges,,,,,,,no IP contract,,80,,4.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.78,percent of total billed charges,,,,,,no IP contract,,,78,,4.33,percent of total billed charges,,,70,,3.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.72,3324,
benztropine 2 mg Tab,00603-2435-21,NDC,,,,inpatient,1,EA,5.95,3.57,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.06,percent of total billed charges,,,85,,5.06,percent of total billed charges,,,49,,2.92,percent of total billed charges,,,90,,5.36,percent of total billed charges,,,,,,,no IP contract,,80,,4.76,percent of total billed charges,,,,,,,no IP contract,,50,,2.98,percent of total billed charges,,,,,,no IP contract,,,78,,4.64,percent of total billed charges,,,70,,4.17,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.92,3324,
00603-2544-21 - APAP/butalbital/caffeine 325 mg-50 mg-40 mg Tab,00603-2544-21,NDC,,,,inpatient,1,EA,8.9,5.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.57,percent of total billed charges,,,85,,7.57,percent of total billed charges,,,49,,4.36,percent of total billed charges,,,90,,8.01,percent of total billed charges,,,,,,,no IP contract,,80,,7.12,percent of total billed charges,,,,,,,no IP contract,,50,,4.45,percent of total billed charges,,,,,,no IP contract,,,78,,6.94,percent of total billed charges,,,70,,6.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.36,3324,
00603-3581-21 - felodipine 2.5 mg ER Ta,00603-3581-21,NDC,,,,inpatient,1,EA,15.85,9.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.47,percent of total billed charges,,,85,,13.47,percent of total billed charges,,,49,,7.77,percent of total billed charges,,,90,,14.27,percent of total billed charges,,,,,,,no IP contract,,80,,12.68,percent of total billed charges,,,,,,,no IP contract,,50,,7.93,percent of total billed charges,,,,,,no IP contract,,,78,,12.36,percent of total billed charges,,,70,,11.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.77,3324,
00603-3855-21 - hydrochlorothiazide 12.5 mg Cap,00603-3855-21,NDC,,,,inpatient,1,EA,7.15,4.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.08,percent of total billed charges,,,85,,6.08,percent of total billed charges,,,49,,3.5,percent of total billed charges,,,90,,6.44,percent of total billed charges,,,,,,,no IP contract,,80,,5.72,percent of total billed charges,,,,,,,no IP contract,,50,,3.58,percent of total billed charges,,,,,,no IP contract,,,78,,5.58,percent of total billed charges,,,70,,5.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.5,3324,
00603-4173-16 - potassium chloride 20 mEq REC P,00603-4173-16,NDC,,,,inpatient,1,UN,5.2,3.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.42,percent of total billed charges,,,85,,4.42,percent of total billed charges,,,49,,2.55,percent of total billed charges,,,90,,4.68,percent of total billed charges,,,,,,,no IP contract,,80,,4.16,percent of total billed charges,,,,,,,no IP contract,,50,,2.6,percent of total billed charges,,,,,,no IP contract,,,78,,4.06,percent of total billed charges,,,70,,3.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.55,3324,
00603-4173-16 - potassium chloride 20 mEq REC P,00603-4173-16,NDC,,,,inpatient,1,UN,5.2,3.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.42,percent of total billed charges,,,85,,4.42,percent of total billed charges,,,49,,2.55,percent of total billed charges,,,90,,4.68,percent of total billed charges,,,,,,,no IP contract,,80,,4.16,percent of total billed charges,,,,,,,no IP contract,,50,,2.6,percent of total billed charges,,,,,,no IP contract,,,78,,4.06,percent of total billed charges,,,70,,3.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.55,3324,
00603-4593-21 - methylPREDNISolone 4 mg Tab,00603-4593-21,NDC,,,,inpatient,1,EA,15.2,9.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.92,percent of total billed charges,,,85,,12.92,percent of total billed charges,,,49,,7.45,percent of total billed charges,,,90,,13.68,percent of total billed charges,,,,,,,no IP contract,,80,,12.16,percent of total billed charges,,,,,,,no IP contract,,50,,7.6,percent of total billed charges,,,,,,no IP contract,,,78,,11.86,percent of total billed charges,,,70,,10.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.45,3324,
00603-5165-21 - phenobarbital 16.2 mg Tab,00603-5165-21,NDC,,,,inpatient,1,EA,5.75,3.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.89,percent of total billed charges,,,85,,4.89,percent of total billed charges,,,49,,2.82,percent of total billed charges,,,90,,5.18,percent of total billed charges,,,,,,,no IP contract,,80,,4.6,percent of total billed charges,,,,,,,no IP contract,,50,,2.88,percent of total billed charges,,,,,,no IP contract,,,78,,4.49,percent of total billed charges,,,70,,4.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.82,3324,
00603-5167-21 - phenobarbital 60 mg Tab,00603-5167-21,NDC,,,,inpatient,1,EA,5.9,3.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.02,percent of total billed charges,,,85,,5.02,percent of total billed charges,,,49,,2.89,percent of total billed charges,,,90,,5.31,percent of total billed charges,,,,,,,no IP contract,,80,,4.72,percent of total billed charges,,,,,,,no IP contract,,50,,2.95,percent of total billed charges,,,,,,no IP contract,,,78,,4.6,percent of total billed charges,,,70,,4.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.89,3324,
00603-5168-21 - phenobarbital 100 mg Tab,00603-5168-21,NDC,,,,inpatient,1,EA,6,3.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.1,percent of total billed charges,,,85,,5.1,percent of total billed charges,,,49,,2.94,percent of total billed charges,,,90,,5.4,percent of total billed charges,,,,,,,no IP contract,,80,,4.8,percent of total billed charges,,,,,,,no IP contract,,50,,3,percent of total billed charges,,,,,,no IP contract,,,78,,4.68,percent of total billed charges,,,70,,4.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.94,3324,
00603-5482-21 - propranolol 10 mg Tab,00603-5482-21,NDC,,,,inpatient,1,EA,6.55,3.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.57,percent of total billed charges,,,85,,5.57,percent of total billed charges,,,49,,3.21,percent of total billed charges,,,90,,5.9,percent of total billed charges,,,,,,,no IP contract,,80,,5.24,percent of total billed charges,,,,,,,no IP contract,,50,,3.28,percent of total billed charges,,,,,,no IP contract,,,78,,5.11,percent of total billed charges,,,70,,4.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.21,3324,
00603-5483-21 - propranolol 20 mg Tab,00603-5483-21,NDC,,,,inpatient,1,EA,6.7,4.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.7,percent of total billed charges,,,85,,5.7,percent of total billed charges,,,49,,3.28,percent of total billed charges,,,90,,6.03,percent of total billed charges,,,,,,,no IP contract,,80,,5.36,percent of total billed charges,,,,,,,no IP contract,,50,,3.35,percent of total billed charges,,,,,,no IP contract,,,78,,5.23,percent of total billed charges,,,70,,4.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.28,3324,
00603-5484-21 - propranolol 40 mg Tab,00603-5484-21,NDC,,,,inpatient,1,EA,9.3,5.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.91,percent of total billed charges,,,85,,7.91,percent of total billed charges,,,49,,4.56,percent of total billed charges,,,90,,8.37,percent of total billed charges,,,,,,,no IP contract,,80,,7.44,percent of total billed charges,,,,,,,no IP contract,,50,,4.65,percent of total billed charges,,,,,,no IP contract,,,78,,7.25,percent of total billed charges,,,70,,6.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.56,3324,
00603-5769-21 - sotalol 80 mg Tab,00603-5769-21,NDC,,,,inpatient,1,EA,24.2,14.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.57,percent of total billed charges,,,85,,20.57,percent of total billed charges,,,49,,11.86,percent of total billed charges,,,90,,21.78,percent of total billed charges,,,,,,,no IP contract,,80,,19.36,percent of total billed charges,,,,,,,no IP contract,,50,,12.1,percent of total billed charges,,,,,,no IP contract,,,78,,18.88,percent of total billed charges,,,70,,16.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.86,3324,
00603-5801-21 - sulfaSALAzine 500 mg Tab,00603-5801-21,NDC,,,,inpatient,1,EA,5.8,3.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.93,percent of total billed charges,,,85,,4.93,percent of total billed charges,,,49,,2.84,percent of total billed charges,,,90,,5.22,percent of total billed charges,,,,,,,no IP contract,,80,,4.64,percent of total billed charges,,,,,,,no IP contract,,50,,2.9,percent of total billed charges,,,,,,no IP contract,,,78,,4.52,percent of total billed charges,,,70,,4.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.84,3324,
00603-7818-78 - nystatin topical 100000 units/g Cream,00603-7818-78,NDC,,,,inpatient,1,UN,229.15,137.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,185.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,194.78,percent of total billed charges,,,85,,194.78,percent of total billed charges,,,49,,112.28,percent of total billed charges,,,90,,206.24,percent of total billed charges,,,,,,,no IP contract,,80,,183.32,percent of total billed charges,,,,,,,no IP contract,,50,,114.58,percent of total billed charges,,,,,,no IP contract,,,78,,178.74,percent of total billed charges,,,70,,160.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,112.28,3324,
00603-7861-90 - triamcinolone topical 0.025% Cream,00603-7861-90,NDC,,,,inpatient,1,UN,102.5,61.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,83.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,87.13,percent of total billed charges,,,85,,87.13,percent of total billed charges,,,49,,50.23,percent of total billed charges,,,90,,92.25,percent of total billed charges,,,,,,,no IP contract,,80,,82,percent of total billed charges,,,,,,,no IP contract,,50,,51.25,percent of total billed charges,,,,,,no IP contract,,,78,,79.95,percent of total billed charges,,,70,,71.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,50.23,3324,
00641-0376-25 - diphenhydrAMINE 50 mg/mL Soln,00641-0376-25,NDC,,,,inpatient,1,ML,17.6,10.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.96,percent of total billed charges,,,85,,14.96,percent of total billed charges,,,49,,8.62,percent of total billed charges,,,90,,15.84,percent of total billed charges,,,,,,,no IP contract,,80,,14.08,percent of total billed charges,,,,,,,no IP contract,,50,,8.8,percent of total billed charges,,,,,,no IP contract,,,78,,13.73,percent of total billed charges,,,70,,12.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.62,3324,
00641-0400-12 - heparin 5000 units/mL Soln,00641-0400-12,NDC,,,,inpatient,1,ML,22.2,13.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.87,percent of total billed charges,,,85,,18.87,percent of total billed charges,,,49,,10.88,percent of total billed charges,,,90,,19.98,percent of total billed charges,,,,,,,no IP contract,,80,,17.76,percent of total billed charges,,,,,,,no IP contract,,50,,11.1,percent of total billed charges,,,,,,no IP contract,,,78,,17.32,percent of total billed charges,,,70,,15.54,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.88,3324,
00641-0491-25 - prochlorperazine 5 mg/mL Soln,00641-0491-25,NDC,,,,inpatient,1,ML,35.8,21.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.43,percent of total billed charges,,,85,,30.43,percent of total billed charges,,,49,,17.54,percent of total billed charges,,,90,,32.22,percent of total billed charges,,,,,,,no IP contract,,80,,28.64,percent of total billed charges,,,,,,,no IP contract,,50,,17.9,percent of total billed charges,,,,,,no IP contract,,,78,,27.92,percent of total billed charges,,,70,,25.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.54,3324,
00641-1410-35 - digoxin 250 mcg/mL (0.25 mg/mL) Soln,00641-1410-35,NDC,,,,inpatient,2,ML,20.1,12.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.09,percent of total billed charges,,,85,,17.09,percent of total billed charges,,,49,,9.85,percent of total billed charges,,,90,,18.09,percent of total billed charges,,,,,,,no IP contract,,80,,16.08,percent of total billed charges,,,,,,,no IP contract,,50,,10.05,percent of total billed charges,,,,,,no IP contract,,,78,,15.68,percent of total billed charges,,,70,,14.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.85,3324,
00641-2442-45 - heparin 10 units/mL Soln,00641-2442-45,NDC,,,,inpatient,30,ML,24.5,14.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.83,percent of total billed charges,,,85,,20.83,percent of total billed charges,,,49,,12.01,percent of total billed charges,,,90,,22.05,percent of total billed charges,,,,,,,no IP contract,,80,,19.6,percent of total billed charges,,,,,,,no IP contract,,50,,12.25,percent of total billed charges,,,,,,no IP contract,,,78,,19.11,percent of total billed charges,,,70,,17.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.01,3324,
00641-6001-25 - LORazepam 2 mg/mL Soln,00641-6001-25,NDC,,,,inpatient,1,ML,24.4,14.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.74,percent of total billed charges,,,85,,20.74,percent of total billed charges,,,49,,11.96,percent of total billed charges,,,90,,21.96,percent of total billed charges,,,,,,,no IP contract,,80,,19.52,percent of total billed charges,,,,,,,no IP contract,,50,,12.2,percent of total billed charges,,,,,,no IP contract,,,78,,19.03,percent of total billed charges,,,70,,17.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.96,3324,
00641-6007-10 - bumetanide 0.25 mg/mL Soln,00641-6007-10,NDC,,,,inpatient,1,ML,34.6,20.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.41,percent of total billed charges,,,85,,29.41,percent of total billed charges,,,49,,16.95,percent of total billed charges,,,90,,31.14,percent of total billed charges,,,,,,,no IP contract,,80,,27.68,percent of total billed charges,,,,,,,no IP contract,,50,,17.3,percent of total billed charges,,,,,,no IP contract,,,78,,26.99,percent of total billed charges,,,70,,24.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.95,3324,
00641-6008-10 - bumetanide 0.25 mg/mL Soln,00641-6008-10,NDC,,,,inpatient,4,ML,32.25,19.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,26.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,27.41,percent of total billed charges,,,85,,27.41,percent of total billed charges,,,49,,15.8,percent of total billed charges,,,90,,29.03,percent of total billed charges,,,,,,,no IP contract,,80,,25.8,percent of total billed charges,,,,,,,no IP contract,,50,,16.13,percent of total billed charges,,,,,,no IP contract,,,78,,25.16,percent of total billed charges,,,70,,22.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.8,3324,
00641-6044-25 - lorazepam 2 mg/mL Soln,00641-6044-25,NDC,,,,inpatient,1,ML,12.9,7.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.97,percent of total billed charges,,,85,,10.97,percent of total billed charges,,,49,,6.32,percent of total billed charges,,,90,,11.61,percent of total billed charges,,,,,,,no IP contract,,80,,10.32,percent of total billed charges,,,,,,,no IP contract,,50,,6.45,percent of total billed charges,,,,,,no IP contract,,,78,,10.06,percent of total billed charges,,,70,,9.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.32,3324,
00641-6046-10 - LORazepam 2 mg/mL Soln,00641-6046-10,NDC,,,,inpatient,1,ML,12.15,7.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.33,percent of total billed charges,,,85,,10.33,percent of total billed charges,,,49,,5.95,percent of total billed charges,,,90,,10.94,percent of total billed charges,,,,,,,no IP contract,,80,,9.72,percent of total billed charges,,,,,,,no IP contract,,50,,6.08,percent of total billed charges,,,,,,no IP contract,,,78,,9.48,percent of total billed charges,,,70,,8.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.95,3324,
00641-6048-25 - LORazepam 2 mg/mL Soln,00641-6048-25,NDC,,,,inpatient,1,ML,12.9,7.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.97,percent of total billed charges,,,85,,10.97,percent of total billed charges,,,49,,6.32,percent of total billed charges,,,90,,11.61,percent of total billed charges,,,,,,,no IP contract,,80,,10.32,percent of total billed charges,,,,,,,no IP contract,,50,,6.45,percent of total billed charges,,,,,,no IP contract,,,78,,10.06,percent of total billed charges,,,70,,9.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.32,3324,
00641-6061-25 - midazolam 5 mg/mL Soln,00641-6061-25,NDC,,,,inpatient,1,ML,17.4,10.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.79,percent of total billed charges,,,85,,14.79,percent of total billed charges,,,49,,8.53,percent of total billed charges,,,90,,15.66,percent of total billed charges,,,,,,,no IP contract,,80,,13.92,percent of total billed charges,,,,,,,no IP contract,,50,,8.7,percent of total billed charges,,,,,,no IP contract,,,78,,13.57,percent of total billed charges,,,70,,12.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.53,3324,
00641-6080-25 - ondansetron 2 mg/mL Soln,00641-6080-25,NDC,,,,inpatient,2,ML,18.95,11.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.11,percent of total billed charges,,,85,,16.11,percent of total billed charges,,,49,,9.29,percent of total billed charges,,,90,,17.06,percent of total billed charges,,,,,,,no IP contract,,80,,15.16,percent of total billed charges,,,,,,,no IP contract,,50,,9.48,percent of total billed charges,,,,,,no IP contract,,,78,,14.78,percent of total billed charges,,,70,,13.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.29,3324,
00641-6116-10 - ampicillin-sulbactam 1 g-0.5 g REC I,00641-6116-10,NDC,,,,inpatient,1,EA,110.1,66.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,89.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,93.59,percent of total billed charges,,,85,,93.59,percent of total billed charges,,,49,,53.95,percent of total billed charges,,,90,,99.09,percent of total billed charges,,,,,,,no IP contract,,80,,88.08,percent of total billed charges,,,,,,,no IP contract,,50,,55.05,percent of total billed charges,,,,,,no IP contract,,,78,,85.88,percent of total billed charges,,,70,,77.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,53.95,3324,
00641-6117-10 - ampicillin-sulbactam 2 g-1 g REC I,00641-6117-10,NDC,,,,inpatient,8,ML,86.4,51.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,69.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,73.44,percent of total billed charges,,,85,,73.44,percent of total billed charges,,,49,,42.34,percent of total billed charges,,,90,,77.76,percent of total billed charges,,,,,,,no IP contract,,80,,69.12,percent of total billed charges,,,,,,,no IP contract,,50,,43.2,percent of total billed charges,,,,,,no IP contract,,,78,,67.39,percent of total billed charges,,,70,,60.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,42.34,3324,
00641-6132-25 - naloxone 0.4 mg/mL Soln,00641-6132-25,NDC,,,,inpatient,1,ML,110.5,66.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,89.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,93.93,percent of total billed charges,,,85,,93.93,percent of total billed charges,,,49,,54.15,percent of total billed charges,,,90,,99.45,percent of total billed charges,,,,,,,no IP contract,,80,,88.4,percent of total billed charges,,,,,,,no IP contract,,50,,55.25,percent of total billed charges,,,,,,no IP contract,,,78,,86.19,percent of total billed charges,,,70,,77.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,54.15,3324,
00641-6162-10 - bumetanide  0.25 mg/mL Injection,00641-6162-10,NDC,,,,inpatient,1,ML,34.6,20.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.41,percent of total billed charges,,,85,,29.41,percent of total billed charges,,,49,,16.95,percent of total billed charges,,,90,,31.14,percent of total billed charges,,,,,,,no IP contract,,80,,27.68,percent of total billed charges,,,,,,,no IP contract,,50,,17.3,percent of total billed charges,,,,,,no IP contract,,,78,,26.99,percent of total billed charges,,,70,,24.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.95,3324,
00641-6175-10 - octreotide 100 mcg/mL Soln,00641-6175-10,NDC,,,,inpatient,1,ML,75.1,45.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63.84,percent of total billed charges,,,85,,63.84,percent of total billed charges,,,49,,36.8,percent of total billed charges,,,90,,67.59,percent of total billed charges,,,,,,,no IP contract,,80,,60.08,percent of total billed charges,,,,,,,no IP contract,,50,,37.55,percent of total billed charges,,,,,,no IP contract,,,78,,58.58,percent of total billed charges,,,70,,52.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.8,3324,
00641-6184-25 - digoxin 250 mcg/mL (0.25 mg/mL) Soln,00641-6184-25,NDC,,,,inpatient,2,ML,64.95,38.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,52.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,55.21,percent of total billed charges,,,85,,55.21,percent of total billed charges,,,49,,31.83,percent of total billed charges,,,90,,58.46,percent of total billed charges,,,,,,,no IP contract,,80,,51.96,percent of total billed charges,,,,,,,no IP contract,,50,,32.48,percent of total billed charges,,,,,,no IP contract,,,78,,50.66,percent of total billed charges,,,70,,45.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.83,3324,
00662-5340-66 - doxepin 10 mg Cap,00662-5340-66,NDC,,,,inpatient,1,EA,6.6,3.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.61,percent of total billed charges,,,85,,5.61,percent of total billed charges,,,49,,3.23,percent of total billed charges,,,90,,5.94,percent of total billed charges,,,,,,,no IP contract,,80,,5.28,percent of total billed charges,,,,,,,no IP contract,,50,,3.3,percent of total billed charges,,,,,,no IP contract,,,78,,5.15,percent of total billed charges,,,70,,4.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.23,3324,
00662-5350-66 - doxepin 25 mg Cap,00662-5350-66,NDC,,,,inpatient,1,EA,7.55,4.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.42,percent of total billed charges,,,85,,6.42,percent of total billed charges,,,49,,3.7,percent of total billed charges,,,90,,6.8,percent of total billed charges,,,,,,,no IP contract,,80,,6.04,percent of total billed charges,,,,,,,no IP contract,,50,,3.78,percent of total billed charges,,,,,,no IP contract,,,78,,5.89,percent of total billed charges,,,70,,5.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.7,3324,
00677-0070-10 - ferrous sulfate 325 mg Tab,00677-0070-10,NDC,,,,inpatient,1,EA,4,2.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.4,percent of total billed charges,,,85,,3.4,percent of total billed charges,,,49,,1.96,percent of total billed charges,,,90,,3.6,percent of total billed charges,,,,,,,no IP contract,,80,,3.2,percent of total billed charges,,,,,,,no IP contract,,50,,2,percent of total billed charges,,,,,,no IP contract,,,78,,3.12,percent of total billed charges,,,70,,2.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.96,3324,
00703-3301-04 - octreotide 50 mcg/mL Soln,00703-3301-04,NDC,,,,inpatient,1,ML,51.05,30.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,41.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,43.39,percent of total billed charges,,,85,,43.39,percent of total billed charges,,,49,,25.01,percent of total billed charges,,,90,,45.95,percent of total billed charges,,,,,,,no IP contract,,80,,40.84,percent of total billed charges,,,,,,,no IP contract,,50,,25.53,percent of total billed charges,,,,,,no IP contract,,,78,,39.82,percent of total billed charges,,,70,,35.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.01,3324,
00703-4502-04 - metoclopramide 5 mg/mL Soln,00703-4502-04,NDC,,,,inpatient,2,ML,14.4,8.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.24,percent of total billed charges,,,85,,12.24,percent of total billed charges,,,49,,7.06,percent of total billed charges,,,90,,12.96,percent of total billed charges,,,,,,,no IP contract,,80,,11.52,percent of total billed charges,,,,,,,no IP contract,,50,,7.2,percent of total billed charges,,,,,,no IP contract,,,78,,11.23,percent of total billed charges,,,70,,10.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.06,3324,
00703-7171-04 - prochlorperazine 5 mg/mL Soln,00703-7171-04,NDC,,,,inpatient,1,ML,90.4,54.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,73.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,76.84,percent of total billed charges,,,85,,76.84,percent of total billed charges,,,49,,44.3,percent of total billed charges,,,90,,81.36,percent of total billed charges,,,,,,,no IP contract,,80,,72.32,percent of total billed charges,,,,,,,no IP contract,,50,,45.2,percent of total billed charges,,,,,,no IP contract,,,78,,70.51,percent of total billed charges,,,70,,63.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,44.3,3324,
00703-7311-04 - calcitriol 1 mcg/mL Soln,00703-7311-04,NDC,,,,inpatient,1,ML,119.65,71.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,96.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,101.7,percent of total billed charges,,,85,,101.7,percent of total billed charges,,,49,,58.63,percent of total billed charges,,,90,,107.69,percent of total billed charges,,,,,,,no IP contract,,80,,95.72,percent of total billed charges,,,,,,,no IP contract,,50,,59.83,percent of total billed charges,,,,,,no IP contract,,,78,,93.33,percent of total billed charges,,,70,,83.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.63,3324,
00703-8530-23 - enoxaparin 30 mg/0.3 mL Soln,00703-8530-23,NDC,,,,inpatient,0.3,ML,191.9,115.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,155.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,163.12,percent of total billed charges,,,85,,163.12,percent of total billed charges,,,49,,94.03,percent of total billed charges,,,90,,172.71,percent of total billed charges,,,,,,,no IP contract,,80,,153.52,percent of total billed charges,,,,,,,no IP contract,,50,,95.95,percent of total billed charges,,,,,,no IP contract,,,78,,149.68,percent of total billed charges,,,70,,134.33,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,94.03,3324,
00703-8540-23 - enoxaparin 40 mg/0.4 mL Soln,00703-8540-23,NDC,,,,inpatient,0.4,ML,191.5,114.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,155.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,162.78,percent of total billed charges,,,85,,162.78,percent of total billed charges,,,49,,93.84,percent of total billed charges,,,90,,172.35,percent of total billed charges,,,,,,,no IP contract,,80,,153.2,percent of total billed charges,,,,,,,no IP contract,,50,,95.75,percent of total billed charges,,,,,,no IP contract,,,78,,149.37,percent of total billed charges,,,70,,134.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,93.84,3324,
00703-8610-21 - enoxaparin 120 mg/0.8 mL Soln,00703-8610-21,NDC,,,,inpatient,0.8,ML,282.9,169.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,229.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,240.47,percent of total billed charges,,,85,,240.47,percent of total billed charges,,,49,,138.62,percent of total billed charges,,,90,,254.61,percent of total billed charges,,,,,,,no IP contract,,80,,226.32,percent of total billed charges,,,,,,,no IP contract,,50,,141.45,percent of total billed charges,,,,,,no IP contract,,,78,,220.66,percent of total billed charges,,,70,,198.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,138.62,3324,
00703-9032-03 - amikacin 250 mg/mL Soln,00703-9032-03,NDC,,,,inpatient,1,ML,66.25,39.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,53.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.31,percent of total billed charges,,,85,,56.31,percent of total billed charges,,,49,,32.46,percent of total billed charges,,,90,,59.63,percent of total billed charges,,,,,,,no IP contract,,80,,53,percent of total billed charges,,,,,,,no IP contract,,50,,33.13,percent of total billed charges,,,,,,no IP contract,,,78,,51.68,percent of total billed charges,,,70,,46.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.46,3324,
00703-9503-03 - sulfamethoxazole-trimethoprim 80 mg-16 mg/mL Soln,00703-9503-03,NDC,,,,inpatient,10,ML,79.3,47.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,64.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,67.41,percent of total billed charges,,,85,,67.41,percent of total billed charges,,,49,,38.86,percent of total billed charges,,,90,,71.37,percent of total billed charges,,,,,,,no IP contract,,80,,63.44,percent of total billed charges,,,,,,,no IP contract,,50,,39.65,percent of total billed charges,,,,,,no IP contract,,,78,,61.85,percent of total billed charges,,,70,,55.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,38.86,3324,
00703-9514-03 - sulfamethoxazole-trimethoprim 80 mg-16 mg/mL Soln,00703-9514-03,NDC,,,,inpatient,10,ML,82.65,49.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,66.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,70.25,percent of total billed charges,,,85,,70.25,percent of total billed charges,,,49,,40.5,percent of total billed charges,,,90,,74.39,percent of total billed charges,,,,,,,no IP contract,,80,,66.12,percent of total billed charges,,,,,,,no IP contract,,50,,41.33,percent of total billed charges,,,,,,no IP contract,,,78,,64.47,percent of total billed charges,,,70,,57.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,40.5,3324,
00703-9514-93 - sulfamethoxazole-trimethoprim 80 mg-16 mg/mL Soln,00703-9514-93,NDC,,,,inpatient,10,ML,135.75,81.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,109.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,115.39,percent of total billed charges,,,85,,115.39,percent of total billed charges,,,49,,66.52,percent of total billed charges,,,90,,122.18,percent of total billed charges,,,,,,,no IP contract,,80,,108.6,percent of total billed charges,,,,,,,no IP contract,,50,,67.88,percent of total billed charges,,,,,,no IP contract,,,78,,105.89,percent of total billed charges,,,70,,95.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,66.52,3324,
00713-0108-09 - benzocaine-trimethobenzamide 2%-200 mg Supp,00713-0108-09,NDC,,,,inpatient,1,UN,14.9,8.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.67,percent of total billed charges,,,85,,12.67,percent of total billed charges,,,49,,7.3,percent of total billed charges,,,90,,13.41,percent of total billed charges,,,,,,,no IP contract,,80,,11.92,percent of total billed charges,,,,,,,no IP contract,,50,,7.45,percent of total billed charges,,,,,,no IP contract,,,78,,11.62,percent of total billed charges,,,70,,10.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.3,3324,
00713-0108-50 - benzocaine-trimethobenzamide 2%-200 mg Supp,00713-0108-50,NDC,,,,inpatient,1,UN,14.8,8.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.58,percent of total billed charges,,,85,,12.58,percent of total billed charges,,,49,,7.25,percent of total billed charges,,,90,,13.32,percent of total billed charges,,,,,,,no IP contract,,80,,11.84,percent of total billed charges,,,,,,,no IP contract,,50,,7.4,percent of total billed charges,,,,,,no IP contract,,,78,,11.54,percent of total billed charges,,,70,,10.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.25,3324,
00713-0109-01 - bisacodyl 10 mg Supp,00713-0109-01,NDC,,,,inpatient,1,UN,5.4,3.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.59,percent of total billed charges,,,85,,4.59,percent of total billed charges,,,49,,2.65,percent of total billed charges,,,90,,4.86,percent of total billed charges,,,,,,,no IP contract,,80,,4.32,percent of total billed charges,,,,,,,no IP contract,,50,,2.7,percent of total billed charges,,,,,,no IP contract,,,78,,4.21,percent of total billed charges,,,70,,3.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.65,3324,
00713-0135-12 - prochlorperazine 25 mg Supp,00713-0135-12,NDC,,,,inpatient,1,UN,110.35,66.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,89.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,93.8,percent of total billed charges,,,85,,93.8,percent of total billed charges,,,49,,54.07,percent of total billed charges,,,90,,99.32,percent of total billed charges,,,,,,,no IP contract,,80,,88.28,percent of total billed charges,,,,,,,no IP contract,,50,,55.18,percent of total billed charges,,,,,,no IP contract,,,78,,86.07,percent of total billed charges,,,70,,77.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,54.07,3324,
00713-0165-12 - acetaminophen 650 mg Supp,00713-0165-12,NDC,,,,inpatient,1,UN,9.45,5.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.03,percent of total billed charges,,,85,,8.03,percent of total billed charges,,,49,,4.63,percent of total billed charges,,,90,,8.51,percent of total billed charges,,,,,,,no IP contract,,80,,7.56,percent of total billed charges,,,,,,,no IP contract,,50,,4.73,percent of total billed charges,,,,,,no IP contract,,,78,,7.37,percent of total billed charges,,,70,,6.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.63,3324,
00713-0226-80 - triamcinolone topical 0.025% Cream,00713-0226-80,NDC,,,,inpatient,1,UN,95.85,57.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,77.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,81.47,percent of total billed charges,,,85,,81.47,percent of total billed charges,,,49,,46.97,percent of total billed charges,,,90,,86.27,percent of total billed charges,,,,,,,no IP contract,,80,,76.68,percent of total billed charges,,,,,,,no IP contract,,50,,47.93,percent of total billed charges,,,,,,no IP contract,,,78,,74.76,percent of total billed charges,,,70,,67.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,46.97,3324,
00713-0229-80 - triamcinolone topical 0.025% Ointm,00713-0229-80,NDC,,,,inpatient,1,UN,62.55,37.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,50.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,53.17,percent of total billed charges,,,85,,53.17,percent of total billed charges,,,49,,30.65,percent of total billed charges,,,90,,56.3,percent of total billed charges,,,,,,,no IP contract,,80,,50.04,percent of total billed charges,,,,,,,no IP contract,,50,,31.28,percent of total billed charges,,,,,,no IP contract,,,78,,48.79,percent of total billed charges,,,70,,43.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,30.65,3324,
00713-0252-37 - miconazole topical 2% Cream,00713-0252-37,NDC,,,,inpatient,1,UN,71.8,43.08,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,58.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,61.03,percent of total billed charges,,,85,,61.03,percent of total billed charges,,,49,,35.18,percent of total billed charges,,,90,,64.62,percent of total billed charges,,,,,,,no IP contract,,80,,57.44,percent of total billed charges,,,,,,,no IP contract,,50,,35.9,percent of total billed charges,,,,,,no IP contract,,,78,,56,percent of total billed charges,,,70,,50.26,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,35.18,3324,
00713-0280-31 - bacitracin topical 500 units/g Ointm,00713-0280-31,NDC,,,,inpatient,1,UN,39.2,23.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.32,percent of total billed charges,,,85,,33.32,percent of total billed charges,,,49,,19.21,percent of total billed charges,,,90,,35.28,percent of total billed charges,,,,,,,no IP contract,,80,,31.36,percent of total billed charges,,,,,,,no IP contract,,50,,19.6,percent of total billed charges,,,,,,no IP contract,,,78,,30.58,percent of total billed charges,,,70,,27.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.21,3324,
00713-0317-88 - ciclopirox topical 8% Soln,00713-0317-88,NDC,,,,inpatient,1,UN,225.3,135.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,182.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,191.51,percent of total billed charges,,,85,,191.51,percent of total billed charges,,,49,,110.4,percent of total billed charges,,,90,,202.77,percent of total billed charges,,,,,,,no IP contract,,80,,180.24,percent of total billed charges,,,,,,,no IP contract,,50,,112.65,percent of total billed charges,,,,,,no IP contract,,,78,,175.73,percent of total billed charges,,,70,,157.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,110.4,3324,
00713-0503-12 - hydrocortisone topical 25 mg Supp,00713-0503-12,NDC,,,,inpatient,1,UN,183.9,110.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,148.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,156.32,percent of total billed charges,,,85,,156.32,percent of total billed charges,,,49,,90.11,percent of total billed charges,,,90,,165.51,percent of total billed charges,,,,,,,no IP contract,,80,,147.12,percent of total billed charges,,,,,,,no IP contract,,50,,91.95,percent of total billed charges,,,,,,no IP contract,,,78,,143.44,percent of total billed charges,,,70,,128.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,90.11,3324,
00713-0631-31 - fluticasone topical 0.05% Cream,00713-0631-31,NDC,,,,inpatient,1,UN,294.1,176.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,238.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,249.99,percent of total billed charges,,,85,,249.99,percent of total billed charges,,,49,,144.11,percent of total billed charges,,,90,,264.69,percent of total billed charges,,,,,,,no IP contract,,80,,235.28,percent of total billed charges,,,,,,,no IP contract,,50,,147.05,percent of total billed charges,,,,,,no IP contract,,,78,,229.4,percent of total billed charges,,,70,,205.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,144.11,3324,
00713-0656-31 - clobetasol topical 0.05% Ointm,00713-0656-31,NDC,,,,inpatient,1,UN,2173.35,1304.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1760.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1847.35,percent of total billed charges,,,85,,1847.35,percent of total billed charges,,,49,,1064.94,percent of total billed charges,,,90,,1956.02,percent of total billed charges,,,,,,,no IP contract,,80,,1738.68,percent of total billed charges,,,,,,,no IP contract,,50,,1086.68,percent of total billed charges,,,,,,no IP contract,,,78,,1695.21,percent of total billed charges,,,70,,1521.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
00713-0678-31 - nystatin topical 100000 units/g Cream,00713-0678-31,NDC,,,,inpatient,1,UN,219.15,131.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,177.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,186.28,percent of total billed charges,,,85,,186.28,percent of total billed charges,,,49,,107.38,percent of total billed charges,,,90,,197.24,percent of total billed charges,,,,,,,no IP contract,,80,,175.32,percent of total billed charges,,,,,,,no IP contract,,50,,109.58,percent of total billed charges,,,,,,no IP contract,,,78,,170.94,percent of total billed charges,,,70,,153.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,107.38,3324,
00713-0682-31 - gentamicin topical 0.1% Ointm,00713-0682-31,NDC,,,,inpatient,1,EA,831.4,498.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,673.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,706.69,percent of total billed charges,,,85,,706.69,percent of total billed charges,,,49,,407.39,percent of total billed charges,,,90,,748.26,percent of total billed charges,,,,,,,no IP contract,,80,,665.12,percent of total billed charges,,,,,,,no IP contract,,50,,415.7,percent of total billed charges,,,,,,no IP contract,,,78,,648.49,percent of total billed charges,,,70,,581.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,407.39,3324,
00713-0686-31 - nystatin topical 100000 units/g Ointm,00713-0686-31,NDC,,,,inpatient,1,UN,229.15,137.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,185.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,194.78,percent of total billed charges,,,85,,194.78,percent of total billed charges,,,49,,112.28,percent of total billed charges,,,90,,206.24,percent of total billed charges,,,,,,,no IP contract,,80,,183.32,percent of total billed charges,,,,,,,no IP contract,,50,,114.58,percent of total billed charges,,,,,,no IP contract,,,78,,178.74,percent of total billed charges,,,70,,160.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,112.28,3324,
00731-0401-06 - zinc sulfate 220 mg Cap,00731-0401-06,NDC,,,,inpatient,1,EA,4.8,2.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.08,percent of total billed charges,,,85,,4.08,percent of total billed charges,,,49,,2.35,percent of total billed charges,,,90,,4.32,percent of total billed charges,,,,,,,no IP contract,,80,,3.84,percent of total billed charges,,,,,,,no IP contract,,50,,2.4,percent of total billed charges,,,,,,no IP contract,,,78,,3.74,percent of total billed charges,,,70,,3.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.35,3324,
00766-1651-60 - calcium carbonate 1250 mg Tab,00766-1651-60,NDC,,,,inpatient,1,EA,4.45,2.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.78,percent of total billed charges,,,85,,3.78,percent of total billed charges,,,49,,2.18,percent of total billed charges,,,90,,4.01,percent of total billed charges,,,,,,,no IP contract,,80,,3.56,percent of total billed charges,,,,,,,no IP contract,,50,,2.23,percent of total billed charges,,,,,,no IP contract,,,78,,3.47,percent of total billed charges,,,70,,3.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.18,3324,
00766-1651-60 - calcium carbonate 1250 mg Tab,00766-1651-60,NDC,,,,inpatient,1,EA,4.45,2.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.78,percent of total billed charges,,,85,,3.78,percent of total billed charges,,,49,,2.18,percent of total billed charges,,,90,,4.01,percent of total billed charges,,,,,,,no IP contract,,80,,3.56,percent of total billed charges,,,,,,,no IP contract,,50,,2.23,percent of total billed charges,,,,,,no IP contract,,,78,,3.47,percent of total billed charges,,,70,,3.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.18,3324,
00777-3104-02 - fluoxetine 10 mg Cap,00777-3104-02,NDC,,,,inpatient,1,EA,42.2,25.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,35.87,percent of total billed charges,,,85,,35.87,percent of total billed charges,,,49,,20.68,percent of total billed charges,,,90,,37.98,percent of total billed charges,,,,,,,no IP contract,,80,,33.76,percent of total billed charges,,,,,,,no IP contract,,50,,21.1,percent of total billed charges,,,,,,no IP contract,,,78,,32.92,percent of total billed charges,,,70,,29.54,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.68,3324,
ALPRAZolam 0.25 mg Tab,00781-1061-01,NDC,,,,inpatient,1,EA,11.25,6.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.56,percent of total billed charges,,,85,,9.56,percent of total billed charges,,,49,,5.51,percent of total billed charges,,,90,,10.13,percent of total billed charges,,,,,,,no IP contract,,80,,9,percent of total billed charges,,,,,,,no IP contract,,50,,5.63,percent of total billed charges,,,,,,no IP contract,,,78,,8.78,percent of total billed charges,,,70,,7.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.51,3324,
00781-1078-01 - atenolol 25 mg Tab,00781-1078-01,NDC,,,,inpatient,1,EA,10.35,6.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.8,percent of total billed charges,,,85,,8.8,percent of total billed charges,,,49,,5.07,percent of total billed charges,,,90,,9.32,percent of total billed charges,,,,,,,no IP contract,,80,,8.28,percent of total billed charges,,,,,,,no IP contract,,50,,5.18,percent of total billed charges,,,,,,no IP contract,,,78,,8.07,percent of total billed charges,,,70,,7.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.07,3324,
00781-1375-13 - meclizine 25 mg Tab,00781-1375-13,NDC,,,,inpatient,1,EA,4.7,2.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4,percent of total billed charges,,,85,,4,percent of total billed charges,,,49,,2.3,percent of total billed charges,,,90,,4.23,percent of total billed charges,,,,,,,no IP contract,,80,,3.76,percent of total billed charges,,,,,,,no IP contract,,50,,2.35,percent of total billed charges,,,,,,no IP contract,,,78,,3.67,percent of total billed charges,,,70,,3.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.3,3324,
00781-1391-01 - haloperidol 0.5 mg Tab,00781-1391-01,NDC,,,,inpatient,1,EA,5.75,3.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.89,percent of total billed charges,,,85,,4.89,percent of total billed charges,,,49,,2.82,percent of total billed charges,,,90,,5.18,percent of total billed charges,,,,,,,no IP contract,,80,,4.6,percent of total billed charges,,,,,,,no IP contract,,50,,2.88,percent of total billed charges,,,,,,no IP contract,,,78,,4.49,percent of total billed charges,,,70,,4.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.82,3324,
00781-1392-01 - haloperidol 1 mg Tab,00781-1392-01,NDC,,,,inpatient,1,EA,6.6,3.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.61,percent of total billed charges,,,85,,5.61,percent of total billed charges,,,49,,3.23,percent of total billed charges,,,90,,5.94,percent of total billed charges,,,,,,,no IP contract,,80,,5.28,percent of total billed charges,,,,,,,no IP contract,,50,,3.3,percent of total billed charges,,,,,,no IP contract,,,78,,5.15,percent of total billed charges,,,70,,4.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.23,3324,
00781-1486-01 - amitriptyline 10 mg Tab,00781-1486-01,NDC,,,,inpatient,1,EA,5.25,3.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.46,percent of total billed charges,,,85,,4.46,percent of total billed charges,,,49,,2.57,percent of total billed charges,,,90,,4.73,percent of total billed charges,,,,,,,no IP contract,,80,,4.2,percent of total billed charges,,,,,,,no IP contract,,50,,2.63,percent of total billed charges,,,,,,no IP contract,,,78,,4.1,percent of total billed charges,,,70,,3.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.57,3324,
00781-1526-01 - potassium chloride 10 mEq ER Ta,00781-1526-01,NDC,,,,inpatient,1,EA,8.3,4.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.06,percent of total billed charges,,,85,,7.06,percent of total billed charges,,,49,,4.07,percent of total billed charges,,,90,,7.47,percent of total billed charges,,,,,,,no IP contract,,80,,6.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.15,percent of total billed charges,,,,,,no IP contract,,,78,,6.47,percent of total billed charges,,,70,,5.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.07,3324,
00781-1635-01 - isosorbide dinitrate 5 mg Tab,00781-1635-01,NDC,,,,inpatient,1,EA,4.95,2.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.21,percent of total billed charges,,,85,,4.21,percent of total billed charges,,,49,,2.43,percent of total billed charges,,,90,,4.46,percent of total billed charges,,,,,,,no IP contract,,80,,3.96,percent of total billed charges,,,,,,,no IP contract,,50,,2.48,percent of total billed charges,,,,,,no IP contract,,,78,,3.86,percent of total billed charges,,,70,,3.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.43,3324,
00781-1695-10 - isosorbide dinitrate 20 mg Tab,00781-1695-10,NDC,,,,inpatient,1,EA,13.3,7.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.31,percent of total billed charges,,,85,,11.31,percent of total billed charges,,,49,,6.52,percent of total billed charges,,,90,,11.97,percent of total billed charges,,,,,,,no IP contract,,80,,10.64,percent of total billed charges,,,,,,,no IP contract,,50,,6.65,percent of total billed charges,,,,,,no IP contract,,,78,,10.37,percent of total billed charges,,,70,,9.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.52,3324,
00781-1716-01 - chlorproMAZINE 25 mg Tab,00781-1716-01,NDC,,,,inpatient,1,EA,7.8,4.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.63,percent of total billed charges,,,85,,6.63,percent of total billed charges,,,49,,3.82,percent of total billed charges,,,90,,7.02,percent of total billed charges,,,,,,,no IP contract,,80,,6.24,percent of total billed charges,,,,,,,no IP contract,,50,,3.9,percent of total billed charges,,,,,,no IP contract,,,78,,6.08,percent of total billed charges,,,70,,5.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.82,3324,
00781-1766-13 - imipramine 50 mg Tab,00781-1766-13,NDC,,,,inpatient,1,EA,15.45,9.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.13,percent of total billed charges,,,85,,13.13,percent of total billed charges,,,49,,7.57,percent of total billed charges,,,90,,13.91,percent of total billed charges,,,,,,,no IP contract,,80,,12.36,percent of total billed charges,,,,,,,no IP contract,,50,,7.73,percent of total billed charges,,,,,,no IP contract,,,78,,12.05,percent of total billed charges,,,70,,10.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.57,3324,
00781-1785-01 - diclofenac sodium 25 mg EC Tab,00781-1785-01,NDC,,,,inpatient,1,EA,8.6,5.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.31,percent of total billed charges,,,85,,7.31,percent of total billed charges,,,49,,4.21,percent of total billed charges,,,90,,7.74,percent of total billed charges,,,,,,,no IP contract,,80,,6.88,percent of total billed charges,,,,,,,no IP contract,,50,,4.3,percent of total billed charges,,,,,,no IP contract,,,78,,6.71,percent of total billed charges,,,70,,6.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.21,3324,
amoxicillin-clavulanate 500 mg-125 mg Tab,00781-1831-01,NDC,,,,inpatient,1,EA,33,19.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,26.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.05,percent of total billed charges,,,85,,28.05,percent of total billed charges,,,49,,16.17,percent of total billed charges,,,90,,29.7,percent of total billed charges,,,,,,,no IP contract,,80,,26.4,percent of total billed charges,,,,,,,no IP contract,,50,,16.5,percent of total billed charges,,,,,,no IP contract,,,78,,25.74,percent of total billed charges,,,70,,23.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.17,3324,
00781-1874-31 - amoxicillin-clavulanate 250 mg-125 mg Tab,00781-1874-31,NDC,,,,inpatient,1,EA,36.6,21.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.11,percent of total billed charges,,,85,,31.11,percent of total billed charges,,,49,,17.93,percent of total billed charges,,,90,,32.94,percent of total billed charges,,,,,,,no IP contract,,80,,29.28,percent of total billed charges,,,,,,,no IP contract,,50,,18.3,percent of total billed charges,,,,,,no IP contract,,,78,,28.55,percent of total billed charges,,,70,,25.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.93,3324,
00781-1943-82 - amoxicillin-clavulanate 1000 mg-62.5 mg ER Ta,00781-1943-82,NDC,,,,inpatient,1,EA,64.8,38.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,52.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,55.08,percent of total billed charges,,,85,,55.08,percent of total billed charges,,,49,,31.75,percent of total billed charges,,,90,,58.32,percent of total billed charges,,,,,,,no IP contract,,80,,51.84,percent of total billed charges,,,,,,,no IP contract,,50,,32.4,percent of total billed charges,,,,,,no IP contract,,,78,,50.54,percent of total billed charges,,,70,,45.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.75,3324,
00781-1961-60 - clarithromycin 250 mg Tab,00781-1961-60,NDC,,,,inpatient,1,EA,51.7,31.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,41.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,43.95,percent of total billed charges,,,85,,43.95,percent of total billed charges,,,49,,25.33,percent of total billed charges,,,90,,46.53,percent of total billed charges,,,,,,,no IP contract,,80,,41.36,percent of total billed charges,,,,,,,no IP contract,,50,,25.85,percent of total billed charges,,,,,,no IP contract,,,78,,40.33,percent of total billed charges,,,70,,36.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.33,3324,
00781-1971-01 - desipramine 10 mg Tab,00781-1971-01,NDC,,,,inpatient,1,EA,12.75,7.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.84,percent of total billed charges,,,85,,10.84,percent of total billed charges,,,49,,6.25,percent of total billed charges,,,90,,11.48,percent of total billed charges,,,,,,,no IP contract,,80,,10.2,percent of total billed charges,,,,,,,no IP contract,,50,,6.38,percent of total billed charges,,,,,,no IP contract,,,78,,9.95,percent of total billed charges,,,70,,8.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.25,3324,
00781-2020-01 - amoxicillin 250 mg Cap,00781-2020-01,NDC,,,,inpatient,1,EA,5.8,3.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.93,percent of total billed charges,,,85,,4.93,percent of total billed charges,,,49,,2.84,percent of total billed charges,,,90,,5.22,percent of total billed charges,,,,,,,no IP contract,,80,,4.64,percent of total billed charges,,,,,,,no IP contract,,50,,2.9,percent of total billed charges,,,,,,no IP contract,,,78,,4.52,percent of total billed charges,,,70,,4.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.84,3324,
00781-2102-01 - tacrolimus 0.5 mg Cap,00781-2102-01,NDC,,,,inpatient,1,EA,21.55,12.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.32,percent of total billed charges,,,85,,18.32,percent of total billed charges,,,49,,10.56,percent of total billed charges,,,90,,19.4,percent of total billed charges,,,,,,,no IP contract,,80,,17.24,percent of total billed charges,,,,,,,no IP contract,,50,,10.78,percent of total billed charges,,,,,,no IP contract,,,78,,16.81,percent of total billed charges,,,70,,15.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.56,3324,
00781-2103-01 - tacrolimus 1 mg Cap,00781-2103-01,NDC,,,,inpatient,1,EA,39.3,23.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.41,percent of total billed charges,,,85,,33.41,percent of total billed charges,,,49,,19.26,percent of total billed charges,,,90,,35.37,percent of total billed charges,,,,,,,no IP contract,,80,,31.44,percent of total billed charges,,,,,,,no IP contract,,50,,19.65,percent of total billed charges,,,,,,no IP contract,,,78,,30.65,percent of total billed charges,,,70,,27.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.26,3324,
00781-2104-01 - tacrolimus 5 mg Cap,00781-2104-01,NDC,,,,inpatient,1,EA,46.75,28.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,37.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,39.74,percent of total billed charges,,,85,,39.74,percent of total billed charges,,,49,,22.91,percent of total billed charges,,,90,,42.08,percent of total billed charges,,,,,,,no IP contract,,80,,37.4,percent of total billed charges,,,,,,,no IP contract,,50,,23.38,percent of total billed charges,,,,,,no IP contract,,,78,,36.47,percent of total billed charges,,,70,,32.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.91,3324,
00781-2144-01 - ampicillin 250 mg Cap,00781-2144-01,NDC,,,,inpatient,1,EA,5.65,3.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.8,percent of total billed charges,,,85,,4.8,percent of total billed charges,,,49,,2.77,percent of total billed charges,,,90,,5.09,percent of total billed charges,,,,,,,no IP contract,,80,,4.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.83,percent of total billed charges,,,,,,no IP contract,,,78,,4.41,percent of total billed charges,,,70,,3.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.77,3324,
00781-2145-01 - ampicillin 500 mg Cap,00781-2145-01,NDC,,,,inpatient,1,EA,7,4.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.95,percent of total billed charges,,,85,,5.95,percent of total billed charges,,,49,,3.43,percent of total billed charges,,,90,,6.3,percent of total billed charges,,,,,,,no IP contract,,80,,5.6,percent of total billed charges,,,,,,,no IP contract,,50,,3.5,percent of total billed charges,,,,,,no IP contract,,,78,,5.46,percent of total billed charges,,,70,,4.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.43,3324,
00781-2258-01 - dicloxacillin 500 mg Cap,00781-2258-01,NDC,,,,inpatient,1,EA,13.35,8.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.35,percent of total billed charges,,,85,,11.35,percent of total billed charges,,,49,,6.54,percent of total billed charges,,,90,,12.02,percent of total billed charges,,,,,,,no IP contract,,80,,10.68,percent of total billed charges,,,,,,,no IP contract,,50,,6.68,percent of total billed charges,,,,,,no IP contract,,,78,,10.41,percent of total billed charges,,,70,,9.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.54,3324,
00781-2335-01 - amphetamine-dextroamphetamine 10 mg ER Ca,00781-2335-01,NDC,,,,inpatient,1,EA,16.4,9.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.94,percent of total billed charges,,,85,,13.94,percent of total billed charges,,,49,,8.04,percent of total billed charges,,,90,,14.76,percent of total billed charges,,,,,,,no IP contract,,80,,13.12,percent of total billed charges,,,,,,,no IP contract,,50,,8.2,percent of total billed charges,,,,,,no IP contract,,,78,,12.79,percent of total billed charges,,,70,,11.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.04,3324,
00781-2613-01 - amoxicillin 500 mg Cap,00781-2613-01,NDC,,,,inpatient,1,EA,7.25,4.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.16,percent of total billed charges,,,85,,6.16,percent of total billed charges,,,49,,3.55,percent of total billed charges,,,90,,6.53,percent of total billed charges,,,,,,,no IP contract,,80,,5.8,percent of total billed charges,,,,,,,no IP contract,,50,,3.63,percent of total billed charges,,,,,,no IP contract,,,78,,5.66,percent of total billed charges,,,70,,5.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.55,3324,
00781-2613-05 - amoxicillin 500 mg Cap,00781-2613-05,NDC,,,,inpatient,1,EA,6.85,4.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.82,percent of total billed charges,,,85,,5.82,percent of total billed charges,,,49,,3.36,percent of total billed charges,,,90,,6.17,percent of total billed charges,,,,,,,no IP contract,,80,,5.48,percent of total billed charges,,,,,,,no IP contract,,50,,3.43,percent of total billed charges,,,,,,no IP contract,,,78,,5.34,percent of total billed charges,,,70,,4.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.36,3324,
00781-2693-44 - temozolomide 100 mg Cap,00781-2693-44,NDC,,,,inpatient,1,EA,2011.85,1207.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1629.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1710.07,percent of total billed charges,,,85,,1710.07,percent of total billed charges,,,49,,985.81,percent of total billed charges,,,90,,1810.67,percent of total billed charges,,,,,,,no IP contract,,80,,1609.48,percent of total billed charges,,,,,,,no IP contract,,50,,1005.93,percent of total billed charges,,,,,,no IP contract,,,78,,1569.24,percent of total billed charges,,,70,,1408.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
00781-2693-75 - temozolomide 100 mg Cap,00781-2693-75,NDC,,,,inpatient,1,EA,2011.75,1207.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1629.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1709.99,percent of total billed charges,,,85,,1709.99,percent of total billed charges,,,49,,985.76,percent of total billed charges,,,90,,1810.58,percent of total billed charges,,,,,,,no IP contract,,80,,1609.4,percent of total billed charges,,,,,,,no IP contract,,50,,1005.88,percent of total billed charges,,,,,,no IP contract,,,78,,1569.17,percent of total billed charges,,,70,,1408.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
00781-3103-95 - oxacillin 10 g REC I,00781-3103-95,NDC,,,,inpatient,10,ML,680.1,408.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,550.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,578.09,percent of total billed charges,,,85,,578.09,percent of total billed charges,,,49,,333.25,percent of total billed charges,,,90,,612.09,percent of total billed charges,,,,,,,no IP contract,,80,,544.08,percent of total billed charges,,,,,,,no IP contract,,50,,340.05,percent of total billed charges,,,,,,no IP contract,,,78,,530.48,percent of total billed charges,,,70,,476.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,333.25,3324,
00781-3113-95 - piperacillin-tazobactam 3 g-0.375 g REC I,00781-3113-95,NDC,,,,inpatient,1,EA,164.95,98.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,133.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,140.21,percent of total billed charges,,,85,,140.21,percent of total billed charges,,,49,,80.83,percent of total billed charges,,,90,,148.46,percent of total billed charges,,,,,,,no IP contract,,80,,131.96,percent of total billed charges,,,,,,,no IP contract,,50,,82.48,percent of total billed charges,,,,,,no IP contract,,,78,,128.66,percent of total billed charges,,,70,,115.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,80.83,3324,
00781-3114-95 - piperacillin-tazobactam 4 g-0.5 g REC I,00781-3114-95,NDC,,,,inpatient,1,EA,269.95,161.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,218.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,229.46,percent of total billed charges,,,85,,229.46,percent of total billed charges,,,49,,132.28,percent of total billed charges,,,90,,242.96,percent of total billed charges,,,,,,,no IP contract,,80,,215.96,percent of total billed charges,,,,,,,no IP contract,,50,,134.98,percent of total billed charges,,,,,,no IP contract,,,78,,210.56,percent of total billed charges,,,70,,188.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,132.28,3324,
nafcillin 1 g REC I,00781-3124-95,NDC,,,,inpatient,1,EA,147.1,88.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,119.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,125.04,percent of total billed charges,,,85,,125.04,percent of total billed charges,,,49,,72.08,percent of total billed charges,,,90,,132.39,percent of total billed charges,,,,,,,no IP contract,,80,,117.68,percent of total billed charges,,,,,,,no IP contract,,50,,73.55,percent of total billed charges,,,,,,no IP contract,,,78,,114.74,percent of total billed charges,,,70,,102.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,72.08,3324,
nafcillin 2 g REC Inj,00781-3125-95,NDC,,,,inpatient,1,EA,150.55,90.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,121.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,127.97,percent of total billed charges,,,85,,127.97,percent of total billed charges,,,49,,73.77,percent of total billed charges,,,90,,135.5,percent of total billed charges,,,,,,,no IP contract,,80,,120.44,percent of total billed charges,,,,,,,no IP contract,,50,,75.28,percent of total billed charges,,,,,,no IP contract,,,78,,117.43,percent of total billed charges,,,70,,105.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,73.77,3324,
00781-3133-63 - enoxaparin  30 mg Soln,00781-3133-63,NDC,,,,inpatient,0.3,ML,214.6,128.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,173.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,182.41,percent of total billed charges,,,85,,182.41,percent of total billed charges,,,49,,105.15,percent of total billed charges,,,90,,193.14,percent of total billed charges,,,,,,,no IP contract,,80,,171.68,percent of total billed charges,,,,,,,no IP contract,,50,,107.3,percent of total billed charges,,,,,,no IP contract,,,78,,167.39,percent of total billed charges,,,70,,150.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,105.15,3324,
00781-3159-72 - OLANZapine 10 mg REC I,00781-3159-72,NDC,,,,inpatient,2,ML,359.15,215.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,290.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,305.28,percent of total billed charges,,,85,,305.28,percent of total billed charges,,,49,,175.98,percent of total billed charges,,,90,,323.24,percent of total billed charges,,,,,,,no IP contract,,80,,287.32,percent of total billed charges,,,,,,,no IP contract,,50,,179.58,percent of total billed charges,,,,,,no IP contract,,,78,,280.14,percent of total billed charges,,,70,,251.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,175.98,3324,
00781-3356-66 - enoxaparin 60 mg/0.6 mL Soln,00781-3356-66,NDC,,,,inpatient,0.6,ML,420.45,252.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,340.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,357.38,percent of total billed charges,,,85,,357.38,percent of total billed charges,,,49,,206.02,percent of total billed charges,,,90,,378.41,percent of total billed charges,,,,,,,no IP contract,,80,,336.36,percent of total billed charges,,,,,,,no IP contract,,50,,210.23,percent of total billed charges,,,,,,no IP contract,,,78,,327.95,percent of total billed charges,,,70,,294.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,206.02,3324,
00781-3407-95 - ampicillin 500 mg REC I,00781-3407-95,NDC,,,,inpatient,1,EA,111.85,67.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,90.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,95.07,percent of total billed charges,,,85,,95.07,percent of total billed charges,,,49,,54.81,percent of total billed charges,,,90,,100.67,percent of total billed charges,,,,,,,no IP contract,,80,,89.48,percent of total billed charges,,,,,,,no IP contract,,50,,55.93,percent of total billed charges,,,,,,no IP contract,,,78,,87.24,percent of total billed charges,,,70,,78.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,54.81,3324,
00781-3408-95 - ampicillin 2 g REC I,00781-3408-95,NDC,,,,inpatient,1,EA,214.65,128.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,173.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,182.45,percent of total billed charges,,,85,,182.45,percent of total billed charges,,,49,,105.18,percent of total billed charges,,,90,,193.19,percent of total billed charges,,,,,,,no IP contract,,80,,171.72,percent of total billed charges,,,,,,,no IP contract,,50,,107.33,percent of total billed charges,,,,,,no IP contract,,,78,,167.43,percent of total billed charges,,,70,,150.26,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,105.18,3324,
00781-3428-68 - enoxaparin 80 mg/0.8 mL Soln,00781-3428-68,NDC,,,,inpatient,0.8,ML,557.45,334.47,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,451.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,473.83,percent of total billed charges,,,85,,473.83,percent of total billed charges,,,49,,273.15,percent of total billed charges,,,90,,501.71,percent of total billed charges,,,,,,,no IP contract,,80,,445.96,percent of total billed charges,,,,,,,no IP contract,,50,,278.73,percent of total billed charges,,,,,,no IP contract,,,78,,434.81,percent of total billed charges,,,70,,390.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,273.15,3324,
00781-3440-95 - cosyntropin 0.25 mg REC I,00781-3440-95,NDC,,,,inpatient,1,ML,820.65,492.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,664.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,697.55,percent of total billed charges,,,85,,697.55,percent of total billed charges,,,49,,402.12,percent of total billed charges,,,90,,738.59,percent of total billed charges,,,,,,,no IP contract,,80,,656.52,percent of total billed charges,,,,,,,no IP contract,,50,,410.33,percent of total billed charges,,,,,,no IP contract,,,78,,640.11,percent of total billed charges,,,70,,574.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,402.12,3324,
00781-3450-95 - ceFAZolin 500 mg REC I,00781-3450-95,NDC,,,,inpatient,1,EA,116.55,69.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,94.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,99.07,percent of total billed charges,,,85,,99.07,percent of total billed charges,,,49,,57.11,percent of total billed charges,,,90,,104.9,percent of total billed charges,,,,,,,no IP contract,,80,,93.24,percent of total billed charges,,,,,,,no IP contract,,50,,58.28,percent of total billed charges,,,,,,no IP contract,,,78,,90.91,percent of total billed charges,,,70,,81.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,57.11,3324,
00781-3500-69 - enoxaparin Inj 100 mg Syringe,00781-3500-69,NDC,,,,inpatient,1,ML,694.5,416.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,562.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,590.33,percent of total billed charges,,,85,,590.33,percent of total billed charges,,,49,,340.31,percent of total billed charges,,,90,,625.05,percent of total billed charges,,,,,,,no IP contract,,80,,555.6,percent of total billed charges,,,,,,,no IP contract,,50,,347.25,percent of total billed charges,,,,,,no IP contract,,,78,,541.71,percent of total billed charges,,,70,,486.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,340.31,3324,
00781-3655-69 - enoxaparin  150 mg Soln,00781-3655-69,NDC,,,,inpatient,1,ML,1037.55,622.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,840.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,881.92,percent of total billed charges,,,85,,881.92,percent of total billed charges,,,49,,508.4,percent of total billed charges,,,90,,933.8,percent of total billed charges,,,,,,,no IP contract,,80,,830.04,percent of total billed charges,,,,,,,no IP contract,,50,,518.78,percent of total billed charges,,,,,,no IP contract,,,78,,809.29,percent of total billed charges,,,70,,726.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,508.4,3324,
00781-5022-01 - methylPREDNISolone 4 mg Tab,00781-5022-01,NDC,,,,inpatient,1,EA,9.3,5.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.91,percent of total billed charges,,,85,,7.91,percent of total billed charges,,,49,,4.56,percent of total billed charges,,,90,,8.37,percent of total billed charges,,,,,,,no IP contract,,80,,7.44,percent of total billed charges,,,,,,,no IP contract,,50,,4.65,percent of total billed charges,,,,,,no IP contract,,,78,,7.25,percent of total billed charges,,,70,,6.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.56,3324,
00781-5175-01 - mycophenolate mofetil 500 mg Tab,00781-5175-01,NDC,,,,inpatient,1,EA,66.85,40.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,54.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.82,percent of total billed charges,,,85,,56.82,percent of total billed charges,,,49,,32.76,percent of total billed charges,,,90,,60.17,percent of total billed charges,,,,,,,no IP contract,,80,,53.48,percent of total billed charges,,,,,,,no IP contract,,50,,33.43,percent of total billed charges,,,,,,no IP contract,,,78,,52.14,percent of total billed charges,,,70,,46.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.76,3324,
00781-5218-01 - desipramine 10 mg Tab,00781-5218-01,NDC,,,,inpatient,1,EA,15.9,9.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.52,percent of total billed charges,,,85,,13.52,percent of total billed charges,,,49,,7.79,percent of total billed charges,,,90,,14.31,percent of total billed charges,,,,,,,no IP contract,,80,,12.72,percent of total billed charges,,,,,,,no IP contract,,50,,7.95,percent of total billed charges,,,,,,no IP contract,,,78,,12.4,percent of total billed charges,,,70,,11.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.79,3324,
00781-5239-64 - ondansetron 8 mg DIS T,00781-5239-64,NDC,,,,inpatient,1,EA,299,179.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,242.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,254.15,percent of total billed charges,,,85,,254.15,percent of total billed charges,,,49,,146.51,percent of total billed charges,,,90,,269.1,percent of total billed charges,,,,,,,no IP contract,,80,,239.2,percent of total billed charges,,,,,,,no IP contract,,50,,149.5,percent of total billed charges,,,,,,no IP contract,,,78,,233.22,percent of total billed charges,,,70,,209.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,146.51,3324,
00781-5325-01 - bromocriptine 2.5 mg Tab,00781-5325-01,NDC,,,,inpatient,1,EA,21.15,12.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.98,percent of total billed charges,,,85,,17.98,percent of total billed charges,,,49,,10.36,percent of total billed charges,,,90,,19.04,percent of total billed charges,,,,,,,no IP contract,,80,,16.92,percent of total billed charges,,,,,,,no IP contract,,50,,10.58,percent of total billed charges,,,,,,no IP contract,,,78,,16.5,percent of total billed charges,,,70,,14.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.36,3324,
00781-5325-31 - bromocriptine 2.5 mg Tab,00781-5325-31,NDC,,,,inpatient,1,EA,53.65,32.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,43.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,45.6,percent of total billed charges,,,85,,45.6,percent of total billed charges,,,49,,26.29,percent of total billed charges,,,90,,48.29,percent of total billed charges,,,,,,,no IP contract,,80,,42.92,percent of total billed charges,,,,,,,no IP contract,,50,,26.83,percent of total billed charges,,,,,,no IP contract,,,78,,41.85,percent of total billed charges,,,70,,37.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.29,3324,
00781-5422-31 - pioglitazone 45 mg Tab,00781-5422-31,NDC,,,,inpatient,1,EA,96.1,57.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,77.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,81.69,percent of total billed charges,,,85,,81.69,percent of total billed charges,,,49,,47.09,percent of total billed charges,,,90,,86.49,percent of total billed charges,,,,,,,no IP contract,,80,,76.88,percent of total billed charges,,,,,,,no IP contract,,50,,48.05,percent of total billed charges,,,,,,no IP contract,,,78,,74.96,percent of total billed charges,,,70,,67.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,47.09,3324,
00781-5438-20 - cefpodoxime 100 mg Tab,00781-5438-20,NDC,,,,inpatient,1,EA,57.4,34.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,46.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,48.79,percent of total billed charges,,,85,,48.79,percent of total billed charges,,,49,,28.13,percent of total billed charges,,,90,,51.66,percent of total billed charges,,,,,,,no IP contract,,80,,45.92,percent of total billed charges,,,,,,,no IP contract,,50,,28.7,percent of total billed charges,,,,,,no IP contract,,,78,,44.77,percent of total billed charges,,,70,,40.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,28.13,3324,
00781-5439-20 - cefpodoxime 200 mg Tab,00781-5439-20,NDC,,,,inpatient,1,EA,54.8,32.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,44.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,46.58,percent of total billed charges,,,85,,46.58,percent of total billed charges,,,49,,26.85,percent of total billed charges,,,90,,49.32,percent of total billed charges,,,,,,,no IP contract,,80,,43.84,percent of total billed charges,,,,,,,no IP contract,,50,,27.4,percent of total billed charges,,,,,,no IP contract,,,78,,42.74,percent of total billed charges,,,70,,38.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.85,3324,
00781-5637-01 - carbidopa/entacapone/levodopa 25 mg-200 mg-100 mg Tab,00781-5637-01,NDC,,,,inpatient,1,EA,3.75,2.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.19,percent of total billed charges,,,85,,3.19,percent of total billed charges,,,49,,1.84,percent of total billed charges,,,90,,3.38,percent of total billed charges,,,,,,,no IP contract,,80,,3,percent of total billed charges,,,,,,,no IP contract,,50,,1.88,percent of total billed charges,,,,,,no IP contract,,,78,,2.93,percent of total billed charges,,,70,,2.63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.84,3324,
00781-5654-01 - carbidopa/entacapone/levodopa 37.5 mg-200 mg-150 mg Tab,00781-5654-01,NDC,,,,inpatient,1,EA,33.65,20.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.6,percent of total billed charges,,,85,,28.6,percent of total billed charges,,,49,,16.49,percent of total billed charges,,,90,,30.29,percent of total billed charges,,,,,,,no IP contract,,80,,26.92,percent of total billed charges,,,,,,,no IP contract,,50,,16.83,percent of total billed charges,,,,,,no IP contract,,,78,,26.25,percent of total billed charges,,,70,,23.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.49,3324,
00781-5669-01 - carbidopa/entacapone/levodopa 50 mg-200 mg-200 mg Tab,00781-5669-01,NDC,,,,inpatient,1,EA,33.65,20.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.6,percent of total billed charges,,,85,,28.6,percent of total billed charges,,,49,,16.49,percent of total billed charges,,,90,,30.29,percent of total billed charges,,,,,,,no IP contract,,80,,26.92,percent of total billed charges,,,,,,,no IP contract,,50,,16.83,percent of total billed charges,,,,,,no IP contract,,,78,,26.25,percent of total billed charges,,,70,,23.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.49,3324,
00781-5690-31 - ezetimibe 10 mg Tab,00781-5690-31,NDC,,,,inpatient,1,EA,6.6,3.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.61,percent of total billed charges,,,85,,5.61,percent of total billed charges,,,49,,3.23,percent of total billed charges,,,90,,5.94,percent of total billed charges,,,,,,,no IP contract,,80,,5.28,percent of total billed charges,,,,,,,no IP contract,,50,,3.3,percent of total billed charges,,,,,,no IP contract,,,78,,5.15,percent of total billed charges,,,70,,4.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.23,3324,
00781-5748-01 - methylphenidate 5 mg Tab,00781-5748-01,NDC,,,,inpatient,1,EA,8.35,5.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.1,percent of total billed charges,,,85,,7.1,percent of total billed charges,,,49,,4.09,percent of total billed charges,,,90,,7.52,percent of total billed charges,,,,,,,no IP contract,,80,,6.68,percent of total billed charges,,,,,,,no IP contract,,50,,4.18,percent of total billed charges,,,,,,no IP contract,,,78,,6.51,percent of total billed charges,,,70,,5.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.09,3324,
00781-5914-01 - chlorproMAZINE 25 mg Tab,00781-5914-01,NDC,,,,inpatient,1,EA,11.75,7.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.99,percent of total billed charges,,,85,,9.99,percent of total billed charges,,,49,,5.76,percent of total billed charges,,,90,,10.58,percent of total billed charges,,,,,,,no IP contract,,80,,9.4,percent of total billed charges,,,,,,,no IP contract,,50,,5.88,percent of total billed charges,,,,,,no IP contract,,,78,,9.17,percent of total billed charges,,,70,,8.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.76,3324,
00781-5987-01 - carBAMazepine 200 mg ER Ta,00781-5987-01,NDC,,,,inpatient,1,EA,14.95,8.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.71,percent of total billed charges,,,85,,12.71,percent of total billed charges,,,49,,7.33,percent of total billed charges,,,90,,13.46,percent of total billed charges,,,,,,,no IP contract,,80,,11.96,percent of total billed charges,,,,,,,no IP contract,,50,,7.48,percent of total billed charges,,,,,,no IP contract,,,78,,11.66,percent of total billed charges,,,70,,10.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.33,3324,
00781-6014-70 - brinzolamide ophthalmic 1% Susp,00781-6014-70,NDC,,,,inpatient,1,UN,3058,1834.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2476.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2599.3,percent of total billed charges,,,85,,2599.3,percent of total billed charges,,,49,,1498.42,percent of total billed charges,,,90,,2752.2,percent of total billed charges,,,,,,,no IP contract,,80,,2446.4,percent of total billed charges,,,,,,,no IP contract,,50,,1529,percent of total billed charges,,,,,,no IP contract,,,78,,2385.24,percent of total billed charges,,,70,,2140.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
00781-6139-54 - amoxicillin-clavulanate 600 mg-42.9 mg/5 mL REC P,00781-6139-54,NDC,,,,inpatient,1,ML,10.9,6.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.27,percent of total billed charges,,,85,,9.27,percent of total billed charges,,,49,,5.34,percent of total billed charges,,,90,,9.81,percent of total billed charges,,,,,,,no IP contract,,80,,8.72,percent of total billed charges,,,,,,,no IP contract,,50,,5.45,percent of total billed charges,,,,,,no IP contract,,,78,,8.5,percent of total billed charges,,,70,,7.63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.34,3324,
00781-6153-94 - penicillin G sodium 5000000 units REC I,00781-6153-94,NDC,,,,inpatient,5,ML,513.7,308.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,416.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,436.65,percent of total billed charges,,,85,,436.65,percent of total billed charges,,,49,,251.71,percent of total billed charges,,,90,,462.33,percent of total billed charges,,,,,,,no IP contract,,80,,410.96,percent of total billed charges,,,,,,,no IP contract,,50,,256.85,percent of total billed charges,,,,,,no IP contract,,,78,,400.69,percent of total billed charges,,,70,,359.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,251.71,3324,
00781-6153-95 - penicillin G sodium 5000000 units REC I,00781-6153-95,NDC,,,,inpatient,5,ML,513.7,308.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,416.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,436.65,percent of total billed charges,,,85,,436.65,percent of total billed charges,,,49,,251.71,percent of total billed charges,,,90,,462.33,percent of total billed charges,,,,,,,no IP contract,,80,,410.96,percent of total billed charges,,,,,,,no IP contract,,50,,256.85,percent of total billed charges,,,,,,no IP contract,,,78,,400.69,percent of total billed charges,,,70,,359.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,251.71,3324,
00781-6169-52 - cefpodoxime 100 mg/5 mL REC P,00781-6169-52,NDC,,,,inpatient,1,ML,14.5,8.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.33,percent of total billed charges,,,85,,12.33,percent of total billed charges,,,49,,7.11,percent of total billed charges,,,90,,13.05,percent of total billed charges,,,,,,,no IP contract,,80,,11.6,percent of total billed charges,,,,,,,no IP contract,,50,,7.25,percent of total billed charges,,,,,,no IP contract,,,78,,11.31,percent of total billed charges,,,70,,10.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.11,3324,
00781-6186-67 - ciprofloxacin-dexamethasone otic 0.3%-0.1% Susp,00781-6186-67,NDC,,,,inpatient,1,UN,2343.3,1405.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1898.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1991.81,percent of total billed charges,,,85,,1991.81,percent of total billed charges,,,49,,1148.22,percent of total billed charges,,,90,,2108.97,percent of total billed charges,,,,,,,no IP contract,,80,,1874.64,percent of total billed charges,,,,,,,no IP contract,,50,,1171.65,percent of total billed charges,,,,,,no IP contract,,,78,,1827.77,percent of total billed charges,,,70,,1640.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
00781-7077-87 - metroNIDAZOLE topical 0.75% Gel,00781-7077-87,NDC,,,,inpatient,1,UN,1217,730.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,985.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1034.45,percent of total billed charges,,,85,,1034.45,percent of total billed charges,,,49,,596.33,percent of total billed charges,,,90,,1095.3,percent of total billed charges,,,,,,,no IP contract,,80,,973.6,percent of total billed charges,,,,,,,no IP contract,,50,,608.5,percent of total billed charges,,,,,,no IP contract,,,78,,949.26,percent of total billed charges,,,70,,851.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,596.33,3324,
00781-7240-55 - fentanyl 12 mcg/hr ER Fi,00781-7240-55,NDC,,,,inpatient,1,UN,174.5,104.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,141.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,148.33,percent of total billed charges,,,85,,148.33,percent of total billed charges,,,49,,85.51,percent of total billed charges,,,90,,157.05,percent of total billed charges,,,,,,,no IP contract,,80,,139.6,percent of total billed charges,,,,,,,no IP contract,,50,,87.25,percent of total billed charges,,,,,,no IP contract,,,78,,136.11,percent of total billed charges,,,70,,122.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,85.51,3324,
00781-7296-85 - albuterol 90 mcg/inh Aeros,00781-7296-85,NDC,,,,inpatient,1,UN,484.35,290.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,392.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,411.7,percent of total billed charges,,,85,,411.7,percent of total billed charges,,,49,,237.33,percent of total billed charges,,,90,,435.92,percent of total billed charges,,,,,,,no IP contract,,80,,387.48,percent of total billed charges,,,,,,,no IP contract,,50,,242.18,percent of total billed charges,,,,,,no IP contract,,,78,,377.79,percent of total billed charges,,,70,,339.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,237.33,3324,
00781-7304-31 - rivastigmine ER patch 4.6 mg/24 hr Patch,00781-7304-31,NDC,,,,inpatient,1,UN,150,90,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,121.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,127.5,percent of total billed charges,,,85,,127.5,percent of total billed charges,,,49,,73.5,percent of total billed charges,,,90,,135,percent of total billed charges,,,,,,,no IP contract,,80,,120,percent of total billed charges,,,,,,,no IP contract,,50,,75,percent of total billed charges,,,,,,no IP contract,,,78,,117,percent of total billed charges,,,70,,105,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,73.5,3324,
00781-7309-31 - rivastigmine 9.5 mg/24 hr ER Fi,00781-7309-31,NDC,,,,inpatient,1,UN,150,90,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,121.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,127.5,percent of total billed charges,,,85,,127.5,percent of total billed charges,,,49,,73.5,percent of total billed charges,,,90,,135,percent of total billed charges,,,,,,,no IP contract,,80,,120,percent of total billed charges,,,,,,,no IP contract,,50,,75,percent of total billed charges,,,,,,no IP contract,,,78,,117,percent of total billed charges,,,70,,105,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,73.5,3324,
00781-9210-95 - piperacillin-tazobactam 2 g-0.25 g REC I,00781-9210-95,NDC,,,,inpatient,1,EA,113.1,67.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,91.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,96.14,percent of total billed charges,,,85,,96.14,percent of total billed charges,,,49,,55.42,percent of total billed charges,,,90,,101.79,percent of total billed charges,,,,,,,no IP contract,,80,,90.48,percent of total billed charges,,,,,,,no IP contract,,50,,56.55,percent of total billed charges,,,,,,no IP contract,,,78,,88.22,percent of total billed charges,,,70,,79.17,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,55.42,3324,
00781-9213-95 - piperacillin-tazobactam 3 g-0.375 g REC I,00781-9213-95,NDC,,,,inpatient,1,EA,164.95,98.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,133.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,140.21,percent of total billed charges,,,85,,140.21,percent of total billed charges,,,49,,80.83,percent of total billed charges,,,90,,148.46,percent of total billed charges,,,,,,,no IP contract,,80,,131.96,percent of total billed charges,,,,,,,no IP contract,,50,,82.48,percent of total billed charges,,,,,,no IP contract,,,78,,128.66,percent of total billed charges,,,70,,115.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,80.83,3324,
00781-9214-95 - piperacillin-TAZObactam 4.5 gm REC Injection,00781-9214-95,NDC,,,,inpatient,1,EA,269.95,161.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,218.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,229.46,percent of total billed charges,,,85,,229.46,percent of total billed charges,,,49,,132.28,percent of total billed charges,,,90,,242.96,percent of total billed charges,,,,,,,no IP contract,,80,,215.96,percent of total billed charges,,,,,,,no IP contract,,50,,134.98,percent of total billed charges,,,,,,no IP contract,,,78,,210.56,percent of total billed charges,,,70,,188.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,132.28,3324,
00781-9404-95 - ampicillin 1 g REC I,00781-9404-95,NDC,,,,inpatient,1,EA,147.1,88.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,119.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,125.04,percent of total billed charges,,,85,,125.04,percent of total billed charges,,,49,,72.08,percent of total billed charges,,,90,,132.39,percent of total billed charges,,,,,,,no IP contract,,80,,117.68,percent of total billed charges,,,,,,,no IP contract,,50,,73.55,percent of total billed charges,,,,,,no IP contract,,,78,,114.74,percent of total billed charges,,,70,,102.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,72.08,3324,
00781-9408-95 - ampicillin 2 g REC I,00781-9408-95,NDC,,,,inpatient,1,EA,214.65,128.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,173.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,182.45,percent of total billed charges,,,85,,182.45,percent of total billed charges,,,49,,105.18,percent of total billed charges,,,90,,193.19,percent of total billed charges,,,,,,,no IP contract,,80,,171.72,percent of total billed charges,,,,,,,no IP contract,,50,,107.33,percent of total billed charges,,,,,,no IP contract,,,78,,167.43,percent of total billed charges,,,70,,150.26,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,105.18,3324,
00781-9412-92 - ampicillin 1 g REC I,00781-9412-92,NDC,,,,inpatient,1,EA,147.1,88.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,119.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,125.04,percent of total billed charges,,,85,,125.04,percent of total billed charges,,,49,,72.08,percent of total billed charges,,,90,,132.39,percent of total billed charges,,,,,,,no IP contract,,80,,117.68,percent of total billed charges,,,,,,,no IP contract,,50,,73.55,percent of total billed charges,,,,,,no IP contract,,,78,,114.74,percent of total billed charges,,,70,,102.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,72.08,3324,
00832-0225-00 - morphine 10 mg/24 hr ER Ca,00832-0225-00,NDC,,,,inpatient,1,EA,41.45,24.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,35.23,percent of total billed charges,,,85,,35.23,percent of total billed charges,,,49,,20.31,percent of total billed charges,,,90,,37.31,percent of total billed charges,,,,,,,no IP contract,,80,,33.16,percent of total billed charges,,,,,,,no IP contract,,50,,20.73,percent of total billed charges,,,,,,no IP contract,,,78,,32.33,percent of total billed charges,,,70,,29.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.31,3324,
00832-0301-00 - chlorproMAZINE 25 mg Tab,00832-0301-00,NDC,,,,inpatient,1,EA,8.05,4.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.84,percent of total billed charges,,,85,,6.84,percent of total billed charges,,,49,,3.94,percent of total billed charges,,,90,,7.25,percent of total billed charges,,,,,,,no IP contract,,80,,6.44,percent of total billed charges,,,,,,,no IP contract,,50,,4.03,percent of total billed charges,,,,,,no IP contract,,,78,,6.28,percent of total billed charges,,,70,,5.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.94,3324,
00832-0310-11 - valproic acid 250 mg Cap,00832-0310-11,NDC,,,,inpatient,1,EA,12,7.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.2,percent of total billed charges,,,85,,10.2,percent of total billed charges,,,49,,5.88,percent of total billed charges,,,90,,10.8,percent of total billed charges,,,,,,,no IP contract,,80,,9.6,percent of total billed charges,,,,,,,no IP contract,,50,,6,percent of total billed charges,,,,,,no IP contract,,,78,,9.36,percent of total billed charges,,,70,,8.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.88,3324,
00832-0510-00 - bethanechol 5 mg Tab,00832-0510-00,NDC,,,,inpatient,1,EA,11,6.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.35,percent of total billed charges,,,85,,9.35,percent of total billed charges,,,49,,5.39,percent of total billed charges,,,90,,9.9,percent of total billed charges,,,,,,,no IP contract,,80,,8.8,percent of total billed charges,,,,,,,no IP contract,,50,,5.5,percent of total billed charges,,,,,,no IP contract,,,78,,8.58,percent of total billed charges,,,70,,7.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.39,3324,
00832-0511-01 - bethanechol 10 mg Tab,00832-0511-01,NDC,,,,inpatient,1,EA,16.55,9.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.07,percent of total billed charges,,,85,,14.07,percent of total billed charges,,,49,,8.11,percent of total billed charges,,,90,,14.9,percent of total billed charges,,,,,,,no IP contract,,80,,13.24,percent of total billed charges,,,,,,,no IP contract,,50,,8.28,percent of total billed charges,,,,,,no IP contract,,,78,,12.91,percent of total billed charges,,,70,,11.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.11,3324,
00832-0512-01 - bethanechol 25 mg Tab,00832-0512-01,NDC,,,,inpatient,1,EA,25.05,15.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.29,percent of total billed charges,,,85,,21.29,percent of total billed charges,,,49,,12.27,percent of total billed charges,,,90,,22.55,percent of total billed charges,,,,,,,no IP contract,,80,,20.04,percent of total billed charges,,,,,,,no IP contract,,50,,12.53,percent of total billed charges,,,,,,no IP contract,,,78,,19.54,percent of total billed charges,,,70,,17.54,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.27,3324,
00832-0540-11 - bumetanide 0.5 mg Tab,00832-0540-11,NDC,,,,inpatient,1,EA,23.15,13.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.68,percent of total billed charges,,,85,,19.68,percent of total billed charges,,,49,,11.34,percent of total billed charges,,,90,,20.84,percent of total billed charges,,,,,,,no IP contract,,80,,18.52,percent of total billed charges,,,,,,,no IP contract,,50,,11.58,percent of total billed charges,,,,,,no IP contract,,,78,,18.06,percent of total billed charges,,,70,,16.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.34,3324,
00832-0542-11 - bumetanide 2 mg Tab,00832-0542-11,NDC,,,,inpatient,1,EA,27.35,16.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.25,percent of total billed charges,,,85,,23.25,percent of total billed charges,,,49,,13.4,percent of total billed charges,,,90,,24.62,percent of total billed charges,,,,,,,no IP contract,,80,,21.88,percent of total billed charges,,,,,,,no IP contract,,50,,13.68,percent of total billed charges,,,,,,no IP contract,,,78,,21.33,percent of total billed charges,,,70,,19.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.4,3324,
00832-0580-11 - clobazam 10 mg Tab,00832-0580-11,NDC,,,,inpatient,1,EA,18.45,11.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.68,percent of total billed charges,,,85,,15.68,percent of total billed charges,,,49,,9.04,percent of total billed charges,,,90,,16.61,percent of total billed charges,,,,,,,no IP contract,,80,,14.76,percent of total billed charges,,,,,,,no IP contract,,50,,9.23,percent of total billed charges,,,,,,no IP contract,,,78,,14.39,percent of total billed charges,,,70,,12.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.04,3324,
00832-0595-30 - exemestane 25 mg Tab,00832-0595-30,NDC,,,,inpatient,1,EA,164.65,98.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,133.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,139.95,percent of total billed charges,,,85,,139.95,percent of total billed charges,,,49,,80.68,percent of total billed charges,,,90,,148.19,percent of total billed charges,,,,,,,no IP contract,,80,,131.72,percent of total billed charges,,,,,,,no IP contract,,50,,82.33,percent of total billed charges,,,,,,no IP contract,,,78,,128.43,percent of total billed charges,,,70,,115.26,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,80.68,3324,
00832-1211-00 - warfarin 1 mg Tab,00832-1211-00,NDC,,,,inpatient,1,EA,8.65,5.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.35,percent of total billed charges,,,85,,7.35,percent of total billed charges,,,49,,4.24,percent of total billed charges,,,90,,7.79,percent of total billed charges,,,,,,,no IP contract,,80,,6.92,percent of total billed charges,,,,,,,no IP contract,,50,,4.33,percent of total billed charges,,,,,,no IP contract,,,78,,6.75,percent of total billed charges,,,70,,6.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.24,3324,
00832-1211-01 - warfarin 1 mg Tab,00832-1211-01,NDC,,,,inpatient,1,EA,7.7,4.62,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.55,percent of total billed charges,,,85,,6.55,percent of total billed charges,,,49,,3.77,percent of total billed charges,,,90,,6.93,percent of total billed charges,,,,,,,no IP contract,,80,,6.16,percent of total billed charges,,,,,,,no IP contract,,50,,3.85,percent of total billed charges,,,,,,no IP contract,,,78,,6.01,percent of total billed charges,,,70,,5.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.77,3324,
00832-1211-89 - warfarin 1 mg Tab,00832-1211-89,NDC,,,,inpatient,1,EA,7.7,4.62,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.55,percent of total billed charges,,,85,,6.55,percent of total billed charges,,,49,,3.77,percent of total billed charges,,,90,,6.93,percent of total billed charges,,,,,,,no IP contract,,80,,6.16,percent of total billed charges,,,,,,,no IP contract,,50,,3.85,percent of total billed charges,,,,,,no IP contract,,,78,,6.01,percent of total billed charges,,,70,,5.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.77,3324,
00832-1212-01 - warfarin 2 mg Tab,00832-1212-01,NDC,,,,inpatient,1,EA,7.9,4.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.72,percent of total billed charges,,,85,,6.72,percent of total billed charges,,,49,,3.87,percent of total billed charges,,,90,,7.11,percent of total billed charges,,,,,,,no IP contract,,80,,6.32,percent of total billed charges,,,,,,,no IP contract,,50,,3.95,percent of total billed charges,,,,,,no IP contract,,,78,,6.16,percent of total billed charges,,,70,,5.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.87,3324,
00832-1213-01 - warfarin 2.5 mg Tab,00832-1213-01,NDC,,,,inpatient,1,EA,9.65,5.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.2,percent of total billed charges,,,85,,8.2,percent of total billed charges,,,49,,4.73,percent of total billed charges,,,90,,8.69,percent of total billed charges,,,,,,,no IP contract,,80,,7.72,percent of total billed charges,,,,,,,no IP contract,,50,,4.83,percent of total billed charges,,,,,,no IP contract,,,78,,7.53,percent of total billed charges,,,70,,6.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.73,3324,
00832-1214-01 - warfarin 3 mg Tab,00832-1214-01,NDC,,,,inpatient,1,EA,9.05,5.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.69,percent of total billed charges,,,85,,7.69,percent of total billed charges,,,49,,4.43,percent of total billed charges,,,90,,8.15,percent of total billed charges,,,,,,,no IP contract,,80,,7.24,percent of total billed charges,,,,,,,no IP contract,,50,,4.53,percent of total billed charges,,,,,,no IP contract,,,78,,7.06,percent of total billed charges,,,70,,6.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.43,3324,
00832-1214-89 - warfarin 3 mg Tab,00832-1214-89,NDC,,,,inpatient,1,EA,8.05,4.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.84,percent of total billed charges,,,85,,6.84,percent of total billed charges,,,49,,3.94,percent of total billed charges,,,90,,7.25,percent of total billed charges,,,,,,,no IP contract,,80,,6.44,percent of total billed charges,,,,,,,no IP contract,,50,,4.03,percent of total billed charges,,,,,,no IP contract,,,78,,6.28,percent of total billed charges,,,70,,5.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.94,3324,
00832-1215-01 - warfarin 4 mg Tab,00832-1215-01,NDC,,,,inpatient,1,EA,9.05,5.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.69,percent of total billed charges,,,85,,7.69,percent of total billed charges,,,49,,4.43,percent of total billed charges,,,90,,8.15,percent of total billed charges,,,,,,,no IP contract,,80,,7.24,percent of total billed charges,,,,,,,no IP contract,,50,,4.53,percent of total billed charges,,,,,,no IP contract,,,78,,7.06,percent of total billed charges,,,70,,6.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.43,3324,
00832-1216-00 - warfarin 5 mg Tab,00832-1216-00,NDC,,,,inpatient,1,EA,9.85,5.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.37,percent of total billed charges,,,85,,8.37,percent of total billed charges,,,49,,4.83,percent of total billed charges,,,90,,8.87,percent of total billed charges,,,,,,,no IP contract,,80,,7.88,percent of total billed charges,,,,,,,no IP contract,,50,,4.93,percent of total billed charges,,,,,,no IP contract,,,78,,7.68,percent of total billed charges,,,70,,6.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.83,3324,
00832-1216-01 - warfarin 5 mg Tab,00832-1216-01,NDC,,,,inpatient,1,EA,9.85,5.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.37,percent of total billed charges,,,85,,8.37,percent of total billed charges,,,49,,4.83,percent of total billed charges,,,90,,8.87,percent of total billed charges,,,,,,,no IP contract,,80,,7.88,percent of total billed charges,,,,,,,no IP contract,,50,,4.93,percent of total billed charges,,,,,,no IP contract,,,78,,7.68,percent of total billed charges,,,70,,6.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.83,3324,
00832-1216-89 - warfarin 5 mg Tab,00832-1216-89,NDC,,,,inpatient,1,EA,8.2,4.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.97,percent of total billed charges,,,85,,6.97,percent of total billed charges,,,49,,4.02,percent of total billed charges,,,90,,7.38,percent of total billed charges,,,,,,,no IP contract,,80,,6.56,percent of total billed charges,,,,,,,no IP contract,,50,,4.1,percent of total billed charges,,,,,,no IP contract,,,78,,6.4,percent of total billed charges,,,70,,5.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.02,3324,
00832-1217-01 - warfarin 6 mg Tab,00832-1217-01,NDC,,,,inpatient,1,EA,10.9,6.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.27,percent of total billed charges,,,85,,9.27,percent of total billed charges,,,49,,5.34,percent of total billed charges,,,90,,9.81,percent of total billed charges,,,,,,,no IP contract,,80,,8.72,percent of total billed charges,,,,,,,no IP contract,,50,,5.45,percent of total billed charges,,,,,,no IP contract,,,78,,8.5,percent of total billed charges,,,70,,7.63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.34,3324,
00832-1218-01 - warfarin 7.5 mg Tab,00832-1218-01,NDC,,,,inpatient,1,EA,11.95,7.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.16,percent of total billed charges,,,85,,10.16,percent of total billed charges,,,49,,5.86,percent of total billed charges,,,90,,10.76,percent of total billed charges,,,,,,,no IP contract,,80,,9.56,percent of total billed charges,,,,,,,no IP contract,,50,,5.98,percent of total billed charges,,,,,,no IP contract,,,78,,9.32,percent of total billed charges,,,70,,8.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.86,3324,
haloperidol 1 mg Tab,00832-1520-01,NDC,,,,inpatient,1,EA,7.7,4.62,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.55,percent of total billed charges,,,85,,6.55,percent of total billed charges,,,49,,3.77,percent of total billed charges,,,90,,6.93,percent of total billed charges,,,,,,,no IP contract,,80,,6.16,percent of total billed charges,,,,,,,no IP contract,,50,,3.85,percent of total billed charges,,,,,,no IP contract,,,78,,6.01,percent of total billed charges,,,70,,5.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.77,3324,
00832-6023-11 - carBAMazepine 200 mg ER Ta,00832-6023-11,NDC,,,,inpatient,1,EA,20.35,12.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.3,percent of total billed charges,,,85,,17.3,percent of total billed charges,,,49,,9.97,percent of total billed charges,,,90,,18.32,percent of total billed charges,,,,,,,no IP contract,,80,,16.28,percent of total billed charges,,,,,,,no IP contract,,50,,10.18,percent of total billed charges,,,,,,no IP contract,,,78,,15.87,percent of total billed charges,,,70,,14.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.97,3324,
00832-6032-12 - FLUoxetine 20 mg/5 mL Soln,00832-6032-12,NDC,,,,inpatient,1,ML,13.6,8.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.56,percent of total billed charges,,,85,,11.56,percent of total billed charges,,,49,,6.66,percent of total billed charges,,,90,,12.24,percent of total billed charges,,,,,,,no IP contract,,80,,10.88,percent of total billed charges,,,,,,,no IP contract,,50,,6.8,percent of total billed charges,,,,,,no IP contract,,,78,,10.61,percent of total billed charges,,,70,,9.52,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.66,3324,
00832-6045-50 - famotidine 40 mg/5 mL REC P,00832-6045-50,NDC,,,,inpatient,1,ML,34.9,20.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.67,percent of total billed charges,,,85,,29.67,percent of total billed charges,,,49,,17.1,percent of total billed charges,,,90,,31.41,percent of total billed charges,,,,,,,no IP contract,,80,,27.92,percent of total billed charges,,,,,,,no IP contract,,50,,17.45,percent of total billed charges,,,,,,no IP contract,,,78,,27.22,percent of total billed charges,,,70,,24.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.1,3324,
00832-7124-01 - divalproex sodium 500 mg EC Tablet,00832-7124-01,NDC,,,,inpatient,1,EA,4.95,2.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.21,percent of total billed charges,,,85,,4.21,percent of total billed charges,,,49,,2.43,percent of total billed charges,,,90,,4.46,percent of total billed charges,,,,,,,no IP contract,,80,,3.96,percent of total billed charges,,,,,,,no IP contract,,50,,2.48,percent of total billed charges,,,,,,no IP contract,,,78,,3.86,percent of total billed charges,,,70,,3.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.43,3324,
00869-3105-10 - magnesium sulfate - Powde,00869-3105-10,NDC,,,,inpatient,2,UN,9.2,5.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.82,percent of total billed charges,,,85,,7.82,percent of total billed charges,,,49,,4.51,percent of total billed charges,,,90,,8.28,percent of total billed charges,,,,,,,no IP contract,,80,,7.36,percent of total billed charges,,,,,,,no IP contract,,50,,4.6,percent of total billed charges,,,,,,no IP contract,,,78,,7.18,percent of total billed charges,,,70,,6.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.51,3324,
00870-4026-53 - multivitamins drops 50 ml 0.6 mL Soln,00870-4026-53,NDC,,,,inpatient,1,ML,99.9,59.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,80.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,84.92,percent of total billed charges,,,85,,84.92,percent of total billed charges,,,49,,48.95,percent of total billed charges,,,90,,89.91,percent of total billed charges,,,,,,,no IP contract,,80,,79.92,percent of total billed charges,,,,,,,no IP contract,,50,,49.95,percent of total billed charges,,,,,,no IP contract,,,78,,77.92,percent of total billed charges,,,70,,69.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,48.95,3324,
00904-0201-61 - amitriptyline 25 mg Tab,00904-0201-61,NDC,,,,inpatient,1,EA,8.9,5.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.57,percent of total billed charges,,,85,,7.57,percent of total billed charges,,,49,,4.36,percent of total billed charges,,,90,,8.01,percent of total billed charges,,,,,,,no IP contract,,80,,7.12,percent of total billed charges,,,,,,,no IP contract,,50,,4.45,percent of total billed charges,,,,,,no IP contract,,,78,,6.94,percent of total billed charges,,,70,,6.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.36,3324,
00904-0202-61 - amitriptyline 50 mg Tab,00904-0202-61,NDC,,,,inpatient,1,EA,9.45,5.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.03,percent of total billed charges,,,85,,8.03,percent of total billed charges,,,49,,4.63,percent of total billed charges,,,90,,8.51,percent of total billed charges,,,,,,,no IP contract,,80,,7.56,percent of total billed charges,,,,,,,no IP contract,,50,,4.73,percent of total billed charges,,,,,,no IP contract,,,78,,7.37,percent of total billed charges,,,70,,6.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.63,3324,
00904-0274-60 - vitamin E 400 intl units Cap,00904-0274-60,NDC,,,,inpatient,1,EA,4.3,2.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.66,percent of total billed charges,,,85,,3.66,percent of total billed charges,,,49,,2.11,percent of total billed charges,,,90,,3.87,percent of total billed charges,,,,,,,no IP contract,,80,,3.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.15,percent of total billed charges,,,,,,no IP contract,,,78,,3.35,percent of total billed charges,,,70,,3.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.11,3324,
00904-0274-60 - vitamin E 400 intl units Cap,00904-0274-60,NDC,,,,inpatient,1,EA,4.3,2.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.66,percent of total billed charges,,,85,,3.66,percent of total billed charges,,,49,,2.11,percent of total billed charges,,,90,,3.87,percent of total billed charges,,,,,,,no IP contract,,80,,3.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.15,percent of total billed charges,,,,,,no IP contract,,,78,,3.35,percent of total billed charges,,,70,,3.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.11,3324,
00904-0522-60 - ascorbic acid 250 mg Tab,00904-0522-60,NDC,,,,inpatient,1,EA,4.05,2.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.44,percent of total billed charges,,,85,,3.44,percent of total billed charges,,,49,,1.98,percent of total billed charges,,,90,,3.65,percent of total billed charges,,,,,,,no IP contract,,80,,3.24,percent of total billed charges,,,,,,,no IP contract,,50,,2.03,percent of total billed charges,,,,,,no IP contract,,,78,,3.16,percent of total billed charges,,,70,,2.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.98,3324,
00904-0523-60 - ascorbic acid 500 mg Tab,00904-0523-60,NDC,,,,inpatient,1,EA,4.3,2.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.66,percent of total billed charges,,,85,,3.66,percent of total billed charges,,,49,,2.11,percent of total billed charges,,,90,,3.87,percent of total billed charges,,,,,,,no IP contract,,80,,3.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.15,percent of total billed charges,,,,,,no IP contract,,,78,,3.35,percent of total billed charges,,,70,,3.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.11,3324,
00904-0523-61 - ascorbic acid 500 mg Tab,00904-0523-61,NDC,,,,inpatient,1,EA,4.4,2.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.74,percent of total billed charges,,,85,,3.74,percent of total billed charges,,,49,,2.16,percent of total billed charges,,,90,,3.96,percent of total billed charges,,,,,,,no IP contract,,80,,3.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.2,percent of total billed charges,,,,,,no IP contract,,,78,,3.43,percent of total billed charges,,,70,,3.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.16,3324,
00904-0526-60 - ascorbic acid 500 mg Chew,00904-0526-60,NDC,,,,inpatient,1,EA,4.3,2.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.66,percent of total billed charges,,,85,,3.66,percent of total billed charges,,,49,,2.11,percent of total billed charges,,,90,,3.87,percent of total billed charges,,,,,,,no IP contract,,80,,3.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.15,percent of total billed charges,,,,,,no IP contract,,,78,,3.35,percent of total billed charges,,,70,,3.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.11,3324,
00904-0734-31 - bacitracin/neomycin/polymyxin B topical 400 units-3.5 mg-5000 units/g Ointm,00904-0734-31,NDC,,,,inpatient,1,UN,36.7,22.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.2,percent of total billed charges,,,85,,31.2,percent of total billed charges,,,49,,17.98,percent of total billed charges,,,90,,33.03,percent of total billed charges,,,,,,,no IP contract,,80,,29.36,percent of total billed charges,,,,,,,no IP contract,,50,,18.35,percent of total billed charges,,,,,,no IP contract,,,78,,28.63,percent of total billed charges,,,70,,25.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.98,3324,
00904-1055-61 - benztropine 0.5 mg Tab,00904-1055-61,NDC,,,,inpatient,1,EA,5.5,3.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.68,percent of total billed charges,,,85,,4.68,percent of total billed charges,,,49,,2.7,percent of total billed charges,,,90,,4.95,percent of total billed charges,,,,,,,no IP contract,,80,,4.4,percent of total billed charges,,,,,,,no IP contract,,50,,2.75,percent of total billed charges,,,,,,no IP contract,,,78,,4.29,percent of total billed charges,,,70,,3.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.7,3324,
00904-1056-61 - benztropine 1 mg Tab,00904-1056-61,NDC,,,,inpatient,1,EA,5.4,3.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.59,percent of total billed charges,,,85,,4.59,percent of total billed charges,,,49,,2.65,percent of total billed charges,,,90,,4.86,percent of total billed charges,,,,,,,no IP contract,,80,,4.32,percent of total billed charges,,,,,,,no IP contract,,50,,2.7,percent of total billed charges,,,,,,no IP contract,,,78,,4.21,percent of total billed charges,,,70,,3.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.65,3324,
00904-1086-61 - dipyridamole 25 mg Tab,00904-1086-61,NDC,,,,inpatient,1,EA,7.4,4.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.29,percent of total billed charges,,,85,,6.29,percent of total billed charges,,,49,,3.63,percent of total billed charges,,,90,,6.66,percent of total billed charges,,,,,,,no IP contract,,80,,5.92,percent of total billed charges,,,,,,,no IP contract,,50,,3.7,percent of total billed charges,,,,,,no IP contract,,,78,,5.77,percent of total billed charges,,,70,,5.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.63,3324,
00904-1132-13 - cyanocobalamin 100 mcg Tab,00904-1132-13,NDC,,,,inpatient,1,EA,3.9,2.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.32,percent of total billed charges,,,85,,3.32,percent of total billed charges,,,49,,1.91,percent of total billed charges,,,90,,3.51,percent of total billed charges,,,,,,,no IP contract,,80,,3.12,percent of total billed charges,,,,,,,no IP contract,,50,,1.95,percent of total billed charges,,,,,,no IP contract,,,78,,3.04,percent of total billed charges,,,70,,2.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.91,3324,
00904-1882-60 - calcium-vitamin D 250 mg-125 units Tab,00904-1882-60,NDC,,,,inpatient,1,EA,3.9,2.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.32,percent of total billed charges,,,85,,3.32,percent of total billed charges,,,49,,1.91,percent of total billed charges,,,90,,3.51,percent of total billed charges,,,,,,,no IP contract,,80,,3.12,percent of total billed charges,,,,,,,no IP contract,,50,,1.95,percent of total billed charges,,,,,,no IP contract,,,78,,3.04,percent of total billed charges,,,70,,2.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.91,3324,
00904-1882-61 - calcium-vitamin D 250 mg-125 units Tab,00904-1882-61,NDC,,,,inpatient,1,EA,4.45,2.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.78,percent of total billed charges,,,85,,3.78,percent of total billed charges,,,49,,2.18,percent of total billed charges,,,90,,4.01,percent of total billed charges,,,,,,,no IP contract,,80,,3.56,percent of total billed charges,,,,,,,no IP contract,,50,,2.23,percent of total billed charges,,,,,,no IP contract,,,78,,3.47,percent of total billed charges,,,70,,3.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.18,3324,
00904-1883-61 - calcium carbonate 1250 mg Tab,00904-1883-61,NDC,,,,inpatient,1,EA,4.7,2.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4,percent of total billed charges,,,85,,4,percent of total billed charges,,,49,,2.3,percent of total billed charges,,,90,,4.23,percent of total billed charges,,,,,,,no IP contract,,80,,3.76,percent of total billed charges,,,,,,,no IP contract,,50,,2.35,percent of total billed charges,,,,,,no IP contract,,,78,,3.67,percent of total billed charges,,,70,,3.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.3,3324,
00904-1988-60 - acetaminophen 500 mg Tab,00904-1988-60,NDC,,,,inpatient,1,EA,4.15,2.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.53,percent of total billed charges,,,85,,3.53,percent of total billed charges,,,49,,2.03,percent of total billed charges,,,90,,3.74,percent of total billed charges,,,,,,,no IP contract,,80,,3.32,percent of total billed charges,,,,,,,no IP contract,,50,,2.08,percent of total billed charges,,,,,,no IP contract,,,78,,3.24,percent of total billed charges,,,70,,2.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.03,3324,
00904-2085-60 - vitamin A 10000 units Cap,00904-2085-60,NDC,,,,inpatient,1,EA,4.05,2.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.44,percent of total billed charges,,,85,,3.44,percent of total billed charges,,,49,,1.98,percent of total billed charges,,,90,,3.65,percent of total billed charges,,,,,,,no IP contract,,80,,3.24,percent of total billed charges,,,,,,,no IP contract,,50,,2.03,percent of total billed charges,,,,,,no IP contract,,,78,,3.16,percent of total billed charges,,,70,,2.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.98,3324,
00904-2244-61 - docusate sodium 100 mg Cap,00904-2244-61,NDC,,,,inpatient,1,EA,5.2,3.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.42,percent of total billed charges,,,85,,4.42,percent of total billed charges,,,49,,2.55,percent of total billed charges,,,90,,4.68,percent of total billed charges,,,,,,,no IP contract,,80,,4.16,percent of total billed charges,,,,,,,no IP contract,,50,,2.6,percent of total billed charges,,,,,,no IP contract,,,78,,4.06,percent of total billed charges,,,70,,3.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.55,3324,
00904-2244-61 - docusate sodium 100 mg Cap,00904-2244-61,NDC,,,,inpatient,1,EA,5.2,3.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.42,percent of total billed charges,,,85,,4.42,percent of total billed charges,,,49,,2.55,percent of total billed charges,,,90,,4.68,percent of total billed charges,,,,,,,no IP contract,,80,,4.16,percent of total billed charges,,,,,,,no IP contract,,50,,2.6,percent of total billed charges,,,,,,no IP contract,,,78,,4.06,percent of total billed charges,,,70,,3.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.55,3324,
00904-2272-60 - niacin 500 mg Tab,00904-2272-60,NDC,,,,inpatient,1,EA,4.2,2.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.57,percent of total billed charges,,,85,,3.57,percent of total billed charges,,,49,,2.06,percent of total billed charges,,,90,,3.78,percent of total billed charges,,,,,,,no IP contract,,80,,3.36,percent of total billed charges,,,,,,,no IP contract,,50,,2.1,percent of total billed charges,,,,,,no IP contract,,,78,,3.28,percent of total billed charges,,,70,,2.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.06,3324,
00904-2621-60 - multivitamin Multiple Vitamins Chew,00904-2621-60,NDC,,,,inpatient,1,EA,4.05,2.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.44,percent of total billed charges,,,85,,3.44,percent of total billed charges,,,49,,1.98,percent of total billed charges,,,90,,3.65,percent of total billed charges,,,,,,,no IP contract,,80,,3.24,percent of total billed charges,,,,,,,no IP contract,,50,,2.03,percent of total billed charges,,,,,,no IP contract,,,78,,3.16,percent of total billed charges,,,70,,2.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.98,3324,
00904-2621-70 - multivitamin Multiple Vitamins Chew,00904-2621-70,NDC,,,,inpatient,1,EA,4.05,2.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.44,percent of total billed charges,,,85,,3.44,percent of total billed charges,,,49,,1.98,percent of total billed charges,,,90,,3.65,percent of total billed charges,,,,,,,no IP contract,,80,,3.24,percent of total billed charges,,,,,,,no IP contract,,50,,2.03,percent of total billed charges,,,,,,no IP contract,,,78,,3.16,percent of total billed charges,,,70,,2.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.98,3324,
00904-2821-61 - oxybutynin 5 mg Tab,00904-2821-61,NDC,,,,inpatient,1,EA,9.55,5.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.12,percent of total billed charges,,,85,,8.12,percent of total billed charges,,,49,,4.68,percent of total billed charges,,,90,,8.6,percent of total billed charges,,,,,,,no IP contract,,80,,7.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.78,percent of total billed charges,,,,,,no IP contract,,,78,,7.45,percent of total billed charges,,,70,,6.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.68,3324,
00904-2920-61 - verapamil 80 mg Tab,00904-2920-61,NDC,,,,inpatient,1,EA,8.35,5.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.1,percent of total billed charges,,,85,,7.1,percent of total billed charges,,,49,,4.09,percent of total billed charges,,,90,,7.52,percent of total billed charges,,,,,,,no IP contract,,80,,6.68,percent of total billed charges,,,,,,,no IP contract,,50,,4.18,percent of total billed charges,,,,,,no IP contract,,,78,,6.51,percent of total billed charges,,,70,,5.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.09,3324,
00904-2924-61 - verapamil 120 mg Tab,00904-2924-61,NDC,,,,inpatient,1,EA,9.8,5.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.33,percent of total billed charges,,,85,,8.33,percent of total billed charges,,,49,,4.8,percent of total billed charges,,,90,,8.82,percent of total billed charges,,,,,,,no IP contract,,80,,7.84,percent of total billed charges,,,,,,,no IP contract,,50,,4.9,percent of total billed charges,,,,,,no IP contract,,,78,,7.64,percent of total billed charges,,,70,,6.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.8,3324,
00904-3220-35 - carbamide peroxide otic 6.5% Soln,00904-3220-35,NDC,,,,inpatient,5,UN,30.45,18.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.88,percent of total billed charges,,,85,,25.88,percent of total billed charges,,,49,,14.92,percent of total billed charges,,,90,,27.41,percent of total billed charges,,,,,,,no IP contract,,80,,24.36,percent of total billed charges,,,,,,,no IP contract,,50,,15.23,percent of total billed charges,,,,,,no IP contract,,,78,,23.75,percent of total billed charges,,,70,,21.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.92,3324,
00904-3854-61 - carbamazepine 100 mg Chew,00904-3854-61,NDC,,,,inpatient,1,EA,6.15,3.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.23,percent of total billed charges,,,85,,5.23,percent of total billed charges,,,49,,3.01,percent of total billed charges,,,90,,5.54,percent of total billed charges,,,,,,,no IP contract,,80,,4.92,percent of total billed charges,,,,,,,no IP contract,,50,,3.08,percent of total billed charges,,,,,,no IP contract,,,78,,4.8,percent of total billed charges,,,70,,4.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.01,3324,
00904-3991-61 - trazodone 100 mg Tab,00904-3991-61,NDC,,,,inpatient,1,EA,10.05,6.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.54,percent of total billed charges,,,85,,8.54,percent of total billed charges,,,49,,4.92,percent of total billed charges,,,90,,9.05,percent of total billed charges,,,,,,,no IP contract,,80,,8.04,percent of total billed charges,,,,,,,no IP contract,,50,,5.03,percent of total billed charges,,,,,,no IP contract,,,78,,7.84,percent of total billed charges,,,70,,7.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.92,3324,
00904-4043-60 - omega-3 polyunsaturated fatty acids - Cap,00904-4043-60,NDC,,,,inpatient,1,EA,4.4,2.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.74,percent of total billed charges,,,85,,3.74,percent of total billed charges,,,49,,2.16,percent of total billed charges,,,90,,3.96,percent of total billed charges,,,,,,,no IP contract,,80,,3.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.2,percent of total billed charges,,,,,,no IP contract,,,78,,3.43,percent of total billed charges,,,70,,3.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.16,3324,
00904-4215-51 - arginine 500 mg Tab,00904-4215-51,NDC,,,,inpatient,1,EA,4.55,2.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.87,percent of total billed charges,,,85,,3.87,percent of total billed charges,,,49,,2.23,percent of total billed charges,,,90,,4.1,percent of total billed charges,,,,,,,no IP contract,,80,,3.64,percent of total billed charges,,,,,,,no IP contract,,50,,2.28,percent of total billed charges,,,,,,no IP contract,,,78,,3.55,percent of total billed charges,,,70,,3.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.23,3324,
00904-4218-13 - cyanocobalamin 250 mcg Tab,00904-4218-13,NDC,,,,inpatient,1,EA,4.05,2.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.44,percent of total billed charges,,,85,,3.44,percent of total billed charges,,,49,,1.98,percent of total billed charges,,,90,,3.65,percent of total billed charges,,,,,,,no IP contract,,80,,3.24,percent of total billed charges,,,,,,,no IP contract,,50,,2.03,percent of total billed charges,,,,,,no IP contract,,,78,,3.16,percent of total billed charges,,,70,,2.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.98,3324,
00904-5042-60 - multivitamin with minerals Therapeutic Multiple Vitamins with Minerals Tab,00904-5042-60,NDC,,,,inpatient,1,EA,4.3,2.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.66,percent of total billed charges,,,85,,3.66,percent of total billed charges,,,49,,2.11,percent of total billed charges,,,90,,3.87,percent of total billed charges,,,,,,,no IP contract,,80,,3.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.15,percent of total billed charges,,,,,,no IP contract,,,78,,3.35,percent of total billed charges,,,70,,3.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.11,3324,
00904-5046-61 - captopril 25 mg Tab,00904-5046-61,NDC,,,,inpatient,1,EA,10.2,6.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.67,percent of total billed charges,,,85,,8.67,percent of total billed charges,,,49,,5,percent of total billed charges,,,90,,9.18,percent of total billed charges,,,,,,,no IP contract,,80,,8.16,percent of total billed charges,,,,,,,no IP contract,,50,,5.1,percent of total billed charges,,,,,,no IP contract,,,78,,7.96,percent of total billed charges,,,70,,7.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5,3324,
00904-5053-24 - pseudoephedrine 30 mg Tab,00904-5053-24,NDC,,,,inpatient,1,EA,4.4,2.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.74,percent of total billed charges,,,85,,3.74,percent of total billed charges,,,49,,2.16,percent of total billed charges,,,90,,3.96,percent of total billed charges,,,,,,,no IP contract,,80,,3.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.2,percent of total billed charges,,,,,,no IP contract,,,78,,3.43,percent of total billed charges,,,70,,3.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.16,3324,
00904-5135-59 - APAP/ASA/caffeine 250 mg-250 mg-65 mg Tab,00904-5135-59,NDC,,,,inpatient,1,EA,4.15,2.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.53,percent of total billed charges,,,85,,3.53,percent of total billed charges,,,49,,2.03,percent of total billed charges,,,90,,3.74,percent of total billed charges,,,,,,,no IP contract,,80,,3.32,percent of total billed charges,,,,,,,no IP contract,,50,,2.08,percent of total billed charges,,,,,,no IP contract,,,78,,3.24,percent of total billed charges,,,70,,2.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.03,3324,
00904-5186-60 - ibuprofen 600 mg Tab,00904-5186-60,NDC,,,,inpatient,1,EA,4.15,2.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.53,percent of total billed charges,,,85,,3.53,percent of total billed charges,,,49,,2.03,percent of total billed charges,,,90,,3.74,percent of total billed charges,,,,,,,no IP contract,,80,,3.32,percent of total billed charges,,,,,,,no IP contract,,50,,2.08,percent of total billed charges,,,,,,no IP contract,,,78,,3.24,percent of total billed charges,,,70,,2.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.03,3324,
00904-5186-61 - ibuprofen 600 mg Tab,00904-5186-61,NDC,,,,inpatient,1,EA,6.2,3.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.27,percent of total billed charges,,,85,,5.27,percent of total billed charges,,,49,,3.04,percent of total billed charges,,,90,,5.58,percent of total billed charges,,,,,,,no IP contract,,80,,4.96,percent of total billed charges,,,,,,,no IP contract,,50,,3.1,percent of total billed charges,,,,,,no IP contract,,,78,,4.84,percent of total billed charges,,,70,,4.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.04,3324,
00904-5224-52 - lactase 3000 units Tab,00904-5224-52,NDC,,,,inpatient,1,EA,4.85,2.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.12,percent of total billed charges,,,85,,4.12,percent of total billed charges,,,49,,2.38,percent of total billed charges,,,90,,4.37,percent of total billed charges,,,,,,,no IP contract,,80,,3.88,percent of total billed charges,,,,,,,no IP contract,,50,,2.43,percent of total billed charges,,,,,,no IP contract,,,78,,3.78,percent of total billed charges,,,70,,3.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.38,3324,
00904-5309-20 - ibuprofen 100 mg/5 mL Susp,00904-5309-20,NDC,,,,inpatient,1,ML,55.4,33.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,44.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,47.09,percent of total billed charges,,,85,,47.09,percent of total billed charges,,,49,,27.15,percent of total billed charges,,,90,,49.86,percent of total billed charges,,,,,,,no IP contract,,80,,44.32,percent of total billed charges,,,,,,,no IP contract,,50,,27.7,percent of total billed charges,,,,,,no IP contract,,,78,,43.21,percent of total billed charges,,,70,,38.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.15,3324,
00904-5332-60 - zinc sulfate 220 mg Cap,00904-5332-60,NDC,,,,inpatient,1,EA,4.15,2.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.53,percent of total billed charges,,,85,,3.53,percent of total billed charges,,,49,,2.03,percent of total billed charges,,,90,,3.74,percent of total billed charges,,,,,,,no IP contract,,80,,3.32,percent of total billed charges,,,,,,,no IP contract,,50,,2.08,percent of total billed charges,,,,,,no IP contract,,,78,,3.24,percent of total billed charges,,,70,,2.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.03,3324,
00904-5354-31 - diphenhydrAMINE-zinc acetate topical 2%-0.1% Cream,00904-5354-31,NDC,,,,inpatient,1,UN,46.55,27.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,37.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,39.57,percent of total billed charges,,,85,,39.57,percent of total billed charges,,,49,,22.81,percent of total billed charges,,,90,,41.9,percent of total billed charges,,,,,,,no IP contract,,80,,37.24,percent of total billed charges,,,,,,,no IP contract,,50,,23.28,percent of total billed charges,,,,,,no IP contract,,,78,,36.31,percent of total billed charges,,,70,,32.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.81,3324,
00904-5392-61 - atenolol 25 mg Tab,00904-5392-61,NDC,,,,inpatient,1,EA,9.45,5.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.03,percent of total billed charges,,,85,,8.03,percent of total billed charges,,,49,,4.63,percent of total billed charges,,,90,,8.51,percent of total billed charges,,,,,,,no IP contract,,80,,7.56,percent of total billed charges,,,,,,,no IP contract,,50,,4.73,percent of total billed charges,,,,,,no IP contract,,,78,,7.37,percent of total billed charges,,,70,,6.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.63,3324,
00904-5448-61 - pentoxifylline 400 mg ER Ta,00904-5448-61,NDC,,,,inpatient,1,EA,6.3,3.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.36,percent of total billed charges,,,85,,5.36,percent of total billed charges,,,49,,3.09,percent of total billed charges,,,90,,5.67,percent of total billed charges,,,,,,,no IP contract,,80,,5.04,percent of total billed charges,,,,,,,no IP contract,,50,,3.15,percent of total billed charges,,,,,,no IP contract,,,78,,4.91,percent of total billed charges,,,70,,4.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.09,3324,
00904-5452-09 - senna 8.8 mg/5 mL Syrup,00904-5452-09,NDC,,,,inpatient,1,ML,6,3.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.1,percent of total billed charges,,,85,,5.1,percent of total billed charges,,,49,,2.94,percent of total billed charges,,,90,,5.4,percent of total billed charges,,,,,,,no IP contract,,80,,4.8,percent of total billed charges,,,,,,,no IP contract,,50,,3,percent of total billed charges,,,,,,no IP contract,,,78,,4.68,percent of total billed charges,,,70,,4.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.94,3324,
00904-5460-61 - calcium-vitamin D 500 mg-200 intl units Tab,00904-5460-61,NDC,,,,inpatient,1,EA,4.6,2.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.91,percent of total billed charges,,,85,,3.91,percent of total billed charges,,,49,,2.25,percent of total billed charges,,,90,,4.14,percent of total billed charges,,,,,,,no IP contract,,80,,3.68,percent of total billed charges,,,,,,,no IP contract,,50,,2.3,percent of total billed charges,,,,,,no IP contract,,,78,,3.59,percent of total billed charges,,,70,,3.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.25,3324,
00904-5460-72 - calcium-vitamin D 500 mg-200 intl units Tab,00904-5460-72,NDC,,,,inpatient,1,EA,4.15,2.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.53,percent of total billed charges,,,85,,3.53,percent of total billed charges,,,49,,2.03,percent of total billed charges,,,90,,3.74,percent of total billed charges,,,,,,,no IP contract,,80,,3.32,percent of total billed charges,,,,,,,no IP contract,,50,,2.08,percent of total billed charges,,,,,,no IP contract,,,78,,3.24,percent of total billed charges,,,70,,2.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.03,3324,
00904-5481-18 - chondroitin-glucosamine 400 mg-500 mg Cap,00904-5481-18,NDC,,,,inpatient,1,EA,6.35,3.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.4,percent of total billed charges,,,85,,5.4,percent of total billed charges,,,49,,3.11,percent of total billed charges,,,90,,5.72,percent of total billed charges,,,,,,,no IP contract,,80,,5.08,percent of total billed charges,,,,,,,no IP contract,,50,,3.18,percent of total billed charges,,,,,,no IP contract,,,78,,4.95,percent of total billed charges,,,70,,4.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.11,3324,
00904-5481-52 - glucosamine/chondroitin 500mg/400mg Cap,00904-5481-52,NDC,,,,inpatient,1,EA,6.35,3.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.4,percent of total billed charges,,,85,,5.4,percent of total billed charges,,,49,,3.11,percent of total billed charges,,,90,,5.72,percent of total billed charges,,,,,,,no IP contract,,80,,5.08,percent of total billed charges,,,,,,,no IP contract,,50,,3.18,percent of total billed charges,,,,,,no IP contract,,,78,,4.95,percent of total billed charges,,,70,,4.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.11,3324,
00904-5495-46 - nitroglycerin 0.2 mg/hr ER Fi,00904-5495-46,NDC,,,,inpatient,1,EA,22.7,13.62,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.3,percent of total billed charges,,,85,,19.3,percent of total billed charges,,,49,,11.12,percent of total billed charges,,,90,,20.43,percent of total billed charges,,,,,,,no IP contract,,80,,18.16,percent of total billed charges,,,,,,,no IP contract,,50,,11.35,percent of total billed charges,,,,,,no IP contract,,,78,,17.71,percent of total billed charges,,,70,,15.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.12,3324,
00904-5496-46 - nitroglycerin 0.4 mg/hr ER Fi,00904-5496-46,NDC,,,,inpatient,1,UN,24.65,14.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.95,percent of total billed charges,,,85,,20.95,percent of total billed charges,,,49,,12.08,percent of total billed charges,,,90,,22.19,percent of total billed charges,,,,,,,no IP contract,,80,,19.72,percent of total billed charges,,,,,,,no IP contract,,50,,12.33,percent of total billed charges,,,,,,no IP contract,,,78,,19.23,percent of total billed charges,,,70,,17.26,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.08,3324,
00904-5502-61 - enalapril 5 mg Tab,00904-5502-61,NDC,,,,inpatient,1,EA,12.25,7.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.41,percent of total billed charges,,,85,,10.41,percent of total billed charges,,,49,,6,percent of total billed charges,,,90,,11.03,percent of total billed charges,,,,,,,no IP contract,,80,,9.8,percent of total billed charges,,,,,,,no IP contract,,50,,6.13,percent of total billed charges,,,,,,no IP contract,,,78,,9.56,percent of total billed charges,,,70,,8.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6,3324,
00904-5522-61 - doxazosin 1 mg Tab,00904-5522-61,NDC,,,,inpatient,1,EA,11.95,7.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.16,percent of total billed charges,,,85,,10.16,percent of total billed charges,,,49,,5.86,percent of total billed charges,,,90,,10.76,percent of total billed charges,,,,,,,no IP contract,,80,,9.56,percent of total billed charges,,,,,,,no IP contract,,50,,5.98,percent of total billed charges,,,,,,no IP contract,,,78,,9.32,percent of total billed charges,,,70,,8.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.86,3324,
00904-5524-61 - doxazosin 4 mg Tab,00904-5524-61,NDC,,,,inpatient,1,EA,11.95,7.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.16,percent of total billed charges,,,85,,10.16,percent of total billed charges,,,49,,5.86,percent of total billed charges,,,90,,10.76,percent of total billed charges,,,,,,,no IP contract,,80,,9.56,percent of total billed charges,,,,,,,no IP contract,,50,,5.98,percent of total billed charges,,,,,,no IP contract,,,78,,9.32,percent of total billed charges,,,70,,8.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.86,3324,
00904-5551-59 - diphenhydrAMINE 25 mg Tab,00904-5551-59,NDC,,,,inpatient,1,EA,4.3,2.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.66,percent of total billed charges,,,85,,3.66,percent of total billed charges,,,49,,2.11,percent of total billed charges,,,90,,3.87,percent of total billed charges,,,,,,,no IP contract,,80,,3.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.15,percent of total billed charges,,,,,,no IP contract,,,78,,3.35,percent of total billed charges,,,70,,3.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.11,3324,
00904-5577-20 - ibuprofen 100 mg/5 mL Susp,00904-5577-20,NDC,,,,inpatient,1,ML,45.4,27.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,38.59,percent of total billed charges,,,85,,38.59,percent of total billed charges,,,49,,22.25,percent of total billed charges,,,90,,40.86,percent of total billed charges,,,,,,,no IP contract,,80,,36.32,percent of total billed charges,,,,,,,no IP contract,,50,,22.7,percent of total billed charges,,,,,,no IP contract,,,78,,35.41,percent of total billed charges,,,70,,31.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.25,3324,
00904-5609-61 - enalapril 2.5 mg Tab,00904-5609-61,NDC,,,,inpatient,1,EA,10.9,6.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.27,percent of total billed charges,,,85,,9.27,percent of total billed charges,,,49,,5.34,percent of total billed charges,,,90,,9.81,percent of total billed charges,,,,,,,no IP contract,,80,,8.72,percent of total billed charges,,,,,,,no IP contract,,50,,5.45,percent of total billed charges,,,,,,no IP contract,,,78,,8.5,percent of total billed charges,,,70,,7.63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.34,3324,
00904-5610-61 - enalapril 10 mg Tab,00904-5610-61,NDC,,,,inpatient,1,EA,13.3,7.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.31,percent of total billed charges,,,85,,11.31,percent of total billed charges,,,49,,6.52,percent of total billed charges,,,90,,11.97,percent of total billed charges,,,,,,,no IP contract,,80,,10.64,percent of total billed charges,,,,,,,no IP contract,,50,,6.65,percent of total billed charges,,,,,,no IP contract,,,78,,10.37,percent of total billed charges,,,70,,9.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.52,3324,
00904-5611-61 - enalapril 20 mg Tab,00904-5611-61,NDC,,,,inpatient,1,EA,17.25,10.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.66,percent of total billed charges,,,85,,14.66,percent of total billed charges,,,49,,8.45,percent of total billed charges,,,90,,15.53,percent of total billed charges,,,,,,,no IP contract,,80,,13.8,percent of total billed charges,,,,,,,no IP contract,,50,,8.63,percent of total billed charges,,,,,,no IP contract,,,78,,13.46,percent of total billed charges,,,70,,12.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.45,3324,
00904-5616-46 - ubiquinone 50 mg Cap,00904-5616-46,NDC,,,,inpatient,1,EA,9,5.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.65,percent of total billed charges,,,85,,7.65,percent of total billed charges,,,49,,4.41,percent of total billed charges,,,90,,8.1,percent of total billed charges,,,,,,,no IP contract,,80,,7.2,percent of total billed charges,,,,,,,no IP contract,,50,,4.5,percent of total billed charges,,,,,,no IP contract,,,78,,7.02,percent of total billed charges,,,70,,6.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.41,3324,
00904-5643-61 - docusate-senna 50 mg-8.6 mg Tab,00904-5643-61,NDC,,,,inpatient,1,EA,5.35,3.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.55,percent of total billed charges,,,85,,4.55,percent of total billed charges,,,49,,2.62,percent of total billed charges,,,90,,4.82,percent of total billed charges,,,,,,,no IP contract,,80,,4.28,percent of total billed charges,,,,,,,no IP contract,,50,,2.68,percent of total billed charges,,,,,,no IP contract,,,78,,4.17,percent of total billed charges,,,70,,3.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.62,3324,
00904-5676-61 - PARoxetine 10 mg Tab,00904-5676-61,NDC,,,,inpatient,1,EA,26.15,15.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.23,percent of total billed charges,,,85,,22.23,percent of total billed charges,,,49,,12.81,percent of total billed charges,,,90,,23.54,percent of total billed charges,,,,,,,no IP contract,,80,,20.92,percent of total billed charges,,,,,,,no IP contract,,50,,13.08,percent of total billed charges,,,,,,no IP contract,,,78,,20.4,percent of total billed charges,,,70,,18.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.81,3324,
00904-5684-61 - omeprazole 20 mg DR Ca,00904-5684-61,NDC,,,,inpatient,1,EA,29.1,17.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.74,percent of total billed charges,,,85,,24.74,percent of total billed charges,,,49,,14.26,percent of total billed charges,,,90,,26.19,percent of total billed charges,,,,,,,no IP contract,,80,,23.28,percent of total billed charges,,,,,,,no IP contract,,50,,14.55,percent of total billed charges,,,,,,no IP contract,,,78,,22.7,percent of total billed charges,,,70,,20.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.26,3324,
00904-5711-35 - oxymetazoline nasal 0.05% Spray,00904-5711-35,NDC,,,,inpatient,1,UN,44.2,26.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,35.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,37.57,percent of total billed charges,,,85,,37.57,percent of total billed charges,,,49,,21.66,percent of total billed charges,,,90,,39.78,percent of total billed charges,,,,,,,no IP contract,,80,,35.36,percent of total billed charges,,,,,,,no IP contract,,50,,22.1,percent of total billed charges,,,,,,no IP contract,,,78,,34.48,percent of total billed charges,,,70,,30.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.66,3324,
00904-5784-61 - fluoxetine 10 mg Cap,00904-5784-61,NDC,,,,inpatient,1,EA,23.05,13.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.59,percent of total billed charges,,,85,,19.59,percent of total billed charges,,,49,,11.29,percent of total billed charges,,,90,,20.75,percent of total billed charges,,,,,,,no IP contract,,80,,18.44,percent of total billed charges,,,,,,,no IP contract,,50,,11.53,percent of total billed charges,,,,,,no IP contract,,,78,,17.98,percent of total billed charges,,,70,,16.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.29,3324,
00904-5785-61 - fluoxetine 20 mg Cap,00904-5785-61,NDC,,,,inpatient,1,EA,23.55,14.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.02,percent of total billed charges,,,85,,20.02,percent of total billed charges,,,49,,11.54,percent of total billed charges,,,90,,21.2,percent of total billed charges,,,,,,,no IP contract,,80,,18.84,percent of total billed charges,,,,,,,no IP contract,,50,,11.78,percent of total billed charges,,,,,,no IP contract,,,78,,18.37,percent of total billed charges,,,70,,16.49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.54,3324,
00904-5789-61 - acyclovir 200 mg Cap,00904-5789-61,NDC,,,,inpatient,1,EA,16,9.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.6,percent of total billed charges,,,85,,13.6,percent of total billed charges,,,49,,7.84,percent of total billed charges,,,90,,14.4,percent of total billed charges,,,,,,,no IP contract,,80,,12.8,percent of total billed charges,,,,,,,no IP contract,,50,,8,percent of total billed charges,,,,,,no IP contract,,,78,,12.48,percent of total billed charges,,,70,,11.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.84,3324,
00904-5790-61 - acyclovir 400 mg Tab,00904-5790-61,NDC,,,,inpatient,1,EA,21.1,12.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.94,percent of total billed charges,,,85,,17.94,percent of total billed charges,,,49,,10.34,percent of total billed charges,,,90,,18.99,percent of total billed charges,,,,,,,no IP contract,,80,,16.88,percent of total billed charges,,,,,,,no IP contract,,50,,10.55,percent of total billed charges,,,,,,no IP contract,,,78,,16.46,percent of total billed charges,,,70,,14.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.34,3324,
00904-5793-61 - loratadine 10 mg Tab,00904-5793-61,NDC,,,,inpatient,1,EA,10.2,6.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.67,percent of total billed charges,,,85,,8.67,percent of total billed charges,,,49,,5,percent of total billed charges,,,90,,9.18,percent of total billed charges,,,,,,,no IP contract,,80,,8.16,percent of total billed charges,,,,,,,no IP contract,,50,,5.1,percent of total billed charges,,,,,,no IP contract,,,78,,7.96,percent of total billed charges,,,70,,7.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5,3324,
00904-5794-61 - metformin 500 mg ER Ta,00904-5794-61,NDC,,,,inpatient,1,EA,9.25,5.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.86,percent of total billed charges,,,85,,7.86,percent of total billed charges,,,49,,4.53,percent of total billed charges,,,90,,8.33,percent of total billed charges,,,,,,,no IP contract,,80,,7.4,percent of total billed charges,,,,,,,no IP contract,,50,,4.63,percent of total billed charges,,,,,,no IP contract,,,78,,7.22,percent of total billed charges,,,70,,6.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.53,3324,
00904-5800-61 - simvastatin 10 mg Tab,00904-5800-61,NDC,,,,inpatient,1,EA,23.85,14.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.27,percent of total billed charges,,,85,,20.27,percent of total billed charges,,,49,,11.69,percent of total billed charges,,,90,,21.47,percent of total billed charges,,,,,,,no IP contract,,80,,19.08,percent of total billed charges,,,,,,,no IP contract,,50,,11.93,percent of total billed charges,,,,,,no IP contract,,,78,,18.6,percent of total billed charges,,,70,,16.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.69,3324,
00904-5802-61 - simvastatin 40 mg Tab,00904-5802-61,NDC,,,,inpatient,1,EA,38.8,23.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.98,percent of total billed charges,,,85,,32.98,percent of total billed charges,,,49,,19.01,percent of total billed charges,,,90,,34.92,percent of total billed charges,,,,,,,no IP contract,,80,,31.04,percent of total billed charges,,,,,,,no IP contract,,50,,19.4,percent of total billed charges,,,,,,no IP contract,,,78,,30.26,percent of total billed charges,,,70,,27.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.01,3324,
00904-5823-60 - cholecalciferol 400 intl units Tab,00904-5823-60,NDC,,,,inpatient,1,EA,4,2.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.4,percent of total billed charges,,,85,,3.4,percent of total billed charges,,,49,,1.96,percent of total billed charges,,,90,,3.6,percent of total billed charges,,,,,,,no IP contract,,80,,3.2,percent of total billed charges,,,,,,,no IP contract,,50,,2,percent of total billed charges,,,,,,no IP contract,,,78,,3.12,percent of total billed charges,,,70,,2.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.96,3324,
"00904-5824-61 - cholecalciferol 1,000 unit(s) Tab",00904-5824-61,NDC,,,,inpatient,1,EA,4.3,2.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.66,percent of total billed charges,,,85,,3.66,percent of total billed charges,,,49,,2.11,percent of total billed charges,,,90,,3.87,percent of total billed charges,,,,,,,no IP contract,,80,,3.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.15,percent of total billed charges,,,,,,no IP contract,,,78,,3.35,percent of total billed charges,,,70,,3.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.11,3324,
00904-5852-61 - cetirizine 10 mg Tab,00904-5852-61,NDC,,,,inpatient,1,EA,23.15,13.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.68,percent of total billed charges,,,85,,19.68,percent of total billed charges,,,49,,11.34,percent of total billed charges,,,90,,20.84,percent of total billed charges,,,,,,,no IP contract,,80,,18.52,percent of total billed charges,,,,,,,no IP contract,,50,,11.58,percent of total billed charges,,,,,,no IP contract,,,78,,18.06,percent of total billed charges,,,70,,16.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.34,3324,
00904-5853-61 - ibuprofen 400 mg Tab,00904-5853-61,NDC,,,,inpatient,1,EA,175.15,105.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,141.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,148.88,percent of total billed charges,,,85,,148.88,percent of total billed charges,,,49,,85.82,percent of total billed charges,,,90,,157.64,percent of total billed charges,,,,,,,no IP contract,,80,,140.12,percent of total billed charges,,,,,,,no IP contract,,50,,87.58,percent of total billed charges,,,,,,no IP contract,,,78,,136.62,percent of total billed charges,,,70,,122.61,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,85.82,3324,
00904-5854-61 - ibuprofen 600 mg Tab,00904-5854-61,NDC,,,,inpatient,1,EA,6.2,3.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.27,percent of total billed charges,,,85,,5.27,percent of total billed charges,,,49,,3.04,percent of total billed charges,,,90,,5.58,percent of total billed charges,,,,,,,no IP contract,,80,,4.96,percent of total billed charges,,,,,,,no IP contract,,50,,3.1,percent of total billed charges,,,,,,no IP contract,,,78,,4.84,percent of total billed charges,,,70,,4.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.04,3324,
00904-5859-61 - ALPRAZolam 0.5 mg Tab,00904-5859-61,NDC,,,,inpatient,1,EA,11.6,6.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.86,percent of total billed charges,,,85,,9.86,percent of total billed charges,,,49,,5.68,percent of total billed charges,,,90,,10.44,percent of total billed charges,,,,,,,no IP contract,,80,,9.28,percent of total billed charges,,,,,,,no IP contract,,50,,5.8,percent of total billed charges,,,,,,no IP contract,,,78,,9.05,percent of total billed charges,,,70,,8.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.68,3324,
00904-5880-61 - diazepam 5 mg Tab,00904-5880-61,NDC,,,,inpatient,1,EA,8.1,4.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.89,percent of total billed charges,,,85,,6.89,percent of total billed charges,,,49,,3.97,percent of total billed charges,,,90,,7.29,percent of total billed charges,,,,,,,no IP contract,,80,,6.48,percent of total billed charges,,,,,,,no IP contract,,50,,4.05,percent of total billed charges,,,,,,no IP contract,,,78,,6.32,percent of total billed charges,,,70,,5.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.97,3324,
00904-5892-61 - pravastatin 20 mg Tab,00904-5892-61,NDC,,,,inpatient,1,EA,23.7,14.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.15,percent of total billed charges,,,85,,20.15,percent of total billed charges,,,49,,11.61,percent of total billed charges,,,90,,21.33,percent of total billed charges,,,,,,,no IP contract,,80,,18.96,percent of total billed charges,,,,,,,no IP contract,,50,,11.85,percent of total billed charges,,,,,,no IP contract,,,78,,18.49,percent of total billed charges,,,70,,16.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.61,3324,
00904-5922-61 - digoxin 250 mcg (0.25 mg) Tab,00904-5922-61,NDC,,,,inpatient,1,EA,17.2,10.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.62,percent of total billed charges,,,85,,14.62,percent of total billed charges,,,49,,8.43,percent of total billed charges,,,90,,15.48,percent of total billed charges,,,,,,,no IP contract,,80,,13.76,percent of total billed charges,,,,,,,no IP contract,,50,,8.6,percent of total billed charges,,,,,,no IP contract,,,78,,13.42,percent of total billed charges,,,70,,12.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.43,3324,
00904-5928-61 - labetalol 100 mg Tab,00904-5928-61,NDC,,,,inpatient,1,EA,21.95,13.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.66,percent of total billed charges,,,85,,18.66,percent of total billed charges,,,49,,10.76,percent of total billed charges,,,90,,19.76,percent of total billed charges,,,,,,,no IP contract,,80,,17.56,percent of total billed charges,,,,,,,no IP contract,,50,,10.98,percent of total billed charges,,,,,,no IP contract,,,78,,17.12,percent of total billed charges,,,70,,15.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.76,3324,
00904-5929-61 - labetalol 200 mg Tab,00904-5929-61,NDC,,,,inpatient,1,EA,9.95,5.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.46,percent of total billed charges,,,85,,8.46,percent of total billed charges,,,49,,4.88,percent of total billed charges,,,90,,8.96,percent of total billed charges,,,,,,,no IP contract,,80,,7.96,percent of total billed charges,,,,,,,no IP contract,,50,,4.98,percent of total billed charges,,,,,,no IP contract,,,78,,7.76,percent of total billed charges,,,70,,6.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.88,3324,
00904-5959-61 - clindamycin 150 mg Cap,00904-5959-61,NDC,,,,inpatient,1,EA,9.65,5.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.2,percent of total billed charges,,,85,,8.2,percent of total billed charges,,,49,,4.73,percent of total billed charges,,,90,,8.69,percent of total billed charges,,,,,,,no IP contract,,80,,7.72,percent of total billed charges,,,,,,,no IP contract,,50,,4.83,percent of total billed charges,,,,,,no IP contract,,,78,,7.53,percent of total billed charges,,,70,,6.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.73,3324,
00904-5984-26 - ammonium lactate topical 12% Lotio,00904-5984-26,NDC,,,,inpatient,1,UN,327.85,196.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,265.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,278.67,percent of total billed charges,,,85,,278.67,percent of total billed charges,,,49,,160.65,percent of total billed charges,,,90,,295.07,percent of total billed charges,,,,,,,no IP contract,,80,,262.28,percent of total billed charges,,,,,,,no IP contract,,50,,163.93,percent of total billed charges,,,,,,no IP contract,,,78,,255.72,percent of total billed charges,,,70,,229.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,160.65,3324,
00904-5986-60 - cholecalciferol 5000 intl units Cap,00904-5986-60,NDC,,,,inpatient,1,EA,4.3,2.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.66,percent of total billed charges,,,85,,3.66,percent of total billed charges,,,49,,2.11,percent of total billed charges,,,90,,3.87,percent of total billed charges,,,,,,,no IP contract,,80,,3.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.15,percent of total billed charges,,,,,,no IP contract,,,78,,3.35,percent of total billed charges,,,70,,3.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.11,3324,
00904-5990-61 - divalproex sodium 250 mg ER Ta,00904-5990-61,NDC,,,,inpatient,1,EA,20.75,12.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.64,percent of total billed charges,,,85,,17.64,percent of total billed charges,,,49,,10.17,percent of total billed charges,,,90,,18.68,percent of total billed charges,,,,,,,no IP contract,,80,,16.6,percent of total billed charges,,,,,,,no IP contract,,50,,10.38,percent of total billed charges,,,,,,no IP contract,,,78,,16.19,percent of total billed charges,,,70,,14.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.17,3324,
00904-6007-60 - LORazepam 0.5 mg Tab,00904-6007-60,NDC,,,,inpatient,1,EA,10.75,6.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.14,percent of total billed charges,,,85,,9.14,percent of total billed charges,,,49,,5.27,percent of total billed charges,,,90,,9.68,percent of total billed charges,,,,,,,no IP contract,,80,,8.6,percent of total billed charges,,,,,,,no IP contract,,50,,5.38,percent of total billed charges,,,,,,no IP contract,,,78,,8.39,percent of total billed charges,,,70,,7.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.27,3324,
00904-6007-61 - LORazepam 0.5 mg Tab,00904-6007-61,NDC,,,,inpatient,1,EA,6.15,3.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.23,percent of total billed charges,,,85,,5.23,percent of total billed charges,,,49,,3.01,percent of total billed charges,,,90,,5.54,percent of total billed charges,,,,,,,no IP contract,,80,,4.92,percent of total billed charges,,,,,,,no IP contract,,50,,3.08,percent of total billed charges,,,,,,no IP contract,,,78,,4.8,percent of total billed charges,,,70,,4.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.01,3324,
00904-6008-60 - LORazepam 1 mg Tab,00904-6008-60,NDC,,,,inpatient,1,EA,6,3.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.1,percent of total billed charges,,,85,,5.1,percent of total billed charges,,,49,,2.94,percent of total billed charges,,,90,,5.4,percent of total billed charges,,,,,,,no IP contract,,80,,4.8,percent of total billed charges,,,,,,,no IP contract,,50,,3,percent of total billed charges,,,,,,no IP contract,,,78,,4.68,percent of total billed charges,,,70,,4.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.94,3324,
00904-6008-61 - LORazepam 1 mg Tab,00904-6008-61,NDC,,,,inpatient,1,EA,6.25,3.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.31,percent of total billed charges,,,85,,5.31,percent of total billed charges,,,49,,3.06,percent of total billed charges,,,90,,5.63,percent of total billed charges,,,,,,,no IP contract,,80,,5,percent of total billed charges,,,,,,,no IP contract,,50,,3.13,percent of total billed charges,,,,,,no IP contract,,,78,,4.88,percent of total billed charges,,,70,,4.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.06,3324,
00904-6019-46 - bicalutamide 50 mg Tab,00904-6019-46,NDC,,,,inpatient,1,EA,134.7,80.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,109.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,114.5,percent of total billed charges,,,85,,114.5,percent of total billed charges,,,49,,66,percent of total billed charges,,,90,,121.23,percent of total billed charges,,,,,,,no IP contract,,80,,107.76,percent of total billed charges,,,,,,,no IP contract,,50,,67.35,percent of total billed charges,,,,,,no IP contract,,,78,,105.07,percent of total billed charges,,,70,,94.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,66,3324,
00904-6052-61 - levETIRAcetam 500 mg Tab,00904-6052-61,NDC,,,,inpatient,1,EA,28.95,17.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.61,percent of total billed charges,,,85,,24.61,percent of total billed charges,,,49,,14.19,percent of total billed charges,,,90,,26.06,percent of total billed charges,,,,,,,no IP contract,,80,,23.16,percent of total billed charges,,,,,,,no IP contract,,50,,14.48,percent of total billed charges,,,,,,no IP contract,,,78,,22.58,percent of total billed charges,,,70,,20.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.19,3324,
00904-6053-61 - levETIRAcetam 750 mg Tab,00904-6053-61,NDC,,,,inpatient,1,EA,37.85,22.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.17,percent of total billed charges,,,85,,32.17,percent of total billed charges,,,49,,18.55,percent of total billed charges,,,90,,34.07,percent of total billed charges,,,,,,,no IP contract,,80,,30.28,percent of total billed charges,,,,,,,no IP contract,,50,,18.93,percent of total billed charges,,,,,,no IP contract,,,78,,29.52,percent of total billed charges,,,70,,26.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.55,3324,
00904-6074-61 - loratadine 10 mg Tab,00904-6074-61,NDC,,,,inpatient,1,EA,10.2,6.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.67,percent of total billed charges,,,85,,8.67,percent of total billed charges,,,49,,5,percent of total billed charges,,,90,,9.18,percent of total billed charges,,,,,,,no IP contract,,80,,8.16,percent of total billed charges,,,,,,,no IP contract,,50,,5.1,percent of total billed charges,,,,,,no IP contract,,,78,,7.96,percent of total billed charges,,,70,,7.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5,3324,
00904-6082-61 - zolpidem 5 mg Tab,00904-6082-61,NDC,,,,inpatient,1,EA,44,26.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,35.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,37.4,percent of total billed charges,,,85,,37.4,percent of total billed charges,,,49,,21.56,percent of total billed charges,,,90,,39.6,percent of total billed charges,,,,,,,no IP contract,,80,,35.2,percent of total billed charges,,,,,,,no IP contract,,50,,22,percent of total billed charges,,,,,,no IP contract,,,78,,34.32,percent of total billed charges,,,70,,30.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.56,3324,
00904-6084-61 - citalopram 10 mg Tab,00904-6084-61,NDC,,,,inpatient,1,EA,23.15,13.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.68,percent of total billed charges,,,85,,19.68,percent of total billed charges,,,49,,11.34,percent of total billed charges,,,90,,20.84,percent of total billed charges,,,,,,,no IP contract,,80,,18.52,percent of total billed charges,,,,,,,no IP contract,,50,,11.58,percent of total billed charges,,,,,,no IP contract,,,78,,18.06,percent of total billed charges,,,70,,16.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.34,3324,
00904-6085-61 - citalopram 20 mg Tab,00904-6085-61,NDC,,,,inpatient,1,EA,25.2,15.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.42,percent of total billed charges,,,85,,21.42,percent of total billed charges,,,49,,12.35,percent of total billed charges,,,90,,22.68,percent of total billed charges,,,,,,,no IP contract,,80,,20.16,percent of total billed charges,,,,,,,no IP contract,,50,,12.6,percent of total billed charges,,,,,,no IP contract,,,78,,19.66,percent of total billed charges,,,70,,17.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.35,3324,
00904-6101-61 - clonazePAM 0.5 mg Tab,00904-6101-61,NDC,,,,inpatient,1,EA,11.4,6.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.69,percent of total billed charges,,,85,,9.69,percent of total billed charges,,,49,,5.59,percent of total billed charges,,,90,,10.26,percent of total billed charges,,,,,,,no IP contract,,80,,9.12,percent of total billed charges,,,,,,,no IP contract,,50,,5.7,percent of total billed charges,,,,,,no IP contract,,,78,,8.89,percent of total billed charges,,,70,,7.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.59,3324,
00904-6172-61 - carBAMazepine 200 mg Tab,00904-6172-61,NDC,,,,inpatient,1,EA,7.4,4.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.29,percent of total billed charges,,,85,,6.29,percent of total billed charges,,,49,,3.63,percent of total billed charges,,,90,,6.66,percent of total billed charges,,,,,,,no IP contract,,80,,5.92,percent of total billed charges,,,,,,,no IP contract,,50,,3.7,percent of total billed charges,,,,,,no IP contract,,,78,,5.77,percent of total billed charges,,,70,,5.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.63,3324,
00904-6206-09 - senna 8.8 mg/5 mL Syrup,00904-6206-09,NDC,,,,inpatient,1,ML,6,3.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.1,percent of total billed charges,,,85,,5.1,percent of total billed charges,,,49,,2.94,percent of total billed charges,,,90,,5.4,percent of total billed charges,,,,,,,no IP contract,,80,,4.8,percent of total billed charges,,,,,,,no IP contract,,50,,3,percent of total billed charges,,,,,,no IP contract,,,78,,4.68,percent of total billed charges,,,70,,4.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.94,3324,
00904-6214-89 - fexofenadine 180 mg Tab,00904-6214-89,NDC,,,,inpatient,1,EA,9.55,5.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.12,percent of total billed charges,,,85,,8.12,percent of total billed charges,,,49,,4.68,percent of total billed charges,,,90,,8.6,percent of total billed charges,,,,,,,no IP contract,,80,,7.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.78,percent of total billed charges,,,,,,no IP contract,,,78,,7.45,percent of total billed charges,,,70,,6.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.68,3324,
00904-6237-61 - carbidopa-levodopa 25 mg-100 mg Tab,00904-6237-61,NDC,,,,inpatient,1,EA,8.6,5.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.31,percent of total billed charges,,,85,,7.31,percent of total billed charges,,,49,,4.21,percent of total billed charges,,,90,,7.74,percent of total billed charges,,,,,,,no IP contract,,80,,6.88,percent of total billed charges,,,,,,,no IP contract,,50,,4.3,percent of total billed charges,,,,,,no IP contract,,,78,,6.71,percent of total billed charges,,,70,,6.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.21,3324,
00904-6238-61 - carbidopa-levodopa 25 mg-250 mg Tab,00904-6238-61,NDC,,,,inpatient,1,EA,10.65,6.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.05,percent of total billed charges,,,85,,9.05,percent of total billed charges,,,49,,5.22,percent of total billed charges,,,90,,9.59,percent of total billed charges,,,,,,,no IP contract,,80,,8.52,percent of total billed charges,,,,,,,no IP contract,,50,,5.33,percent of total billed charges,,,,,,no IP contract,,,78,,8.31,percent of total billed charges,,,70,,7.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.22,3324,
00904-6283-61 - olanzapine 2.5 mg Tab,00904-6283-61,NDC,,,,inpatient,1,EA,92.85,55.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,75.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,78.92,percent of total billed charges,,,85,,78.92,percent of total billed charges,,,49,,45.5,percent of total billed charges,,,90,,83.57,percent of total billed charges,,,,,,,no IP contract,,80,,74.28,percent of total billed charges,,,,,,,no IP contract,,50,,46.43,percent of total billed charges,,,,,,no IP contract,,,78,,72.42,percent of total billed charges,,,70,,65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,45.5,3324,
00904-6284-61 - olanzapine  5 mg Tab,00904-6284-61,NDC,,,,inpatient,1,EA,108.9,65.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,88.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,92.57,percent of total billed charges,,,85,,92.57,percent of total billed charges,,,49,,53.36,percent of total billed charges,,,90,,98.01,percent of total billed charges,,,,,,,no IP contract,,80,,87.12,percent of total billed charges,,,,,,,no IP contract,,50,,54.45,percent of total billed charges,,,,,,no IP contract,,,78,,84.94,percent of total billed charges,,,70,,76.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,53.36,3324,
00904-6286-06 - OLANZapine 15 mg Tab,00904-6286-06,NDC,,,,inpatient,1,EA,241.3,144.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,195.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,205.11,percent of total billed charges,,,85,,205.11,percent of total billed charges,,,49,,118.24,percent of total billed charges,,,90,,217.17,percent of total billed charges,,,,,,,no IP contract,,80,,193.04,percent of total billed charges,,,,,,,no IP contract,,50,,120.65,percent of total billed charges,,,,,,no IP contract,,,78,,188.21,percent of total billed charges,,,70,,168.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,118.24,3324,
00904-6289-09 - senna 8.8 mg/5 mL Syrup,00904-6289-09,NDC,,,,inpatient,1,ML,5.85,3.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.97,percent of total billed charges,,,85,,4.97,percent of total billed charges,,,49,,2.87,percent of total billed charges,,,90,,5.27,percent of total billed charges,,,,,,,no IP contract,,80,,4.68,percent of total billed charges,,,,,,,no IP contract,,50,,2.93,percent of total billed charges,,,,,,no IP contract,,,78,,4.56,percent of total billed charges,,,70,,4.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.87,3324,
00904-6290-61 - atorvastatin 10 mg Tab,00904-6290-61,NDC,,,,inpatient,1,EA,7.8,4.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.63,percent of total billed charges,,,85,,6.63,percent of total billed charges,,,49,,3.82,percent of total billed charges,,,90,,7.02,percent of total billed charges,,,,,,,no IP contract,,80,,6.24,percent of total billed charges,,,,,,,no IP contract,,50,,3.9,percent of total billed charges,,,,,,no IP contract,,,78,,6.08,percent of total billed charges,,,70,,5.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.82,3324,
00904-6291-06 - atorvastatin 20 mg Tab,00904-6291-06,NDC,,,,inpatient,1,EA,6.05,3.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.14,percent of total billed charges,,,85,,5.14,percent of total billed charges,,,49,,2.96,percent of total billed charges,,,90,,5.45,percent of total billed charges,,,,,,,no IP contract,,80,,4.84,percent of total billed charges,,,,,,,no IP contract,,50,,3.03,percent of total billed charges,,,,,,no IP contract,,,78,,4.72,percent of total billed charges,,,70,,4.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.96,3324,
00904-6291-61 - atorvastatin 20 mg Tab,00904-6291-61,NDC,,,,inpatient,1,EA,7.95,4.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.76,percent of total billed charges,,,85,,6.76,percent of total billed charges,,,49,,3.9,percent of total billed charges,,,90,,7.16,percent of total billed charges,,,,,,,no IP contract,,80,,6.36,percent of total billed charges,,,,,,,no IP contract,,50,,3.98,percent of total billed charges,,,,,,no IP contract,,,78,,6.2,percent of total billed charges,,,70,,5.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.9,3324,
00904-6292-61 - atorvastatin 40 mg Tab,00904-6292-61,NDC,,,,inpatient,1,EA,9.3,5.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.91,percent of total billed charges,,,85,,7.91,percent of total billed charges,,,49,,4.56,percent of total billed charges,,,90,,8.37,percent of total billed charges,,,,,,,no IP contract,,80,,7.44,percent of total billed charges,,,,,,,no IP contract,,50,,4.65,percent of total billed charges,,,,,,no IP contract,,,78,,7.25,percent of total billed charges,,,70,,6.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.56,3324,
00904-6293-04 - atorvastatin 80 mg Tab,00904-6293-04,NDC,,,,inpatient,1,EA,19.25,11.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.36,percent of total billed charges,,,85,,16.36,percent of total billed charges,,,49,,9.43,percent of total billed charges,,,90,,17.33,percent of total billed charges,,,,,,,no IP contract,,80,,15.4,percent of total billed charges,,,,,,,no IP contract,,50,,9.63,percent of total billed charges,,,,,,no IP contract,,,78,,15.02,percent of total billed charges,,,70,,13.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.43,3324,
00904-6294-61 - clopidogrel 75 mg Tab,00904-6294-61,NDC,,,,inpatient,1,EA,38.5,23.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.73,percent of total billed charges,,,85,,32.73,percent of total billed charges,,,49,,18.87,percent of total billed charges,,,90,,34.65,percent of total billed charges,,,,,,,no IP contract,,80,,30.8,percent of total billed charges,,,,,,,no IP contract,,50,,19.25,percent of total billed charges,,,,,,no IP contract,,,78,,30.03,percent of total billed charges,,,70,,26.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.87,3324,
00904-6300-61 - carvedilol 3.125 mg Tab,00904-6300-61,NDC,,,,inpatient,1,EA,20.5,12.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.43,percent of total billed charges,,,85,,17.43,percent of total billed charges,,,49,,10.05,percent of total billed charges,,,90,,18.45,percent of total billed charges,,,,,,,no IP contract,,80,,16.4,percent of total billed charges,,,,,,,no IP contract,,50,,10.25,percent of total billed charges,,,,,,no IP contract,,,78,,15.99,percent of total billed charges,,,70,,14.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.05,3324,
00904-6301-61 - carvedilol 6.25 mg Tab,00904-6301-61,NDC,,,,inpatient,1,EA,20.5,12.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.43,percent of total billed charges,,,85,,17.43,percent of total billed charges,,,49,,10.05,percent of total billed charges,,,90,,18.45,percent of total billed charges,,,,,,,no IP contract,,80,,16.4,percent of total billed charges,,,,,,,no IP contract,,50,,10.25,percent of total billed charges,,,,,,no IP contract,,,78,,15.99,percent of total billed charges,,,70,,14.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.05,3324,
00904-6302-61 - carvedilol 12.5 mg Tab,00904-6302-61,NDC,,,,inpatient,1,EA,20.5,12.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.43,percent of total billed charges,,,85,,17.43,percent of total billed charges,,,49,,10.05,percent of total billed charges,,,90,,18.45,percent of total billed charges,,,,,,,no IP contract,,80,,16.4,percent of total billed charges,,,,,,,no IP contract,,50,,10.25,percent of total billed charges,,,,,,no IP contract,,,78,,15.99,percent of total billed charges,,,70,,14.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.05,3324,
00904-6303-61 - carvedilol 25 mg Tab,00904-6303-61,NDC,,,,inpatient,1,EA,20.5,12.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.43,percent of total billed charges,,,85,,17.43,percent of total billed charges,,,49,,10.05,percent of total billed charges,,,90,,18.45,percent of total billed charges,,,,,,,no IP contract,,80,,16.4,percent of total billed charges,,,,,,,no IP contract,,50,,10.25,percent of total billed charges,,,,,,no IP contract,,,78,,15.99,percent of total billed charges,,,70,,14.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.05,3324,
00904-6323-61 - metoprolol 50 mg ER Ta,00904-6323-61,NDC,,,,inpatient,1,EA,13.7,8.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.65,percent of total billed charges,,,85,,11.65,percent of total billed charges,,,49,,6.71,percent of total billed charges,,,90,,12.33,percent of total billed charges,,,,,,,no IP contract,,80,,10.96,percent of total billed charges,,,,,,,no IP contract,,50,,6.85,percent of total billed charges,,,,,,no IP contract,,,78,,10.69,percent of total billed charges,,,70,,9.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.71,3324,
00904-6334-35 - tetrahydrozoline ophthalmic 0.05% Soln,00904-6334-35,NDC,,,,inpatient,1,UN,24.2,14.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.57,percent of total billed charges,,,85,,20.57,percent of total billed charges,,,49,,11.86,percent of total billed charges,,,90,,21.78,percent of total billed charges,,,,,,,no IP contract,,80,,19.36,percent of total billed charges,,,,,,,no IP contract,,50,,12.1,percent of total billed charges,,,,,,no IP contract,,,78,,18.88,percent of total billed charges,,,70,,16.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.86,3324,
00904-6337-24 - pseudoephedrine 30 mg Tab,00904-6337-24,NDC,,,,inpatient,1,EA,4.2,2.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.57,percent of total billed charges,,,85,,3.57,percent of total billed charges,,,49,,2.06,percent of total billed charges,,,90,,3.78,percent of total billed charges,,,,,,,no IP contract,,80,,3.36,percent of total billed charges,,,,,,,no IP contract,,50,,2.1,percent of total billed charges,,,,,,no IP contract,,,78,,3.28,percent of total billed charges,,,70,,2.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.06,3324,
00904-6341-61 - metoprolol 50 mg Tab,00904-6341-61,NDC,,,,inpatient,1,EA,9.85,5.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.37,percent of total billed charges,,,85,,8.37,percent of total billed charges,,,49,,4.83,percent of total billed charges,,,90,,8.87,percent of total billed charges,,,,,,,no IP contract,,80,,7.88,percent of total billed charges,,,,,,,no IP contract,,50,,4.93,percent of total billed charges,,,,,,no IP contract,,,78,,7.68,percent of total billed charges,,,70,,6.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.83,3324,
00904-6342-61 - metoprolol 100 mg Tab,00904-6342-61,NDC,,,,inpatient,1,EA,12.5,7.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.63,percent of total billed charges,,,85,,10.63,percent of total billed charges,,,49,,6.13,percent of total billed charges,,,90,,11.25,percent of total billed charges,,,,,,,no IP contract,,80,,10,percent of total billed charges,,,,,,,no IP contract,,50,,6.25,percent of total billed charges,,,,,,no IP contract,,,78,,9.75,percent of total billed charges,,,70,,8.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.13,3324,
00904-6351-61 - levofloxacin 250 mg Tab,00904-6351-61,NDC,,,,inpatient,1,EA,120.95,72.57,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,97.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,102.81,percent of total billed charges,,,85,,102.81,percent of total billed charges,,,49,,59.27,percent of total billed charges,,,90,,108.86,percent of total billed charges,,,,,,,no IP contract,,80,,96.76,percent of total billed charges,,,,,,,no IP contract,,50,,60.48,percent of total billed charges,,,,,,no IP contract,,,78,,94.34,percent of total billed charges,,,70,,84.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,59.27,3324,
00904-6352-61 - levofloxacin 500 mg Tab,00904-6352-61,NDC,,,,inpatient,1,EA,137.55,82.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,111.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,116.92,percent of total billed charges,,,85,,116.92,percent of total billed charges,,,49,,67.4,percent of total billed charges,,,90,,123.8,percent of total billed charges,,,,,,,no IP contract,,80,,110.04,percent of total billed charges,,,,,,,no IP contract,,50,,68.78,percent of total billed charges,,,,,,no IP contract,,,78,,107.29,percent of total billed charges,,,70,,96.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,67.4,3324,
00904-6353-61 - levoFLOXacin 750 mg Tab,00904-6353-61,NDC,,,,inpatient,1,EA,199.45,119.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,161.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,169.53,percent of total billed charges,,,85,,169.53,percent of total billed charges,,,49,,97.73,percent of total billed charges,,,90,,179.51,percent of total billed charges,,,,,,,no IP contract,,80,,159.56,percent of total billed charges,,,,,,,no IP contract,,50,,99.73,percent of total billed charges,,,,,,no IP contract,,,78,,155.57,percent of total billed charges,,,70,,139.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,97.73,3324,
00904-6357-61 - risperiDONE 0.25 mg Tab,00904-6357-61,NDC,,,,inpatient,1,EA,32.3,19.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,26.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,27.46,percent of total billed charges,,,85,,27.46,percent of total billed charges,,,49,,15.83,percent of total billed charges,,,90,,29.07,percent of total billed charges,,,,,,,no IP contract,,80,,25.84,percent of total billed charges,,,,,,,no IP contract,,50,,16.15,percent of total billed charges,,,,,,no IP contract,,,78,,25.19,percent of total billed charges,,,70,,22.61,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.83,3324,
00904-6358-61 - risperiDONE 0.5 mg Tab,00904-6358-61,NDC,,,,inpatient,1,EA,5.75,3.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.89,percent of total billed charges,,,85,,4.89,percent of total billed charges,,,49,,2.82,percent of total billed charges,,,90,,5.18,percent of total billed charges,,,,,,,no IP contract,,80,,4.6,percent of total billed charges,,,,,,,no IP contract,,50,,2.88,percent of total billed charges,,,,,,no IP contract,,,78,,4.49,percent of total billed charges,,,70,,4.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.82,3324,
00904-6359-61 - risperiDONE 1 mg Tab,00904-6359-61,NDC,,,,inpatient,1,EA,40.1,24.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34.09,percent of total billed charges,,,85,,34.09,percent of total billed charges,,,49,,19.65,percent of total billed charges,,,90,,36.09,percent of total billed charges,,,,,,,no IP contract,,80,,32.08,percent of total billed charges,,,,,,,no IP contract,,50,,20.05,percent of total billed charges,,,,,,no IP contract,,,78,,31.28,percent of total billed charges,,,70,,28.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.65,3324,
00904-6360-61 - risperiDONE 2 mg Tab,00904-6360-61,NDC,,,,inpatient,1,EA,59.95,35.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,48.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,50.96,percent of total billed charges,,,85,,50.96,percent of total billed charges,,,49,,29.38,percent of total billed charges,,,90,,53.96,percent of total billed charges,,,,,,,no IP contract,,80,,47.96,percent of total billed charges,,,,,,,no IP contract,,50,,29.98,percent of total billed charges,,,,,,no IP contract,,,78,,46.76,percent of total billed charges,,,70,,41.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,29.38,3324,
00904-6369-61 - amLODIPine 2.5 mg Tab,00904-6369-61,NDC,,,,inpatient,1,EA,16.45,9.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.98,percent of total billed charges,,,85,,13.98,percent of total billed charges,,,49,,8.06,percent of total billed charges,,,90,,14.81,percent of total billed charges,,,,,,,no IP contract,,80,,13.16,percent of total billed charges,,,,,,,no IP contract,,50,,8.23,percent of total billed charges,,,,,,no IP contract,,,78,,12.83,percent of total billed charges,,,70,,11.52,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.06,3324,
00904-6370-61 - amLODIPine 5 mg Tab,00904-6370-61,NDC,,,,inpatient,1,EA,16.85,10.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.32,percent of total billed charges,,,85,,14.32,percent of total billed charges,,,49,,8.26,percent of total billed charges,,,90,,15.17,percent of total billed charges,,,,,,,no IP contract,,80,,13.48,percent of total billed charges,,,,,,,no IP contract,,50,,8.43,percent of total billed charges,,,,,,no IP contract,,,78,,13.14,percent of total billed charges,,,70,,11.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.26,3324,
00904-6371-61 - amLODIPine 10 mg Tab,00904-6371-61,NDC,,,,inpatient,1,EA,21.7,13.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.45,percent of total billed charges,,,85,,18.45,percent of total billed charges,,,49,,10.63,percent of total billed charges,,,90,,19.53,percent of total billed charges,,,,,,,no IP contract,,80,,17.36,percent of total billed charges,,,,,,,no IP contract,,50,,10.85,percent of total billed charges,,,,,,no IP contract,,,78,,16.93,percent of total billed charges,,,70,,15.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.63,3324,
00904-6373-61 - rOPINIRole 0.25 mg Tab,00904-6373-61,NDC,,,,inpatient,1,EA,8.5,5.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.23,percent of total billed charges,,,85,,7.23,percent of total billed charges,,,49,,4.17,percent of total billed charges,,,90,,7.65,percent of total billed charges,,,,,,,no IP contract,,80,,6.8,percent of total billed charges,,,,,,,no IP contract,,50,,4.25,percent of total billed charges,,,,,,no IP contract,,,78,,6.63,percent of total billed charges,,,70,,5.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.17,3324,
00904-6374-61 - rOPINIRole 1 mg Tab,00904-6374-61,NDC,,,,inpatient,1,EA,10.6,6.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.01,percent of total billed charges,,,85,,9.01,percent of total billed charges,,,49,,5.19,percent of total billed charges,,,90,,9.54,percent of total billed charges,,,,,,,no IP contract,,80,,8.48,percent of total billed charges,,,,,,,no IP contract,,50,,5.3,percent of total billed charges,,,,,,no IP contract,,,78,,8.27,percent of total billed charges,,,70,,7.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.19,3324,
00904-6390-61 - losartan 50 mg Tab,00904-6390-61,NDC,,,,inpatient,1,EA,22.05,13.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.74,percent of total billed charges,,,85,,18.74,percent of total billed charges,,,49,,10.8,percent of total billed charges,,,90,,19.85,percent of total billed charges,,,,,,,no IP contract,,80,,17.64,percent of total billed charges,,,,,,,no IP contract,,50,,11.03,percent of total billed charges,,,,,,no IP contract,,,78,,17.2,percent of total billed charges,,,70,,15.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.8,3324,
00904-6391-61 - losartan 25 mg Tab,00904-6391-61,NDC,,,,inpatient,1,EA,9.4,5.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.99,percent of total billed charges,,,85,,7.99,percent of total billed charges,,,49,,4.61,percent of total billed charges,,,90,,8.46,percent of total billed charges,,,,,,,no IP contract,,80,,7.52,percent of total billed charges,,,,,,,no IP contract,,50,,4.7,percent of total billed charges,,,,,,no IP contract,,,78,,7.33,percent of total billed charges,,,70,,6.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.61,3324,
00904-6401-61 - tamsulosin 0.4 mg Cap,00904-6401-61,NDC,,,,inpatient,1,EA,37.3,22.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.71,percent of total billed charges,,,85,,31.71,percent of total billed charges,,,49,,18.28,percent of total billed charges,,,90,,33.57,percent of total billed charges,,,,,,,no IP contract,,80,,29.84,percent of total billed charges,,,,,,,no IP contract,,50,,18.65,percent of total billed charges,,,,,,no IP contract,,,78,,29.09,percent of total billed charges,,,70,,26.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.28,3324,
00904-6407-61 - bisacodyl 5 mg EC Ta,00904-6407-61,NDC,,,,inpatient,1,EA,4.4,2.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.74,percent of total billed charges,,,85,,3.74,percent of total billed charges,,,49,,2.16,percent of total billed charges,,,90,,3.96,percent of total billed charges,,,,,,,no IP contract,,80,,3.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.2,percent of total billed charges,,,,,,no IP contract,,,78,,3.43,percent of total billed charges,,,70,,3.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.16,3324,
00904-6409-61 - donepezil 10 mg Tab,00904-6409-61,NDC,,,,inpatient,1,EA,54.45,32.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,44.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,46.28,percent of total billed charges,,,85,,46.28,percent of total billed charges,,,49,,26.68,percent of total billed charges,,,90,,49.01,percent of total billed charges,,,,,,,no IP contract,,80,,43.56,percent of total billed charges,,,,,,,no IP contract,,50,,27.23,percent of total billed charges,,,,,,no IP contract,,,78,,42.47,percent of total billed charges,,,70,,38.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.68,3324,
00904-6412-92 - calcium carbonate 500 mg Chew,00904-6412-92,NDC,,,,inpatient,1,EA,4,2.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.4,percent of total billed charges,,,85,,3.4,percent of total billed charges,,,49,,1.96,percent of total billed charges,,,90,,3.6,percent of total billed charges,,,,,,,no IP contract,,80,,3.2,percent of total billed charges,,,,,,,no IP contract,,50,,2,percent of total billed charges,,,,,,no IP contract,,,78,,3.12,percent of total billed charges,,,70,,2.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.96,3324,
00904-6418-61 - tiZANidine 4 mg Tab,00904-6418-61,NDC,,,,inpatient,1,EA,17.8,10.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.13,percent of total billed charges,,,85,,15.13,percent of total billed charges,,,49,,8.72,percent of total billed charges,,,90,,16.02,percent of total billed charges,,,,,,,no IP contract,,80,,14.24,percent of total billed charges,,,,,,,no IP contract,,50,,8.9,percent of total billed charges,,,,,,no IP contract,,,78,,13.88,percent of total billed charges,,,70,,12.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.72,3324,
00904-6420-61 - acetaminophen-hydrocodone 325 mg-7.5 mg Tab,00904-6420-61,NDC,,,,inpatient,1,EA,10.65,6.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.05,percent of total billed charges,,,85,,9.05,percent of total billed charges,,,49,,5.22,percent of total billed charges,,,90,,9.59,percent of total billed charges,,,,,,,no IP contract,,80,,8.52,percent of total billed charges,,,,,,,no IP contract,,50,,5.33,percent of total billed charges,,,,,,no IP contract,,,78,,8.31,percent of total billed charges,,,70,,7.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.22,3324,
00904-6422-81 - polyethylene glycol 3350 - REC P,00904-6422-81,NDC,,,,inpatient,1,EA,16,9.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.6,percent of total billed charges,,,85,,13.6,percent of total billed charges,,,49,,7.84,percent of total billed charges,,,90,,14.4,percent of total billed charges,,,,,,,no IP contract,,80,,12.8,percent of total billed charges,,,,,,,no IP contract,,50,,8,percent of total billed charges,,,,,,no IP contract,,,78,,12.48,percent of total billed charges,,,70,,11.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.84,3324,
00904-6426-61 - escitalopram 10 mg Tab,00904-6426-61,NDC,,,,inpatient,1,EA,38.65,23.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.85,percent of total billed charges,,,85,,32.85,percent of total billed charges,,,49,,18.94,percent of total billed charges,,,90,,34.79,percent of total billed charges,,,,,,,no IP contract,,80,,30.92,percent of total billed charges,,,,,,,no IP contract,,50,,19.33,percent of total billed charges,,,,,,no IP contract,,,78,,30.15,percent of total billed charges,,,70,,27.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.94,3324,
escitalopram 20 mg Tab,00904-6427-61,NDC,,,,inpatient,1,EA,40.15,24.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34.13,percent of total billed charges,,,85,,34.13,percent of total billed charges,,,49,,19.67,percent of total billed charges,,,90,,36.14,percent of total billed charges,,,,,,,no IP contract,,80,,32.12,percent of total billed charges,,,,,,,no IP contract,,50,,20.08,percent of total billed charges,,,,,,no IP contract,,,78,,31.32,percent of total billed charges,,,70,,28.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.67,3324,
00904-6434-80 - senna 8.6 mg Tab,00904-6434-80,NDC,,,,inpatient,1,EA,4,2.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.4,percent of total billed charges,,,85,,3.4,percent of total billed charges,,,49,,1.96,percent of total billed charges,,,90,,3.6,percent of total billed charges,,,,,,,no IP contract,,80,,3.2,percent of total billed charges,,,,,,,no IP contract,,50,,2,percent of total billed charges,,,,,,no IP contract,,,78,,3.12,percent of total billed charges,,,70,,2.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.96,3324,
00904-6436-04 - temazepam 7.5 mg Cap,00904-6436-04,NDC,,,,inpatient,1,EA,44.85,26.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,38.12,percent of total billed charges,,,85,,38.12,percent of total billed charges,,,49,,21.98,percent of total billed charges,,,90,,40.37,percent of total billed charges,,,,,,,no IP contract,,80,,35.88,percent of total billed charges,,,,,,,no IP contract,,50,,22.43,percent of total billed charges,,,,,,no IP contract,,,78,,34.98,percent of total billed charges,,,70,,31.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.98,3324,
00904-6440-61 - hydrALAZINE 10 mg Tab,00904-6440-61,NDC,,,,inpatient,1,EA,4.8,2.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.08,percent of total billed charges,,,85,,4.08,percent of total billed charges,,,49,,2.35,percent of total billed charges,,,90,,4.32,percent of total billed charges,,,,,,,no IP contract,,80,,3.84,percent of total billed charges,,,,,,,no IP contract,,50,,2.4,percent of total billed charges,,,,,,no IP contract,,,78,,3.74,percent of total billed charges,,,70,,3.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.35,3324,
00904-6442-61 - hydrALAZINE 50 mg Tab,00904-6442-61,NDC,,,,inpatient,1,EA,5.1,3.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.34,percent of total billed charges,,,85,,4.34,percent of total billed charges,,,49,,2.5,percent of total billed charges,,,90,,4.59,percent of total billed charges,,,,,,,no IP contract,,80,,4.08,percent of total billed charges,,,,,,,no IP contract,,50,,2.55,percent of total billed charges,,,,,,no IP contract,,,78,,3.98,percent of total billed charges,,,70,,3.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.5,3324,
00904-6449-61 - isosorbide mononitrate 30 mg ER Ta,00904-6449-61,NDC,,,,inpatient,1,EA,17,10.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.45,percent of total billed charges,,,85,,14.45,percent of total billed charges,,,49,,8.33,percent of total billed charges,,,90,,15.3,percent of total billed charges,,,,,,,no IP contract,,80,,13.6,percent of total billed charges,,,,,,,no IP contract,,50,,8.5,percent of total billed charges,,,,,,no IP contract,,,78,,13.26,percent of total billed charges,,,70,,11.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.33,3324,
00904-6455-61 - docusate sodium 100 mg Cap,00904-6455-61,NDC,,,,inpatient,1,EA,5.2,3.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.42,percent of total billed charges,,,85,,4.42,percent of total billed charges,,,49,,2.55,percent of total billed charges,,,90,,4.68,percent of total billed charges,,,,,,,no IP contract,,80,,4.16,percent of total billed charges,,,,,,,no IP contract,,50,,2.6,percent of total billed charges,,,,,,no IP contract,,,78,,4.06,percent of total billed charges,,,70,,3.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.55,3324,
00904-6474-61 - pantoprazole 40 mg EC Ta,00904-6474-61,NDC,,,,inpatient,1,EA,36.35,21.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.9,percent of total billed charges,,,85,,30.9,percent of total billed charges,,,49,,17.81,percent of total billed charges,,,90,,32.72,percent of total billed charges,,,,,,,no IP contract,,80,,29.08,percent of total billed charges,,,,,,,no IP contract,,50,,18.18,percent of total billed charges,,,,,,no IP contract,,,78,,28.35,percent of total billed charges,,,70,,25.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.81,3324,
00904-6475-61 - baclofen 10 mg Tab,00904-6475-61,NDC,,,,inpatient,1,EA,7.8,4.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.63,percent of total billed charges,,,85,,6.63,percent of total billed charges,,,49,,3.82,percent of total billed charges,,,90,,7.02,percent of total billed charges,,,,,,,no IP contract,,80,,6.24,percent of total billed charges,,,,,,,no IP contract,,50,,3.9,percent of total billed charges,,,,,,no IP contract,,,78,,6.08,percent of total billed charges,,,70,,5.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.82,3324,
00904-6477-61 - donepezil 5 mg Tab,00904-6477-61,NDC,,,,inpatient,1,EA,5.1,3.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.34,percent of total billed charges,,,85,,4.34,percent of total billed charges,,,49,,2.5,percent of total billed charges,,,90,,4.59,percent of total billed charges,,,,,,,no IP contract,,80,,4.08,percent of total billed charges,,,,,,,no IP contract,,50,,2.55,percent of total billed charges,,,,,,no IP contract,,,78,,3.98,percent of total billed charges,,,70,,3.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.5,3324,
00904-6478-61 - donepezil 10 mg Tab,00904-6478-61,NDC,,,,inpatient,1,EA,5.1,3.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.34,percent of total billed charges,,,85,,4.34,percent of total billed charges,,,49,,2.5,percent of total billed charges,,,90,,4.59,percent of total billed charges,,,,,,,no IP contract,,80,,4.08,percent of total billed charges,,,,,,,no IP contract,,50,,2.55,percent of total billed charges,,,,,,no IP contract,,,78,,3.98,percent of total billed charges,,,70,,3.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.5,3324,
00904-6485-61 - lisinopril 10 mg Tab,00904-6485-61,NDC,,,,inpatient,1,EA,7.9,4.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.72,percent of total billed charges,,,85,,6.72,percent of total billed charges,,,49,,3.87,percent of total billed charges,,,90,,7.11,percent of total billed charges,,,,,,,no IP contract,,80,,6.32,percent of total billed charges,,,,,,,no IP contract,,50,,3.95,percent of total billed charges,,,,,,no IP contract,,,78,,6.16,percent of total billed charges,,,70,,5.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.87,3324,
00904-6486-61 - lisinopril 20 mg Tab,00904-6486-61,NDC,,,,inpatient,1,EA,4.2,2.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.57,percent of total billed charges,,,85,,3.57,percent of total billed charges,,,49,,2.06,percent of total billed charges,,,90,,3.78,percent of total billed charges,,,,,,,no IP contract,,80,,3.36,percent of total billed charges,,,,,,,no IP contract,,50,,2.1,percent of total billed charges,,,,,,no IP contract,,,78,,3.28,percent of total billed charges,,,70,,2.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.06,3324,
fluconazole 200 mg Tab,00904-6501-06,NDC,,,,inpatient,1,EA,17.65,10.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15,percent of total billed charges,,,85,,15,percent of total billed charges,,,49,,8.65,percent of total billed charges,,,90,,15.89,percent of total billed charges,,,,,,,no IP contract,,80,,14.12,percent of total billed charges,,,,,,,no IP contract,,50,,8.83,percent of total billed charges,,,,,,no IP contract,,,78,,13.77,percent of total billed charges,,,70,,12.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.65,3324,
00904-6502-61 - celecoxib 100 mg Cap,00904-6502-61,NDC,,,,inpatient,1,EA,12.15,7.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.33,percent of total billed charges,,,85,,10.33,percent of total billed charges,,,49,,5.95,percent of total billed charges,,,90,,10.94,percent of total billed charges,,,,,,,no IP contract,,80,,9.72,percent of total billed charges,,,,,,,no IP contract,,50,,6.08,percent of total billed charges,,,,,,no IP contract,,,78,,9.48,percent of total billed charges,,,70,,8.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.95,3324,
00904-6503-61 - celecoxib 200 mg Cap,00904-6503-61,NDC,,,,inpatient,1,EA,17.65,10.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15,percent of total billed charges,,,85,,15,percent of total billed charges,,,49,,8.65,percent of total billed charges,,,90,,15.89,percent of total billed charges,,,,,,,no IP contract,,80,,14.12,percent of total billed charges,,,,,,,no IP contract,,50,,8.83,percent of total billed charges,,,,,,no IP contract,,,78,,13.77,percent of total billed charges,,,70,,12.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.65,3324,
00904-6505-06 - memantine 5 mg Tab,00904-6505-06,NDC,,,,inpatient,1,EA,7.7,4.62,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.55,percent of total billed charges,,,85,,6.55,percent of total billed charges,,,49,,3.77,percent of total billed charges,,,90,,6.93,percent of total billed charges,,,,,,,no IP contract,,80,,6.16,percent of total billed charges,,,,,,,no IP contract,,50,,3.85,percent of total billed charges,,,,,,no IP contract,,,78,,6.01,percent of total billed charges,,,70,,5.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.77,3324,
00904-6505-61 - memantine 5 mg Tab,00904-6505-61,NDC,,,,inpatient,1,EA,6.55,3.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.57,percent of total billed charges,,,85,,5.57,percent of total billed charges,,,49,,3.21,percent of total billed charges,,,90,,5.9,percent of total billed charges,,,,,,,no IP contract,,80,,5.24,percent of total billed charges,,,,,,,no IP contract,,50,,3.28,percent of total billed charges,,,,,,no IP contract,,,78,,5.11,percent of total billed charges,,,70,,4.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.21,3324,
00904-6506-61 - memantine 10 mg Tab,00904-6506-61,NDC,,,,inpatient,1,EA,11.4,6.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.69,percent of total billed charges,,,85,,9.69,percent of total billed charges,,,49,,5.59,percent of total billed charges,,,90,,10.26,percent of total billed charges,,,,,,,no IP contract,,80,,9.12,percent of total billed charges,,,,,,,no IP contract,,50,,5.7,percent of total billed charges,,,,,,no IP contract,,,78,,8.89,percent of total billed charges,,,70,,7.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.59,3324,
00904-6519-61 - mirtazapine 15 mg Tab,00904-6519-61,NDC,,,,inpatient,1,EA,26.55,15.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.57,percent of total billed charges,,,85,,22.57,percent of total billed charges,,,49,,13.01,percent of total billed charges,,,90,,23.9,percent of total billed charges,,,,,,,no IP contract,,80,,21.24,percent of total billed charges,,,,,,,no IP contract,,50,,13.28,percent of total billed charges,,,,,,no IP contract,,,78,,20.71,percent of total billed charges,,,70,,18.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.01,3324,
00904-6522-61 - senna 8.6 mg Tab,00904-6522-61,NDC,,,,inpatient,1,EA,4.45,2.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.78,percent of total billed charges,,,85,,3.78,percent of total billed charges,,,49,,2.18,percent of total billed charges,,,90,,4.01,percent of total billed charges,,,,,,,no IP contract,,80,,3.56,percent of total billed charges,,,,,,,no IP contract,,50,,2.23,percent of total billed charges,,,,,,no IP contract,,,78,,3.47,percent of total billed charges,,,70,,3.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.18,3324,
00904-6550-61 - propranolol 10 mg Tab,00904-6550-61,NDC,,,,inpatient,1,EA,6.6,3.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.61,percent of total billed charges,,,85,,5.61,percent of total billed charges,,,49,,3.23,percent of total billed charges,,,90,,5.94,percent of total billed charges,,,,,,,no IP contract,,80,,5.28,percent of total billed charges,,,,,,,no IP contract,,50,,3.3,percent of total billed charges,,,,,,no IP contract,,,78,,5.15,percent of total billed charges,,,70,,4.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.23,3324,
00904-6555-61 - traZODone 100 mg Tab,00904-6555-61,NDC,,,,inpatient,1,EA,10.05,6.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.54,percent of total billed charges,,,85,,8.54,percent of total billed charges,,,49,,4.92,percent of total billed charges,,,90,,9.05,percent of total billed charges,,,,,,,no IP contract,,80,,8.04,percent of total billed charges,,,,,,,no IP contract,,50,,5.03,percent of total billed charges,,,,,,no IP contract,,,78,,7.84,percent of total billed charges,,,70,,7.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.92,3324,
00904-6556-61 - amiodarone 200 mg Tab,00904-6556-61,NDC,,,,inpatient,1,EA,8.5,5.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.23,percent of total billed charges,,,85,,7.23,percent of total billed charges,,,49,,4.17,percent of total billed charges,,,90,,7.65,percent of total billed charges,,,,,,,no IP contract,,80,,6.8,percent of total billed charges,,,,,,,no IP contract,,50,,4.25,percent of total billed charges,,,,,,no IP contract,,,78,,6.63,percent of total billed charges,,,70,,5.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.17,3324,
morphine 30 mg/8 to 12 hr ER Ta,00904-6558-61,NDC,,,,inpatient,1,EA,17.9,10.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.22,percent of total billed charges,,,85,,15.22,percent of total billed charges,,,49,,8.77,percent of total billed charges,,,90,,16.11,percent of total billed charges,,,,,,,no IP contract,,80,,14.32,percent of total billed charges,,,,,,,no IP contract,,50,,8.95,percent of total billed charges,,,,,,no IP contract,,,78,,13.96,percent of total billed charges,,,70,,12.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.77,3324,
00904-6564-61 - benzonatate 100 mg Cap,00904-6564-61,NDC,,,,inpatient,1,EA,8.5,5.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.23,percent of total billed charges,,,85,,7.23,percent of total billed charges,,,49,,4.17,percent of total billed charges,,,90,,7.65,percent of total billed charges,,,,,,,no IP contract,,80,,6.8,percent of total billed charges,,,,,,,no IP contract,,50,,4.25,percent of total billed charges,,,,,,no IP contract,,,78,,6.63,percent of total billed charges,,,70,,5.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.17,3324,
00904-6585-61 - buPROPion 150 mg/12 hours ER Ta,00904-6585-61,NDC,,,,inpatient,1,EA,9.4,5.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.99,percent of total billed charges,,,85,,7.99,percent of total billed charges,,,49,,4.61,percent of total billed charges,,,90,,8.46,percent of total billed charges,,,,,,,no IP contract,,80,,7.52,percent of total billed charges,,,,,,,no IP contract,,50,,4.7,percent of total billed charges,,,,,,no IP contract,,,78,,7.33,percent of total billed charges,,,70,,6.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.61,3324,
00904-6617-61 - hydrOXYzine hydrochloride 25 mg Tab,00904-6617-61,NDC,,,,inpatient,1,EA,6.2,3.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.27,percent of total billed charges,,,85,,5.27,percent of total billed charges,,,49,,3.04,percent of total billed charges,,,90,,5.58,percent of total billed charges,,,,,,,no IP contract,,80,,4.96,percent of total billed charges,,,,,,,no IP contract,,50,,3.1,percent of total billed charges,,,,,,no IP contract,,,78,,4.84,percent of total billed charges,,,70,,4.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.04,3324,
00904-6627-35 - carbamide peroxide otic 6.5% Soln,00904-6627-35,NDC,,,,inpatient,5,UN,24.2,14.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.57,percent of total billed charges,,,85,,20.57,percent of total billed charges,,,49,,11.86,percent of total billed charges,,,90,,21.78,percent of total billed charges,,,,,,,no IP contract,,80,,19.36,percent of total billed charges,,,,,,,no IP contract,,50,,12.1,percent of total billed charges,,,,,,no IP contract,,,78,,18.88,percent of total billed charges,,,70,,16.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.86,3324,
00904-6638-61 - QUEtiapine 25 mg Tab,00904-6638-61,NDC,,,,inpatient,1,EA,6.6,3.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.61,percent of total billed charges,,,85,,5.61,percent of total billed charges,,,49,,3.23,percent of total billed charges,,,90,,5.94,percent of total billed charges,,,,,,,no IP contract,,80,,5.28,percent of total billed charges,,,,,,,no IP contract,,50,,3.3,percent of total billed charges,,,,,,no IP contract,,,78,,5.15,percent of total billed charges,,,70,,4.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.23,3324,
00904-6639-61 - QUEtiapine 50 mg Tab,00904-6639-61,NDC,,,,inpatient,1,EA,8.3,4.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.06,percent of total billed charges,,,85,,7.06,percent of total billed charges,,,49,,4.07,percent of total billed charges,,,90,,7.47,percent of total billed charges,,,,,,,no IP contract,,80,,6.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.15,percent of total billed charges,,,,,,no IP contract,,,78,,6.47,percent of total billed charges,,,70,,5.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.07,3324,
00904-6665-61 - gabapentin 100 mg Cap,00904-6665-61,NDC,,,,inpatient,1,EA,4.95,2.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.21,percent of total billed charges,,,85,,4.21,percent of total billed charges,,,49,,2.43,percent of total billed charges,,,90,,4.46,percent of total billed charges,,,,,,,no IP contract,,80,,3.96,percent of total billed charges,,,,,,,no IP contract,,50,,2.48,percent of total billed charges,,,,,,no IP contract,,,78,,3.86,percent of total billed charges,,,70,,3.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.43,3324,
00904-6666-61 - gabapentin 300 mg Cap,00904-6666-61,NDC,,,,inpatient,1,EA,5.4,3.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.59,percent of total billed charges,,,85,,4.59,percent of total billed charges,,,49,,2.65,percent of total billed charges,,,90,,4.86,percent of total billed charges,,,,,,,no IP contract,,80,,4.32,percent of total billed charges,,,,,,,no IP contract,,50,,2.7,percent of total billed charges,,,,,,no IP contract,,,78,,4.21,percent of total billed charges,,,70,,3.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.65,3324,
00904-6667-61 - gabapentin 400 mg Cap,00904-6667-61,NDC,,,,inpatient,1,EA,5.8,3.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.93,percent of total billed charges,,,85,,4.93,percent of total billed charges,,,49,,2.84,percent of total billed charges,,,90,,5.22,percent of total billed charges,,,,,,,no IP contract,,80,,4.64,percent of total billed charges,,,,,,,no IP contract,,50,,2.9,percent of total billed charges,,,,,,no IP contract,,,78,,4.52,percent of total billed charges,,,70,,4.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.84,3324,
00904-6671-06 - sildenafil 20 mg Tab,00904-6671-06,NDC,,,,inpatient,1,EA,11.85,7.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.07,percent of total billed charges,,,85,,10.07,percent of total billed charges,,,49,,5.81,percent of total billed charges,,,90,,10.67,percent of total billed charges,,,,,,,no IP contract,,80,,9.48,percent of total billed charges,,,,,,,no IP contract,,50,,5.93,percent of total billed charges,,,,,,no IP contract,,,78,,9.24,percent of total billed charges,,,70,,8.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.81,3324,
00904-6689-61 - metFORMIN 500 mg Tab,00904-6689-61,NDC,,,,inpatient,1,EA,4.45,2.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.78,percent of total billed charges,,,85,,3.78,percent of total billed charges,,,49,,2.18,percent of total billed charges,,,90,,4.01,percent of total billed charges,,,,,,,no IP contract,,80,,3.56,percent of total billed charges,,,,,,,no IP contract,,50,,2.23,percent of total billed charges,,,,,,no IP contract,,,78,,3.47,percent of total billed charges,,,70,,3.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.18,3324,
omega-3 polyunsaturated fatty acids ethyl esters 1000 mg Cap,00904-6706-06,NDC,,,,inpatient,1,EA,36,21.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.6,percent of total billed charges,,,85,,30.6,percent of total billed charges,,,49,,17.64,percent of total billed charges,,,90,,32.4,percent of total billed charges,,,,,,,no IP contract,,80,,28.8,percent of total billed charges,,,,,,,no IP contract,,50,,18,percent of total billed charges,,,,,,no IP contract,,,78,,28.08,percent of total billed charges,,,70,,25.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.64,3324,
00904-6709-61 - glycopyrrolate 1 mg Tab,00904-6709-61,NDC,,,,inpatient,1,EA,14.15,8.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.03,percent of total billed charges,,,85,,12.03,percent of total billed charges,,,49,,6.93,percent of total billed charges,,,90,,12.74,percent of total billed charges,,,,,,,no IP contract,,80,,11.32,percent of total billed charges,,,,,,,no IP contract,,50,,7.08,percent of total billed charges,,,,,,no IP contract,,,78,,11.04,percent of total billed charges,,,70,,9.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.93,3324,
00904-6713-18 - aspirin 81 mg EC Ta,00904-6713-18,NDC,,,,inpatient,1,EA,3.9,2.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.32,percent of total billed charges,,,85,,3.32,percent of total billed charges,,,49,,1.91,percent of total billed charges,,,90,,3.51,percent of total billed charges,,,,,,,no IP contract,,80,,3.12,percent of total billed charges,,,,,,,no IP contract,,50,,1.95,percent of total billed charges,,,,,,no IP contract,,,78,,3.04,percent of total billed charges,,,70,,2.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.91,3324,
00904-6717-86 - cetirizine 10 mg Tab,00904-6717-86,NDC,,,,inpatient,1,EA,4.3,2.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.66,percent of total billed charges,,,85,,3.66,percent of total billed charges,,,49,,2.11,percent of total billed charges,,,90,,3.87,percent of total billed charges,,,,,,,no IP contract,,80,,3.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.15,percent of total billed charges,,,,,,no IP contract,,,78,,3.35,percent of total billed charges,,,70,,3.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.11,3324,
00904-6719-80 - acetaminophen 325 mg Tab,00904-6719-80,NDC,,,,inpatient,1,EA,3.9,2.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.32,percent of total billed charges,,,85,,3.32,percent of total billed charges,,,49,,1.91,percent of total billed charges,,,90,,3.51,percent of total billed charges,,,,,,,no IP contract,,80,,3.12,percent of total billed charges,,,,,,,no IP contract,,50,,1.95,percent of total billed charges,,,,,,no IP contract,,,78,,3.04,percent of total billed charges,,,70,,2.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.91,3324,
00904-6720-59 - acetaminophen 500 mg Tab,00904-6720-59,NDC,,,,inpatient,1,EA,4,2.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.4,percent of total billed charges,,,85,,3.4,percent of total billed charges,,,49,,1.96,percent of total billed charges,,,90,,3.6,percent of total billed charges,,,,,,,no IP contract,,80,,3.2,percent of total billed charges,,,,,,,no IP contract,,50,,2,percent of total billed charges,,,,,,no IP contract,,,78,,3.12,percent of total billed charges,,,70,,2.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.96,3324,
00904-6725-59 - senna 8.6 mg Tab,00904-6725-59,NDC,,,,inpatient,1,EA,4,2.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.4,percent of total billed charges,,,85,,3.4,percent of total billed charges,,,49,,1.96,percent of total billed charges,,,90,,3.6,percent of total billed charges,,,,,,,no IP contract,,80,,3.2,percent of total billed charges,,,,,,,no IP contract,,50,,2,percent of total billed charges,,,,,,no IP contract,,,78,,3.12,percent of total billed charges,,,70,,2.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.96,3324,
00904-6730-61 - acetaminophen 500 mg Tab,00904-6730-61,NDC,,,,inpatient,1,EA,4.05,2.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.44,percent of total billed charges,,,85,,3.44,percent of total billed charges,,,49,,1.98,percent of total billed charges,,,90,,3.65,percent of total billed charges,,,,,,,no IP contract,,80,,3.24,percent of total billed charges,,,,,,,no IP contract,,50,,2.03,percent of total billed charges,,,,,,no IP contract,,,78,,3.16,percent of total billed charges,,,70,,2.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.98,3324,
00904-6745-61 - dronabinol 2.5 mg Cap,00904-6745-61,NDC,,,,inpatient,1,EA,52.65,31.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,42.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,44.75,percent of total billed charges,,,85,,44.75,percent of total billed charges,,,49,,25.8,percent of total billed charges,,,90,,47.39,percent of total billed charges,,,,,,,no IP contract,,80,,42.12,percent of total billed charges,,,,,,,no IP contract,,50,,26.33,percent of total billed charges,,,,,,no IP contract,,,78,,41.07,percent of total billed charges,,,70,,36.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.8,3324,
00904-6751-80 - aspirin 81 mg EC Ta,00904-6751-80,NDC,,,,inpatient,1,EA,3.9,2.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.32,percent of total billed charges,,,85,,3.32,percent of total billed charges,,,49,,1.91,percent of total billed charges,,,90,,3.51,percent of total billed charges,,,,,,,no IP contract,,80,,3.12,percent of total billed charges,,,,,,,no IP contract,,50,,1.95,percent of total billed charges,,,,,,no IP contract,,,78,,3.04,percent of total billed charges,,,70,,2.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.91,3324,
00904-6761-30 - oxymetazoline 0.05% Spray,00904-6761-30,NDC,,,,inpatient,1,UN,24.2,14.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.57,percent of total billed charges,,,85,,20.57,percent of total billed charges,,,49,,11.86,percent of total billed charges,,,90,,21.78,percent of total billed charges,,,,,,,no IP contract,,80,,19.36,percent of total billed charges,,,,,,,no IP contract,,50,,12.1,percent of total billed charges,,,,,,no IP contract,,,78,,18.88,percent of total billed charges,,,70,,16.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.86,3324,
00904-6765-20 - cetirizine 1 mg/mL Syrup,00904-6765-20,NDC,,,,inpatient,1,ML,5.85,3.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.97,percent of total billed charges,,,85,,4.97,percent of total billed charges,,,49,,2.87,percent of total billed charges,,,90,,5.27,percent of total billed charges,,,,,,,no IP contract,,80,,4.68,percent of total billed charges,,,,,,,no IP contract,,50,,2.93,percent of total billed charges,,,,,,no IP contract,,,78,,4.56,percent of total billed charges,,,70,,4.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.87,3324,
00904-6773-61 - acetaminophen 325 mg Tab,00904-6773-61,NDC,,,,inpatient,1,EA,4.05,2.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.44,percent of total billed charges,,,85,,3.44,percent of total billed charges,,,49,,1.98,percent of total billed charges,,,90,,3.65,percent of total billed charges,,,,,,,no IP contract,,80,,3.24,percent of total billed charges,,,,,,,no IP contract,,50,,2.03,percent of total billed charges,,,,,,no IP contract,,,78,,3.16,percent of total billed charges,,,70,,2.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.98,3324,
00904-6783-70 - aspirin 81 mg EC Ta,00904-6783-70,NDC,,,,inpatient,1,EA,3.9,2.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.32,percent of total billed charges,,,85,,3.32,percent of total billed charges,,,49,,1.91,percent of total billed charges,,,90,,3.51,percent of total billed charges,,,,,,,no IP contract,,80,,3.12,percent of total billed charges,,,,,,,no IP contract,,50,,1.95,percent of total billed charges,,,,,,no IP contract,,,78,,3.04,percent of total billed charges,,,70,,2.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.91,3324,
mycophenolic acid 360 mg EC Ta,00904-6786-04,NDC,,,,inpatient,1,EA,97,58.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,78.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,82.45,percent of total billed charges,,,85,,82.45,percent of total billed charges,,,49,,47.53,percent of total billed charges,,,90,,87.3,percent of total billed charges,,,,,,,no IP contract,,80,,77.6,percent of total billed charges,,,,,,,no IP contract,,50,,48.5,percent of total billed charges,,,,,,no IP contract,,,78,,75.66,percent of total billed charges,,,70,,67.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,47.53,3324,
00904-6791-04 - modafinil 100 mg Tab,00904-6791-04,NDC,,,,inpatient,1,EA,98.65,59.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,79.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,83.85,percent of total billed charges,,,85,,83.85,percent of total billed charges,,,49,,48.34,percent of total billed charges,,,90,,88.79,percent of total billed charges,,,,,,,no IP contract,,80,,78.92,percent of total billed charges,,,,,,,no IP contract,,50,,49.33,percent of total billed charges,,,,,,no IP contract,,,78,,76.95,percent of total billed charges,,,70,,69.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,48.34,3324,
00904-6794-89 - aspirin 81 mg Chew,00904-6794-89,NDC,,,,inpatient,1,EA,4,2.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.4,percent of total billed charges,,,85,,3.4,percent of total billed charges,,,49,,1.96,percent of total billed charges,,,90,,3.6,percent of total billed charges,,,,,,,no IP contract,,80,,3.2,percent of total billed charges,,,,,,,no IP contract,,50,,2,percent of total billed charges,,,,,,no IP contract,,,78,,3.12,percent of total billed charges,,,70,,2.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.96,3324,
00904-6797-61 - lisinopril 5 mg Tab,00904-6797-61,NDC,,,,inpatient,1,EA,4.45,2.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.78,percent of total billed charges,,,85,,3.78,percent of total billed charges,,,49,,2.18,percent of total billed charges,,,90,,4.01,percent of total billed charges,,,,,,,no IP contract,,80,,3.56,percent of total billed charges,,,,,,,no IP contract,,50,,2.23,percent of total billed charges,,,,,,no IP contract,,,78,,3.47,percent of total billed charges,,,70,,3.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.18,3324,
00904-6798-61 - lisinopril 10 mg Tab,00904-6798-61,NDC,,,,inpatient,1,EA,4.3,2.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.66,percent of total billed charges,,,85,,3.66,percent of total billed charges,,,49,,2.11,percent of total billed charges,,,90,,3.87,percent of total billed charges,,,,,,,no IP contract,,80,,3.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.15,percent of total billed charges,,,,,,no IP contract,,,78,,3.35,percent of total billed charges,,,70,,3.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.11,3324,
00904-6799-61 - lisinopril 20 mg Tab,00904-6799-61,NDC,,,,inpatient,1,EA,4.45,2.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.78,percent of total billed charges,,,85,,3.78,percent of total billed charges,,,49,,2.18,percent of total billed charges,,,90,,4.01,percent of total billed charges,,,,,,,no IP contract,,80,,3.56,percent of total billed charges,,,,,,,no IP contract,,50,,2.23,percent of total billed charges,,,,,,no IP contract,,,78,,3.47,percent of total billed charges,,,70,,3.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.18,3324,
00904-6808-61 - montelukast 10 mg Tab,00904-6808-61,NDC,,,,inpatient,1,EA,7,4.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.95,percent of total billed charges,,,85,,5.95,percent of total billed charges,,,49,,3.43,percent of total billed charges,,,90,,6.3,percent of total billed charges,,,,,,,no IP contract,,80,,5.6,percent of total billed charges,,,,,,,no IP contract,,50,,3.5,percent of total billed charges,,,,,,no IP contract,,,78,,5.46,percent of total billed charges,,,70,,4.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.43,3324,
midodrine 5 mg Tab,00904-6818-06,NDC,,,,inpatient,1,EA,9.55,5.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.12,percent of total billed charges,,,85,,8.12,percent of total billed charges,,,49,,4.68,percent of total billed charges,,,90,,8.6,percent of total billed charges,,,,,,,no IP contract,,80,,7.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.78,percent of total billed charges,,,,,,no IP contract,,,78,,7.45,percent of total billed charges,,,70,,6.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.68,3324,
00904-6820-76 - acetaminophen 160 mg/5 mL LIQ,00904-6820-76,NDC,,,,inpatient,20.3,ML,22.1,13.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.79,percent of total billed charges,,,85,,18.79,percent of total billed charges,,,49,,10.83,percent of total billed charges,,,90,,19.89,percent of total billed charges,,,,,,,no IP contract,,80,,17.68,percent of total billed charges,,,,,,,no IP contract,,50,,11.05,percent of total billed charges,,,,,,no IP contract,,,78,,17.24,percent of total billed charges,,,70,,15.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.83,3324,
00904-6836-20 - loperamide 1 mg/7.5 mL LIQ,00904-6836-20,NDC,,,,inpatient,7.5,ML,45.4,27.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,38.59,percent of total billed charges,,,85,,38.59,percent of total billed charges,,,49,,22.25,percent of total billed charges,,,90,,40.86,percent of total billed charges,,,,,,,no IP contract,,80,,36.32,percent of total billed charges,,,,,,,no IP contract,,50,,22.7,percent of total billed charges,,,,,,no IP contract,,,78,,35.41,percent of total billed charges,,,70,,31.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.25,3324,
divalproex sodium 250 mg EC Ta,00904-6860-61,NDC,,,,inpatient,1,EA,5.75,3.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.89,percent of total billed charges,,,85,,4.89,percent of total billed charges,,,49,,2.82,percent of total billed charges,,,90,,5.18,percent of total billed charges,,,,,,,no IP contract,,80,,4.6,percent of total billed charges,,,,,,,no IP contract,,50,,2.88,percent of total billed charges,,,,,,no IP contract,,,78,,4.49,percent of total billed charges,,,70,,4.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.82,3324,
00904-6861-90 - divalproex sodium 500 mg EC Ta,00904-6861-90,NDC,,,,inpatient,1,EA,6.95,4.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.91,percent of total billed charges,,,85,,5.91,percent of total billed charges,,,49,,3.41,percent of total billed charges,,,90,,6.26,percent of total billed charges,,,,,,,no IP contract,,80,,5.56,percent of total billed charges,,,,,,,no IP contract,,50,,3.48,percent of total billed charges,,,,,,no IP contract,,,78,,5.42,percent of total billed charges,,,70,,4.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.41,3324,
00904-6868-61 - traZODone 50 mg Tab,00904-6868-61,NDC,,,,inpatient,1,EA,5,3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.25,percent of total billed charges,,,85,,4.25,percent of total billed charges,,,49,,2.45,percent of total billed charges,,,90,,4.5,percent of total billed charges,,,,,,,no IP contract,,80,,4,percent of total billed charges,,,,,,,no IP contract,,50,,2.5,percent of total billed charges,,,,,,no IP contract,,,78,,3.9,percent of total billed charges,,,70,,3.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.45,3324,
00904-6914-61 - methylPREDNISolone 4 mg Tab,00904-6914-61,NDC,,,,inpatient,1,EA,21.55,12.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.32,percent of total billed charges,,,85,,18.32,percent of total billed charges,,,49,,10.56,percent of total billed charges,,,90,,19.4,percent of total billed charges,,,,,,,no IP contract,,80,,17.24,percent of total billed charges,,,,,,,no IP contract,,50,,10.78,percent of total billed charges,,,,,,no IP contract,,,78,,16.81,percent of total billed charges,,,70,,15.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.56,3324,
sertraline 100 mg Tab,00904-6926-61,NDC,,,,inpatient,1,EA,8.2,4.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.97,percent of total billed charges,,,85,,6.97,percent of total billed charges,,,49,,4.02,percent of total billed charges,,,90,,7.38,percent of total billed charges,,,,,,,no IP contract,,80,,6.56,percent of total billed charges,,,,,,,no IP contract,,50,,4.1,percent of total billed charges,,,,,,no IP contract,,,78,,6.4,percent of total billed charges,,,70,,5.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.02,3324,
levothyroxine 50 mcg (0.05 mg) Tab,00904-6950-61,NDC,,,,inpatient,1,EA,8.3,4.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.06,percent of total billed charges,,,85,,7.06,percent of total billed charges,,,49,,4.07,percent of total billed charges,,,90,,7.47,percent of total billed charges,,,,,,,no IP contract,,80,,6.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.15,percent of total billed charges,,,,,,no IP contract,,,78,,6.47,percent of total billed charges,,,70,,5.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.07,3324,
00904-6966-61 - oxyCODONE 5 mg Tab,00904-6966-61,NDC,,,,inpatient,1,EA,8.65,5.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.35,percent of total billed charges,,,85,,7.35,percent of total billed charges,,,49,,4.24,percent of total billed charges,,,90,,7.79,percent of total billed charges,,,,,,,no IP contract,,80,,6.92,percent of total billed charges,,,,,,,no IP contract,,50,,4.33,percent of total billed charges,,,,,,no IP contract,,,78,,6.75,percent of total billed charges,,,70,,6.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.24,3324,
pseudoephedrine 30 mg Tab,00904-6990-61,NDC,,,,inpatient,1,EA,4.15,2.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.53,percent of total billed charges,,,85,,3.53,percent of total billed charges,,,49,,2.03,percent of total billed charges,,,90,,3.74,percent of total billed charges,,,,,,,no IP contract,,80,,3.32,percent of total billed charges,,,,,,,no IP contract,,50,,2.08,percent of total billed charges,,,,,,no IP contract,,,78,,3.24,percent of total billed charges,,,70,,2.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.03,3324,
00904-7000-61 - pregabalin 75 mg Cap,00904-7000-61,NDC,,,,inpatient,1,EA,11.15,6.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.48,percent of total billed charges,,,85,,9.48,percent of total billed charges,,,49,,5.46,percent of total billed charges,,,90,,10.04,percent of total billed charges,,,,,,,no IP contract,,80,,8.92,percent of total billed charges,,,,,,,no IP contract,,50,,5.58,percent of total billed charges,,,,,,no IP contract,,,78,,8.7,percent of total billed charges,,,70,,7.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.46,3324,
00904-7041-61 - allopurinol 100 mg Tab,00904-7041-61,NDC,,,,inpatient,1,EA,7,4.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.95,percent of total billed charges,,,85,,5.95,percent of total billed charges,,,49,,3.43,percent of total billed charges,,,90,,6.3,percent of total billed charges,,,,,,,no IP contract,,80,,5.6,percent of total billed charges,,,,,,,no IP contract,,50,,3.5,percent of total billed charges,,,,,,no IP contract,,,78,,5.46,percent of total billed charges,,,70,,4.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.43,3324,
DULoxetine 20 mg DR Ca,00904-7043-61,NDC,,,,inpatient,1,EA,19.1,11.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.24,percent of total billed charges,,,85,,16.24,percent of total billed charges,,,49,,9.36,percent of total billed charges,,,90,,17.19,percent of total billed charges,,,,,,,no IP contract,,80,,15.28,percent of total billed charges,,,,,,,no IP contract,,50,,9.55,percent of total billed charges,,,,,,no IP contract,,,78,,14.9,percent of total billed charges,,,70,,13.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.36,3324,
00904-7045-61 - DULoxetine 60 mg DR Ca,00904-7045-61,NDC,,,,inpatient,1,EA,17.5,10.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.88,percent of total billed charges,,,85,,14.88,percent of total billed charges,,,49,,8.58,percent of total billed charges,,,90,,15.75,percent of total billed charges,,,,,,,no IP contract,,80,,14,percent of total billed charges,,,,,,,no IP contract,,50,,8.75,percent of total billed charges,,,,,,no IP contract,,,78,,13.65,percent of total billed charges,,,70,,12.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.58,3324,
00904-7050-60 - fexofenadine 180 mg Tab,00904-7050-60,NDC,,,,inpatient,1,EA,5,3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.25,percent of total billed charges,,,85,,4.25,percent of total billed charges,,,49,,2.45,percent of total billed charges,,,90,,4.5,percent of total billed charges,,,,,,,no IP contract,,80,,4,percent of total billed charges,,,,,,,no IP contract,,50,,2.5,percent of total billed charges,,,,,,no IP contract,,,78,,3.9,percent of total billed charges,,,70,,3.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.45,3324,
00904-7057-61 - methocarbamol 500 mg Tab,00904-7057-61,NDC,,,,inpatient,1,EA,6.35,3.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.4,percent of total billed charges,,,85,,5.4,percent of total billed charges,,,49,,3.11,percent of total billed charges,,,90,,5.72,percent of total billed charges,,,,,,,no IP contract,,80,,5.08,percent of total billed charges,,,,,,,no IP contract,,50,,3.18,percent of total billed charges,,,,,,no IP contract,,,78,,4.95,percent of total billed charges,,,70,,4.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.11,3324,
NIFEdipine 90 mg ER Ta,00904-7082-06,NDC,,,,inpatient,1,EA,12.1,7.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.29,percent of total billed charges,,,85,,10.29,percent of total billed charges,,,49,,5.93,percent of total billed charges,,,90,,10.89,percent of total billed charges,,,,,,,no IP contract,,80,,9.68,percent of total billed charges,,,,,,,no IP contract,,50,,6.05,percent of total billed charges,,,,,,no IP contract,,,78,,9.44,percent of total billed charges,,,70,,8.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.93,3324,
00904-7083-61 - ciprofloxacin 500 mg Tab,00904-7083-61,NDC,,,,inpatient,1,EA,6.6,3.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.61,percent of total billed charges,,,85,,5.61,percent of total billed charges,,,49,,3.23,percent of total billed charges,,,90,,5.94,percent of total billed charges,,,,,,,no IP contract,,80,,5.28,percent of total billed charges,,,,,,,no IP contract,,50,,3.3,percent of total billed charges,,,,,,no IP contract,,,78,,5.15,percent of total billed charges,,,70,,4.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.23,3324,
tacrolimus 1 mg Cap,00904-7097-61,NDC,,,,inpatient,1,EA,16.85,10.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.32,percent of total billed charges,,,85,,14.32,percent of total billed charges,,,49,,8.26,percent of total billed charges,,,90,,15.17,percent of total billed charges,,,,,,,no IP contract,,80,,13.48,percent of total billed charges,,,,,,,no IP contract,,50,,8.43,percent of total billed charges,,,,,,no IP contract,,,78,,13.14,percent of total billed charges,,,70,,11.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.26,3324,
busPIRone 10 mg Tab,00904-7121-61,NDC,,,,inpatient,1,EA,5.5,3.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.68,percent of total billed charges,,,85,,4.68,percent of total billed charges,,,49,,2.7,percent of total billed charges,,,90,,4.95,percent of total billed charges,,,,,,,no IP contract,,80,,4.4,percent of total billed charges,,,,,,,no IP contract,,50,,2.75,percent of total billed charges,,,,,,no IP contract,,,78,,4.29,percent of total billed charges,,,70,,3.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.7,3324,
00904-7124-61 - levETIRAcetam 500 mg Tab,00904-7124-61,NDC,,,,inpatient,1,EA,5.8,3.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.93,percent of total billed charges,,,85,,4.93,percent of total billed charges,,,49,,2.84,percent of total billed charges,,,90,,5.22,percent of total billed charges,,,,,,,no IP contract,,80,,4.64,percent of total billed charges,,,,,,,no IP contract,,50,,2.9,percent of total billed charges,,,,,,no IP contract,,,78,,4.52,percent of total billed charges,,,70,,4.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.84,3324,
00904-7125-61 - levETIRAcetam 750 mg Tab,00904-7125-61,NDC,,,,inpatient,1,EA,6.55,3.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.57,percent of total billed charges,,,85,,5.57,percent of total billed charges,,,49,,3.21,percent of total billed charges,,,90,,5.9,percent of total billed charges,,,,,,,no IP contract,,80,,5.24,percent of total billed charges,,,,,,,no IP contract,,50,,3.28,percent of total billed charges,,,,,,no IP contract,,,78,,5.11,percent of total billed charges,,,70,,4.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.21,3324,
predniSONE 20 mg Tab,00904-7127-61,NDC,,,,inpatient,1,EA,5.4,3.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.59,percent of total billed charges,,,85,,4.59,percent of total billed charges,,,49,,2.65,percent of total billed charges,,,90,,4.86,percent of total billed charges,,,,,,,no IP contract,,80,,4.32,percent of total billed charges,,,,,,,no IP contract,,50,,2.7,percent of total billed charges,,,,,,no IP contract,,,78,,4.21,percent of total billed charges,,,70,,3.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.65,3324,
nitrofurantoin macrocrystals-monohydrate 100 mg Cap,00904-7137-61,NDC,,,,inpatient,1,EA,25.85,15.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.97,percent of total billed charges,,,85,,21.97,percent of total billed charges,,,49,,12.67,percent of total billed charges,,,90,,23.27,percent of total billed charges,,,,,,,no IP contract,,80,,20.68,percent of total billed charges,,,,,,,no IP contract,,50,,12.93,percent of total billed charges,,,,,,no IP contract,,,78,,20.16,percent of total billed charges,,,70,,18.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.67,3324,
00904-7142-12 - bisacodyl 10 mg Supp,00904-7142-12,NDC,,,,inpatient,1,UN,5.55,3.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.72,percent of total billed charges,,,85,,4.72,percent of total billed charges,,,49,,2.72,percent of total billed charges,,,90,,5,percent of total billed charges,,,,,,,no IP contract,,80,,4.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.78,percent of total billed charges,,,,,,no IP contract,,,78,,4.33,percent of total billed charges,,,70,,3.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.72,3324,
00904-7142-60 - bisacodyl 10 mg Supp,00904-7142-60,NDC,,,,inpatient,1,UN,4.95,2.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.21,percent of total billed charges,,,85,,4.21,percent of total billed charges,,,49,,2.43,percent of total billed charges,,,90,,4.46,percent of total billed charges,,,,,,,no IP contract,,80,,3.96,percent of total billed charges,,,,,,,no IP contract,,50,,2.48,percent of total billed charges,,,,,,no IP contract,,,78,,3.86,percent of total billed charges,,,70,,3.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.43,3324,
droNABinol 5 mg Cap,00904-7145-04,NDC,,,,inpatient,1,EA,101.8,61.08,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,82.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,86.53,percent of total billed charges,,,85,,86.53,percent of total billed charges,,,49,,49.88,percent of total billed charges,,,90,,91.62,percent of total billed charges,,,,,,,no IP contract,,80,,81.44,percent of total billed charges,,,,,,,no IP contract,,50,,50.9,percent of total billed charges,,,,,,no IP contract,,,78,,79.4,percent of total billed charges,,,70,,71.26,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,49.88,3324,
00904-7162-61 - metFORMIN 500 mg Tab,00904-7162-61,NDC,,,,inpatient,1,EA,4.45,2.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.78,percent of total billed charges,,,85,,3.78,percent of total billed charges,,,49,,2.18,percent of total billed charges,,,90,,4.01,percent of total billed charges,,,,,,,no IP contract,,80,,3.56,percent of total billed charges,,,,,,,no IP contract,,50,,2.23,percent of total billed charges,,,,,,no IP contract,,,78,,3.47,percent of total billed charges,,,70,,3.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.18,3324,
00904-7177-61 - furosemide 20 mg Tab,00904-7177-61,NDC,,,,inpatient,1,EA,4.55,2.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.87,percent of total billed charges,,,85,,3.87,percent of total billed charges,,,49,,2.23,percent of total billed charges,,,90,,4.1,percent of total billed charges,,,,,,,no IP contract,,80,,3.64,percent of total billed charges,,,,,,,no IP contract,,50,,2.28,percent of total billed charges,,,,,,no IP contract,,,78,,3.55,percent of total billed charges,,,70,,3.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.23,3324,
00904-7178-61 - furosemide 40 mg Tab,00904-7178-61,NDC,,,,inpatient,1,EA,4.55,2.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.87,percent of total billed charges,,,85,,3.87,percent of total billed charges,,,49,,2.23,percent of total billed charges,,,90,,4.1,percent of total billed charges,,,,,,,no IP contract,,80,,3.64,percent of total billed charges,,,,,,,no IP contract,,50,,2.28,percent of total billed charges,,,,,,no IP contract,,,78,,3.55,percent of total billed charges,,,70,,3.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.23,3324,
traMADol 50 mg Tab,00904-7179-61,NDC,,,,inpatient,1,EA,5.2,3.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.42,percent of total billed charges,,,85,,4.42,percent of total billed charges,,,49,,2.55,percent of total billed charges,,,90,,4.68,percent of total billed charges,,,,,,,no IP contract,,80,,4.16,percent of total billed charges,,,,,,,no IP contract,,50,,2.6,percent of total billed charges,,,,,,no IP contract,,,78,,4.06,percent of total billed charges,,,70,,3.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.55,3324,
00904-7183-61 - docusate sodium 100 mg Cap,00904-7183-61,NDC,,,,inpatient,1,EA,4.3,2.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.66,percent of total billed charges,,,85,,3.66,percent of total billed charges,,,49,,2.11,percent of total billed charges,,,90,,3.87,percent of total billed charges,,,,,,,no IP contract,,80,,3.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.15,percent of total billed charges,,,,,,no IP contract,,,78,,3.35,percent of total billed charges,,,70,,3.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.11,3324,
nebivolol 5 mg Tab,00904-7189-04,NDC,,,,inpatient,1,EA,30.55,18.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.97,percent of total billed charges,,,85,,25.97,percent of total billed charges,,,49,,14.97,percent of total billed charges,,,90,,27.5,percent of total billed charges,,,,,,,no IP contract,,80,,24.44,percent of total billed charges,,,,,,,no IP contract,,50,,15.28,percent of total billed charges,,,,,,no IP contract,,,78,,23.83,percent of total billed charges,,,70,,21.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.97,3324,
00904-7214-61 - buPROPion 150 mg/12 hours ER Ta,00904-7214-61,NDC,,,,inpatient,1,EA,9.4,5.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.99,percent of total billed charges,,,85,,7.99,percent of total billed charges,,,49,,4.61,percent of total billed charges,,,90,,8.46,percent of total billed charges,,,,,,,no IP contract,,80,,7.52,percent of total billed charges,,,,,,,no IP contract,,50,,4.7,percent of total billed charges,,,,,,no IP contract,,,78,,7.33,percent of total billed charges,,,70,,6.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.61,3324,
dilTIAZem 180 mg/24 hours ER Ca,00904-7218-61,NDC,,,,inpatient,1,EA,7.55,4.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.42,percent of total billed charges,,,85,,6.42,percent of total billed charges,,,49,,3.7,percent of total billed charges,,,90,,6.8,percent of total billed charges,,,,,,,no IP contract,,80,,6.04,percent of total billed charges,,,,,,,no IP contract,,50,,3.78,percent of total billed charges,,,,,,no IP contract,,,78,,5.89,percent of total billed charges,,,70,,5.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.7,3324,
saccharomyces boulardii lyo 250 mg Cap,00904-7230-06,NDC,,,,inpatient,1,EA,10.5,6.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.93,percent of total billed charges,,,85,,8.93,percent of total billed charges,,,49,,5.15,percent of total billed charges,,,90,,9.45,percent of total billed charges,,,,,,,no IP contract,,80,,8.4,percent of total billed charges,,,,,,,no IP contract,,50,,5.25,percent of total billed charges,,,,,,no IP contract,,,78,,8.19,percent of total billed charges,,,70,,7.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.15,3324,
megestrol 40 mg Tab,00904-7236-61,NDC,,,,inpatient,1,EA,6.05,3.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.14,percent of total billed charges,,,85,,5.14,percent of total billed charges,,,49,,2.96,percent of total billed charges,,,90,,5.45,percent of total billed charges,,,,,,,no IP contract,,80,,4.84,percent of total billed charges,,,,,,,no IP contract,,50,,3.03,percent of total billed charges,,,,,,no IP contract,,,78,,4.72,percent of total billed charges,,,70,,4.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.96,3324,
lacosamide 50 mg Tab,00904-7244-68,NDC,,,,inpatient,1,EA,17.75,10.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.09,percent of total billed charges,,,85,,15.09,percent of total billed charges,,,49,,8.7,percent of total billed charges,,,90,,15.98,percent of total billed charges,,,,,,,no IP contract,,80,,14.2,percent of total billed charges,,,,,,,no IP contract,,50,,8.88,percent of total billed charges,,,,,,no IP contract,,,78,,13.85,percent of total billed charges,,,70,,12.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.7,3324,
lacosamide 100 mg Tab,00904-7245-68,NDC,,,,inpatient,1,EA,25.9,15.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.02,percent of total billed charges,,,85,,22.02,percent of total billed charges,,,49,,12.69,percent of total billed charges,,,90,,23.31,percent of total billed charges,,,,,,,no IP contract,,80,,20.72,percent of total billed charges,,,,,,,no IP contract,,50,,12.95,percent of total billed charges,,,,,,no IP contract,,,78,,20.2,percent of total billed charges,,,70,,18.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.69,3324,
00904-7252-61 - senna 8.6 mg Tab,00904-7252-61,NDC,,,,inpatient,1,EA,4.2,2.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.57,percent of total billed charges,,,85,,3.57,percent of total billed charges,,,49,,2.06,percent of total billed charges,,,90,,3.78,percent of total billed charges,,,,,,,no IP contract,,80,,3.36,percent of total billed charges,,,,,,,no IP contract,,50,,2.1,percent of total billed charges,,,,,,no IP contract,,,78,,3.28,percent of total billed charges,,,70,,2.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.06,3324,
00904-7257-61 - carbidopa-levodopa 25 mg-100 mg Tab,00904-7257-61,NDC,,,,inpatient,1,EA,5.65,3.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.8,percent of total billed charges,,,85,,4.8,percent of total billed charges,,,49,,2.77,percent of total billed charges,,,90,,5.09,percent of total billed charges,,,,,,,no IP contract,,80,,4.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.83,percent of total billed charges,,,,,,no IP contract,,,78,,4.41,percent of total billed charges,,,70,,3.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.77,3324,
nystatin 100000 units/mL Susp,00904-7276-70,NDC,,,,inpatient,1,EA,21.25,12.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.06,percent of total billed charges,,,85,,18.06,percent of total billed charges,,,49,,10.41,percent of total billed charges,,,90,,19.13,percent of total billed charges,,,,,,,no IP contract,,80,,17,percent of total billed charges,,,,,,,no IP contract,,50,,10.63,percent of total billed charges,,,,,,no IP contract,,,78,,16.58,percent of total billed charges,,,70,,14.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.41,3324,
promethazine 25 mg Tab,00904-7304-61,NDC,,,,inpatient,1,EA,5.25,3.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.46,percent of total billed charges,,,85,,4.46,percent of total billed charges,,,49,,2.57,percent of total billed charges,,,90,,4.73,percent of total billed charges,,,,,,,no IP contract,,80,,4.2,percent of total billed charges,,,,,,,no IP contract,,50,,2.63,percent of total billed charges,,,,,,no IP contract,,,78,,4.1,percent of total billed charges,,,70,,3.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.57,3324,
carvedilol 3.125 mg Tab,00904-7305-61,NDC,,,,inpatient,1,EA,12.5,7.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.63,percent of total billed charges,,,85,,10.63,percent of total billed charges,,,49,,6.13,percent of total billed charges,,,90,,11.25,percent of total billed charges,,,,,,,no IP contract,,80,,10,percent of total billed charges,,,,,,,no IP contract,,50,,6.25,percent of total billed charges,,,,,,no IP contract,,,78,,9.75,percent of total billed charges,,,70,,8.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.13,3324,
carvedilol 25 mg Tab,00904-7308-61,NDC,,,,inpatient,1,EA,4.7,2.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4,percent of total billed charges,,,85,,4,percent of total billed charges,,,49,,2.3,percent of total billed charges,,,90,,4.23,percent of total billed charges,,,,,,,no IP contract,,80,,3.76,percent of total billed charges,,,,,,,no IP contract,,50,,2.35,percent of total billed charges,,,,,,no IP contract,,,78,,3.67,percent of total billed charges,,,70,,3.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.3,3324,
00904-7318-13 - omega-3 polyunsaturated fatty acids 500 mg Cap,00904-7318-13,NDC,,,,inpatient,1,EA,4.2,2.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.57,percent of total billed charges,,,85,,3.57,percent of total billed charges,,,49,,2.06,percent of total billed charges,,,90,,3.78,percent of total billed charges,,,,,,,no IP contract,,80,,3.36,percent of total billed charges,,,,,,,no IP contract,,50,,2.1,percent of total billed charges,,,,,,no IP contract,,,78,,3.28,percent of total billed charges,,,70,,2.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.06,3324,
azithromycin 250 mg Tab,00904-7350-06,NDC,,,,inpatient,1,EA,15.6,9.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.26,percent of total billed charges,,,85,,13.26,percent of total billed charges,,,49,,7.64,percent of total billed charges,,,90,,14.04,percent of total billed charges,,,,,,,no IP contract,,80,,12.48,percent of total billed charges,,,,,,,no IP contract,,50,,7.8,percent of total billed charges,,,,,,no IP contract,,,78,,12.17,percent of total billed charges,,,70,,10.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.64,3324,
risperiDONE 0.5 mg Tab,00904-7361-61,NDC,,,,inpatient,1,EA,5.75,3.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.89,percent of total billed charges,,,85,,4.89,percent of total billed charges,,,49,,2.82,percent of total billed charges,,,90,,5.18,percent of total billed charges,,,,,,,no IP contract,,80,,4.6,percent of total billed charges,,,,,,,no IP contract,,50,,2.88,percent of total billed charges,,,,,,no IP contract,,,78,,4.49,percent of total billed charges,,,70,,4.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.82,3324,
meclizine 25 mg Tab,00904-7376-61,NDC,,,,inpatient,1,EA,8.2,4.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.97,percent of total billed charges,,,85,,6.97,percent of total billed charges,,,49,,4.02,percent of total billed charges,,,90,,7.38,percent of total billed charges,,,,,,,no IP contract,,80,,6.56,percent of total billed charges,,,,,,,no IP contract,,50,,4.1,percent of total billed charges,,,,,,no IP contract,,,78,,6.4,percent of total billed charges,,,70,,5.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.02,3324,
00904-7590-83 - ferrous sulfate 325 mg Tab,00904-7590-83,NDC,,,,inpatient,1,EA,4,2.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.4,percent of total billed charges,,,85,,3.4,percent of total billed charges,,,49,,1.96,percent of total billed charges,,,90,,3.6,percent of total billed charges,,,,,,,no IP contract,,80,,3.2,percent of total billed charges,,,,,,,no IP contract,,50,,2,percent of total billed charges,,,,,,no IP contract,,,78,,3.12,percent of total billed charges,,,70,,2.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.96,3324,
00904-7623-31 - hydrocortisone topical 1% Cream,00904-7623-31,NDC,,,,inpatient,1,UN,34.2,20.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.07,percent of total billed charges,,,85,,29.07,percent of total billed charges,,,49,,16.76,percent of total billed charges,,,90,,30.78,percent of total billed charges,,,,,,,no IP contract,,80,,27.36,percent of total billed charges,,,,,,,no IP contract,,50,,17.1,percent of total billed charges,,,,,,no IP contract,,,78,,26.68,percent of total billed charges,,,70,,23.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.76,3324,
00904-7720-61 - carbidopa-levodopa 25 mg-250 mg Tab,00904-7720-61,NDC,,,,inpatient,1,EA,12.35,7.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.5,percent of total billed charges,,,85,,10.5,percent of total billed charges,,,49,,6.05,percent of total billed charges,,,90,,11.12,percent of total billed charges,,,,,,,no IP contract,,80,,9.88,percent of total billed charges,,,,,,,no IP contract,,50,,6.18,percent of total billed charges,,,,,,no IP contract,,,78,,9.63,percent of total billed charges,,,70,,8.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.05,3324,
00904-7734-45 - miconazole topical 2% Cream,00904-7734-45,NDC,,,,inpatient,1,UN,96.85,58.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,78.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,82.32,percent of total billed charges,,,85,,82.32,percent of total billed charges,,,49,,47.46,percent of total billed charges,,,90,,87.17,percent of total billed charges,,,,,,,no IP contract,,80,,77.48,percent of total billed charges,,,,,,,no IP contract,,50,,48.43,percent of total billed charges,,,,,,no IP contract,,,78,,75.54,percent of total billed charges,,,70,,67.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,47.46,3324,
00904-7809-61 - cyclobenzaprine 10 mg Tab,00904-7809-61,NDC,,,,inpatient,1,EA,13.45,8.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.43,percent of total billed charges,,,85,,11.43,percent of total billed charges,,,49,,6.59,percent of total billed charges,,,90,,12.11,percent of total billed charges,,,,,,,no IP contract,,80,,10.76,percent of total billed charges,,,,,,,no IP contract,,50,,6.73,percent of total billed charges,,,,,,no IP contract,,,78,,10.49,percent of total billed charges,,,70,,9.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.59,3324,
00904-7822-31 - clotrimazole topical 1% Cream,00904-7822-31,NDC,,,,inpatient,1,UN,79.2,47.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,64.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,67.32,percent of total billed charges,,,85,,67.32,percent of total billed charges,,,49,,38.81,percent of total billed charges,,,90,,71.28,percent of total billed charges,,,,,,,no IP contract,,80,,63.36,percent of total billed charges,,,,,,,no IP contract,,50,,39.6,percent of total billed charges,,,,,,no IP contract,,,78,,61.78,percent of total billed charges,,,70,,55.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,38.81,3324,
00904-7914-61 - ibuprofen 200 mg Tab,00904-7914-61,NDC,,,,inpatient,1,EA,4.4,2.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.74,percent of total billed charges,,,85,,3.74,percent of total billed charges,,,49,,2.16,percent of total billed charges,,,90,,3.96,percent of total billed charges,,,,,,,no IP contract,,80,,3.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.2,percent of total billed charges,,,,,,no IP contract,,,78,,3.43,percent of total billed charges,,,70,,3.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.16,3324,
00904-7927-60 - bisacodyl 5 mg EC Ta,00904-7927-60,NDC,,,,inpatient,1,EA,4.3,2.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.66,percent of total billed charges,,,85,,3.66,percent of total billed charges,,,49,,2.11,percent of total billed charges,,,90,,3.87,percent of total billed charges,,,,,,,no IP contract,,80,,3.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.15,percent of total billed charges,,,,,,no IP contract,,,78,,3.35,percent of total billed charges,,,70,,3.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.11,3324,
immune globulin intravenous 10% Soln,00944-2700-05,NDC,,,,inpatient,1,EA,10847.75,6508.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8786.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9220.59,percent of total billed charges,,,85,,9220.59,percent of total billed charges,,,49,,5315.4,percent of total billed charges,,,90,,9762.98,percent of total billed charges,,,,,,,no IP contract,,80,,8678.2,percent of total billed charges,,,,,,,no IP contract,,50,,5423.88,percent of total billed charges,,,,,,no IP contract,,,78,,8461.25,percent of total billed charges,,,70,,7593.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,9762.98,
immune globulin intravenous and subcutaneous 10% Soln,00944-2700-06,NDC,,,,inpatient,1,EA,21683.1,13009.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17563.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18430.64,percent of total billed charges,,,85,,18430.64,percent of total billed charges,,,49,,10624.72,percent of total billed charges,,,90,,19514.79,percent of total billed charges,,,,,,,no IP contract,,80,,17346.48,percent of total billed charges,,,,,,,no IP contract,,50,,10841.55,percent of total billed charges,,,,,,no IP contract,,,78,,16912.82,percent of total billed charges,,,70,,15178.17,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,19514.79,
immune globulin intravenous and subcutaneous 10% Soln,00944-2700-07,NDC,,,,inpatient,1,EA,34536.35,20721.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27974.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29355.9,percent of total billed charges,,,85,,29355.9,percent of total billed charges,,,49,,16922.81,percent of total billed charges,,,90,,31082.72,percent of total billed charges,,,,,,,no IP contract,,80,,27629.08,percent of total billed charges,,,,,,,no IP contract,,50,,17268.18,percent of total billed charges,,,,,,no IP contract,,,78,,26938.35,percent of total billed charges,,,70,,24175.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,19895.42,100% of Medicare,,,,,19895.42,100% of Medicare,,,,,19895.42,100% of Medicare,,,,,19895.42,100% of Medicare,,,,,19895.42,100% of Medicare,,,,,19895.42,100% of Medicare,,,,,19895.42,100% of Medicare,,,,,19895.42,100% of Medicare,,,,,19895.42,100% of Medicare,,,,,19895.42,100% of Medicare,,,,,19895.42,100% of Medicare,,,,,,19895.42,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,31082.72,
00955-1004-10 - enoxaparin 40 mg/0.4 mL Soln,00955-1004-10,NDC,,,,inpatient,0.4,ML,282.8,169.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,229.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,240.38,percent of total billed charges,,,85,,240.38,percent of total billed charges,,,49,,138.57,percent of total billed charges,,,90,,254.52,percent of total billed charges,,,,,,,no IP contract,,80,,226.24,percent of total billed charges,,,,,,,no IP contract,,50,,141.4,percent of total billed charges,,,,,,no IP contract,,,78,,220.58,percent of total billed charges,,,70,,197.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,138.57,3324,
00955-1006-10 - enoxaparin 60 mg/0.6 mL Soln,00955-1006-10,NDC,,,,inpatient,0.6,ML,461.1,276.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,373.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,391.94,percent of total billed charges,,,85,,391.94,percent of total billed charges,,,49,,225.94,percent of total billed charges,,,90,,414.99,percent of total billed charges,,,,,,,no IP contract,,80,,368.88,percent of total billed charges,,,,,,,no IP contract,,50,,230.55,percent of total billed charges,,,,,,no IP contract,,,78,,359.66,percent of total billed charges,,,70,,322.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,225.94,3324,
00955-1008-10 - enoxaparin 80 mg/0.8 mL Soln,00955-1008-10,NDC,,,,inpatient,0.8,ML,225.45,135.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,182.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,191.63,percent of total billed charges,,,85,,191.63,percent of total billed charges,,,49,,110.47,percent of total billed charges,,,90,,202.91,percent of total billed charges,,,,,,,no IP contract,,80,,180.36,percent of total billed charges,,,,,,,no IP contract,,50,,112.73,percent of total billed charges,,,,,,no IP contract,,,78,,175.85,percent of total billed charges,,,70,,157.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,110.47,3324,
00955-1010-10 - enoxaparin 100 mg/mL Soln,00955-1010-10,NDC,,,,inpatient,1,ML,225.45,135.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,182.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,191.63,percent of total billed charges,,,85,,191.63,percent of total billed charges,,,49,,110.47,percent of total billed charges,,,90,,202.91,percent of total billed charges,,,,,,,no IP contract,,80,,180.36,percent of total billed charges,,,,,,,no IP contract,,50,,112.73,percent of total billed charges,,,,,,no IP contract,,,78,,175.85,percent of total billed charges,,,70,,157.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,110.47,3324,
00955-1012-10 - enoxaparin 120 mg/0.8 mL Soln,00955-1012-10,NDC,,,,inpatient,0.8,ML,913.1,547.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,739.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,776.14,percent of total billed charges,,,85,,776.14,percent of total billed charges,,,49,,447.42,percent of total billed charges,,,90,,821.79,percent of total billed charges,,,,,,,no IP contract,,80,,730.48,percent of total billed charges,,,,,,,no IP contract,,50,,456.55,percent of total billed charges,,,,,,no IP contract,,,78,,712.22,percent of total billed charges,,,70,,639.17,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,447.42,3324,
00955-1015-10 - enoxaparin 150 mg/mL Soln,00955-1015-10,NDC,,,,inpatient,1,ML,333.55,200.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,270.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,283.52,percent of total billed charges,,,85,,283.52,percent of total billed charges,,,49,,163.44,percent of total billed charges,,,90,,300.2,percent of total billed charges,,,,,,,no IP contract,,80,,266.84,percent of total billed charges,,,,,,,no IP contract,,50,,166.78,percent of total billed charges,,,,,,no IP contract,,,78,,260.17,percent of total billed charges,,,70,,233.49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,163.44,3324,
00955-1041-90 - irbesartan 150 mg Tab,00955-1041-90,NDC,,,,inpatient,1,EA,26.5,15.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.53,percent of total billed charges,,,85,,22.53,percent of total billed charges,,,49,,12.99,percent of total billed charges,,,90,,23.85,percent of total billed charges,,,,,,,no IP contract,,80,,21.2,percent of total billed charges,,,,,,,no IP contract,,50,,13.25,percent of total billed charges,,,,,,no IP contract,,,78,,20.67,percent of total billed charges,,,70,,18.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.99,3324,
00955-1052-90 - sevelamer carbonate 0.8 g REC P,00955-1052-90,NDC,,,,inpatient,30,ML,94.05,56.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,76.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,79.94,percent of total billed charges,,,85,,79.94,percent of total billed charges,,,49,,46.08,percent of total billed charges,,,90,,84.65,percent of total billed charges,,,,,,,no IP contract,,80,,75.24,percent of total billed charges,,,,,,,no IP contract,,50,,47.03,percent of total billed charges,,,,,,no IP contract,,,78,,73.36,percent of total billed charges,,,70,,65.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,46.08,3324,
00955-1054-90 - sevelamer carbonate 2.4 g REC P,00955-1054-90,NDC,,,,inpatient,60,ML,94.05,56.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,76.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,79.94,percent of total billed charges,,,85,,79.94,percent of total billed charges,,,49,,46.08,percent of total billed charges,,,90,,84.65,percent of total billed charges,,,,,,,no IP contract,,80,,75.24,percent of total billed charges,,,,,,,no IP contract,,50,,47.03,percent of total billed charges,,,,,,no IP contract,,,78,,73.36,percent of total billed charges,,,70,,65.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,46.08,3324,
00955-1702-10 - zolpidem 6.25 mg ER Ta,00955-1702-10,NDC,,,,inpatient,1,EA,56.4,33.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,45.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,47.94,percent of total billed charges,,,85,,47.94,percent of total billed charges,,,49,,27.64,percent of total billed charges,,,90,,50.76,percent of total billed charges,,,,,,,no IP contract,,80,,45.12,percent of total billed charges,,,,,,,no IP contract,,50,,28.2,percent of total billed charges,,,,,,no IP contract,,,78,,43.99,percent of total billed charges,,,70,,39.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.64,3324,
00990-7075-26 - potassium chloride 20 mEq/100 mL Soln,00990-7075-26,NDC,,,,inpatient,100,ML,108.4,65.04,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,87.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,92.14,percent of total billed charges,,,85,,92.14,percent of total billed charges,,,49,,53.12,percent of total billed charges,,,90,,97.56,percent of total billed charges,,,,,,,no IP contract,,80,,86.72,percent of total billed charges,,,,,,,no IP contract,,50,,54.2,percent of total billed charges,,,,,,no IP contract,,,78,,84.55,percent of total billed charges,,,70,,75.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,53.12,3324,
00990-7953-09 - LVP solution Lactated Ringers Injection Soln,00990-7953-09,NDC,,,,inpatient,1000,ML,118.7,71.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,96.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,100.9,percent of total billed charges,,,85,,100.9,percent of total billed charges,,,49,,58.16,percent of total billed charges,,,90,,106.83,percent of total billed charges,,,,,,,no IP contract,,80,,94.96,percent of total billed charges,,,,,,,no IP contract,,50,,59.35,percent of total billed charges,,,,,,no IP contract,,,78,,92.59,percent of total billed charges,,,70,,83.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.16,3324,
00990-7983-09 - LVP solution Sodium Chloride 0.9% Soln,00990-7983-09,NDC,,,,inpatient,1000,ML,118.7,71.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,96.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,100.9,percent of total billed charges,,,85,,100.9,percent of total billed charges,,,49,,58.16,percent of total billed charges,,,90,,106.83,percent of total billed charges,,,,,,,no IP contract,,80,,94.96,percent of total billed charges,,,,,,,no IP contract,,50,,59.35,percent of total billed charges,,,,,,no IP contract,,,78,,92.59,percent of total billed charges,,,70,,83.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.16,3324,
00998-0203-15 - pilocarpine ophthalmic 1% Soln,00998-0203-15,NDC,,,,inpatient,1,UN,207.9,124.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,168.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,176.72,percent of total billed charges,,,85,,176.72,percent of total billed charges,,,49,,101.87,percent of total billed charges,,,90,,187.11,percent of total billed charges,,,,,,,no IP contract,,80,,166.32,percent of total billed charges,,,,,,,no IP contract,,50,,103.95,percent of total billed charges,,,,,,no IP contract,,,78,,162.16,percent of total billed charges,,,70,,145.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,101.87,3324,
00998-0615-05 - dexamethasone ophthalmic 0.1% Susp,00998-0615-05,NDC,,,,inpatient,1,UN,357,214.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,289.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,303.45,percent of total billed charges,,,85,,303.45,percent of total billed charges,,,49,,174.93,percent of total billed charges,,,90,,321.3,percent of total billed charges,,,,,,,no IP contract,,80,,285.6,percent of total billed charges,,,,,,,no IP contract,,50,,178.5,percent of total billed charges,,,,,,no IP contract,,,78,,278.46,percent of total billed charges,,,70,,249.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,174.93,3324,
01015-8117-20 - Saliva Substitute 1 Spray,01015-8117-20,NDC,,,,inpatient,1,UN,47.05,28.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,38.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,39.99,percent of total billed charges,,,85,,39.99,percent of total billed charges,,,49,,23.05,percent of total billed charges,,,90,,42.35,percent of total billed charges,,,,,,,no IP contract,,80,,37.64,percent of total billed charges,,,,,,,no IP contract,,50,,23.53,percent of total billed charges,,,,,,no IP contract,,,78,,36.7,percent of total billed charges,,,70,,32.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.05,3324,
01015-8117-20 - saliva substitute 1 spray(s) Spray,01015-8117-20,NDC,,,,inpatient,1,UN,47.05,28.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,38.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,39.99,percent of total billed charges,,,85,,39.99,percent of total billed charges,,,49,,23.05,percent of total billed charges,,,90,,42.35,percent of total billed charges,,,,,,,no IP contract,,80,,37.64,percent of total billed charges,,,,,,,no IP contract,,50,,23.53,percent of total billed charges,,,,,,no IP contract,,,78,,36.7,percent of total billed charges,,,70,,32.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.05,3324,
01031-0222-40 - benzocaine 1 app Gel,01031-0222-40,NDC,,,,inpatient,1,UN,38.95,23.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.11,percent of total billed charges,,,85,,33.11,percent of total billed charges,,,49,,19.09,percent of total billed charges,,,90,,35.06,percent of total billed charges,,,,,,,no IP contract,,80,,31.16,percent of total billed charges,,,,,,,no IP contract,,50,,19.48,percent of total billed charges,,,,,,no IP contract,,,78,,30.38,percent of total billed charges,,,70,,27.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.09,3324,
01033-1000-09 - Witch Hazel 1 pad Pad,01033-1000-09,NDC,,,,inpatient,1,UN,875.15,525.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,708.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,743.88,percent of total billed charges,,,85,,743.88,percent of total billed charges,,,49,,428.82,percent of total billed charges,,,90,,787.64,percent of total billed charges,,,,,,,no IP contract,,80,,700.12,percent of total billed charges,,,,,,,no IP contract,,50,,437.58,percent of total billed charges,,,,,,no IP contract,,,78,,682.62,percent of total billed charges,,,70,,612.61,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,428.82,3324,
01170-1002-15 -,01170-1002-15,NDC,,,,inpatient,1,UN,39.2,23.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.32,percent of total billed charges,,,85,,33.32,percent of total billed charges,,,49,,19.21,percent of total billed charges,,,90,,35.28,percent of total billed charges,,,,,,,no IP contract,,80,,31.36,percent of total billed charges,,,,,,,no IP contract,,50,,19.6,percent of total billed charges,,,,,,no IP contract,,,78,,30.58,percent of total billed charges,,,70,,27.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.21,3324,
ROOM/BED: General,0118,RC,,,,inpatient,,,2925,1755,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2369.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2486.25,percent of total billed charges,,,85,,2486.25,percent of total billed charges,,,49,,1433.25,percent of total billed charges,,,90,,2632.5,percent of total billed charges,,,,,,,no IP contract,,80,,2340,percent of total billed charges,,,,,,,no IP contract,,50,,1462.5,percent of total billed charges,,,,,,no IP contract,,,78,,2281.5,percent of total billed charges,,,70,,2047.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
ROOM/BED: Neuro,0118,RC,,,,inpatient,,,3272,1963.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2650.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2781.2,percent of total billed charges,,,85,,2781.2,percent of total billed charges,,,49,,1603.28,percent of total billed charges,,,90,,2944.8,percent of total billed charges,,,,,,,no IP contract,,80,,2617.6,percent of total billed charges,,,,,,,no IP contract,,50,,1636,percent of total billed charges,,,,,,no IP contract,,,78,,2552.16,percent of total billed charges,,,70,,2290.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
ROOM/BED: International,0118,RC,,,,inpatient,,,3819,2291.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3093.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3246.15,percent of total billed charges,,,85,,3246.15,percent of total billed charges,,,49,,1871.31,percent of total billed charges,,,90,,3437.1,percent of total billed charges,,,,,,,no IP contract,,80,,3055.2,percent of total billed charges,,,,,,,no IP contract,,50,,1909.5,percent of total billed charges,,,,,,no IP contract,,,78,,2978.82,percent of total billed charges,,,70,,2673.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3437.1,
01650-0023-24 -,01650-0023-24,NDC,,,,inpatient,1,UN,15.3,9.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.01,percent of total billed charges,,,85,,13.01,percent of total billed charges,,,49,,7.5,percent of total billed charges,,,90,,13.77,percent of total billed charges,,,,,,,no IP contract,,80,,12.24,percent of total billed charges,,,,,,,no IP contract,,50,,7.65,percent of total billed charges,,,,,,no IP contract,,,78,,11.93,percent of total billed charges,,,70,,10.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.5,3324,
01650-0023-24 - aluminum acetate 1 packet(s) Powder,01650-0023-24,NDC,,,,inpatient,1,UN,15.3,9.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.01,percent of total billed charges,,,85,,13.01,percent of total billed charges,,,49,,7.5,percent of total billed charges,,,90,,13.77,percent of total billed charges,,,,,,,no IP contract,,80,,12.24,percent of total billed charges,,,,,,,no IP contract,,50,,7.65,percent of total billed charges,,,,,,no IP contract,,,78,,11.93,percent of total billed charges,,,70,,10.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.5,3324,
01650-0088-06 -,01650-0088-06,NDC,,,,inpatient,1,EA,5.1,3.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.34,percent of total billed charges,,,85,,4.34,percent of total billed charges,,,49,,2.5,percent of total billed charges,,,90,,4.59,percent of total billed charges,,,,,,,no IP contract,,80,,4.08,percent of total billed charges,,,,,,,no IP contract,,50,,2.55,percent of total billed charges,,,,,,no IP contract,,,78,,3.98,percent of total billed charges,,,70,,3.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.5,3324,
Arginaid,0250,RC,,,,inpatient,,,2,1.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1.7,percent of total billed charges,,,85,,1.7,percent of total billed charges,,,49,,0.98,percent of total billed charges,,,90,,1.8,percent of total billed charges,,,,,,,no IP contract,,80,,1.6,percent of total billed charges,,,,,,,no IP contract,,50,,1,percent of total billed charges,,,,,,no IP contract,,,78,,1.56,percent of total billed charges,,,70,,1.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,0.98,3324,
Isocal HN,0250,RC,,,,inpatient,,,4,2.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.4,percent of total billed charges,,,85,,3.4,percent of total billed charges,,,49,,1.96,percent of total billed charges,,,90,,3.6,percent of total billed charges,,,,,,,no IP contract,,80,,3.2,percent of total billed charges,,,,,,,no IP contract,,50,,2,percent of total billed charges,,,,,,no IP contract,,,78,,3.12,percent of total billed charges,,,70,,2.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.96,3324,
Kindercal with Fiber,0250,RC,,,,inpatient,,,5,3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.25,percent of total billed charges,,,85,,4.25,percent of total billed charges,,,49,,2.45,percent of total billed charges,,,90,,4.5,percent of total billed charges,,,,,,,no IP contract,,80,,4,percent of total billed charges,,,,,,,no IP contract,,50,,2.5,percent of total billed charges,,,,,,no IP contract,,,78,,3.9,percent of total billed charges,,,70,,3.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.45,3324,
Pedialyte,0250,RC,,,,inpatient,,,5,3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.25,percent of total billed charges,,,85,,4.25,percent of total billed charges,,,49,,2.45,percent of total billed charges,,,90,,4.5,percent of total billed charges,,,,,,,no IP contract,,80,,4,percent of total billed charges,,,,,,,no IP contract,,50,,2.5,percent of total billed charges,,,,,,no IP contract,,,78,,3.9,percent of total billed charges,,,70,,3.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.45,3324,
Resource Fruit Beverage- Berry,0250,RC,,,,inpatient,,,5,3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.25,percent of total billed charges,,,85,,4.25,percent of total billed charges,,,49,,2.45,percent of total billed charges,,,90,,4.5,percent of total billed charges,,,,,,,no IP contract,,80,,4,percent of total billed charges,,,,,,,no IP contract,,50,,2.5,percent of total billed charges,,,,,,no IP contract,,,78,,3.9,percent of total billed charges,,,70,,3.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.45,3324,
Resource Fruit Beverage- Orange,0250,RC,,,,inpatient,,,5,3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.25,percent of total billed charges,,,85,,4.25,percent of total billed charges,,,49,,2.45,percent of total billed charges,,,90,,4.5,percent of total billed charges,,,,,,,no IP contract,,80,,4,percent of total billed charges,,,,,,,no IP contract,,50,,2.5,percent of total billed charges,,,,,,no IP contract,,,78,,3.9,percent of total billed charges,,,70,,3.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.45,3324,
Resource Fruit Beverage- Peach,0250,RC,,,,inpatient,,,5,3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.25,percent of total billed charges,,,85,,4.25,percent of total billed charges,,,49,,2.45,percent of total billed charges,,,90,,4.5,percent of total billed charges,,,,,,,no IP contract,,80,,4,percent of total billed charges,,,,,,,no IP contract,,50,,2.5,percent of total billed charges,,,,,,no IP contract,,,78,,3.9,percent of total billed charges,,,70,,3.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.45,3324,
Traumacal,0250,RC,,,,inpatient,,,6,3.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.1,percent of total billed charges,,,85,,5.1,percent of total billed charges,,,49,,2.94,percent of total billed charges,,,90,,5.4,percent of total billed charges,,,,,,,no IP contract,,80,,4.8,percent of total billed charges,,,,,,,no IP contract,,50,,3,percent of total billed charges,,,,,,no IP contract,,,78,,4.68,percent of total billed charges,,,70,,4.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.94,3324,
Pediasure,0250,RC,,,,inpatient,,,7,4.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.95,percent of total billed charges,,,85,,5.95,percent of total billed charges,,,49,,3.43,percent of total billed charges,,,90,,6.3,percent of total billed charges,,,,,,,no IP contract,,80,,5.6,percent of total billed charges,,,,,,,no IP contract,,50,,3.5,percent of total billed charges,,,,,,no IP contract,,,78,,5.46,percent of total billed charges,,,70,,4.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.43,3324,
Pediasure with fiber,0250,RC,,,,inpatient,,,7,4.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.95,percent of total billed charges,,,85,,5.95,percent of total billed charges,,,49,,3.43,percent of total billed charges,,,90,,6.3,percent of total billed charges,,,,,,,no IP contract,,80,,5.6,percent of total billed charges,,,,,,,no IP contract,,50,,3.5,percent of total billed charges,,,,,,no IP contract,,,78,,5.46,percent of total billed charges,,,70,,4.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.43,3324,
Crucial,0250,RC,,,,inpatient,,,8,4.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.8,percent of total billed charges,,,85,,6.8,percent of total billed charges,,,49,,3.92,percent of total billed charges,,,90,,7.2,percent of total billed charges,,,,,,,no IP contract,,80,,6.4,percent of total billed charges,,,,,,,no IP contract,,50,,4,percent of total billed charges,,,,,,no IP contract,,,78,,6.24,percent of total billed charges,,,70,,5.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.92,3324,
Diabetisource AC,0250,RC,,,,inpatient,,,8,4.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.8,percent of total billed charges,,,85,,6.8,percent of total billed charges,,,49,,3.92,percent of total billed charges,,,90,,7.2,percent of total billed charges,,,,,,,no IP contract,,80,,6.4,percent of total billed charges,,,,,,,no IP contract,,50,,4,percent of total billed charges,,,,,,no IP contract,,,78,,6.24,percent of total billed charges,,,70,,5.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.92,3324,
Fibersource HN,0250,RC,,,,inpatient,,,8,4.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.8,percent of total billed charges,,,85,,6.8,percent of total billed charges,,,49,,3.92,percent of total billed charges,,,90,,7.2,percent of total billed charges,,,,,,,no IP contract,,80,,6.4,percent of total billed charges,,,,,,,no IP contract,,50,,4,percent of total billed charges,,,,,,no IP contract,,,78,,6.24,percent of total billed charges,,,70,,5.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.92,3324,
Glucerna- Chocolate,0250,RC,,,,inpatient,,,8,4.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.8,percent of total billed charges,,,85,,6.8,percent of total billed charges,,,49,,3.92,percent of total billed charges,,,90,,7.2,percent of total billed charges,,,,,,,no IP contract,,80,,6.4,percent of total billed charges,,,,,,,no IP contract,,50,,4,percent of total billed charges,,,,,,no IP contract,,,78,,6.24,percent of total billed charges,,,70,,5.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.92,3324,
Glucerna- Vanilla,0250,RC,,,,inpatient,,,8,4.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.8,percent of total billed charges,,,85,,6.8,percent of total billed charges,,,49,,3.92,percent of total billed charges,,,90,,7.2,percent of total billed charges,,,,,,,no IP contract,,80,,6.4,percent of total billed charges,,,,,,,no IP contract,,50,,4,percent of total billed charges,,,,,,no IP contract,,,78,,6.24,percent of total billed charges,,,70,,5.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.92,3324,
Isosource,0250,RC,,,,inpatient,,,8,4.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.8,percent of total billed charges,,,85,,6.8,percent of total billed charges,,,49,,3.92,percent of total billed charges,,,90,,7.2,percent of total billed charges,,,,,,,no IP contract,,80,,6.4,percent of total billed charges,,,,,,,no IP contract,,50,,4,percent of total billed charges,,,,,,no IP contract,,,78,,6.24,percent of total billed charges,,,70,,5.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.92,3324,
Isosource 1.5,0250,RC,,,,inpatient,,,8,4.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.8,percent of total billed charges,,,85,,6.8,percent of total billed charges,,,49,,3.92,percent of total billed charges,,,90,,7.2,percent of total billed charges,,,,,,,no IP contract,,80,,6.4,percent of total billed charges,,,,,,,no IP contract,,50,,4,percent of total billed charges,,,,,,no IP contract,,,78,,6.24,percent of total billed charges,,,70,,5.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.92,3324,
Peptamen Jr.,0250,RC,,,,inpatient,,,8,4.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.8,percent of total billed charges,,,85,,6.8,percent of total billed charges,,,49,,3.92,percent of total billed charges,,,90,,7.2,percent of total billed charges,,,,,,,no IP contract,,80,,6.4,percent of total billed charges,,,,,,,no IP contract,,50,,4,percent of total billed charges,,,,,,no IP contract,,,78,,6.24,percent of total billed charges,,,70,,5.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.92,3324,
Resource 2.0,0250,RC,,,,inpatient,,,8,4.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.8,percent of total billed charges,,,85,,6.8,percent of total billed charges,,,49,,3.92,percent of total billed charges,,,90,,7.2,percent of total billed charges,,,,,,,no IP contract,,80,,6.4,percent of total billed charges,,,,,,,no IP contract,,50,,4,percent of total billed charges,,,,,,no IP contract,,,78,,6.24,percent of total billed charges,,,70,,5.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.92,3324,
Resource Pulmonary,0250,RC,,,,inpatient,,,8,4.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.8,percent of total billed charges,,,85,,6.8,percent of total billed charges,,,49,,3.92,percent of total billed charges,,,90,,7.2,percent of total billed charges,,,,,,,no IP contract,,80,,6.4,percent of total billed charges,,,,,,,no IP contract,,50,,4,percent of total billed charges,,,,,,no IP contract,,,78,,6.24,percent of total billed charges,,,70,,5.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.92,3324,
Resource Renal,0250,RC,,,,inpatient,,,8,4.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.8,percent of total billed charges,,,85,,6.8,percent of total billed charges,,,49,,3.92,percent of total billed charges,,,90,,7.2,percent of total billed charges,,,,,,,no IP contract,,80,,6.4,percent of total billed charges,,,,,,,no IP contract,,50,,4,percent of total billed charges,,,,,,no IP contract,,,78,,6.24,percent of total billed charges,,,70,,5.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.92,3324,
Thicken Up,0250,RC,,,,inpatient,,,8,4.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.8,percent of total billed charges,,,85,,6.8,percent of total billed charges,,,49,,3.92,percent of total billed charges,,,90,,7.2,percent of total billed charges,,,,,,,no IP contract,,80,,6.4,percent of total billed charges,,,,,,,no IP contract,,50,,4,percent of total billed charges,,,,,,no IP contract,,,78,,6.24,percent of total billed charges,,,70,,5.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.92,3324,
Vivonex Pediatric,0250,RC,,,,inpatient,,,8,4.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.8,percent of total billed charges,,,85,,6.8,percent of total billed charges,,,49,,3.92,percent of total billed charges,,,90,,7.2,percent of total billed charges,,,,,,,no IP contract,,80,,6.4,percent of total billed charges,,,,,,,no IP contract,,50,,4,percent of total billed charges,,,,,,no IP contract,,,78,,6.24,percent of total billed charges,,,70,,5.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.92,3324,
Enfamil 20 kcal,0250,RC,,,,inpatient,,,18,10.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.3,percent of total billed charges,,,85,,15.3,percent of total billed charges,,,49,,8.82,percent of total billed charges,,,90,,16.2,percent of total billed charges,,,,,,,no IP contract,,80,,14.4,percent of total billed charges,,,,,,,no IP contract,,50,,9,percent of total billed charges,,,,,,no IP contract,,,78,,14.04,percent of total billed charges,,,70,,12.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.82,3324,
Enfamil 24 kcal,0250,RC,,,,inpatient,,,18,10.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.3,percent of total billed charges,,,85,,15.3,percent of total billed charges,,,49,,8.82,percent of total billed charges,,,90,,16.2,percent of total billed charges,,,,,,,no IP contract,,80,,14.4,percent of total billed charges,,,,,,,no IP contract,,50,,9,percent of total billed charges,,,,,,no IP contract,,,78,,14.04,percent of total billed charges,,,70,,12.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.82,3324,
UROSTOMY DRAIN TUBE ADAPTOR,0270,RC,,,,inpatient,,,6,3.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.1,percent of total billed charges,,,85,,5.1,percent of total billed charges,,,49,,2.94,percent of total billed charges,,,90,,5.4,percent of total billed charges,,,,,,,no IP contract,,80,,4.8,percent of total billed charges,,,,,,,no IP contract,,50,,3,percent of total billed charges,,,,,,no IP contract,,,78,,4.68,percent of total billed charges,,,70,,4.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.94,3324,
OSTOMY HYDROCOLLOID BARRIER EXTENDERS,0270,RC,,,,inpatient,,,9,5.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.65,percent of total billed charges,,,85,,7.65,percent of total billed charges,,,49,,4.41,percent of total billed charges,,,90,,8.1,percent of total billed charges,,,,,,,no IP contract,,80,,7.2,percent of total billed charges,,,,,,,no IP contract,,50,,4.5,percent of total billed charges,,,,,,no IP contract,,,78,,7.02,percent of total billed charges,,,70,,6.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.41,3324,
NON  ADHERENT CONTACT LAYER DRESSING 2X2,0270,RC,,,,inpatient,,,11,6.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.35,percent of total billed charges,,,85,,9.35,percent of total billed charges,,,49,,5.39,percent of total billed charges,,,90,,9.9,percent of total billed charges,,,,,,,no IP contract,,80,,8.8,percent of total billed charges,,,,,,,no IP contract,,50,,5.5,percent of total billed charges,,,,,,no IP contract,,,78,,8.58,percent of total billed charges,,,70,,7.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.39,3324,
POLYMEN FENESTRATED TRACH TUBE FOAM DRESSING,0270,RC,,,,inpatient,,,11,6.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.35,percent of total billed charges,,,85,,9.35,percent of total billed charges,,,49,,5.39,percent of total billed charges,,,90,,9.9,percent of total billed charges,,,,,,,no IP contract,,80,,8.8,percent of total billed charges,,,,,,,no IP contract,,50,,5.5,percent of total billed charges,,,,,,no IP contract,,,78,,8.58,percent of total billed charges,,,70,,7.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.39,3324,
OSTOMY BELT,0270,RC,,,,inpatient,,,12,7.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.2,percent of total billed charges,,,85,,10.2,percent of total billed charges,,,49,,5.88,percent of total billed charges,,,90,,10.8,percent of total billed charges,,,,,,,no IP contract,,80,,9.6,percent of total billed charges,,,,,,,no IP contract,,50,,6,percent of total billed charges,,,,,,no IP contract,,,78,,9.36,percent of total billed charges,,,70,,8.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.88,3324,
XTRASORB SUPER ABSORBENT DRESSING 4 X 5 in,0270,RC,,,,inpatient,,,17,10.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.45,percent of total billed charges,,,85,,14.45,percent of total billed charges,,,49,,8.33,percent of total billed charges,,,90,,15.3,percent of total billed charges,,,,,,,no IP contract,,80,,13.6,percent of total billed charges,,,,,,,no IP contract,,50,,8.5,percent of total billed charges,,,,,,no IP contract,,,78,,13.26,percent of total billed charges,,,70,,11.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.33,3324,
DRESSING 15CM X 20 CM TEGADERM,0270,RC,,,,inpatient,,,18,10.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.3,percent of total billed charges,,,85,,15.3,percent of total billed charges,,,49,,8.82,percent of total billed charges,,,90,,16.2,percent of total billed charges,,,,,,,no IP contract,,80,,14.4,percent of total billed charges,,,,,,,no IP contract,,50,,9,percent of total billed charges,,,,,,no IP contract,,,78,,14.04,percent of total billed charges,,,70,,12.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.82,3324,
MEPILEX BORDER FLEX 3 X 3 FOAM,0270,RC,,,,inpatient,,,27,16.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.95,percent of total billed charges,,,85,,22.95,percent of total billed charges,,,49,,13.23,percent of total billed charges,,,90,,24.3,percent of total billed charges,,,,,,,no IP contract,,80,,21.6,percent of total billed charges,,,,,,,no IP contract,,50,,13.5,percent of total billed charges,,,,,,no IP contract,,,78,,21.06,percent of total billed charges,,,70,,18.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.23,3324,
URGO TUL CONTACT DRESSING 4X5,0270,RC,,,,inpatient,,,29,17.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.65,percent of total billed charges,,,85,,24.65,percent of total billed charges,,,49,,14.21,percent of total billed charges,,,90,,26.1,percent of total billed charges,,,,,,,no IP contract,,80,,23.2,percent of total billed charges,,,,,,,no IP contract,,50,,14.5,percent of total billed charges,,,,,,no IP contract,,,78,,22.62,percent of total billed charges,,,70,,20.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.21,3324,
MEPILEX BORDER LITE 4X4 FOAM,0270,RC,,,,inpatient,,,32,19.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,25.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,27.2,percent of total billed charges,,,85,,27.2,percent of total billed charges,,,49,,15.68,percent of total billed charges,,,90,,28.8,percent of total billed charges,,,,,,,no IP contract,,80,,25.6,percent of total billed charges,,,,,,,no IP contract,,50,,16,percent of total billed charges,,,,,,no IP contract,,,78,,24.96,percent of total billed charges,,,70,,22.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.68,3324,
DERMABLUE & FOAM WOUND DRESSING 4X5 1/4 in,0270,RC,,,,inpatient,,,33,19.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,26.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.05,percent of total billed charges,,,85,,28.05,percent of total billed charges,,,49,,16.17,percent of total billed charges,,,90,,29.7,percent of total billed charges,,,,,,,no IP contract,,80,,26.4,percent of total billed charges,,,,,,,no IP contract,,50,,16.5,percent of total billed charges,,,,,,no IP contract,,,78,,25.74,percent of total billed charges,,,70,,23.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.17,3324,
MEPILEX NON BORDER 6X6 FOAM,0270,RC,,,,inpatient,,,34,20.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.9,percent of total billed charges,,,85,,28.9,percent of total billed charges,,,49,,16.66,percent of total billed charges,,,90,,30.6,percent of total billed charges,,,,,,,no IP contract,,80,,27.2,percent of total billed charges,,,,,,,no IP contract,,50,,17,percent of total billed charges,,,,,,no IP contract,,,78,,26.52,percent of total billed charges,,,70,,23.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.66,3324,
TRACH DIC #4,0270,RC,,,,inpatient,,,34,20.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.9,percent of total billed charges,,,85,,28.9,percent of total billed charges,,,49,,16.66,percent of total billed charges,,,90,,30.6,percent of total billed charges,,,,,,,no IP contract,,80,,27.2,percent of total billed charges,,,,,,,no IP contract,,50,,17,percent of total billed charges,,,,,,no IP contract,,,78,,26.52,percent of total billed charges,,,70,,23.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.66,3324,
TRACH DIC #6,0270,RC,,,,inpatient,,,34,20.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.9,percent of total billed charges,,,85,,28.9,percent of total billed charges,,,49,,16.66,percent of total billed charges,,,90,,30.6,percent of total billed charges,,,,,,,no IP contract,,80,,27.2,percent of total billed charges,,,,,,,no IP contract,,50,,17,percent of total billed charges,,,,,,no IP contract,,,78,,26.52,percent of total billed charges,,,70,,23.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.66,3324,
TRACH DIC #8,0270,RC,,,,inpatient,,,34,20.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.9,percent of total billed charges,,,85,,28.9,percent of total billed charges,,,49,,16.66,percent of total billed charges,,,90,,30.6,percent of total billed charges,,,,,,,no IP contract,,80,,27.2,percent of total billed charges,,,,,,,no IP contract,,50,,17,percent of total billed charges,,,,,,no IP contract,,,78,,26.52,percent of total billed charges,,,70,,23.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.66,3324,
MEPILEX NON BORDER 4 X 4 FOAM,0270,RC,,,,inpatient,,,35,21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.75,percent of total billed charges,,,85,,29.75,percent of total billed charges,,,49,,17.15,percent of total billed charges,,,90,,31.5,percent of total billed charges,,,,,,,no IP contract,,80,,28,percent of total billed charges,,,,,,,no IP contract,,50,,17.5,percent of total billed charges,,,,,,no IP contract,,,78,,27.3,percent of total billed charges,,,70,,24.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.15,3324,
OSTOMY TWO PIECE STANDARD POUCH 1 3/4 GREEN,0270,RC,,,,inpatient,,,36,21.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.6,percent of total billed charges,,,85,,30.6,percent of total billed charges,,,49,,17.64,percent of total billed charges,,,90,,32.4,percent of total billed charges,,,,,,,no IP contract,,80,,28.8,percent of total billed charges,,,,,,,no IP contract,,50,,18,percent of total billed charges,,,,,,no IP contract,,,78,,28.08,percent of total billed charges,,,70,,25.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.64,3324,
OSTOMY TWO PIECE STANDARD POUCH 2 1/4 RED,0270,RC,,,,inpatient,,,36,21.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.6,percent of total billed charges,,,85,,30.6,percent of total billed charges,,,49,,17.64,percent of total billed charges,,,90,,32.4,percent of total billed charges,,,,,,,no IP contract,,80,,28.8,percent of total billed charges,,,,,,,no IP contract,,50,,18,percent of total billed charges,,,,,,no IP contract,,,78,,28.08,percent of total billed charges,,,70,,25.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.64,3324,
OSTOMY TWO PIECE STANDARD POUCH 2 3/4 BLUE,0270,RC,,,,inpatient,,,36,21.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.6,percent of total billed charges,,,85,,30.6,percent of total billed charges,,,49,,17.64,percent of total billed charges,,,90,,32.4,percent of total billed charges,,,,,,,no IP contract,,80,,28.8,percent of total billed charges,,,,,,,no IP contract,,50,,18,percent of total billed charges,,,,,,no IP contract,,,78,,28.08,percent of total billed charges,,,70,,25.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.64,3324,
OSTOMY WAFER FLAT TWO PIECE 2 3/4 IN BLUE,0270,RC,,,,inpatient,,,36,21.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.6,percent of total billed charges,,,85,,30.6,percent of total billed charges,,,49,,17.64,percent of total billed charges,,,90,,32.4,percent of total billed charges,,,,,,,no IP contract,,80,,28.8,percent of total billed charges,,,,,,,no IP contract,,50,,18,percent of total billed charges,,,,,,no IP contract,,,78,,28.08,percent of total billed charges,,,70,,25.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.64,3324,
TRACH DCP #6,0270,RC,,,,inpatient,,,37,22.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.45,percent of total billed charges,,,85,,31.45,percent of total billed charges,,,49,,18.13,percent of total billed charges,,,90,,33.3,percent of total billed charges,,,,,,,no IP contract,,80,,29.6,percent of total billed charges,,,,,,,no IP contract,,50,,18.5,percent of total billed charges,,,,,,no IP contract,,,78,,28.86,percent of total billed charges,,,70,,25.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.13,3324,
MEPILEX BORDER FLEX 4 X 4 FOAM,0270,RC,,,,inpatient,,,38,22.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.3,percent of total billed charges,,,85,,32.3,percent of total billed charges,,,49,,18.62,percent of total billed charges,,,90,,34.2,percent of total billed charges,,,,,,,no IP contract,,80,,30.4,percent of total billed charges,,,,,,,no IP contract,,50,,19,percent of total billed charges,,,,,,no IP contract,,,78,,29.64,percent of total billed charges,,,70,,26.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.62,3324,
SILVER CALCIUM AGINATE DRESSING 4X4.75,0270,RC,,,,inpatient,,,39,23.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.15,percent of total billed charges,,,85,,33.15,percent of total billed charges,,,49,,19.11,percent of total billed charges,,,90,,35.1,percent of total billed charges,,,,,,,no IP contract,,80,,31.2,percent of total billed charges,,,,,,,no IP contract,,50,,19.5,percent of total billed charges,,,,,,no IP contract,,,78,,30.42,percent of total billed charges,,,70,,27.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.11,3324,
TRACH DCP #4,0270,RC,,,,inpatient,,,40,24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34,percent of total billed charges,,,85,,34,percent of total billed charges,,,49,,19.6,percent of total billed charges,,,90,,36,percent of total billed charges,,,,,,,no IP contract,,80,,32,percent of total billed charges,,,,,,,no IP contract,,50,,20,percent of total billed charges,,,,,,no IP contract,,,78,,31.2,percent of total billed charges,,,70,,28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.6,3324,
XTRASORB SUPER ABSORBENT DRESSING 6 X 9 in,0270,RC,,,,inpatient,,,43,25.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36.55,percent of total billed charges,,,85,,36.55,percent of total billed charges,,,49,,21.07,percent of total billed charges,,,90,,38.7,percent of total billed charges,,,,,,,no IP contract,,80,,34.4,percent of total billed charges,,,,,,,no IP contract,,50,,21.5,percent of total billed charges,,,,,,no IP contract,,,78,,33.54,percent of total billed charges,,,70,,30.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.07,3324,
UROSTOMY POUCH 1 3/4 GREEN,0270,RC,,,,inpatient,,,46,27.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,37.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,39.1,percent of total billed charges,,,85,,39.1,percent of total billed charges,,,49,,22.54,percent of total billed charges,,,90,,41.4,percent of total billed charges,,,,,,,no IP contract,,80,,36.8,percent of total billed charges,,,,,,,no IP contract,,50,,23,percent of total billed charges,,,,,,no IP contract,,,78,,35.88,percent of total billed charges,,,70,,32.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.54,3324,
UROSTOMY POUCH 2 1/4 RED,0270,RC,,,,inpatient,,,46,27.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,37.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,39.1,percent of total billed charges,,,85,,39.1,percent of total billed charges,,,49,,22.54,percent of total billed charges,,,90,,41.4,percent of total billed charges,,,,,,,no IP contract,,80,,36.8,percent of total billed charges,,,,,,,no IP contract,,50,,23,percent of total billed charges,,,,,,no IP contract,,,78,,35.88,percent of total billed charges,,,70,,32.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.54,3324,
MEPILEX BORDER FLEX HEEL FOAM,0270,RC,,,,inpatient,,,47,28.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,38.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,39.95,percent of total billed charges,,,85,,39.95,percent of total billed charges,,,49,,23.03,percent of total billed charges,,,90,,42.3,percent of total billed charges,,,,,,,no IP contract,,80,,37.6,percent of total billed charges,,,,,,,no IP contract,,50,,23.5,percent of total billed charges,,,,,,no IP contract,,,78,,36.66,percent of total billed charges,,,70,,32.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.03,3324,
ENF NG TUBE 5FR FEEDING,0270,RC,,,,inpatient,,,48,28.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,38.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,40.8,percent of total billed charges,,,85,,40.8,percent of total billed charges,,,49,,23.52,percent of total billed charges,,,90,,43.2,percent of total billed charges,,,,,,,no IP contract,,80,,38.4,percent of total billed charges,,,,,,,no IP contract,,50,,24,percent of total billed charges,,,,,,no IP contract,,,78,,37.44,percent of total billed charges,,,70,,33.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.52,3324,
ENF NG TUBE 6.5FR FEEDING,0270,RC,,,,inpatient,,,48,28.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,38.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,40.8,percent of total billed charges,,,85,,40.8,percent of total billed charges,,,49,,23.52,percent of total billed charges,,,90,,43.2,percent of total billed charges,,,,,,,no IP contract,,80,,38.4,percent of total billed charges,,,,,,,no IP contract,,50,,24,percent of total billed charges,,,,,,no IP contract,,,78,,37.44,percent of total billed charges,,,70,,33.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.52,3324,
ENF NG TUBE 8FR FEEDING,0270,RC,,,,inpatient,,,48,28.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,38.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,40.8,percent of total billed charges,,,85,,40.8,percent of total billed charges,,,49,,23.52,percent of total billed charges,,,90,,43.2,percent of total billed charges,,,,,,,no IP contract,,80,,38.4,percent of total billed charges,,,,,,,no IP contract,,50,,24,percent of total billed charges,,,,,,no IP contract,,,78,,37.44,percent of total billed charges,,,70,,33.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.52,3324,
OSTOMY WAFER CONVEX TWO PIECE 2 1/4 GREEN,0270,RC,,,,inpatient,,,50,30,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,40.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,42.5,percent of total billed charges,,,85,,42.5,percent of total billed charges,,,49,,24.5,percent of total billed charges,,,90,,45,percent of total billed charges,,,,,,,no IP contract,,80,,40,percent of total billed charges,,,,,,,no IP contract,,50,,25,percent of total billed charges,,,,,,no IP contract,,,78,,39,percent of total billed charges,,,70,,35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.5,3324,
OSTOMY WAFER CONVEX TWO PIECE 2 3/4 BLUE,0270,RC,,,,inpatient,,,50,30,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,40.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,42.5,percent of total billed charges,,,85,,42.5,percent of total billed charges,,,49,,24.5,percent of total billed charges,,,90,,45,percent of total billed charges,,,,,,,no IP contract,,80,,40,percent of total billed charges,,,,,,,no IP contract,,50,,25,percent of total billed charges,,,,,,no IP contract,,,78,,39,percent of total billed charges,,,70,,35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.5,3324,
BANDAGE COMPRILAN 6 CM LYMPHEDEMA,0270,RC,,,,inpatient,,,51,30.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,41.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,43.35,percent of total billed charges,,,85,,43.35,percent of total billed charges,,,49,,24.99,percent of total billed charges,,,90,,45.9,percent of total billed charges,,,,,,,no IP contract,,80,,40.8,percent of total billed charges,,,,,,,no IP contract,,50,,25.5,percent of total billed charges,,,,,,no IP contract,,,78,,39.78,percent of total billed charges,,,70,,35.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,28748.186,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.99,28748.19,
DRESSING PROMOGRAN MATRIX 4.34SQ IN,0270,RC,,,,inpatient,,,55,33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,44.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,46.75,percent of total billed charges,,,85,,46.75,percent of total billed charges,,,49,,26.95,percent of total billed charges,,,90,,49.5,percent of total billed charges,,,,,,,no IP contract,,80,,44,percent of total billed charges,,,,,,,no IP contract,,50,,27.5,percent of total billed charges,,,,,,no IP contract,,,78,,42.9,percent of total billed charges,,,70,,38.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.95,3324,
OSTOMY FLAT ONE PIECE POUCHING SYTEM,0270,RC,,,,inpatient,,,56,33.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,45.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,47.6,percent of total billed charges,,,85,,47.6,percent of total billed charges,,,49,,27.44,percent of total billed charges,,,90,,50.4,percent of total billed charges,,,,,,,no IP contract,,80,,44.8,percent of total billed charges,,,,,,,no IP contract,,50,,28,percent of total billed charges,,,,,,no IP contract,,,78,,43.68,percent of total billed charges,,,70,,39.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.44,3324,
MEPILEX BORDER FLEX 6 X 6 FOAM,0270,RC,,,,inpatient,,,57,34.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,46.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,48.45,percent of total billed charges,,,85,,48.45,percent of total billed charges,,,49,,27.93,percent of total billed charges,,,90,,51.3,percent of total billed charges,,,,,,,no IP contract,,80,,45.6,percent of total billed charges,,,,,,,no IP contract,,50,,28.5,percent of total billed charges,,,,,,no IP contract,,,78,,44.46,percent of total billed charges,,,70,,39.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.93,3324,
NPWT WOUND VAC TRANSPARENT ADHESIVE FILM,0270,RC,,,,inpatient,,,58,34.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,46.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,49.3,percent of total billed charges,,,85,,49.3,percent of total billed charges,,,49,,28.42,percent of total billed charges,,,90,,52.2,percent of total billed charges,,,,,,,no IP contract,,80,,46.4,percent of total billed charges,,,,,,,no IP contract,,50,,29,percent of total billed charges,,,,,,no IP contract,,,78,,45.24,percent of total billed charges,,,70,,40.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,28.42,3324,
TRACH CARE 8 FRENCH PED ELBOW TRACH,0270,RC,,,,inpatient,,,58,34.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,46.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,49.3,percent of total billed charges,,,85,,49.3,percent of total billed charges,,,49,,28.42,percent of total billed charges,,,90,,52.2,percent of total billed charges,,,,,,,no IP contract,,80,,46.4,percent of total billed charges,,,,,,,no IP contract,,50,,29,percent of total billed charges,,,,,,no IP contract,,,78,,45.24,percent of total billed charges,,,70,,40.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,28.42,3324,
MEPILEX BORDER SACRUM SMALL FOAM,0270,RC,,,,inpatient,,,63,37.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,51.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,53.55,percent of total billed charges,,,85,,53.55,percent of total billed charges,,,49,,30.87,percent of total billed charges,,,90,,56.7,percent of total billed charges,,,,,,,no IP contract,,80,,50.4,percent of total billed charges,,,,,,,no IP contract,,50,,31.5,percent of total billed charges,,,,,,no IP contract,,,78,,49.14,percent of total billed charges,,,70,,44.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,30.87,3324,
MEPILEX TRANSFER NON ADHERENT FOAM 6X8 IN,0270,RC,,,,inpatient,,,63,37.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,51.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,53.55,percent of total billed charges,,,85,,53.55,percent of total billed charges,,,49,,30.87,percent of total billed charges,,,90,,56.7,percent of total billed charges,,,,,,,no IP contract,,80,,50.4,percent of total billed charges,,,,,,,no IP contract,,50,,31.5,percent of total billed charges,,,,,,no IP contract,,,78,,49.14,percent of total billed charges,,,70,,44.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,30.87,3324,
MEPILEX AG SILVER FOAM 4X4,0270,RC,,,,inpatient,,,67,40.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,54.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.95,percent of total billed charges,,,85,,56.95,percent of total billed charges,,,49,,32.83,percent of total billed charges,,,90,,60.3,percent of total billed charges,,,,,,,no IP contract,,80,,53.6,percent of total billed charges,,,,,,,no IP contract,,50,,33.5,percent of total billed charges,,,,,,no IP contract,,,78,,52.26,percent of total billed charges,,,70,,46.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.83,3324,
MEDIHONEY GEL 1.5 TUBE,0270,RC,,,,inpatient,,,75,45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63.75,percent of total billed charges,,,85,,63.75,percent of total billed charges,,,49,,36.75,percent of total billed charges,,,90,,67.5,percent of total billed charges,,,,,,,no IP contract,,80,,60,percent of total billed charges,,,,,,,no IP contract,,50,,37.5,percent of total billed charges,,,,,,no IP contract,,,78,,58.5,percent of total billed charges,,,70,,52.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.75,3324,
MEDIHONEY HCS HONEYCOLLOID ADHESIVE DRESSING 4.5X4.5,0270,RC,,,,inpatient,,,75,45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63.75,percent of total billed charges,,,85,,63.75,percent of total billed charges,,,49,,36.75,percent of total billed charges,,,90,,67.5,percent of total billed charges,,,,,,,no IP contract,,80,,60,percent of total billed charges,,,,,,,no IP contract,,50,,37.5,percent of total billed charges,,,,,,no IP contract,,,78,,58.5,percent of total billed charges,,,70,,52.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.75,3324,
ENF NG TUBE 10FR FEEDING,0270,RC,,,,inpatient,,,78,46.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,63.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,66.3,percent of total billed charges,,,85,,66.3,percent of total billed charges,,,49,,38.22,percent of total billed charges,,,90,,70.2,percent of total billed charges,,,,,,,no IP contract,,80,,62.4,percent of total billed charges,,,,,,,no IP contract,,50,,39,percent of total billed charges,,,,,,no IP contract,,,78,,60.84,percent of total billed charges,,,70,,54.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,38.22,3324,
MEDIHONEY CALCIUM ALGINATE DRESSING 4 X 5 in,0270,RC,,,,inpatient,,,80,48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,64.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,68,percent of total billed charges,,,85,,68,percent of total billed charges,,,49,,39.2,percent of total billed charges,,,90,,72,percent of total billed charges,,,,,,,no IP contract,,80,,64,percent of total billed charges,,,,,,,no IP contract,,50,,40,percent of total billed charges,,,,,,no IP contract,,,78,,62.4,percent of total billed charges,,,70,,56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,39.2,3324,
BANDAGE COMPRILAN 10CM LYMPHEDEMA,0270,RC,,,,inpatient,,,83,49.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,67.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,70.55,percent of total billed charges,,,85,,70.55,percent of total billed charges,,,49,,40.67,percent of total billed charges,,,90,,74.7,percent of total billed charges,,,,,,,no IP contract,,80,,66.4,percent of total billed charges,,,,,,,no IP contract,,50,,41.5,percent of total billed charges,,,,,,no IP contract,,,78,,64.74,percent of total billed charges,,,70,,58.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,42206.3175,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,40.67,42206.32,
OSTOMY TWO PIECE HIGH OUTPUT POUCH 2 3/4 BLUE,0270,RC,,,,inpatient,,,85,51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,68.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,72.25,percent of total billed charges,,,85,,72.25,percent of total billed charges,,,49,,41.65,percent of total billed charges,,,90,,76.5,percent of total billed charges,,,,,,,no IP contract,,80,,68,percent of total billed charges,,,,,,,no IP contract,,50,,42.5,percent of total billed charges,,,,,,no IP contract,,,78,,66.3,percent of total billed charges,,,70,,59.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,41.65,3324,
OSTOMY TWO PIECE HIGH OUPUT POUCH 1 3/4 GREEN,0270,RC,,,,inpatient,,,87,52.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,70.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,73.95,percent of total billed charges,,,85,,73.95,percent of total billed charges,,,49,,42.63,percent of total billed charges,,,90,,78.3,percent of total billed charges,,,,,,,no IP contract,,80,,69.6,percent of total billed charges,,,,,,,no IP contract,,50,,43.5,percent of total billed charges,,,,,,no IP contract,,,78,,67.86,percent of total billed charges,,,70,,60.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,42.63,3324,
OSTOMY BARRIER RING,0270,RC,,,,inpatient,,,90,54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,72.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,76.5,percent of total billed charges,,,85,,76.5,percent of total billed charges,,,49,,44.1,percent of total billed charges,,,90,,81,percent of total billed charges,,,,,,,no IP contract,,80,,72,percent of total billed charges,,,,,,,no IP contract,,50,,45,percent of total billed charges,,,,,,no IP contract,,,78,,70.2,percent of total billed charges,,,70,,63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,44.1,3324,
BANDAGE COMPRILAN 12CM LYMPHEDEMA,0270,RC,,,,inpatient,,,101,60.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,81.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,85.85,percent of total billed charges,,,85,,85.85,percent of total billed charges,,,49,,49.49,percent of total billed charges,,,90,,90.9,percent of total billed charges,,,,,,,no IP contract,,80,,80.8,percent of total billed charges,,,,,,,no IP contract,,50,,50.5,percent of total billed charges,,,,,,no IP contract,,,78,,78.78,percent of total billed charges,,,70,,70.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,49.49,3324,
MEPILEX BORDER SACRUM REGULAR FOAM,0270,RC,,,,inpatient,,,102,61.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,82.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,86.7,percent of total billed charges,,,85,,86.7,percent of total billed charges,,,49,,49.98,percent of total billed charges,,,90,,91.8,percent of total billed charges,,,,,,,no IP contract,,80,,81.6,percent of total billed charges,,,,,,,no IP contract,,50,,51,percent of total billed charges,,,,,,no IP contract,,,78,,79.56,percent of total billed charges,,,70,,71.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,49.98,3324,
PEAK FLOW METER,0270,RC,,,,inpatient,,,122,73.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,98.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,103.7,percent of total billed charges,,,85,,103.7,percent of total billed charges,,,49,,59.78,percent of total billed charges,,,90,,109.8,percent of total billed charges,,,,,,,no IP contract,,80,,97.6,percent of total billed charges,,,,,,,no IP contract,,50,,61,percent of total billed charges,,,,,,no IP contract,,,78,,95.16,percent of total billed charges,,,70,,85.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,59.78,3324,
Oxygen Therapy Charge,0270,RC,,,,inpatient,,,149,89.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,120.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,126.65,percent of total billed charges,,,85,,126.65,percent of total billed charges,,,49,,73.01,percent of total billed charges,,,90,,134.1,percent of total billed charges,,,,,,,no IP contract,,80,,119.2,percent of total billed charges,,,,,,,no IP contract,,50,,74.5,percent of total billed charges,,,,,,no IP contract,,,78,,116.22,percent of total billed charges,,,70,,104.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,73.01,3324,
Oxygen Therapy Charge,0270,RC,,,,inpatient,,,149,89.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,120.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,126.65,percent of total billed charges,,,85,,126.65,percent of total billed charges,,,49,,73.01,percent of total billed charges,,,90,,134.1,percent of total billed charges,,,,,,,no IP contract,,80,,119.2,percent of total billed charges,,,,,,,no IP contract,,50,,74.5,percent of total billed charges,,,,,,no IP contract,,,78,,116.22,percent of total billed charges,,,70,,104.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,73.01,3324,
ENF ADJUST GTUBE 12FR,0270,RC,,,,inpatient,,,153,91.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,123.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,130.05,percent of total billed charges,,,85,,130.05,percent of total billed charges,,,49,,74.97,percent of total billed charges,,,90,,137.7,percent of total billed charges,,,,,,,no IP contract,,80,,122.4,percent of total billed charges,,,,,,,no IP contract,,50,,76.5,percent of total billed charges,,,,,,no IP contract,,,78,,119.34,percent of total billed charges,,,70,,107.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,74.97,3324,
High Humidity Trach Collar Charge-Equipment,0270,RC,,,,inpatient,,,172,103.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,139.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,146.2,percent of total billed charges,,,85,,146.2,percent of total billed charges,,,49,,84.28,percent of total billed charges,,,90,,154.8,percent of total billed charges,,,,,,,no IP contract,,80,,137.6,percent of total billed charges,,,,,,,no IP contract,,50,,86,percent of total billed charges,,,,,,no IP contract,,,78,,134.16,percent of total billed charges,,,70,,120.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,84.28,3324,
AVOGEL HYDROGEL SCAR SHEET 8X8,0270,RC,,,,inpatient,,,189,113.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,153.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,160.65,percent of total billed charges,,,85,,160.65,percent of total billed charges,,,49,,92.61,percent of total billed charges,,,90,,170.1,percent of total billed charges,,,,,,,no IP contract,,80,,151.2,percent of total billed charges,,,,,,,no IP contract,,50,,94.5,percent of total billed charges,,,,,,no IP contract,,,78,,147.42,percent of total billed charges,,,70,,132.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,26751.2925,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,92.61,26751.29,
EMST150,0270,RC,,,,inpatient,,,226,135.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,183.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,192.1,percent of total billed charges,,,85,,192.1,percent of total billed charges,,,49,,110.74,percent of total billed charges,,,90,,203.4,percent of total billed charges,,,,,,,no IP contract,,80,,180.8,percent of total billed charges,,,,,,,no IP contract,,50,,113,percent of total billed charges,,,,,,no IP contract,,,78,,176.28,percent of total billed charges,,,70,,158.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,110.74,3324,
TUBE GAST BALLOON MIC 20F,0270,RC,,,,inpatient,,,234,140.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,189.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,198.9,percent of total billed charges,,,85,,198.9,percent of total billed charges,,,49,,114.66,percent of total billed charges,,,90,,210.6,percent of total billed charges,,,,,,,no IP contract,,80,,187.2,percent of total billed charges,,,,,,,no IP contract,,50,,117,percent of total billed charges,,,,,,no IP contract,,,78,,182.52,percent of total billed charges,,,70,,163.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,114.66,3324,
MEPILEX AG SILVER FOAM 8X8,0270,RC,,,,inpatient,,,246,147.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,199.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,209.1,percent of total billed charges,,,85,,209.1,percent of total billed charges,,,49,,120.54,percent of total billed charges,,,90,,221.4,percent of total billed charges,,,,,,,no IP contract,,80,,196.8,percent of total billed charges,,,,,,,no IP contract,,50,,123,percent of total billed charges,,,,,,no IP contract,,,78,,191.88,percent of total billed charges,,,70,,172.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,120.54,3324,
TRACH TUBE # 3.0 PED,0270,RC,,,,inpatient,,,255,153,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,206.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,216.75,percent of total billed charges,,,85,,216.75,percent of total billed charges,,,49,,124.95,percent of total billed charges,,,90,,229.5,percent of total billed charges,,,,,,,no IP contract,,80,,204,percent of total billed charges,,,,,,,no IP contract,,50,,127.5,percent of total billed charges,,,,,,no IP contract,,,78,,198.9,percent of total billed charges,,,70,,178.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,124.95,3324,
TUBE GAST BALLOON MIC 12FR 5CC,0270,RC,,,,inpatient,,,258,154.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,208.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,219.3,percent of total billed charges,,,85,,219.3,percent of total billed charges,,,49,,126.42,percent of total billed charges,,,90,,232.2,percent of total billed charges,,,,,,,no IP contract,,80,,206.4,percent of total billed charges,,,,,,,no IP contract,,50,,129,percent of total billed charges,,,,,,no IP contract,,,78,,201.24,percent of total billed charges,,,70,,180.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,126.42,3324,
TUBE GAST BALLOON MIC 14FR 20CC,0270,RC,,,,inpatient,,,258,154.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,208.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,219.3,percent of total billed charges,,,85,,219.3,percent of total billed charges,,,49,,126.42,percent of total billed charges,,,90,,232.2,percent of total billed charges,,,,,,,no IP contract,,80,,206.4,percent of total billed charges,,,,,,,no IP contract,,50,,129,percent of total billed charges,,,,,,no IP contract,,,78,,201.24,percent of total billed charges,,,70,,180.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,126.42,3324,
TRACH TUBE # 5.5 PED,0270,RC,,,,inpatient,,,261,156.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,211.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,221.85,percent of total billed charges,,,85,,221.85,percent of total billed charges,,,49,,127.89,percent of total billed charges,,,90,,234.9,percent of total billed charges,,,,,,,no IP contract,,80,,208.8,percent of total billed charges,,,,,,,no IP contract,,50,,130.5,percent of total billed charges,,,,,,no IP contract,,,78,,203.58,percent of total billed charges,,,70,,182.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,127.89,3324,
TRACH 5.5 PDL,0270,RC,,,,inpatient,,,266,159.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,215.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,226.1,percent of total billed charges,,,85,,226.1,percent of total billed charges,,,49,,130.34,percent of total billed charges,,,90,,239.4,percent of total billed charges,,,,,,,no IP contract,,80,,212.8,percent of total billed charges,,,,,,,no IP contract,,50,,133,percent of total billed charges,,,,,,no IP contract,,,78,,207.48,percent of total billed charges,,,70,,186.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,130.34,3324,
TRACH TUBE # 5.0 PED,0270,RC,,,,inpatient,,,285,171,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,230.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,242.25,percent of total billed charges,,,85,,242.25,percent of total billed charges,,,49,,139.65,percent of total billed charges,,,90,,256.5,percent of total billed charges,,,,,,,no IP contract,,80,,228,percent of total billed charges,,,,,,,no IP contract,,50,,142.5,percent of total billed charges,,,,,,no IP contract,,,78,,222.3,percent of total billed charges,,,70,,199.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,139.65,3324,
"SLING, GIVMOHR; EXTRA LARGE",0270,RC,,,,inpatient,,,289,173.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,234.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,245.65,percent of total billed charges,,,85,,245.65,percent of total billed charges,,,49,,141.61,percent of total billed charges,,,90,,260.1,percent of total billed charges,,,,,,,no IP contract,,80,,231.2,percent of total billed charges,,,,,,,no IP contract,,50,,144.5,percent of total billed charges,,,,,,no IP contract,,,78,,225.42,percent of total billed charges,,,70,,202.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,141.61,3324,
TUBE GAST BALLOON MIC 16FR 20CC,0270,RC,,,,inpatient,,,298,178.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,241.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,253.3,percent of total billed charges,,,85,,253.3,percent of total billed charges,,,49,,146.02,percent of total billed charges,,,90,,268.2,percent of total billed charges,,,,,,,no IP contract,,80,,238.4,percent of total billed charges,,,,,,,no IP contract,,50,,149,percent of total billed charges,,,,,,no IP contract,,,78,,232.44,percent of total billed charges,,,70,,208.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,146.02,3324,
TRACH CFS #8,0270,RC,,,,inpatient,,,329,197.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,266.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,279.65,percent of total billed charges,,,85,,279.65,percent of total billed charges,,,49,,161.21,percent of total billed charges,,,90,,296.1,percent of total billed charges,,,,,,,no IP contract,,80,,263.2,percent of total billed charges,,,,,,,no IP contract,,50,,164.5,percent of total billed charges,,,,,,no IP contract,,,78,,256.62,percent of total billed charges,,,70,,230.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,161.21,3324,
TRACH TUBE CFS # 4,0270,RC,,,,inpatient,,,329,197.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,266.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,279.65,percent of total billed charges,,,85,,279.65,percent of total billed charges,,,49,,161.21,percent of total billed charges,,,90,,296.1,percent of total billed charges,,,,,,,no IP contract,,80,,263.2,percent of total billed charges,,,,,,,no IP contract,,50,,164.5,percent of total billed charges,,,,,,no IP contract,,,78,,256.62,percent of total billed charges,,,70,,230.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,161.21,3324,
TUBE GAST BALLOON MIC 18FR 20CC,0270,RC,,,,inpatient,,,353,211.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,285.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,300.05,percent of total billed charges,,,85,,300.05,percent of total billed charges,,,49,,172.97,percent of total billed charges,,,90,,317.7,percent of total billed charges,,,,,,,no IP contract,,80,,282.4,percent of total billed charges,,,,,,,no IP contract,,50,,176.5,percent of total billed charges,,,,,,no IP contract,,,78,,275.34,percent of total billed charges,,,70,,247.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,172.97,3324,
TRACH DCT #8,0270,RC,,,,inpatient,,,363,217.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,294.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,308.55,percent of total billed charges,,,85,,308.55,percent of total billed charges,,,49,,177.87,percent of total billed charges,,,90,,326.7,percent of total billed charges,,,,,,,no IP contract,,80,,290.4,percent of total billed charges,,,,,,,no IP contract,,50,,181.5,percent of total billed charges,,,,,,no IP contract,,,78,,283.14,percent of total billed charges,,,70,,254.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,177.87,3324,
TRACH DCT #6,0270,RC,,,,inpatient,,,379,227.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,306.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,322.15,percent of total billed charges,,,85,,322.15,percent of total billed charges,,,49,,185.71,percent of total billed charges,,,90,,341.1,percent of total billed charges,,,,,,,no IP contract,,80,,303.2,percent of total billed charges,,,,,,,no IP contract,,50,,189.5,percent of total billed charges,,,,,,no IP contract,,,78,,295.62,percent of total billed charges,,,70,,265.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,185.71,3324,
TRACH TUBE LPC # 4,0270,RC,,,,inpatient,,,381,228.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,308.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,323.85,percent of total billed charges,,,85,,323.85,percent of total billed charges,,,49,,186.69,percent of total billed charges,,,90,,342.9,percent of total billed charges,,,,,,,no IP contract,,80,,304.8,percent of total billed charges,,,,,,,no IP contract,,50,,190.5,percent of total billed charges,,,,,,no IP contract,,,78,,297.18,percent of total billed charges,,,70,,266.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,186.69,3324,
SLING GIVMOHR SMALL,0270,RC,,,,inpatient,,,395,237,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,319.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,335.75,percent of total billed charges,,,85,,335.75,percent of total billed charges,,,49,,193.55,percent of total billed charges,,,90,,355.5,percent of total billed charges,,,,,,,no IP contract,,80,,316,percent of total billed charges,,,,,,,no IP contract,,50,,197.5,percent of total billed charges,,,,,,no IP contract,,,78,,308.1,percent of total billed charges,,,70,,276.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,193.55,3324,
PLUG CLOSURE FLANGE 10MM,0270,RC,,,,inpatient,,,410,246,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,332.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,348.5,percent of total billed charges,,,85,,348.5,percent of total billed charges,,,49,,200.9,percent of total billed charges,,,90,,369,percent of total billed charges,,,,,,,no IP contract,,80,,328,percent of total billed charges,,,,,,,no IP contract,,50,,205,percent of total billed charges,,,,,,no IP contract,,,78,,319.8,percent of total billed charges,,,70,,287,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,200.9,3324,
PLUG CLOSURE FLANGE 12MM,0270,RC,,,,inpatient,,,410,246,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,332.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,348.5,percent of total billed charges,,,85,,348.5,percent of total billed charges,,,49,,200.9,percent of total billed charges,,,90,,369,percent of total billed charges,,,,,,,no IP contract,,80,,328,percent of total billed charges,,,,,,,no IP contract,,50,,205,percent of total billed charges,,,,,,no IP contract,,,78,,319.8,percent of total billed charges,,,70,,287,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,200.9,3324,
TRACH TUBE CUFFLESS # 7 BIVONA,0270,RC,,,,inpatient,,,426,255.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,345.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,362.1,percent of total billed charges,,,85,,362.1,percent of total billed charges,,,49,,208.74,percent of total billed charges,,,90,,383.4,percent of total billed charges,,,,,,,no IP contract,,80,,340.8,percent of total billed charges,,,,,,,no IP contract,,50,,213,percent of total billed charges,,,,,,no IP contract,,,78,,332.28,percent of total billed charges,,,70,,298.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,208.74,3324,
TRACH TUBE CUFFLESS # 8 BIVONA,0270,RC,,,,inpatient,,,426,255.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,345.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,362.1,percent of total billed charges,,,85,,362.1,percent of total billed charges,,,49,,208.74,percent of total billed charges,,,90,,383.4,percent of total billed charges,,,,,,,no IP contract,,80,,340.8,percent of total billed charges,,,,,,,no IP contract,,50,,213,percent of total billed charges,,,,,,no IP contract,,,78,,332.28,percent of total billed charges,,,70,,298.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,208.74,3324,
TRACH TUBE CUFFLESS # 6 BIVONA,0270,RC,,,,inpatient,,,427,256.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,345.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,362.95,percent of total billed charges,,,85,,362.95,percent of total billed charges,,,49,,209.23,percent of total billed charges,,,90,,384.3,percent of total billed charges,,,,,,,no IP contract,,80,,341.6,percent of total billed charges,,,,,,,no IP contract,,50,,213.5,percent of total billed charges,,,,,,no IP contract,,,78,,333.06,percent of total billed charges,,,70,,298.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,209.23,3324,
PASSY MUIR VALVE CLEAR SPEAKING,0270,RC,,,,inpatient,,,438,262.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,354.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,372.3,percent of total billed charges,,,85,,372.3,percent of total billed charges,,,49,,214.62,percent of total billed charges,,,90,,394.2,percent of total billed charges,,,,,,,no IP contract,,80,,350.4,percent of total billed charges,,,,,,,no IP contract,,50,,219,percent of total billed charges,,,,,,no IP contract,,,78,,341.64,percent of total billed charges,,,70,,306.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,214.62,3324,
TRACH TUBE TTS # 8 BIVONA,0270,RC,,,,inpatient,,,438,262.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,354.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,372.3,percent of total billed charges,,,85,,372.3,percent of total billed charges,,,49,,214.62,percent of total billed charges,,,90,,394.2,percent of total billed charges,,,,,,,no IP contract,,80,,350.4,percent of total billed charges,,,,,,,no IP contract,,50,,219,percent of total billed charges,,,,,,no IP contract,,,78,,341.64,percent of total billed charges,,,70,,306.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,214.62,3324,
TRACH TUBE CUFFLESS PEDS # 4.0,0270,RC,,,,inpatient,,,498,298.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,403.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,423.3,percent of total billed charges,,,85,,423.3,percent of total billed charges,,,49,,244.02,percent of total billed charges,,,90,,448.2,percent of total billed charges,,,,,,,no IP contract,,80,,398.4,percent of total billed charges,,,,,,,no IP contract,,50,,249,percent of total billed charges,,,,,,no IP contract,,,78,,388.44,percent of total billed charges,,,70,,348.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,244.02,3324,
TRACH TUBE CUFFLESS # 5 BIVONA,0270,RC,,,,inpatient,,,506,303.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,409.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,430.1,percent of total billed charges,,,85,,430.1,percent of total billed charges,,,49,,247.94,percent of total billed charges,,,90,,455.4,percent of total billed charges,,,,,,,no IP contract,,80,,404.8,percent of total billed charges,,,,,,,no IP contract,,50,,253,percent of total billed charges,,,,,,no IP contract,,,78,,394.68,percent of total billed charges,,,70,,354.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,247.94,3324,
TRACH TUBE CUFFLESS # 9 BIVONA,0270,RC,,,,inpatient,,,506,303.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,409.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,430.1,percent of total billed charges,,,85,,430.1,percent of total billed charges,,,49,,247.94,percent of total billed charges,,,90,,455.4,percent of total billed charges,,,,,,,no IP contract,,80,,404.8,percent of total billed charges,,,,,,,no IP contract,,50,,253,percent of total billed charges,,,,,,no IP contract,,,78,,394.68,percent of total billed charges,,,70,,354.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,247.94,3324,
TRACH TUBE TTS # 9.0 BIVONA,0270,RC,,,,inpatient,,,547,328.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,443.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,464.95,percent of total billed charges,,,85,,464.95,percent of total billed charges,,,49,,268.03,percent of total billed charges,,,90,,492.3,percent of total billed charges,,,,,,,no IP contract,,80,,437.6,percent of total billed charges,,,,,,,no IP contract,,50,,273.5,percent of total billed charges,,,,,,no IP contract,,,78,,426.66,percent of total billed charges,,,70,,382.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,268.03,3324,
TRACH TUBE TTS # 6 BIVONA,0270,RC,,,,inpatient,,,579,347.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,468.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,492.15,percent of total billed charges,,,85,,492.15,percent of total billed charges,,,49,,283.71,percent of total billed charges,,,90,,521.1,percent of total billed charges,,,,,,,no IP contract,,80,,463.2,percent of total billed charges,,,,,,,no IP contract,,50,,289.5,percent of total billed charges,,,,,,no IP contract,,,78,,451.62,percent of total billed charges,,,70,,405.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,283.71,3324,
TRACH TUBE TTS # 7 BIVONA,0270,RC,,,,inpatient,,,579,347.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,468.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,492.15,percent of total billed charges,,,85,,492.15,percent of total billed charges,,,49,,283.71,percent of total billed charges,,,90,,521.1,percent of total billed charges,,,,,,,no IP contract,,80,,463.2,percent of total billed charges,,,,,,,no IP contract,,50,,289.5,percent of total billed charges,,,,,,no IP contract,,,78,,451.62,percent of total billed charges,,,70,,405.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,283.71,3324,
TRACH TUBE TTS # 7.5 BIVONA,0270,RC,,,,inpatient,,,579,347.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,468.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,492.15,percent of total billed charges,,,85,,492.15,percent of total billed charges,,,49,,283.71,percent of total billed charges,,,90,,521.1,percent of total billed charges,,,,,,,no IP contract,,80,,463.2,percent of total billed charges,,,,,,,no IP contract,,50,,289.5,percent of total billed charges,,,,,,no IP contract,,,78,,451.62,percent of total billed charges,,,70,,405.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,283.71,3324,
ENFMINIONE 12FR 1.5CM,0270,RC,,,,inpatient,,,620,372,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,502.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,527,percent of total billed charges,,,85,,527,percent of total billed charges,,,49,,303.8,percent of total billed charges,,,90,,558,percent of total billed charges,,,,,,,no IP contract,,80,,496,percent of total billed charges,,,,,,,no IP contract,,50,,310,percent of total billed charges,,,,,,no IP contract,,,78,,483.6,percent of total billed charges,,,70,,434,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,303.8,3324,
ENFMINIONE 14FR 2.5CM,0270,RC,,,,inpatient,,,620,372,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,502.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,527,percent of total billed charges,,,85,,527,percent of total billed charges,,,49,,303.8,percent of total billed charges,,,90,,558,percent of total billed charges,,,,,,,no IP contract,,80,,496,percent of total billed charges,,,,,,,no IP contract,,50,,310,percent of total billed charges,,,,,,no IP contract,,,78,,483.6,percent of total billed charges,,,70,,434,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,303.8,3324,
ENFMINIONE 14FR 2CM,0270,RC,,,,inpatient,,,620,372,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,502.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,527,percent of total billed charges,,,85,,527,percent of total billed charges,,,49,,303.8,percent of total billed charges,,,90,,558,percent of total billed charges,,,,,,,no IP contract,,80,,496,percent of total billed charges,,,,,,,no IP contract,,50,,310,percent of total billed charges,,,,,,no IP contract,,,78,,483.6,percent of total billed charges,,,70,,434,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,303.8,3324,
ENFMINIONE 16FR 3CM,0270,RC,,,,inpatient,,,662,397.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,536.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,562.7,percent of total billed charges,,,85,,562.7,percent of total billed charges,,,49,,324.38,percent of total billed charges,,,90,,595.8,percent of total billed charges,,,,,,,no IP contract,,80,,529.6,percent of total billed charges,,,,,,,no IP contract,,50,,331,percent of total billed charges,,,,,,no IP contract,,,78,,516.36,percent of total billed charges,,,70,,463.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,324.38,3324,
TRACH TUBE TTS # 8.5 BIVONA,0270,RC,,,,inpatient,,,672,403.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,544.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,571.2,percent of total billed charges,,,85,,571.2,percent of total billed charges,,,49,,329.28,percent of total billed charges,,,90,,604.8,percent of total billed charges,,,,,,,no IP contract,,80,,537.6,percent of total billed charges,,,,,,,no IP contract,,50,,336,percent of total billed charges,,,,,,no IP contract,,,78,,524.16,percent of total billed charges,,,70,,470.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,329.28,3324,
"TRACH,FLEX-END PED 4.0 TTS",0270,RC,,,,inpatient,,,820,492,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,664.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,697,percent of total billed charges,,,85,,697,percent of total billed charges,,,49,,401.8,percent of total billed charges,,,90,,738,percent of total billed charges,,,,,,,no IP contract,,80,,656,percent of total billed charges,,,,,,,no IP contract,,50,,410,percent of total billed charges,,,,,,no IP contract,,,78,,639.6,percent of total billed charges,,,70,,574,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,401.8,3324,
"TRACH,FLEX-END PED 4.5 TTS",0270,RC,,,,inpatient,,,820,492,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,664.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,697,percent of total billed charges,,,85,,697,percent of total billed charges,,,49,,401.8,percent of total billed charges,,,90,,738,percent of total billed charges,,,,,,,no IP contract,,80,,656,percent of total billed charges,,,,,,,no IP contract,,50,,410,percent of total billed charges,,,,,,no IP contract,,,78,,639.6,percent of total billed charges,,,70,,574,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,401.8,3324,
"TRACH,FLEX-END PED 5.0 TTS",0270,RC,,,,inpatient,,,820,492,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,664.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,697,percent of total billed charges,,,85,,697,percent of total billed charges,,,49,,401.8,percent of total billed charges,,,90,,738,percent of total billed charges,,,,,,,no IP contract,,80,,656,percent of total billed charges,,,,,,,no IP contract,,50,,410,percent of total billed charges,,,,,,no IP contract,,,78,,639.6,percent of total billed charges,,,70,,574,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,401.8,3324,
"TRACH,FLEX-END PED 5.5 TTS",0270,RC,,,,inpatient,,,820,492,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,664.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,697,percent of total billed charges,,,85,,697,percent of total billed charges,,,49,,401.8,percent of total billed charges,,,90,,738,percent of total billed charges,,,,,,,no IP contract,,80,,656,percent of total billed charges,,,,,,,no IP contract,,50,,410,percent of total billed charges,,,,,,no IP contract,,,78,,639.6,percent of total billed charges,,,70,,574,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,401.8,3324,
TRACH TUBE FLEXTEND CUFFLESS PEDS # 5.0,0270,RC,,,,inpatient,,,1171,702.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,948.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,995.35,percent of total billed charges,,,85,,995.35,percent of total billed charges,,,49,,573.79,percent of total billed charges,,,90,,1053.9,percent of total billed charges,,,,,,,no IP contract,,80,,936.8,percent of total billed charges,,,,,,,no IP contract,,50,,585.5,percent of total billed charges,,,,,,no IP contract,,,78,,913.38,percent of total billed charges,,,70,,819.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,573.79,3324,
FLEXI SEAL SIGNAL FMS,0270,RC,,,,inpatient,,,1238,742.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1002.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1052.3,percent of total billed charges,,,85,,1052.3,percent of total billed charges,,,49,,606.62,percent of total billed charges,,,90,,1114.2,percent of total billed charges,,,,,,,no IP contract,,80,,990.4,percent of total billed charges,,,,,,,no IP contract,,50,,619,percent of total billed charges,,,,,,no IP contract,,,78,,965.64,percent of total billed charges,,,70,,866.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,606.62,3324,
TRACH CUFFED 5.0 TTS BIVONA,0270,RC,,,,inpatient,,,1567,940.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1269.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1331.95,percent of total billed charges,,,85,,1331.95,percent of total billed charges,,,49,,767.83,percent of total billed charges,,,90,,1410.3,percent of total billed charges,,,,,,,no IP contract,,80,,1253.6,percent of total billed charges,,,,,,,no IP contract,,50,,783.5,percent of total billed charges,,,,,,no IP contract,,,78,,1222.26,percent of total billed charges,,,70,,1096.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,767.83,3324,
ABSORBENT WOUND DRESSING 4X4,0272,RC,,,,inpatient,,,8,4.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.8,percent of total billed charges,,,85,,6.8,percent of total billed charges,,,49,,3.92,percent of total billed charges,,,90,,7.2,percent of total billed charges,,,,,,,no IP contract,,80,,6.4,percent of total billed charges,,,,,,,no IP contract,,50,,4,percent of total billed charges,,,,,,no IP contract,,,78,,6.24,percent of total billed charges,,,70,,5.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.92,3324,
ABSORBENT WOUND DRESSING 4X8,0272,RC,,,,inpatient,,,18,10.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.3,percent of total billed charges,,,85,,15.3,percent of total billed charges,,,49,,8.82,percent of total billed charges,,,90,,16.2,percent of total billed charges,,,,,,,no IP contract,,80,,14.4,percent of total billed charges,,,,,,,no IP contract,,50,,9,percent of total billed charges,,,,,,no IP contract,,,78,,14.04,percent of total billed charges,,,70,,12.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.82,3324,
DRESSING DRAWTEX NON-AHD HYDRO 4X4,0272,RC,,,,inpatient,,,30,18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.5,percent of total billed charges,,,85,,25.5,percent of total billed charges,,,49,,14.7,percent of total billed charges,,,90,,27,percent of total billed charges,,,,,,,no IP contract,,80,,24,percent of total billed charges,,,,,,,no IP contract,,50,,15,percent of total billed charges,,,,,,no IP contract,,,78,,23.4,percent of total billed charges,,,70,,21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.7,3324,
HYDROGEL IMPREGNATEED GAUZE PAD 4X4,0272,RC,,,,inpatient,,,34,20.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.9,percent of total billed charges,,,85,,28.9,percent of total billed charges,,,49,,16.66,percent of total billed charges,,,90,,30.6,percent of total billed charges,,,,,,,no IP contract,,80,,27.2,percent of total billed charges,,,,,,,no IP contract,,50,,17,percent of total billed charges,,,,,,no IP contract,,,78,,26.52,percent of total billed charges,,,70,,23.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.66,3324,
DIC 7.0MM XLONG TIN,0272,RC,,,,inpatient,,,38,22.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.3,percent of total billed charges,,,85,,32.3,percent of total billed charges,,,49,,18.62,percent of total billed charges,,,90,,34.2,percent of total billed charges,,,,,,,no IP contract,,80,,30.4,percent of total billed charges,,,,,,,no IP contract,,50,,19,percent of total billed charges,,,,,,no IP contract,,,78,,29.64,percent of total billed charges,,,70,,26.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.62,3324,
DIC 6.0MM XLONG TIN,0272,RC,,,,inpatient,,,40,24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34,percent of total billed charges,,,85,,34,percent of total billed charges,,,49,,19.6,percent of total billed charges,,,90,,36,percent of total billed charges,,,,,,,no IP contract,,80,,32,percent of total billed charges,,,,,,,no IP contract,,50,,20,percent of total billed charges,,,,,,no IP contract,,,78,,31.2,percent of total billed charges,,,70,,28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.6,3324,
DIC 8.0MM XLONG TIN,0272,RC,,,,inpatient,,,45,27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,38.25,percent of total billed charges,,,85,,38.25,percent of total billed charges,,,49,,22.05,percent of total billed charges,,,90,,40.5,percent of total billed charges,,,,,,,no IP contract,,80,,36,percent of total billed charges,,,,,,,no IP contract,,50,,22.5,percent of total billed charges,,,,,,no IP contract,,,78,,35.1,percent of total billed charges,,,70,,31.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.05,3324,
AQUACEL  HYDROFIBER DRESSING 6x6,0272,RC,,,,inpatient,,,50,30,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,40.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,42.5,percent of total billed charges,,,85,,42.5,percent of total billed charges,,,49,,24.5,percent of total billed charges,,,90,,45,percent of total billed charges,,,,,,,no IP contract,,80,,40,percent of total billed charges,,,,,,,no IP contract,,50,,25,percent of total billed charges,,,,,,no IP contract,,,78,,39,percent of total billed charges,,,70,,35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,24890.33,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.5,24890.33,
AQUACEL AG SILVER HYDROFIBER RIBBON ROPE 2CM,0272,RC,,,,inpatient,,,65,39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,52.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,55.25,percent of total billed charges,,,85,,55.25,percent of total billed charges,,,49,,31.85,percent of total billed charges,,,90,,58.5,percent of total billed charges,,,,,,,no IP contract,,80,,52,percent of total billed charges,,,,,,,no IP contract,,50,,32.5,percent of total billed charges,,,,,,no IP contract,,,78,,50.7,percent of total billed charges,,,70,,45.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.85,3324,
"TRACH, 10.0MM DISPOS INNER CANN-10EA",0272,RC,,,,inpatient,,,118,70.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,95.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,100.3,percent of total billed charges,,,85,,100.3,percent of total billed charges,,,49,,57.82,percent of total billed charges,,,90,,106.2,percent of total billed charges,,,,,,,no IP contract,,80,,94.4,percent of total billed charges,,,,,,,no IP contract,,50,,59,percent of total billed charges,,,,,,no IP contract,,,78,,92.04,percent of total billed charges,,,70,,82.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,57.82,3324,
"TRACH, 9.0MM DISPOS INNER CANN-10EA",0272,RC,,,,inpatient,,,118,70.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,95.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,100.3,percent of total billed charges,,,85,,100.3,percent of total billed charges,,,49,,57.82,percent of total billed charges,,,90,,106.2,percent of total billed charges,,,,,,,no IP contract,,80,,94.4,percent of total billed charges,,,,,,,no IP contract,,50,,59,percent of total billed charges,,,,,,no IP contract,,,78,,92.04,percent of total billed charges,,,70,,82.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,57.82,3324,
AQUACEL AG SILVER HYDROFIBER DRESSING 6x6,0272,RC,,,,inpatient,,,125,75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,101.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,106.25,percent of total billed charges,,,85,,106.25,percent of total billed charges,,,49,,61.25,percent of total billed charges,,,90,,112.5,percent of total billed charges,,,,,,,no IP contract,,80,,100,percent of total billed charges,,,,,,,no IP contract,,50,,62.5,percent of total billed charges,,,,,,no IP contract,,,78,,97.5,percent of total billed charges,,,70,,87.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,61.25,3324,
SHILEY FLEX 10 UNCUFFED 10UN10A,0272,RC,,,,inpatient,,,153,91.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,123.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,130.05,percent of total billed charges,,,85,,130.05,percent of total billed charges,,,49,,74.97,percent of total billed charges,,,90,,137.7,percent of total billed charges,,,,,,,no IP contract,,80,,122.4,percent of total billed charges,,,,,,,no IP contract,,50,,76.5,percent of total billed charges,,,,,,no IP contract,,,78,,119.34,percent of total billed charges,,,70,,107.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,74.97,3324,
SHILEY FLEX 4 UNCUFFED 4UN65A,0272,RC,,,,inpatient,,,153,91.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,123.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,130.05,percent of total billed charges,,,85,,130.05,percent of total billed charges,,,49,,74.97,percent of total billed charges,,,90,,137.7,percent of total billed charges,,,,,,,no IP contract,,80,,122.4,percent of total billed charges,,,,,,,no IP contract,,50,,76.5,percent of total billed charges,,,,,,no IP contract,,,78,,119.34,percent of total billed charges,,,70,,107.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,74.97,3324,
SHILEY FLEX 5 UNCUFFED 5UN70A,0272,RC,,,,inpatient,,,153,91.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,123.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,130.05,percent of total billed charges,,,85,,130.05,percent of total billed charges,,,49,,74.97,percent of total billed charges,,,90,,137.7,percent of total billed charges,,,,,,,no IP contract,,80,,122.4,percent of total billed charges,,,,,,,no IP contract,,50,,76.5,percent of total billed charges,,,,,,no IP contract,,,78,,119.34,percent of total billed charges,,,70,,107.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,74.97,3324,
SHILEY FLEX 6 UNCUFFED 6UN75A,0272,RC,,,,inpatient,,,153,91.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,123.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,130.05,percent of total billed charges,,,85,,130.05,percent of total billed charges,,,49,,74.97,percent of total billed charges,,,90,,137.7,percent of total billed charges,,,,,,,no IP contract,,80,,122.4,percent of total billed charges,,,,,,,no IP contract,,50,,76.5,percent of total billed charges,,,,,,no IP contract,,,78,,119.34,percent of total billed charges,,,70,,107.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,74.97,3324,
SHILEY FLEX 7 UNCUFFED 7UN80A,0272,RC,,,,inpatient,,,153,91.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,123.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,130.05,percent of total billed charges,,,85,,130.05,percent of total billed charges,,,49,,74.97,percent of total billed charges,,,90,,137.7,percent of total billed charges,,,,,,,no IP contract,,80,,122.4,percent of total billed charges,,,,,,,no IP contract,,50,,76.5,percent of total billed charges,,,,,,no IP contract,,,78,,119.34,percent of total billed charges,,,70,,107.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,74.97,3324,
SHILEY FLEX 8 UNCUFFED 8UN85A,0272,RC,,,,inpatient,,,153,91.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,123.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,130.05,percent of total billed charges,,,85,,130.05,percent of total billed charges,,,49,,74.97,percent of total billed charges,,,90,,137.7,percent of total billed charges,,,,,,,no IP contract,,80,,122.4,percent of total billed charges,,,,,,,no IP contract,,50,,76.5,percent of total billed charges,,,,,,no IP contract,,,78,,119.34,percent of total billed charges,,,70,,107.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,74.97,3324,
SHILEY FLEX 9 UNCUFFED 9UN90A,0272,RC,,,,inpatient,,,153,91.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,123.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,130.05,percent of total billed charges,,,85,,130.05,percent of total billed charges,,,49,,74.97,percent of total billed charges,,,90,,137.7,percent of total billed charges,,,,,,,no IP contract,,80,,122.4,percent of total billed charges,,,,,,,no IP contract,,50,,76.5,percent of total billed charges,,,,,,no IP contract,,,78,,119.34,percent of total billed charges,,,70,,107.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,74.97,3324,
EMST 75 LITE,0272,RC,,,,inpatient,,,160,96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,129.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,136,percent of total billed charges,,,85,,136,percent of total billed charges,,,49,,78.4,percent of total billed charges,,,90,,144,percent of total billed charges,,,,,,,no IP contract,,80,,128,percent of total billed charges,,,,,,,no IP contract,,50,,80,percent of total billed charges,,,,,,no IP contract,,,78,,124.8,percent of total billed charges,,,70,,112,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,78.4,3324,
SHILEY FLEX 10 CUFFED 10CN10A,0272,RC,,,,inpatient,,,167,100.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,135.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,141.95,percent of total billed charges,,,85,,141.95,percent of total billed charges,,,49,,81.83,percent of total billed charges,,,90,,150.3,percent of total billed charges,,,,,,,no IP contract,,80,,133.6,percent of total billed charges,,,,,,,no IP contract,,50,,83.5,percent of total billed charges,,,,,,no IP contract,,,78,,130.26,percent of total billed charges,,,70,,116.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,81.83,3324,
SHILEY FLEX 4 CUFFED 4CN65A,0272,RC,,,,inpatient,,,167,100.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,135.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,141.95,percent of total billed charges,,,85,,141.95,percent of total billed charges,,,49,,81.83,percent of total billed charges,,,90,,150.3,percent of total billed charges,,,,,,,no IP contract,,80,,133.6,percent of total billed charges,,,,,,,no IP contract,,50,,83.5,percent of total billed charges,,,,,,no IP contract,,,78,,130.26,percent of total billed charges,,,70,,116.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,81.83,3324,
SHILEY FLEX 5 CUFFED 5CN70A,0272,RC,,,,inpatient,,,167,100.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,135.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,141.95,percent of total billed charges,,,85,,141.95,percent of total billed charges,,,49,,81.83,percent of total billed charges,,,90,,150.3,percent of total billed charges,,,,,,,no IP contract,,80,,133.6,percent of total billed charges,,,,,,,no IP contract,,50,,83.5,percent of total billed charges,,,,,,no IP contract,,,78,,130.26,percent of total billed charges,,,70,,116.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,81.83,3324,
SHILEY FLEX 6 CUFFED 6CN75A,0272,RC,,,,inpatient,,,167,100.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,135.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,141.95,percent of total billed charges,,,85,,141.95,percent of total billed charges,,,49,,81.83,percent of total billed charges,,,90,,150.3,percent of total billed charges,,,,,,,no IP contract,,80,,133.6,percent of total billed charges,,,,,,,no IP contract,,50,,83.5,percent of total billed charges,,,,,,no IP contract,,,78,,130.26,percent of total billed charges,,,70,,116.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,81.83,3324,
SHILEY FLEX 7 CUFFED 7CN80A,0272,RC,,,,inpatient,,,167,100.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,135.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,141.95,percent of total billed charges,,,85,,141.95,percent of total billed charges,,,49,,81.83,percent of total billed charges,,,90,,150.3,percent of total billed charges,,,,,,,no IP contract,,80,,133.6,percent of total billed charges,,,,,,,no IP contract,,50,,83.5,percent of total billed charges,,,,,,no IP contract,,,78,,130.26,percent of total billed charges,,,70,,116.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,81.83,3324,
SHILEY FLEX 8 CUFFED 8CN85A,0272,RC,,,,inpatient,,,167,100.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,135.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,141.95,percent of total billed charges,,,85,,141.95,percent of total billed charges,,,49,,81.83,percent of total billed charges,,,90,,150.3,percent of total billed charges,,,,,,,no IP contract,,80,,133.6,percent of total billed charges,,,,,,,no IP contract,,50,,83.5,percent of total billed charges,,,,,,no IP contract,,,78,,130.26,percent of total billed charges,,,70,,116.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,81.83,3324,
SHILEY FLEX 9 CUFFED 9CN90A,0272,RC,,,,inpatient,,,167,100.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,135.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,141.95,percent of total billed charges,,,85,,141.95,percent of total billed charges,,,49,,81.83,percent of total billed charges,,,90,,150.3,percent of total billed charges,,,,,,,no IP contract,,80,,133.6,percent of total billed charges,,,,,,,no IP contract,,50,,83.5,percent of total billed charges,,,,,,no IP contract,,,78,,130.26,percent of total billed charges,,,70,,116.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,81.83,3324,
DRESSING  AQUACEL AG SURGICAL 6',0272,RC,,,,inpatient,,,169,101.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,136.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,143.65,percent of total billed charges,,,85,,143.65,percent of total billed charges,,,49,,82.81,percent of total billed charges,,,90,,152.1,percent of total billed charges,,,,,,,no IP contract,,80,,135.2,percent of total billed charges,,,,,,,no IP contract,,50,,84.5,percent of total billed charges,,,,,,no IP contract,,,78,,131.82,percent of total billed charges,,,70,,118.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,82.81,3324,
DRESSING AQUACEL AG SURGICAL 10',0272,RC,,,,inpatient,,,211,126.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,170.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,179.35,percent of total billed charges,,,85,,179.35,percent of total billed charges,,,49,,103.39,percent of total billed charges,,,90,,189.9,percent of total billed charges,,,,,,,no IP contract,,80,,168.8,percent of total billed charges,,,,,,,no IP contract,,50,,105.5,percent of total billed charges,,,,,,no IP contract,,,78,,164.58,percent of total billed charges,,,70,,147.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,103.39,3324,
DRESSING AQUACEL AG SURGICAL 14',0272,RC,,,,inpatient,,,235,141,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,190.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,199.75,percent of total billed charges,,,85,,199.75,percent of total billed charges,,,49,,115.15,percent of total billed charges,,,90,,211.5,percent of total billed charges,,,,,,,no IP contract,,80,,188,percent of total billed charges,,,,,,,no IP contract,,50,,117.5,percent of total billed charges,,,,,,no IP contract,,,78,,183.3,percent of total billed charges,,,70,,164.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,115.15,3324,
SHILEY 6.0MM  XLT DISTAL CUFFLESS,0272,RC,,,,inpatient,,,353,211.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,285.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,300.05,percent of total billed charges,,,85,,300.05,percent of total billed charges,,,49,,172.97,percent of total billed charges,,,90,,317.7,percent of total billed charges,,,,,,,no IP contract,,80,,282.4,percent of total billed charges,,,,,,,no IP contract,,50,,176.5,percent of total billed charges,,,,,,no IP contract,,,78,,275.34,percent of total billed charges,,,70,,247.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,172.97,3324,
SHILEY 6.0MM  XLT PROXIMAL CUFFLESS,0272,RC,,,,inpatient,,,353,211.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,285.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,300.05,percent of total billed charges,,,85,,300.05,percent of total billed charges,,,49,,172.97,percent of total billed charges,,,90,,317.7,percent of total billed charges,,,,,,,no IP contract,,80,,282.4,percent of total billed charges,,,,,,,no IP contract,,50,,176.5,percent of total billed charges,,,,,,no IP contract,,,78,,275.34,percent of total billed charges,,,70,,247.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,172.97,3324,
SHILEY 6.0MM XLT DISTAL CUFFED,0272,RC,,,,inpatient,,,353,211.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,285.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,300.05,percent of total billed charges,,,85,,300.05,percent of total billed charges,,,49,,172.97,percent of total billed charges,,,90,,317.7,percent of total billed charges,,,,,,,no IP contract,,80,,282.4,percent of total billed charges,,,,,,,no IP contract,,50,,176.5,percent of total billed charges,,,,,,no IP contract,,,78,,275.34,percent of total billed charges,,,70,,247.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,172.97,3324,
SHILEY 8.0MM XLT DISTAL CUFFED,0272,RC,,,,inpatient,,,353,211.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,285.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,300.05,percent of total billed charges,,,85,,300.05,percent of total billed charges,,,49,,172.97,percent of total billed charges,,,90,,317.7,percent of total billed charges,,,,,,,no IP contract,,80,,282.4,percent of total billed charges,,,,,,,no IP contract,,50,,176.5,percent of total billed charges,,,,,,no IP contract,,,78,,275.34,percent of total billed charges,,,70,,247.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,172.97,3324,
SHILEY 8.0MM XLT DISTAL CUFFLESS,0272,RC,,,,inpatient,,,353,211.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,285.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,300.05,percent of total billed charges,,,85,,300.05,percent of total billed charges,,,49,,172.97,percent of total billed charges,,,90,,317.7,percent of total billed charges,,,,,,,no IP contract,,80,,282.4,percent of total billed charges,,,,,,,no IP contract,,50,,176.5,percent of total billed charges,,,,,,no IP contract,,,78,,275.34,percent of total billed charges,,,70,,247.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,172.97,3324,
SHILEY 8.0MM XLT PROXIMAL CUFFED,0272,RC,,,,inpatient,,,353,211.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,285.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,300.05,percent of total billed charges,,,85,,300.05,percent of total billed charges,,,49,,172.97,percent of total billed charges,,,90,,317.7,percent of total billed charges,,,,,,,no IP contract,,80,,282.4,percent of total billed charges,,,,,,,no IP contract,,50,,176.5,percent of total billed charges,,,,,,no IP contract,,,78,,275.34,percent of total billed charges,,,70,,247.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,172.97,3324,
SHILEY 8.0MM XLT PROXIMAL CUFFLESS,0272,RC,,,,inpatient,,,353,211.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,285.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,300.05,percent of total billed charges,,,85,,300.05,percent of total billed charges,,,49,,172.97,percent of total billed charges,,,90,,317.7,percent of total billed charges,,,,,,,no IP contract,,80,,282.4,percent of total billed charges,,,,,,,no IP contract,,50,,176.5,percent of total billed charges,,,,,,no IP contract,,,78,,275.34,percent of total billed charges,,,70,,247.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,172.97,3324,
SHILEY 6.0MM XLT PROXIMAL CUFFED,0272,RC,,,,inpatient,,,359,215.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,290.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,305.15,percent of total billed charges,,,85,,305.15,percent of total billed charges,,,49,,175.91,percent of total billed charges,,,90,,323.1,percent of total billed charges,,,,,,,no IP contract,,80,,287.2,percent of total billed charges,,,,,,,no IP contract,,50,,179.5,percent of total billed charges,,,,,,no IP contract,,,78,,280.02,percent of total billed charges,,,70,,251.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,175.91,3324,
DIC 5.0MM XLONG TIN,0272,RC,,,,inpatient,,,410,246,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,332.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,348.5,percent of total billed charges,,,85,,348.5,percent of total billed charges,,,49,,200.9,percent of total billed charges,,,90,,369,percent of total billed charges,,,,,,,no IP contract,,80,,328,percent of total billed charges,,,,,,,no IP contract,,50,,205,percent of total billed charges,,,,,,no IP contract,,,78,,319.8,percent of total billed charges,,,70,,287,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,200.9,3324,
SHILEY 5.0MM  XLT DISTAL CUFFED,0272,RC,,,,inpatient,,,509,305.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,412.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,432.65,percent of total billed charges,,,85,,432.65,percent of total billed charges,,,49,,249.41,percent of total billed charges,,,90,,458.1,percent of total billed charges,,,,,,,no IP contract,,80,,407.2,percent of total billed charges,,,,,,,no IP contract,,50,,254.5,percent of total billed charges,,,,,,no IP contract,,,78,,397.02,percent of total billed charges,,,70,,356.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,249.41,3324,
RHINOLARYNGO SLIM SCOPES DISPOSABLE,0272,RC,,,,inpatient,,,693,415.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,561.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,589.05,percent of total billed charges,,,85,,589.05,percent of total billed charges,,,49,,339.57,percent of total billed charges,,,90,,623.7,percent of total billed charges,,,,,,,no IP contract,,80,,554.4,percent of total billed charges,,,,,,,no IP contract,,50,,346.5,percent of total billed charges,,,,,,no IP contract,,,78,,540.54,percent of total billed charges,,,70,,485.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,339.57,3324,
SLING GIVMOHR LG,0279,RC,,,,inpatient,,,381,228.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,308.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,323.85,percent of total billed charges,,,85,,323.85,percent of total billed charges,,,49,,186.69,percent of total billed charges,,,90,,342.9,percent of total billed charges,,,,,,,no IP contract,,80,,304.8,percent of total billed charges,,,,,,,no IP contract,,50,,190.5,percent of total billed charges,,,,,,no IP contract,,,78,,297.18,percent of total billed charges,,,70,,266.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,186.69,3324,
SLING GIVMOHR M,0279,RC,,,,inpatient,,,395,237,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,319.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,335.75,percent of total billed charges,,,85,,335.75,percent of total billed charges,,,49,,193.55,percent of total billed charges,,,90,,355.5,percent of total billed charges,,,,,,,no IP contract,,80,,316,percent of total billed charges,,,,,,,no IP contract,,50,,197.5,percent of total billed charges,,,,,,no IP contract,,,78,,308.1,percent of total billed charges,,,70,,276.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,193.55,3324,
TRACH TUBE CUFFLESS PEDS # 4.5,0279,RC,,,,inpatient,,,443,265.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,358.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,376.55,percent of total billed charges,,,85,,376.55,percent of total billed charges,,,49,,217.07,percent of total billed charges,,,90,,398.7,percent of total billed charges,,,,,,,no IP contract,,80,,354.4,percent of total billed charges,,,,,,,no IP contract,,50,,221.5,percent of total billed charges,,,,,,no IP contract,,,78,,345.54,percent of total billed charges,,,70,,310.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,217.07,3324,
RIC Laboratory Bench,0301,RC,,,,inpatient,,,2,1.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1.7,percent of total billed charges,,,85,,1.7,percent of total billed charges,,,49,,0.98,percent of total billed charges,,,90,,1.8,percent of total billed charges,,,,,,,no IP contract,,80,,1.6,percent of total billed charges,,,,,,,no IP contract,,50,,1,percent of total billed charges,,,,,,no IP contract,,,78,,1.56,percent of total billed charges,,,70,,1.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,0.98,3324,
"Immunoglobulins, Quantitative IgA, IgG, IgM",0301,RC,,,,inpatient,,,1018,610.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,824.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,865.3,percent of total billed charges,,,85,,865.3,percent of total billed charges,,,49,,498.82,percent of total billed charges,,,90,,916.2,percent of total billed charges,,,,,,,no IP contract,,80,,814.4,percent of total billed charges,,,,,,,no IP contract,,50,,509,percent of total billed charges,,,,,,no IP contract,,,78,,794.04,percent of total billed charges,,,70,,712.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,498.82,3324,
03160-4011-60 -,03160-4011-60,NDC,,,,inpatient,1,EA,17.25,10.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.66,percent of total billed charges,,,85,,14.66,percent of total billed charges,,,49,,8.45,percent of total billed charges,,,90,,15.53,percent of total billed charges,,,,,,,no IP contract,,80,,13.8,percent of total billed charges,,,,,,,no IP contract,,50,,8.63,percent of total billed charges,,,,,,no IP contract,,,78,,13.46,percent of total billed charges,,,70,,12.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.45,3324,
saccharomyces boulardii lyo cap 250 mg Cap,04142-0000-07,NDC,,,,inpatient,1,EA,6.2,3.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.27,percent of total billed charges,,,85,,5.27,percent of total billed charges,,,49,,3.04,percent of total billed charges,,,90,,5.58,percent of total billed charges,,,,,,,no IP contract,,80,,4.96,percent of total billed charges,,,,,,,no IP contract,,50,,3.1,percent of total billed charges,,,,,,no IP contract,,,78,,4.84,percent of total billed charges,,,70,,4.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.04,3324,
04142-0004-07 - saccharomyces boulardii lyo 250 mg Cap,04142-0004-07,NDC,,,,inpatient,1,EA,6.2,3.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.27,percent of total billed charges,,,85,,5.27,percent of total billed charges,,,49,,3.04,percent of total billed charges,,,90,,5.58,percent of total billed charges,,,,,,,no IP contract,,80,,4.96,percent of total billed charges,,,,,,,no IP contract,,50,,3.1,percent of total billed charges,,,,,,no IP contract,,,78,,4.84,percent of total billed charges,,,70,,4.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.04,3324,
HHTC Charge-Subsequent,0460,RC,,,,inpatient,,,145,87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,117.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,123.25,percent of total billed charges,,,85,,123.25,percent of total billed charges,,,49,,71.05,percent of total billed charges,,,90,,130.5,percent of total billed charges,,,,,,,no IP contract,,80,,116,percent of total billed charges,,,,,,,no IP contract,,50,,72.5,percent of total billed charges,,,,,,no IP contract,,,78,,113.1,percent of total billed charges,,,70,,101.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,71.05,3324,
Pulmonary Group Education IP,0460,RC,,,,inpatient,,,184,110.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,149.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,156.4,percent of total billed charges,,,85,,156.4,percent of total billed charges,,,49,,90.16,percent of total billed charges,,,90,,165.6,percent of total billed charges,,,,,,,no IP contract,,80,,147.2,percent of total billed charges,,,,,,,no IP contract,,50,,92,percent of total billed charges,,,,,,no IP contract,,,78,,143.52,percent of total billed charges,,,70,,128.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,90.16,3324,
05048-0100-30 -,05048-0100-30,NDC,,,,inpatient,1,UN,464.05,278.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,375.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,394.44,percent of total billed charges,,,85,,394.44,percent of total billed charges,,,49,,227.38,percent of total billed charges,,,90,,417.65,percent of total billed charges,,,,,,,no IP contract,,80,,371.24,percent of total billed charges,,,,,,,no IP contract,,50,,232.03,percent of total billed charges,,,,,,no IP contract,,,78,,361.96,percent of total billed charges,,,70,,324.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,227.38,3324,
05048-0220-30 -,05048-0220-30,NDC,,,,inpatient,1,UN,741.45,444.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,600.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,630.23,percent of total billed charges,,,85,,630.23,percent of total billed charges,,,49,,363.31,percent of total billed charges,,,90,,667.31,percent of total billed charges,,,,,,,no IP contract,,80,,593.16,percent of total billed charges,,,,,,,no IP contract,,50,,370.73,percent of total billed charges,,,,,,no IP contract,,,78,,578.33,percent of total billed charges,,,70,,519.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,363.31,3324,
05764-8002-01 -,05764-8002-01,NDC,,,,inpatient,1,UN,8.9,5.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.57,percent of total billed charges,,,85,,7.57,percent of total billed charges,,,49,,4.36,percent of total billed charges,,,90,,8.01,percent of total billed charges,,,,,,,no IP contract,,80,,7.12,percent of total billed charges,,,,,,,no IP contract,,50,,4.45,percent of total billed charges,,,,,,no IP contract,,,78,,6.94,percent of total billed charges,,,70,,6.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.36,3324,
07346-2062-85 -,07346-2062-85,NDC,,,,inpatient,1,UN,84.2,50.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,68.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,71.57,percent of total billed charges,,,85,,71.57,percent of total billed charges,,,49,,41.26,percent of total billed charges,,,90,,75.78,percent of total billed charges,,,,,,,no IP contract,,80,,67.36,percent of total billed charges,,,,,,,no IP contract,,50,,42.1,percent of total billed charges,,,,,,no IP contract,,,78,,65.68,percent of total billed charges,,,70,,58.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,41.26,3324,
"07431-2013-80 - cyanocobalamin 1,000 mcg Tab",07431-2013-80,NDC,,,,inpatient,1,EA,4.3,2.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.66,percent of total billed charges,,,85,,3.66,percent of total billed charges,,,49,,2.11,percent of total billed charges,,,90,,3.87,percent of total billed charges,,,,,,,no IP contract,,80,,3.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.15,percent of total billed charges,,,,,,no IP contract,,,78,,3.35,percent of total billed charges,,,70,,3.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.11,3324,
07685-5700-29 - pill pulverizer 1 Device,07685-5700-29,NDC,,,,inpatient,1,EA,30.8,18.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.18,percent of total billed charges,,,85,,26.18,percent of total billed charges,,,49,,15.09,percent of total billed charges,,,90,,27.72,percent of total billed charges,,,,,,,no IP contract,,80,,24.64,percent of total billed charges,,,,,,,no IP contract,,50,,15.4,percent of total billed charges,,,,,,no IP contract,,,78,,24.02,percent of total billed charges,,,70,,21.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.09,3324,
07685-5700-58 - pill splitter 1 EA Device,07685-5700-58,NDC,,,,inpatient,1,EA,30.8,18.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.18,percent of total billed charges,,,85,,26.18,percent of total billed charges,,,49,,15.09,percent of total billed charges,,,90,,27.72,percent of total billed charges,,,,,,,no IP contract,,80,,24.64,percent of total billed charges,,,,,,,no IP contract,,50,,15.4,percent of total billed charges,,,,,,no IP contract,,,78,,24.02,percent of total billed charges,,,70,,21.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.09,3324,
Hemodialysis Procedure Charge,0801,RC,,,,inpatient,,,2422,1453.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1961.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2058.7,percent of total billed charges,,,85,,2058.7,percent of total billed charges,,,49,,1186.78,percent of total billed charges,,,90,,2179.8,percent of total billed charges,,,,,,,no IP contract,,80,,1937.6,percent of total billed charges,,,,,,,no IP contract,,50,,1211,percent of total billed charges,,,,,,no IP contract,,,78,,1889.16,percent of total billed charges,,,70,,1695.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
sodium hyaluronate 10 mg/mL Soln,08024-0724-20,NDC,,,,inpatient,1,EA,525.4,315.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,425.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,446.59,percent of total billed charges,,,85,,446.59,percent of total billed charges,,,49,,257.45,percent of total billed charges,,,90,,472.86,percent of total billed charges,,,,,,,no IP contract,,80,,420.32,percent of total billed charges,,,,,,,no IP contract,,50,,262.7,percent of total billed charges,,,,,,no IP contract,,,78,,409.81,percent of total billed charges,,,70,,367.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,257.45,3324,
08290-3064-14 - heparin flush 10 units/mL Soln,08290-3064-14,NDC,,,,inpatient,5,ML,13.95,8.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.86,percent of total billed charges,,,85,,11.86,percent of total billed charges,,,49,,6.84,percent of total billed charges,,,90,,12.56,percent of total billed charges,,,,,,,no IP contract,,80,,11.16,percent of total billed charges,,,,,,,no IP contract,,50,,6.98,percent of total billed charges,,,,,,no IP contract,,,78,,10.88,percent of total billed charges,,,70,,9.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.84,3324,
08290-3064-24 - heparin flush 100 units/mL Soln,08290-3064-24,NDC,,,,inpatient,5,ML,13.95,8.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.86,percent of total billed charges,,,85,,11.86,percent of total billed charges,,,49,,6.84,percent of total billed charges,,,90,,12.56,percent of total billed charges,,,,,,,no IP contract,,80,,11.16,percent of total billed charges,,,,,,,no IP contract,,50,,6.98,percent of total billed charges,,,,,,no IP contract,,,78,,10.88,percent of total billed charges,,,70,,9.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.84,3324,
Private Duty Nursing,0989,RC,,,,inpatient,,,74,44.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,59.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,62.9,percent of total billed charges,,,85,,62.9,percent of total billed charges,,,49,,36.26,percent of total billed charges,,,90,,66.6,percent of total billed charges,,,,,,,no IP contract,,80,,59.2,percent of total billed charges,,,,,,,no IP contract,,50,,37,percent of total billed charges,,,,,,no IP contract,,,78,,57.72,percent of total billed charges,,,70,,51.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.26,3324,
"International Case Managment, per hour",0998,RC,,,,inpatient,,,98,58.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,79.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,83.3,percent of total billed charges,,,85,,83.3,percent of total billed charges,,,49,,48.02,percent of total billed charges,,,90,,88.2,percent of total billed charges,,,,,,,no IP contract,,80,,78.4,percent of total billed charges,,,,,,,no IP contract,,50,,49,percent of total billed charges,,,,,,no IP contract,,,78,,76.44,percent of total billed charges,,,70,,68.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,48.02,3324,
10006-0700-12 - pyridoxine 50 mg Tab,10006-0700-12,NDC,,,,inpatient,1,EA,4,2.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.4,percent of total billed charges,,,85,,3.4,percent of total billed charges,,,49,,1.96,percent of total billed charges,,,90,,3.6,percent of total billed charges,,,,,,,no IP contract,,80,,3.2,percent of total billed charges,,,,,,,no IP contract,,50,,2,percent of total billed charges,,,,,,no IP contract,,,78,,3.12,percent of total billed charges,,,70,,2.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.96,3324,
10006-0700-28 - magnesium oxide 400 mg Tab,10006-0700-28,NDC,,,,inpatient,1,EA,4.55,2.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.87,percent of total billed charges,,,85,,3.87,percent of total billed charges,,,49,,2.23,percent of total billed charges,,,90,,4.1,percent of total billed charges,,,,,,,no IP contract,,80,,3.64,percent of total billed charges,,,,,,,no IP contract,,50,,2.28,percent of total billed charges,,,,,,no IP contract,,,78,,3.55,percent of total billed charges,,,70,,3.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.23,3324,
"10006-0700-33 - cholecalciferol [D3] 1,000 International_Unit Tab",10006-0700-33,NDC,,,,inpatient,1,EA,4.2,2.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.57,percent of total billed charges,,,85,,3.57,percent of total billed charges,,,49,,2.06,percent of total billed charges,,,90,,3.78,percent of total billed charges,,,,,,,no IP contract,,80,,3.36,percent of total billed charges,,,,,,,no IP contract,,50,,2.1,percent of total billed charges,,,,,,no IP contract,,,78,,3.28,percent of total billed charges,,,70,,2.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.06,3324,
10006-0700-38 - calcium-vitamin D 500 mg-200 intl units Tab,10006-0700-38,NDC,,,,inpatient,1,EA,4.2,2.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.57,percent of total billed charges,,,85,,3.57,percent of total billed charges,,,49,,2.06,percent of total billed charges,,,90,,3.78,percent of total billed charges,,,,,,,no IP contract,,80,,3.36,percent of total billed charges,,,,,,,no IP contract,,50,,2.1,percent of total billed charges,,,,,,no IP contract,,,78,,3.28,percent of total billed charges,,,70,,2.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.06,3324,
10006-0730-16 - pyridoxine 50 mg Tab,10006-0730-16,NDC,,,,inpatient,1,EA,3.9,2.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.32,percent of total billed charges,,,85,,3.32,percent of total billed charges,,,49,,1.91,percent of total billed charges,,,90,,3.51,percent of total billed charges,,,,,,,no IP contract,,80,,3.12,percent of total billed charges,,,,,,,no IP contract,,50,,1.95,percent of total billed charges,,,,,,no IP contract,,,78,,3.04,percent of total billed charges,,,70,,2.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.91,3324,
10006-0730-34 - folic acid 0.4 mg Tab,10006-0730-34,NDC,,,,inpatient,1,EA,4,2.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.4,percent of total billed charges,,,85,,3.4,percent of total billed charges,,,49,,1.96,percent of total billed charges,,,90,,3.6,percent of total billed charges,,,,,,,no IP contract,,80,,3.2,percent of total billed charges,,,,,,,no IP contract,,50,,2,percent of total billed charges,,,,,,no IP contract,,,78,,3.12,percent of total billed charges,,,70,,2.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.96,3324,
10019-0030-04 - ketorolac 30 mg/mL Soln,10019-0030-04,NDC,,,,inpatient,1,ML,15.9,9.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.52,percent of total billed charges,,,85,,13.52,percent of total billed charges,,,49,,7.79,percent of total billed charges,,,90,,14.31,percent of total billed charges,,,,,,,no IP contract,,80,,12.72,percent of total billed charges,,,,,,,no IP contract,,50,,7.95,percent of total billed charges,,,,,,no IP contract,,,78,,12.4,percent of total billed charges,,,70,,11.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.79,3324,
10019-0506-10 - bumetanide 0.25 mg/mL Soln,10019-0506-10,NDC,,,,inpatient,1,ML,34.6,20.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.41,percent of total billed charges,,,85,,29.41,percent of total billed charges,,,49,,16.95,percent of total billed charges,,,90,,31.14,percent of total billed charges,,,,,,,no IP contract,,80,,27.68,percent of total billed charges,,,,,,,no IP contract,,50,,17.3,percent of total billed charges,,,,,,no IP contract,,,78,,26.99,percent of total billed charges,,,70,,24.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.95,3324,
10019-0611-03 - cefazolin 1 g REC I,10019-0611-03,NDC,,,,inpatient,1,EA,50.5,30.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,40.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,42.93,percent of total billed charges,,,85,,42.93,percent of total billed charges,,,49,,24.75,percent of total billed charges,,,90,,45.45,percent of total billed charges,,,,,,,no IP contract,,80,,40.4,percent of total billed charges,,,,,,,no IP contract,,50,,25.25,percent of total billed charges,,,,,,no IP contract,,,78,,39.39,percent of total billed charges,,,70,,35.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.75,3324,
10122-0902-12 - zileuton 600 mg ER Ta,10122-0902-12,NDC,,,,inpatient,1,EA,83.25,49.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,67.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,70.76,percent of total billed charges,,,85,,70.76,percent of total billed charges,,,49,,40.79,percent of total billed charges,,,90,,74.93,percent of total billed charges,,,,,,,no IP contract,,80,,66.6,percent of total billed charges,,,,,,,no IP contract,,50,,41.63,percent of total billed charges,,,,,,no IP contract,,,78,,64.94,percent of total billed charges,,,70,,58.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,40.79,3324,
labetalol 100 mg Tab,10135-0711-01,NDC,,,,inpatient,1,EA,5.2,3.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.42,percent of total billed charges,,,85,,4.42,percent of total billed charges,,,49,,2.55,percent of total billed charges,,,90,,4.68,percent of total billed charges,,,,,,,no IP contract,,80,,4.16,percent of total billed charges,,,,,,,no IP contract,,50,,2.6,percent of total billed charges,,,,,,no IP contract,,,78,,4.06,percent of total billed charges,,,70,,3.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.55,3324,
10144-0427-60 - dalfampridine 10 mg ER Ta,10144-0427-60,NDC,,,,inpatient,1,EA,159.15,95.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,128.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,135.28,percent of total billed charges,,,85,,135.28,percent of total billed charges,,,49,,77.98,percent of total billed charges,,,90,,143.24,percent of total billed charges,,,,,,,no IP contract,,80,,127.32,percent of total billed charges,,,,,,,no IP contract,,50,,79.58,percent of total billed charges,,,,,,no IP contract,,,78,,124.14,percent of total billed charges,,,70,,111.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,77.98,3324,
10144-0592-15 - tizanidine 2 mg Tab,10144-0592-15,NDC,,,,inpatient,1,EA,15.65,9.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.3,percent of total billed charges,,,85,,13.3,percent of total billed charges,,,49,,7.67,percent of total billed charges,,,90,,14.09,percent of total billed charges,,,,,,,no IP contract,,80,,12.52,percent of total billed charges,,,,,,,no IP contract,,50,,7.83,percent of total billed charges,,,,,,no IP contract,,,78,,12.21,percent of total billed charges,,,70,,10.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.67,3324,
10144-0592-15 - tizanidine 2 mg Tab,10144-0592-15,NDC,,,,inpatient,1,EA,15.65,9.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.3,percent of total billed charges,,,85,,13.3,percent of total billed charges,,,49,,7.67,percent of total billed charges,,,90,,14.09,percent of total billed charges,,,,,,,no IP contract,,80,,12.52,percent of total billed charges,,,,,,,no IP contract,,50,,7.83,percent of total billed charges,,,,,,no IP contract,,,78,,12.21,percent of total billed charges,,,70,,10.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.67,3324,
10147-0750-04 - ketoconazole topical 2% Shamp,10147-0750-04,NDC,,,,inpatient,1,UN,239.15,143.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,193.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,203.28,percent of total billed charges,,,85,,203.28,percent of total billed charges,,,49,,117.18,percent of total billed charges,,,90,,215.24,percent of total billed charges,,,,,,,no IP contract,,80,,191.32,percent of total billed charges,,,,,,,no IP contract,,50,,119.58,percent of total billed charges,,,,,,no IP contract,,,78,,186.54,percent of total billed charges,,,70,,167.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,117.18,3324,
10147-1700-03 - itraconazole 100 mg Cap,10147-1700-03,NDC,,,,inpatient,1,EA,77.6,46.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,62.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,65.96,percent of total billed charges,,,85,,65.96,percent of total billed charges,,,49,,38.02,percent of total billed charges,,,90,,69.84,percent of total billed charges,,,,,,,no IP contract,,80,,62.08,percent of total billed charges,,,,,,,no IP contract,,50,,38.8,percent of total billed charges,,,,,,no IP contract,,,78,,60.53,percent of total billed charges,,,70,,54.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,38.02,3324,
10310-0319-46 - benzocaine 20 % 20% Gel,10310-0319-46,NDC,,,,inpatient,1,UN,45.4,27.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,38.59,percent of total billed charges,,,85,,38.59,percent of total billed charges,,,49,,22.25,percent of total billed charges,,,90,,40.86,percent of total billed charges,,,,,,,no IP contract,,80,,36.32,percent of total billed charges,,,,,,,no IP contract,,50,,22.7,percent of total billed charges,,,,,,no IP contract,,,78,,35.41,percent of total billed charges,,,70,,31.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.25,3324,
10337-0804-45 - doxepin topical 5% Cream,10337-0804-45,NDC,,,,inpatient,1,UN,3266.65,1959.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2645.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2776.65,percent of total billed charges,,,85,,2776.65,percent of total billed charges,,,49,,1600.66,percent of total billed charges,,,90,,2939.99,percent of total billed charges,,,,,,,no IP contract,,80,,2613.32,percent of total billed charges,,,,,,,no IP contract,,50,,1633.33,percent of total billed charges,,,,,,no IP contract,,,78,,2547.99,percent of total billed charges,,,70,,2286.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
rimabotulinumtoxinB 5000 units/mL Soln,10454-0710-10,NDC,,,,inpatient,1,EA,1195.7,717.42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,968.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1016.35,percent of total billed charges,,,85,,1016.35,percent of total billed charges,,,49,,585.89,percent of total billed charges,,,90,,1076.13,percent of total billed charges,,,,,,,no IP contract,,80,,956.56,percent of total billed charges,,,,,,,no IP contract,,50,,597.85,percent of total billed charges,,,,,,no IP contract,,,78,,932.65,percent of total billed charges,,,70,,836.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,585.89,3324,
rimabotulinumtoxinB 5000 units/mL Soln,10454-0711-10,NDC,,,,inpatient,1,EA,2391.4,1434.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1937.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2032.69,percent of total billed charges,,,85,,2032.69,percent of total billed charges,,,49,,1171.79,percent of total billed charges,,,90,,2152.26,percent of total billed charges,,,,,,,no IP contract,,80,,1913.12,percent of total billed charges,,,,,,,no IP contract,,50,,1195.7,percent of total billed charges,,,,,,no IP contract,,,78,,1865.29,percent of total billed charges,,,70,,1673.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
10702-0008-01 - oxyCODONE 15 mg Tab,10702-0008-01,NDC,,,,inpatient,1,EA,21.15,12.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.98,percent of total billed charges,,,85,,17.98,percent of total billed charges,,,49,,10.36,percent of total billed charges,,,90,,19.04,percent of total billed charges,,,,,,,no IP contract,,80,,16.92,percent of total billed charges,,,,,,,no IP contract,,50,,10.58,percent of total billed charges,,,,,,no IP contract,,,78,,16.5,percent of total billed charges,,,70,,14.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.36,3324,
10702-0010-01 - hydrOXYzine hydrochloride 10 mg Tab,10702-0010-01,NDC,,,,inpatient,1,EA,8.85,5.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.52,percent of total billed charges,,,85,,7.52,percent of total billed charges,,,49,,4.34,percent of total billed charges,,,90,,7.97,percent of total billed charges,,,,,,,no IP contract,,80,,7.08,percent of total billed charges,,,,,,,no IP contract,,50,,4.43,percent of total billed charges,,,,,,no IP contract,,,78,,6.9,percent of total billed charges,,,70,,6.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.34,3324,
10702-0016-06 - indomethacin 75 mg ER Ca,10702-0016-06,NDC,,,,inpatient,1,EA,28,16.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.8,percent of total billed charges,,,85,,23.8,percent of total billed charges,,,49,,13.72,percent of total billed charges,,,90,,25.2,percent of total billed charges,,,,,,,no IP contract,,80,,22.4,percent of total billed charges,,,,,,,no IP contract,,50,,14,percent of total billed charges,,,,,,no IP contract,,,78,,21.84,percent of total billed charges,,,70,,19.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.72,3324,
dextroamphetamine 5 mg Tab,10702-0065-01,NDC,,,,inpatient,1,EA,29.6,17.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.16,percent of total billed charges,,,85,,25.16,percent of total billed charges,,,49,,14.5,percent of total billed charges,,,90,,26.64,percent of total billed charges,,,,,,,no IP contract,,80,,23.68,percent of total billed charges,,,,,,,no IP contract,,50,,14.8,percent of total billed charges,,,,,,no IP contract,,,78,,23.09,percent of total billed charges,,,70,,20.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.5,3324,
10702-0070-06 - oxyMORphone 5 mg Tab,10702-0070-06,NDC,,,,inpatient,1,EA,35.15,21.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.88,percent of total billed charges,,,85,,29.88,percent of total billed charges,,,49,,17.22,percent of total billed charges,,,90,,31.64,percent of total billed charges,,,,,,,no IP contract,,80,,28.12,percent of total billed charges,,,,,,,no IP contract,,50,,17.58,percent of total billed charges,,,,,,no IP contract,,,78,,27.42,percent of total billed charges,,,70,,24.61,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.22,3324,
10702-0101-01 - methylphenidate 10 mg Tab,10702-0101-01,NDC,,,,inpatient,1,EA,14,8.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.9,percent of total billed charges,,,85,,11.9,percent of total billed charges,,,49,,6.86,percent of total billed charges,,,90,,12.6,percent of total billed charges,,,,,,,no IP contract,,80,,11.2,percent of total billed charges,,,,,,,no IP contract,,50,,7,percent of total billed charges,,,,,,no IP contract,,,78,,10.92,percent of total billed charges,,,70,,9.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.86,3324,
10702-0106-01 - dexmethylphenidate 2.5 mg Tab,10702-0106-01,NDC,,,,inpatient,1,EA,11.1,6.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.44,percent of total billed charges,,,85,,9.44,percent of total billed charges,,,49,,5.44,percent of total billed charges,,,90,,9.99,percent of total billed charges,,,,,,,no IP contract,,80,,8.88,percent of total billed charges,,,,,,,no IP contract,,50,,5.55,percent of total billed charges,,,,,,no IP contract,,,78,,8.66,percent of total billed charges,,,70,,7.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.44,3324,
10702-0237-01 - ursodiol 300 mg Cap,10702-0237-01,NDC,,,,inpatient,1,EA,62.25,37.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,50.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,52.91,percent of total billed charges,,,85,,52.91,percent of total billed charges,,,49,,30.5,percent of total billed charges,,,90,,56.03,percent of total billed charges,,,,,,,no IP contract,,80,,49.8,percent of total billed charges,,,,,,,no IP contract,,50,,31.13,percent of total billed charges,,,,,,no IP contract,,,78,,48.56,percent of total billed charges,,,70,,43.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,30.5,3324,
10702-0808-03 - cycloSPORINE ophthalmic 0.05% Emuls,10702-0808-03,NDC,,,,inpatient,1,UN,111.45,66.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,90.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,94.73,percent of total billed charges,,,85,,94.73,percent of total billed charges,,,49,,54.61,percent of total billed charges,,,90,,100.31,percent of total billed charges,,,,,,,no IP contract,,80,,89.16,percent of total billed charges,,,,,,,no IP contract,,50,,55.73,percent of total billed charges,,,,,,no IP contract,,,78,,86.93,percent of total billed charges,,,70,,78.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,54.61,3324,
11509-0003-67 - benzocaine-resorcinol topical 5%-2% Cream,11509-0003-67,NDC,,,,inpatient,1,UN,34.2,20.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.07,percent of total billed charges,,,85,,29.07,percent of total billed charges,,,49,,16.76,percent of total billed charges,,,90,,30.78,percent of total billed charges,,,,,,,no IP contract,,80,,27.36,percent of total billed charges,,,,,,,no IP contract,,50,,17.1,percent of total billed charges,,,,,,no IP contract,,,78,,26.68,percent of total billed charges,,,70,,23.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.76,3324,
benzocaine topical 10 mg Lozen,11509-0209-18,NDC,,,,inpatient,1,EA,10.55,6.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.97,percent of total billed charges,,,85,,8.97,percent of total billed charges,,,49,,5.17,percent of total billed charges,,,90,,9.5,percent of total billed charges,,,,,,,no IP contract,,80,,8.44,percent of total billed charges,,,,,,,no IP contract,,50,,5.28,percent of total billed charges,,,,,,no IP contract,,,78,,8.23,percent of total billed charges,,,70,,7.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.17,3324,
11523-4328-01 - loratadine 5 mg Chew,11523-4328-01,NDC,,,,inpatient,1,EA,12.4,7.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.54,percent of total billed charges,,,85,,10.54,percent of total billed charges,,,49,,6.08,percent of total billed charges,,,90,,11.16,percent of total billed charges,,,,,,,no IP contract,,80,,9.92,percent of total billed charges,,,,,,,no IP contract,,50,,6.2,percent of total billed charges,,,,,,no IP contract,,,78,,9.67,percent of total billed charges,,,70,,8.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.08,3324,
11701-0045-14 - miconazole Topical 2% Cream,11701-0045-14,NDC,,,,inpatient,1,UN,92.05,55.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,74.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,78.24,percent of total billed charges,,,85,,78.24,percent of total billed charges,,,49,,45.1,percent of total billed charges,,,90,,82.85,percent of total billed charges,,,,,,,no IP contract,,80,,73.64,percent of total billed charges,,,,,,,no IP contract,,50,,46.03,percent of total billed charges,,,,,,no IP contract,,,78,,71.8,percent of total billed charges,,,70,,64.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,45.1,3324,
11701-0045-23 - miconazole topical 2% Cream,11701-0045-23,NDC,,,,inpatient,1,UN,139.35,83.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,112.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,118.45,percent of total billed charges,,,85,,118.45,percent of total billed charges,,,49,,68.28,percent of total billed charges,,,90,,125.42,percent of total billed charges,,,,,,,no IP contract,,80,,111.48,percent of total billed charges,,,,,,,no IP contract,,50,,69.68,percent of total billed charges,,,,,,no IP contract,,,78,,108.69,percent of total billed charges,,,70,,97.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,68.28,3324,
11980-0174-05 - prednisoLONE ophthalmic acetate 0.12% Susp,11980-0174-05,NDC,,,,inpatient,1,UN,215.8,129.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,174.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,183.43,percent of total billed charges,,,85,,183.43,percent of total billed charges,,,49,,105.74,percent of total billed charges,,,90,,194.22,percent of total billed charges,,,,,,,no IP contract,,80,,172.64,percent of total billed charges,,,,,,,no IP contract,,50,,107.9,percent of total billed charges,,,,,,no IP contract,,,78,,168.32,percent of total billed charges,,,70,,151.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,105.74,3324,
11980-0228-05 - fluorometholone ophthalmic 0.25% Susp,11980-0228-05,NDC,,,,inpatient,1,UN,279.1,167.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,226.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,237.24,percent of total billed charges,,,85,,237.24,percent of total billed charges,,,49,,136.76,percent of total billed charges,,,90,,251.19,percent of total billed charges,,,,,,,no IP contract,,80,,223.28,percent of total billed charges,,,,,,,no IP contract,,50,,139.55,percent of total billed charges,,,,,,no IP contract,,,78,,217.7,percent of total billed charges,,,70,,195.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,136.76,3324,
11980-0779-05 - ofloxacin ophthalmic 0.3% Soln,11980-0779-05,NDC,,,,inpatient,1,UN,599.8,359.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,485.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,509.83,percent of total billed charges,,,85,,509.83,percent of total billed charges,,,49,,293.9,percent of total billed charges,,,90,,539.82,percent of total billed charges,,,,,,,no IP contract,,80,,479.84,percent of total billed charges,,,,,,,no IP contract,,50,,299.9,percent of total billed charges,,,,,,no IP contract,,,78,,467.84,percent of total billed charges,,,70,,419.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,293.9,3324,
12547-0150-40 - witch hazel 50% Pad,12547-0150-40,NDC,,,,inpatient,1,UN,35.6,21.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.26,percent of total billed charges,,,85,,30.26,percent of total billed charges,,,49,,17.44,percent of total billed charges,,,90,,32.04,percent of total billed charges,,,,,,,no IP contract,,80,,28.48,percent of total billed charges,,,,,,,no IP contract,,50,,17.8,percent of total billed charges,,,,,,no IP contract,,,78,,27.77,percent of total billed charges,,,70,,24.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.44,3324,
12870-0001-01 - silver nitrate Topical - Stick,12870-0001-01,NDC,,,,inpatient,1,EA,13.15,7.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.18,percent of total billed charges,,,85,,11.18,percent of total billed charges,,,49,,6.44,percent of total billed charges,,,90,,11.84,percent of total billed charges,,,,,,,no IP contract,,80,,10.52,percent of total billed charges,,,,,,,no IP contract,,50,,6.58,percent of total billed charges,,,,,,no IP contract,,,78,,10.26,percent of total billed charges,,,70,,9.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.44,3324,
12870-0001-02 - silver nitrate topical - Stick,12870-0001-02,NDC,,,,inpatient,1,EA,15.05,9.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.79,percent of total billed charges,,,85,,12.79,percent of total billed charges,,,49,,7.37,percent of total billed charges,,,90,,13.55,percent of total billed charges,,,,,,,no IP contract,,80,,12.04,percent of total billed charges,,,,,,,no IP contract,,50,,7.53,percent of total billed charges,,,,,,no IP contract,,,78,,11.74,percent of total billed charges,,,70,,10.54,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.37,3324,
13107-0014-01 - glycopyrrolate 1 mg Tab,13107-0014-01,NDC,,,,inpatient,1,EA,14.25,8.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.11,percent of total billed charges,,,85,,12.11,percent of total billed charges,,,49,,6.98,percent of total billed charges,,,90,,12.83,percent of total billed charges,,,,,,,no IP contract,,80,,11.4,percent of total billed charges,,,,,,,no IP contract,,50,,7.13,percent of total billed charges,,,,,,no IP contract,,,78,,11.12,percent of total billed charges,,,70,,9.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.98,3324,
13107-0035-01 - dextroamphetamine 5 mg Tab,13107-0035-01,NDC,,,,inpatient,1,EA,29.6,17.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.16,percent of total billed charges,,,85,,25.16,percent of total billed charges,,,49,,14.5,percent of total billed charges,,,90,,26.64,percent of total billed charges,,,,,,,no IP contract,,80,,23.68,percent of total billed charges,,,,,,,no IP contract,,50,,14.8,percent of total billed charges,,,,,,no IP contract,,,78,,23.09,percent of total billed charges,,,70,,20.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.5,3324,
13107-0109-01 - HYDROmorphone 8 mg Tab,13107-0109-01,NDC,,,,inpatient,1,EA,14.8,8.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.58,percent of total billed charges,,,85,,12.58,percent of total billed charges,,,49,,7.25,percent of total billed charges,,,90,,13.32,percent of total billed charges,,,,,,,no IP contract,,80,,11.84,percent of total billed charges,,,,,,,no IP contract,,50,,7.4,percent of total billed charges,,,,,,no IP contract,,,78,,11.54,percent of total billed charges,,,70,,10.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.25,3324,
13517-0113-01 - PHENobarbital 97.2 mg Tab,13517-0113-01,NDC,,,,inpatient,1,EA,15.25,9.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.96,percent of total billed charges,,,85,,12.96,percent of total billed charges,,,49,,7.47,percent of total billed charges,,,90,,13.73,percent of total billed charges,,,,,,,no IP contract,,80,,12.2,percent of total billed charges,,,,,,,no IP contract,,50,,7.63,percent of total billed charges,,,,,,no IP contract,,,78,,11.9,percent of total billed charges,,,70,,10.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.47,3324,
13517-0627-01 - PHENobarbital 64.8 mg Tab,13517-0627-01,NDC,,,,inpatient,1,EA,12.4,7.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.54,percent of total billed charges,,,85,,10.54,percent of total billed charges,,,49,,6.08,percent of total billed charges,,,90,,11.16,percent of total billed charges,,,,,,,no IP contract,,80,,9.92,percent of total billed charges,,,,,,,no IP contract,,50,,6.2,percent of total billed charges,,,,,,no IP contract,,,78,,9.67,percent of total billed charges,,,70,,8.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.08,3324,
13517-0691-01 - PHENobarbital 15 mg Tab,13517-0691-01,NDC,,,,inpatient,1,EA,8.25,4.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.01,percent of total billed charges,,,85,,7.01,percent of total billed charges,,,49,,4.04,percent of total billed charges,,,90,,7.43,percent of total billed charges,,,,,,,no IP contract,,80,,6.6,percent of total billed charges,,,,,,,no IP contract,,50,,4.13,percent of total billed charges,,,,,,no IP contract,,,78,,6.44,percent of total billed charges,,,70,,5.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.04,3324,
13517-0694-01 - PHENobarbital 100 mg Tab,13517-0694-01,NDC,,,,inpatient,1,EA,11.6,6.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.86,percent of total billed charges,,,85,,9.86,percent of total billed charges,,,49,,5.68,percent of total billed charges,,,90,,10.44,percent of total billed charges,,,,,,,no IP contract,,80,,9.28,percent of total billed charges,,,,,,,no IP contract,,50,,5.8,percent of total billed charges,,,,,,no IP contract,,,78,,9.05,percent of total billed charges,,,70,,8.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.68,3324,
13517-0755-01 - PHENobarbital 15 mg Tab,13517-0755-01,NDC,,,,inpatient,1,EA,8.25,4.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.01,percent of total billed charges,,,85,,7.01,percent of total billed charges,,,49,,4.04,percent of total billed charges,,,90,,7.43,percent of total billed charges,,,,,,,no IP contract,,80,,6.6,percent of total billed charges,,,,,,,no IP contract,,50,,4.13,percent of total billed charges,,,,,,no IP contract,,,78,,6.44,percent of total billed charges,,,70,,5.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.04,3324,
13517-0758-01 - PHENobarbital 100 mg Tab,13517-0758-01,NDC,,,,inpatient,1,EA,11.6,6.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.86,percent of total billed charges,,,85,,9.86,percent of total billed charges,,,49,,5.68,percent of total billed charges,,,90,,10.44,percent of total billed charges,,,,,,,no IP contract,,80,,9.28,percent of total billed charges,,,,,,,no IP contract,,50,,5.8,percent of total billed charges,,,,,,no IP contract,,,78,,9.05,percent of total billed charges,,,70,,8.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.68,3324,
13533-0131-01 - tetanus-diphth toxoids (Td) adult/adol 2 units-2 units/0.5 mL Susp,13533-0131-01,NDC,,,,inpatient,0.5,ML,251.35,150.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,203.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,213.65,percent of total billed charges,,,85,,213.65,percent of total billed charges,,,49,,123.16,percent of total billed charges,,,90,,226.22,percent of total billed charges,,,,,,,no IP contract,,80,,201.08,percent of total billed charges,,,,,,,no IP contract,,50,,125.68,percent of total billed charges,,,,,,no IP contract,,,78,,196.05,percent of total billed charges,,,70,,175.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,123.16,3324,
13668-0010-01 - citalopram 20 mg Tab,13668-0010-01,NDC,,,,inpatient,1,EA,25.2,15.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.42,percent of total billed charges,,,85,,21.42,percent of total billed charges,,,49,,12.35,percent of total billed charges,,,90,,22.68,percent of total billed charges,,,,,,,no IP contract,,80,,20.16,percent of total billed charges,,,,,,,no IP contract,,50,,12.6,percent of total billed charges,,,,,,no IP contract,,,78,,19.66,percent of total billed charges,,,70,,17.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.35,3324,
13668-0011-01 - citalopram 40 mg Tab,13668-0011-01,NDC,,,,inpatient,1,EA,25.95,15.57,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.06,percent of total billed charges,,,85,,22.06,percent of total billed charges,,,49,,12.72,percent of total billed charges,,,90,,23.36,percent of total billed charges,,,,,,,no IP contract,,80,,20.76,percent of total billed charges,,,,,,,no IP contract,,50,,12.98,percent of total billed charges,,,,,,no IP contract,,,78,,20.24,percent of total billed charges,,,70,,18.17,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.72,3324,
13668-0016-12 - levetiracetam 750 mg Tab,13668-0016-12,NDC,,,,inpatient,1,EA,41.65,24.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,35.4,percent of total billed charges,,,85,,35.4,percent of total billed charges,,,49,,20.41,percent of total billed charges,,,90,,37.49,percent of total billed charges,,,,,,,no IP contract,,80,,33.32,percent of total billed charges,,,,,,,no IP contract,,50,,20.83,percent of total billed charges,,,,,,no IP contract,,,78,,32.49,percent of total billed charges,,,70,,29.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.41,3324,
13668-0049-60 - lamoTRIgine 200 mg Tab,13668-0049-60,NDC,,,,inpatient,1,EA,48.8,29.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,39.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,41.48,percent of total billed charges,,,85,,41.48,percent of total billed charges,,,49,,23.91,percent of total billed charges,,,90,,43.92,percent of total billed charges,,,,,,,no IP contract,,80,,39.04,percent of total billed charges,,,,,,,no IP contract,,50,,24.4,percent of total billed charges,,,,,,no IP contract,,,78,,38.06,percent of total billed charges,,,70,,34.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.91,3324,
13668-0091-90 - pramipexole 0.125 mg Tab,13668-0091-90,NDC,,,,inpatient,1,EA,27.3,16.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.21,percent of total billed charges,,,85,,23.21,percent of total billed charges,,,49,,13.38,percent of total billed charges,,,90,,24.57,percent of total billed charges,,,,,,,no IP contract,,80,,21.84,percent of total billed charges,,,,,,,no IP contract,,50,,13.65,percent of total billed charges,,,,,,no IP contract,,,78,,21.29,percent of total billed charges,,,70,,19.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.38,3324,
13668-0093-90 - pramipexole 0.5 mg Tab,13668-0093-90,NDC,,,,inpatient,1,EA,27.3,16.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.21,percent of total billed charges,,,85,,23.21,percent of total billed charges,,,49,,13.38,percent of total billed charges,,,90,,24.57,percent of total billed charges,,,,,,,no IP contract,,80,,21.84,percent of total billed charges,,,,,,,no IP contract,,50,,13.65,percent of total billed charges,,,,,,no IP contract,,,78,,21.29,percent of total billed charges,,,70,,19.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.38,3324,
13668-0094-90 - pramipexole 1 mg Tab,13668-0094-90,NDC,,,,inpatient,1,EA,27.3,16.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.21,percent of total billed charges,,,85,,23.21,percent of total billed charges,,,49,,13.38,percent of total billed charges,,,90,,24.57,percent of total billed charges,,,,,,,no IP contract,,80,,21.84,percent of total billed charges,,,,,,,no IP contract,,50,,13.65,percent of total billed charges,,,,,,no IP contract,,,78,,21.29,percent of total billed charges,,,70,,19.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.38,3324,
13668-0095-90 - pramipexole 1.5 mg Tab,13668-0095-90,NDC,,,,inpatient,1,EA,27.3,16.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.21,percent of total billed charges,,,85,,23.21,percent of total billed charges,,,49,,13.38,percent of total billed charges,,,90,,24.57,percent of total billed charges,,,,,,,no IP contract,,80,,21.84,percent of total billed charges,,,,,,,no IP contract,,50,,13.65,percent of total billed charges,,,,,,no IP contract,,,78,,21.29,percent of total billed charges,,,70,,19.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.38,3324,
13668-0181-90 - rosuvastatin 20 mg Tab,13668-0181-90,NDC,,,,inpatient,1,EA,74.9,44.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63.67,percent of total billed charges,,,85,,63.67,percent of total billed charges,,,49,,36.7,percent of total billed charges,,,90,,67.41,percent of total billed charges,,,,,,,no IP contract,,80,,59.92,percent of total billed charges,,,,,,,no IP contract,,50,,37.45,percent of total billed charges,,,,,,no IP contract,,,78,,58.42,percent of total billed charges,,,70,,52.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.7,3324,
13668-0190-30 - tolterodine 4 mg ER Ca,13668-0190-30,NDC,,,,inpatient,1,EA,79.75,47.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,64.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,67.79,percent of total billed charges,,,85,,67.79,percent of total billed charges,,,49,,39.08,percent of total billed charges,,,90,,71.78,percent of total billed charges,,,,,,,no IP contract,,80,,63.8,percent of total billed charges,,,,,,,no IP contract,,50,,39.88,percent of total billed charges,,,,,,no IP contract,,,78,,62.21,percent of total billed charges,,,70,,55.83,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,39.08,3324,
13668-0216-30 - ARIPiprazole 2 mg Tab,13668-0216-30,NDC,,,,inpatient,1,EA,259.1,155.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,209.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,220.24,percent of total billed charges,,,85,,220.24,percent of total billed charges,,,49,,126.96,percent of total billed charges,,,90,,233.19,percent of total billed charges,,,,,,,no IP contract,,80,,207.28,percent of total billed charges,,,,,,,no IP contract,,50,,129.55,percent of total billed charges,,,,,,no IP contract,,,78,,202.1,percent of total billed charges,,,70,,181.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,126.96,3324,
traZODone 50 mg Tab,13668-0330-01,NDC,,,,inpatient,1,EA,12.35,7.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.5,percent of total billed charges,,,85,,10.5,percent of total billed charges,,,49,,6.05,percent of total billed charges,,,90,,11.12,percent of total billed charges,,,,,,,no IP contract,,80,,9.88,percent of total billed charges,,,,,,,no IP contract,,50,,6.18,percent of total billed charges,,,,,,no IP contract,,,78,,9.63,percent of total billed charges,,,70,,8.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.05,3324,
13668-0484-50 - minocycline 100 mg Cap,13668-0484-50,NDC,,,,inpatient,1,EA,17.35,10.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.75,percent of total billed charges,,,85,,14.75,percent of total billed charges,,,49,,8.5,percent of total billed charges,,,90,,15.62,percent of total billed charges,,,,,,,no IP contract,,80,,13.88,percent of total billed charges,,,,,,,no IP contract,,50,,8.68,percent of total billed charges,,,,,,no IP contract,,,78,,13.53,percent of total billed charges,,,70,,12.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.5,3324,
13811-0515-10 - multivitamin Vitamin B Complex with C and Folic Acid Tab,13811-0515-10,NDC,,,,inpatient,1,EA,7.3,4.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.21,percent of total billed charges,,,85,,6.21,percent of total billed charges,,,49,,3.58,percent of total billed charges,,,90,,6.57,percent of total billed charges,,,,,,,no IP contract,,80,,5.84,percent of total billed charges,,,,,,,no IP contract,,50,,3.65,percent of total billed charges,,,,,,no IP contract,,,78,,5.69,percent of total billed charges,,,70,,5.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.58,3324,
13811-0677-30 - leflunomide 10 mg Tab,13811-0677-30,NDC,,,,inpatient,1,EA,54,32.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,43.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,45.9,percent of total billed charges,,,85,,45.9,percent of total billed charges,,,49,,26.46,percent of total billed charges,,,90,,48.6,percent of total billed charges,,,,,,,no IP contract,,80,,43.2,percent of total billed charges,,,,,,,no IP contract,,50,,27,percent of total billed charges,,,,,,no IP contract,,,78,,42.12,percent of total billed charges,,,70,,37.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.46,3324,
13811-0679-30 - aripiprazole 2 mg Tab,13811-0679-30,NDC,,,,inpatient,1,EA,258.85,155.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,209.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,220.02,percent of total billed charges,,,85,,220.02,percent of total billed charges,,,49,,126.84,percent of total billed charges,,,90,,232.97,percent of total billed charges,,,,,,,no IP contract,,80,,207.08,percent of total billed charges,,,,,,,no IP contract,,50,,129.43,percent of total billed charges,,,,,,no IP contract,,,78,,201.9,percent of total billed charges,,,70,,181.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,126.84,3324,
13811-0680-30 - aripiprazole 5 mg Tab,13811-0680-30,NDC,,,,inpatient,1,EA,258.8,155.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,209.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,219.98,percent of total billed charges,,,85,,219.98,percent of total billed charges,,,49,,126.81,percent of total billed charges,,,90,,232.92,percent of total billed charges,,,,,,,no IP contract,,80,,207.04,percent of total billed charges,,,,,,,no IP contract,,50,,129.4,percent of total billed charges,,,,,,no IP contract,,,78,,201.86,percent of total billed charges,,,70,,181.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,126.81,3324,
14539-0653-01 - oxybutynin 5 mg Tab,14539-0653-01,NDC,,,,inpatient,1,EA,6.05,3.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.14,percent of total billed charges,,,85,,5.14,percent of total billed charges,,,49,,2.96,percent of total billed charges,,,90,,5.45,percent of total billed charges,,,,,,,no IP contract,,80,,4.84,percent of total billed charges,,,,,,,no IP contract,,50,,3.03,percent of total billed charges,,,,,,no IP contract,,,78,,4.72,percent of total billed charges,,,70,,4.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.96,3324,
hydrOXYzine pamoate 25 mg Cap,14539-0674-01,NDC,,,,inpatient,1,EA,6.2,3.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.27,percent of total billed charges,,,85,,5.27,percent of total billed charges,,,49,,3.04,percent of total billed charges,,,90,,5.58,percent of total billed charges,,,,,,,no IP contract,,80,,4.96,percent of total billed charges,,,,,,,no IP contract,,50,,3.1,percent of total billed charges,,,,,,no IP contract,,,78,,4.84,percent of total billed charges,,,70,,4.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.04,3324,
potassium chloride 20 mEq/100 mL Soln,14789-0108-10,NDC,,,,inpatient,1,ML,458.25,274.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,371.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,389.51,percent of total billed charges,,,85,,389.51,percent of total billed charges,,,49,,224.54,percent of total billed charges,,,90,,412.43,percent of total billed charges,,,,,,,no IP contract,,80,,366.6,percent of total billed charges,,,,,,,no IP contract,,50,,229.13,percent of total billed charges,,,,,,no IP contract,,,78,,357.44,percent of total billed charges,,,70,,320.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,224.54,3324,
abobotulinumtoxinA 500 units REC I,15054-0500-01,NDC,,,,inpatient,1,EA,3214.25,1928.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2603.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2732.11,percent of total billed charges,,,85,,2732.11,percent of total billed charges,,,49,,1574.98,percent of total billed charges,,,90,,2892.83,percent of total billed charges,,,,,,,no IP contract,,80,,2571.4,percent of total billed charges,,,,,,,no IP contract,,50,,1607.13,percent of total billed charges,,,,,,no IP contract,,,78,,2507.12,percent of total billed charges,,,70,,2249.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
abobotulinumtoxinA 300 units REC I,15054-0530-06,NDC,,,,inpatient,1,EA,1928.9,1157.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1562.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1639.57,percent of total billed charges,,,85,,1639.57,percent of total billed charges,,,49,,945.16,percent of total billed charges,,,90,,1736.01,percent of total billed charges,,,,,,,no IP contract,,80,,1543.12,percent of total billed charges,,,,,,,no IP contract,,50,,964.45,percent of total billed charges,,,,,,no IP contract,,,78,,1504.54,percent of total billed charges,,,70,,1350.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,945.16,3324,
15456-0980-04 - trospium 20 mg Tab,15456-0980-04,NDC,,,,inpatient,1,EA,22.75,13.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.34,percent of total billed charges,,,85,,19.34,percent of total billed charges,,,49,,11.15,percent of total billed charges,,,90,,20.48,percent of total billed charges,,,,,,,no IP contract,,80,,18.2,percent of total billed charges,,,,,,,no IP contract,,50,,11.38,percent of total billed charges,,,,,,no IP contract,,,78,,17.75,percent of total billed charges,,,70,,15.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.15,3324,
15584-0101-01 - efavirenz/emtricitabine/tenofovir 600 mg-200 mg-300 mg Tab,15584-0101-01,NDC,,,,inpatient,1,EA,589.5,353.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,477.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,501.08,percent of total billed charges,,,85,,501.08,percent of total billed charges,,,49,,288.86,percent of total billed charges,,,90,,530.55,percent of total billed charges,,,,,,,no IP contract,,80,,471.6,percent of total billed charges,,,,,,,no IP contract,,50,,294.75,percent of total billed charges,,,,,,no IP contract,,,78,,459.81,percent of total billed charges,,,70,,412.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,288.86,3324,
16252-0540-01 - isradipine 5 mg Cap,16252-0540-01,NDC,,,,inpatient,1,EA,2,1.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1.7,percent of total billed charges,,,85,,1.7,percent of total billed charges,,,49,,0.98,percent of total billed charges,,,90,,1.8,percent of total billed charges,,,,,,,no IP contract,,80,,1.6,percent of total billed charges,,,,,,,no IP contract,,50,,1,percent of total billed charges,,,,,,no IP contract,,,78,,1.56,percent of total billed charges,,,70,,1.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,0.98,3324,
16252-0601-02 - alendronate 70 mg Tab,16252-0601-02,NDC,,,,inpatient,1,EA,165.85,99.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,134.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,140.97,percent of total billed charges,,,85,,140.97,percent of total billed charges,,,49,,81.27,percent of total billed charges,,,90,,149.27,percent of total billed charges,,,,,,,no IP contract,,80,,132.68,percent of total billed charges,,,,,,,no IP contract,,50,,82.93,percent of total billed charges,,,,,,no IP contract,,,78,,129.36,percent of total billed charges,,,70,,116.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,81.27,3324,
16500-0079-09 - multivitamin with iron Multiple Vitamins with Iron Chew,16500-0079-09,NDC,,,,inpatient,1,EA,4.8,2.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.08,percent of total billed charges,,,85,,4.08,percent of total billed charges,,,49,,2.35,percent of total billed charges,,,90,,4.32,percent of total billed charges,,,,,,,no IP contract,,80,,3.84,percent of total billed charges,,,,,,,no IP contract,,50,,2.4,percent of total billed charges,,,,,,no IP contract,,,78,,3.74,percent of total billed charges,,,70,,3.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.35,3324,
16500-0599-20 - Multiple Vitamins with Iron Chew,16500-0599-20,NDC,,,,inpatient,1,EA,4.85,2.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.12,percent of total billed charges,,,85,,4.12,percent of total billed charges,,,49,,2.38,percent of total billed charges,,,90,,4.37,percent of total billed charges,,,,,,,no IP contract,,80,,3.88,percent of total billed charges,,,,,,,no IP contract,,50,,2.43,percent of total billed charges,,,,,,no IP contract,,,78,,3.78,percent of total billed charges,,,70,,3.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.38,3324,
16571-0401-10 - cetirizine 5 mg Tab,16571-0401-10,NDC,,,,inpatient,1,EA,23.6,14.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.06,percent of total billed charges,,,85,,20.06,percent of total billed charges,,,49,,11.56,percent of total billed charges,,,90,,21.24,percent of total billed charges,,,,,,,no IP contract,,80,,18.88,percent of total billed charges,,,,,,,no IP contract,,50,,11.8,percent of total billed charges,,,,,,no IP contract,,,78,,18.41,percent of total billed charges,,,70,,16.52,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.56,3324,
16571-0657-10 - cevimeline 30 mg Cap,16571-0657-10,NDC,,,,inpatient,1,EA,31.5,18.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,25.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.78,percent of total billed charges,,,85,,26.78,percent of total billed charges,,,49,,15.44,percent of total billed charges,,,90,,28.35,percent of total billed charges,,,,,,,no IP contract,,80,,25.2,percent of total billed charges,,,,,,,no IP contract,,50,,15.75,percent of total billed charges,,,,,,no IP contract,,,78,,24.57,percent of total billed charges,,,70,,22.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.44,3324,
16571-0667-01 - PHENobarbital 64.8 mg Tab,16571-0667-01,NDC,,,,inpatient,1,EA,12.4,7.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.54,percent of total billed charges,,,85,,10.54,percent of total billed charges,,,49,,6.08,percent of total billed charges,,,90,,11.16,percent of total billed charges,,,,,,,no IP contract,,80,,9.92,percent of total billed charges,,,,,,,no IP contract,,50,,6.2,percent of total billed charges,,,,,,no IP contract,,,78,,9.67,percent of total billed charges,,,70,,8.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.08,3324,
16571-0668-01 - PHENobarbital 97.2 mg Tab,16571-0668-01,NDC,,,,inpatient,1,EA,15.25,9.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.96,percent of total billed charges,,,85,,12.96,percent of total billed charges,,,49,,7.47,percent of total billed charges,,,90,,13.73,percent of total billed charges,,,,,,,no IP contract,,80,,12.2,percent of total billed charges,,,,,,,no IP contract,,50,,7.63,percent of total billed charges,,,,,,no IP contract,,,78,,11.9,percent of total billed charges,,,70,,10.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.47,3324,
16571-0669-01 - PHENobarbital 100 mg Tab,16571-0669-01,NDC,,,,inpatient,1,EA,11.6,6.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.86,percent of total billed charges,,,85,,9.86,percent of total billed charges,,,49,,5.68,percent of total billed charges,,,90,,10.44,percent of total billed charges,,,,,,,no IP contract,,80,,9.28,percent of total billed charges,,,,,,,no IP contract,,50,,5.8,percent of total billed charges,,,,,,no IP contract,,,78,,9.05,percent of total billed charges,,,70,,8.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.68,3324,
PHENobarbital 16.2 mg Tab,16571-0671-01,NDC,,,,inpatient,1,EA,9.85,5.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.37,percent of total billed charges,,,85,,8.37,percent of total billed charges,,,49,,4.83,percent of total billed charges,,,90,,8.87,percent of total billed charges,,,,,,,no IP contract,,80,,7.88,percent of total billed charges,,,,,,,no IP contract,,50,,4.93,percent of total billed charges,,,,,,no IP contract,,,78,,7.68,percent of total billed charges,,,70,,6.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.83,3324,
16571-0762-09 - levOCARNitine 330 mg Tab,16571-0762-09,NDC,,,,inpatient,1,EA,12.55,7.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.67,percent of total billed charges,,,85,,10.67,percent of total billed charges,,,49,,6.15,percent of total billed charges,,,90,,11.3,percent of total billed charges,,,,,,,no IP contract,,80,,10.04,percent of total billed charges,,,,,,,no IP contract,,50,,6.28,percent of total billed charges,,,,,,no IP contract,,,78,,9.79,percent of total billed charges,,,70,,8.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.15,3324,
enoxaparin 60 mg/0.6 mL Soln,16714-0026-10,NDC,,,,inpatient,1,EA,208.85,125.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,169.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,177.52,percent of total billed charges,,,85,,177.52,percent of total billed charges,,,49,,102.34,percent of total billed charges,,,90,,187.97,percent of total billed charges,,,,,,,no IP contract,,80,,167.08,percent of total billed charges,,,,,,,no IP contract,,50,,104.43,percent of total billed charges,,,,,,no IP contract,,,78,,162.9,percent of total billed charges,,,70,,146.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,102.34,3324,
enoxaparin 80 mg/0.8 mL Soln,16714-0036-10,NDC,,,,inpatient,1,EA,210.65,126.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,170.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,179.05,percent of total billed charges,,,85,,179.05,percent of total billed charges,,,49,,103.22,percent of total billed charges,,,90,,189.59,percent of total billed charges,,,,,,,no IP contract,,80,,168.52,percent of total billed charges,,,,,,,no IP contract,,50,,105.33,percent of total billed charges,,,,,,no IP contract,,,78,,164.31,percent of total billed charges,,,70,,147.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,103.22,3324,
vancomycin 500 mg REC I,16714-0247-10,NDC,,,,inpatient,1,EA,125.5,75.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,101.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,106.68,percent of total billed charges,,,85,,106.68,percent of total billed charges,,,49,,61.5,percent of total billed charges,,,90,,112.95,percent of total billed charges,,,,,,,no IP contract,,80,,100.4,percent of total billed charges,,,,,,,no IP contract,,50,,62.75,percent of total billed charges,,,,,,no IP contract,,,78,,97.89,percent of total billed charges,,,70,,87.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,61.5,3324,
16714-0453-02 - QUEtiapine 50 mg Tab,16714-0453-02,NDC,,,,inpatient,1,EA,55.65,33.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,45.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,47.3,percent of total billed charges,,,85,,47.3,percent of total billed charges,,,49,,27.27,percent of total billed charges,,,90,,50.09,percent of total billed charges,,,,,,,no IP contract,,80,,44.52,percent of total billed charges,,,,,,,no IP contract,,50,,27.83,percent of total billed charges,,,,,,no IP contract,,,78,,43.41,percent of total billed charges,,,70,,38.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.27,3324,
16714-0496-02 - betamethasone-clotrimazole topical 0.05%-1% Cream,16714-0496-02,NDC,,,,inpatient,1,UN,605.25,363.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,490.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,514.46,percent of total billed charges,,,85,,514.46,percent of total billed charges,,,49,,296.57,percent of total billed charges,,,90,,544.73,percent of total billed charges,,,,,,,no IP contract,,80,,484.2,percent of total billed charges,,,,,,,no IP contract,,50,,302.63,percent of total billed charges,,,,,,no IP contract,,,78,,472.1,percent of total billed charges,,,70,,423.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,296.57,3324,
ipratropium nasal 42 mcg/inh Spray,16714-0527-01,NDC,,,,inpatient,1,EA,651.45,390.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,527.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,553.73,percent of total billed charges,,,85,,553.73,percent of total billed charges,,,49,,319.21,percent of total billed charges,,,90,,586.31,percent of total billed charges,,,,,,,no IP contract,,80,,521.16,percent of total billed charges,,,,,,,no IP contract,,50,,325.73,percent of total billed charges,,,,,,no IP contract,,,78,,508.13,percent of total billed charges,,,70,,456.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,319.21,3324,
dexmethylphenidate 20 mg ER Ca,16714-0565-01,NDC,,,,inpatient,1,EA,83.4,50.04,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,67.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,70.89,percent of total billed charges,,,85,,70.89,percent of total billed charges,,,49,,40.87,percent of total billed charges,,,90,,75.06,percent of total billed charges,,,,,,,no IP contract,,80,,66.72,percent of total billed charges,,,,,,,no IP contract,,50,,41.7,percent of total billed charges,,,,,,no IP contract,,,78,,65.05,percent of total billed charges,,,70,,58.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,40.87,3324,
16714-0601-02 - sertraline 20 mg/mL Conc,16714-0601-02,NDC,,,,inpatient,1,ML,14.75,8.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.54,percent of total billed charges,,,85,,12.54,percent of total billed charges,,,49,,7.23,percent of total billed charges,,,90,,13.28,percent of total billed charges,,,,,,,no IP contract,,80,,11.8,percent of total billed charges,,,,,,,no IP contract,,50,,7.38,percent of total billed charges,,,,,,no IP contract,,,78,,11.51,percent of total billed charges,,,70,,10.33,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.23,3324,
ciprofloxacin-dexamethasone otic 0.3%-0.1% Susp,16714-0628-01,NDC,,,,inpatient,1,EA,2333.9,1400.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1890.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1983.82,percent of total billed charges,,,85,,1983.82,percent of total billed charges,,,49,,1143.61,percent of total billed charges,,,90,,2100.51,percent of total billed charges,,,,,,,no IP contract,,80,,1867.12,percent of total billed charges,,,,,,,no IP contract,,50,,1166.95,percent of total billed charges,,,,,,no IP contract,,,78,,1820.44,percent of total billed charges,,,70,,1633.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
16714-0632-01 - alendronate 35 mg Tab,16714-0632-01,NDC,,,,inpatient,1,EA,167.85,100.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,135.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,142.67,percent of total billed charges,,,85,,142.67,percent of total billed charges,,,49,,82.25,percent of total billed charges,,,90,,151.07,percent of total billed charges,,,,,,,no IP contract,,80,,134.28,percent of total billed charges,,,,,,,no IP contract,,50,,83.93,percent of total billed charges,,,,,,no IP contract,,,78,,130.92,percent of total billed charges,,,70,,117.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,82.25,3324,
16714-0633-01 - alendronate 70 mg Tab,16714-0633-01,NDC,,,,inpatient,1,EA,166.1,99.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,134.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,141.19,percent of total billed charges,,,85,,141.19,percent of total billed charges,,,49,,81.39,percent of total billed charges,,,90,,149.49,percent of total billed charges,,,,,,,no IP contract,,80,,132.88,percent of total billed charges,,,,,,,no IP contract,,50,,83.05,percent of total billed charges,,,,,,no IP contract,,,78,,129.56,percent of total billed charges,,,70,,116.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,81.39,3324,
pioglitazone 45 mg Tab,16714-0647-01,NDC,,,,inpatient,1,EA,96.2,57.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,77.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,81.77,percent of total billed charges,,,85,,81.77,percent of total billed charges,,,49,,47.14,percent of total billed charges,,,90,,86.58,percent of total billed charges,,,,,,,no IP contract,,80,,76.96,percent of total billed charges,,,,,,,no IP contract,,50,,48.1,percent of total billed charges,,,,,,no IP contract,,,78,,75.04,percent of total billed charges,,,70,,67.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,47.14,3324,
simvastatin 10 mg Tab,16714-0682-02,NDC,,,,inpatient,1,EA,25.85,15.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.97,percent of total billed charges,,,85,,21.97,percent of total billed charges,,,49,,12.67,percent of total billed charges,,,90,,23.27,percent of total billed charges,,,,,,,no IP contract,,80,,20.68,percent of total billed charges,,,,,,,no IP contract,,50,,12.93,percent of total billed charges,,,,,,no IP contract,,,78,,20.16,percent of total billed charges,,,70,,18.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.67,3324,
rasagiline 0.5 mg Tab,16714-0770-01,NDC,,,,inpatient,1,EA,202.5,121.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,164.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,172.13,percent of total billed charges,,,85,,172.13,percent of total billed charges,,,49,,99.23,percent of total billed charges,,,90,,182.25,percent of total billed charges,,,,,,,no IP contract,,80,,162,percent of total billed charges,,,,,,,no IP contract,,50,,101.25,percent of total billed charges,,,,,,no IP contract,,,78,,157.95,percent of total billed charges,,,70,,141.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,99.23,3324,
rasagiline 1 mg Tab,16714-0771-01,NDC,,,,inpatient,1,EA,202.5,121.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,164.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,172.13,percent of total billed charges,,,85,,172.13,percent of total billed charges,,,49,,99.23,percent of total billed charges,,,90,,182.25,percent of total billed charges,,,,,,,no IP contract,,80,,162,percent of total billed charges,,,,,,,no IP contract,,50,,101.25,percent of total billed charges,,,,,,no IP contract,,,78,,157.95,percent of total billed charges,,,70,,141.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,99.23,3324,
triamcinolone topical 0.1% Cream,16714-0986-04,NDC,,,,inpatient,1,EA,236.15,141.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,191.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,200.73,percent of total billed charges,,,85,,200.73,percent of total billed charges,,,49,,115.71,percent of total billed charges,,,90,,212.54,percent of total billed charges,,,,,,,no IP contract,,80,,188.92,percent of total billed charges,,,,,,,no IP contract,,50,,118.08,percent of total billed charges,,,,,,no IP contract,,,78,,184.2,percent of total billed charges,,,70,,165.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,115.71,3324,
16729-0019-01 - mycophenolate mofetil 500 mg Tab,16729-0019-01,NDC,,,,inpatient,1,EA,26.25,15.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.31,percent of total billed charges,,,85,,22.31,percent of total billed charges,,,49,,12.86,percent of total billed charges,,,90,,23.63,percent of total billed charges,,,,,,,no IP contract,,80,,21,percent of total billed charges,,,,,,,no IP contract,,50,,13.13,percent of total billed charges,,,,,,no IP contract,,,78,,20.48,percent of total billed charges,,,70,,18.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.86,3324,
16729-0022-15 - pioglitazone 45 mg Tab,16729-0022-15,NDC,,,,inpatient,1,EA,96.2,57.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,77.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,81.77,percent of total billed charges,,,85,,81.77,percent of total billed charges,,,49,,47.14,percent of total billed charges,,,90,,86.58,percent of total billed charges,,,,,,,no IP contract,,80,,76.96,percent of total billed charges,,,,,,,no IP contract,,50,,48.1,percent of total billed charges,,,,,,no IP contract,,,78,,75.04,percent of total billed charges,,,70,,67.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,47.14,3324,
16729-0023-10 - bicalutamide 50 mg Tab,16729-0023-10,NDC,,,,inpatient,1,EA,149.7,89.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,121.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,127.25,percent of total billed charges,,,85,,127.25,percent of total billed charges,,,49,,73.35,percent of total billed charges,,,90,,134.73,percent of total billed charges,,,,,,,no IP contract,,80,,119.76,percent of total billed charges,,,,,,,no IP contract,,50,,74.85,percent of total billed charges,,,,,,no IP contract,,,78,,116.77,percent of total billed charges,,,70,,104.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,73.35,3324,
16729-0034-10 - letrozole 2.5 mg Tab,16729-0034-10,NDC,,,,inpatient,1,EA,147.3,88.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,119.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,125.21,percent of total billed charges,,,85,,125.21,percent of total billed charges,,,49,,72.18,percent of total billed charges,,,90,,132.57,percent of total billed charges,,,,,,,no IP contract,,80,,117.84,percent of total billed charges,,,,,,,no IP contract,,50,,73.65,percent of total billed charges,,,,,,no IP contract,,,78,,114.89,percent of total billed charges,,,70,,103.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,72.18,3324,
16729-0034-15 - letrozole 2.5 mg Tab,16729-0034-15,NDC,,,,inpatient,1,EA,147.3,88.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,119.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,125.21,percent of total billed charges,,,85,,125.21,percent of total billed charges,,,49,,72.18,percent of total billed charges,,,90,,132.57,percent of total billed charges,,,,,,,no IP contract,,80,,117.84,percent of total billed charges,,,,,,,no IP contract,,50,,73.65,percent of total billed charges,,,,,,no IP contract,,,78,,114.89,percent of total billed charges,,,70,,103.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,72.18,3324,
16729-0035-15 - anastrozole 1 mg Tab,16729-0035-15,NDC,,,,inpatient,1,EA,109.55,65.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,88.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,93.12,percent of total billed charges,,,85,,93.12,percent of total billed charges,,,49,,53.68,percent of total billed charges,,,90,,98.6,percent of total billed charges,,,,,,,no IP contract,,80,,87.64,percent of total billed charges,,,,,,,no IP contract,,50,,54.78,percent of total billed charges,,,,,,no IP contract,,,78,,85.45,percent of total billed charges,,,70,,76.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,53.68,3324,
16729-0041-01 - tacrolimus 0.5 mg Cap,16729-0041-01,NDC,,,,inpatient,1,EA,21.55,12.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.32,percent of total billed charges,,,85,,18.32,percent of total billed charges,,,49,,10.56,percent of total billed charges,,,90,,19.4,percent of total billed charges,,,,,,,no IP contract,,80,,17.24,percent of total billed charges,,,,,,,no IP contract,,50,,10.78,percent of total billed charges,,,,,,no IP contract,,,78,,16.81,percent of total billed charges,,,70,,15.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.56,3324,
16729-0042-01 - tacrolimus 1 mg Cap,16729-0042-01,NDC,,,,inpatient,1,EA,39.3,23.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.41,percent of total billed charges,,,85,,33.41,percent of total billed charges,,,49,,19.26,percent of total billed charges,,,90,,35.37,percent of total billed charges,,,,,,,no IP contract,,80,,31.44,percent of total billed charges,,,,,,,no IP contract,,50,,19.65,percent of total billed charges,,,,,,no IP contract,,,78,,30.65,percent of total billed charges,,,70,,27.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.26,3324,
16729-0043-01 - tacrolimus 5 mg Cap,16729-0043-01,NDC,,,,inpatient,1,EA,181.1,108.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,146.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,153.94,percent of total billed charges,,,85,,153.94,percent of total billed charges,,,49,,88.74,percent of total billed charges,,,90,,162.99,percent of total billed charges,,,,,,,no IP contract,,80,,144.88,percent of total billed charges,,,,,,,no IP contract,,50,,90.55,percent of total billed charges,,,,,,no IP contract,,,78,,141.26,percent of total billed charges,,,70,,126.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,88.74,3324,
16729-0048-54 - temozolomide 5 mg Cap,16729-0048-54,NDC,,,,inpatient,1,EA,118.8,71.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,96.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,100.98,percent of total billed charges,,,85,,100.98,percent of total billed charges,,,49,,58.21,percent of total billed charges,,,90,,106.92,percent of total billed charges,,,,,,,no IP contract,,80,,95.04,percent of total billed charges,,,,,,,no IP contract,,50,,59.4,percent of total billed charges,,,,,,no IP contract,,,78,,92.66,percent of total billed charges,,,70,,83.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.21,3324,
16729-0049-54 - temozolomide 20 mg Cap,16729-0049-54,NDC,,,,inpatient,1,EA,461.35,276.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,373.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,392.15,percent of total billed charges,,,85,,392.15,percent of total billed charges,,,49,,226.06,percent of total billed charges,,,90,,415.22,percent of total billed charges,,,,,,,no IP contract,,80,,369.08,percent of total billed charges,,,,,,,no IP contract,,50,,230.68,percent of total billed charges,,,,,,no IP contract,,,78,,359.85,percent of total billed charges,,,70,,322.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,226.06,3324,
16729-0050-54 - temozolomide 100 mg Cap,16729-0050-54,NDC,,,,inpatient,1,EA,2291.5,1374.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1856.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1947.78,percent of total billed charges,,,85,,1947.78,percent of total billed charges,,,49,,1122.84,percent of total billed charges,,,90,,2062.35,percent of total billed charges,,,,,,,no IP contract,,80,,1833.2,percent of total billed charges,,,,,,,no IP contract,,50,,1145.75,percent of total billed charges,,,,,,no IP contract,,,78,,1787.37,percent of total billed charges,,,70,,1604.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
16729-0090-01 - finasteride 5 mg Tab,16729-0090-01,NDC,,,,inpatient,1,EA,28.7,17.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.4,percent of total billed charges,,,85,,24.4,percent of total billed charges,,,49,,14.06,percent of total billed charges,,,90,,25.83,percent of total billed charges,,,,,,,no IP contract,,80,,22.96,percent of total billed charges,,,,,,,no IP contract,,50,,14.35,percent of total billed charges,,,,,,no IP contract,,,78,,22.39,percent of total billed charges,,,70,,20.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.06,3324,
16729-0094-01 - mycophenolate mofetil 250 mg Cap,16729-0094-01,NDC,,,,inpatient,1,EA,15.05,9.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.79,percent of total billed charges,,,85,,12.79,percent of total billed charges,,,49,,7.37,percent of total billed charges,,,90,,13.55,percent of total billed charges,,,,,,,no IP contract,,80,,12.04,percent of total billed charges,,,,,,,no IP contract,,50,,7.53,percent of total billed charges,,,,,,no IP contract,,,78,,11.74,percent of total billed charges,,,70,,10.54,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.37,3324,
16729-0136-00 - clonazePAM 0.5 mg Tab,16729-0136-00,NDC,,,,inpatient,1,EA,11.65,6.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.9,percent of total billed charges,,,85,,9.9,percent of total billed charges,,,49,,5.71,percent of total billed charges,,,90,,10.49,percent of total billed charges,,,,,,,no IP contract,,80,,9.32,percent of total billed charges,,,,,,,no IP contract,,50,,5.83,percent of total billed charges,,,,,,no IP contract,,,78,,9.09,percent of total billed charges,,,70,,8.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.71,3324,
16729-0137-00 - clonazePAM 1 mg Tab,16729-0137-00,NDC,,,,inpatient,1,EA,12.6,7.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.71,percent of total billed charges,,,85,,10.71,percent of total billed charges,,,49,,6.17,percent of total billed charges,,,90,,11.34,percent of total billed charges,,,,,,,no IP contract,,80,,10.08,percent of total billed charges,,,,,,,no IP contract,,50,,6.3,percent of total billed charges,,,,,,no IP contract,,,78,,9.83,percent of total billed charges,,,70,,8.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.17,3324,
16729-0169-01 - escitalopram 10 mg Tab,16729-0169-01,NDC,,,,inpatient,1,EA,41.35,24.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,35.15,percent of total billed charges,,,85,,35.15,percent of total billed charges,,,49,,20.26,percent of total billed charges,,,90,,37.22,percent of total billed charges,,,,,,,no IP contract,,80,,33.08,percent of total billed charges,,,,,,,no IP contract,,50,,20.68,percent of total billed charges,,,,,,no IP contract,,,78,,32.25,percent of total billed charges,,,70,,28.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.26,3324,
16729-0171-01 - amitriptyline 10 mg Tab,16729-0171-01,NDC,,,,inpatient,1,EA,6.35,3.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.4,percent of total billed charges,,,85,,5.4,percent of total billed charges,,,49,,3.11,percent of total billed charges,,,90,,5.72,percent of total billed charges,,,,,,,no IP contract,,80,,5.08,percent of total billed charges,,,,,,,no IP contract,,50,,3.18,percent of total billed charges,,,,,,no IP contract,,,78,,4.95,percent of total billed charges,,,70,,4.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.11,3324,
16729-0173-01 - amitriptyline 50 mg Tab,16729-0173-01,NDC,,,,inpatient,1,EA,13.9,8.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.82,percent of total billed charges,,,85,,11.82,percent of total billed charges,,,49,,6.81,percent of total billed charges,,,90,,12.51,percent of total billed charges,,,,,,,no IP contract,,80,,11.12,percent of total billed charges,,,,,,,no IP contract,,50,,6.95,percent of total billed charges,,,,,,no IP contract,,,78,,10.84,percent of total billed charges,,,70,,9.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.81,3324,
16729-0174-01 - amitriptyline 75 mg Tab,16729-0174-01,NDC,,,,inpatient,1,EA,19,11.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.15,percent of total billed charges,,,85,,16.15,percent of total billed charges,,,49,,9.31,percent of total billed charges,,,90,,17.1,percent of total billed charges,,,,,,,no IP contract,,80,,15.2,percent of total billed charges,,,,,,,no IP contract,,50,,9.5,percent of total billed charges,,,,,,no IP contract,,,78,,14.82,percent of total billed charges,,,70,,13.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.31,3324,
16729-0175-01 - amitriptyline 100 mg Tab,16729-0175-01,NDC,,,,inpatient,1,EA,24,14.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.4,percent of total billed charges,,,85,,20.4,percent of total billed charges,,,49,,11.76,percent of total billed charges,,,90,,21.6,percent of total billed charges,,,,,,,no IP contract,,80,,19.2,percent of total billed charges,,,,,,,no IP contract,,50,,12,percent of total billed charges,,,,,,no IP contract,,,78,,18.72,percent of total billed charges,,,70,,16.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.76,3324,
16729-0183-01 - hydroCHLOROthiazide 25 mg Tab,16729-0183-01,NDC,,,,inpatient,1,EA,4.45,2.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.78,percent of total billed charges,,,85,,3.78,percent of total billed charges,,,49,,2.18,percent of total billed charges,,,90,,4.01,percent of total billed charges,,,,,,,no IP contract,,80,,3.56,percent of total billed charges,,,,,,,no IP contract,,50,,2.23,percent of total billed charges,,,,,,no IP contract,,,78,,3.47,percent of total billed charges,,,70,,3.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.18,3324,
16729-0189-29 - mycophenolic acid 360 mg EC Ta,16729-0189-29,NDC,,,,inpatient,1,EA,76.5,45.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,61.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,65.03,percent of total billed charges,,,85,,65.03,percent of total billed charges,,,49,,37.49,percent of total billed charges,,,90,,68.85,percent of total billed charges,,,,,,,no IP contract,,80,,61.2,percent of total billed charges,,,,,,,no IP contract,,50,,38.25,percent of total billed charges,,,,,,no IP contract,,,78,,59.67,percent of total billed charges,,,70,,53.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,37.49,3324,
16729-0226-01 - spironolactone 50 mg Tab,16729-0226-01,NDC,,,,inpatient,1,EA,10.35,6.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.8,percent of total billed charges,,,85,,8.8,percent of total billed charges,,,49,,5.07,percent of total billed charges,,,90,,9.32,percent of total billed charges,,,,,,,no IP contract,,80,,8.28,percent of total billed charges,,,,,,,no IP contract,,50,,5.18,percent of total billed charges,,,,,,no IP contract,,,78,,8.07,percent of total billed charges,,,70,,7.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.07,3324,
16729-0261-29 - mycophenolic acid 180 mg EC Ta,16729-0261-29,NDC,,,,inpatient,1,EA,40.15,24.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34.13,percent of total billed charges,,,85,,34.13,percent of total billed charges,,,49,,19.67,percent of total billed charges,,,90,,36.14,percent of total billed charges,,,,,,,no IP contract,,80,,32.12,percent of total billed charges,,,,,,,no IP contract,,50,,20.08,percent of total billed charges,,,,,,no IP contract,,,78,,31.32,percent of total billed charges,,,70,,28.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.67,3324,
16729-0286-15 - rosuvastatin 20 mg Tab,16729-0286-15,NDC,,,,inpatient,1,EA,74.9,44.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63.67,percent of total billed charges,,,85,,63.67,percent of total billed charges,,,49,,36.7,percent of total billed charges,,,90,,67.41,percent of total billed charges,,,,,,,no IP contract,,80,,59.92,percent of total billed charges,,,,,,,no IP contract,,50,,37.45,percent of total billed charges,,,,,,no IP contract,,,78,,58.42,percent of total billed charges,,,70,,52.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.7,3324,
16729-0293-10 - eplerenone 25 mg Tab,16729-0293-10,NDC,,,,inpatient,1,EA,38.35,23.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.6,percent of total billed charges,,,85,,32.6,percent of total billed charges,,,49,,18.79,percent of total billed charges,,,90,,34.52,percent of total billed charges,,,,,,,no IP contract,,80,,30.68,percent of total billed charges,,,,,,,no IP contract,,50,,19.18,percent of total billed charges,,,,,,no IP contract,,,78,,29.91,percent of total billed charges,,,70,,26.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.79,3324,
16729-0422-12 - tacrolimus topical 0.1% Ointm,16729-0422-12,NDC,,,,inpatient,1,UN,2420.75,1452.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1960.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2057.64,percent of total billed charges,,,85,,2057.64,percent of total billed charges,,,49,,1186.17,percent of total billed charges,,,90,,2178.68,percent of total billed charges,,,,,,,no IP contract,,80,,1936.6,percent of total billed charges,,,,,,,no IP contract,,50,,1210.38,percent of total billed charges,,,,,,no IP contract,,,78,,1888.19,percent of total billed charges,,,70,,1694.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
16729-0440-10 - cinacalcet 30 mg Tab,16729-0440-10,NDC,,,,inpatient,1,EA,247.5,148.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,200.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,210.38,percent of total billed charges,,,85,,210.38,percent of total billed charges,,,49,,121.28,percent of total billed charges,,,90,,222.75,percent of total billed charges,,,,,,,no IP contract,,80,,198,percent of total billed charges,,,,,,,no IP contract,,50,,123.75,percent of total billed charges,,,,,,no IP contract,,,78,,193.05,percent of total billed charges,,,70,,173.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,121.28,3324,
16729-0440-15 - cinacalcet 30 mg Tab,16729-0440-15,NDC,,,,inpatient,1,EA,247.5,148.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,200.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,210.38,percent of total billed charges,,,85,,210.38,percent of total billed charges,,,49,,121.28,percent of total billed charges,,,90,,222.75,percent of total billed charges,,,,,,,no IP contract,,80,,198,percent of total billed charges,,,,,,,no IP contract,,50,,123.75,percent of total billed charges,,,,,,no IP contract,,,78,,193.05,percent of total billed charges,,,70,,173.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,121.28,3324,
16729-0443-15 - buPROPion 150 mg/24 hours ER Ta,16729-0443-15,NDC,,,,inpatient,1,EA,45.3,27.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,38.51,percent of total billed charges,,,85,,38.51,percent of total billed charges,,,49,,22.2,percent of total billed charges,,,90,,40.77,percent of total billed charges,,,,,,,no IP contract,,80,,36.24,percent of total billed charges,,,,,,,no IP contract,,50,,22.65,percent of total billed charges,,,,,,no IP contract,,,78,,35.33,percent of total billed charges,,,70,,31.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.2,3324,
16729-0444-10 - buPROPion 300 mg/24 hours ER Ta,16729-0444-10,NDC,,,,inpatient,1,EA,53.9,32.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,43.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,45.82,percent of total billed charges,,,85,,45.82,percent of total billed charges,,,49,,26.41,percent of total billed charges,,,90,,48.51,percent of total billed charges,,,,,,,no IP contract,,80,,43.12,percent of total billed charges,,,,,,,no IP contract,,50,,26.95,percent of total billed charges,,,,,,no IP contract,,,78,,42.04,percent of total billed charges,,,70,,37.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.41,3324,
16729-0486-01 - methotrexate 2.5 mg Tab,16729-0486-01,NDC,,,,inpatient,1,EA,35.7,21.42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.35,percent of total billed charges,,,85,,30.35,percent of total billed charges,,,49,,17.49,percent of total billed charges,,,90,,32.13,percent of total billed charges,,,,,,,no IP contract,,80,,28.56,percent of total billed charges,,,,,,,no IP contract,,50,,17.85,percent of total billed charges,,,,,,no IP contract,,,78,,27.85,percent of total billed charges,,,70,,24.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.49,3324,
16729-0490-12 - dofetilide 125 mcg Cap,16729-0490-12,NDC,,,,inpatient,1,EA,68.7,41.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,55.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,58.4,percent of total billed charges,,,85,,58.4,percent of total billed charges,,,49,,33.66,percent of total billed charges,,,90,,61.83,percent of total billed charges,,,,,,,no IP contract,,80,,54.96,percent of total billed charges,,,,,,,no IP contract,,50,,34.35,percent of total billed charges,,,,,,no IP contract,,,78,,53.59,percent of total billed charges,,,70,,48.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,33.66,3324,
16729-0491-12 - dofetilide 250 mcg Cap,16729-0491-12,NDC,,,,inpatient,1,EA,68.7,41.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,55.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,58.4,percent of total billed charges,,,85,,58.4,percent of total billed charges,,,49,,33.66,percent of total billed charges,,,90,,61.83,percent of total billed charges,,,,,,,no IP contract,,80,,54.96,percent of total billed charges,,,,,,,no IP contract,,50,,34.35,percent of total billed charges,,,,,,no IP contract,,,78,,53.59,percent of total billed charges,,,70,,48.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,33.66,3324,
16729-0492-12 - dofetilide 500 mcg Cap,16729-0492-12,NDC,,,,inpatient,1,EA,68.7,41.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,55.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,58.4,percent of total billed charges,,,85,,58.4,percent of total billed charges,,,49,,33.66,percent of total billed charges,,,90,,61.83,percent of total billed charges,,,,,,,no IP contract,,80,,54.96,percent of total billed charges,,,,,,,no IP contract,,50,,34.35,percent of total billed charges,,,,,,no IP contract,,,78,,53.59,percent of total billed charges,,,70,,48.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,33.66,3324,
17204-0434-40 - magnesium amino acids chelate 133 mg Tab,17204-0434-40,NDC,,,,inpatient,1,EA,4.4,2.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.74,percent of total billed charges,,,85,,3.74,percent of total billed charges,,,49,,2.16,percent of total billed charges,,,90,,3.96,percent of total billed charges,,,,,,,no IP contract,,80,,3.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.2,percent of total billed charges,,,,,,no IP contract,,,78,,3.43,percent of total billed charges,,,70,,3.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.16,3324,
17314-9330-01 - citric acid-sodium citrate 334 mg-500 mg/5 mL Soln,17314-9330-01,NDC,,,,inpatient,1,ML,5.85,3.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.97,percent of total billed charges,,,85,,4.97,percent of total billed charges,,,49,,2.87,percent of total billed charges,,,90,,5.27,percent of total billed charges,,,,,,,no IP contract,,80,,4.68,percent of total billed charges,,,,,,,no IP contract,,50,,2.93,percent of total billed charges,,,,,,no IP contract,,,78,,4.56,percent of total billed charges,,,70,,4.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.87,3324,
17433-9876-03 - docusate 283 mg Enema,17433-9876-03,NDC,,,,inpatient,5,ML,21.7,13.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.45,percent of total billed charges,,,85,,18.45,percent of total billed charges,,,49,,10.63,percent of total billed charges,,,90,,19.53,percent of total billed charges,,,,,,,no IP contract,,80,,17.36,percent of total billed charges,,,,,,,no IP contract,,50,,10.85,percent of total billed charges,,,,,,no IP contract,,,78,,16.93,percent of total billed charges,,,70,,15.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.63,3324,
17478-0040-01 - lorazepam 2 mg/mL Soln,17478-0040-01,NDC,,,,inpatient,1,ML,15.9,9.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.52,percent of total billed charges,,,85,,13.52,percent of total billed charges,,,49,,7.79,percent of total billed charges,,,90,,14.31,percent of total billed charges,,,,,,,no IP contract,,80,,12.72,percent of total billed charges,,,,,,,no IP contract,,50,,7.95,percent of total billed charges,,,,,,no IP contract,,,78,,12.4,percent of total billed charges,,,70,,11.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.79,3324,
17478-0070-35 - erythromycin ophthalmic 0.5% Ointm,17478-0070-35,NDC,,,,inpatient,1,UN,50.05,30.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,40.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,42.54,percent of total billed charges,,,85,,42.54,percent of total billed charges,,,49,,24.52,percent of total billed charges,,,90,,45.05,percent of total billed charges,,,,,,,no IP contract,,80,,40.04,percent of total billed charges,,,,,,,no IP contract,,50,,25.03,percent of total billed charges,,,,,,no IP contract,,,78,,39.04,percent of total billed charges,,,70,,35.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.52,3324,
17478-0209-10 - ketorolac ophthalmic 0.5% Soln,17478-0209-10,NDC,,,,inpatient,1,UN,899.3,539.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,728.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,764.41,percent of total billed charges,,,85,,764.41,percent of total billed charges,,,49,,440.66,percent of total billed charges,,,90,,809.37,percent of total billed charges,,,,,,,no IP contract,,80,,719.44,percent of total billed charges,,,,,,,no IP contract,,50,,449.65,percent of total billed charges,,,,,,no IP contract,,,78,,701.45,percent of total billed charges,,,70,,629.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,440.66,3324,
17478-0283-10 - gentamicin ophthalmic 0.3% Soln,17478-0283-10,NDC,,,,inpatient,1,UN,169.15,101.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,137.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,143.78,percent of total billed charges,,,85,,143.78,percent of total billed charges,,,49,,82.88,percent of total billed charges,,,90,,152.24,percent of total billed charges,,,,,,,no IP contract,,80,,135.32,percent of total billed charges,,,,,,,no IP contract,,50,,84.58,percent of total billed charges,,,,,,no IP contract,,,78,,131.94,percent of total billed charges,,,70,,118.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,82.88,3324,
17478-0288-10 - timolol ophthalmic 0.5% Soln,17478-0288-10,NDC,,,,inpatient,1,UN,59.6,35.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,48.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,50.66,percent of total billed charges,,,85,,50.66,percent of total billed charges,,,49,,29.2,percent of total billed charges,,,90,,53.64,percent of total billed charges,,,,,,,no IP contract,,80,,47.68,percent of total billed charges,,,,,,,no IP contract,,50,,29.8,percent of total billed charges,,,,,,no IP contract,,,78,,46.49,percent of total billed charges,,,70,,41.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,29.2,3324,
17478-0340-38 - tobramycin 60 mg/mL Soln,17478-0340-38,NDC,,,,inpatient,5,ML,532.75,319.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,431.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,452.84,percent of total billed charges,,,85,,452.84,percent of total billed charges,,,49,,261.05,percent of total billed charges,,,90,,479.48,percent of total billed charges,,,,,,,no IP contract,,80,,426.2,percent of total billed charges,,,,,,,no IP contract,,50,,266.38,percent of total billed charges,,,,,,no IP contract,,,78,,415.55,percent of total billed charges,,,70,,372.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,261.05,3324,
"17478-0622-35 - sodium chloride, hypertonic, ophthalmic 5% Ointm",17478-0622-35,NDC,,,,inpatient,1,UN,110.1,66.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,89.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,93.59,percent of total billed charges,,,85,,93.59,percent of total billed charges,,,49,,53.95,percent of total billed charges,,,90,,99.09,percent of total billed charges,,,,,,,no IP contract,,80,,88.08,percent of total billed charges,,,,,,,no IP contract,,50,,55.05,percent of total billed charges,,,,,,no IP contract,,,78,,85.88,percent of total billed charges,,,70,,77.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,53.95,3324,
17478-0703-11 - polymyxin B-trimethoprim ophthalmic 10000 units-1 mg/mL Soln,17478-0703-11,NDC,,,,inpatient,1,UN,155,93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,125.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,131.75,percent of total billed charges,,,85,,131.75,percent of total billed charges,,,49,,75.95,percent of total billed charges,,,90,,139.5,percent of total billed charges,,,,,,,no IP contract,,80,,124,percent of total billed charges,,,,,,,no IP contract,,50,,77.5,percent of total billed charges,,,,,,no IP contract,,,78,,120.9,percent of total billed charges,,,70,,108.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,75.95,3324,
17478-0713-10 - ofloxacin ophthalmic 0.3% Soln,17478-0713-10,NDC,,,,inpatient,1,UN,346.15,207.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,280.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,294.23,percent of total billed charges,,,85,,294.23,percent of total billed charges,,,49,,169.61,percent of total billed charges,,,90,,311.54,percent of total billed charges,,,,,,,no IP contract,,80,,276.92,percent of total billed charges,,,,,,,no IP contract,,50,,173.08,percent of total billed charges,,,,,,no IP contract,,,78,,270,percent of total billed charges,,,70,,242.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,169.61,3324,
17478-0717-10 - ketotifen ophthalmic 0.025% Soln,17478-0717-10,NDC,,,,inpatient,1,UN,110.85,66.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,89.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,94.22,percent of total billed charges,,,85,,94.22,percent of total billed charges,,,49,,54.32,percent of total billed charges,,,90,,99.77,percent of total billed charges,,,,,,,no IP contract,,80,,88.68,percent of total billed charges,,,,,,,no IP contract,,50,,55.43,percent of total billed charges,,,,,,no IP contract,,,78,,86.46,percent of total billed charges,,,70,,77.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,54.32,3324,
17478-0766-10 - progesterone 100 mg Cap,17478-0766-10,NDC,,,,inpatient,1,EA,20.5,12.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.43,percent of total billed charges,,,85,,17.43,percent of total billed charges,,,49,,10.05,percent of total billed charges,,,90,,18.45,percent of total billed charges,,,,,,,no IP contract,,80,,16.4,percent of total billed charges,,,,,,,no IP contract,,50,,10.25,percent of total billed charges,,,,,,no IP contract,,,78,,15.99,percent of total billed charges,,,70,,14.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.05,3324,
17478-0931-01 - calcitriol 1 mcg/mL Soln,17478-0931-01,NDC,,,,inpatient,1,ML,61.5,36.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,49.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,52.28,percent of total billed charges,,,85,,52.28,percent of total billed charges,,,49,,30.14,percent of total billed charges,,,90,,55.35,percent of total billed charges,,,,,,,no IP contract,,80,,49.2,percent of total billed charges,,,,,,,no IP contract,,50,,30.75,percent of total billed charges,,,,,,no IP contract,,,78,,47.97,percent of total billed charges,,,70,,43.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,30.14,3324,
17856-0093-01 - amantadine 100 mg / 10 mL Soln,17856-0093-01,NDC,,,,inpatient,10,ML,114.55,68.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,92.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,97.37,percent of total billed charges,,,85,,97.37,percent of total billed charges,,,49,,56.13,percent of total billed charges,,,90,,103.1,percent of total billed charges,,,,,,,no IP contract,,80,,91.64,percent of total billed charges,,,,,,,no IP contract,,50,,57.28,percent of total billed charges,,,,,,no IP contract,,,78,,89.35,percent of total billed charges,,,70,,80.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,56.13,3324,
17856-0398-02 - docusate UD cup 100 mg/10 mL Soln,17856-0398-02,NDC,,,,inpatient,10,ML,9.6,5.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.16,percent of total billed charges,,,85,,8.16,percent of total billed charges,,,49,,4.7,percent of total billed charges,,,90,,8.64,percent of total billed charges,,,,,,,no IP contract,,80,,7.68,percent of total billed charges,,,,,,,no IP contract,,50,,4.8,percent of total billed charges,,,,,,no IP contract,,,78,,7.49,percent of total billed charges,,,70,,6.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.7,3324,
17856-0412-20 - polyethylene glycol 17 gm Powder,17856-0412-20,NDC,,,,inpatient,1,EA,23.7,14.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.15,percent of total billed charges,,,85,,20.15,percent of total billed charges,,,49,,11.61,percent of total billed charges,,,90,,21.33,percent of total billed charges,,,,,,,no IP contract,,80,,18.96,percent of total billed charges,,,,,,,no IP contract,,50,,11.85,percent of total billed charges,,,,,,no IP contract,,,78,,18.49,percent of total billed charges,,,70,,16.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.61,3324,
17856-0412-20 - polyethylene glycol 17 gm UD 17 gm REC Powder,17856-0412-20,NDC,,,,inpatient,1,EA,23.7,14.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.15,percent of total billed charges,,,85,,20.15,percent of total billed charges,,,49,,11.61,percent of total billed charges,,,90,,21.33,percent of total billed charges,,,,,,,no IP contract,,80,,18.96,percent of total billed charges,,,,,,,no IP contract,,50,,11.85,percent of total billed charges,,,,,,no IP contract,,,78,,18.49,percent of total billed charges,,,70,,16.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.61,3324,
"nystatin 500,000 units/5 mL Oral susp 500,000 unit(s) / 5 mL Susp",17856-0538-01,NDC,,,,inpatient,1,EA,47.05,28.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,38.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,39.99,percent of total billed charges,,,85,,39.99,percent of total billed charges,,,49,,23.05,percent of total billed charges,,,90,,42.35,percent of total billed charges,,,,,,,no IP contract,,80,,37.64,percent of total billed charges,,,,,,,no IP contract,,50,,23.53,percent of total billed charges,,,,,,no IP contract,,,78,,36.7,percent of total billed charges,,,70,,32.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.05,3324,
17856-0574-01 - levETIRAcetam 500 mg / 5 mL Soln,17856-0574-01,NDC,,,,inpatient,5,ML,164.55,98.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,133.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,139.87,percent of total billed charges,,,85,,139.87,percent of total billed charges,,,49,,80.63,percent of total billed charges,,,90,,148.1,percent of total billed charges,,,,,,,no IP contract,,80,,131.64,percent of total billed charges,,,,,,,no IP contract,,50,,82.28,percent of total billed charges,,,,,,no IP contract,,,78,,128.35,percent of total billed charges,,,70,,115.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,80.63,3324,
17856-0646-01 - amantadine UD 100 mg/10 mL Syrup,17856-0646-01,NDC,,,,inpatient,10,ML,17.9,10.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.22,percent of total billed charges,,,85,,15.22,percent of total billed charges,,,49,,8.77,percent of total billed charges,,,90,,16.11,percent of total billed charges,,,,,,,no IP contract,,80,,14.32,percent of total billed charges,,,,,,,no IP contract,,50,,8.95,percent of total billed charges,,,,,,no IP contract,,,78,,13.96,percent of total billed charges,,,70,,12.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.77,3324,
17856-0842-01 - ascorbic acid 500 mg / 5 mL Soln,17856-0842-01,NDC,,,,inpatient,5,ML,14.1,8.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.99,percent of total billed charges,,,85,,11.99,percent of total billed charges,,,49,,6.91,percent of total billed charges,,,90,,12.69,percent of total billed charges,,,,,,,no IP contract,,80,,11.28,percent of total billed charges,,,,,,,no IP contract,,50,,7.05,percent of total billed charges,,,,,,no IP contract,,,78,,11,percent of total billed charges,,,70,,9.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.91,3324,
17856-1000-01 - sennosides  17.6 mg / 10 mL Syrup,17856-1000-01,NDC,,,,inpatient,10,ML,18.85,11.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.02,percent of total billed charges,,,85,,16.02,percent of total billed charges,,,49,,9.24,percent of total billed charges,,,90,,16.97,percent of total billed charges,,,,,,,no IP contract,,80,,15.08,percent of total billed charges,,,,,,,no IP contract,,50,,9.43,percent of total billed charges,,,,,,no IP contract,,,78,,14.7,percent of total billed charges,,,70,,13.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.24,3324,
17856-1275-01 - sennosides  17.6 mg / 10 mL Syrup,17856-1275-01,NDC,,,,inpatient,10,ML,15.85,9.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.47,percent of total billed charges,,,85,,13.47,percent of total billed charges,,,49,,7.77,percent of total billed charges,,,90,,14.27,percent of total billed charges,,,,,,,no IP contract,,80,,12.68,percent of total billed charges,,,,,,,no IP contract,,50,,7.93,percent of total billed charges,,,,,,no IP contract,,,78,,12.36,percent of total billed charges,,,70,,11.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.77,3324,
17856-2002-03 - chlorhexidine gluconate 15 mL Soln,17856-2002-03,NDC,,,,inpatient,15,ML,11,6.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.35,percent of total billed charges,,,85,,9.35,percent of total billed charges,,,49,,5.39,percent of total billed charges,,,90,,9.9,percent of total billed charges,,,,,,,no IP contract,,80,,8.8,percent of total billed charges,,,,,,,no IP contract,,50,,5.5,percent of total billed charges,,,,,,no IP contract,,,78,,8.58,percent of total billed charges,,,70,,7.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.39,3324,
17856-4344-01 - multivitamin with minerals LIQ [Certa-Vite] UD 15 mL Soln,17856-4344-01,NDC,,,,inpatient,15,ML,14.8,8.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.58,percent of total billed charges,,,85,,12.58,percent of total billed charges,,,49,,7.25,percent of total billed charges,,,90,,13.32,percent of total billed charges,,,,,,,no IP contract,,80,,11.84,percent of total billed charges,,,,,,,no IP contract,,50,,7.4,percent of total billed charges,,,,,,no IP contract,,,78,,11.54,percent of total billed charges,,,70,,10.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.25,3324,
20555-0001-00 - ascorbic acid 250 mg Tab,20555-0001-00,NDC,,,,inpatient,1,EA,4,2.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.4,percent of total billed charges,,,85,,3.4,percent of total billed charges,,,49,,1.96,percent of total billed charges,,,90,,3.6,percent of total billed charges,,,,,,,no IP contract,,80,,3.2,percent of total billed charges,,,,,,,no IP contract,,50,,2,percent of total billed charges,,,,,,no IP contract,,,78,,3.12,percent of total billed charges,,,70,,2.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.96,3324,
20555-0022-00 - multivitamin with minerals Therapeutic Multiple Vitamins with Minerals Tab,20555-0022-00,NDC,,,,inpatient,1,EA,4.05,2.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.44,percent of total billed charges,,,85,,3.44,percent of total billed charges,,,49,,1.98,percent of total billed charges,,,90,,3.65,percent of total billed charges,,,,,,,no IP contract,,80,,3.24,percent of total billed charges,,,,,,,no IP contract,,50,,2.03,percent of total billed charges,,,,,,no IP contract,,,78,,3.16,percent of total billed charges,,,70,,2.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.98,3324,
20555-0025-00 - calcium-vitamin D 250 mg-125 units Tab,20555-0025-00,NDC,,,,inpatient,1,EA,4.2,2.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.57,percent of total billed charges,,,85,,3.57,percent of total billed charges,,,49,,2.06,percent of total billed charges,,,90,,3.78,percent of total billed charges,,,,,,,no IP contract,,80,,3.36,percent of total billed charges,,,,,,,no IP contract,,50,,2.1,percent of total billed charges,,,,,,no IP contract,,,78,,3.28,percent of total billed charges,,,70,,2.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.06,3324,
20555-0032-00 - cyanocobalamin 500 mcg Tab,20555-0032-00,NDC,,,,inpatient,1,EA,5.4,3.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.59,percent of total billed charges,,,85,,4.59,percent of total billed charges,,,49,,2.65,percent of total billed charges,,,90,,4.86,percent of total billed charges,,,,,,,no IP contract,,80,,4.32,percent of total billed charges,,,,,,,no IP contract,,50,,2.7,percent of total billed charges,,,,,,no IP contract,,,78,,4.21,percent of total billed charges,,,70,,3.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.65,3324,
"20555-0033-00 - cholecalciferol 1,000 International_Unit Tab",20555-0033-00,NDC,,,,inpatient,1,EA,4.15,2.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.53,percent of total billed charges,,,85,,3.53,percent of total billed charges,,,49,,2.03,percent of total billed charges,,,90,,3.74,percent of total billed charges,,,,,,,no IP contract,,80,,3.32,percent of total billed charges,,,,,,,no IP contract,,50,,2.08,percent of total billed charges,,,,,,no IP contract,,,78,,3.24,percent of total billed charges,,,70,,2.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.03,3324,
20555-0036-00 - melatonin 3 mg Tab,20555-0036-00,NDC,,,,inpatient,1,EA,5.2,3.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.42,percent of total billed charges,,,85,,4.42,percent of total billed charges,,,49,,2.55,percent of total billed charges,,,90,,4.68,percent of total billed charges,,,,,,,no IP contract,,80,,4.16,percent of total billed charges,,,,,,,no IP contract,,50,,2.6,percent of total billed charges,,,,,,no IP contract,,,78,,4.06,percent of total billed charges,,,70,,3.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.55,3324,
melatonin 3 mg Tab,20555-0036-01,NDC,,,,inpatient,1,EA,5.2,3.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.42,percent of total billed charges,,,85,,4.42,percent of total billed charges,,,49,,2.55,percent of total billed charges,,,90,,4.68,percent of total billed charges,,,,,,,no IP contract,,80,,4.16,percent of total billed charges,,,,,,,no IP contract,,50,,2.6,percent of total billed charges,,,,,,no IP contract,,,78,,4.06,percent of total billed charges,,,70,,3.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.55,3324,
21922-0001-01 - fluocinonide topical 0.05% Soln,21922-0001-01,NDC,,,,inpatient,1,UN,1378.7,827.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1116.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1171.9,percent of total billed charges,,,85,,1171.9,percent of total billed charges,,,49,,675.56,percent of total billed charges,,,90,,1240.83,percent of total billed charges,,,,,,,no IP contract,,80,,1102.96,percent of total billed charges,,,,,,,no IP contract,,50,,689.35,percent of total billed charges,,,,,,no IP contract,,,78,,1075.39,percent of total billed charges,,,70,,965.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,675.56,3324,
21922-0016-04 - clobetasol topical 0.05% Cream,21922-0016-04,NDC,,,,inpatient,1,UN,1077.55,646.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,872.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,915.92,percent of total billed charges,,,85,,915.92,percent of total billed charges,,,49,,528,percent of total billed charges,,,90,,969.8,percent of total billed charges,,,,,,,no IP contract,,80,,862.04,percent of total billed charges,,,,,,,no IP contract,,50,,538.78,percent of total billed charges,,,,,,no IP contract,,,78,,840.49,percent of total billed charges,,,70,,754.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,528,3324,
21922-0017-05 - clobetasol topical 0.05% Ointm,21922-0017-05,NDC,,,,inpatient,1,UN,2085.9,1251.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1689.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1773.02,percent of total billed charges,,,85,,1773.02,percent of total billed charges,,,49,,1022.09,percent of total billed charges,,,90,,1877.31,percent of total billed charges,,,,,,,no IP contract,,80,,1668.72,percent of total billed charges,,,,,,,no IP contract,,50,,1042.95,percent of total billed charges,,,,,,no IP contract,,,78,,1627,percent of total billed charges,,,70,,1460.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
21922-0019-02 - testosterone 50 mg/5 g (1%) Gel,21922-0019-02,NDC,,,,inpatient,1,UN,153.7,92.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,124.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,130.65,percent of total billed charges,,,85,,130.65,percent of total billed charges,,,49,,75.31,percent of total billed charges,,,90,,138.33,percent of total billed charges,,,,,,,no IP contract,,80,,122.96,percent of total billed charges,,,,,,,no IP contract,,50,,76.85,percent of total billed charges,,,,,,no IP contract,,,78,,119.89,percent of total billed charges,,,70,,107.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,75.31,3324,
21922-0025-05 - ketoconazole topical 2% Cream,21922-0025-05,NDC,,,,inpatient,1,UN,1746.05,1047.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1414.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1484.14,percent of total billed charges,,,85,,1484.14,percent of total billed charges,,,49,,855.56,percent of total billed charges,,,90,,1571.45,percent of total billed charges,,,,,,,no IP contract,,80,,1396.84,percent of total billed charges,,,,,,,no IP contract,,50,,873.03,percent of total billed charges,,,,,,no IP contract,,,78,,1361.92,percent of total billed charges,,,70,,1222.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,855.56,3324,
mupirocin topical 2% Cream,21922-0029-05,NDC,,,,inpatient,1,EA,3470.35,2082.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2810.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2949.8,percent of total billed charges,,,85,,2949.8,percent of total billed charges,,,49,,1700.47,percent of total billed charges,,,90,,3123.32,percent of total billed charges,,,,,,,no IP contract,,80,,2776.28,percent of total billed charges,,,,,,,no IP contract,,50,,1735.18,percent of total billed charges,,,,,,no IP contract,,,78,,2706.87,percent of total billed charges,,,70,,2429.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
clindamycin topical 1% Lotio,21922-0036-01,NDC,,,,inpatient,1,EA,1208.75,725.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,979.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1027.44,percent of total billed charges,,,85,,1027.44,percent of total billed charges,,,49,,592.29,percent of total billed charges,,,90,,1087.88,percent of total billed charges,,,,,,,no IP contract,,80,,967,percent of total billed charges,,,,,,,no IP contract,,50,,604.38,percent of total billed charges,,,,,,no IP contract,,,78,,942.83,percent of total billed charges,,,70,,846.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,592.29,3324,
23155-0026-01 - verapamil 80 mg Tab,23155-0026-01,NDC,,,,inpatient,1,EA,6.3,3.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.36,percent of total billed charges,,,85,,5.36,percent of total billed charges,,,49,,3.09,percent of total billed charges,,,90,,5.67,percent of total billed charges,,,,,,,no IP contract,,80,,5.04,percent of total billed charges,,,,,,,no IP contract,,50,,3.15,percent of total billed charges,,,,,,no IP contract,,,78,,4.91,percent of total billed charges,,,70,,4.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.09,3324,
23155-0043-03 - leflunomide 10 mg Tab,23155-0043-03,NDC,,,,inpatient,1,EA,134.35,80.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,108.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,114.2,percent of total billed charges,,,85,,114.2,percent of total billed charges,,,49,,65.83,percent of total billed charges,,,90,,120.92,percent of total billed charges,,,,,,,no IP contract,,80,,107.48,percent of total billed charges,,,,,,,no IP contract,,50,,67.18,percent of total billed charges,,,,,,no IP contract,,,78,,104.79,percent of total billed charges,,,70,,94.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,65.83,3324,
23155-0057-01 - glyBURIDE 2.5 mg Tab,23155-0057-01,NDC,,,,inpatient,1,EA,7.5,4.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.38,percent of total billed charges,,,85,,6.38,percent of total billed charges,,,49,,3.68,percent of total billed charges,,,90,,6.75,percent of total billed charges,,,,,,,no IP contract,,80,,6,percent of total billed charges,,,,,,,no IP contract,,50,,3.75,percent of total billed charges,,,,,,no IP contract,,,78,,5.85,percent of total billed charges,,,70,,5.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.68,3324,
23155-0058-01 - glyBURIDE 5 mg Tab,23155-0058-01,NDC,,,,inpatient,1,EA,10.05,6.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.54,percent of total billed charges,,,85,,8.54,percent of total billed charges,,,49,,4.92,percent of total billed charges,,,90,,9.05,percent of total billed charges,,,,,,,no IP contract,,80,,8.04,percent of total billed charges,,,,,,,no IP contract,,50,,5.03,percent of total billed charges,,,,,,no IP contract,,,78,,7.84,percent of total billed charges,,,70,,7.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.92,3324,
23155-0071-01 - methIMAzole 10 mg Tab,23155-0071-01,NDC,,,,inpatient,1,EA,9.95,5.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.46,percent of total billed charges,,,85,,8.46,percent of total billed charges,,,49,,4.88,percent of total billed charges,,,90,,8.96,percent of total billed charges,,,,,,,no IP contract,,80,,7.96,percent of total billed charges,,,,,,,no IP contract,,50,,4.98,percent of total billed charges,,,,,,no IP contract,,,78,,7.76,percent of total billed charges,,,70,,6.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.88,3324,
23155-0102-01 - metFORMIN 500 mg Tab,23155-0102-01,NDC,,,,inpatient,1,EA,9.4,5.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.99,percent of total billed charges,,,85,,7.99,percent of total billed charges,,,49,,4.61,percent of total billed charges,,,90,,8.46,percent of total billed charges,,,,,,,no IP contract,,80,,7.52,percent of total billed charges,,,,,,,no IP contract,,50,,4.7,percent of total billed charges,,,,,,no IP contract,,,78,,7.33,percent of total billed charges,,,70,,6.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.61,3324,
23155-0216-31 - cidofovir 75 mg/mL Soln,23155-0216-31,NDC,,,,inpatient,5,ML,7455.45,4473.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6038.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6337.13,percent of total billed charges,,,85,,6337.13,percent of total billed charges,,,49,,3653.17,percent of total billed charges,,,90,,6709.91,percent of total billed charges,,,,,,,no IP contract,,80,,5964.36,percent of total billed charges,,,,,,,no IP contract,,50,,3727.73,percent of total billed charges,,,,,,no IP contract,,,78,,5815.25,percent of total billed charges,,,70,,5218.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,6709.91,
23155-0288-01 - acetaZOLAMIDE 250 mg Tab,23155-0288-01,NDC,,,,inpatient,1,EA,26.7,16.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.7,percent of total billed charges,,,85,,22.7,percent of total billed charges,,,49,,13.08,percent of total billed charges,,,90,,24.03,percent of total billed charges,,,,,,,no IP contract,,80,,21.36,percent of total billed charges,,,,,,,no IP contract,,50,,13.35,percent of total billed charges,,,,,,no IP contract,,,78,,20.83,percent of total billed charges,,,70,,18.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.08,3324,
23155-0290-41 - amikacin 250 mg/mL Soln,23155-0290-41,NDC,,,,inpatient,1,ML,50.65,30.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,41.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,43.05,percent of total billed charges,,,85,,43.05,percent of total billed charges,,,49,,24.82,percent of total billed charges,,,90,,45.59,percent of total billed charges,,,,,,,no IP contract,,80,,40.52,percent of total billed charges,,,,,,,no IP contract,,50,,25.33,percent of total billed charges,,,,,,no IP contract,,,78,,39.51,percent of total billed charges,,,70,,35.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.82,3324,
23155-0292-51 - cetirizine 1 mg/mL Syrup,23155-0292-51,NDC,,,,inpatient,1,ML,7.9,4.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.72,percent of total billed charges,,,85,,6.72,percent of total billed charges,,,49,,3.87,percent of total billed charges,,,90,,7.11,percent of total billed charges,,,,,,,no IP contract,,80,,6.32,percent of total billed charges,,,,,,,no IP contract,,50,,3.95,percent of total billed charges,,,,,,no IP contract,,,78,,6.16,percent of total billed charges,,,70,,5.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.87,3324,
23155-0486-01 - verapamil 120 mg Tab,23155-0486-01,NDC,,,,inpatient,1,EA,6.95,4.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.91,percent of total billed charges,,,85,,5.91,percent of total billed charges,,,49,,3.41,percent of total billed charges,,,90,,6.26,percent of total billed charges,,,,,,,no IP contract,,80,,5.56,percent of total billed charges,,,,,,,no IP contract,,50,,3.48,percent of total billed charges,,,,,,no IP contract,,,78,,5.42,percent of total billed charges,,,70,,4.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.41,3324,
23155-0497-42 - prochlorperazine 5 mg/mL Soln,23155-0497-42,NDC,,,,inpatient,1,ML,196.45,117.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,159.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,166.98,percent of total billed charges,,,85,,166.98,percent of total billed charges,,,49,,96.26,percent of total billed charges,,,90,,176.81,percent of total billed charges,,,,,,,no IP contract,,80,,157.16,percent of total billed charges,,,,,,,no IP contract,,50,,98.23,percent of total billed charges,,,,,,no IP contract,,,78,,153.23,percent of total billed charges,,,70,,137.52,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,96.26,3324,
niMODipine 30 mg Cap,23155-0512-30,NDC,,,,inpatient,1,EA,156.7,94.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,126.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,133.2,percent of total billed charges,,,85,,133.2,percent of total billed charges,,,49,,76.78,percent of total billed charges,,,90,,141.03,percent of total billed charges,,,,,,,no IP contract,,80,,125.36,percent of total billed charges,,,,,,,no IP contract,,50,,78.35,percent of total billed charges,,,,,,no IP contract,,,78,,122.23,percent of total billed charges,,,70,,109.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,76.78,3324,
23155-0606-01 - glycopyrrolate 1 mg Tab,23155-0606-01,NDC,,,,inpatient,1,EA,14.25,8.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.11,percent of total billed charges,,,85,,12.11,percent of total billed charges,,,49,,6.98,percent of total billed charges,,,90,,12.83,percent of total billed charges,,,,,,,no IP contract,,80,,11.4,percent of total billed charges,,,,,,,no IP contract,,50,,7.13,percent of total billed charges,,,,,,no IP contract,,,78,,11.12,percent of total billed charges,,,70,,9.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.98,3324,
23155-0662-03 - calcitriol 0.25 mg Cap,23155-0662-03,NDC,,,,inpatient,1,EA,6.35,3.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.4,percent of total billed charges,,,85,,5.4,percent of total billed charges,,,49,,3.11,percent of total billed charges,,,90,,5.72,percent of total billed charges,,,,,,,no IP contract,,80,,5.08,percent of total billed charges,,,,,,,no IP contract,,50,,3.18,percent of total billed charges,,,,,,no IP contract,,,78,,4.95,percent of total billed charges,,,70,,4.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.11,3324,
23155-0694-01 - allopurinol 300 mg Tab,23155-0694-01,NDC,,,,inpatient,1,EA,11.15,6.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.48,percent of total billed charges,,,85,,9.48,percent of total billed charges,,,49,,5.46,percent of total billed charges,,,90,,10.04,percent of total billed charges,,,,,,,no IP contract,,80,,8.92,percent of total billed charges,,,,,,,no IP contract,,50,,5.58,percent of total billed charges,,,,,,no IP contract,,,78,,8.7,percent of total billed charges,,,70,,7.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.46,3324,
23155-0747-03 - rasagiline 1 mg Tab,23155-0747-03,NDC,,,,inpatient,1,EA,31.15,18.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,25.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.48,percent of total billed charges,,,85,,26.48,percent of total billed charges,,,49,,15.26,percent of total billed charges,,,90,,28.04,percent of total billed charges,,,,,,,no IP contract,,80,,24.92,percent of total billed charges,,,,,,,no IP contract,,50,,15.58,percent of total billed charges,,,,,,no IP contract,,,78,,24.3,percent of total billed charges,,,70,,21.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.26,3324,
23155-0767-01 - tetracycline 500 mg Cap,23155-0767-01,NDC,,,,inpatient,1,EA,129.05,77.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,104.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,109.69,percent of total billed charges,,,85,,109.69,percent of total billed charges,,,49,,63.23,percent of total billed charges,,,90,,116.15,percent of total billed charges,,,,,,,no IP contract,,80,,103.24,percent of total billed charges,,,,,,,no IP contract,,50,,64.53,percent of total billed charges,,,,,,no IP contract,,,78,,100.66,percent of total billed charges,,,70,,90.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,63.23,3324,
enalapril 10 mg Tab,23155-0772-01,NDC,,,,inpatient,1,EA,19.25,11.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.36,percent of total billed charges,,,85,,16.36,percent of total billed charges,,,49,,9.43,percent of total billed charges,,,90,,17.33,percent of total billed charges,,,,,,,no IP contract,,80,,15.4,percent of total billed charges,,,,,,,no IP contract,,50,,9.63,percent of total billed charges,,,,,,no IP contract,,,78,,15.02,percent of total billed charges,,,70,,13.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.43,3324,
23155-0785-41 - amikacin 250 mg/mL Soln,23155-0785-41,NDC,,,,inpatient,1,ML,37.25,22.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.66,percent of total billed charges,,,85,,31.66,percent of total billed charges,,,49,,18.25,percent of total billed charges,,,90,,33.53,percent of total billed charges,,,,,,,no IP contract,,80,,29.8,percent of total billed charges,,,,,,,no IP contract,,50,,18.63,percent of total billed charges,,,,,,no IP contract,,,78,,29.06,percent of total billed charges,,,70,,26.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.25,3324,
hydrALAZINE 50 mg Tab,23155-0834-01,NDC,,,,inpatient,1,EA,8.3,4.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.06,percent of total billed charges,,,85,,7.06,percent of total billed charges,,,49,,4.07,percent of total billed charges,,,90,,7.47,percent of total billed charges,,,,,,,no IP contract,,80,,6.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.15,percent of total billed charges,,,,,,no IP contract,,,78,,6.47,percent of total billed charges,,,70,,5.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.07,3324,
vancomycin 250 mg Cap,23155-0859-78,NDC,,,,inpatient,1,EA,462.7,277.62,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,374.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,393.3,percent of total billed charges,,,85,,393.3,percent of total billed charges,,,49,,226.72,percent of total billed charges,,,90,,416.43,percent of total billed charges,,,,,,,no IP contract,,80,,370.16,percent of total billed charges,,,,,,,no IP contract,,50,,231.35,percent of total billed charges,,,,,,no IP contract,,,78,,360.91,percent of total billed charges,,,70,,323.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,226.72,3324,
lisinopril 20 mg Tab,23155-0879-01,NDC,,,,inpatient,1,EA,12.25,7.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.41,percent of total billed charges,,,85,,10.41,percent of total billed charges,,,49,,6,percent of total billed charges,,,90,,11.03,percent of total billed charges,,,,,,,no IP contract,,80,,9.8,percent of total billed charges,,,,,,,no IP contract,,50,,6.13,percent of total billed charges,,,,,,no IP contract,,,78,,9.56,percent of total billed charges,,,70,,8.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6,3324,
24208-0295-05 - dexamethasone-tobramycin ophthalmic 0.1%-0.3% Susp,24208-0295-05,NDC,,,,inpatient,1,UN,2189.2,1313.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1773.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1860.82,percent of total billed charges,,,85,,1860.82,percent of total billed charges,,,49,,1072.71,percent of total billed charges,,,90,,1970.28,percent of total billed charges,,,,,,,no IP contract,,80,,1751.36,percent of total billed charges,,,,,,,no IP contract,,50,,1094.6,percent of total billed charges,,,,,,no IP contract,,,78,,1707.58,percent of total billed charges,,,70,,1532.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
24208-0295-25 - dexamethasone-tobramycin ophthalmic 0.1%-0.3% Susp,24208-0295-25,NDC,,,,inpatient,1,UN,2030.9,1218.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1645.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1726.27,percent of total billed charges,,,85,,1726.27,percent of total billed charges,,,49,,995.14,percent of total billed charges,,,90,,1827.81,percent of total billed charges,,,,,,,no IP contract,,80,,1624.72,percent of total billed charges,,,,,,,no IP contract,,50,,1015.45,percent of total billed charges,,,,,,no IP contract,,,78,,1584.1,percent of total billed charges,,,70,,1421.63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
24208-0299-10 - loteprednol ophthalmic 0.5% Susp,24208-0299-10,NDC,,,,inpatient,1,UN,3153.8,1892.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2554.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2680.73,percent of total billed charges,,,85,,2680.73,percent of total billed charges,,,49,,1545.36,percent of total billed charges,,,90,,2838.42,percent of total billed charges,,,,,,,no IP contract,,80,,2523.04,percent of total billed charges,,,,,,,no IP contract,,50,,1576.9,percent of total billed charges,,,,,,no IP contract,,,78,,2459.96,percent of total billed charges,,,70,,2207.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
24208-0299-15 - loteprednol ophthalmic 0.5% Susp,24208-0299-15,NDC,,,,inpatient,1,UN,748.1,448.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,605.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,635.89,percent of total billed charges,,,85,,635.89,percent of total billed charges,,,49,,366.57,percent of total billed charges,,,90,,673.29,percent of total billed charges,,,,,,,no IP contract,,80,,598.48,percent of total billed charges,,,,,,,no IP contract,,50,,374.05,percent of total billed charges,,,,,,no IP contract,,,78,,583.52,percent of total billed charges,,,70,,523.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,366.57,3324,
24208-0299-25 - loteprednol ophthalmic 0.5% Susp,24208-0299-25,NDC,,,,inpatient,1,UN,651.45,390.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,527.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,553.73,percent of total billed charges,,,85,,553.73,percent of total billed charges,,,49,,319.21,percent of total billed charges,,,90,,586.31,percent of total billed charges,,,,,,,no IP contract,,80,,521.16,percent of total billed charges,,,,,,,no IP contract,,50,,325.73,percent of total billed charges,,,,,,no IP contract,,,78,,508.13,percent of total billed charges,,,70,,456.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,319.21,3324,
24208-0315-10 - polymyxin B-trimethoprim ophthalmic 10000 units-1 mg/mL Soln,24208-0315-10,NDC,,,,inpatient,1,UN,154.15,92.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,124.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,131.03,percent of total billed charges,,,85,,131.03,percent of total billed charges,,,49,,75.53,percent of total billed charges,,,90,,138.74,percent of total billed charges,,,,,,,no IP contract,,80,,123.32,percent of total billed charges,,,,,,,no IP contract,,50,,77.08,percent of total billed charges,,,,,,no IP contract,,,78,,120.24,percent of total billed charges,,,70,,107.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,75.53,3324,
24208-0342-05 - desmopressin 10 mcg/inh Spray,24208-0342-05,NDC,,,,inpatient,1,UN,1203.35,722.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,974.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1022.85,percent of total billed charges,,,85,,1022.85,percent of total billed charges,,,49,,589.64,percent of total billed charges,,,90,,1083.02,percent of total billed charges,,,,,,,no IP contract,,80,,962.68,percent of total billed charges,,,,,,,no IP contract,,50,,601.68,percent of total billed charges,,,,,,no IP contract,,,78,,938.61,percent of total billed charges,,,70,,842.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,589.64,3324,
24208-0399-15 - ipratropium nasal 42 mcg/inh Spray,24208-0399-15,NDC,,,,inpatient,1,UN,389.05,233.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,315.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,330.69,percent of total billed charges,,,85,,330.69,percent of total billed charges,,,49,,190.63,percent of total billed charges,,,90,,350.15,percent of total billed charges,,,,,,,no IP contract,,80,,311.24,percent of total billed charges,,,,,,,no IP contract,,50,,194.53,percent of total billed charges,,,,,,no IP contract,,,78,,303.46,percent of total billed charges,,,70,,272.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,190.63,3324,
24208-0410-05 - ofloxacin otic 0.3% Soln,24208-0410-05,NDC,,,,inpatient,1,UN,162.9,97.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,131.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,138.47,percent of total billed charges,,,85,,138.47,percent of total billed charges,,,49,,79.82,percent of total billed charges,,,90,,146.61,percent of total billed charges,,,,,,,no IP contract,,80,,130.32,percent of total billed charges,,,,,,,no IP contract,,50,,81.45,percent of total billed charges,,,,,,no IP contract,,,78,,127.06,percent of total billed charges,,,70,,114.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,79.82,3324,
24208-0411-10 - brimonidine ophthalmic 0.2% Soln,24208-0411-10,NDC,,,,inpatient,1,UN,293.3,175.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,237.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,249.31,percent of total billed charges,,,85,,249.31,percent of total billed charges,,,49,,143.72,percent of total billed charges,,,90,,263.97,percent of total billed charges,,,,,,,no IP contract,,80,,234.64,percent of total billed charges,,,,,,,no IP contract,,50,,146.65,percent of total billed charges,,,,,,no IP contract,,,78,,228.77,percent of total billed charges,,,70,,205.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,143.72,3324,
24208-0432-62 - multivitamin with minerals Antioxidant Multiple Vitamins and Minerals Tab,24208-0432-62,NDC,,,,inpatient,1,EA,4.7,2.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4,percent of total billed charges,,,85,,4,percent of total billed charges,,,49,,2.3,percent of total billed charges,,,90,,4.23,percent of total billed charges,,,,,,,no IP contract,,80,,3.76,percent of total billed charges,,,,,,,no IP contract,,50,,2.35,percent of total billed charges,,,,,,no IP contract,,,78,,3.67,percent of total billed charges,,,70,,3.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.3,3324,
24208-0485-10 - dorzolamide ophthalmic 2% Soln,24208-0485-10,NDC,,,,inpatient,1,UN,391.55,234.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,317.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,332.82,percent of total billed charges,,,85,,332.82,percent of total billed charges,,,49,,191.86,percent of total billed charges,,,90,,352.4,percent of total billed charges,,,,,,,no IP contract,,80,,313.24,percent of total billed charges,,,,,,,no IP contract,,50,,195.78,percent of total billed charges,,,,,,no IP contract,,,78,,305.41,percent of total billed charges,,,70,,274.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,191.86,3324,
24208-0486-10 - dorzolamide-timolol ophthalmic 2.23%-0.68% Soln,24208-0486-10,NDC,,,,inpatient,1,UN,571.5,342.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,462.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,485.78,percent of total billed charges,,,85,,485.78,percent of total billed charges,,,49,,280.04,percent of total billed charges,,,90,,514.35,percent of total billed charges,,,,,,,no IP contract,,80,,457.2,percent of total billed charges,,,,,,,no IP contract,,50,,285.75,percent of total billed charges,,,,,,no IP contract,,,78,,445.77,percent of total billed charges,,,70,,400.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,280.04,3324,
24208-0555-55 - bacitracin-polymyxin B ophthalmic 500 units-10000 units/g Ointm,24208-0555-55,NDC,,,,inpatient,1,UN,223.8,134.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,181.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,190.23,percent of total billed charges,,,85,,190.23,percent of total billed charges,,,49,,109.66,percent of total billed charges,,,90,,201.42,percent of total billed charges,,,,,,,no IP contract,,80,,179.04,percent of total billed charges,,,,,,,no IP contract,,50,,111.9,percent of total billed charges,,,,,,no IP contract,,,78,,174.56,percent of total billed charges,,,70,,156.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,109.66,3324,
24208-0631-10 - hydrocortisone/neomycin/polymyxin B otic 1%-0.35%-10000 units/mL Soln,24208-0631-10,NDC,,,,inpatient,1,UN,265.8,159.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,215.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,225.93,percent of total billed charges,,,85,,225.93,percent of total billed charges,,,49,,130.24,percent of total billed charges,,,90,,239.22,percent of total billed charges,,,,,,,no IP contract,,80,,212.64,percent of total billed charges,,,,,,,no IP contract,,50,,132.9,percent of total billed charges,,,,,,no IP contract,,,78,,207.32,percent of total billed charges,,,70,,186.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,130.24,3324,
24208-0676-15 - pilocarpine ophthalmic 1% Soln,24208-0676-15,NDC,,,,inpatient,1,UN,85.45,51.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,69.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,72.63,percent of total billed charges,,,85,,72.63,percent of total billed charges,,,49,,41.87,percent of total billed charges,,,90,,76.91,percent of total billed charges,,,,,,,no IP contract,,80,,68.36,percent of total billed charges,,,,,,,no IP contract,,50,,42.73,percent of total billed charges,,,,,,no IP contract,,,78,,66.65,percent of total billed charges,,,70,,59.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,41.87,3324,
24208-0720-02 - dexamethasone ophthalmic 0.1% Soln,24208-0720-02,NDC,,,,inpatient,1,UN,185.8,111.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,150.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,157.93,percent of total billed charges,,,85,,157.93,percent of total billed charges,,,49,,91.04,percent of total billed charges,,,90,,167.22,percent of total billed charges,,,,,,,no IP contract,,80,,148.64,percent of total billed charges,,,,,,,no IP contract,,50,,92.9,percent of total billed charges,,,,,,no IP contract,,,78,,144.92,percent of total billed charges,,,70,,130.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,91.04,3324,
24208-0790-62 - gramicidin/neomycin/polymyxin B ophthalmic 0.025 mg-1.75 mg-10000 units/mL Soln,24208-0790-62,NDC,,,,inpatient,1,UN,247.45,148.47,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,200.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,210.33,percent of total billed charges,,,85,,210.33,percent of total billed charges,,,49,,121.25,percent of total billed charges,,,90,,222.71,percent of total billed charges,,,,,,,no IP contract,,80,,197.96,percent of total billed charges,,,,,,,no IP contract,,50,,123.73,percent of total billed charges,,,,,,no IP contract,,,78,,193.01,percent of total billed charges,,,70,,173.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,121.25,3324,
24338-0102-13 - erythromycin 250 mg Tab,24338-0102-13,NDC,,,,inpatient,1,EA,19.8,11.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.83,percent of total billed charges,,,85,,16.83,percent of total billed charges,,,49,,9.7,percent of total billed charges,,,90,,17.82,percent of total billed charges,,,,,,,no IP contract,,80,,15.84,percent of total billed charges,,,,,,,no IP contract,,50,,9.9,percent of total billed charges,,,,,,no IP contract,,,78,,15.44,percent of total billed charges,,,70,,13.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.7,3324,
sotalol 5 mg/mL Soln,24338-0530-25,NDC,,,,inpatient,1,mL,27,16.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.95,percent of total billed charges,,,85,,22.95,percent of total billed charges,,,49,,13.23,percent of total billed charges,,,90,,24.3,percent of total billed charges,,,,,,,no IP contract,,80,,21.6,percent of total billed charges,,,,,,,no IP contract,,50,,13.5,percent of total billed charges,,,,,,no IP contract,,,78,,21.06,percent of total billed charges,,,70,,18.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.23,3324,
24357-0701-30 - lidocaine topical 4% Cream,24357-0701-30,NDC,,,,inpatient,1,UN,289.1,173.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,234.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,245.74,percent of total billed charges,,,85,,245.74,percent of total billed charges,,,49,,141.66,percent of total billed charges,,,90,,260.19,percent of total billed charges,,,,,,,no IP contract,,80,,231.28,percent of total billed charges,,,,,,,no IP contract,,50,,144.55,percent of total billed charges,,,,,,no IP contract,,,78,,225.5,percent of total billed charges,,,70,,202.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,141.66,3324,
24385-0118-78 - simethicone 80 mg Chew,24385-0118-78,NDC,,,,inpatient,1,EA,4,2.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.4,percent of total billed charges,,,85,,3.4,percent of total billed charges,,,49,,1.96,percent of total billed charges,,,90,,3.6,percent of total billed charges,,,,,,,no IP contract,,80,,3.2,percent of total billed charges,,,,,,,no IP contract,,50,,2,percent of total billed charges,,,,,,no IP contract,,,78,,3.12,percent of total billed charges,,,70,,2.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.96,3324,
24385-0165-53 - trolamine salicylate topical 10% Cream,24385-0165-53,NDC,,,,inpatient,1,UN,89.2,53.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,72.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,75.82,percent of total billed charges,,,85,,75.82,percent of total billed charges,,,49,,43.71,percent of total billed charges,,,90,,80.28,percent of total billed charges,,,,,,,no IP contract,,80,,71.36,percent of total billed charges,,,,,,,no IP contract,,50,,44.6,percent of total billed charges,,,,,,no IP contract,,,78,,69.58,percent of total billed charges,,,70,,62.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,43.71,3324,
24385-0190-03 - hydrocortisone topical 0.5% Cream,24385-0190-03,NDC,,,,inpatient,1,UN,19.2,11.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.32,percent of total billed charges,,,85,,16.32,percent of total billed charges,,,49,,9.41,percent of total billed charges,,,90,,17.28,percent of total billed charges,,,,,,,no IP contract,,80,,15.36,percent of total billed charges,,,,,,,no IP contract,,50,,9.6,percent of total billed charges,,,,,,no IP contract,,,78,,14.98,percent of total billed charges,,,70,,13.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.41,3324,
24385-0205-01 - clotrimazole topical 1% Cream,24385-0205-01,NDC,,,,inpatient,1,UN,54.2,32.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,43.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,46.07,percent of total billed charges,,,85,,46.07,percent of total billed charges,,,49,,26.56,percent of total billed charges,,,90,,48.78,percent of total billed charges,,,,,,,no IP contract,,80,,43.36,percent of total billed charges,,,,,,,no IP contract,,50,,27.1,percent of total billed charges,,,,,,no IP contract,,,78,,42.28,percent of total billed charges,,,70,,37.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.56,3324,
24385-0210-03 - diphenhydramine-zinc acetate topical 2%-0.1% Cream,24385-0210-03,NDC,,,,inpatient,1,UN,30.2,18.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.67,percent of total billed charges,,,85,,25.67,percent of total billed charges,,,49,,14.8,percent of total billed charges,,,90,,27.18,percent of total billed charges,,,,,,,no IP contract,,80,,24.16,percent of total billed charges,,,,,,,no IP contract,,50,,15.1,percent of total billed charges,,,,,,no IP contract,,,78,,23.56,percent of total billed charges,,,70,,21.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.8,3324,
24385-0361-26 - ibuprofen 100 mg/5 mL Susp,24385-0361-26,NDC,,,,inpatient,1,ML,45.4,27.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,38.59,percent of total billed charges,,,85,,38.59,percent of total billed charges,,,49,,22.25,percent of total billed charges,,,90,,40.86,percent of total billed charges,,,,,,,no IP contract,,80,,36.32,percent of total billed charges,,,,,,,no IP contract,,50,,22.7,percent of total billed charges,,,,,,no IP contract,,,78,,35.41,percent of total billed charges,,,70,,31.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.25,3324,
24385-0484-78 - acetaminophen 500 mg Tab,24385-0484-78,NDC,,,,inpatient,1,EA,4,2.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.4,percent of total billed charges,,,85,,3.4,percent of total billed charges,,,49,,1.96,percent of total billed charges,,,90,,3.6,percent of total billed charges,,,,,,,no IP contract,,80,,3.2,percent of total billed charges,,,,,,,no IP contract,,50,,2,percent of total billed charges,,,,,,no IP contract,,,78,,3.12,percent of total billed charges,,,70,,2.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.96,3324,
24385-0905-26 - ibuprofen 100 mg/5 mL Susp,24385-0905-26,NDC,,,,inpatient,1,ML,35.4,21.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.09,percent of total billed charges,,,85,,30.09,percent of total billed charges,,,49,,17.35,percent of total billed charges,,,90,,31.86,percent of total billed charges,,,,,,,no IP contract,,80,,28.32,percent of total billed charges,,,,,,,no IP contract,,50,,17.7,percent of total billed charges,,,,,,no IP contract,,,78,,27.61,percent of total billed charges,,,70,,24.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.35,3324,
24470-0909-60 - benzoyl peroxide topical 5% Gel,24470-0909-60,NDC,,,,inpatient,1,UN,259.1,155.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,209.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,220.24,percent of total billed charges,,,85,,220.24,percent of total billed charges,,,49,,126.96,percent of total billed charges,,,90,,233.19,percent of total billed charges,,,,,,,no IP contract,,80,,207.28,percent of total billed charges,,,,,,,no IP contract,,50,,129.55,percent of total billed charges,,,,,,no IP contract,,,78,,202.1,percent of total billed charges,,,70,,181.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,126.96,3324,
dilTIAZem 300 mg/24 hours ER Ca,24979-0029-07,NDC,,,,inpatient,1,EA,18.95,11.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.11,percent of total billed charges,,,85,,16.11,percent of total billed charges,,,49,,9.29,percent of total billed charges,,,90,,17.06,percent of total billed charges,,,,,,,no IP contract,,80,,15.16,percent of total billed charges,,,,,,,no IP contract,,50,,9.48,percent of total billed charges,,,,,,no IP contract,,,78,,14.78,percent of total billed charges,,,70,,13.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.29,3324,
24979-0133-01 - terbutaline 5 mg Tab,24979-0133-01,NDC,,,,inpatient,1,EA,56.7,34.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,45.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,48.2,percent of total billed charges,,,85,,48.2,percent of total billed charges,,,49,,27.78,percent of total billed charges,,,90,,51.03,percent of total billed charges,,,,,,,no IP contract,,80,,45.36,percent of total billed charges,,,,,,,no IP contract,,50,,28.35,percent of total billed charges,,,,,,no IP contract,,,78,,44.23,percent of total billed charges,,,70,,39.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.78,3324,
mycophenolic acid 360 mg EC Ta,24979-0161-44,NDC,,,,inpatient,1,EA,76.4,45.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,61.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,64.94,percent of total billed charges,,,85,,64.94,percent of total billed charges,,,49,,37.44,percent of total billed charges,,,90,,68.76,percent of total billed charges,,,,,,,no IP contract,,80,,61.12,percent of total billed charges,,,,,,,no IP contract,,50,,38.2,percent of total billed charges,,,,,,no IP contract,,,78,,59.59,percent of total billed charges,,,70,,53.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,37.44,3324,
25010-0205-15 - ethacrynic acid 25 mg Tab,25010-0205-15,NDC,,,,inpatient,1,EA,18.35,11.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.6,percent of total billed charges,,,85,,15.6,percent of total billed charges,,,49,,8.99,percent of total billed charges,,,90,,16.52,percent of total billed charges,,,,,,,no IP contract,,80,,14.68,percent of total billed charges,,,,,,,no IP contract,,50,,9.18,percent of total billed charges,,,,,,no IP contract,,,78,,14.31,percent of total billed charges,,,70,,12.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.99,3324,
25010-0215-15 - ethacrynic acid 25 mg Tab,25010-0215-15,NDC,,,,inpatient,1,EA,205.7,123.42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,166.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,174.85,percent of total billed charges,,,85,,174.85,percent of total billed charges,,,49,,100.79,percent of total billed charges,,,90,,185.13,percent of total billed charges,,,,,,,no IP contract,,80,,164.56,percent of total billed charges,,,,,,,no IP contract,,50,,102.85,percent of total billed charges,,,,,,no IP contract,,,78,,160.45,percent of total billed charges,,,70,,143.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,100.79,3324,
25010-0405-15 - phytonadione 5 mg Tab,25010-0405-15,NDC,,,,inpatient,1,EA,20.2,12.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.17,percent of total billed charges,,,85,,17.17,percent of total billed charges,,,49,,9.9,percent of total billed charges,,,90,,18.18,percent of total billed charges,,,,,,,no IP contract,,80,,16.16,percent of total billed charges,,,,,,,no IP contract,,50,,10.1,percent of total billed charges,,,,,,no IP contract,,,78,,15.76,percent of total billed charges,,,70,,14.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.9,3324,
25021-0113-82 - fluconazole 200 mg/100 mL-0.9% Soln,25021-0113-82,NDC,,,,inpatient,100,ML,150.05,90.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,121.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,127.54,percent of total billed charges,,,85,,127.54,percent of total billed charges,,,49,,73.52,percent of total billed charges,,,90,,135.05,percent of total billed charges,,,,,,,no IP contract,,80,,120.04,percent of total billed charges,,,,,,,no IP contract,,50,,75.03,percent of total billed charges,,,,,,no IP contract,,,78,,117.04,percent of total billed charges,,,70,,105.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,73.52,3324,
25021-0114-87 - ciprofloxacin 400 mg/200 mL-5% Soln,25021-0114-87,NDC,,,,inpatient,200,ML,91.75,55.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,74.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,77.99,percent of total billed charges,,,85,,77.99,percent of total billed charges,,,49,,44.96,percent of total billed charges,,,90,,82.58,percent of total billed charges,,,,,,,no IP contract,,80,,73.4,percent of total billed charges,,,,,,,no IP contract,,50,,45.88,percent of total billed charges,,,,,,no IP contract,,,78,,71.57,percent of total billed charges,,,70,,64.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,44.96,3324,
clindamycin 150 mg/mL Soln,25021-0115-04,NDC,,,,inpatient,1,mL,18.2,10.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.47,percent of total billed charges,,,85,,15.47,percent of total billed charges,,,49,,8.92,percent of total billed charges,,,90,,16.38,percent of total billed charges,,,,,,,no IP contract,,80,,14.56,percent of total billed charges,,,,,,,no IP contract,,50,,9.1,percent of total billed charges,,,,,,no IP contract,,,78,,14.2,percent of total billed charges,,,70,,12.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.92,3324,
25021-0127-20 - cefTAZidime 1 g REC I,25021-0127-20,NDC,,,,inpatient,1,EA,57.9,34.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,46.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,49.22,percent of total billed charges,,,85,,49.22,percent of total billed charges,,,49,,28.37,percent of total billed charges,,,90,,52.11,percent of total billed charges,,,,,,,no IP contract,,80,,46.32,percent of total billed charges,,,,,,,no IP contract,,50,,28.95,percent of total billed charges,,,,,,no IP contract,,,78,,45.16,percent of total billed charges,,,70,,40.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,28.37,3324,
25021-0157-99 - vancomycin 5 g REC I,25021-0157-99,NDC,,,,inpatient,50,ML,408.3,244.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,330.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,347.06,percent of total billed charges,,,85,,347.06,percent of total billed charges,,,49,,200.07,percent of total billed charges,,,90,,367.47,percent of total billed charges,,,,,,,no IP contract,,80,,326.64,percent of total billed charges,,,,,,,no IP contract,,50,,204.15,percent of total billed charges,,,,,,no IP contract,,,78,,318.47,percent of total billed charges,,,70,,285.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,200.07,3324,
25021-0159-10 - colistimethate 150 mg (colistin base) REC I,25021-0159-10,NDC,,,,inpatient,2,ML,265.85,159.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,215.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,225.97,percent of total billed charges,,,85,,225.97,percent of total billed charges,,,49,,130.27,percent of total billed charges,,,90,,239.27,percent of total billed charges,,,,,,,no IP contract,,80,,212.68,percent of total billed charges,,,,,,,no IP contract,,50,,132.93,percent of total billed charges,,,,,,no IP contract,,,78,,207.36,percent of total billed charges,,,70,,186.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,130.27,3324,
25021-0164-30 - piperacillin-tazobactam 2 g-0.25 g REC I,25021-0164-30,NDC,,,,inpatient,1,EA,80.15,48.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,64.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,68.13,percent of total billed charges,,,85,,68.13,percent of total billed charges,,,49,,39.27,percent of total billed charges,,,90,,72.14,percent of total billed charges,,,,,,,no IP contract,,80,,64.12,percent of total billed charges,,,,,,,no IP contract,,50,,40.08,percent of total billed charges,,,,,,no IP contract,,,78,,62.52,percent of total billed charges,,,70,,56.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,39.27,3324,
25021-0166-48 - piperacillin-tazobactam 4 g-0.5 g REC I,25021-0166-48,NDC,,,,inpatient,1,EA,220.05,132.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,178.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,187.04,percent of total billed charges,,,85,,187.04,percent of total billed charges,,,49,,107.82,percent of total billed charges,,,90,,198.05,percent of total billed charges,,,,,,,no IP contract,,80,,176.04,percent of total billed charges,,,,,,,no IP contract,,50,,110.03,percent of total billed charges,,,,,,no IP contract,,,78,,171.64,percent of total billed charges,,,70,,154.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,107.82,3324,
25021-0173-02 - amikacin 250 mg/mL Soln,25021-0173-02,NDC,,,,inpatient,1,ML,48.5,29.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,39.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,41.23,percent of total billed charges,,,85,,41.23,percent of total billed charges,,,49,,23.77,percent of total billed charges,,,90,,43.65,percent of total billed charges,,,,,,,no IP contract,,80,,38.8,percent of total billed charges,,,,,,,no IP contract,,50,,24.25,percent of total billed charges,,,,,,no IP contract,,,78,,37.83,percent of total billed charges,,,70,,33.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.77,3324,
25021-0176-20 - piperacillin-tazobactam 3 g-0.375 g REC I,25021-0176-20,NDC,,,,inpatient,1,EA,98.35,59.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,79.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,83.6,percent of total billed charges,,,85,,83.6,percent of total billed charges,,,49,,48.19,percent of total billed charges,,,90,,88.52,percent of total billed charges,,,,,,,no IP contract,,80,,78.68,percent of total billed charges,,,,,,,no IP contract,,50,,49.18,percent of total billed charges,,,,,,no IP contract,,,78,,76.71,percent of total billed charges,,,70,,68.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,48.19,3324,
25021-0179-15 - DAPTOmycin 350 mg REC I,25021-0179-15,NDC,,,,inpatient,7,ML,2844,1706.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2303.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2417.4,percent of total billed charges,,,85,,2417.4,percent of total billed charges,,,49,,1393.56,percent of total billed charges,,,90,,2559.6,percent of total billed charges,,,,,,,no IP contract,,80,,2275.2,percent of total billed charges,,,,,,,no IP contract,,50,,1422,percent of total billed charges,,,,,,no IP contract,,,78,,2218.32,percent of total billed charges,,,70,,1990.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
25021-0184-66 - fluconazole 200 mg/100 mL-0.9% Soln,25021-0184-66,NDC,,,,inpatient,100,ML,100.05,60.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,81.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,85.04,percent of total billed charges,,,85,,85.04,percent of total billed charges,,,49,,49.02,percent of total billed charges,,,90,,90.05,percent of total billed charges,,,,,,,no IP contract,,80,,80.04,percent of total billed charges,,,,,,,no IP contract,,50,,50.03,percent of total billed charges,,,,,,no IP contract,,,78,,78.04,percent of total billed charges,,,70,,70.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,49.02,3324,
25021-0184-82 - fluconazole 200 mg/100 mL-0.9% Soln,25021-0184-82,NDC,,,,inpatient,100,ML,150.05,90.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,121.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,127.54,percent of total billed charges,,,85,,127.54,percent of total billed charges,,,49,,73.52,percent of total billed charges,,,90,,135.05,percent of total billed charges,,,,,,,no IP contract,,80,,120.04,percent of total billed charges,,,,,,,no IP contract,,50,,75.03,percent of total billed charges,,,,,,no IP contract,,,78,,117.04,percent of total billed charges,,,70,,105.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,73.52,3324,
25021-0184-87 - fluconazole 400 mg/200 mL-0.9% Soln,25021-0184-87,NDC,,,,inpatient,200,ML,191.7,115.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,155.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,162.95,percent of total billed charges,,,85,,162.95,percent of total billed charges,,,49,,93.93,percent of total billed charges,,,90,,172.53,percent of total billed charges,,,,,,,no IP contract,,80,,153.36,percent of total billed charges,,,,,,,no IP contract,,50,,95.85,percent of total billed charges,,,,,,no IP contract,,,78,,149.53,percent of total billed charges,,,70,,134.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,93.93,3324,
25021-0190-10 - micafungin  50 mg REC Injection,25021-0190-10,NDC,,,,inpatient,5,ML,993.05,595.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,804.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,844.09,percent of total billed charges,,,85,,844.09,percent of total billed charges,,,49,,486.59,percent of total billed charges,,,90,,893.75,percent of total billed charges,,,,,,,no IP contract,,80,,794.44,percent of total billed charges,,,,,,,no IP contract,,50,,496.53,percent of total billed charges,,,,,,no IP contract,,,78,,774.58,percent of total billed charges,,,70,,695.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,486.59,3324,
25021-0191-10 - micafungin 100 mg REC Injection,25021-0191-10,NDC,,,,inpatient,5,ML,1944.4,1166.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1574.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1652.74,percent of total billed charges,,,85,,1652.74,percent of total billed charges,,,49,,952.76,percent of total billed charges,,,90,,1749.96,percent of total billed charges,,,,,,,no IP contract,,80,,1555.52,percent of total billed charges,,,,,,,no IP contract,,50,,972.2,percent of total billed charges,,,,,,no IP contract,,,78,,1516.63,percent of total billed charges,,,70,,1361.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,952.76,3324,
25021-0311-04 - fuROSEmide 40 MG / 1 ML Injection,25021-0311-04,NDC,,,,inpatient,4,ML,37.65,22.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32,percent of total billed charges,,,85,,32,percent of total billed charges,,,49,,18.45,percent of total billed charges,,,90,,33.89,percent of total billed charges,,,,,,,no IP contract,,80,,30.12,percent of total billed charges,,,,,,,no IP contract,,50,,18.83,percent of total billed charges,,,,,,no IP contract,,,78,,29.37,percent of total billed charges,,,70,,26.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.45,3324,
25021-0400-10 - heparin 1000 units/mL Soln,25021-0400-10,NDC,,,,inpatient,10,ML,45.55,27.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,38.72,percent of total billed charges,,,85,,38.72,percent of total billed charges,,,49,,22.32,percent of total billed charges,,,90,,41,percent of total billed charges,,,,,,,no IP contract,,80,,36.44,percent of total billed charges,,,,,,,no IP contract,,50,,22.78,percent of total billed charges,,,,,,no IP contract,,,78,,35.53,percent of total billed charges,,,70,,31.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.32,3324,
"25021-0402-01 - heparin 5,000 unit(s) Injection",25021-0402-01,NDC,,,,inpatient,1,ML,35.65,21.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.3,percent of total billed charges,,,85,,30.3,percent of total billed charges,,,49,,17.47,percent of total billed charges,,,90,,32.09,percent of total billed charges,,,,,,,no IP contract,,80,,28.52,percent of total billed charges,,,,,,,no IP contract,,50,,17.83,percent of total billed charges,,,,,,no IP contract,,,78,,27.81,percent of total billed charges,,,70,,24.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.47,3324,
enoxaparin 150 mg/mL Soln,25021-0411-71,NDC,,,,inpatient,1,EA,143.85,86.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,116.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,122.27,percent of total billed charges,,,85,,122.27,percent of total billed charges,,,49,,70.49,percent of total billed charges,,,90,,129.47,percent of total billed charges,,,,,,,no IP contract,,80,,115.08,percent of total billed charges,,,,,,,no IP contract,,50,,71.93,percent of total billed charges,,,,,,no IP contract,,,78,,112.2,percent of total billed charges,,,70,,100.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,70.49,3324,
25021-0452-01 - octreotide 100 mcg/mL Soln,25021-0452-01,NDC,,,,inpatient,1,ML,75.1,45.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63.84,percent of total billed charges,,,85,,63.84,percent of total billed charges,,,49,,36.8,percent of total billed charges,,,90,,67.59,percent of total billed charges,,,,,,,no IP contract,,80,,60.08,percent of total billed charges,,,,,,,no IP contract,,50,,37.55,percent of total billed charges,,,,,,no IP contract,,,78,,58.58,percent of total billed charges,,,70,,52.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.8,3324,
25021-0500-02 - thiamine 100 mg/mL Soln,25021-0500-02,NDC,,,,inpatient,2,ML,110,66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,89.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,93.5,percent of total billed charges,,,85,,93.5,percent of total billed charges,,,49,,53.9,percent of total billed charges,,,90,,99,percent of total billed charges,,,,,,,no IP contract,,80,,88,percent of total billed charges,,,,,,,no IP contract,,50,,55,percent of total billed charges,,,,,,no IP contract,,,78,,85.8,percent of total billed charges,,,70,,77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,53.9,3324,
25021-0673-76 - lidocaine topical 2% Gel,25021-0673-76,NDC,,,,inpatient,6,ML,68.7,41.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,55.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,58.4,percent of total billed charges,,,85,,58.4,percent of total billed charges,,,49,,33.66,percent of total billed charges,,,90,,61.83,percent of total billed charges,,,,,,,no IP contract,,80,,54.96,percent of total billed charges,,,,,,,no IP contract,,50,,34.35,percent of total billed charges,,,,,,no IP contract,,,78,,53.59,percent of total billed charges,,,70,,48.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,33.66,3324,
25021-0801-66 - zoledronic acid 4 mg/5 mL Soln,25021-0801-66,NDC,,,,inpatient,1,ML,758.15,454.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,614.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,644.43,percent of total billed charges,,,85,,644.43,percent of total billed charges,,,49,,371.49,percent of total billed charges,,,90,,682.34,percent of total billed charges,,,,,,,no IP contract,,80,,606.52,percent of total billed charges,,,,,,,no IP contract,,50,,379.08,percent of total billed charges,,,,,,no IP contract,,,78,,591.36,percent of total billed charges,,,70,,530.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,371.49,3324,
27241-0049-10 - entacapone 200 mg Tab,27241-0049-10,NDC,,,,inpatient,1,EA,39.9,23.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.92,percent of total billed charges,,,85,,33.92,percent of total billed charges,,,49,,19.55,percent of total billed charges,,,90,,35.91,percent of total billed charges,,,,,,,no IP contract,,80,,31.92,percent of total billed charges,,,,,,,no IP contract,,50,,19.95,percent of total billed charges,,,,,,no IP contract,,,78,,31.12,percent of total billed charges,,,70,,27.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.55,3324,
27241-0115-01 - divalproex sodium 125 mg DR Ca,27241-0115-01,NDC,,,,inpatient,1,EA,12.75,7.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.84,percent of total billed charges,,,85,,10.84,percent of total billed charges,,,49,,6.25,percent of total billed charges,,,90,,11.48,percent of total billed charges,,,,,,,no IP contract,,80,,10.2,percent of total billed charges,,,,,,,no IP contract,,50,,6.38,percent of total billed charges,,,,,,no IP contract,,,78,,9.95,percent of total billed charges,,,70,,8.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.25,3324,
27241-0124-03 - sildenafil 20 mg Tab,27241-0124-03,NDC,,,,inpatient,1,EA,162.8,97.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,131.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,138.38,percent of total billed charges,,,85,,138.38,percent of total billed charges,,,49,,79.77,percent of total billed charges,,,90,,146.52,percent of total billed charges,,,,,,,no IP contract,,80,,130.24,percent of total billed charges,,,,,,,no IP contract,,50,,81.4,percent of total billed charges,,,,,,no IP contract,,,78,,126.98,percent of total billed charges,,,70,,113.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,79.77,3324,
27241-0158-60 - valGANciclovir 450 mg Tab,27241-0158-60,NDC,,,,inpatient,1,EA,550.65,330.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,446.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,468.05,percent of total billed charges,,,85,,468.05,percent of total billed charges,,,49,,269.82,percent of total billed charges,,,90,,495.59,percent of total billed charges,,,,,,,no IP contract,,80,,440.52,percent of total billed charges,,,,,,,no IP contract,,50,,275.33,percent of total billed charges,,,,,,no IP contract,,,78,,429.51,percent of total billed charges,,,70,,385.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,269.82,3324,
27241-0191-30 - tolterodine 2 mg ER Ca,27241-0191-30,NDC,,,,inpatient,1,EA,108.3,64.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,87.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,92.06,percent of total billed charges,,,85,,92.06,percent of total billed charges,,,49,,53.07,percent of total billed charges,,,90,,97.47,percent of total billed charges,,,,,,,no IP contract,,80,,86.64,percent of total billed charges,,,,,,,no IP contract,,50,,54.15,percent of total billed charges,,,,,,no IP contract,,,78,,84.47,percent of total billed charges,,,70,,75.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,53.07,3324,
27241-0242-01 - guanFACINE 1 mg Tab,27241-0242-01,NDC,,,,inpatient,1,EA,13.9,8.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.82,percent of total billed charges,,,85,,11.82,percent of total billed charges,,,49,,6.81,percent of total billed charges,,,90,,12.51,percent of total billed charges,,,,,,,no IP contract,,80,,11.12,percent of total billed charges,,,,,,,no IP contract,,50,,6.95,percent of total billed charges,,,,,,no IP contract,,,78,,10.84,percent of total billed charges,,,70,,9.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.81,3324,
arformoterol 15 mcg/2 mL Soln,27437-0055-30,NDC,,,,inpatient,1,EA,196.8,118.08,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,159.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,167.28,percent of total billed charges,,,85,,167.28,percent of total billed charges,,,49,,96.43,percent of total billed charges,,,90,,177.12,percent of total billed charges,,,,,,,no IP contract,,80,,157.44,percent of total billed charges,,,,,,,no IP contract,,50,,98.4,percent of total billed charges,,,,,,no IP contract,,,78,,153.5,percent of total billed charges,,,70,,137.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,96.43,3324,
risperiDONE 1 mg/mL Soln,27808-0002-01,NDC,,,,inpatient,1,mL,52,31.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,42.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,44.2,percent of total billed charges,,,85,,44.2,percent of total billed charges,,,49,,25.48,percent of total billed charges,,,90,,46.8,percent of total billed charges,,,,,,,no IP contract,,80,,41.6,percent of total billed charges,,,,,,,no IP contract,,50,,26,percent of total billed charges,,,,,,no IP contract,,,78,,40.56,percent of total billed charges,,,70,,36.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.48,3324,
27808-0155-01 - rosuvastatin 5 mg Tab,27808-0155-01,NDC,,,,inpatient,1,EA,74.9,44.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63.67,percent of total billed charges,,,85,,63.67,percent of total billed charges,,,49,,36.7,percent of total billed charges,,,90,,67.41,percent of total billed charges,,,,,,,no IP contract,,80,,59.92,percent of total billed charges,,,,,,,no IP contract,,50,,37.45,percent of total billed charges,,,,,,no IP contract,,,78,,58.42,percent of total billed charges,,,70,,52.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.7,3324,
27808-0157-01 - rosuvastatin 20 mg Tab,27808-0157-01,NDC,,,,inpatient,1,EA,74.9,44.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63.67,percent of total billed charges,,,85,,63.67,percent of total billed charges,,,49,,36.7,percent of total billed charges,,,90,,67.41,percent of total billed charges,,,,,,,no IP contract,,80,,59.92,percent of total billed charges,,,,,,,no IP contract,,50,,37.45,percent of total billed charges,,,,,,no IP contract,,,78,,58.42,percent of total billed charges,,,70,,52.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.7,3324,
29033-0004-12 - carBAMazepine 300 mg ER Ca,29033-0004-12,NDC,,,,inpatient,1,EA,18.05,10.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.34,percent of total billed charges,,,85,,15.34,percent of total billed charges,,,49,,8.84,percent of total billed charges,,,90,,16.25,percent of total billed charges,,,,,,,no IP contract,,80,,14.44,percent of total billed charges,,,,,,,no IP contract,,50,,9.03,percent of total billed charges,,,,,,no IP contract,,,78,,14.08,percent of total billed charges,,,70,,12.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.84,3324,
29033-0036-30 - dapsone 25 mg Tab,29033-0036-30,NDC,,,,inpatient,1,EA,23.45,14.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.93,percent of total billed charges,,,85,,19.93,percent of total billed charges,,,49,,11.49,percent of total billed charges,,,90,,21.11,percent of total billed charges,,,,,,,no IP contract,,80,,18.76,percent of total billed charges,,,,,,,no IP contract,,50,,11.73,percent of total billed charges,,,,,,no IP contract,,,78,,18.29,percent of total billed charges,,,70,,16.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.49,3324,
29300-0111-01 - lamoTRIgine 25 mg Tab,29300-0111-01,NDC,,,,inpatient,1,EA,37.35,22.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.75,percent of total billed charges,,,85,,31.75,percent of total billed charges,,,49,,18.3,percent of total billed charges,,,90,,33.62,percent of total billed charges,,,,,,,no IP contract,,80,,29.88,percent of total billed charges,,,,,,,no IP contract,,50,,18.68,percent of total billed charges,,,,,,no IP contract,,,78,,29.13,percent of total billed charges,,,70,,26.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.3,3324,
29300-0114-16 - lamoTRIgine 200 mg Tab,29300-0114-16,NDC,,,,inpatient,1,EA,49.7,29.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,40.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,42.25,percent of total billed charges,,,85,,42.25,percent of total billed charges,,,49,,24.35,percent of total billed charges,,,90,,44.73,percent of total billed charges,,,,,,,no IP contract,,80,,39.76,percent of total billed charges,,,,,,,no IP contract,,50,,24.85,percent of total billed charges,,,,,,no IP contract,,,78,,38.77,percent of total billed charges,,,70,,34.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.35,3324,
29300-0126-01 - bisoprolol 5 mg Tab,29300-0126-01,NDC,,,,inpatient,1,EA,13.5,8.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.48,percent of total billed charges,,,85,,11.48,percent of total billed charges,,,49,,6.62,percent of total billed charges,,,90,,12.15,percent of total billed charges,,,,,,,no IP contract,,80,,10.8,percent of total billed charges,,,,,,,no IP contract,,50,,6.75,percent of total billed charges,,,,,,no IP contract,,,78,,10.53,percent of total billed charges,,,70,,9.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.62,3324,
29300-0130-01 - hydroCHLOROthiazide 12.5 mg Cap,29300-0130-01,NDC,,,,inpatient,1,EA,7.15,4.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.08,percent of total billed charges,,,85,,6.08,percent of total billed charges,,,49,,3.5,percent of total billed charges,,,90,,6.44,percent of total billed charges,,,,,,,no IP contract,,80,,5.72,percent of total billed charges,,,,,,,no IP contract,,50,,3.58,percent of total billed charges,,,,,,no IP contract,,,78,,5.58,percent of total billed charges,,,70,,5.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.5,3324,
cloNIDine 0.3 mg Tab,29300-0137-01,NDC,,,,inpatient,1,EA,8.85,5.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.52,percent of total billed charges,,,85,,7.52,percent of total billed charges,,,49,,4.34,percent of total billed charges,,,90,,7.97,percent of total billed charges,,,,,,,no IP contract,,80,,7.08,percent of total billed charges,,,,,,,no IP contract,,50,,4.43,percent of total billed charges,,,,,,no IP contract,,,78,,6.9,percent of total billed charges,,,70,,6.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.34,3324,
29300-0239-16 - tolterodine 1 mg Tab,29300-0239-16,NDC,,,,inpatient,1,EA,30.15,18.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.63,percent of total billed charges,,,85,,25.63,percent of total billed charges,,,49,,14.77,percent of total billed charges,,,90,,27.14,percent of total billed charges,,,,,,,no IP contract,,80,,24.12,percent of total billed charges,,,,,,,no IP contract,,50,,15.08,percent of total billed charges,,,,,,no IP contract,,,78,,23.52,percent of total billed charges,,,70,,21.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.77,3324,
29300-0244-01 - busPIRone 5 mg Tab,29300-0244-01,NDC,,,,inpatient,1,EA,9.95,5.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.46,percent of total billed charges,,,85,,8.46,percent of total billed charges,,,49,,4.88,percent of total billed charges,,,90,,8.96,percent of total billed charges,,,,,,,no IP contract,,80,,7.96,percent of total billed charges,,,,,,,no IP contract,,50,,4.98,percent of total billed charges,,,,,,no IP contract,,,78,,7.76,percent of total billed charges,,,70,,6.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.88,3324,
traMADol 50 mg Tab,29300-0355-01,NDC,,,,inpatient,1,EA,10.4,6.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.84,percent of total billed charges,,,85,,8.84,percent of total billed charges,,,49,,5.1,percent of total billed charges,,,90,,9.36,percent of total billed charges,,,,,,,no IP contract,,80,,8.32,percent of total billed charges,,,,,,,no IP contract,,50,,5.2,percent of total billed charges,,,,,,no IP contract,,,78,,8.11,percent of total billed charges,,,70,,7.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.1,3324,
29300-0415-01 - cyclobenzaprine 10 mg Tab,29300-0415-01,NDC,,,,inpatient,1,EA,13.05,7.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.09,percent of total billed charges,,,85,,11.09,percent of total billed charges,,,49,,6.39,percent of total billed charges,,,90,,11.75,percent of total billed charges,,,,,,,no IP contract,,80,,10.44,percent of total billed charges,,,,,,,no IP contract,,50,,6.53,percent of total billed charges,,,,,,no IP contract,,,78,,10.18,percent of total billed charges,,,70,,9.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.39,3324,
29300-0419-01 - amitriptyline 10 mg Tab,29300-0419-01,NDC,,,,inpatient,1,EA,6.35,3.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.4,percent of total billed charges,,,85,,5.4,percent of total billed charges,,,49,,3.11,percent of total billed charges,,,90,,5.72,percent of total billed charges,,,,,,,no IP contract,,80,,5.08,percent of total billed charges,,,,,,,no IP contract,,50,,3.18,percent of total billed charges,,,,,,no IP contract,,,78,,4.95,percent of total billed charges,,,70,,4.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.11,3324,
29300-0422-01 - amitriptyline 75 mg Tab,29300-0422-01,NDC,,,,inpatient,1,EA,19,11.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.15,percent of total billed charges,,,85,,16.15,percent of total billed charges,,,49,,9.31,percent of total billed charges,,,90,,17.1,percent of total billed charges,,,,,,,no IP contract,,80,,15.2,percent of total billed charges,,,,,,,no IP contract,,50,,9.5,percent of total billed charges,,,,,,no IP contract,,,78,,14.82,percent of total billed charges,,,70,,13.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.31,3324,
29300-0423-01 - amitriptyline 100 mg Tab,29300-0423-01,NDC,,,,inpatient,1,EA,24,14.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.4,percent of total billed charges,,,85,,20.4,percent of total billed charges,,,49,,11.76,percent of total billed charges,,,90,,21.6,percent of total billed charges,,,,,,,no IP contract,,80,,19.2,percent of total billed charges,,,,,,,no IP contract,,50,,12,percent of total billed charges,,,,,,no IP contract,,,78,,18.72,percent of total billed charges,,,70,,16.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.76,3324,
calcitriol 1 mcg/mL LIQ,30698-0911-15,NDC,,,,inpatient,1,mL,129.7,77.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,105.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,110.25,percent of total billed charges,,,85,,110.25,percent of total billed charges,,,49,,63.55,percent of total billed charges,,,90,,116.73,percent of total billed charges,,,,,,,no IP contract,,80,,103.76,percent of total billed charges,,,,,,,no IP contract,,50,,64.85,percent of total billed charges,,,,,,no IP contract,,,78,,101.17,percent of total billed charges,,,70,,90.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,63.55,3324,
31604-0012-81 - thiamine 100 mg Tab,31604-0012-81,NDC,,,,inpatient,1,EA,4.15,2.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.53,percent of total billed charges,,,85,,3.53,percent of total billed charges,,,49,,2.03,percent of total billed charges,,,90,,3.74,percent of total billed charges,,,,,,,no IP contract,,80,,3.32,percent of total billed charges,,,,,,,no IP contract,,50,,2.08,percent of total billed charges,,,,,,no IP contract,,,78,,3.24,percent of total billed charges,,,70,,2.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.03,3324,
31604-0012-90 - cyanocobalamin 500 mcg Tab,31604-0012-90,NDC,,,,inpatient,1,EA,4.4,2.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.74,percent of total billed charges,,,85,,3.74,percent of total billed charges,,,49,,2.16,percent of total billed charges,,,90,,3.96,percent of total billed charges,,,,,,,no IP contract,,80,,3.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.2,percent of total billed charges,,,,,,no IP contract,,,78,,3.43,percent of total billed charges,,,70,,3.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.16,3324,
31604-0014-96 - ascorbic acid 500 mg Chew tab,31604-0014-96,NDC,,,,inpatient,1,EA,4.8,2.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.08,percent of total billed charges,,,85,,4.08,percent of total billed charges,,,49,,2.35,percent of total billed charges,,,90,,4.32,percent of total billed charges,,,,,,,no IP contract,,80,,3.84,percent of total billed charges,,,,,,,no IP contract,,50,,2.4,percent of total billed charges,,,,,,no IP contract,,,78,,3.74,percent of total billed charges,,,70,,3.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.35,3324,
31722-0006-31 - itraconazole 10 mg/mL Soln,31722-0006-31,NDC,,,,inpatient,1,ML,26,15.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.1,percent of total billed charges,,,85,,22.1,percent of total billed charges,,,49,,12.74,percent of total billed charges,,,90,,23.4,percent of total billed charges,,,,,,,no IP contract,,80,,20.8,percent of total billed charges,,,,,,,no IP contract,,50,,13,percent of total billed charges,,,,,,no IP contract,,,78,,20.28,percent of total billed charges,,,70,,18.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.74,3324,
mexiletine 200 mg Cap,31722-0037-01,NDC,,,,inpatient,1,EA,27.9,16.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.72,percent of total billed charges,,,85,,23.72,percent of total billed charges,,,49,,13.67,percent of total billed charges,,,90,,25.11,percent of total billed charges,,,,,,,no IP contract,,80,,22.32,percent of total billed charges,,,,,,,no IP contract,,50,,13.95,percent of total billed charges,,,,,,no IP contract,,,78,,21.76,percent of total billed charges,,,70,,19.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.67,3324,
captopril 25 mg Tab,31722-0142-01,NDC,,,,inpatient,1,EA,17.1,10.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.54,percent of total billed charges,,,85,,14.54,percent of total billed charges,,,49,,8.38,percent of total billed charges,,,90,,15.39,percent of total billed charges,,,,,,,no IP contract,,80,,13.68,percent of total billed charges,,,,,,,no IP contract,,50,,8.55,percent of total billed charges,,,,,,no IP contract,,,78,,13.34,percent of total billed charges,,,70,,11.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.38,3324,
31722-0163-01 - amphetamine-dextroamphetamine 20 mg Tab,31722-0163-01,NDC,,,,inpatient,1,EA,19.65,11.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.7,percent of total billed charges,,,85,,16.7,percent of total billed charges,,,49,,9.63,percent of total billed charges,,,90,,17.69,percent of total billed charges,,,,,,,no IP contract,,80,,15.72,percent of total billed charges,,,,,,,no IP contract,,50,,9.83,percent of total billed charges,,,,,,no IP contract,,,78,,15.33,percent of total billed charges,,,70,,13.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.63,3324,
31722-0173-01 - methylphenidate 5 mg Tab,31722-0173-01,NDC,,,,inpatient,1,EA,11.6,6.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.86,percent of total billed charges,,,85,,9.86,percent of total billed charges,,,49,,5.68,percent of total billed charges,,,90,,10.44,percent of total billed charges,,,,,,,no IP contract,,80,,9.28,percent of total billed charges,,,,,,,no IP contract,,50,,5.8,percent of total billed charges,,,,,,no IP contract,,,78,,9.05,percent of total billed charges,,,70,,8.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.68,3324,
31722-0212-90 - sertraline 25 mg Tab,31722-0212-90,NDC,,,,inpatient,1,EA,26.25,15.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.31,percent of total billed charges,,,85,,22.31,percent of total billed charges,,,49,,12.86,percent of total billed charges,,,90,,23.63,percent of total billed charges,,,,,,,no IP contract,,80,,21,percent of total billed charges,,,,,,,no IP contract,,50,,13.13,percent of total billed charges,,,,,,no IP contract,,,78,,20.48,percent of total billed charges,,,70,,18.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.86,3324,
31722-0222-01 - gabapentin 300 mg Cap,31722-0222-01,NDC,,,,inpatient,1,EA,14.4,8.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.24,percent of total billed charges,,,85,,12.24,percent of total billed charges,,,49,,7.06,percent of total billed charges,,,90,,12.96,percent of total billed charges,,,,,,,no IP contract,,80,,11.52,percent of total billed charges,,,,,,,no IP contract,,50,,7.2,percent of total billed charges,,,,,,no IP contract,,,78,,11.23,percent of total billed charges,,,70,,10.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.06,3324,
31722-0229-01 - dexmethylphenidate 5 mg ER Ca,31722-0229-01,NDC,,,,inpatient,1,EA,70.4,42.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,57.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,59.84,percent of total billed charges,,,85,,59.84,percent of total billed charges,,,49,,34.5,percent of total billed charges,,,90,,63.36,percent of total billed charges,,,,,,,no IP contract,,80,,56.32,percent of total billed charges,,,,,,,no IP contract,,50,,35.2,percent of total billed charges,,,,,,no IP contract,,,78,,54.91,percent of total billed charges,,,70,,49.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,34.5,3324,
31722-0232-01 - dexmethylphenidate 20 mg ER Ca,31722-0232-01,NDC,,,,inpatient,1,EA,83.4,50.04,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,67.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,70.89,percent of total billed charges,,,85,,70.89,percent of total billed charges,,,49,,40.87,percent of total billed charges,,,90,,75.06,percent of total billed charges,,,,,,,no IP contract,,80,,66.72,percent of total billed charges,,,,,,,no IP contract,,50,,41.7,percent of total billed charges,,,,,,no IP contract,,,78,,65.05,percent of total billed charges,,,70,,58.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,40.87,3324,
lamoTRIgine 200 mg ER Ta,31722-0243-30,NDC,,,,inpatient,1,EA,258.8,155.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,209.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,219.98,percent of total billed charges,,,85,,219.98,percent of total billed charges,,,49,,126.81,percent of total billed charges,,,90,,232.92,percent of total billed charges,,,,,,,no IP contract,,80,,207.04,percent of total billed charges,,,,,,,no IP contract,,50,,129.4,percent of total billed charges,,,,,,no IP contract,,,78,,201.86,percent of total billed charges,,,70,,181.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,126.81,3324,
31722-0279-60 - topiramate 50 mg Tab,31722-0279-60,NDC,,,,inpatient,1,EA,43.9,26.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,35.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,37.32,percent of total billed charges,,,85,,37.32,percent of total billed charges,,,49,,21.51,percent of total billed charges,,,90,,39.51,percent of total billed charges,,,,,,,no IP contract,,80,,35.12,percent of total billed charges,,,,,,,no IP contract,,50,,21.95,percent of total billed charges,,,,,,no IP contract,,,78,,34.24,percent of total billed charges,,,70,,30.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.51,3324,
31722-0308-01 - OLANZapine 10 mg Injection,31722-0308-01,NDC,,,,inpatient,2,ML,356.2,213.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,288.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,302.77,percent of total billed charges,,,85,,302.77,percent of total billed charges,,,49,,174.54,percent of total billed charges,,,90,,320.58,percent of total billed charges,,,,,,,no IP contract,,80,,284.96,percent of total billed charges,,,,,,,no IP contract,,50,,178.1,percent of total billed charges,,,,,,no IP contract,,,78,,277.84,percent of total billed charges,,,70,,249.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,174.54,3324,
31722-0504-30 - efavirenz 600 mg Tab,31722-0504-30,NDC,,,,inpatient,1,EA,300.05,180.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,243.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,255.04,percent of total billed charges,,,85,,255.04,percent of total billed charges,,,49,,147.02,percent of total billed charges,,,90,,270.05,percent of total billed charges,,,,,,,no IP contract,,80,,240.04,percent of total billed charges,,,,,,,no IP contract,,50,,150.03,percent of total billed charges,,,,,,no IP contract,,,78,,234.04,percent of total billed charges,,,70,,210.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,147.02,3324,
31722-0513-90 - simvastatin 40 mg Tab,31722-0513-90,NDC,,,,inpatient,1,EA,42.85,25.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36.42,percent of total billed charges,,,85,,36.42,percent of total billed charges,,,49,,21,percent of total billed charges,,,90,,38.57,percent of total billed charges,,,,,,,no IP contract,,80,,34.28,percent of total billed charges,,,,,,,no IP contract,,50,,21.43,percent of total billed charges,,,,,,no IP contract,,,78,,33.42,percent of total billed charges,,,70,,30,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21,3324,
31722-0520-01 - hydrALAZINE 25 mg Tab,31722-0520-01,NDC,,,,inpatient,1,EA,7.9,4.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.72,percent of total billed charges,,,85,,6.72,percent of total billed charges,,,49,,3.87,percent of total billed charges,,,90,,7.11,percent of total billed charges,,,,,,,no IP contract,,80,,6.32,percent of total billed charges,,,,,,,no IP contract,,50,,3.95,percent of total billed charges,,,,,,no IP contract,,,78,,6.16,percent of total billed charges,,,70,,5.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.87,3324,
31722-0525-90 - finasteride 5 mg Tab,31722-0525-90,NDC,,,,inpatient,1,EA,28.55,17.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.27,percent of total billed charges,,,85,,24.27,percent of total billed charges,,,49,,13.99,percent of total billed charges,,,90,,25.7,percent of total billed charges,,,,,,,no IP contract,,80,,22.84,percent of total billed charges,,,,,,,no IP contract,,50,,14.28,percent of total billed charges,,,,,,no IP contract,,,78,,22.27,percent of total billed charges,,,70,,19.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.99,3324,
31722-0526-30 - finasteride 1 mg Tab,31722-0526-30,NDC,,,,inpatient,1,EA,25.35,15.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.55,percent of total billed charges,,,85,,21.55,percent of total billed charges,,,49,,12.42,percent of total billed charges,,,90,,22.82,percent of total billed charges,,,,,,,no IP contract,,80,,20.28,percent of total billed charges,,,,,,,no IP contract,,50,,12.68,percent of total billed charges,,,,,,no IP contract,,,78,,19.77,percent of total billed charges,,,70,,17.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.42,3324,
31722-0526-90 - finasteride 1 mg Tab,31722-0526-90,NDC,,,,inpatient,1,EA,23.2,13.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.72,percent of total billed charges,,,85,,19.72,percent of total billed charges,,,49,,11.37,percent of total billed charges,,,90,,20.88,percent of total billed charges,,,,,,,no IP contract,,80,,18.56,percent of total billed charges,,,,,,,no IP contract,,50,,11.6,percent of total billed charges,,,,,,no IP contract,,,78,,18.1,percent of total billed charges,,,70,,16.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.37,3324,
31722-0530-01 - torsemide 10 mg Tab,31722-0530-01,NDC,,,,inpatient,1,EA,9.4,5.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.99,percent of total billed charges,,,85,,7.99,percent of total billed charges,,,49,,4.61,percent of total billed charges,,,90,,8.46,percent of total billed charges,,,,,,,no IP contract,,80,,7.52,percent of total billed charges,,,,,,,no IP contract,,50,,4.7,percent of total billed charges,,,,,,no IP contract,,,78,,7.33,percent of total billed charges,,,70,,6.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.61,3324,
31722-0532-01 - torsemide 100 mg Tab,31722-0532-01,NDC,,,,inpatient,1,EA,28,16.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.8,percent of total billed charges,,,85,,23.8,percent of total billed charges,,,49,,13.72,percent of total billed charges,,,90,,25.2,percent of total billed charges,,,,,,,no IP contract,,80,,22.4,percent of total billed charges,,,,,,,no IP contract,,50,,14,percent of total billed charges,,,,,,no IP contract,,,78,,21.84,percent of total billed charges,,,70,,19.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.72,3324,
31722-0533-01 - methocarbamol 500 mg Tab,31722-0533-01,NDC,,,,inpatient,1,EA,7.9,4.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.72,percent of total billed charges,,,85,,6.72,percent of total billed charges,,,49,,3.87,percent of total billed charges,,,90,,7.11,percent of total billed charges,,,,,,,no IP contract,,80,,6.32,percent of total billed charges,,,,,,,no IP contract,,50,,3.95,percent of total billed charges,,,,,,no IP contract,,,78,,6.16,percent of total billed charges,,,70,,5.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.87,3324,
31722-0542-01 - indomethacin 25 mg Cap,31722-0542-01,NDC,,,,inpatient,1,EA,6.85,4.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.82,percent of total billed charges,,,85,,5.82,percent of total billed charges,,,49,,3.36,percent of total billed charges,,,90,,6.17,percent of total billed charges,,,,,,,no IP contract,,80,,5.48,percent of total billed charges,,,,,,,no IP contract,,50,,3.43,percent of total billed charges,,,,,,no IP contract,,,78,,5.34,percent of total billed charges,,,70,,4.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.36,3324,
31722-0557-60 - abacavir 300 mg Tab,31722-0557-60,NDC,,,,inpatient,1,EA,83.7,50.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,67.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,71.15,percent of total billed charges,,,85,,71.15,percent of total billed charges,,,49,,41.01,percent of total billed charges,,,90,,75.33,percent of total billed charges,,,,,,,no IP contract,,80,,66.96,percent of total billed charges,,,,,,,no IP contract,,50,,41.85,percent of total billed charges,,,,,,no IP contract,,,78,,65.29,percent of total billed charges,,,70,,58.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,41.01,3324,
31722-0564-24 - citalopram 10 mg/5 mL Soln,31722-0564-24,NDC,,,,inpatient,1,ML,9.5,5.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.08,percent of total billed charges,,,85,,8.08,percent of total billed charges,,,49,,4.66,percent of total billed charges,,,90,,8.55,percent of total billed charges,,,,,,,no IP contract,,80,,7.6,percent of total billed charges,,,,,,,no IP contract,,50,,4.75,percent of total billed charges,,,,,,no IP contract,,,78,,7.41,percent of total billed charges,,,70,,6.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.66,3324,
31722-0569-24 - escitalopram 5 mg/5 mL Soln,31722-0569-24,NDC,,,,inpatient,1,ML,12,7.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.2,percent of total billed charges,,,85,,10.2,percent of total billed charges,,,49,,5.88,percent of total billed charges,,,90,,10.8,percent of total billed charges,,,,,,,no IP contract,,80,,9.6,percent of total billed charges,,,,,,,no IP contract,,50,,6,percent of total billed charges,,,,,,no IP contract,,,78,,9.36,percent of total billed charges,,,70,,8.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.88,3324,
31722-0597-30 - ritonavir 100 mg Tab,31722-0597-30,NDC,,,,inpatient,1,EA,77.45,46.47,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,62.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,65.83,percent of total billed charges,,,85,,65.83,percent of total billed charges,,,49,,37.95,percent of total billed charges,,,90,,69.71,percent of total billed charges,,,,,,,no IP contract,,80,,61.96,percent of total billed charges,,,,,,,no IP contract,,50,,38.73,percent of total billed charges,,,,,,no IP contract,,,78,,60.41,percent of total billed charges,,,70,,54.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,37.95,3324,
31722-0700-90 - losartan 25 mg Tab,31722-0700-90,NDC,,,,inpatient,1,EA,17.1,10.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.54,percent of total billed charges,,,85,,14.54,percent of total billed charges,,,49,,8.38,percent of total billed charges,,,90,,15.39,percent of total billed charges,,,,,,,no IP contract,,80,,13.68,percent of total billed charges,,,,,,,no IP contract,,50,,8.55,percent of total billed charges,,,,,,no IP contract,,,78,,13.34,percent of total billed charges,,,70,,11.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.38,3324,
31722-0701-90 - losartan 50 mg Tab,31722-0701-90,NDC,,,,inpatient,1,EA,21.7,13.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.45,percent of total billed charges,,,85,,18.45,percent of total billed charges,,,49,,10.63,percent of total billed charges,,,90,,19.53,percent of total billed charges,,,,,,,no IP contract,,80,,17.36,percent of total billed charges,,,,,,,no IP contract,,50,,10.85,percent of total billed charges,,,,,,no IP contract,,,78,,16.93,percent of total billed charges,,,70,,15.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.63,3324,
31722-0704-30 - valACYclovir 500 mg Tab,31722-0704-30,NDC,,,,inpatient,1,EA,61.2,36.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,49.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,52.02,percent of total billed charges,,,85,,52.02,percent of total billed charges,,,49,,29.99,percent of total billed charges,,,90,,55.08,percent of total billed charges,,,,,,,no IP contract,,80,,48.96,percent of total billed charges,,,,,,,no IP contract,,50,,30.6,percent of total billed charges,,,,,,no IP contract,,,78,,47.74,percent of total billed charges,,,70,,42.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,29.99,3324,
31722-0713-90 - pantoprazole 40 mg EC Ta,31722-0713-90,NDC,,,,inpatient,1,EA,45.7,27.42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,37.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,38.85,percent of total billed charges,,,85,,38.85,percent of total billed charges,,,49,,22.39,percent of total billed charges,,,90,,41.13,percent of total billed charges,,,,,,,no IP contract,,80,,36.56,percent of total billed charges,,,,,,,no IP contract,,50,,22.85,percent of total billed charges,,,,,,no IP contract,,,78,,35.65,percent of total billed charges,,,70,,31.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.39,3324,
31722-0727-30 - montelukast 4 mg Chew,31722-0727-30,NDC,,,,inpatient,1,EA,48.8,29.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,39.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,41.48,percent of total billed charges,,,85,,41.48,percent of total billed charges,,,49,,23.91,percent of total billed charges,,,90,,43.92,percent of total billed charges,,,,,,,no IP contract,,80,,39.04,percent of total billed charges,,,,,,,no IP contract,,50,,24.4,percent of total billed charges,,,,,,no IP contract,,,78,,38.06,percent of total billed charges,,,70,,34.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.91,3324,
31722-0805-60 - tolterodine 1 mg Tab,31722-0805-60,NDC,,,,inpatient,1,EA,30.15,18.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.63,percent of total billed charges,,,85,,25.63,percent of total billed charges,,,49,,14.77,percent of total billed charges,,,90,,27.14,percent of total billed charges,,,,,,,no IP contract,,80,,24.12,percent of total billed charges,,,,,,,no IP contract,,50,,15.08,percent of total billed charges,,,,,,no IP contract,,,78,,23.52,percent of total billed charges,,,70,,21.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.77,3324,
31722-0812-60 - lacosamide 50 mg Tab,31722-0812-60,NDC,,,,inpatient,1,EA,101.15,60.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,81.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,85.98,percent of total billed charges,,,85,,85.98,percent of total billed charges,,,49,,49.56,percent of total billed charges,,,90,,91.04,percent of total billed charges,,,,,,,no IP contract,,80,,80.92,percent of total billed charges,,,,,,,no IP contract,,50,,50.58,percent of total billed charges,,,,,,no IP contract,,,78,,78.9,percent of total billed charges,,,70,,70.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,49.56,3324,
31722-0813-60 - lacosamide 100 mg Tab,31722-0813-60,NDC,,,,inpatient,1,EA,7.5,4.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.38,percent of total billed charges,,,85,,6.38,percent of total billed charges,,,49,,3.68,percent of total billed charges,,,90,,6.75,percent of total billed charges,,,,,,,no IP contract,,80,,6,percent of total billed charges,,,,,,,no IP contract,,50,,3.75,percent of total billed charges,,,,,,no IP contract,,,78,,5.85,percent of total billed charges,,,70,,5.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.68,3324,
31722-0832-60 - valGANciclovir 450 mg Tab,31722-0832-60,NDC,,,,inpatient,1,EA,515.8,309.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,417.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,438.43,percent of total billed charges,,,85,,438.43,percent of total billed charges,,,49,,252.74,percent of total billed charges,,,90,,464.22,percent of total billed charges,,,,,,,no IP contract,,80,,412.64,percent of total billed charges,,,,,,,no IP contract,,50,,257.9,percent of total billed charges,,,,,,no IP contract,,,78,,402.32,percent of total billed charges,,,70,,361.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,252.74,3324,
31722-0833-30 - entecavir 0.5 mg Tab,31722-0833-30,NDC,,,,inpatient,1,EA,357.05,214.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,289.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,303.49,percent of total billed charges,,,85,,303.49,percent of total billed charges,,,49,,174.95,percent of total billed charges,,,90,,321.35,percent of total billed charges,,,,,,,no IP contract,,80,,285.64,percent of total billed charges,,,,,,,no IP contract,,50,,178.53,percent of total billed charges,,,,,,no IP contract,,,78,,278.5,percent of total billed charges,,,70,,249.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,174.95,3324,
31722-0882-90 - rosuvastatin 5 mg Tab,31722-0882-90,NDC,,,,inpatient,1,EA,74.9,44.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63.67,percent of total billed charges,,,85,,63.67,percent of total billed charges,,,49,,36.7,percent of total billed charges,,,90,,67.41,percent of total billed charges,,,,,,,no IP contract,,80,,59.92,percent of total billed charges,,,,,,,no IP contract,,50,,37.45,percent of total billed charges,,,,,,no IP contract,,,78,,58.42,percent of total billed charges,,,70,,52.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.7,3324,
31722-0884-90 - rosuvastatin 20 mg Tab,31722-0884-90,NDC,,,,inpatient,1,EA,74.9,44.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63.67,percent of total billed charges,,,85,,63.67,percent of total billed charges,,,49,,36.7,percent of total billed charges,,,90,,67.41,percent of total billed charges,,,,,,,no IP contract,,80,,59.92,percent of total billed charges,,,,,,,no IP contract,,50,,37.45,percent of total billed charges,,,,,,no IP contract,,,78,,58.42,percent of total billed charges,,,70,,52.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.7,3324,
32909-0723-01 - barium sulfate 2.1% Susp,32909-0723-01,NDC,,,,inpatient,450,ML,42.9,25.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36.47,percent of total billed charges,,,85,,36.47,percent of total billed charges,,,49,,21.02,percent of total billed charges,,,90,,38.61,percent of total billed charges,,,,,,,no IP contract,,80,,34.32,percent of total billed charges,,,,,,,no IP contract,,50,,21.45,percent of total billed charges,,,,,,no IP contract,,,78,,33.46,percent of total billed charges,,,70,,30.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.02,3324,
32909-0725-03 - barium sulfate 2.1% Susp,32909-0725-03,NDC,,,,inpatient,450,ML,42.9,25.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36.47,percent of total billed charges,,,85,,36.47,percent of total billed charges,,,49,,21.02,percent of total billed charges,,,90,,38.61,percent of total billed charges,,,,,,,no IP contract,,80,,34.32,percent of total billed charges,,,,,,,no IP contract,,50,,21.45,percent of total billed charges,,,,,,no IP contract,,,78,,33.46,percent of total billed charges,,,70,,30.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.02,3324,
32909-0755-03 - barium sulfate 2.1% Susp,32909-0755-03,NDC,,,,inpatient,450,ML,42.9,25.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36.47,percent of total billed charges,,,85,,36.47,percent of total billed charges,,,49,,21.02,percent of total billed charges,,,90,,38.61,percent of total billed charges,,,,,,,no IP contract,,80,,34.32,percent of total billed charges,,,,,,,no IP contract,,50,,21.45,percent of total billed charges,,,,,,no IP contract,,,78,,33.46,percent of total billed charges,,,70,,30.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.02,3324,
32909-0775-03 - barium sulfate 2.1% Susp,32909-0775-03,NDC,,,,inpatient,450,ML,42.9,25.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36.47,percent of total billed charges,,,85,,36.47,percent of total billed charges,,,49,,21.02,percent of total billed charges,,,90,,38.61,percent of total billed charges,,,,,,,no IP contract,,80,,34.32,percent of total billed charges,,,,,,,no IP contract,,50,,21.45,percent of total billed charges,,,,,,no IP contract,,,78,,33.46,percent of total billed charges,,,70,,30.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.02,3324,
32909-0945-03 - barium sulfate 0.1% Susp,32909-0945-03,NDC,,,,inpatient,450,ML,80.4,48.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,65.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,68.34,percent of total billed charges,,,85,,68.34,percent of total billed charges,,,49,,39.4,percent of total billed charges,,,90,,72.36,percent of total billed charges,,,,,,,no IP contract,,80,,64.32,percent of total billed charges,,,,,,,no IP contract,,50,,40.2,percent of total billed charges,,,,,,no IP contract,,,78,,62.71,percent of total billed charges,,,70,,56.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,39.4,3324,
33342-0001-09 - lamiVUDine 150 mg Tab,33342-0001-09,NDC,,,,inpatient,1,EA,60.65,36.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,49.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,51.55,percent of total billed charges,,,85,,51.55,percent of total billed charges,,,49,,29.72,percent of total billed charges,,,90,,54.59,percent of total billed charges,,,,,,,no IP contract,,80,,48.52,percent of total billed charges,,,,,,,no IP contract,,50,,30.33,percent of total billed charges,,,,,,no IP contract,,,78,,47.31,percent of total billed charges,,,70,,42.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,29.72,3324,
33342-0047-10 - irbesartan 75 mg Tab,33342-0047-10,NDC,,,,inpatient,1,EA,27.05,16.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.99,percent of total billed charges,,,85,,22.99,percent of total billed charges,,,49,,13.25,percent of total billed charges,,,90,,24.35,percent of total billed charges,,,,,,,no IP contract,,80,,21.64,percent of total billed charges,,,,,,,no IP contract,,50,,13.53,percent of total billed charges,,,,,,no IP contract,,,78,,21.1,percent of total billed charges,,,70,,18.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.25,3324,
33342-0048-07 - irbesartan 150 mg Tab,33342-0048-07,NDC,,,,inpatient,1,EA,28.25,16.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.01,percent of total billed charges,,,85,,24.01,percent of total billed charges,,,49,,13.84,percent of total billed charges,,,90,,25.43,percent of total billed charges,,,,,,,no IP contract,,80,,22.6,percent of total billed charges,,,,,,,no IP contract,,50,,14.13,percent of total billed charges,,,,,,no IP contract,,,78,,22.04,percent of total billed charges,,,70,,19.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.84,3324,
33342-0054-07 - pioglitazone 15 mg Tab,33342-0054-07,NDC,,,,inpatient,1,EA,59.55,35.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,48.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,50.62,percent of total billed charges,,,85,,50.62,percent of total billed charges,,,49,,29.18,percent of total billed charges,,,90,,53.6,percent of total billed charges,,,,,,,no IP contract,,80,,47.64,percent of total billed charges,,,,,,,no IP contract,,50,,29.78,percent of total billed charges,,,,,,no IP contract,,,78,,46.45,percent of total billed charges,,,70,,41.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,29.18,3324,
33342-0056-10 - pioglitazone 45 mg Tab,33342-0056-10,NDC,,,,inpatient,1,EA,96.1,57.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,77.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,81.69,percent of total billed charges,,,85,,81.69,percent of total billed charges,,,49,,47.09,percent of total billed charges,,,90,,86.49,percent of total billed charges,,,,,,,no IP contract,,80,,76.88,percent of total billed charges,,,,,,,no IP contract,,50,,48.05,percent of total billed charges,,,,,,no IP contract,,,78,,74.96,percent of total billed charges,,,70,,67.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,47.09,3324,
33342-0089-09 - rivastigmine 1.5 mg Cap,33342-0089-09,NDC,,,,inpatient,1,EA,35.85,21.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.47,percent of total billed charges,,,85,,30.47,percent of total billed charges,,,49,,17.57,percent of total billed charges,,,90,,32.27,percent of total billed charges,,,,,,,no IP contract,,80,,28.68,percent of total billed charges,,,,,,,no IP contract,,50,,17.93,percent of total billed charges,,,,,,no IP contract,,,78,,27.96,percent of total billed charges,,,70,,25.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.57,3324,
oseltamivir 30 mg Cap,33342-0256-66,NDC,,,,inpatient,1,EA,116.55,69.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,94.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,99.07,percent of total billed charges,,,85,,99.07,percent of total billed charges,,,49,,57.11,percent of total billed charges,,,90,,104.9,percent of total billed charges,,,,,,,no IP contract,,80,,93.24,percent of total billed charges,,,,,,,no IP contract,,50,,58.28,percent of total billed charges,,,,,,no IP contract,,,78,,90.91,percent of total billed charges,,,70,,81.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,57.11,3324,
33342-0258-66 - oseltamivir 75 mg Cap,33342-0258-66,NDC,,,,inpatient,1,EA,126.75,76.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,102.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,107.74,percent of total billed charges,,,85,,107.74,percent of total billed charges,,,49,,62.11,percent of total billed charges,,,90,,114.08,percent of total billed charges,,,,,,,no IP contract,,80,,101.4,percent of total billed charges,,,,,,,no IP contract,,50,,63.38,percent of total billed charges,,,,,,no IP contract,,,78,,98.87,percent of total billed charges,,,70,,88.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,62.11,3324,
clobetasol topical 0.05% Soln,33342-0321-86,NDC,,,,inpatient,1,EA,1729.35,1037.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1400.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1469.95,percent of total billed charges,,,85,,1469.95,percent of total billed charges,,,49,,847.38,percent of total billed charges,,,90,,1556.42,percent of total billed charges,,,,,,,no IP contract,,80,,1383.48,percent of total billed charges,,,,,,,no IP contract,,50,,864.68,percent of total billed charges,,,,,,no IP contract,,,78,,1348.89,percent of total billed charges,,,70,,1210.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,847.38,3324,
33342-0333-15 - triamcinolone topical 0.1% Ointm,33342-0333-15,NDC,,,,inpatient,1,UN,55.45,33.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,44.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,47.13,percent of total billed charges,,,85,,47.13,percent of total billed charges,,,49,,27.17,percent of total billed charges,,,90,,49.91,percent of total billed charges,,,,,,,no IP contract,,80,,44.36,percent of total billed charges,,,,,,,no IP contract,,50,,27.73,percent of total billed charges,,,,,,no IP contract,,,78,,43.25,percent of total billed charges,,,70,,38.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.17,3324,
35046-0001-55 - calcium citrate 950 mg (200 mg elemental calcium) Tab,35046-0001-55,NDC,,,,inpatient,1,EA,4.45,2.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.78,percent of total billed charges,,,85,,3.78,percent of total billed charges,,,49,,2.18,percent of total billed charges,,,90,,4.01,percent of total billed charges,,,,,,,no IP contract,,80,,3.56,percent of total billed charges,,,,,,,no IP contract,,50,,2.23,percent of total billed charges,,,,,,no IP contract,,,78,,3.47,percent of total billed charges,,,70,,3.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.18,3324,
35046-0004-31 - ubiquinone 50 mg Cap,35046-0004-31,NDC,,,,inpatient,1,EA,6.2,3.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.27,percent of total billed charges,,,85,,5.27,percent of total billed charges,,,49,,3.04,percent of total billed charges,,,90,,5.58,percent of total billed charges,,,,,,,no IP contract,,80,,4.96,percent of total billed charges,,,,,,,no IP contract,,50,,3.1,percent of total billed charges,,,,,,no IP contract,,,78,,4.84,percent of total billed charges,,,70,,4.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.04,3324,
35573-0428-80 - pantoprazole 40 mg EC Ta,35573-0428-80,NDC,,,,inpatient,1,EA,7.4,4.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.29,percent of total billed charges,,,85,,6.29,percent of total billed charges,,,49,,3.63,percent of total billed charges,,,90,,6.66,percent of total billed charges,,,,,,,no IP contract,,80,,5.92,percent of total billed charges,,,,,,,no IP contract,,50,,3.7,percent of total billed charges,,,,,,no IP contract,,,78,,5.77,percent of total billed charges,,,70,,5.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.63,3324,
36000-0009-24 - ciprofloxacin 400 mg/200 mL-5% Soln,36000-0009-24,NDC,,,,inpatient,200,ML,108.4,65.04,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,87.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,92.14,percent of total billed charges,,,85,,92.14,percent of total billed charges,,,49,,53.12,percent of total billed charges,,,90,,97.56,percent of total billed charges,,,,,,,no IP contract,,80,,86.72,percent of total billed charges,,,,,,,no IP contract,,50,,54.2,percent of total billed charges,,,,,,no IP contract,,,78,,84.55,percent of total billed charges,,,70,,75.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,53.12,3324,
36000-0012-25 - ondansetron 2 mg/mL Soln,36000-0012-25,NDC,,,,inpatient,2,ML,14.9,8.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.67,percent of total billed charges,,,85,,12.67,percent of total billed charges,,,49,,7.3,percent of total billed charges,,,90,,13.41,percent of total billed charges,,,,,,,no IP contract,,80,,11.92,percent of total billed charges,,,,,,,no IP contract,,50,,7.45,percent of total billed charges,,,,,,no IP contract,,,78,,11.62,percent of total billed charges,,,70,,10.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.3,3324,
36000-0033-10 - metoprolol 1 mg/mL Soln,36000-0033-10,NDC,,,,inpatient,5,ML,23.25,13.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.76,percent of total billed charges,,,85,,19.76,percent of total billed charges,,,49,,11.39,percent of total billed charges,,,90,,20.93,percent of total billed charges,,,,,,,no IP contract,,80,,18.6,percent of total billed charges,,,,,,,no IP contract,,50,,11.63,percent of total billed charges,,,,,,no IP contract,,,78,,18.14,percent of total billed charges,,,70,,16.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.39,3324,
36000-0308-10 - naloxone 0.4 mg/mL Soln,36000-0308-10,NDC,,,,inpatient,1,ML,59.9,35.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,48.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,50.92,percent of total billed charges,,,85,,50.92,percent of total billed charges,,,49,,29.35,percent of total billed charges,,,90,,53.91,percent of total billed charges,,,,,,,no IP contract,,80,,47.92,percent of total billed charges,,,,,,,no IP contract,,50,,29.95,percent of total billed charges,,,,,,no IP contract,,,78,,46.72,percent of total billed charges,,,70,,41.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,29.35,3324,
37000-0024-04 - psyllium 3.4 g/5.2 g REC P,37000-0024-04,NDC,,,,inpatient,1,UN,9.65,5.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.2,percent of total billed charges,,,85,,8.2,percent of total billed charges,,,49,,4.73,percent of total billed charges,,,90,,8.69,percent of total billed charges,,,,,,,no IP contract,,80,,7.72,percent of total billed charges,,,,,,,no IP contract,,50,,4.83,percent of total billed charges,,,,,,no IP contract,,,78,,7.53,percent of total billed charges,,,70,,6.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.73,3324,
37000-0477-09 - bismuth subsalicylate 262 mg Chew,37000-0477-09,NDC,,,,inpatient,1,EA,4.95,2.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.21,percent of total billed charges,,,85,,4.21,percent of total billed charges,,,49,,2.43,percent of total billed charges,,,90,,4.46,percent of total billed charges,,,,,,,no IP contract,,80,,3.96,percent of total billed charges,,,,,,,no IP contract,,50,,2.48,percent of total billed charges,,,,,,no IP contract,,,78,,3.86,percent of total billed charges,,,70,,3.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.43,3324,
37000-0803-01 - oxymetazoline nasal 0.05% Spray,37000-0803-01,NDC,,,,inpatient,1,UN,109.2,65.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,88.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,92.82,percent of total billed charges,,,85,,92.82,percent of total billed charges,,,49,,53.51,percent of total billed charges,,,90,,98.28,percent of total billed charges,,,,,,,no IP contract,,80,,87.36,percent of total billed charges,,,,,,,no IP contract,,50,,54.6,percent of total billed charges,,,,,,no IP contract,,,78,,85.18,percent of total billed charges,,,70,,76.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,53.51,3324,
38779-1779-08 -,38779-1779-08,NDC,,,,inpatient,1,ML,5.75,3.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.89,percent of total billed charges,,,85,,4.89,percent of total billed charges,,,49,,2.82,percent of total billed charges,,,90,,5.18,percent of total billed charges,,,,,,,no IP contract,,80,,4.6,percent of total billed charges,,,,,,,no IP contract,,50,,2.88,percent of total billed charges,,,,,,no IP contract,,,78,,4.49,percent of total billed charges,,,70,,4.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.82,3324,
39328-0057-50 - ferrous sulfate (as elemental iron) 15 mg/mL LIQ,39328-0057-50,NDC,,,,inpatient,1,ML,6.9,4.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.87,percent of total billed charges,,,85,,5.87,percent of total billed charges,,,49,,3.38,percent of total billed charges,,,90,,6.21,percent of total billed charges,,,,,,,no IP contract,,80,,5.52,percent of total billed charges,,,,,,,no IP contract,,50,,3.45,percent of total billed charges,,,,,,no IP contract,,,78,,5.38,percent of total billed charges,,,70,,4.83,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.38,3324,
39328-0062-50 - sodium hypochlorite topical 0.5% Soln,39328-0062-50,NDC,,,,inpatient,1,UN,39.4,23.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.49,percent of total billed charges,,,85,,33.49,percent of total billed charges,,,49,,19.31,percent of total billed charges,,,90,,35.46,percent of total billed charges,,,,,,,no IP contract,,80,,31.52,percent of total billed charges,,,,,,,no IP contract,,50,,19.7,percent of total billed charges,,,,,,no IP contract,,,78,,30.73,percent of total billed charges,,,70,,27.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.31,3324,
39328-0063-25 - sodium hypochlorite topical 0.25% Soln,39328-0063-25,NDC,,,,inpatient,1,UN,39.4,23.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.49,percent of total billed charges,,,85,,33.49,percent of total billed charges,,,49,,19.31,percent of total billed charges,,,90,,35.46,percent of total billed charges,,,,,,,no IP contract,,80,,31.52,percent of total billed charges,,,,,,,no IP contract,,50,,19.7,percent of total billed charges,,,,,,no IP contract,,,78,,30.73,percent of total billed charges,,,70,,27.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.31,3324,
39328-0357-60 - ergocalciferol 8000 intl units/mL Soln,39328-0357-60,NDC,,,,inpatient,1,ML,19.25,11.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.36,percent of total billed charges,,,85,,16.36,percent of total billed charges,,,49,,9.43,percent of total billed charges,,,90,,17.33,percent of total billed charges,,,,,,,no IP contract,,80,,15.4,percent of total billed charges,,,,,,,no IP contract,,50,,9.63,percent of total billed charges,,,,,,no IP contract,,,78,,15.02,percent of total billed charges,,,70,,13.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.43,3324,
39822-1001-07 - tranexamic acid 100 mg/mL Soln,39822-1001-07,NDC,,,,inpatient,10,ML,315.75,189.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,255.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,268.39,percent of total billed charges,,,85,,268.39,percent of total billed charges,,,49,,154.72,percent of total billed charges,,,90,,284.18,percent of total billed charges,,,,,,,no IP contract,,80,,252.6,percent of total billed charges,,,,,,,no IP contract,,50,,157.88,percent of total billed charges,,,,,,no IP contract,,,78,,246.29,percent of total billed charges,,,70,,221.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,154.72,3324,
39822-1055-05 - amphotericin B 50 mg REC I,39822-1055-05,NDC,,,,inpatient,1,EA,393.75,236.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,318.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,334.69,percent of total billed charges,,,85,,334.69,percent of total billed charges,,,49,,192.94,percent of total billed charges,,,90,,354.38,percent of total billed charges,,,,,,,no IP contract,,80,,315,percent of total billed charges,,,,,,,no IP contract,,50,,196.88,percent of total billed charges,,,,,,no IP contract,,,78,,307.13,percent of total billed charges,,,70,,275.63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,192.94,3324,
39822-3015-01 - nystatin topical 100000 units/g Powde,39822-3015-01,NDC,,,,inpatient,1,UN,214.15,128.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,173.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,182.03,percent of total billed charges,,,85,,182.03,percent of total billed charges,,,49,,104.93,percent of total billed charges,,,90,,192.74,percent of total billed charges,,,,,,,no IP contract,,80,,171.32,percent of total billed charges,,,,,,,no IP contract,,50,,107.08,percent of total billed charges,,,,,,no IP contract,,,78,,167.04,percent of total billed charges,,,70,,149.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,104.93,3324,
desmopressin 4 mcg/mL Soln,39822-6200-02,NDC,,,,inpatient,1,mL,220.05,132.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,178.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,187.04,percent of total billed charges,,,85,,187.04,percent of total billed charges,,,49,,107.82,percent of total billed charges,,,90,,198.05,percent of total billed charges,,,,,,,no IP contract,,80,,176.04,percent of total billed charges,,,,,,,no IP contract,,50,,110.03,percent of total billed charges,,,,,,no IP contract,,,78,,171.64,percent of total billed charges,,,70,,154.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,107.82,3324,
41100-0809-55 - loratadine chew 5 mg Chew tab,41100-0809-55,NDC,,,,inpatient,1,EA,10.2,6.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.67,percent of total billed charges,,,85,,8.67,percent of total billed charges,,,49,,5,percent of total billed charges,,,90,,9.18,percent of total billed charges,,,,,,,no IP contract,,80,,8.16,percent of total billed charges,,,,,,,no IP contract,,50,,5.1,percent of total billed charges,,,,,,no IP contract,,,78,,7.96,percent of total billed charges,,,70,,7.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5,3324,
41167-0570-03 - trolamine salicylate 10% Cream,41167-0570-03,NDC,,,,inpatient,1,UN,129.2,77.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,104.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,109.82,percent of total billed charges,,,85,,109.82,percent of total billed charges,,,49,,63.31,percent of total billed charges,,,90,,116.28,percent of total billed charges,,,,,,,no IP contract,,80,,103.36,percent of total billed charges,,,,,,,no IP contract,,50,,64.6,percent of total billed charges,,,,,,no IP contract,,,78,,100.78,percent of total billed charges,,,70,,90.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,63.31,3324,
41167-4244-04 - fexofenadine 30 mg/5 mL Susp,41167-4244-04,NDC,,,,inpatient,1,ML,6.15,3.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.23,percent of total billed charges,,,85,,5.23,percent of total billed charges,,,49,,3.01,percent of total billed charges,,,90,,5.54,percent of total billed charges,,,,,,,no IP contract,,80,,4.92,percent of total billed charges,,,,,,,no IP contract,,50,,3.08,percent of total billed charges,,,,,,no IP contract,,,78,,4.8,percent of total billed charges,,,70,,4.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.01,3324,
41167-4320-05 - fexofenadine-pseudoephedrine 180 mg-240 mg ER Ta,41167-4320-05,NDC,,,,inpatient,1,EA,22.5,13.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.13,percent of total billed charges,,,85,,19.13,percent of total billed charges,,,49,,11.03,percent of total billed charges,,,90,,20.25,percent of total billed charges,,,,,,,no IP contract,,80,,18,percent of total billed charges,,,,,,,no IP contract,,50,,11.25,percent of total billed charges,,,,,,no IP contract,,,78,,17.55,percent of total billed charges,,,70,,15.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.03,3324,
colistimethate 150 mg (colistin base) REC I,42023-0107-01,NDC,,,,inpatient,1,EA,292.55,175.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,236.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,248.67,percent of total billed charges,,,85,,248.67,percent of total billed charges,,,49,,143.35,percent of total billed charges,,,90,,263.3,percent of total billed charges,,,,,,,no IP contract,,80,,234.04,percent of total billed charges,,,,,,,no IP contract,,50,,146.28,percent of total billed charges,,,,,,no IP contract,,,78,,228.19,percent of total billed charges,,,70,,204.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,143.35,3324,
42023-0107-06 - colistimethate 150 mg (colistin base) REC I,42023-0107-06,NDC,,,,inpatient,2,ML,292.55,175.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,236.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,248.67,percent of total billed charges,,,85,,248.67,percent of total billed charges,,,49,,143.35,percent of total billed charges,,,90,,263.3,percent of total billed charges,,,,,,,no IP contract,,80,,234.04,percent of total billed charges,,,,,,,no IP contract,,50,,146.28,percent of total billed charges,,,,,,no IP contract,,,78,,228.19,percent of total billed charges,,,70,,204.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,143.35,3324,
42023-0124-01 - dantrolene 25 mg Cap,42023-0124-01,NDC,,,,inpatient,1,EA,14.25,8.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.11,percent of total billed charges,,,85,,12.11,percent of total billed charges,,,49,,6.98,percent of total billed charges,,,90,,12.83,percent of total billed charges,,,,,,,no IP contract,,80,,11.4,percent of total billed charges,,,,,,,no IP contract,,50,,7.13,percent of total billed charges,,,,,,no IP contract,,,78,,11.12,percent of total billed charges,,,70,,9.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.98,3324,
42023-0131-01 - colistimethate 150 mg (colistin base) REC I,42023-0131-01,NDC,,,,inpatient,2,ML,292.5,175.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,236.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,248.63,percent of total billed charges,,,85,,248.63,percent of total billed charges,,,49,,143.33,percent of total billed charges,,,90,,263.25,percent of total billed charges,,,,,,,no IP contract,,80,,234,percent of total billed charges,,,,,,,no IP contract,,50,,146.25,percent of total billed charges,,,,,,no IP contract,,,78,,228.15,percent of total billed charges,,,70,,204.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,143.33,3324,
42023-0131-06 - colistimethate 150 mg (colistin base) REC I,42023-0131-06,NDC,,,,inpatient,2,ML,292.5,175.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,236.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,248.63,percent of total billed charges,,,85,,248.63,percent of total billed charges,,,49,,143.33,percent of total billed charges,,,90,,263.25,percent of total billed charges,,,,,,,no IP contract,,80,,234,percent of total billed charges,,,,,,,no IP contract,,50,,146.25,percent of total billed charges,,,,,,no IP contract,,,78,,228.15,percent of total billed charges,,,70,,204.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,143.33,3324,
42037-0104-78 - carbamide peroxide otic 6.5% Soln,42037-0104-78,NDC,,,,inpatient,5,UN,47.95,28.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,38.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,40.76,percent of total billed charges,,,85,,40.76,percent of total billed charges,,,49,,23.5,percent of total billed charges,,,90,,43.16,percent of total billed charges,,,,,,,no IP contract,,80,,38.36,percent of total billed charges,,,,,,,no IP contract,,50,,23.98,percent of total billed charges,,,,,,no IP contract,,,78,,37.4,percent of total billed charges,,,70,,33.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.5,3324,
42192-0330-01 - thyroid desiccated 60 mg Tab,42192-0330-01,NDC,,,,inpatient,1,EA,12.1,7.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.29,percent of total billed charges,,,85,,10.29,percent of total billed charges,,,49,,5.93,percent of total billed charges,,,90,,10.89,percent of total billed charges,,,,,,,no IP contract,,80,,9.68,percent of total billed charges,,,,,,,no IP contract,,50,,6.05,percent of total billed charges,,,,,,no IP contract,,,78,,9.44,percent of total billed charges,,,70,,8.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.93,3324,
42192-0339-01 - hyoscyamine 0.125 mg Tab,42192-0339-01,NDC,,,,inpatient,1,EA,10.6,6.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.01,percent of total billed charges,,,85,,9.01,percent of total billed charges,,,49,,5.19,percent of total billed charges,,,90,,9.54,percent of total billed charges,,,,,,,no IP contract,,80,,8.48,percent of total billed charges,,,,,,,no IP contract,,50,,5.3,percent of total billed charges,,,,,,no IP contract,,,78,,8.27,percent of total billed charges,,,70,,7.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.19,3324,
42211-0101-11 - indomethacin 25 mg/5 mL Susp,42211-0101-11,NDC,,,,inpatient,1,ML,19.15,11.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.28,percent of total billed charges,,,85,,16.28,percent of total billed charges,,,49,,9.38,percent of total billed charges,,,90,,17.24,percent of total billed charges,,,,,,,no IP contract,,80,,15.32,percent of total billed charges,,,,,,,no IP contract,,50,,9.58,percent of total billed charges,,,,,,no IP contract,,,78,,14.94,percent of total billed charges,,,70,,13.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.38,3324,
42291-0067-30 - atomoxetine 40 mg Cap,42291-0067-30,NDC,,,,inpatient,1,EA,126.8,76.08,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,102.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,107.78,percent of total billed charges,,,85,,107.78,percent of total billed charges,,,49,,62.13,percent of total billed charges,,,90,,114.12,percent of total billed charges,,,,,,,no IP contract,,80,,101.44,percent of total billed charges,,,,,,,no IP contract,,50,,63.4,percent of total billed charges,,,,,,no IP contract,,,78,,98.9,percent of total billed charges,,,70,,88.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,62.13,3324,
42291-0472-01 - carbidopa-levodopa 25 mg-100 mg Tab,42291-0472-01,NDC,,,,inpatient,1,EA,10.75,6.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.14,percent of total billed charges,,,85,,9.14,percent of total billed charges,,,49,,5.27,percent of total billed charges,,,90,,9.68,percent of total billed charges,,,,,,,no IP contract,,80,,8.6,percent of total billed charges,,,,,,,no IP contract,,50,,5.38,percent of total billed charges,,,,,,no IP contract,,,78,,8.39,percent of total billed charges,,,70,,7.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.27,3324,
propranolol 80 mg ER Ca,42291-0523-01,NDC,,,,inpatient,1,EA,22.75,13.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.34,percent of total billed charges,,,85,,19.34,percent of total billed charges,,,49,,11.15,percent of total billed charges,,,90,,20.48,percent of total billed charges,,,,,,,no IP contract,,80,,18.2,percent of total billed charges,,,,,,,no IP contract,,50,,11.38,percent of total billed charges,,,,,,no IP contract,,,78,,17.75,percent of total billed charges,,,70,,15.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.15,3324,
42291-0752-01 - tacrolimus 0.5 mg Cap,42291-0752-01,NDC,,,,inpatient,1,EA,21.45,12.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.23,percent of total billed charges,,,85,,18.23,percent of total billed charges,,,49,,10.51,percent of total billed charges,,,90,,19.31,percent of total billed charges,,,,,,,no IP contract,,80,,17.16,percent of total billed charges,,,,,,,no IP contract,,50,,10.73,percent of total billed charges,,,,,,no IP contract,,,78,,16.73,percent of total billed charges,,,70,,15.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.51,3324,
42291-0753-01 - tacrolimus 1 mg Cap,42291-0753-01,NDC,,,,inpatient,1,EA,39.3,23.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.41,percent of total billed charges,,,85,,33.41,percent of total billed charges,,,49,,19.26,percent of total billed charges,,,90,,35.37,percent of total billed charges,,,,,,,no IP contract,,80,,31.44,percent of total billed charges,,,,,,,no IP contract,,50,,19.65,percent of total billed charges,,,,,,no IP contract,,,78,,30.65,percent of total billed charges,,,70,,27.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.26,3324,
sucralfate 1 g/10 mL Susp,42291-0781-42,NDC,,,,inpatient,1,mL,10.15,6.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.63,percent of total billed charges,,,85,,8.63,percent of total billed charges,,,49,,4.97,percent of total billed charges,,,90,,9.14,percent of total billed charges,,,,,,,no IP contract,,80,,8.12,percent of total billed charges,,,,,,,no IP contract,,50,,5.08,percent of total billed charges,,,,,,no IP contract,,,78,,7.92,percent of total billed charges,,,70,,7.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.97,3324,
42291-0868-90 - traZODone 50 mg Tab,42291-0868-90,NDC,,,,inpatient,1,EA,7.1,4.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.04,percent of total billed charges,,,85,,6.04,percent of total billed charges,,,49,,3.48,percent of total billed charges,,,90,,6.39,percent of total billed charges,,,,,,,no IP contract,,80,,5.68,percent of total billed charges,,,,,,,no IP contract,,50,,3.55,percent of total billed charges,,,,,,no IP contract,,,78,,5.54,percent of total billed charges,,,70,,4.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.48,3324,
ursodiol 300 mg Cap,42291-0923-01,NDC,,,,inpatient,1,EA,62.25,37.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,50.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,52.91,percent of total billed charges,,,85,,52.91,percent of total billed charges,,,49,,30.5,percent of total billed charges,,,90,,56.03,percent of total billed charges,,,,,,,no IP contract,,80,,49.8,percent of total billed charges,,,,,,,no IP contract,,50,,31.13,percent of total billed charges,,,,,,no IP contract,,,78,,48.56,percent of total billed charges,,,70,,43.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,30.5,3324,
42292-0002-20 - digoxin 250 mcg Tab,42292-0002-20,NDC,,,,inpatient,1,EA,24.2,14.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.57,percent of total billed charges,,,85,,20.57,percent of total billed charges,,,49,,11.86,percent of total billed charges,,,90,,21.78,percent of total billed charges,,,,,,,no IP contract,,80,,19.36,percent of total billed charges,,,,,,,no IP contract,,50,,12.1,percent of total billed charges,,,,,,no IP contract,,,78,,18.88,percent of total billed charges,,,70,,16.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.86,3324,
42292-0003-20 - digoxin 125 mcg (0.125 mg) Tab,42292-0003-20,NDC,,,,inpatient,1,EA,12.25,7.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.41,percent of total billed charges,,,85,,10.41,percent of total billed charges,,,49,,6,percent of total billed charges,,,90,,11.03,percent of total billed charges,,,,,,,no IP contract,,80,,9.8,percent of total billed charges,,,,,,,no IP contract,,50,,6.13,percent of total billed charges,,,,,,no IP contract,,,78,,9.56,percent of total billed charges,,,70,,8.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6,3324,
42292-0008-03 - linezolid 600 mg Tab,42292-0008-03,NDC,,,,inpatient,1,EA,37,22.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.45,percent of total billed charges,,,85,,31.45,percent of total billed charges,,,49,,18.13,percent of total billed charges,,,90,,33.3,percent of total billed charges,,,,,,,no IP contract,,80,,29.6,percent of total billed charges,,,,,,,no IP contract,,50,,18.5,percent of total billed charges,,,,,,no IP contract,,,78,,28.86,percent of total billed charges,,,70,,25.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.13,3324,
42292-0036-03 - olmesartan 20 mg Tab,42292-0036-03,NDC,,,,inpatient,1,EA,53.75,32.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,43.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,45.69,percent of total billed charges,,,85,,45.69,percent of total billed charges,,,49,,26.34,percent of total billed charges,,,90,,48.38,percent of total billed charges,,,,,,,no IP contract,,80,,43,percent of total billed charges,,,,,,,no IP contract,,50,,26.88,percent of total billed charges,,,,,,no IP contract,,,78,,41.93,percent of total billed charges,,,70,,37.63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.34,3324,
42292-0038-20 - levothyroxine 88 mcg (0.088 mg) Tab,42292-0038-20,NDC,,,,inpatient,1,EA,8.3,4.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.06,percent of total billed charges,,,85,,7.06,percent of total billed charges,,,49,,4.07,percent of total billed charges,,,90,,7.47,percent of total billed charges,,,,,,,no IP contract,,80,,6.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.15,percent of total billed charges,,,,,,no IP contract,,,78,,6.47,percent of total billed charges,,,70,,5.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.07,3324,
42292-0039-20 - levothyroxine 112 mcg (0.112 mg) Tab,42292-0039-20,NDC,,,,inpatient,1,EA,9,5.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.65,percent of total billed charges,,,85,,7.65,percent of total billed charges,,,49,,4.41,percent of total billed charges,,,90,,8.1,percent of total billed charges,,,,,,,no IP contract,,80,,7.2,percent of total billed charges,,,,,,,no IP contract,,50,,4.5,percent of total billed charges,,,,,,no IP contract,,,78,,7.02,percent of total billed charges,,,70,,6.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.41,3324,
42543-0140-50 - hydrocortisone 5 mg Tab,42543-0140-50,NDC,,,,inpatient,1,EA,6.55,3.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.57,percent of total billed charges,,,85,,5.57,percent of total billed charges,,,49,,3.21,percent of total billed charges,,,90,,5.9,percent of total billed charges,,,,,,,no IP contract,,80,,5.24,percent of total billed charges,,,,,,,no IP contract,,50,,3.28,percent of total billed charges,,,,,,no IP contract,,,78,,5.11,percent of total billed charges,,,70,,4.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.21,3324,
42543-0141-01 - hydrocortisone 10 mg Tab,42543-0141-01,NDC,,,,inpatient,1,EA,8.35,5.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.1,percent of total billed charges,,,85,,7.1,percent of total billed charges,,,49,,4.09,percent of total billed charges,,,90,,7.52,percent of total billed charges,,,,,,,no IP contract,,80,,6.68,percent of total billed charges,,,,,,,no IP contract,,50,,4.18,percent of total billed charges,,,,,,no IP contract,,,78,,6.51,percent of total billed charges,,,70,,5.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.09,3324,
42543-0971-06 - hydroCORTisone 10 mg Tab,42543-0971-06,NDC,,,,inpatient,1,EA,5.55,3.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.72,percent of total billed charges,,,85,,4.72,percent of total billed charges,,,49,,2.72,percent of total billed charges,,,90,,5,percent of total billed charges,,,,,,,no IP contract,,80,,4.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.78,percent of total billed charges,,,,,,no IP contract,,,78,,4.33,percent of total billed charges,,,70,,3.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.72,3324,
42571-0100-01 - glimepiride 1 mg Tab,42571-0100-01,NDC,,,,inpatient,1,EA,7,4.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.95,percent of total billed charges,,,85,,5.95,percent of total billed charges,,,49,,3.43,percent of total billed charges,,,90,,6.3,percent of total billed charges,,,,,,,no IP contract,,80,,5.6,percent of total billed charges,,,,,,,no IP contract,,50,,3.5,percent of total billed charges,,,,,,no IP contract,,,78,,5.46,percent of total billed charges,,,70,,4.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.43,3324,
42571-0137-26 - ketorolac ophthalmic 0.5% Soln,42571-0137-26,NDC,,,,inpatient,1,UN,892.2,535.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,722.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,758.37,percent of total billed charges,,,85,,758.37,percent of total billed charges,,,49,,437.18,percent of total billed charges,,,90,,802.98,percent of total billed charges,,,,,,,no IP contract,,80,,713.76,percent of total billed charges,,,,,,,no IP contract,,50,,446.1,percent of total billed charges,,,,,,no IP contract,,,78,,695.92,percent of total billed charges,,,70,,624.54,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,437.18,3324,
42571-0141-26 - dorzolamide ophthalmic 2% Soln,42571-0141-26,NDC,,,,inpatient,1,UN,565.65,339.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,458.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,480.8,percent of total billed charges,,,85,,480.8,percent of total billed charges,,,49,,277.17,percent of total billed charges,,,90,,509.09,percent of total billed charges,,,,,,,no IP contract,,80,,452.52,percent of total billed charges,,,,,,,no IP contract,,50,,282.83,percent of total billed charges,,,,,,no IP contract,,,78,,441.21,percent of total billed charges,,,70,,395.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,277.17,3324,
42571-0162-42 - amoxicillin-clavulanate 875 mg-125 mg Tab,42571-0162-42,NDC,,,,inpatient,1,EA,43.95,26.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,35.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,37.36,percent of total billed charges,,,85,,37.36,percent of total billed charges,,,49,,21.54,percent of total billed charges,,,90,,39.56,percent of total billed charges,,,,,,,no IP contract,,80,,35.16,percent of total billed charges,,,,,,,no IP contract,,50,,21.98,percent of total billed charges,,,,,,no IP contract,,,78,,34.28,percent of total billed charges,,,70,,30.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.54,3324,
42571-0221-30 - rasagiline 1 mg Tab,42571-0221-30,NDC,,,,inpatient,1,EA,202.55,121.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,164.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,172.17,percent of total billed charges,,,85,,172.17,percent of total billed charges,,,49,,99.25,percent of total billed charges,,,90,,182.3,percent of total billed charges,,,,,,,no IP contract,,80,,162.04,percent of total billed charges,,,,,,,no IP contract,,50,,101.28,percent of total billed charges,,,,,,no IP contract,,,78,,157.99,percent of total billed charges,,,70,,141.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,99.25,3324,
42571-0243-01 - acetaZOLAMIDE 500 mg ER Ca,42571-0243-01,NDC,,,,inpatient,1,EA,37.95,22.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.26,percent of total billed charges,,,85,,32.26,percent of total billed charges,,,49,,18.6,percent of total billed charges,,,90,,34.16,percent of total billed charges,,,,,,,no IP contract,,80,,30.36,percent of total billed charges,,,,,,,no IP contract,,50,,18.98,percent of total billed charges,,,,,,no IP contract,,,78,,29.6,percent of total billed charges,,,70,,26.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.6,3324,
42571-0250-01 - clindamycin 75 mg Cap,42571-0250-01,NDC,,,,inpatient,1,EA,9.55,5.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.12,percent of total billed charges,,,85,,8.12,percent of total billed charges,,,49,,4.68,percent of total billed charges,,,90,,8.6,percent of total billed charges,,,,,,,no IP contract,,80,,7.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.78,percent of total billed charges,,,,,,no IP contract,,,78,,7.45,percent of total billed charges,,,70,,6.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.68,3324,
42571-0315-01 - cloBAZam 10 mg Tab,42571-0315-01,NDC,,,,inpatient,1,EA,154.85,92.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,125.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,131.62,percent of total billed charges,,,85,,131.62,percent of total billed charges,,,49,,75.88,percent of total billed charges,,,90,,139.37,percent of total billed charges,,,,,,,no IP contract,,80,,123.88,percent of total billed charges,,,,,,,no IP contract,,50,,77.43,percent of total billed charges,,,,,,no IP contract,,,78,,120.78,percent of total billed charges,,,70,,108.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,75.88,3324,
42571-0332-01 - methenamine hippurate 1 g Tab,42571-0332-01,NDC,,,,inpatient,1,EA,20.5,12.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.43,percent of total billed charges,,,85,,17.43,percent of total billed charges,,,49,,10.05,percent of total billed charges,,,90,,18.45,percent of total billed charges,,,,,,,no IP contract,,80,,16.4,percent of total billed charges,,,,,,,no IP contract,,50,,10.25,percent of total billed charges,,,,,,no IP contract,,,78,,15.99,percent of total billed charges,,,70,,14.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.05,3324,
42571-0362-99 - clobetasol topical 0.05% Soln,42571-0362-99,NDC,,,,inpatient,1,UN,1729.35,1037.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1400.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1469.95,percent of total billed charges,,,85,,1469.95,percent of total billed charges,,,49,,847.38,percent of total billed charges,,,90,,1556.42,percent of total billed charges,,,,,,,no IP contract,,80,,1383.48,percent of total billed charges,,,,,,,no IP contract,,50,,864.68,percent of total billed charges,,,,,,no IP contract,,,78,,1348.89,percent of total billed charges,,,70,,1210.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,847.38,3324,
42794-0018-02 - liothyronine 5 mcg Tab,42794-0018-02,NDC,,,,inpatient,1,EA,10.1,6.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.59,percent of total billed charges,,,85,,8.59,percent of total billed charges,,,49,,4.95,percent of total billed charges,,,90,,9.09,percent of total billed charges,,,,,,,no IP contract,,80,,8.08,percent of total billed charges,,,,,,,no IP contract,,50,,5.05,percent of total billed charges,,,,,,no IP contract,,,78,,7.88,percent of total billed charges,,,70,,7.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.95,3324,
42794-0018-12 - liothyronine 5 mcg Tab,42794-0018-12,NDC,,,,inpatient,1,EA,10.65,6.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.05,percent of total billed charges,,,85,,9.05,percent of total billed charges,,,49,,5.22,percent of total billed charges,,,90,,9.59,percent of total billed charges,,,,,,,no IP contract,,80,,8.52,percent of total billed charges,,,,,,,no IP contract,,50,,5.33,percent of total billed charges,,,,,,no IP contract,,,78,,8.31,percent of total billed charges,,,70,,7.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.22,3324,
42794-0019-12 - liothyronine 25 mcg Tab,42794-0019-12,NDC,,,,inpatient,1,EA,12.65,7.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.75,percent of total billed charges,,,85,,10.75,percent of total billed charges,,,49,,6.2,percent of total billed charges,,,90,,11.39,percent of total billed charges,,,,,,,no IP contract,,80,,10.12,percent of total billed charges,,,,,,,no IP contract,,50,,6.33,percent of total billed charges,,,,,,no IP contract,,,78,,9.87,percent of total billed charges,,,70,,8.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.2,3324,
42799-0119-01 - bumetanide 0.5 mg Tab,42799-0119-01,NDC,,,,inpatient,1,EA,22.9,13.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.47,percent of total billed charges,,,85,,19.47,percent of total billed charges,,,49,,11.22,percent of total billed charges,,,90,,20.61,percent of total billed charges,,,,,,,no IP contract,,80,,18.32,percent of total billed charges,,,,,,,no IP contract,,50,,11.45,percent of total billed charges,,,,,,no IP contract,,,78,,17.86,percent of total billed charges,,,70,,16.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.22,3324,
42799-0120-01 - bumetanide 1 mg Tab,42799-0120-01,NDC,,,,inpatient,1,EA,25.05,15.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.29,percent of total billed charges,,,85,,21.29,percent of total billed charges,,,49,,12.27,percent of total billed charges,,,90,,22.55,percent of total billed charges,,,,,,,no IP contract,,80,,20.04,percent of total billed charges,,,,,,,no IP contract,,50,,12.53,percent of total billed charges,,,,,,no IP contract,,,78,,19.54,percent of total billed charges,,,70,,17.54,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.27,3324,
42799-0121-01 - bumetanide 2 mg Tab,42799-0121-01,NDC,,,,inpatient,1,EA,27.2,16.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.12,percent of total billed charges,,,85,,23.12,percent of total billed charges,,,49,,13.33,percent of total billed charges,,,90,,24.48,percent of total billed charges,,,,,,,no IP contract,,80,,21.76,percent of total billed charges,,,,,,,no IP contract,,50,,13.6,percent of total billed charges,,,,,,no IP contract,,,78,,21.22,percent of total billed charges,,,70,,19.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.33,3324,
42799-0123-01 - carbidopa 25 mg Tab,42799-0123-01,NDC,,,,inpatient,1,EA,227.4,136.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,184.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,193.29,percent of total billed charges,,,85,,193.29,percent of total billed charges,,,49,,111.43,percent of total billed charges,,,90,,204.66,percent of total billed charges,,,,,,,no IP contract,,80,,181.92,percent of total billed charges,,,,,,,no IP contract,,50,,113.7,percent of total billed charges,,,,,,no IP contract,,,78,,177.37,percent of total billed charges,,,70,,159.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,111.43,3324,
42799-0217-01 - opium 10% (equivalent to morphine 10 mg/mL) Tinct,42799-0217-01,NDC,,,,inpatient,0.1,ML,57.75,34.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,46.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,49.09,percent of total billed charges,,,85,,49.09,percent of total billed charges,,,49,,28.3,percent of total billed charges,,,90,,51.98,percent of total billed charges,,,,,,,no IP contract,,80,,46.2,percent of total billed charges,,,,,,,no IP contract,,50,,28.88,percent of total billed charges,,,,,,no IP contract,,,78,,45.05,percent of total billed charges,,,70,,40.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,28.3,3324,
pantoprazole 40 mg ECGR,42799-0952-30,NDC,,,,inpatient,1,EA,138.9,83.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,112.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,118.07,percent of total billed charges,,,85,,118.07,percent of total billed charges,,,49,,68.06,percent of total billed charges,,,90,,125.01,percent of total billed charges,,,,,,,no IP contract,,80,,111.12,percent of total billed charges,,,,,,,no IP contract,,50,,69.45,percent of total billed charges,,,,,,no IP contract,,,78,,108.34,percent of total billed charges,,,70,,97.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,68.06,3324,
42806-0160-01 - hydrOXYzine hydrochloride 25 mg Tab,42806-0160-01,NDC,,,,inpatient,1,EA,11.15,6.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.48,percent of total billed charges,,,85,,9.48,percent of total billed charges,,,49,,5.46,percent of total billed charges,,,90,,10.04,percent of total billed charges,,,,,,,no IP contract,,80,,8.92,percent of total billed charges,,,,,,,no IP contract,,50,,5.58,percent of total billed charges,,,,,,no IP contract,,,78,,8.7,percent of total billed charges,,,70,,7.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.46,3324,
42806-0160-05 - hydrOXYzine hydrochloride 25 mg Tab,42806-0160-05,NDC,,,,inpatient,1,EA,10.6,6.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.01,percent of total billed charges,,,85,,9.01,percent of total billed charges,,,49,,5.19,percent of total billed charges,,,90,,9.54,percent of total billed charges,,,,,,,no IP contract,,80,,8.48,percent of total billed charges,,,,,,,no IP contract,,50,,5.3,percent of total billed charges,,,,,,no IP contract,,,78,,8.27,percent of total billed charges,,,70,,7.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.19,3324,
42806-0266-95 - cholestyramine 4 g/9 g REC P,42806-0266-95,NDC,,,,inpatient,1,UN,30.45,18.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.88,percent of total billed charges,,,85,,25.88,percent of total billed charges,,,49,,14.92,percent of total billed charges,,,90,,27.41,percent of total billed charges,,,,,,,no IP contract,,80,,24.36,percent of total billed charges,,,,,,,no IP contract,,50,,15.23,percent of total billed charges,,,,,,no IP contract,,,78,,23.75,percent of total billed charges,,,70,,21.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.92,3324,
leucovorin 25 mg Tab,42806-0359-25,NDC,,,,inpatient,1,EA,92.7,55.62,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,75.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,78.8,percent of total billed charges,,,85,,78.8,percent of total billed charges,,,49,,45.42,percent of total billed charges,,,90,,83.43,percent of total billed charges,,,,,,,no IP contract,,80,,74.16,percent of total billed charges,,,,,,,no IP contract,,50,,46.35,percent of total billed charges,,,,,,no IP contract,,,78,,72.31,percent of total billed charges,,,70,,64.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,45.42,3324,
42806-0362-01 - doxycycline 20 mg Tab,42806-0362-01,NDC,,,,inpatient,1,EA,9.7,5.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.25,percent of total billed charges,,,85,,8.25,percent of total billed charges,,,49,,4.75,percent of total billed charges,,,90,,8.73,percent of total billed charges,,,,,,,no IP contract,,80,,7.76,percent of total billed charges,,,,,,,no IP contract,,50,,4.85,percent of total billed charges,,,,,,no IP contract,,,78,,7.57,percent of total billed charges,,,70,,6.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.75,3324,
42806-0501-09 - niCARdipine 20 mg Cap,42806-0501-09,NDC,,,,inpatient,1,EA,21.55,12.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.32,percent of total billed charges,,,85,,18.32,percent of total billed charges,,,49,,10.56,percent of total billed charges,,,90,,19.4,percent of total billed charges,,,,,,,no IP contract,,80,,17.24,percent of total billed charges,,,,,,,no IP contract,,50,,10.78,percent of total billed charges,,,,,,no IP contract,,,78,,16.81,percent of total billed charges,,,70,,15.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.56,3324,
42806-0503-01 - ursodiol 300 mg Cap,42806-0503-01,NDC,,,,inpatient,1,EA,62.25,37.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,50.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,52.91,percent of total billed charges,,,85,,52.91,percent of total billed charges,,,49,,30.5,percent of total billed charges,,,90,,56.03,percent of total billed charges,,,,,,,no IP contract,,80,,49.8,percent of total billed charges,,,,,,,no IP contract,,50,,31.13,percent of total billed charges,,,,,,no IP contract,,,78,,48.56,percent of total billed charges,,,70,,43.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,30.5,3324,
OXcarbazepine 300 mg/5 mL Susp,42806-0600-22,NDC,,,,inpatient,1,mL,14.5,8.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.33,percent of total billed charges,,,85,,12.33,percent of total billed charges,,,49,,7.11,percent of total billed charges,,,90,,13.05,percent of total billed charges,,,,,,,no IP contract,,80,,11.6,percent of total billed charges,,,,,,,no IP contract,,50,,7.25,percent of total billed charges,,,,,,no IP contract,,,78,,11.31,percent of total billed charges,,,70,,10.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.11,3324,
entecavir 0.5 mg Tab,42806-0658-30,NDC,,,,inpatient,1,EA,357.1,214.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,289.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,303.54,percent of total billed charges,,,85,,303.54,percent of total billed charges,,,49,,174.98,percent of total billed charges,,,90,,321.39,percent of total billed charges,,,,,,,no IP contract,,80,,285.68,percent of total billed charges,,,,,,,no IP contract,,50,,178.55,percent of total billed charges,,,,,,no IP contract,,,78,,278.54,percent of total billed charges,,,70,,249.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,174.98,3324,
42806-0714-01 - benzonatate 100 mg Cap,42806-0714-01,NDC,,,,inpatient,1,EA,23.7,14.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.15,percent of total billed charges,,,85,,20.15,percent of total billed charges,,,49,,11.61,percent of total billed charges,,,90,,21.33,percent of total billed charges,,,,,,,no IP contract,,80,,18.96,percent of total billed charges,,,,,,,no IP contract,,50,,11.85,percent of total billed charges,,,,,,no IP contract,,,78,,18.49,percent of total billed charges,,,70,,16.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.61,3324,
42858-0001-01 - oxyCODONE 5 mg Tab,42858-0001-01,NDC,,,,inpatient,1,EA,6.1,3.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.19,percent of total billed charges,,,85,,5.19,percent of total billed charges,,,49,,2.99,percent of total billed charges,,,90,,5.49,percent of total billed charges,,,,,,,no IP contract,,80,,4.88,percent of total billed charges,,,,,,,no IP contract,,50,,3.05,percent of total billed charges,,,,,,no IP contract,,,78,,4.76,percent of total billed charges,,,70,,4.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.99,3324,
42858-0001-10 - oxyCODONE 5 mg Tab,42858-0001-10,NDC,,,,inpatient,1,EA,10.6,6.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.01,percent of total billed charges,,,85,,9.01,percent of total billed charges,,,49,,5.19,percent of total billed charges,,,90,,9.54,percent of total billed charges,,,,,,,no IP contract,,80,,8.48,percent of total billed charges,,,,,,,no IP contract,,50,,5.3,percent of total billed charges,,,,,,no IP contract,,,78,,8.27,percent of total billed charges,,,70,,7.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.19,3324,
42858-0301-25 - hydromorphone 2 mg Tab,42858-0301-25,NDC,,,,inpatient,1,EA,11.35,6.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.65,percent of total billed charges,,,85,,9.65,percent of total billed charges,,,49,,5.56,percent of total billed charges,,,90,,10.22,percent of total billed charges,,,,,,,no IP contract,,80,,9.08,percent of total billed charges,,,,,,,no IP contract,,50,,5.68,percent of total billed charges,,,,,,no IP contract,,,78,,8.85,percent of total billed charges,,,70,,7.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.56,3324,
42858-0302-25 - HYDROmorphone 4 mg Tab,42858-0302-25,NDC,,,,inpatient,1,EA,11.4,6.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.69,percent of total billed charges,,,85,,9.69,percent of total billed charges,,,49,,5.59,percent of total billed charges,,,90,,10.26,percent of total billed charges,,,,,,,no IP contract,,80,,9.12,percent of total billed charges,,,,,,,no IP contract,,50,,5.7,percent of total billed charges,,,,,,no IP contract,,,78,,8.89,percent of total billed charges,,,70,,7.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.59,3324,
42858-0303-01 - hydromorphone 8 mg Tab,42858-0303-01,NDC,,,,inpatient,1,EA,14.5,8.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.33,percent of total billed charges,,,85,,12.33,percent of total billed charges,,,49,,7.11,percent of total billed charges,,,90,,13.05,percent of total billed charges,,,,,,,no IP contract,,80,,11.6,percent of total billed charges,,,,,,,no IP contract,,50,,7.25,percent of total billed charges,,,,,,no IP contract,,,78,,11.31,percent of total billed charges,,,70,,10.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.11,3324,
42858-0401-45 - methylphenidate (40/60 release) 10 mg/24 hr ER Ca,42858-0401-45,NDC,,,,inpatient,1,EA,88.7,53.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,71.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,75.4,percent of total billed charges,,,85,,75.4,percent of total billed charges,,,49,,43.46,percent of total billed charges,,,90,,79.83,percent of total billed charges,,,,,,,no IP contract,,80,,70.96,percent of total billed charges,,,,,,,no IP contract,,50,,44.35,percent of total billed charges,,,,,,no IP contract,,,78,,69.19,percent of total billed charges,,,70,,62.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,43.46,3324,
42858-0703-03 - paroxetine  12.5 mg ER Tablet,42858-0703-03,NDC,,,,inpatient,1,EA,22.9,13.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.47,percent of total billed charges,,,85,,19.47,percent of total billed charges,,,49,,11.22,percent of total billed charges,,,90,,20.61,percent of total billed charges,,,,,,,no IP contract,,80,,18.32,percent of total billed charges,,,,,,,no IP contract,,50,,11.45,percent of total billed charges,,,,,,no IP contract,,,78,,17.86,percent of total billed charges,,,70,,16.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.22,3324,
42858-0705-03 - paroxetine 25 mg ER Tablet,42858-0705-03,NDC,,,,inpatient,1,EA,23.85,14.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.27,percent of total billed charges,,,85,,20.27,percent of total billed charges,,,49,,11.69,percent of total billed charges,,,90,,21.47,percent of total billed charges,,,,,,,no IP contract,,80,,19.08,percent of total billed charges,,,,,,,no IP contract,,50,,11.93,percent of total billed charges,,,,,,no IP contract,,,78,,18.6,percent of total billed charges,,,70,,16.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.69,3324,
42858-0726-01 - amphetamine-dextroamphetamine 20 mg Tab,42858-0726-01,NDC,,,,inpatient,1,EA,7.35,4.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.25,percent of total billed charges,,,85,,6.25,percent of total billed charges,,,49,,3.6,percent of total billed charges,,,90,,6.62,percent of total billed charges,,,,,,,no IP contract,,80,,5.88,percent of total billed charges,,,,,,,no IP contract,,50,,3.68,percent of total billed charges,,,,,,no IP contract,,,78,,5.73,percent of total billed charges,,,70,,5.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.6,3324,
42858-0804-01 - morphine 100 mg/8 hr ER Ta,42858-0804-01,NDC,,,,inpatient,1,EA,82.05,49.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,66.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,69.74,percent of total billed charges,,,85,,69.74,percent of total billed charges,,,49,,40.2,percent of total billed charges,,,90,,73.85,percent of total billed charges,,,,,,,no IP contract,,80,,65.64,percent of total billed charges,,,,,,,no IP contract,,50,,41.03,percent of total billed charges,,,,,,no IP contract,,,78,,64,percent of total billed charges,,,70,,57.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,40.2,3324,
42858-0867-06 - dronabinol 2.5 mg Cap,42858-0867-06,NDC,,,,inpatient,1,EA,22.25,13.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.91,percent of total billed charges,,,85,,18.91,percent of total billed charges,,,49,,10.9,percent of total billed charges,,,90,,20.03,percent of total billed charges,,,,,,,no IP contract,,80,,17.8,percent of total billed charges,,,,,,,no IP contract,,50,,11.13,percent of total billed charges,,,,,,no IP contract,,,78,,17.36,percent of total billed charges,,,70,,15.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.9,3324,
42858-0868-06 - dronabinol 5 mg Cap,42858-0868-06,NDC,,,,inpatient,1,EA,40.6,24.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34.51,percent of total billed charges,,,85,,34.51,percent of total billed charges,,,49,,19.89,percent of total billed charges,,,90,,36.54,percent of total billed charges,,,,,,,no IP contract,,80,,32.48,percent of total billed charges,,,,,,,no IP contract,,50,,20.3,percent of total billed charges,,,,,,no IP contract,,,78,,31.67,percent of total billed charges,,,70,,28.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.89,3324,
ROPivacaine 0.5% Soln,43066-0023-10,NDC,,,,inpatient,1,EA,90.25,54.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,73.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,76.71,percent of total billed charges,,,85,,76.71,percent of total billed charges,,,49,,44.22,percent of total billed charges,,,90,,81.23,percent of total billed charges,,,,,,,no IP contract,,80,,72.2,percent of total billed charges,,,,,,,no IP contract,,50,,45.13,percent of total billed charges,,,,,,no IP contract,,,78,,70.4,percent of total billed charges,,,70,,63.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,44.22,3324,
43199-0011-01 - hyoscyamine 0.125 mg Tab,43199-0011-01,NDC,,,,inpatient,1,EA,10.6,6.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.01,percent of total billed charges,,,85,,9.01,percent of total billed charges,,,49,,5.19,percent of total billed charges,,,90,,9.54,percent of total billed charges,,,,,,,no IP contract,,80,,8.48,percent of total billed charges,,,,,,,no IP contract,,50,,5.3,percent of total billed charges,,,,,,no IP contract,,,78,,8.27,percent of total billed charges,,,70,,7.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.19,3324,
43199-0013-01 - hyoscyamine 0.125 mg Tab,43199-0013-01,NDC,,,,inpatient,1,EA,10.6,6.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.01,percent of total billed charges,,,85,,9.01,percent of total billed charges,,,49,,5.19,percent of total billed charges,,,90,,9.54,percent of total billed charges,,,,,,,no IP contract,,80,,8.48,percent of total billed charges,,,,,,,no IP contract,,50,,5.3,percent of total billed charges,,,,,,no IP contract,,,78,,8.27,percent of total billed charges,,,70,,7.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.19,3324,
43199-0014-01 - hyoscyamine 0.375 mg ER Ta,43199-0014-01,NDC,,,,inpatient,1,EA,16.55,9.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.07,percent of total billed charges,,,85,,14.07,percent of total billed charges,,,49,,8.11,percent of total billed charges,,,90,,14.9,percent of total billed charges,,,,,,,no IP contract,,80,,13.24,percent of total billed charges,,,,,,,no IP contract,,50,,8.28,percent of total billed charges,,,,,,no IP contract,,,78,,12.91,percent of total billed charges,,,70,,11.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.11,3324,
43199-0020-01 - methenamine hippurate 1 g Tab,43199-0020-01,NDC,,,,inpatient,1,EA,20.45,12.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.38,percent of total billed charges,,,85,,17.38,percent of total billed charges,,,49,,10.02,percent of total billed charges,,,90,,18.41,percent of total billed charges,,,,,,,no IP contract,,80,,16.36,percent of total billed charges,,,,,,,no IP contract,,50,,10.23,percent of total billed charges,,,,,,no IP contract,,,78,,15.95,percent of total billed charges,,,70,,14.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.02,3324,
43292-0558-81 - cholecalciferol 400 intl units Tab,43292-0558-81,NDC,,,,inpatient,1,EA,4,2.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.4,percent of total billed charges,,,85,,3.4,percent of total billed charges,,,49,,1.96,percent of total billed charges,,,90,,3.6,percent of total billed charges,,,,,,,no IP contract,,80,,3.2,percent of total billed charges,,,,,,,no IP contract,,50,,2,percent of total billed charges,,,,,,no IP contract,,,78,,3.12,percent of total billed charges,,,70,,2.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.96,3324,
fluocinonide topical 0.05% Soln,43386-0026-06,NDC,,,,inpatient,1,EA,973.85,584.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,788.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,827.77,percent of total billed charges,,,85,,827.77,percent of total billed charges,,,49,,477.19,percent of total billed charges,,,90,,876.47,percent of total billed charges,,,,,,,no IP contract,,80,,779.08,percent of total billed charges,,,,,,,no IP contract,,50,,486.93,percent of total billed charges,,,,,,no IP contract,,,78,,759.6,percent of total billed charges,,,70,,681.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,477.19,3324,
43386-0450-11 - nitrofurantoin oral Susp 25 mg / 5 mL Susp,43386-0450-11,NDC,,,,inpatient,1,ML,31.9,19.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,25.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,27.12,percent of total billed charges,,,85,,27.12,percent of total billed charges,,,49,,15.63,percent of total billed charges,,,90,,28.71,percent of total billed charges,,,,,,,no IP contract,,80,,25.52,percent of total billed charges,,,,,,,no IP contract,,50,,15.95,percent of total billed charges,,,,,,no IP contract,,,78,,24.88,percent of total billed charges,,,70,,22.33,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.63,3324,
43386-0570-01 - methylphenidate 2.5 mg Chew,43386-0570-01,NDC,,,,inpatient,1,EA,28.95,17.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.61,percent of total billed charges,,,85,,24.61,percent of total billed charges,,,49,,14.19,percent of total billed charges,,,90,,26.06,percent of total billed charges,,,,,,,no IP contract,,80,,23.16,percent of total billed charges,,,,,,,no IP contract,,50,,14.48,percent of total billed charges,,,,,,no IP contract,,,78,,22.58,percent of total billed charges,,,70,,20.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.19,3324,
43386-0660-03 - trimethobenzamide 300 mg Cap,43386-0660-03,NDC,,,,inpatient,1,EA,20.35,12.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.3,percent of total billed charges,,,85,,17.3,percent of total billed charges,,,49,,9.97,percent of total billed charges,,,90,,18.32,percent of total billed charges,,,,,,,no IP contract,,80,,16.28,percent of total billed charges,,,,,,,no IP contract,,50,,10.18,percent of total billed charges,,,,,,no IP contract,,,78,,15.87,percent of total billed charges,,,70,,14.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.97,3324,
43388-0281-01 - diazepam 20 mg Gel,43388-0281-01,NDC,,,,inpatient,1,EA,3038.05,1822.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2460.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2582.34,percent of total billed charges,,,85,,2582.34,percent of total billed charges,,,49,,1488.64,percent of total billed charges,,,90,,2734.25,percent of total billed charges,,,,,,,no IP contract,,80,,2430.44,percent of total billed charges,,,,,,,no IP contract,,50,,1519.03,percent of total billed charges,,,,,,no IP contract,,,78,,2369.68,percent of total billed charges,,,70,,2126.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
43547-0222-15 - levETIRAcetam 500 mg Tab,43547-0222-15,NDC,,,,inpatient,1,EA,31.8,19.08,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,25.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,27.03,percent of total billed charges,,,85,,27.03,percent of total billed charges,,,49,,15.58,percent of total billed charges,,,90,,28.62,percent of total billed charges,,,,,,,no IP contract,,80,,25.44,percent of total billed charges,,,,,,,no IP contract,,50,,15.9,percent of total billed charges,,,,,,no IP contract,,,78,,24.8,percent of total billed charges,,,70,,22.26,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.58,3324,
levETIRAcetam 750 mg Tab,43547-0223-15,NDC,,,,inpatient,1,EA,41.5,24.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,35.28,percent of total billed charges,,,85,,35.28,percent of total billed charges,,,49,,20.34,percent of total billed charges,,,90,,37.35,percent of total billed charges,,,,,,,no IP contract,,80,,33.2,percent of total billed charges,,,,,,,no IP contract,,50,,20.75,percent of total billed charges,,,,,,no IP contract,,,78,,32.37,percent of total billed charges,,,70,,29.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.34,3324,
43547-0275-09 - donepezil 5 mg Tab,43547-0275-09,NDC,,,,inpatient,1,EA,72.65,43.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,58.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,61.75,percent of total billed charges,,,85,,61.75,percent of total billed charges,,,49,,35.6,percent of total billed charges,,,90,,65.39,percent of total billed charges,,,,,,,no IP contract,,80,,58.12,percent of total billed charges,,,,,,,no IP contract,,50,,36.33,percent of total billed charges,,,,,,no IP contract,,,78,,56.67,percent of total billed charges,,,70,,50.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,35.6,3324,
43547-0289-10 - buPROPion 150 mg/12 hours ER Ta,43547-0289-10,NDC,,,,inpatient,1,EA,19.25,11.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.36,percent of total billed charges,,,85,,16.36,percent of total billed charges,,,49,,9.43,percent of total billed charges,,,90,,17.33,percent of total billed charges,,,,,,,no IP contract,,80,,15.4,percent of total billed charges,,,,,,,no IP contract,,50,,9.63,percent of total billed charges,,,,,,no IP contract,,,78,,15.02,percent of total billed charges,,,70,,13.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.43,3324,
43547-0337-10 - benazepril 20 mg Tab,43547-0337-10,NDC,,,,inpatient,1,EA,12.15,7.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.33,percent of total billed charges,,,85,,10.33,percent of total billed charges,,,49,,5.95,percent of total billed charges,,,90,,10.94,percent of total billed charges,,,,,,,no IP contract,,80,,9.72,percent of total billed charges,,,,,,,no IP contract,,50,,6.08,percent of total billed charges,,,,,,no IP contract,,,78,,9.48,percent of total billed charges,,,70,,8.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.95,3324,
43547-0338-10 - benazepril 40 mg Tab,43547-0338-10,NDC,,,,inpatient,1,EA,12.15,7.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.33,percent of total billed charges,,,85,,10.33,percent of total billed charges,,,49,,5.95,percent of total billed charges,,,90,,10.94,percent of total billed charges,,,,,,,no IP contract,,80,,9.72,percent of total billed charges,,,,,,,no IP contract,,50,,6.08,percent of total billed charges,,,,,,no IP contract,,,78,,9.48,percent of total billed charges,,,70,,8.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.95,3324,
43547-0360-09 - losartan 25 mg Tab,43547-0360-09,NDC,,,,inpatient,1,EA,17.2,10.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.62,percent of total billed charges,,,85,,14.62,percent of total billed charges,,,49,,8.43,percent of total billed charges,,,90,,15.48,percent of total billed charges,,,,,,,no IP contract,,80,,13.76,percent of total billed charges,,,,,,,no IP contract,,50,,8.6,percent of total billed charges,,,,,,no IP contract,,,78,,13.42,percent of total billed charges,,,70,,12.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.43,3324,
43547-0377-03 - voriconazole 50 mg Tab,43547-0377-03,NDC,,,,inpatient,1,EA,103.7,62.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,88.15,percent of total billed charges,,,85,,88.15,percent of total billed charges,,,49,,50.81,percent of total billed charges,,,90,,93.33,percent of total billed charges,,,,,,,no IP contract,,80,,82.96,percent of total billed charges,,,,,,,no IP contract,,50,,51.85,percent of total billed charges,,,,,,no IP contract,,,78,,80.89,percent of total billed charges,,,70,,72.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,50.81,3324,
43547-0525-09 - nebivolol 5 mg Tab,43547-0525-09,NDC,,,,inpatient,1,EA,41.5,24.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,35.28,percent of total billed charges,,,85,,35.28,percent of total billed charges,,,49,,20.34,percent of total billed charges,,,90,,37.35,percent of total billed charges,,,,,,,no IP contract,,80,,33.2,percent of total billed charges,,,,,,,no IP contract,,50,,20.75,percent of total billed charges,,,,,,no IP contract,,,78,,32.37,percent of total billed charges,,,70,,29.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.34,3324,
43547-0545-10 - enalapril 2.5 mg Tab,43547-0545-10,NDC,,,,inpatient,1,EA,15.45,9.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.13,percent of total billed charges,,,85,,13.13,percent of total billed charges,,,49,,7.57,percent of total billed charges,,,90,,13.91,percent of total billed charges,,,,,,,no IP contract,,80,,12.36,percent of total billed charges,,,,,,,no IP contract,,50,,7.73,percent of total billed charges,,,,,,no IP contract,,,78,,12.05,percent of total billed charges,,,70,,10.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.57,3324,
43547-0547-10 - enalapril 10 mg Tab,43547-0547-10,NDC,,,,inpatient,1,EA,19.25,11.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.36,percent of total billed charges,,,85,,16.36,percent of total billed charges,,,49,,9.43,percent of total billed charges,,,90,,17.33,percent of total billed charges,,,,,,,no IP contract,,80,,15.4,percent of total billed charges,,,,,,,no IP contract,,50,,9.63,percent of total billed charges,,,,,,no IP contract,,,78,,15.02,percent of total billed charges,,,70,,13.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.43,3324,
43547-0548-10 - enalapril 20 mg Tab,43547-0548-10,NDC,,,,inpatient,1,EA,5.2,3.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.42,percent of total billed charges,,,85,,4.42,percent of total billed charges,,,49,,2.55,percent of total billed charges,,,90,,4.68,percent of total billed charges,,,,,,,no IP contract,,80,,4.16,percent of total billed charges,,,,,,,no IP contract,,50,,2.6,percent of total billed charges,,,,,,no IP contract,,,78,,4.06,percent of total billed charges,,,70,,3.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.55,3324,
43598-0204-53 - amoxicillin-clavulanate 250 mg-62.5 mg/5 mL REC P,43598-0204-53,NDC,,,,inpatient,1,ML,17.25,10.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.66,percent of total billed charges,,,85,,14.66,percent of total billed charges,,,49,,8.45,percent of total billed charges,,,90,,15.53,percent of total billed charges,,,,,,,no IP contract,,80,,13.8,percent of total billed charges,,,,,,,no IP contract,,50,,8.63,percent of total billed charges,,,,,,no IP contract,,,78,,13.46,percent of total billed charges,,,70,,12.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.45,3324,
43598-0326-75 - ciprofloxacin-dexamethasone otic 0.3%-0.1% Susp,43598-0326-75,NDC,,,,inpatient,1,UN,2250.2,1350.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1822.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1912.67,percent of total billed charges,,,85,,1912.67,percent of total billed charges,,,49,,1102.6,percent of total billed charges,,,90,,2025.18,percent of total billed charges,,,,,,,no IP contract,,80,,1800.16,percent of total billed charges,,,,,,,no IP contract,,50,,1125.1,percent of total billed charges,,,,,,no IP contract,,,78,,1755.16,percent of total billed charges,,,70,,1575.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
43598-0339-60 - aspirin-dipyridamole 25 mg-200 mg ER Ca,43598-0339-60,NDC,,,,inpatient,1,EA,70.3,42.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,56.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,59.76,percent of total billed charges,,,85,,59.76,percent of total billed charges,,,49,,34.45,percent of total billed charges,,,90,,63.27,percent of total billed charges,,,,,,,no IP contract,,80,,56.24,percent of total billed charges,,,,,,,no IP contract,,50,,35.15,percent of total billed charges,,,,,,no IP contract,,,78,,54.83,percent of total billed charges,,,70,,49.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,34.45,3324,
phytonadione 10 mg/mL Soln,43598-0405-16,NDC,,,,inpatient,1,mL,441.95,265.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,357.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,375.66,percent of total billed charges,,,85,,375.66,percent of total billed charges,,,49,,216.56,percent of total billed charges,,,90,,397.76,percent of total billed charges,,,,,,,no IP contract,,80,,353.56,percent of total billed charges,,,,,,,no IP contract,,50,,220.98,percent of total billed charges,,,,,,no IP contract,,,78,,344.72,percent of total billed charges,,,70,,309.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,216.56,3324,
nitroglycerin 0.4 mg Tab,43598-0436-11,NDC,,,,inpatient,1,EA,206.55,123.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,167.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,175.57,percent of total billed charges,,,85,,175.57,percent of total billed charges,,,49,,101.21,percent of total billed charges,,,90,,185.9,percent of total billed charges,,,,,,,no IP contract,,80,,165.24,percent of total billed charges,,,,,,,no IP contract,,50,,103.28,percent of total billed charges,,,,,,no IP contract,,,78,,161.11,percent of total billed charges,,,70,,144.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,101.21,3324,
43598-0446-74 - nicotine patch(es) 7 mg Patch,43598-0446-74,NDC,,,,inpatient,1,UN,24.15,14.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.53,percent of total billed charges,,,85,,20.53,percent of total billed charges,,,49,,11.83,percent of total billed charges,,,90,,21.74,percent of total billed charges,,,,,,,no IP contract,,80,,19.32,percent of total billed charges,,,,,,,no IP contract,,50,,12.08,percent of total billed charges,,,,,,no IP contract,,,78,,18.84,percent of total billed charges,,,70,,16.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.83,3324,
43598-0447-74 - nicotine patch(es) 14 mg/24 hr Patch,43598-0447-74,NDC,,,,inpatient,1,UN,26.95,16.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.91,percent of total billed charges,,,85,,22.91,percent of total billed charges,,,49,,13.21,percent of total billed charges,,,90,,24.26,percent of total billed charges,,,,,,,no IP contract,,80,,21.56,percent of total billed charges,,,,,,,no IP contract,,50,,13.48,percent of total billed charges,,,,,,no IP contract,,,78,,21.02,percent of total billed charges,,,70,,18.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.21,3324,
43598-0448-28 - nicotine patch(es) 21 mg/24 hr Patch,43598-0448-28,NDC,,,,inpatient,1,UN,25.2,15.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.42,percent of total billed charges,,,85,,21.42,percent of total billed charges,,,49,,12.35,percent of total billed charges,,,90,,22.68,percent of total billed charges,,,,,,,no IP contract,,80,,20.16,percent of total billed charges,,,,,,,no IP contract,,50,,12.6,percent of total billed charges,,,,,,no IP contract,,,78,,19.66,percent of total billed charges,,,70,,17.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.35,3324,
43598-0478-90 - sevelamer carbonate 0.8 g REC P,43598-0478-90,NDC,,,,inpatient,30,ML,149.25,89.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,120.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,126.86,percent of total billed charges,,,85,,126.86,percent of total billed charges,,,49,,73.13,percent of total billed charges,,,90,,134.33,percent of total billed charges,,,,,,,no IP contract,,80,,119.4,percent of total billed charges,,,,,,,no IP contract,,50,,74.63,percent of total billed charges,,,,,,no IP contract,,,78,,116.42,percent of total billed charges,,,70,,104.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,73.13,3324,
43598-0479-90 - sevelamer carbonate 2.4 g REC P,43598-0479-90,NDC,,,,inpatient,60,ML,149.25,89.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,120.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,126.86,percent of total billed charges,,,85,,126.86,percent of total billed charges,,,49,,73.13,percent of total billed charges,,,90,,134.33,percent of total billed charges,,,,,,,no IP contract,,80,,119.4,percent of total billed charges,,,,,,,no IP contract,,50,,74.63,percent of total billed charges,,,,,,no IP contract,,,78,,116.42,percent of total billed charges,,,70,,104.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,73.13,3324,
43598-0606-10 - fondaparinux syringe 10 mg / 0.8 mL Soln,43598-0606-10,NDC,,,,inpatient,0.8,ML,749.05,449.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,606.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,636.69,percent of total billed charges,,,85,,636.69,percent of total billed charges,,,49,,367.03,percent of total billed charges,,,90,,674.15,percent of total billed charges,,,,,,,no IP contract,,80,,599.24,percent of total billed charges,,,,,,,no IP contract,,50,,374.53,percent of total billed charges,,,,,,no IP contract,,,78,,584.26,percent of total billed charges,,,70,,524.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,367.03,3324,
43598-0607-10 - fondaparinux syringe 2.5 mg / 0.5 mL Soln,43598-0607-10,NDC,,,,inpatient,0.5,ML,257.15,154.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,208.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,218.58,percent of total billed charges,,,85,,218.58,percent of total billed charges,,,49,,126,percent of total billed charges,,,90,,231.44,percent of total billed charges,,,,,,,no IP contract,,80,,205.72,percent of total billed charges,,,,,,,no IP contract,,50,,128.58,percent of total billed charges,,,,,,no IP contract,,,78,,200.58,percent of total billed charges,,,70,,180.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,126,3324,
43598-0609-10 - fondaparinux 7.5 mg/0.6 mL Soln,43598-0609-10,NDC,,,,inpatient,0.6,ML,995.65,597.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,806.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,846.3,percent of total billed charges,,,85,,846.3,percent of total billed charges,,,49,,487.87,percent of total billed charges,,,90,,896.09,percent of total billed charges,,,,,,,no IP contract,,80,,796.52,percent of total billed charges,,,,,,,no IP contract,,50,,497.83,percent of total billed charges,,,,,,no IP contract,,,78,,776.61,percent of total billed charges,,,70,,696.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,487.87,3324,
43598-0674-50 - cefixime 200 mg/5 mL REC P,43598-0674-50,NDC,,,,inpatient,1,ML,79.65,47.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,64.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,67.7,percent of total billed charges,,,85,,67.7,percent of total billed charges,,,49,,39.03,percent of total billed charges,,,90,,71.69,percent of total billed charges,,,,,,,no IP contract,,80,,63.72,percent of total billed charges,,,,,,,no IP contract,,50,,39.83,percent of total billed charges,,,,,,no IP contract,,,78,,62.13,percent of total billed charges,,,70,,55.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,39.03,3324,
43598-0977-10 - diclofenac topical 1% Gel,43598-0977-10,NDC,,,,inpatient,1,EA,125.85,75.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,101.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,106.97,percent of total billed charges,,,85,,106.97,percent of total billed charges,,,49,,61.67,percent of total billed charges,,,90,,113.27,percent of total billed charges,,,,,,,no IP contract,,80,,100.68,percent of total billed charges,,,,,,,no IP contract,,50,,62.93,percent of total billed charges,,,,,,no IP contract,,,78,,98.16,percent of total billed charges,,,70,,88.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,61.67,3324,
43900-0976-47 - guar gum 100% REC P,43900-0976-47,NDC,,,,inpatient,1,UN,7.65,4.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.5,percent of total billed charges,,,85,,6.5,percent of total billed charges,,,49,,3.75,percent of total billed charges,,,90,,6.89,percent of total billed charges,,,,,,,no IP contract,,80,,6.12,percent of total billed charges,,,,,,,no IP contract,,50,,3.83,percent of total billed charges,,,,,,no IP contract,,,78,,5.97,percent of total billed charges,,,70,,5.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.75,3324,
43975-0304-10 - indapamide 2.5 mg Tab,43975-0304-10,NDC,,,,inpatient,1,EA,16.15,9.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.73,percent of total billed charges,,,85,,13.73,percent of total billed charges,,,49,,7.91,percent of total billed charges,,,90,,14.54,percent of total billed charges,,,,,,,no IP contract,,80,,12.92,percent of total billed charges,,,,,,,no IP contract,,50,,8.08,percent of total billed charges,,,,,,no IP contract,,,78,,12.6,percent of total billed charges,,,70,,11.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.91,3324,
44206-0417-06 - immune globulin intravenous 6 g REC I,44206-0417-06,NDC,,,,inpatient,100,ML,5083.4,3050.04,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4117.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4320.89,percent of total billed charges,,,85,,4320.89,percent of total billed charges,,,49,,2490.87,percent of total billed charges,,,90,,4575.06,percent of total billed charges,,,,,,,no IP contract,,80,,4066.72,percent of total billed charges,,,,,,,no IP contract,,50,,2541.7,percent of total billed charges,,,,,,no IP contract,,,78,,3965.05,percent of total billed charges,,,70,,3558.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4575.06,
44206-0418-12 - immune globulin intravenous 12 g REC I,44206-0418-12,NDC,,,,inpatient,200,ML,10131.4,6078.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8206.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8611.69,percent of total billed charges,,,85,,8611.69,percent of total billed charges,,,49,,4964.39,percent of total billed charges,,,90,,9118.26,percent of total billed charges,,,,,,,no IP contract,,80,,8105.12,percent of total billed charges,,,,,,,no IP contract,,50,,5065.7,percent of total billed charges,,,,,,no IP contract,,,78,,7902.49,percent of total billed charges,,,70,,7091.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,9118.26,
44206-0436-05 - immune globulin intravenous 10% Soln,44206-0436-05,NDC,,,,inpatient,50,ML,5622.9,3373.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4554.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4779.47,percent of total billed charges,,,85,,4779.47,percent of total billed charges,,,49,,2755.22,percent of total billed charges,,,90,,5060.61,percent of total billed charges,,,,,,,no IP contract,,80,,4498.32,percent of total billed charges,,,,,,,no IP contract,,50,,2811.45,percent of total billed charges,,,,,,no IP contract,,,78,,4385.86,percent of total billed charges,,,70,,3936.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,5060.61,
44206-0437-10 - immune globulin intravenous 10% Soln,44206-0437-10,NDC,,,,inpatient,100,ML,11170.7,6702.42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9048.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9495.1,percent of total billed charges,,,85,,9495.1,percent of total billed charges,,,49,,5473.64,percent of total billed charges,,,90,,10053.63,percent of total billed charges,,,,,,,no IP contract,,80,,8936.56,percent of total billed charges,,,,,,,no IP contract,,50,,5585.35,percent of total billed charges,,,,,,no IP contract,,,78,,8713.15,percent of total billed charges,,,70,,7819.49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,10053.63,
immune globulin intravenous 10% Soln,44206-0438-20,NDC,,,,inpatient,1,EA,22266.25,13359.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18035.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18926.31,percent of total billed charges,,,85,,18926.31,percent of total billed charges,,,49,,10910.46,percent of total billed charges,,,90,,20039.63,percent of total billed charges,,,,,,,no IP contract,,80,,17813,percent of total billed charges,,,,,,,no IP contract,,50,,11133.13,percent of total billed charges,,,,,,no IP contract,,,78,,17367.68,percent of total billed charges,,,70,,15586.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,20039.63,
44206-0532-11 - cytomegalovirus immune globulin 50 mg/mL Soln,44206-0532-11,NDC,,,,inpatient,1,ML,244.35,146.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,197.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,207.7,percent of total billed charges,,,85,,207.7,percent of total billed charges,,,49,,119.73,percent of total billed charges,,,90,,219.92,percent of total billed charges,,,,,,,no IP contract,,80,,195.48,percent of total billed charges,,,,,,,no IP contract,,50,,122.18,percent of total billed charges,,,,,,no IP contract,,,78,,190.59,percent of total billed charges,,,70,,171.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,119.73,3324,
44567-0103-10 - ampicillin 2 g REC I,44567-0103-10,NDC,,,,inpatient,1,EA,185.1,111.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,149.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,157.34,percent of total billed charges,,,85,,157.34,percent of total billed charges,,,49,,90.7,percent of total billed charges,,,90,,166.59,percent of total billed charges,,,,,,,no IP contract,,80,,148.08,percent of total billed charges,,,,,,,no IP contract,,50,,92.55,percent of total billed charges,,,,,,no IP contract,,,78,,144.38,percent of total billed charges,,,70,,129.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,90.7,3324,
44567-0235-25 - cefTAZidime 1 g REC I,44567-0235-25,NDC,,,,inpatient,1,EA,54.85,32.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,44.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,46.62,percent of total billed charges,,,85,,46.62,percent of total billed charges,,,49,,26.88,percent of total billed charges,,,90,,49.37,percent of total billed charges,,,,,,,no IP contract,,80,,43.88,percent of total billed charges,,,,,,,no IP contract,,50,,27.43,percent of total billed charges,,,,,,no IP contract,,,78,,42.78,percent of total billed charges,,,70,,38.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.88,3324,
44567-0236-10 - cefTAZidime 2 g REC I,44567-0236-10,NDC,,,,inpatient,1,EA,110.5,66.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,89.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,93.93,percent of total billed charges,,,85,,93.93,percent of total billed charges,,,49,,54.15,percent of total billed charges,,,90,,99.45,percent of total billed charges,,,,,,,no IP contract,,80,,88.4,percent of total billed charges,,,,,,,no IP contract,,50,,55.25,percent of total billed charges,,,,,,no IP contract,,,78,,86.19,percent of total billed charges,,,70,,77.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,54.15,3324,
44567-0246-25 - cefOXitin 2 g REC I,44567-0246-25,NDC,,,,inpatient,21,ML,257.85,154.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,208.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,219.17,percent of total billed charges,,,85,,219.17,percent of total billed charges,,,49,,126.35,percent of total billed charges,,,90,,232.07,percent of total billed charges,,,,,,,no IP contract,,80,,206.28,percent of total billed charges,,,,,,,no IP contract,,50,,128.93,percent of total billed charges,,,,,,no IP contract,,,78,,201.12,percent of total billed charges,,,70,,180.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,126.35,3324,
44567-0705-10 - imipenem-cilastatin 500 mg-500 mg REC I,44567-0705-10,NDC,,,,inpatient,10,ML,286,171.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,231.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,243.1,percent of total billed charges,,,85,,243.1,percent of total billed charges,,,49,,140.14,percent of total billed charges,,,90,,257.4,percent of total billed charges,,,,,,,no IP contract,,80,,228.8,percent of total billed charges,,,,,,,no IP contract,,50,,143,percent of total billed charges,,,,,,no IP contract,,,78,,223.08,percent of total billed charges,,,70,,200.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,140.14,3324,
45802-0004-03 - hydrocortisone topical 2.5% Cream,45802-0004-03,NDC,,,,inpatient,1,UN,106.7,64.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,86.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,90.7,percent of total billed charges,,,85,,90.7,percent of total billed charges,,,49,,52.28,percent of total billed charges,,,90,,96.03,percent of total billed charges,,,,,,,no IP contract,,80,,85.36,percent of total billed charges,,,,,,,no IP contract,,50,,53.35,percent of total billed charges,,,,,,no IP contract,,,78,,83.23,percent of total billed charges,,,70,,74.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,52.28,3324,
45802-0014-02 - hydrocortisone topical 2.5% Ointm,45802-0014-02,NDC,,,,inpatient,1,UN,50.85,30.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,41.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,43.22,percent of total billed charges,,,85,,43.22,percent of total billed charges,,,49,,24.92,percent of total billed charges,,,90,,45.77,percent of total billed charges,,,,,,,no IP contract,,80,,40.68,percent of total billed charges,,,,,,,no IP contract,,50,,25.43,percent of total billed charges,,,,,,no IP contract,,,78,,39.66,percent of total billed charges,,,70,,35.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.92,3324,
45802-0040-64 - selenium sulfide Topical 2.5% Lotio,45802-0040-64,NDC,,,,inpatient,1,UN,179.15,107.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,145.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,152.28,percent of total billed charges,,,85,,152.28,percent of total billed charges,,,49,,87.78,percent of total billed charges,,,90,,161.24,percent of total billed charges,,,,,,,no IP contract,,80,,143.32,percent of total billed charges,,,,,,,no IP contract,,50,,89.58,percent of total billed charges,,,,,,no IP contract,,,78,,139.74,percent of total billed charges,,,70,,125.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,87.78,3324,
45802-0046-11 - gentamicin topical 0.1% Ointm,45802-0046-11,NDC,,,,inpatient,1,EA,49.2,29.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,39.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,41.82,percent of total billed charges,,,85,,41.82,percent of total billed charges,,,49,,24.11,percent of total billed charges,,,90,,44.28,percent of total billed charges,,,,,,,no IP contract,,80,,39.36,percent of total billed charges,,,,,,,no IP contract,,50,,24.6,percent of total billed charges,,,,,,no IP contract,,,78,,38.38,percent of total billed charges,,,70,,34.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.11,3324,
45802-0048-11 - nystatin topical 100000 units/g Ointm,45802-0048-11,NDC,,,,inpatient,1,UN,229.15,137.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,185.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,194.78,percent of total billed charges,,,85,,194.78,percent of total billed charges,,,49,,112.28,percent of total billed charges,,,90,,206.24,percent of total billed charges,,,,,,,no IP contract,,80,,183.32,percent of total billed charges,,,,,,,no IP contract,,50,,114.58,percent of total billed charges,,,,,,no IP contract,,,78,,178.74,percent of total billed charges,,,70,,160.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,112.28,3324,
45802-0049-35 - triamcinolone topical 0.5% Ointm,45802-0049-35,NDC,,,,inpatient,1,UN,94.2,56.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,76.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,80.07,percent of total billed charges,,,85,,80.07,percent of total billed charges,,,49,,46.16,percent of total billed charges,,,90,,84.78,percent of total billed charges,,,,,,,no IP contract,,80,,75.36,percent of total billed charges,,,,,,,no IP contract,,50,,47.1,percent of total billed charges,,,,,,no IP contract,,,78,,73.48,percent of total billed charges,,,70,,65.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,46.16,3324,
45802-0055-05 - triamcinolone topical 0.1% Ointm,45802-0055-05,NDC,,,,inpatient,1,UN,349.6,209.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,283.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,297.16,percent of total billed charges,,,85,,297.16,percent of total billed charges,,,49,,171.3,percent of total billed charges,,,90,,314.64,percent of total billed charges,,,,,,,no IP contract,,80,,279.68,percent of total billed charges,,,,,,,no IP contract,,50,,174.8,percent of total billed charges,,,,,,no IP contract,,,78,,272.69,percent of total billed charges,,,70,,244.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,171.3,3324,
45802-0055-35 - triamcinolone topical 0.1% Ointm,45802-0055-35,NDC,,,,inpatient,1,UN,55.45,33.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,44.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,47.13,percent of total billed charges,,,85,,47.13,percent of total billed charges,,,49,,27.17,percent of total billed charges,,,90,,49.91,percent of total billed charges,,,,,,,no IP contract,,80,,44.36,percent of total billed charges,,,,,,,no IP contract,,50,,27.73,percent of total billed charges,,,,,,no IP contract,,,78,,43.25,percent of total billed charges,,,70,,38.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.17,3324,
45802-0056-35 - gentamicin topical 0.1% Cream,45802-0056-35,NDC,,,,inpatient,1,UN,269.1,161.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,217.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,228.74,percent of total billed charges,,,85,,228.74,percent of total billed charges,,,49,,131.86,percent of total billed charges,,,90,,242.19,percent of total billed charges,,,,,,,no IP contract,,80,,215.28,percent of total billed charges,,,,,,,no IP contract,,50,,134.55,percent of total billed charges,,,,,,no IP contract,,,78,,209.9,percent of total billed charges,,,70,,188.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,131.86,3324,
45802-0059-11 - nystatin topical 100000 units/g Cream,45802-0059-11,NDC,,,,inpatient,1,UN,229.15,137.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,185.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,194.78,percent of total billed charges,,,85,,194.78,percent of total billed charges,,,49,,112.28,percent of total billed charges,,,90,,206.24,percent of total billed charges,,,,,,,no IP contract,,80,,183.32,percent of total billed charges,,,,,,,no IP contract,,50,,114.58,percent of total billed charges,,,,,,no IP contract,,,78,,178.74,percent of total billed charges,,,70,,160.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,112.28,3324,
45802-0060-03 - bacitracin topical 500 units/g Ointm,45802-0060-03,NDC,,,,inpatient,1,UN,56.7,34.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,45.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,48.2,percent of total billed charges,,,85,,48.2,percent of total billed charges,,,49,,27.78,percent of total billed charges,,,90,,51.03,percent of total billed charges,,,,,,,no IP contract,,80,,45.36,percent of total billed charges,,,,,,,no IP contract,,50,,28.35,percent of total billed charges,,,,,,no IP contract,,,78,,44.23,percent of total billed charges,,,70,,39.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.78,3324,
45802-0064-05 - triamcinolone topical 0.1% Cream,45802-0064-05,NDC,,,,inpatient,1,UN,198.3,118.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,160.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,168.56,percent of total billed charges,,,85,,168.56,percent of total billed charges,,,49,,97.17,percent of total billed charges,,,90,,178.47,percent of total billed charges,,,,,,,no IP contract,,80,,158.64,percent of total billed charges,,,,,,,no IP contract,,50,,99.15,percent of total billed charges,,,,,,no IP contract,,,78,,154.67,percent of total billed charges,,,70,,138.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,97.17,3324,
45802-0064-35 - triamcinolone topical 0.1% Cream,45802-0064-35,NDC,,,,inpatient,1,UN,55.45,33.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,44.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,47.13,percent of total billed charges,,,85,,47.13,percent of total billed charges,,,49,,27.17,percent of total billed charges,,,90,,49.91,percent of total billed charges,,,,,,,no IP contract,,80,,44.36,percent of total billed charges,,,,,,,no IP contract,,50,,27.73,percent of total billed charges,,,,,,no IP contract,,,78,,43.25,percent of total billed charges,,,70,,38.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.17,3324,
45802-0065-35 - triamcinolone topical 0.5% Cream,45802-0065-35,NDC,,,,inpatient,1,UN,92.95,55.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,75.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,79.01,percent of total billed charges,,,85,,79.01,percent of total billed charges,,,49,,45.55,percent of total billed charges,,,90,,83.66,percent of total billed charges,,,,,,,no IP contract,,80,,74.36,percent of total billed charges,,,,,,,no IP contract,,50,,46.48,percent of total billed charges,,,,,,no IP contract,,,78,,72.5,percent of total billed charges,,,70,,65.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,45.55,3324,
45802-0098-51 - mesalamine 4 g/60 mL Enema,45802-0098-51,NDC,,,,inpatient,60,ML,137.4,82.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,111.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,116.79,percent of total billed charges,,,85,,116.79,percent of total billed charges,,,49,,67.33,percent of total billed charges,,,90,,123.66,percent of total billed charges,,,,,,,no IP contract,,80,,109.92,percent of total billed charges,,,,,,,no IP contract,,50,,68.7,percent of total billed charges,,,,,,no IP contract,,,78,,107.17,percent of total billed charges,,,70,,96.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,67.33,3324,
45802-0112-22 - mupirocin topical 2% Ointm,45802-0112-22,NDC,,,,inpatient,1,UN,102.7,61.62,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,83.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,87.3,percent of total billed charges,,,85,,87.3,percent of total billed charges,,,49,,50.32,percent of total billed charges,,,90,,92.43,percent of total billed charges,,,,,,,no IP contract,,80,,82.16,percent of total billed charges,,,,,,,no IP contract,,50,,51.35,percent of total billed charges,,,,,,no IP contract,,,78,,80.11,percent of total billed charges,,,70,,71.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,50.32,3324,
45802-0138-18 - ciclopirox topical 0.77% Cream,45802-0138-18,NDC,,,,inpatient,1,UN,1148.75,689.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,930.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,976.44,percent of total billed charges,,,85,,976.44,percent of total billed charges,,,49,,562.89,percent of total billed charges,,,90,,1033.88,percent of total billed charges,,,,,,,no IP contract,,80,,919,percent of total billed charges,,,,,,,no IP contract,,50,,574.38,percent of total billed charges,,,,,,no IP contract,,,78,,896.03,percent of total billed charges,,,70,,804.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,562.89,3324,
45802-0143-03 - bacitracin/neomycin/poly B 400 units-3.5 mg-5000 uni Ointment,45802-0143-03,NDC,,,,inpatient,1,UN,61.7,37.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,49.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,52.45,percent of total billed charges,,,85,,52.45,percent of total billed charges,,,49,,30.23,percent of total billed charges,,,90,,55.53,percent of total billed charges,,,,,,,no IP contract,,80,,49.36,percent of total billed charges,,,,,,,no IP contract,,50,,30.85,percent of total billed charges,,,,,,no IP contract,,,78,,48.13,percent of total billed charges,,,70,,43.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,30.23,3324,
45802-0188-16 - mineral oil/petrolatum/phenylephrine topical 14%-74.9%-0.25% Ointm,45802-0188-16,NDC,,,,inpatient,1,UN,46.75,28.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,37.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,39.74,percent of total billed charges,,,85,,39.74,percent of total billed charges,,,49,,22.91,percent of total billed charges,,,90,,42.08,percent of total billed charges,,,,,,,no IP contract,,80,,37.4,percent of total billed charges,,,,,,,no IP contract,,50,,23.38,percent of total billed charges,,,,,,no IP contract,,,78,,36.47,percent of total billed charges,,,70,,32.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.91,3324,
45802-0201-26 - acetaminophen 160 mg/5 mL Susp,45802-0201-26,NDC,,,,inpatient,5,ML,35.4,21.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.09,percent of total billed charges,,,85,,30.09,percent of total billed charges,,,49,,17.35,percent of total billed charges,,,90,,31.86,percent of total billed charges,,,,,,,no IP contract,,80,,28.32,percent of total billed charges,,,,,,,no IP contract,,50,,17.7,percent of total billed charges,,,,,,no IP contract,,,78,,27.61,percent of total billed charges,,,70,,24.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.35,3324,
45802-0203-26 - acetaminophen 160 mg/5 mL Susp,45802-0203-26,NDC,,,,inpatient,5,ML,35.4,21.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.09,percent of total billed charges,,,85,,30.09,percent of total billed charges,,,49,,17.35,percent of total billed charges,,,90,,31.86,percent of total billed charges,,,,,,,no IP contract,,80,,28.32,percent of total billed charges,,,,,,,no IP contract,,50,,17.7,percent of total billed charges,,,,,,no IP contract,,,78,,27.61,percent of total billed charges,,,70,,24.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.35,3324,
45802-0216-96 - benzoyl peroxide topical 5% Gel,45802-0216-96,NDC,,,,inpatient,1,UN,179.15,107.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,145.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,152.28,percent of total billed charges,,,85,,152.28,percent of total billed charges,,,49,,87.78,percent of total billed charges,,,90,,161.24,percent of total billed charges,,,,,,,no IP contract,,80,,143.32,percent of total billed charges,,,,,,,no IP contract,,50,,89.58,percent of total billed charges,,,,,,no IP contract,,,78,,139.74,percent of total billed charges,,,70,,125.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,87.78,3324,
45802-0222-11 - fluticasone topical 0.05% Cream,45802-0222-11,NDC,,,,inpatient,1,UN,294.1,176.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,238.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,249.99,percent of total billed charges,,,85,,249.99,percent of total billed charges,,,49,,144.11,percent of total billed charges,,,90,,264.69,percent of total billed charges,,,,,,,no IP contract,,80,,235.28,percent of total billed charges,,,,,,,no IP contract,,50,,147.05,percent of total billed charges,,,,,,no IP contract,,,78,,229.4,percent of total billed charges,,,70,,205.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,144.11,3324,
45802-0276-03 - hydrocortisone topical 1% Ointm,45802-0276-03,NDC,,,,inpatient,1,UN,39.55,23.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.62,percent of total billed charges,,,85,,33.62,percent of total billed charges,,,49,,19.38,percent of total billed charges,,,90,,35.6,percent of total billed charges,,,,,,,no IP contract,,80,,31.64,percent of total billed charges,,,,,,,no IP contract,,50,,19.78,percent of total billed charges,,,,,,no IP contract,,,78,,30.85,percent of total billed charges,,,70,,27.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.38,3324,
45802-0303-67 - predniSONE 10 mg Tab,45802-0303-67,NDC,,,,inpatient,1,EA,6.05,3.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.14,percent of total billed charges,,,85,,5.14,percent of total billed charges,,,49,,2.96,percent of total billed charges,,,90,,5.45,percent of total billed charges,,,,,,,no IP contract,,80,,4.84,percent of total billed charges,,,,,,,no IP contract,,50,,3.03,percent of total billed charges,,,,,,no IP contract,,,78,,4.72,percent of total billed charges,,,70,,4.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.96,3324,
45802-0308-96 - benzoyl peroxide topical 10% Gel,45802-0308-96,NDC,,,,inpatient,1,UN,184.15,110.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,149.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,156.53,percent of total billed charges,,,85,,156.53,percent of total billed charges,,,49,,90.23,percent of total billed charges,,,90,,165.74,percent of total billed charges,,,,,,,no IP contract,,80,,147.32,percent of total billed charges,,,,,,,no IP contract,,50,,92.08,percent of total billed charges,,,,,,no IP contract,,,78,,143.64,percent of total billed charges,,,70,,128.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,90.23,3324,
45802-0358-03 - diphenhydrAMINE-zinc acetate topical 2%-0.1% Cream,45802-0358-03,NDC,,,,inpatient,1,UN,41.9,25.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,35.62,percent of total billed charges,,,85,,35.62,percent of total billed charges,,,49,,20.53,percent of total billed charges,,,90,,37.71,percent of total billed charges,,,,,,,no IP contract,,80,,33.52,percent of total billed charges,,,,,,,no IP contract,,50,,20.95,percent of total billed charges,,,,,,no IP contract,,,78,,32.68,percent of total billed charges,,,70,,29.33,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.53,3324,
45802-0422-37 - desonide topical 0.05% Cream,45802-0422-37,NDC,,,,inpatient,1,UN,2683.15,1609.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2173.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2280.68,percent of total billed charges,,,85,,2280.68,percent of total billed charges,,,49,,1314.74,percent of total billed charges,,,90,,2414.84,percent of total billed charges,,,,,,,no IP contract,,80,,2146.52,percent of total billed charges,,,,,,,no IP contract,,50,,1341.58,percent of total billed charges,,,,,,no IP contract,,,78,,2092.86,percent of total billed charges,,,70,,1878.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
45802-0425-78 - fexofenadine 60 mg Tab,45802-0425-78,NDC,,,,inpatient,1,EA,9.55,5.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.12,percent of total billed charges,,,85,,8.12,percent of total billed charges,,,49,,4.68,percent of total billed charges,,,90,,8.6,percent of total billed charges,,,,,,,no IP contract,,80,,7.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.78,percent of total billed charges,,,,,,no IP contract,,,78,,7.45,percent of total billed charges,,,70,,6.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.68,3324,
45802-0432-62 - pseudoephedrine 30 mg Tab,45802-0432-62,NDC,,,,inpatient,1,EA,4.6,2.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.91,percent of total billed charges,,,85,,3.91,percent of total billed charges,,,49,,2.25,percent of total billed charges,,,90,,4.14,percent of total billed charges,,,,,,,no IP contract,,80,,3.68,percent of total billed charges,,,,,,,no IP contract,,50,,2.3,percent of total billed charges,,,,,,no IP contract,,,78,,3.59,percent of total billed charges,,,70,,3.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.25,3324,
45802-0433-21 - dextromethorphan 30 mg/5 mL ER Su,45802-0433-21,NDC,,,,inpatient,5,ML,72.9,43.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,59.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,61.97,percent of total billed charges,,,85,,61.97,percent of total billed charges,,,49,,35.72,percent of total billed charges,,,90,,65.61,percent of total billed charges,,,,,,,no IP contract,,80,,58.32,percent of total billed charges,,,,,,,no IP contract,,50,,36.45,percent of total billed charges,,,,,,no IP contract,,,78,,56.86,percent of total billed charges,,,70,,51.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,35.72,3324,
45802-0438-03 - hydrocortisone topical 1% Cream,45802-0438-03,NDC,,,,inpatient,1,UN,44.2,26.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,35.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,37.57,percent of total billed charges,,,85,,37.57,percent of total billed charges,,,49,,21.66,percent of total billed charges,,,90,,39.78,percent of total billed charges,,,,,,,no IP contract,,80,,35.36,percent of total billed charges,,,,,,,no IP contract,,50,,22.1,percent of total billed charges,,,,,,no IP contract,,,78,,34.48,percent of total billed charges,,,70,,30.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.66,3324,
45802-0465-64 - ketoconazole topical 2% Shamp,45802-0465-64,NDC,,,,inpatient,1,UN,239.15,143.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,193.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,203.28,percent of total billed charges,,,85,,203.28,percent of total billed charges,,,49,,117.18,percent of total billed charges,,,90,,215.24,percent of total billed charges,,,,,,,no IP contract,,80,,191.32,percent of total billed charges,,,,,,,no IP contract,,50,,119.58,percent of total billed charges,,,,,,no IP contract,,,78,,186.54,percent of total billed charges,,,70,,167.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,117.18,3324,
45802-0466-11 - econazole topical 1% Cream,45802-0466-11,NDC,,,,inpatient,1,UN,299.1,179.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,242.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,254.24,percent of total billed charges,,,85,,254.24,percent of total billed charges,,,49,,146.56,percent of total billed charges,,,90,,269.19,percent of total billed charges,,,,,,,no IP contract,,80,,239.28,percent of total billed charges,,,,,,,no IP contract,,50,,149.55,percent of total billed charges,,,,,,no IP contract,,,78,,233.3,percent of total billed charges,,,70,,209.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,146.56,3324,
45802-0495-37 - desoximetasone topical 0.25% Cream,45802-0495-37,NDC,,,,inpatient,1,UN,1668.55,1001.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1351.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1418.27,percent of total billed charges,,,85,,1418.27,percent of total billed charges,,,49,,817.59,percent of total billed charges,,,90,,1501.7,percent of total billed charges,,,,,,,no IP contract,,80,,1334.84,percent of total billed charges,,,,,,,no IP contract,,50,,834.28,percent of total billed charges,,,,,,no IP contract,,,78,,1301.47,percent of total billed charges,,,70,,1167.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,817.59,3324,
45802-0562-02 - clindamycin topical 1% Soln,45802-0562-02,NDC,,,,inpatient,1,UN,489.05,293.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,396.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,415.69,percent of total billed charges,,,85,,415.69,percent of total billed charges,,,49,,239.63,percent of total billed charges,,,90,,440.15,percent of total billed charges,,,,,,,no IP contract,,80,,391.24,percent of total billed charges,,,,,,,no IP contract,,50,,244.53,percent of total billed charges,,,,,,no IP contract,,,78,,381.46,percent of total billed charges,,,70,,342.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,239.63,3324,
45802-0571-78 - fexofenadine 180 mg Tab,45802-0571-78,NDC,,,,inpatient,1,EA,7.15,4.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.08,percent of total billed charges,,,85,,6.08,percent of total billed charges,,,49,,3.5,percent of total billed charges,,,90,,6.44,percent of total billed charges,,,,,,,no IP contract,,80,,5.72,percent of total billed charges,,,,,,,no IP contract,,50,,3.58,percent of total billed charges,,,,,,no IP contract,,,78,,5.58,percent of total billed charges,,,70,,5.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.5,3324,
45802-0626-26 - cetirizine 1 mg/mL Syrup,45802-0626-26,NDC,,,,inpatient,1,ML,7.9,4.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.72,percent of total billed charges,,,85,,6.72,percent of total billed charges,,,49,,3.87,percent of total billed charges,,,90,,7.11,percent of total billed charges,,,,,,,no IP contract,,80,,6.32,percent of total billed charges,,,,,,,no IP contract,,50,,3.95,percent of total billed charges,,,,,,no IP contract,,,78,,6.16,percent of total billed charges,,,70,,5.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.87,3324,
45802-0700-01 - tacrolimus topical 0.1% Ointm,45802-0700-01,NDC,,,,inpatient,1,UN,2090.9,1254.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1693.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1777.27,percent of total billed charges,,,85,,1777.27,percent of total billed charges,,,49,,1024.54,percent of total billed charges,,,90,,1881.81,percent of total billed charges,,,,,,,no IP contract,,80,,1672.72,percent of total billed charges,,,,,,,no IP contract,,50,,1045.45,percent of total billed charges,,,,,,no IP contract,,,78,,1630.9,percent of total billed charges,,,70,,1463.63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
45802-0717-08 - terconazole topical 80 mg Supp,45802-0717-08,NDC,,,,inpatient,1,UN,392.8,235.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,318.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,333.88,percent of total billed charges,,,85,,333.88,percent of total billed charges,,,49,,192.47,percent of total billed charges,,,90,,353.52,percent of total billed charges,,,,,,,no IP contract,,80,,314.24,percent of total billed charges,,,,,,,no IP contract,,50,,196.4,percent of total billed charges,,,,,,no IP contract,,,78,,306.38,percent of total billed charges,,,70,,274.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,192.47,3324,
45802-0730-30 - acetaminophen 650 mg Supp,45802-0730-30,NDC,,,,inpatient,1,UN,9.15,5.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.78,percent of total billed charges,,,85,,7.78,percent of total billed charges,,,49,,4.48,percent of total billed charges,,,90,,8.24,percent of total billed charges,,,,,,,no IP contract,,80,,7.32,percent of total billed charges,,,,,,,no IP contract,,50,,4.58,percent of total billed charges,,,,,,no IP contract,,,78,,7.14,percent of total billed charges,,,70,,6.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.48,3324,
45802-0732-30 - acetaminophen 120 mg Supp,45802-0732-30,NDC,,,,inpatient,1,UN,8.45,5.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.18,percent of total billed charges,,,85,,7.18,percent of total billed charges,,,49,,4.14,percent of total billed charges,,,90,,7.61,percent of total billed charges,,,,,,,no IP contract,,80,,6.76,percent of total billed charges,,,,,,,no IP contract,,50,,4.23,percent of total billed charges,,,,,,no IP contract,,,78,,6.59,percent of total billed charges,,,70,,5.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.14,3324,
45802-0880-94 - nystatin-triamcinolone topical 100000 units/g-0.1% Cream,45802-0880-94,NDC,,,,inpatient,1,UN,316.6,189.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,256.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,269.11,percent of total billed charges,,,85,,269.11,percent of total billed charges,,,49,,155.13,percent of total billed charges,,,90,,284.94,percent of total billed charges,,,,,,,no IP contract,,80,,253.28,percent of total billed charges,,,,,,,no IP contract,,50,,158.3,percent of total billed charges,,,,,,no IP contract,,,78,,246.95,percent of total billed charges,,,70,,221.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,155.13,3324,
45802-0953-01 - diclofenac topical 1% Gel,45802-0953-01,NDC,,,,inpatient,1,EA,134.15,80.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,108.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,114.03,percent of total billed charges,,,85,,114.03,percent of total billed charges,,,49,,65.73,percent of total billed charges,,,90,,120.74,percent of total billed charges,,,,,,,no IP contract,,80,,107.32,percent of total billed charges,,,,,,,no IP contract,,50,,67.08,percent of total billed charges,,,,,,no IP contract,,,78,,104.64,percent of total billed charges,,,70,,93.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,65.73,3324,
45802-0980-64 - hydroquinone topical 4% Cream,45802-0980-64,NDC,,,,inpatient,1,EA,62.2,37.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,50.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,52.87,percent of total billed charges,,,85,,52.87,percent of total billed charges,,,49,,30.48,percent of total billed charges,,,90,,55.98,percent of total billed charges,,,,,,,no IP contract,,80,,49.76,percent of total billed charges,,,,,,,no IP contract,,50,,31.1,percent of total billed charges,,,,,,no IP contract,,,78,,48.52,percent of total billed charges,,,70,,43.54,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,30.48,3324,
baclofen 1 mg/mL Soln,45945-0156-02,NDC,,,,inpatient,1,EA,1336.45,801.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1082.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1135.98,percent of total billed charges,,,85,,1135.98,percent of total billed charges,,,49,,654.86,percent of total billed charges,,,90,,1202.81,percent of total billed charges,,,,,,,no IP contract,,80,,1069.16,percent of total billed charges,,,,,,,no IP contract,,50,,668.23,percent of total billed charges,,,,,,no IP contract,,,78,,1042.43,percent of total billed charges,,,70,,935.52,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,654.86,3324,
baclofen 2 mg/mL Soln,45945-0157-02,NDC,,,,inpatient,1,EA,2672.9,1603.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2165.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2271.97,percent of total billed charges,,,85,,2271.97,percent of total billed charges,,,49,,1309.72,percent of total billed charges,,,90,,2405.61,percent of total billed charges,,,,,,,no IP contract,,80,,2138.32,percent of total billed charges,,,,,,,no IP contract,,50,,1336.45,percent of total billed charges,,,,,,no IP contract,,,78,,2084.86,percent of total billed charges,,,70,,1871.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
45963-0341-02 - desipramine 10 mg Tab,45963-0341-02,NDC,,,,inpatient,1,EA,13.2,7.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.22,percent of total billed charges,,,85,,11.22,percent of total billed charges,,,49,,6.47,percent of total billed charges,,,90,,11.88,percent of total billed charges,,,,,,,no IP contract,,80,,10.56,percent of total billed charges,,,,,,,no IP contract,,50,,6.6,percent of total billed charges,,,,,,no IP contract,,,78,,10.3,percent of total billed charges,,,70,,9.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.47,3324,
45963-0342-02 - desipramine 25 mg Tab,45963-0342-02,NDC,,,,inpatient,1,EA,15.1,9.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.84,percent of total billed charges,,,85,,12.84,percent of total billed charges,,,49,,7.4,percent of total billed charges,,,90,,13.59,percent of total billed charges,,,,,,,no IP contract,,80,,12.08,percent of total billed charges,,,,,,,no IP contract,,50,,7.55,percent of total billed charges,,,,,,no IP contract,,,78,,11.78,percent of total billed charges,,,70,,10.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.4,3324,
45963-0556-11 - gabapentin 300 mg Cap,45963-0556-11,NDC,,,,inpatient,1,EA,14.4,8.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.24,percent of total billed charges,,,85,,12.24,percent of total billed charges,,,49,,7.06,percent of total billed charges,,,90,,12.96,percent of total billed charges,,,,,,,no IP contract,,80,,11.52,percent of total billed charges,,,,,,,no IP contract,,50,,7.2,percent of total billed charges,,,,,,no IP contract,,,78,,11.23,percent of total billed charges,,,70,,10.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.06,3324,
45963-0557-11 - gabapentin 400 mg Cap,45963-0557-11,NDC,,,,inpatient,1,EA,16.55,9.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.07,percent of total billed charges,,,85,,14.07,percent of total billed charges,,,49,,8.11,percent of total billed charges,,,90,,14.9,percent of total billed charges,,,,,,,no IP contract,,80,,13.24,percent of total billed charges,,,,,,,no IP contract,,50,,8.28,percent of total billed charges,,,,,,no IP contract,,,78,,12.91,percent of total billed charges,,,70,,11.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.11,3324,
46017-0018-16 - caffeine 200 mg Tab,46017-0018-16,NDC,,,,inpatient,1,EA,5.75,3.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.89,percent of total billed charges,,,85,,4.89,percent of total billed charges,,,49,,2.82,percent of total billed charges,,,90,,5.18,percent of total billed charges,,,,,,,no IP contract,,80,,4.6,percent of total billed charges,,,,,,,no IP contract,,50,,2.88,percent of total billed charges,,,,,,no IP contract,,,78,,4.49,percent of total billed charges,,,70,,4.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.82,3324,
46017-0018-40 - caffeine 200 mg Tab,46017-0018-40,NDC,,,,inpatient,1,EA,5.65,3.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.8,percent of total billed charges,,,85,,4.8,percent of total billed charges,,,49,,2.77,percent of total billed charges,,,90,,5.09,percent of total billed charges,,,,,,,no IP contract,,80,,4.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.83,percent of total billed charges,,,,,,no IP contract,,,78,,4.41,percent of total billed charges,,,70,,3.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.77,3324,
46122-0078-72 - calcium-vitamin D 600 mg-20 mcg Tab,46122-0078-72,NDC,,,,inpatient,1,EA,4.85,2.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.12,percent of total billed charges,,,85,,4.12,percent of total billed charges,,,49,,2.38,percent of total billed charges,,,90,,4.37,percent of total billed charges,,,,,,,no IP contract,,80,,3.88,percent of total billed charges,,,,,,,no IP contract,,50,,2.43,percent of total billed charges,,,,,,no IP contract,,,78,,3.78,percent of total billed charges,,,70,,3.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.38,3324,
46122-0108-46 - permethrin topical 1% Lotio,46122-0108-46,NDC,,,,inpatient,1,UN,97.7,58.62,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,79.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,83.05,percent of total billed charges,,,85,,83.05,percent of total billed charges,,,49,,47.87,percent of total billed charges,,,90,,87.93,percent of total billed charges,,,,,,,no IP contract,,80,,78.16,percent of total billed charges,,,,,,,no IP contract,,50,,48.85,percent of total billed charges,,,,,,no IP contract,,,78,,76.21,percent of total billed charges,,,70,,68.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,47.87,3324,
46122-0211-26 - acetaminophen 160 mg/5 mL Susp,46122-0211-26,NDC,,,,inpatient,5,ML,45.4,27.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,38.59,percent of total billed charges,,,85,,38.59,percent of total billed charges,,,49,,22.25,percent of total billed charges,,,90,,40.86,percent of total billed charges,,,,,,,no IP contract,,80,,36.32,percent of total billed charges,,,,,,,no IP contract,,50,,22.7,percent of total billed charges,,,,,,no IP contract,,,78,,35.41,percent of total billed charges,,,70,,31.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.25,3324,
46122-0390-78 - acetaminophen 325 mg Tab,46122-0390-78,NDC,,,,inpatient,1,EA,3.9,2.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.32,percent of total billed charges,,,85,,3.32,percent of total billed charges,,,49,,1.91,percent of total billed charges,,,90,,3.51,percent of total billed charges,,,,,,,no IP contract,,80,,3.12,percent of total billed charges,,,,,,,no IP contract,,50,,1.95,percent of total billed charges,,,,,,no IP contract,,,78,,3.04,percent of total billed charges,,,70,,2.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.91,3324,
46122-0414-03 - bacitracin/neomycin/poly B [Triple Antibiotic] 400 units-3.5 mg-5000 uni Ointment,46122-0414-03,NDC,,,,inpatient,1,UN,21.7,13.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.45,percent of total billed charges,,,85,,18.45,percent of total billed charges,,,49,,10.63,percent of total billed charges,,,90,,19.53,percent of total billed charges,,,,,,,no IP contract,,80,,17.36,percent of total billed charges,,,,,,,no IP contract,,50,,10.85,percent of total billed charges,,,,,,no IP contract,,,78,,16.93,percent of total billed charges,,,70,,15.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.63,3324,
46122-0450-21 - lidocaine 4% topical 4% Film,46122-0450-21,NDC,,,,inpatient,1,UN,22.2,13.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.87,percent of total billed charges,,,85,,18.87,percent of total billed charges,,,49,,10.88,percent of total billed charges,,,90,,19.98,percent of total billed charges,,,,,,,no IP contract,,80,,17.76,percent of total billed charges,,,,,,,no IP contract,,50,,11.1,percent of total billed charges,,,,,,no IP contract,,,78,,17.32,percent of total billed charges,,,70,,15.54,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.88,3324,
46122-0557-05 - carbamide peroxide otic 6.5% Soln,46122-0557-05,NDC,,,,inpatient,5,UN,34.2,20.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.07,percent of total billed charges,,,85,,29.07,percent of total billed charges,,,49,,16.76,percent of total billed charges,,,90,,30.78,percent of total billed charges,,,,,,,no IP contract,,80,,27.36,percent of total billed charges,,,,,,,no IP contract,,50,,17.1,percent of total billed charges,,,,,,no IP contract,,,78,,26.68,percent of total billed charges,,,70,,23.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.76,3324,
46122-0575-78 - senna 8.6 mg Tab,46122-0575-78,NDC,,,,inpatient,1,EA,4.4,2.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.74,percent of total billed charges,,,85,,3.74,percent of total billed charges,,,49,,2.16,percent of total billed charges,,,90,,3.96,percent of total billed charges,,,,,,,no IP contract,,80,,3.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.2,percent of total billed charges,,,,,,no IP contract,,,78,,3.43,percent of total billed charges,,,70,,3.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.16,3324,
46122-0596-02 - aspirin 325 mg EC Tablet,46122-0596-02,NDC,,,,inpatient,1,EA,3.9,2.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.32,percent of total billed charges,,,85,,3.32,percent of total billed charges,,,49,,1.91,percent of total billed charges,,,90,,3.51,percent of total billed charges,,,,,,,no IP contract,,80,,3.12,percent of total billed charges,,,,,,,no IP contract,,50,,1.95,percent of total billed charges,,,,,,no IP contract,,,78,,3.04,percent of total billed charges,,,70,,2.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.91,3324,
46122-0672-64 - olopatadine 0.1% Soln,46122-0672-64,NDC,,,,inpatient,1,UN,78.35,47.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,63.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,66.6,percent of total billed charges,,,85,,66.6,percent of total billed charges,,,49,,38.39,percent of total billed charges,,,90,,70.52,percent of total billed charges,,,,,,,no IP contract,,80,,62.68,percent of total billed charges,,,,,,,no IP contract,,50,,39.18,percent of total billed charges,,,,,,no IP contract,,,78,,61.11,percent of total billed charges,,,70,,54.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,38.39,3324,
46287-0006-60 - sodium polystyrene sulfonate 15 g/60 mL Susp,46287-0006-60,NDC,,,,inpatient,60,ML,100.4,60.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,81.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,85.34,percent of total billed charges,,,85,,85.34,percent of total billed charges,,,49,,49.2,percent of total billed charges,,,90,,90.36,percent of total billed charges,,,,,,,no IP contract,,80,,80.32,percent of total billed charges,,,,,,,no IP contract,,50,,50.2,percent of total billed charges,,,,,,no IP contract,,,78,,78.31,percent of total billed charges,,,70,,70.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,49.2,3324,
46287-0009-01 - isoniazid 50 mg/5 mL Syrup,46287-0009-01,NDC,,,,inpatient,1,ML,8.5,5.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.23,percent of total billed charges,,,85,,7.23,percent of total billed charges,,,49,,4.17,percent of total billed charges,,,90,,7.65,percent of total billed charges,,,,,,,no IP contract,,80,,6.8,percent of total billed charges,,,,,,,no IP contract,,50,,4.25,percent of total billed charges,,,,,,no IP contract,,,78,,6.63,percent of total billed charges,,,70,,5.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.17,3324,
46287-0020-04 - spironolactone 25 mg/5 mL Susp,46287-0020-04,NDC,,,,inpatient,1,ML,28.35,17.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.1,percent of total billed charges,,,85,,24.1,percent of total billed charges,,,49,,13.89,percent of total billed charges,,,90,,25.52,percent of total billed charges,,,,,,,no IP contract,,80,,22.68,percent of total billed charges,,,,,,,no IP contract,,50,,14.18,percent of total billed charges,,,,,,no IP contract,,,78,,22.11,percent of total billed charges,,,70,,19.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.89,3324,
amLODIPine 1 mg/mL LIQ,46287-0035-15,NDC,,,,inpatient,1,mL,39.75,23.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.79,percent of total billed charges,,,85,,33.79,percent of total billed charges,,,49,,19.48,percent of total billed charges,,,90,,35.78,percent of total billed charges,,,,,,,no IP contract,,80,,31.8,percent of total billed charges,,,,,,,no IP contract,,50,,19.88,percent of total billed charges,,,,,,no IP contract,,,78,,31.01,percent of total billed charges,,,70,,27.83,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.48,3324,
47335-0063-86 - dofetilide 500 mcg Cap,47335-0063-86,NDC,,,,inpatient,1,EA,71.9,43.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,58.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,61.12,percent of total billed charges,,,85,,61.12,percent of total billed charges,,,49,,35.23,percent of total billed charges,,,90,,64.71,percent of total billed charges,,,,,,,no IP contract,,80,,57.52,percent of total billed charges,,,,,,,no IP contract,,50,,35.95,percent of total billed charges,,,,,,no IP contract,,,78,,56.08,percent of total billed charges,,,70,,50.33,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,35.23,3324,
47335-0171-49 - tobramycin 60 mg/mL Soln,47335-0171-49,NDC,,,,inpatient,5,ML,1081.7,649.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,876.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,919.45,percent of total billed charges,,,85,,919.45,percent of total billed charges,,,49,,530.03,percent of total billed charges,,,90,,973.53,percent of total billed charges,,,,,,,no IP contract,,80,,865.36,percent of total billed charges,,,,,,,no IP contract,,50,,540.85,percent of total billed charges,,,,,,no IP contract,,,78,,843.73,percent of total billed charges,,,70,,757.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,530.03,3324,
47335-0187-88 - carbidopa-levodopa 25 mg-100 mg DIS T,47335-0187-88,NDC,,,,inpatient,1,EA,14.8,8.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.58,percent of total billed charges,,,85,,12.58,percent of total billed charges,,,49,,7.25,percent of total billed charges,,,90,,13.32,percent of total billed charges,,,,,,,no IP contract,,80,,11.84,percent of total billed charges,,,,,,,no IP contract,,50,,7.4,percent of total billed charges,,,,,,no IP contract,,,78,,11.54,percent of total billed charges,,,70,,10.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.25,3324,
47335-0220-90 - ketorolac ophthalmic 0.5% Soln,47335-0220-90,NDC,,,,inpatient,1,UN,894.7,536.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,724.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,760.5,percent of total billed charges,,,85,,760.5,percent of total billed charges,,,49,,438.4,percent of total billed charges,,,90,,805.23,percent of total billed charges,,,,,,,no IP contract,,80,,715.76,percent of total billed charges,,,,,,,no IP contract,,50,,447.35,percent of total billed charges,,,,,,no IP contract,,,78,,697.87,percent of total billed charges,,,70,,626.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,438.4,3324,
47335-0290-44 - caffeine citrate 20 mg/mL LIQ,47335-0290-44,NDC,,,,inpatient,1,ML,122.05,73.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,98.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,103.74,percent of total billed charges,,,85,,103.74,percent of total billed charges,,,49,,59.8,percent of total billed charges,,,90,,109.85,percent of total billed charges,,,,,,,no IP contract,,80,,97.64,percent of total billed charges,,,,,,,no IP contract,,50,,61.03,percent of total billed charges,,,,,,no IP contract,,,78,,95.2,percent of total billed charges,,,70,,85.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,59.8,3324,
47335-0307-88 - zolpidem 6.25 mg ER Ta,47335-0307-88,NDC,,,,inpatient,1,EA,56.4,33.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,45.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,47.94,percent of total billed charges,,,85,,47.94,percent of total billed charges,,,49,,27.64,percent of total billed charges,,,90,,50.76,percent of total billed charges,,,,,,,no IP contract,,80,,45.12,percent of total billed charges,,,,,,,no IP contract,,50,,28.2,percent of total billed charges,,,,,,no IP contract,,,78,,43.99,percent of total billed charges,,,70,,39.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.64,3324,
47335-0381-86 - DULoxetine 20 mg DR Ca,47335-0381-86,NDC,,,,inpatient,1,EA,59.4,35.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,48.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,50.49,percent of total billed charges,,,85,,50.49,percent of total billed charges,,,49,,29.11,percent of total billed charges,,,90,,53.46,percent of total billed charges,,,,,,,no IP contract,,80,,47.52,percent of total billed charges,,,,,,,no IP contract,,50,,29.7,percent of total billed charges,,,,,,no IP contract,,,78,,46.33,percent of total billed charges,,,70,,41.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,29.11,3324,
47335-0382-81 - DULoxetine 30 mg DR Ca,47335-0382-81,NDC,,,,inpatient,1,EA,66.05,39.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,53.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.14,percent of total billed charges,,,85,,56.14,percent of total billed charges,,,49,,32.36,percent of total billed charges,,,90,,59.45,percent of total billed charges,,,,,,,no IP contract,,80,,52.84,percent of total billed charges,,,,,,,no IP contract,,50,,33.03,percent of total billed charges,,,,,,no IP contract,,,78,,51.52,percent of total billed charges,,,70,,46.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.36,3324,
47335-0485-83 - bicalutamide 50 mg Tab,47335-0485-83,NDC,,,,inpatient,1,EA,151.15,90.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,122.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,128.48,percent of total billed charges,,,85,,128.48,percent of total billed charges,,,49,,74.06,percent of total billed charges,,,90,,136.04,percent of total billed charges,,,,,,,no IP contract,,80,,120.92,percent of total billed charges,,,,,,,no IP contract,,50,,75.58,percent of total billed charges,,,,,,no IP contract,,,78,,117.9,percent of total billed charges,,,70,,105.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,74.06,3324,
47335-0539-81 - niacin 500 mg ER Ta,47335-0539-81,NDC,,,,inpatient,1,EA,37.45,22.47,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.83,percent of total billed charges,,,85,,31.83,percent of total billed charges,,,49,,18.35,percent of total billed charges,,,90,,33.71,percent of total billed charges,,,,,,,no IP contract,,80,,29.96,percent of total billed charges,,,,,,,no IP contract,,50,,18.73,percent of total billed charges,,,,,,no IP contract,,,78,,29.21,percent of total billed charges,,,70,,26.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.35,3324,
47335-0613-81 - niacin 1000 mg ER Ta,47335-0613-81,NDC,,,,inpatient,1,EA,63.35,38.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,51.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,53.85,percent of total billed charges,,,85,,53.85,percent of total billed charges,,,49,,31.04,percent of total billed charges,,,90,,57.02,percent of total billed charges,,,,,,,no IP contract,,80,,50.68,percent of total billed charges,,,,,,,no IP contract,,50,,31.68,percent of total billed charges,,,,,,no IP contract,,,78,,49.41,percent of total billed charges,,,70,,44.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.04,3324,
budesonide 0.25 mg/2 mL Susp,47335-0631-49,NDC,,,,inpatient,1,EA,37.55,22.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.92,percent of total billed charges,,,85,,31.92,percent of total billed charges,,,49,,18.4,percent of total billed charges,,,90,,33.8,percent of total billed charges,,,,,,,no IP contract,,80,,30.04,percent of total billed charges,,,,,,,no IP contract,,50,,18.78,percent of total billed charges,,,,,,no IP contract,,,78,,29.29,percent of total billed charges,,,70,,26.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.4,3324,
47335-0679-81 - diltiazem 360 mg/24 hours ER Ca,47335-0679-81,NDC,,,,inpatient,1,EA,81.95,49.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,66.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,69.66,percent of total billed charges,,,85,,69.66,percent of total billed charges,,,49,,40.16,percent of total billed charges,,,90,,73.76,percent of total billed charges,,,,,,,no IP contract,,80,,65.56,percent of total billed charges,,,,,,,no IP contract,,50,,40.98,percent of total billed charges,,,,,,no IP contract,,,78,,63.92,percent of total billed charges,,,70,,57.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,40.16,3324,
47335-0779-91 - azelastine nasal 137 mcg/inh Spray,47335-0779-91,NDC,,,,inpatient,1,UN,886.35,531.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,717.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,753.4,percent of total billed charges,,,85,,753.4,percent of total billed charges,,,49,,434.31,percent of total billed charges,,,90,,797.72,percent of total billed charges,,,,,,,no IP contract,,80,,709.08,percent of total billed charges,,,,,,,no IP contract,,50,,443.18,percent of total billed charges,,,,,,no IP contract,,,78,,691.35,percent of total billed charges,,,70,,620.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,434.31,3324,
47335-0788-91 - desmopressin 10 mcg/inh Spray,47335-0788-91,NDC,,,,inpatient,1,UN,2060.5,1236.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1669.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1751.43,percent of total billed charges,,,85,,1751.43,percent of total billed charges,,,49,,1009.65,percent of total billed charges,,,90,,1854.45,percent of total billed charges,,,,,,,no IP contract,,80,,1648.4,percent of total billed charges,,,,,,,no IP contract,,50,,1030.25,percent of total billed charges,,,,,,no IP contract,,,78,,1607.19,percent of total billed charges,,,70,,1442.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
47335-0837-83 - galantamine 24 mg ER Ca,47335-0837-83,NDC,,,,inpatient,1,EA,54.4,32.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,44.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,46.24,percent of total billed charges,,,85,,46.24,percent of total billed charges,,,49,,26.66,percent of total billed charges,,,90,,48.96,percent of total billed charges,,,,,,,no IP contract,,80,,43.52,percent of total billed charges,,,,,,,no IP contract,,50,,27.2,percent of total billed charges,,,,,,no IP contract,,,78,,42.43,percent of total billed charges,,,70,,38.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.66,3324,
47335-0938-90 - azelastine ophthalmic 0.05% Soln,47335-0938-90,NDC,,,,inpatient,1,UN,866.4,519.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,701.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,736.44,percent of total billed charges,,,85,,736.44,percent of total billed charges,,,49,,424.54,percent of total billed charges,,,90,,779.76,percent of total billed charges,,,,,,,no IP contract,,80,,693.12,percent of total billed charges,,,,,,,no IP contract,,50,,433.2,percent of total billed charges,,,,,,no IP contract,,,78,,675.79,percent of total billed charges,,,70,,606.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,424.54,3324,
47469-0003-12 - alpha-lipoic acid 300 mg Cap,47469-0003-12,NDC,,,,inpatient,1,EA,5.25,3.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.46,percent of total billed charges,,,85,,4.46,percent of total billed charges,,,49,,2.57,percent of total billed charges,,,90,,4.73,percent of total billed charges,,,,,,,no IP contract,,80,,4.2,percent of total billed charges,,,,,,,no IP contract,,50,,2.63,percent of total billed charges,,,,,,no IP contract,,,78,,4.1,percent of total billed charges,,,70,,3.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.57,3324,
47469-0004-57 - melatonin 0.25 mg/mL LIQ,47469-0004-57,NDC,,,,inpatient,1,ML,6.15,3.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.23,percent of total billed charges,,,85,,5.23,percent of total billed charges,,,49,,3.01,percent of total billed charges,,,90,,5.54,percent of total billed charges,,,,,,,no IP contract,,80,,4.92,percent of total billed charges,,,,,,,no IP contract,,50,,3.08,percent of total billed charges,,,,,,no IP contract,,,78,,4.8,percent of total billed charges,,,70,,4.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.01,3324,
47469-0004-65 - melatonin 1 mg Tab,47469-0004-65,NDC,,,,inpatient,1,EA,4.2,2.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.57,percent of total billed charges,,,85,,3.57,percent of total billed charges,,,49,,2.06,percent of total billed charges,,,90,,3.78,percent of total billed charges,,,,,,,no IP contract,,80,,3.36,percent of total billed charges,,,,,,,no IP contract,,50,,2.1,percent of total billed charges,,,,,,no IP contract,,,78,,3.28,percent of total billed charges,,,70,,2.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.06,3324,
47781-0335-30 - pyridostigmine 180 mg ER Ta,47781-0335-30,NDC,,,,inpatient,1,EA,201.05,120.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,162.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,170.89,percent of total billed charges,,,85,,170.89,percent of total billed charges,,,49,,98.51,percent of total billed charges,,,90,,180.95,percent of total billed charges,,,,,,,no IP contract,,80,,160.84,percent of total billed charges,,,,,,,no IP contract,,50,,100.53,percent of total billed charges,,,,,,no IP contract,,,78,,156.82,percent of total billed charges,,,70,,140.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,98.51,3324,
47781-0423-47 - fentaNYL 12 mcg/hr ER Fi,47781-0423-47,NDC,,,,inpatient,1,UN,174.5,104.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,141.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,148.33,percent of total billed charges,,,85,,148.33,percent of total billed charges,,,49,,85.51,percent of total billed charges,,,90,,157.05,percent of total billed charges,,,,,,,no IP contract,,80,,139.6,percent of total billed charges,,,,,,,no IP contract,,50,,87.25,percent of total billed charges,,,,,,no IP contract,,,78,,136.11,percent of total billed charges,,,70,,122.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,85.51,3324,
fentaNYL 25 mcg/hr ER Fi,47781-0424-47,NDC,,,,inpatient,1,EA,182.6,109.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,147.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,155.21,percent of total billed charges,,,85,,155.21,percent of total billed charges,,,49,,89.47,percent of total billed charges,,,90,,164.34,percent of total billed charges,,,,,,,no IP contract,,80,,146.08,percent of total billed charges,,,,,,,no IP contract,,50,,91.3,percent of total billed charges,,,,,,no IP contract,,,78,,142.43,percent of total billed charges,,,70,,127.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,89.47,3324,
fentaNYL 100 mcg/hr ER Fi,47781-0428-47,NDC,,,,inpatient,1,EA,661.1,396.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,535.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,561.94,percent of total billed charges,,,85,,561.94,percent of total billed charges,,,49,,323.94,percent of total billed charges,,,90,,594.99,percent of total billed charges,,,,,,,no IP contract,,80,,528.88,percent of total billed charges,,,,,,,no IP contract,,50,,330.55,percent of total billed charges,,,,,,no IP contract,,,78,,515.66,percent of total billed charges,,,70,,462.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,323.94,3324,
47781-0683-30 - rasagiline 0.5 mg Tab,47781-0683-30,NDC,,,,inpatient,1,EA,243.75,146.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,197.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,207.19,percent of total billed charges,,,85,,207.19,percent of total billed charges,,,49,,119.44,percent of total billed charges,,,90,,219.38,percent of total billed charges,,,,,,,no IP contract,,80,,195,percent of total billed charges,,,,,,,no IP contract,,50,,121.88,percent of total billed charges,,,,,,no IP contract,,,78,,190.13,percent of total billed charges,,,70,,170.63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,119.44,3324,
48102-0005-35 - bacitracin/HC/neomycin/polymyxin B ophthalmic 400 units-10 mg-3.5 mg-10000 units/g O,48102-0005-35,NDC,,,,inpatient,1,UN,508.95,305.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,412.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,432.61,percent of total billed charges,,,85,,432.61,percent of total billed charges,,,49,,249.39,percent of total billed charges,,,90,,458.06,percent of total billed charges,,,,,,,no IP contract,,80,,407.16,percent of total billed charges,,,,,,,no IP contract,,50,,254.48,percent of total billed charges,,,,,,no IP contract,,,78,,396.98,percent of total billed charges,,,70,,356.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,249.39,3324,
48102-0045-01 - dexamethasone 0.5 mg Tab,48102-0045-01,NDC,,,,inpatient,1,EA,4.95,2.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.21,percent of total billed charges,,,85,,4.21,percent of total billed charges,,,49,,2.43,percent of total billed charges,,,90,,4.46,percent of total billed charges,,,,,,,no IP contract,,80,,3.96,percent of total billed charges,,,,,,,no IP contract,,50,,2.48,percent of total billed charges,,,,,,no IP contract,,,78,,3.86,percent of total billed charges,,,70,,3.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.43,3324,
48102-0047-01 - dexamethasone 4 mg Tab,48102-0047-01,NDC,,,,inpatient,1,EA,13.3,7.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.31,percent of total billed charges,,,85,,11.31,percent of total billed charges,,,49,,6.52,percent of total billed charges,,,90,,11.97,percent of total billed charges,,,,,,,no IP contract,,80,,10.64,percent of total billed charges,,,,,,,no IP contract,,50,,6.65,percent of total billed charges,,,,,,no IP contract,,,78,,10.37,percent of total billed charges,,,70,,9.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.52,3324,
"48433-0104-01 - cholecalciferol (D3) 1,000 unit(s) Tab",48433-0104-01,NDC,,,,inpatient,1,EA,5,3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.25,percent of total billed charges,,,85,,4.25,percent of total billed charges,,,49,,2.45,percent of total billed charges,,,90,,4.5,percent of total billed charges,,,,,,,no IP contract,,80,,4,percent of total billed charges,,,,,,,no IP contract,,50,,2.5,percent of total billed charges,,,,,,no IP contract,,,78,,3.9,percent of total billed charges,,,70,,3.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.45,3324,
48433-0108-01 - thiamine 100 mg Tab,48433-0108-01,NDC,,,,inpatient,1,EA,5.1,3.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.34,percent of total billed charges,,,85,,4.34,percent of total billed charges,,,49,,2.5,percent of total billed charges,,,90,,4.59,percent of total billed charges,,,,,,,no IP contract,,80,,4.08,percent of total billed charges,,,,,,,no IP contract,,50,,2.55,percent of total billed charges,,,,,,no IP contract,,,78,,3.98,percent of total billed charges,,,70,,3.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.5,3324,
48433-0202-30 - mineral oil 100% LIQ,48433-0202-30,NDC,,,,inpatient,30,ML,12.9,7.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.97,percent of total billed charges,,,85,,10.97,percent of total billed charges,,,49,,6.32,percent of total billed charges,,,90,,11.61,percent of total billed charges,,,,,,,no IP contract,,80,,10.32,percent of total billed charges,,,,,,,no IP contract,,50,,6.45,percent of total billed charges,,,,,,no IP contract,,,78,,10.06,percent of total billed charges,,,70,,9.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.32,3324,
48433-0215-01 - sodium chloride 23.4% Soln,48433-0215-01,NDC,,,,inpatient,1,ML,6.6,3.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.61,percent of total billed charges,,,85,,5.61,percent of total billed charges,,,49,,3.23,percent of total billed charges,,,90,,5.94,percent of total billed charges,,,,,,,no IP contract,,80,,5.28,percent of total billed charges,,,,,,,no IP contract,,50,,3.3,percent of total billed charges,,,,,,no IP contract,,,78,,5.15,percent of total billed charges,,,70,,4.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.23,3324,
48582-0003-30 - saliva substitutes - Soln,48582-0003-30,NDC,,,,inpatient,15,ML,28.95,17.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.61,percent of total billed charges,,,85,,24.61,percent of total billed charges,,,49,,14.19,percent of total billed charges,,,90,,26.06,percent of total billed charges,,,,,,,no IP contract,,80,,23.16,percent of total billed charges,,,,,,,no IP contract,,50,,14.48,percent of total billed charges,,,,,,no IP contract,,,78,,22.58,percent of total billed charges,,,70,,20.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.19,3324,
49100-0400-07 - lactobacillus rhamnosus GG - Cap,49100-0400-07,NDC,,,,inpatient,1,EA,9.7,5.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.25,percent of total billed charges,,,85,,8.25,percent of total billed charges,,,49,,4.75,percent of total billed charges,,,90,,8.73,percent of total billed charges,,,,,,,no IP contract,,80,,7.76,percent of total billed charges,,,,,,,no IP contract,,50,,4.85,percent of total billed charges,,,,,,no IP contract,,,78,,7.57,percent of total billed charges,,,70,,6.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.75,3324,
49100-0400-09 - lactobacillus rhamnosus GG - Cap,49100-0400-09,NDC,,,,inpatient,1,EA,8.2,4.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.97,percent of total billed charges,,,85,,6.97,percent of total billed charges,,,49,,4.02,percent of total billed charges,,,90,,7.38,percent of total billed charges,,,,,,,no IP contract,,80,,6.56,percent of total billed charges,,,,,,,no IP contract,,50,,4.1,percent of total billed charges,,,,,,no IP contract,,,78,,6.4,percent of total billed charges,,,70,,5.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.02,3324,
"influenza virus vaccine, inactivated high-dose preservative-free trivalent Susp",49281-0124-65,NDC,,,,inpatient,1,EA,750.2,450.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,607.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,637.67,percent of total billed charges,,,85,,637.67,percent of total billed charges,,,49,,367.6,percent of total billed charges,,,90,,675.18,percent of total billed charges,,,,,,,no IP contract,,80,,600.16,percent of total billed charges,,,,,,,no IP contract,,50,,375.1,percent of total billed charges,,,,,,no IP contract,,,78,,585.16,percent of total billed charges,,,70,,525.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,367.6,3324,
49281-0225-10 - diphtheria-tetanus toxoids (DT) ped pediatric Susp,49281-0225-10,NDC,,,,inpatient,0.5,ML,638.35,383.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,517.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,542.6,percent of total billed charges,,,85,,542.6,percent of total billed charges,,,49,,312.79,percent of total billed charges,,,90,,574.52,percent of total billed charges,,,,,,,no IP contract,,80,,510.68,percent of total billed charges,,,,,,,no IP contract,,50,,319.18,percent of total billed charges,,,,,,no IP contract,,,78,,497.91,percent of total billed charges,,,70,,446.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,312.79,3324,
49281-0286-10 - diphtheria/tetanus/pertussis (DTaP) ped 15 units-5 units-23 mcg/0.5 mL Susp,49281-0286-10,NDC,,,,inpatient,0.5,ML,292.95,175.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,237.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,249.01,percent of total billed charges,,,85,,249.01,percent of total billed charges,,,49,,143.55,percent of total billed charges,,,90,,263.66,percent of total billed charges,,,,,,,no IP contract,,80,,234.36,percent of total billed charges,,,,,,,no IP contract,,50,,146.48,percent of total billed charges,,,,,,no IP contract,,,78,,228.5,percent of total billed charges,,,70,,205.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,143.55,3324,
49281-0400-10 - tetanus/diphth/pertuss (Tdap) adult/adol 5 units-2 units-15.5 mcg/0.5 mL Susp,49281-0400-10,NDC,,,,inpatient,0.5,ML,470,282,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,380.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,399.5,percent of total billed charges,,,85,,399.5,percent of total billed charges,,,49,,230.3,percent of total billed charges,,,90,,423,percent of total billed charges,,,,,,,no IP contract,,80,,376,percent of total billed charges,,,,,,,no IP contract,,50,,235,percent of total billed charges,,,,,,no IP contract,,,78,,366.6,percent of total billed charges,,,70,,329,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,230.3,3324,
49281-0400-15 - tetanus/diphth/pertuss (Tdap) adult/adol 5 units-2 units-15.5 mcg/0.5 mL Susp,49281-0400-15,NDC,,,,inpatient,0.5,ML,488.25,292.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,395.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,415.01,percent of total billed charges,,,85,,415.01,percent of total billed charges,,,49,,239.24,percent of total billed charges,,,90,,439.43,percent of total billed charges,,,,,,,no IP contract,,80,,390.6,percent of total billed charges,,,,,,,no IP contract,,50,,244.13,percent of total billed charges,,,,,,no IP contract,,,78,,380.84,percent of total billed charges,,,70,,341.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,239.24,3324,
49281-0590-05 - meningococcal conjugate vaccine polysaccharide tetanus toxoid group ACYW Soln,49281-0590-05,NDC,,,,inpatient,0.5,ML,1512.4,907.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1225.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1285.54,percent of total billed charges,,,85,,1285.54,percent of total billed charges,,,49,,741.08,percent of total billed charges,,,90,,1361.16,percent of total billed charges,,,,,,,no IP contract,,80,,1209.92,percent of total billed charges,,,,,,,no IP contract,,50,,756.2,percent of total billed charges,,,,,,no IP contract,,,78,,1179.67,percent of total billed charges,,,70,,1058.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,741.08,3324,
49281-0752-21 - tuberculin purified protein derivative 5 tuberculin units/0.1 mL Soln,49281-0752-21,NDC,,,,inpatient,0.1,ML,58.85,35.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,47.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,50.02,percent of total billed charges,,,85,,50.02,percent of total billed charges,,,49,,28.84,percent of total billed charges,,,90,,52.97,percent of total billed charges,,,,,,,no IP contract,,80,,47.08,percent of total billed charges,,,,,,,no IP contract,,50,,29.43,percent of total billed charges,,,,,,no IP contract,,,78,,45.9,percent of total billed charges,,,70,,41.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,28.84,3324,
49281-0752-22 - tuberculin purified protein derivative 5 tuberculin units/0.1 mL Soln,49281-0752-22,NDC,,,,inpatient,0.1,ML,35,21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.75,percent of total billed charges,,,85,,29.75,percent of total billed charges,,,49,,17.15,percent of total billed charges,,,90,,31.5,percent of total billed charges,,,,,,,no IP contract,,80,,28,percent of total billed charges,,,,,,,no IP contract,,50,,17.5,percent of total billed charges,,,,,,no IP contract,,,78,,27.3,percent of total billed charges,,,70,,24.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.15,3324,
"poliovirus vaccine, inactivated - Susp",49281-0860-10,NDC,,,,inpatient,1,EA,248,148.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,200.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,210.8,percent of total billed charges,,,85,,210.8,percent of total billed charges,,,49,,121.52,percent of total billed charges,,,90,,223.2,percent of total billed charges,,,,,,,no IP contract,,80,,198.4,percent of total billed charges,,,,,,,no IP contract,,50,,124,percent of total billed charges,,,,,,no IP contract,,,78,,193.44,percent of total billed charges,,,70,,173.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,121.52,3324,
"poliovirus vaccine, inactivated - Susp",49281-0860-52,NDC,,,,inpatient,1,EA,274.8,164.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,222.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,233.58,percent of total billed charges,,,85,,233.58,percent of total billed charges,,,49,,134.65,percent of total billed charges,,,90,,247.32,percent of total billed charges,,,,,,,no IP contract,,80,,219.84,percent of total billed charges,,,,,,,no IP contract,,50,,137.4,percent of total billed charges,,,,,,no IP contract,,,78,,214.34,percent of total billed charges,,,70,,192.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,134.65,3324,
49502-0101-02 - EPINEPHrine 0.15 mg Kit,49502-0101-02,NDC,,,,inpatient,1,EA,1589.95,953.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1287.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1351.46,percent of total billed charges,,,85,,1351.46,percent of total billed charges,,,49,,779.08,percent of total billed charges,,,90,,1430.96,percent of total billed charges,,,,,,,no IP contract,,80,,1271.96,percent of total billed charges,,,,,,,no IP contract,,50,,794.98,percent of total billed charges,,,,,,no IP contract,,,78,,1240.16,percent of total billed charges,,,70,,1112.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,779.08,3324,
49502-0102-02 - EPINEPHrine 0.3 mg Kit,49502-0102-02,NDC,,,,inpatient,1,EA,1589.95,953.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1287.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1351.46,percent of total billed charges,,,85,,1351.46,percent of total billed charges,,,49,,779.08,percent of total billed charges,,,90,,1430.96,percent of total billed charges,,,,,,,no IP contract,,80,,1271.96,percent of total billed charges,,,,,,,no IP contract,,50,,794.98,percent of total billed charges,,,,,,no IP contract,,,78,,1240.16,percent of total billed charges,,,70,,1112.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,779.08,3324,
49502-0501-02 - epinephrine 0.15 mg Kit,49502-0501-02,NDC,,,,inpatient,1,EA,700.35,420.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,567.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,595.3,percent of total billed charges,,,85,,595.3,percent of total billed charges,,,49,,343.17,percent of total billed charges,,,90,,630.32,percent of total billed charges,,,,,,,no IP contract,,80,,560.28,percent of total billed charges,,,,,,,no IP contract,,50,,350.18,percent of total billed charges,,,,,,no IP contract,,,78,,546.27,percent of total billed charges,,,70,,490.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,343.17,3324,
49702-0205-48 - lamivudine 10 mg Soln,49702-0205-48,NDC,,,,inpatient,1,ML,9.65,5.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.2,percent of total billed charges,,,85,,8.2,percent of total billed charges,,,49,,4.73,percent of total billed charges,,,90,,8.69,percent of total billed charges,,,,,,,no IP contract,,80,,7.72,percent of total billed charges,,,,,,,no IP contract,,50,,4.83,percent of total billed charges,,,,,,no IP contract,,,78,,7.53,percent of total billed charges,,,70,,6.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.73,3324,
49702-0216-18 - Maraviroc 300 mg Tab,49702-0216-18,NDC,,,,inpatient,1,EA,152.8,91.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,123.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,129.88,percent of total billed charges,,,85,,129.88,percent of total billed charges,,,49,,74.87,percent of total billed charges,,,90,,137.52,percent of total billed charges,,,,,,,no IP contract,,80,,122.24,percent of total billed charges,,,,,,,no IP contract,,50,,76.4,percent of total billed charges,,,,,,no IP contract,,,78,,119.18,percent of total billed charges,,,70,,106.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,74.87,3324,
49702-0224-18 - maraviroc 300 mg Tab,49702-0224-18,NDC,,,,inpatient,1,EA,171.25,102.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,138.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,145.56,percent of total billed charges,,,85,,145.56,percent of total billed charges,,,49,,83.91,percent of total billed charges,,,90,,154.13,percent of total billed charges,,,,,,,no IP contract,,80,,137,percent of total billed charges,,,,,,,no IP contract,,50,,85.63,percent of total billed charges,,,,,,no IP contract,,,78,,133.58,percent of total billed charges,,,70,,119.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,83.91,3324,
49702-0228-13 - dolutegravir 50 mg Tab,49702-0228-13,NDC,,,,inpatient,1,EA,447.75,268.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,362.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,380.59,percent of total billed charges,,,85,,380.59,percent of total billed charges,,,49,,219.4,percent of total billed charges,,,90,,402.98,percent of total billed charges,,,,,,,no IP contract,,80,,358.2,percent of total billed charges,,,,,,,no IP contract,,50,,223.88,percent of total billed charges,,,,,,no IP contract,,,78,,349.25,percent of total billed charges,,,70,,313.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,219.4,3324,
49708-0644-90 - theophylline 200 mg Elixir,49708-0644-90,NDC,,,,inpatient,1,ML,7,4.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.95,percent of total billed charges,,,85,,5.95,percent of total billed charges,,,49,,3.43,percent of total billed charges,,,90,,6.3,percent of total billed charges,,,,,,,no IP contract,,80,,5.6,percent of total billed charges,,,,,,,no IP contract,,50,,3.5,percent of total billed charges,,,,,,no IP contract,,,78,,5.46,percent of total billed charges,,,70,,4.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.43,3324,
49884-0009-01 - isosorbide dinitrate 30 mg Tab,49884-0009-01,NDC,,,,inpatient,1,EA,8.05,4.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.84,percent of total billed charges,,,85,,6.84,percent of total billed charges,,,49,,3.94,percent of total billed charges,,,90,,7.25,percent of total billed charges,,,,,,,no IP contract,,80,,6.44,percent of total billed charges,,,,,,,no IP contract,,50,,4.03,percent of total billed charges,,,,,,no IP contract,,,78,,6.28,percent of total billed charges,,,70,,5.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.94,3324,
49884-0048-01 - dexmethylphenidate 5 mg ER Ca,49884-0048-01,NDC,,,,inpatient,1,EA,70.4,42.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,57.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,59.84,percent of total billed charges,,,85,,59.84,percent of total billed charges,,,49,,34.5,percent of total billed charges,,,90,,63.36,percent of total billed charges,,,,,,,no IP contract,,80,,56.32,percent of total billed charges,,,,,,,no IP contract,,50,,35.2,percent of total billed charges,,,,,,no IP contract,,,78,,54.91,percent of total billed charges,,,70,,49.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,34.5,3324,
49884-0054-01 - imipramine 10 mg Tab,49884-0054-01,NDC,,,,inpatient,1,EA,7.25,4.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.16,percent of total billed charges,,,85,,6.16,percent of total billed charges,,,49,,3.55,percent of total billed charges,,,90,,6.53,percent of total billed charges,,,,,,,no IP contract,,80,,5.8,percent of total billed charges,,,,,,,no IP contract,,50,,3.63,percent of total billed charges,,,,,,no IP contract,,,78,,5.66,percent of total billed charges,,,70,,5.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.55,3324,
49884-0056-01 - imipramine 50 mg Tab,49884-0056-01,NDC,,,,inpatient,1,EA,13.5,8.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.48,percent of total billed charges,,,85,,11.48,percent of total billed charges,,,49,,6.62,percent of total billed charges,,,90,,12.15,percent of total billed charges,,,,,,,no IP contract,,80,,10.8,percent of total billed charges,,,,,,,no IP contract,,50,,6.75,percent of total billed charges,,,,,,no IP contract,,,78,,10.53,percent of total billed charges,,,70,,9.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.62,3324,
glycopyrrolate 1 mg Tab,49884-0065-01,NDC,,,,inpatient,1,EA,14.25,8.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.11,percent of total billed charges,,,85,,12.11,percent of total billed charges,,,49,,6.98,percent of total billed charges,,,90,,12.83,percent of total billed charges,,,,,,,no IP contract,,80,,11.4,percent of total billed charges,,,,,,,no IP contract,,50,,7.13,percent of total billed charges,,,,,,no IP contract,,,78,,11.12,percent of total billed charges,,,70,,9.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.98,3324,
49884-0156-76 - varenicline 1 mg Tab,49884-0156-76,NDC,,,,inpatient,1,EA,73.7,44.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,59.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,62.65,percent of total billed charges,,,85,,62.65,percent of total billed charges,,,49,,36.11,percent of total billed charges,,,90,,66.33,percent of total billed charges,,,,,,,no IP contract,,80,,58.96,percent of total billed charges,,,,,,,no IP contract,,50,,36.85,percent of total billed charges,,,,,,no IP contract,,,78,,57.49,percent of total billed charges,,,70,,51.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.11,3324,
49884-0161-11 - calcitonin 200 intl units/inh Spray,49884-0161-11,NDC,,,,inpatient,1,UN,996.75,598.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,807.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,847.24,percent of total billed charges,,,85,,847.24,percent of total billed charges,,,49,,488.41,percent of total billed charges,,,90,,897.08,percent of total billed charges,,,,,,,no IP contract,,80,,797.4,percent of total billed charges,,,,,,,no IP contract,,50,,498.38,percent of total billed charges,,,,,,no IP contract,,,78,,777.47,percent of total billed charges,,,70,,697.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,488.41,3324,
49884-0165-01 - benztropine 1 mg Tab,49884-0165-01,NDC,,,,inpatient,1,EA,5.55,3.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.72,percent of total billed charges,,,85,,4.72,percent of total billed charges,,,49,,2.72,percent of total billed charges,,,90,,5,percent of total billed charges,,,,,,,no IP contract,,80,,4.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.78,percent of total billed charges,,,,,,no IP contract,,,78,,4.33,percent of total billed charges,,,70,,3.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.72,3324,
49884-0256-01 - minoxidil 2.5 mg Tab,49884-0256-01,NDC,,,,inpatient,1,EA,10.05,6.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.54,percent of total billed charges,,,85,,8.54,percent of total billed charges,,,49,,4.92,percent of total billed charges,,,90,,9.05,percent of total billed charges,,,,,,,no IP contract,,80,,8.04,percent of total billed charges,,,,,,,no IP contract,,50,,5.03,percent of total billed charges,,,,,,no IP contract,,,78,,7.84,percent of total billed charges,,,70,,7.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.92,3324,
49884-0257-01 - minoxidil 10 mg Tab,49884-0257-01,NDC,,,,inpatient,1,EA,17.25,10.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.66,percent of total billed charges,,,85,,14.66,percent of total billed charges,,,49,,8.45,percent of total billed charges,,,90,,15.53,percent of total billed charges,,,,,,,no IP contract,,80,,13.8,percent of total billed charges,,,,,,,no IP contract,,50,,8.63,percent of total billed charges,,,,,,no IP contract,,,78,,13.46,percent of total billed charges,,,70,,12.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.45,3324,
49884-0290-04 - megestrol 40 mg Tab,49884-0290-04,NDC,,,,inpatient,1,EA,12.4,7.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.54,percent of total billed charges,,,85,,10.54,percent of total billed charges,,,49,,6.08,percent of total billed charges,,,90,,11.16,percent of total billed charges,,,,,,,no IP contract,,80,,9.92,percent of total billed charges,,,,,,,no IP contract,,50,,6.2,percent of total billed charges,,,,,,no IP contract,,,78,,9.67,percent of total billed charges,,,70,,8.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.08,3324,
49884-0306-02 - clonazePAM 0.125 mg DIS T,49884-0306-02,NDC,,,,inpatient,1,EA,14.15,8.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.03,percent of total billed charges,,,85,,12.03,percent of total billed charges,,,49,,6.93,percent of total billed charges,,,90,,12.74,percent of total billed charges,,,,,,,no IP contract,,80,,11.32,percent of total billed charges,,,,,,,no IP contract,,50,,7.08,percent of total billed charges,,,,,,no IP contract,,,78,,11.04,percent of total billed charges,,,70,,9.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.93,3324,
49884-0306-52 - clonazePAM 0.125 mg DIS T,49884-0306-52,NDC,,,,inpatient,1,EA,14.15,8.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.03,percent of total billed charges,,,85,,12.03,percent of total billed charges,,,49,,6.93,percent of total billed charges,,,90,,12.74,percent of total billed charges,,,,,,,no IP contract,,80,,11.32,percent of total billed charges,,,,,,,no IP contract,,50,,7.08,percent of total billed charges,,,,,,no IP contract,,,78,,11.04,percent of total billed charges,,,70,,9.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.93,3324,
49884-0307-02 - clonazePAM 0.25 mg DIS T,49884-0307-02,NDC,,,,inpatient,1,EA,14.15,8.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.03,percent of total billed charges,,,85,,12.03,percent of total billed charges,,,49,,6.93,percent of total billed charges,,,90,,12.74,percent of total billed charges,,,,,,,no IP contract,,80,,11.32,percent of total billed charges,,,,,,,no IP contract,,50,,7.08,percent of total billed charges,,,,,,no IP contract,,,78,,11.04,percent of total billed charges,,,70,,9.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.93,3324,
clonazePAM 0.5 mg DIS T,49884-0308-02,NDC,,,,inpatient,1,EA,16.25,9.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.81,percent of total billed charges,,,85,,13.81,percent of total billed charges,,,49,,7.96,percent of total billed charges,,,90,,14.63,percent of total billed charges,,,,,,,no IP contract,,80,,13,percent of total billed charges,,,,,,,no IP contract,,50,,8.13,percent of total billed charges,,,,,,no IP contract,,,78,,12.68,percent of total billed charges,,,70,,11.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.96,3324,
49884-0309-02 - clonazePAM 1 mg DIS T,49884-0309-02,NDC,,,,inpatient,1,EA,15.6,9.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.26,percent of total billed charges,,,85,,13.26,percent of total billed charges,,,49,,7.64,percent of total billed charges,,,90,,14.04,percent of total billed charges,,,,,,,no IP contract,,80,,12.48,percent of total billed charges,,,,,,,no IP contract,,50,,7.8,percent of total billed charges,,,,,,no IP contract,,,78,,12.17,percent of total billed charges,,,70,,10.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.64,3324,
49884-0321-55 - OLANZapine 10 mg DIS T,49884-0321-55,NDC,,,,inpatient,1,EA,170.55,102.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,138.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,144.97,percent of total billed charges,,,85,,144.97,percent of total billed charges,,,49,,83.57,percent of total billed charges,,,90,,153.5,percent of total billed charges,,,,,,,no IP contract,,80,,136.44,percent of total billed charges,,,,,,,no IP contract,,50,,85.28,percent of total billed charges,,,,,,no IP contract,,,78,,133.03,percent of total billed charges,,,70,,119.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,83.57,3324,
49884-0362-01 - dantrolene 25 mg Cap,49884-0362-01,NDC,,,,inpatient,1,EA,11.45,6.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.73,percent of total billed charges,,,85,,9.73,percent of total billed charges,,,49,,5.61,percent of total billed charges,,,90,,10.31,percent of total billed charges,,,,,,,no IP contract,,80,,9.16,percent of total billed charges,,,,,,,no IP contract,,50,,5.73,percent of total billed charges,,,,,,no IP contract,,,78,,8.93,percent of total billed charges,,,70,,8.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.61,3324,
49884-0363-01 - dantrolene 50 mg Cap,49884-0363-01,NDC,,,,inpatient,1,EA,16.25,9.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.81,percent of total billed charges,,,85,,13.81,percent of total billed charges,,,49,,7.96,percent of total billed charges,,,90,,14.63,percent of total billed charges,,,,,,,no IP contract,,80,,13,percent of total billed charges,,,,,,,no IP contract,,50,,8.13,percent of total billed charges,,,,,,no IP contract,,,78,,12.68,percent of total billed charges,,,70,,11.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.96,3324,
49884-0364-01 - dantrolene 100 mg Cap,49884-0364-01,NDC,,,,inpatient,1,EA,19.35,11.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.45,percent of total billed charges,,,85,,16.45,percent of total billed charges,,,49,,9.48,percent of total billed charges,,,90,,17.42,percent of total billed charges,,,,,,,no IP contract,,80,,15.48,percent of total billed charges,,,,,,,no IP contract,,50,,9.68,percent of total billed charges,,,,,,no IP contract,,,78,,15.09,percent of total billed charges,,,70,,13.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.48,3324,
49884-0465-65 - cholestyramine 4 g/9 g REC P,49884-0465-65,NDC,,,,inpatient,1,UN,30.6,18.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.01,percent of total billed charges,,,85,,26.01,percent of total billed charges,,,49,,14.99,percent of total billed charges,,,90,,27.54,percent of total billed charges,,,,,,,no IP contract,,80,,24.48,percent of total billed charges,,,,,,,no IP contract,,50,,15.3,percent of total billed charges,,,,,,no IP contract,,,78,,23.87,percent of total billed charges,,,70,,21.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.99,3324,
49884-0510-72 - testosterone 50 mg/5 g (1%) Gel,49884-0510-72,NDC,,,,inpatient,1,UN,130.35,78.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,105.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,110.8,percent of total billed charges,,,85,,110.8,percent of total billed charges,,,49,,63.87,percent of total billed charges,,,90,,117.32,percent of total billed charges,,,,,,,no IP contract,,80,,104.28,percent of total billed charges,,,,,,,no IP contract,,50,,65.18,percent of total billed charges,,,,,,no IP contract,,,78,,101.67,percent of total billed charges,,,70,,91.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,63.87,3324,
49884-0641-01 - methimazole 10 mg Tab,49884-0641-01,NDC,,,,inpatient,1,EA,9.95,5.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.46,percent of total billed charges,,,85,,8.46,percent of total billed charges,,,49,,4.88,percent of total billed charges,,,90,,8.96,percent of total billed charges,,,,,,,no IP contract,,80,,7.96,percent of total billed charges,,,,,,,no IP contract,,50,,4.98,percent of total billed charges,,,,,,no IP contract,,,78,,7.76,percent of total billed charges,,,70,,6.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.88,3324,
49884-0659-09 - candesartan 8 mg Tab,49884-0659-09,NDC,,,,inpatient,1,EA,29.05,17.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.69,percent of total billed charges,,,85,,24.69,percent of total billed charges,,,49,,14.23,percent of total billed charges,,,90,,26.15,percent of total billed charges,,,,,,,no IP contract,,80,,23.24,percent of total billed charges,,,,,,,no IP contract,,50,,14.53,percent of total billed charges,,,,,,no IP contract,,,78,,22.66,percent of total billed charges,,,70,,20.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.23,3324,
49884-0661-09 - candesartan 32 mg Tab,49884-0661-09,NDC,,,,inpatient,1,EA,38,22.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.3,percent of total billed charges,,,85,,32.3,percent of total billed charges,,,49,,18.62,percent of total billed charges,,,90,,34.2,percent of total billed charges,,,,,,,no IP contract,,80,,30.4,percent of total billed charges,,,,,,,no IP contract,,50,,19,percent of total billed charges,,,,,,no IP contract,,,78,,29.64,percent of total billed charges,,,70,,26.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.62,3324,
49884-0673-14 - cabergoline 0.5 mg Tab,49884-0673-14,NDC,,,,inpatient,1,EA,278.95,167.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,225.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,237.11,percent of total billed charges,,,85,,237.11,percent of total billed charges,,,49,,136.69,percent of total billed charges,,,90,,251.06,percent of total billed charges,,,,,,,no IP contract,,80,,223.16,percent of total billed charges,,,,,,,no IP contract,,50,,139.48,percent of total billed charges,,,,,,no IP contract,,,78,,217.58,percent of total billed charges,,,70,,195.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,136.69,3324,
49884-0793-01 - captopril 12.5 mg Tab,49884-0793-01,NDC,,,,inpatient,1,EA,16.4,9.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.94,percent of total billed charges,,,85,,13.94,percent of total billed charges,,,49,,8.04,percent of total billed charges,,,90,,14.76,percent of total billed charges,,,,,,,no IP contract,,80,,13.12,percent of total billed charges,,,,,,,no IP contract,,50,,8.2,percent of total billed charges,,,,,,no IP contract,,,78,,12.79,percent of total billed charges,,,70,,11.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.04,3324,
49884-0793-01 - captopril 12.5 mg Tab,49884-0793-01,NDC,,,,inpatient,1,EA,16.4,9.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.94,percent of total billed charges,,,85,,13.94,percent of total billed charges,,,49,,8.04,percent of total billed charges,,,90,,14.76,percent of total billed charges,,,,,,,no IP contract,,80,,13.12,percent of total billed charges,,,,,,,no IP contract,,50,,8.2,percent of total billed charges,,,,,,no IP contract,,,78,,12.79,percent of total billed charges,,,70,,11.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.04,3324,
49884-0799-33 - tetracycline 125 mg/5 mL Susp,49884-0799-33,NDC,,,,inpatient,5,ML,7.15,4.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.08,percent of total billed charges,,,85,,6.08,percent of total billed charges,,,49,,3.5,percent of total billed charges,,,90,,6.44,percent of total billed charges,,,,,,,no IP contract,,80,,5.72,percent of total billed charges,,,,,,,no IP contract,,50,,3.58,percent of total billed charges,,,,,,no IP contract,,,78,,5.58,percent of total billed charges,,,70,,5.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.5,3324,
49884-0849-01 - midodrine 5 mg Tab,49884-0849-01,NDC,,,,inpatient,1,EA,23.05,13.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.59,percent of total billed charges,,,85,,19.59,percent of total billed charges,,,49,,11.29,percent of total billed charges,,,90,,20.75,percent of total billed charges,,,,,,,no IP contract,,80,,18.44,percent of total billed charges,,,,,,,no IP contract,,50,,11.53,percent of total billed charges,,,,,,no IP contract,,,78,,17.98,percent of total billed charges,,,70,,16.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.29,3324,
49884-0868-02 - dronabinol 5 mg Cap,49884-0868-02,NDC,,,,inpatient,1,EA,6135.05,3681.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4969.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5214.79,percent of total billed charges,,,85,,5214.79,percent of total billed charges,,,49,,3006.17,percent of total billed charges,,,90,,5521.55,percent of total billed charges,,,,,,,no IP contract,,80,,4908.04,percent of total billed charges,,,,,,,no IP contract,,50,,3067.53,percent of total billed charges,,,,,,no IP contract,,,78,,4785.34,percent of total billed charges,,,70,,4294.54,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,5521.55,
49884-0874-01 - midodrine 10 mg Tab,49884-0874-01,NDC,,,,inpatient,1,EA,42.3,25.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,35.96,percent of total billed charges,,,85,,35.96,percent of total billed charges,,,49,,20.73,percent of total billed charges,,,90,,38.07,percent of total billed charges,,,,,,,no IP contract,,80,,33.84,percent of total billed charges,,,,,,,no IP contract,,50,,21.15,percent of total billed charges,,,,,,no IP contract,,,78,,32.99,percent of total billed charges,,,70,,29.61,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.73,3324,
49938-0101-01 - dapsone 100 mg Tab,49938-0101-01,NDC,,,,inpatient,1,EA,5.5,3.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.68,percent of total billed charges,,,85,,4.68,percent of total billed charges,,,49,,2.7,percent of total billed charges,,,90,,4.95,percent of total billed charges,,,,,,,no IP contract,,80,,4.4,percent of total billed charges,,,,,,,no IP contract,,50,,2.75,percent of total billed charges,,,,,,no IP contract,,,78,,4.29,percent of total billed charges,,,70,,3.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.7,3324,
49938-0101-30 - dapsone 100 mg Tab,49938-0101-30,NDC,,,,inpatient,1,EA,326.85,196.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,264.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,277.82,percent of total billed charges,,,85,,277.82,percent of total billed charges,,,49,,160.16,percent of total billed charges,,,90,,294.17,percent of total billed charges,,,,,,,no IP contract,,80,,261.48,percent of total billed charges,,,,,,,no IP contract,,50,,163.43,percent of total billed charges,,,,,,no IP contract,,,78,,254.94,percent of total billed charges,,,70,,228.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,160.16,3324,
49938-0102-30 - dapsone 25 mg Tab,49938-0102-30,NDC,,,,inpatient,1,EA,12.55,7.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.67,percent of total billed charges,,,85,,10.67,percent of total billed charges,,,49,,6.15,percent of total billed charges,,,90,,11.3,percent of total billed charges,,,,,,,no IP contract,,80,,10.04,percent of total billed charges,,,,,,,no IP contract,,50,,6.28,percent of total billed charges,,,,,,no IP contract,,,78,,9.79,percent of total billed charges,,,70,,8.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.15,3324,
sodium hyaluronate 10 mg/mL Soln,50016-0957-11,NDC,,,,inpatient,1,EA,4576.8,2746.08,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3707.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3890.28,percent of total billed charges,,,85,,3890.28,percent of total billed charges,,,49,,2242.63,percent of total billed charges,,,90,,4119.12,percent of total billed charges,,,,,,,no IP contract,,80,,3661.44,percent of total billed charges,,,,,,,no IP contract,,50,,2288.4,percent of total billed charges,,,,,,no IP contract,,,78,,3569.9,percent of total billed charges,,,70,,3203.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4119.12,
sodium hyaluronate 10 mg/mL Soln,50016-0957-21,NDC,,,,inpatient,1,EA,386.35,231.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,312.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,328.4,percent of total billed charges,,,85,,328.4,percent of total billed charges,,,49,,189.31,percent of total billed charges,,,90,,347.72,percent of total billed charges,,,,,,,no IP contract,,80,,309.08,percent of total billed charges,,,,,,,no IP contract,,50,,193.18,percent of total billed charges,,,,,,no IP contract,,,78,,301.35,percent of total billed charges,,,70,,270.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,189.31,3324,
50111-0323-01 - bethanechol 5 mg Tab,50111-0323-01,NDC,,,,inpatient,1,EA,9.45,5.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.03,percent of total billed charges,,,85,,8.03,percent of total billed charges,,,49,,4.63,percent of total billed charges,,,90,,8.51,percent of total billed charges,,,,,,,no IP contract,,80,,7.56,percent of total billed charges,,,,,,,no IP contract,,50,,4.73,percent of total billed charges,,,,,,no IP contract,,,78,,7.37,percent of total billed charges,,,70,,6.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.63,3324,
50111-0333-01 - metroNIDAZOLE 250 mg Tab,50111-0333-01,NDC,,,,inpatient,1,EA,7.25,4.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.16,percent of total billed charges,,,85,,6.16,percent of total billed charges,,,49,,3.55,percent of total billed charges,,,90,,6.53,percent of total billed charges,,,,,,,no IP contract,,80,,5.8,percent of total billed charges,,,,,,,no IP contract,,50,,3.63,percent of total billed charges,,,,,,no IP contract,,,78,,5.66,percent of total billed charges,,,70,,5.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.55,3324,
50111-0467-01 - propranolol 10 mg Tab,50111-0467-01,NDC,,,,inpatient,1,EA,6.55,3.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.57,percent of total billed charges,,,85,,5.57,percent of total billed charges,,,49,,3.21,percent of total billed charges,,,90,,5.9,percent of total billed charges,,,,,,,no IP contract,,80,,5.24,percent of total billed charges,,,,,,,no IP contract,,50,,3.28,percent of total billed charges,,,,,,no IP contract,,,78,,5.11,percent of total billed charges,,,70,,4.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.21,3324,
50111-0482-01 - theophylline 200 mg ER Ta,50111-0482-01,NDC,,,,inpatient,1,EA,6.6,3.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.61,percent of total billed charges,,,85,,5.61,percent of total billed charges,,,49,,3.23,percent of total billed charges,,,90,,5.94,percent of total billed charges,,,,,,,no IP contract,,80,,5.28,percent of total billed charges,,,,,,,no IP contract,,50,,3.3,percent of total billed charges,,,,,,no IP contract,,,78,,5.15,percent of total billed charges,,,70,,4.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.23,3324,
50111-0482-01 - theophylline 200 mg ER Tab,50111-0482-01,NDC,,,,inpatient,1,EA,6.6,3.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.61,percent of total billed charges,,,85,,5.61,percent of total billed charges,,,49,,3.23,percent of total billed charges,,,90,,5.94,percent of total billed charges,,,,,,,no IP contract,,80,,5.28,percent of total billed charges,,,,,,,no IP contract,,50,,3.3,percent of total billed charges,,,,,,no IP contract,,,78,,5.15,percent of total billed charges,,,70,,4.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.23,3324,
50111-0560-01 - traZODone 50 mg Tab,50111-0560-01,NDC,,,,inpatient,1,EA,12.35,7.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.5,percent of total billed charges,,,85,,10.5,percent of total billed charges,,,49,,6.05,percent of total billed charges,,,90,,11.12,percent of total billed charges,,,,,,,no IP contract,,80,,9.88,percent of total billed charges,,,,,,,no IP contract,,50,,6.18,percent of total billed charges,,,,,,no IP contract,,,78,,9.63,percent of total billed charges,,,70,,8.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.05,3324,
50111-0648-01 - fluoxetine 20 mg Cap,50111-0648-01,NDC,,,,inpatient,1,EA,25.05,15.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.29,percent of total billed charges,,,85,,21.29,percent of total billed charges,,,49,,12.27,percent of total billed charges,,,90,,22.55,percent of total billed charges,,,,,,,no IP contract,,80,,20.04,percent of total billed charges,,,,,,,no IP contract,,50,,12.53,percent of total billed charges,,,,,,no IP contract,,,78,,19.54,percent of total billed charges,,,70,,17.54,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.27,3324,
50111-0787-66 - azithromycin 250 mg Tab,50111-0787-66,NDC,,,,inpatient,1,EA,17.25,10.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.66,percent of total billed charges,,,85,,14.66,percent of total billed charges,,,49,,8.45,percent of total billed charges,,,90,,15.53,percent of total billed charges,,,,,,,no IP contract,,80,,13.8,percent of total billed charges,,,,,,,no IP contract,,50,,8.63,percent of total billed charges,,,,,,no IP contract,,,78,,13.46,percent of total billed charges,,,70,,12.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.45,3324,
50111-0916-01 - torsemide 10 mg Tab,50111-0916-01,NDC,,,,inpatient,1,EA,9.4,5.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.99,percent of total billed charges,,,85,,7.99,percent of total billed charges,,,49,,4.61,percent of total billed charges,,,90,,8.46,percent of total billed charges,,,,,,,no IP contract,,80,,7.52,percent of total billed charges,,,,,,,no IP contract,,50,,4.7,percent of total billed charges,,,,,,no IP contract,,,78,,7.33,percent of total billed charges,,,70,,6.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.61,3324,
50111-0917-01 - torsemide 20 mg Tab,50111-0917-01,NDC,,,,inpatient,1,EA,10.35,6.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.8,percent of total billed charges,,,85,,8.8,percent of total billed charges,,,49,,5.07,percent of total billed charges,,,90,,9.32,percent of total billed charges,,,,,,,no IP contract,,80,,8.28,percent of total billed charges,,,,,,,no IP contract,,50,,5.18,percent of total billed charges,,,,,,no IP contract,,,78,,8.07,percent of total billed charges,,,70,,7.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.07,3324,
50228-0146-01 - hydroCHLOROthiazide 12.5 mg Cap,50228-0146-01,NDC,,,,inpatient,1,EA,7.15,4.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.08,percent of total billed charges,,,85,,6.08,percent of total billed charges,,,49,,3.5,percent of total billed charges,,,90,,6.44,percent of total billed charges,,,,,,,no IP contract,,80,,5.72,percent of total billed charges,,,,,,,no IP contract,,50,,3.58,percent of total billed charges,,,,,,no IP contract,,,78,,5.58,percent of total billed charges,,,70,,5.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.5,3324,
celecoxib 200 mg Cap,50228-0158-01,NDC,,,,inpatient,1,EA,64.1,38.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,51.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,54.49,percent of total billed charges,,,85,,54.49,percent of total billed charges,,,49,,31.41,percent of total billed charges,,,90,,57.69,percent of total billed charges,,,,,,,no IP contract,,80,,51.28,percent of total billed charges,,,,,,,no IP contract,,50,,32.05,percent of total billed charges,,,,,,no IP contract,,,78,,50,percent of total billed charges,,,70,,44.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.41,3324,
50228-0179-01 - gabapentin 100 mg Cap,50228-0179-01,NDC,,,,inpatient,1,EA,8.05,4.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.84,percent of total billed charges,,,85,,6.84,percent of total billed charges,,,49,,3.94,percent of total billed charges,,,90,,7.25,percent of total billed charges,,,,,,,no IP contract,,80,,6.44,percent of total billed charges,,,,,,,no IP contract,,50,,4.03,percent of total billed charges,,,,,,no IP contract,,,78,,6.28,percent of total billed charges,,,70,,5.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.94,3324,
50228-0181-01 - gabapentin 400 mg Cap,50228-0181-01,NDC,,,,inpatient,1,EA,4.6,2.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.91,percent of total billed charges,,,85,,3.91,percent of total billed charges,,,49,,2.25,percent of total billed charges,,,90,,4.14,percent of total billed charges,,,,,,,no IP contract,,80,,3.68,percent of total billed charges,,,,,,,no IP contract,,50,,2.3,percent of total billed charges,,,,,,no IP contract,,,78,,3.59,percent of total billed charges,,,70,,3.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.25,3324,
lacosamide 50 mg Tab,50228-0192-60,NDC,,,,inpatient,1,EA,94.95,56.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,76.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,80.71,percent of total billed charges,,,85,,80.71,percent of total billed charges,,,49,,46.53,percent of total billed charges,,,90,,85.46,percent of total billed charges,,,,,,,no IP contract,,80,,75.96,percent of total billed charges,,,,,,,no IP contract,,50,,47.48,percent of total billed charges,,,,,,no IP contract,,,78,,74.06,percent of total billed charges,,,70,,66.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,46.53,3324,
lacosamide 100 mg Tab,50228-0193-60,NDC,,,,inpatient,1,EA,145.45,87.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,117.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,123.63,percent of total billed charges,,,85,,123.63,percent of total billed charges,,,49,,71.27,percent of total billed charges,,,90,,130.91,percent of total billed charges,,,,,,,no IP contract,,80,,116.36,percent of total billed charges,,,,,,,no IP contract,,50,,72.73,percent of total billed charges,,,,,,no IP contract,,,78,,113.45,percent of total billed charges,,,70,,101.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,71.27,3324,
50228-0427-30 - solifenacin 5 mg Tab,50228-0427-30,NDC,,,,inpatient,1,EA,114.15,68.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,92.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,97.03,percent of total billed charges,,,85,,97.03,percent of total billed charges,,,49,,55.93,percent of total billed charges,,,90,,102.74,percent of total billed charges,,,,,,,no IP contract,,80,,91.32,percent of total billed charges,,,,,,,no IP contract,,50,,57.08,percent of total billed charges,,,,,,no IP contract,,,78,,89.04,percent of total billed charges,,,70,,79.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,55.93,3324,
50228-0482-05 - dilTIAZem 60 mg Tab,50228-0482-05,NDC,,,,inpatient,1,EA,4.45,2.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.78,percent of total billed charges,,,85,,3.78,percent of total billed charges,,,49,,2.18,percent of total billed charges,,,90,,4.01,percent of total billed charges,,,,,,,no IP contract,,80,,3.56,percent of total billed charges,,,,,,,no IP contract,,50,,2.23,percent of total billed charges,,,,,,no IP contract,,,78,,3.47,percent of total billed charges,,,70,,3.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.18,3324,
50242-0041-64 - alteplase 2 mg REC I,50242-0041-64,NDC,,,,inpatient,2,ML,1163.5,698.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,942.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,988.98,percent of total billed charges,,,85,,988.98,percent of total billed charges,,,49,,570.12,percent of total billed charges,,,90,,1047.15,percent of total billed charges,,,,,,,no IP contract,,80,,930.8,percent of total billed charges,,,,,,,no IP contract,,50,,581.75,percent of total billed charges,,,,,,no IP contract,,,78,,907.53,percent of total billed charges,,,70,,814.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,570.12,3324,
50242-0063-01 - erlotinib 100 mg Tab,50242-0063-01,NDC,,,,inpatient,1,EA,1416.4,849.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1147.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1203.94,percent of total billed charges,,,85,,1203.94,percent of total billed charges,,,49,,694.04,percent of total billed charges,,,90,,1274.76,percent of total billed charges,,,,,,,no IP contract,,80,,1133.12,percent of total billed charges,,,,,,,no IP contract,,50,,708.2,percent of total billed charges,,,,,,no IP contract,,,78,,1104.79,percent of total billed charges,,,70,,991.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,694.04,3324,
50242-0064-01 - erlotinib 150 mg Tab,50242-0064-01,NDC,,,,inpatient,1,EA,1601.55,960.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1297.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1361.32,percent of total billed charges,,,85,,1361.32,percent of total billed charges,,,49,,784.76,percent of total billed charges,,,90,,1441.4,percent of total billed charges,,,,,,,no IP contract,,80,,1281.24,percent of total billed charges,,,,,,,no IP contract,,50,,800.78,percent of total billed charges,,,,,,no IP contract,,,78,,1249.21,percent of total billed charges,,,70,,1121.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,784.76,3324,
50242-0100-40 - dornase alfa 2.5 mg/2.5 mL Soln,50242-0100-40,NDC,,,,inpatient,2.5,ML,883.25,529.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,715.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,750.76,percent of total billed charges,,,85,,750.76,percent of total billed charges,,,49,,432.79,percent of total billed charges,,,90,,794.93,percent of total billed charges,,,,,,,no IP contract,,80,,706.6,percent of total billed charges,,,,,,,no IP contract,,50,,441.63,percent of total billed charges,,,,,,no IP contract,,,78,,688.94,percent of total billed charges,,,70,,618.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,432.79,3324,
50242-0137-01 - tocilizumab 20 mg/mL Soln,50242-0137-01,NDC,J3262,HCPCS,,inpatient,20,ML,8254.35,4952.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6686.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7016.2,percent of total billed charges,,,85,,7016.2,percent of total billed charges,,,49,,4044.63,percent of total billed charges,,,90,,7428.92,percent of total billed charges,,,,,,,no IP contract,,80,,6603.48,percent of total billed charges,,,,,,,no IP contract,,50,,4127.18,percent of total billed charges,,,,,,no IP contract,,,78,,6438.39,percent of total billed charges,,,70,,5778.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,7428.92,
amitriptyline 10 mg Tab,50268-0037-15,NDC,,,,inpatient,1,EA,7.8,4.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.63,percent of total billed charges,,,85,,6.63,percent of total billed charges,,,49,,3.82,percent of total billed charges,,,90,,7.02,percent of total billed charges,,,,,,,no IP contract,,80,,6.24,percent of total billed charges,,,,,,,no IP contract,,50,,3.9,percent of total billed charges,,,,,,no IP contract,,,78,,6.08,percent of total billed charges,,,70,,5.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.82,3324,
50268-0058-13 - atomoxetine 40 mg Cap,50268-0058-13,NDC,,,,inpatient,1,EA,64.15,38.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,51.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,54.53,percent of total billed charges,,,85,,54.53,percent of total billed charges,,,49,,31.43,percent of total billed charges,,,90,,57.74,percent of total billed charges,,,,,,,no IP contract,,80,,51.32,percent of total billed charges,,,,,,,no IP contract,,50,,32.08,percent of total billed charges,,,,,,no IP contract,,,78,,50.04,percent of total billed charges,,,70,,44.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.43,3324,
50268-0061-15 - acyclovir 400 mg Tab,50268-0061-15,NDC,,,,inpatient,1,EA,33.65,20.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.6,percent of total billed charges,,,85,,28.6,percent of total billed charges,,,49,,16.49,percent of total billed charges,,,90,,30.29,percent of total billed charges,,,,,,,no IP contract,,80,,26.92,percent of total billed charges,,,,,,,no IP contract,,50,,16.83,percent of total billed charges,,,,,,no IP contract,,,78,,26.25,percent of total billed charges,,,70,,23.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.49,3324,
50268-0069-15 - amantadine 100 mg Cap,50268-0069-15,NDC,,,,inpatient,1,EA,34.2,20.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.07,percent of total billed charges,,,85,,29.07,percent of total billed charges,,,49,,16.76,percent of total billed charges,,,90,,30.78,percent of total billed charges,,,,,,,no IP contract,,80,,27.36,percent of total billed charges,,,,,,,no IP contract,,50,,17.1,percent of total billed charges,,,,,,no IP contract,,,78,,26.68,percent of total billed charges,,,70,,23.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.76,3324,
50268-0083-15 - amLODIPine 2.5 mg Tab,50268-0083-15,NDC,,,,inpatient,1,EA,10.6,6.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.01,percent of total billed charges,,,85,,9.01,percent of total billed charges,,,49,,5.19,percent of total billed charges,,,90,,9.54,percent of total billed charges,,,,,,,no IP contract,,80,,8.48,percent of total billed charges,,,,,,,no IP contract,,50,,5.3,percent of total billed charges,,,,,,no IP contract,,,78,,8.27,percent of total billed charges,,,70,,7.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.19,3324,
50268-0084-15 - amLODIPine 5 mg Tab,50268-0084-15,NDC,,,,inpatient,1,EA,31.5,18.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,25.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.78,percent of total billed charges,,,85,,26.78,percent of total billed charges,,,49,,15.44,percent of total billed charges,,,90,,28.35,percent of total billed charges,,,,,,,no IP contract,,80,,25.2,percent of total billed charges,,,,,,,no IP contract,,50,,15.75,percent of total billed charges,,,,,,no IP contract,,,78,,24.57,percent of total billed charges,,,70,,22.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.44,3324,
50268-0085-15 - amLODIPine 10 mg Tab,50268-0085-15,NDC,,,,inpatient,1,EA,39.7,23.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.75,percent of total billed charges,,,85,,33.75,percent of total billed charges,,,49,,19.45,percent of total billed charges,,,90,,35.73,percent of total billed charges,,,,,,,no IP contract,,80,,31.76,percent of total billed charges,,,,,,,no IP contract,,50,,19.85,percent of total billed charges,,,,,,no IP contract,,,78,,30.97,percent of total billed charges,,,70,,27.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.45,3324,
ARIPiprazole 5 mg Tab,50268-0088-15,NDC,,,,inpatient,1,EA,241.75,145.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,195.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,205.49,percent of total billed charges,,,85,,205.49,percent of total billed charges,,,49,,118.46,percent of total billed charges,,,90,,217.58,percent of total billed charges,,,,,,,no IP contract,,80,,193.4,percent of total billed charges,,,,,,,no IP contract,,50,,120.88,percent of total billed charges,,,,,,no IP contract,,,78,,188.57,percent of total billed charges,,,70,,169.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,118.46,3324,
ARIPiprazole 10 mg Tab,50268-0089-15,NDC,,,,inpatient,1,EA,241.75,145.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,195.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,205.49,percent of total billed charges,,,85,,205.49,percent of total billed charges,,,49,,118.46,percent of total billed charges,,,90,,217.58,percent of total billed charges,,,,,,,no IP contract,,80,,193.4,percent of total billed charges,,,,,,,no IP contract,,50,,120.88,percent of total billed charges,,,,,,no IP contract,,,78,,188.57,percent of total billed charges,,,70,,169.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,118.46,3324,
50268-0094-15 - atorvastatin 20 mg Tab,50268-0094-15,NDC,,,,inpatient,1,EA,7.95,4.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.76,percent of total billed charges,,,85,,6.76,percent of total billed charges,,,49,,3.9,percent of total billed charges,,,90,,7.16,percent of total billed charges,,,,,,,no IP contract,,80,,6.36,percent of total billed charges,,,,,,,no IP contract,,50,,3.98,percent of total billed charges,,,,,,no IP contract,,,78,,6.2,percent of total billed charges,,,70,,5.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.9,3324,
50268-0095-15 - atorvastatin 40 mg Tab,50268-0095-15,NDC,,,,inpatient,1,EA,7.95,4.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.76,percent of total billed charges,,,85,,6.76,percent of total billed charges,,,49,,3.9,percent of total billed charges,,,90,,7.16,percent of total billed charges,,,,,,,no IP contract,,80,,6.36,percent of total billed charges,,,,,,,no IP contract,,50,,3.98,percent of total billed charges,,,,,,no IP contract,,,78,,6.2,percent of total billed charges,,,70,,5.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.9,3324,
50268-0098-15 - azithromycin 250 mg Tab,50268-0098-15,NDC,,,,inpatient,1,EA,62.6,37.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,50.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,53.21,percent of total billed charges,,,85,,53.21,percent of total billed charges,,,49,,30.67,percent of total billed charges,,,90,,56.34,percent of total billed charges,,,,,,,no IP contract,,80,,50.08,percent of total billed charges,,,,,,,no IP contract,,50,,31.3,percent of total billed charges,,,,,,no IP contract,,,78,,48.83,percent of total billed charges,,,70,,43.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,30.67,3324,
50268-0102-13 - balsalazide 750 mg Cap,50268-0102-13,NDC,,,,inpatient,1,EA,24.8,14.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.08,percent of total billed charges,,,85,,21.08,percent of total billed charges,,,49,,12.15,percent of total billed charges,,,90,,22.32,percent of total billed charges,,,,,,,no IP contract,,80,,19.84,percent of total billed charges,,,,,,,no IP contract,,50,,12.4,percent of total billed charges,,,,,,no IP contract,,,78,,19.34,percent of total billed charges,,,70,,17.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.15,3324,
50268-0106-15 - baclofen 10 mg Tab,50268-0106-15,NDC,,,,inpatient,1,EA,8.75,5.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.44,percent of total billed charges,,,85,,7.44,percent of total billed charges,,,49,,4.29,percent of total billed charges,,,90,,7.88,percent of total billed charges,,,,,,,no IP contract,,80,,7,percent of total billed charges,,,,,,,no IP contract,,50,,4.38,percent of total billed charges,,,,,,no IP contract,,,78,,6.83,percent of total billed charges,,,70,,6.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.29,3324,
50268-0107-15 - baclofen 20 mg Tab,50268-0107-15,NDC,,,,inpatient,1,EA,11.2,6.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.52,percent of total billed charges,,,85,,9.52,percent of total billed charges,,,49,,5.49,percent of total billed charges,,,90,,10.08,percent of total billed charges,,,,,,,no IP contract,,80,,8.96,percent of total billed charges,,,,,,,no IP contract,,50,,5.6,percent of total billed charges,,,,,,no IP contract,,,78,,8.74,percent of total billed charges,,,70,,7.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.49,3324,
50268-0110-15 - benazepril 10 mg Tab,50268-0110-15,NDC,,,,inpatient,1,EA,11.3,6.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.61,percent of total billed charges,,,85,,9.61,percent of total billed charges,,,49,,5.54,percent of total billed charges,,,90,,10.17,percent of total billed charges,,,,,,,no IP contract,,80,,9.04,percent of total billed charges,,,,,,,no IP contract,,50,,5.65,percent of total billed charges,,,,,,no IP contract,,,78,,8.81,percent of total billed charges,,,70,,7.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.54,3324,
50268-0111-15 - benazepril 20 mg Tab,50268-0111-15,NDC,,,,inpatient,1,EA,11.4,6.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.69,percent of total billed charges,,,85,,9.69,percent of total billed charges,,,49,,5.59,percent of total billed charges,,,90,,10.26,percent of total billed charges,,,,,,,no IP contract,,80,,9.12,percent of total billed charges,,,,,,,no IP contract,,50,,5.7,percent of total billed charges,,,,,,no IP contract,,,78,,8.89,percent of total billed charges,,,70,,7.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.59,3324,
bisoprolol 5 mg Tab,50268-0127-15,NDC,,,,inpatient,1,EA,15.1,9.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.84,percent of total billed charges,,,85,,12.84,percent of total billed charges,,,49,,7.4,percent of total billed charges,,,90,,13.59,percent of total billed charges,,,,,,,no IP contract,,80,,12.08,percent of total billed charges,,,,,,,no IP contract,,50,,7.55,percent of total billed charges,,,,,,no IP contract,,,78,,11.78,percent of total billed charges,,,70,,10.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.4,3324,
50268-0130-15 - bumetanide 0.5 mg Tab,50268-0130-15,NDC,,,,inpatient,1,EA,15.9,9.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.52,percent of total billed charges,,,85,,13.52,percent of total billed charges,,,49,,7.79,percent of total billed charges,,,90,,14.31,percent of total billed charges,,,,,,,no IP contract,,80,,12.72,percent of total billed charges,,,,,,,no IP contract,,50,,7.95,percent of total billed charges,,,,,,no IP contract,,,78,,12.4,percent of total billed charges,,,70,,11.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.79,3324,
50268-0131-15 - bumetanide 1 mg Tab,50268-0131-15,NDC,,,,inpatient,1,EA,15.75,9.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.39,percent of total billed charges,,,85,,13.39,percent of total billed charges,,,49,,7.72,percent of total billed charges,,,90,,14.18,percent of total billed charges,,,,,,,no IP contract,,80,,12.6,percent of total billed charges,,,,,,,no IP contract,,50,,7.88,percent of total billed charges,,,,,,no IP contract,,,78,,12.29,percent of total billed charges,,,70,,11.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.72,3324,
50268-0132-15 - bumetanide 2 mg Tab,50268-0132-15,NDC,,,,inpatient,1,EA,20.2,12.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.17,percent of total billed charges,,,85,,17.17,percent of total billed charges,,,49,,9.9,percent of total billed charges,,,90,,18.18,percent of total billed charges,,,,,,,no IP contract,,80,,16.16,percent of total billed charges,,,,,,,no IP contract,,50,,10.1,percent of total billed charges,,,,,,no IP contract,,,78,,15.76,percent of total billed charges,,,70,,14.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.9,3324,
50268-0140-13 - buPROPion 150 mg/24 hours ER Ta,50268-0140-13,NDC,,,,inpatient,1,EA,65.5,39.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,53.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,55.68,percent of total billed charges,,,85,,55.68,percent of total billed charges,,,49,,32.1,percent of total billed charges,,,90,,58.95,percent of total billed charges,,,,,,,no IP contract,,80,,52.4,percent of total billed charges,,,,,,,no IP contract,,50,,32.75,percent of total billed charges,,,,,,no IP contract,,,78,,51.09,percent of total billed charges,,,70,,45.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.1,3324,
50268-0142-15 - buPROPion 75 mg Tab,50268-0142-15,NDC,,,,inpatient,1,EA,16.45,9.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.98,percent of total billed charges,,,85,,13.98,percent of total billed charges,,,49,,8.06,percent of total billed charges,,,90,,14.81,percent of total billed charges,,,,,,,no IP contract,,80,,13.16,percent of total billed charges,,,,,,,no IP contract,,50,,8.23,percent of total billed charges,,,,,,no IP contract,,,78,,12.83,percent of total billed charges,,,70,,11.52,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.06,3324,
buPROPion 100 mg Tab,50268-0143-15,NDC,,,,inpatient,1,EA,20.7,12.42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.6,percent of total billed charges,,,85,,17.6,percent of total billed charges,,,49,,10.14,percent of total billed charges,,,90,,18.63,percent of total billed charges,,,,,,,no IP contract,,80,,16.56,percent of total billed charges,,,,,,,no IP contract,,50,,10.35,percent of total billed charges,,,,,,no IP contract,,,78,,16.15,percent of total billed charges,,,70,,14.49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.14,3324,
50268-0152-15 - cephalexin 500 mg Cap,50268-0152-15,NDC,,,,inpatient,1,EA,13.5,8.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.48,percent of total billed charges,,,85,,11.48,percent of total billed charges,,,49,,6.62,percent of total billed charges,,,90,,12.15,percent of total billed charges,,,,,,,no IP contract,,80,,10.8,percent of total billed charges,,,,,,,no IP contract,,50,,6.75,percent of total billed charges,,,,,,no IP contract,,,78,,10.53,percent of total billed charges,,,70,,9.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.62,3324,
chlorthalidone 25 mg Tab,50268-0167-15,NDC,,,,inpatient,1,EA,22.1,13.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.79,percent of total billed charges,,,85,,18.79,percent of total billed charges,,,49,,10.83,percent of total billed charges,,,90,,19.89,percent of total billed charges,,,,,,,no IP contract,,80,,17.68,percent of total billed charges,,,,,,,no IP contract,,50,,11.05,percent of total billed charges,,,,,,no IP contract,,,78,,17.24,percent of total billed charges,,,70,,15.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.83,3324,
celecoxib 100 mg Cap,50268-0168-15,NDC,,,,inpatient,1,EA,38.55,23.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.77,percent of total billed charges,,,85,,32.77,percent of total billed charges,,,49,,18.89,percent of total billed charges,,,90,,34.7,percent of total billed charges,,,,,,,no IP contract,,80,,30.84,percent of total billed charges,,,,,,,no IP contract,,50,,19.28,percent of total billed charges,,,,,,no IP contract,,,78,,30.07,percent of total billed charges,,,70,,26.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.89,3324,
carBAMazepine 300 mg ER Ca,50268-0172-13,NDC,,,,inpatient,1,EA,36.8,22.08,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.28,percent of total billed charges,,,85,,31.28,percent of total billed charges,,,49,,18.03,percent of total billed charges,,,90,,33.12,percent of total billed charges,,,,,,,no IP contract,,80,,29.44,percent of total billed charges,,,,,,,no IP contract,,50,,18.4,percent of total billed charges,,,,,,no IP contract,,,78,,28.7,percent of total billed charges,,,70,,25.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.03,3324,
clonazePAM 0.5 mg Tab,50268-0173-15,NDC,,,,inpatient,1,EA,11.35,6.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.65,percent of total billed charges,,,85,,9.65,percent of total billed charges,,,49,,5.56,percent of total billed charges,,,90,,10.22,percent of total billed charges,,,,,,,no IP contract,,80,,9.08,percent of total billed charges,,,,,,,no IP contract,,50,,5.68,percent of total billed charges,,,,,,no IP contract,,,78,,8.85,percent of total billed charges,,,70,,7.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.56,3324,
cilostazol 100 mg Tab,50268-0177-15,NDC,,,,inpatient,1,EA,21.7,13.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.45,percent of total billed charges,,,85,,18.45,percent of total billed charges,,,49,,10.63,percent of total billed charges,,,90,,19.53,percent of total billed charges,,,,,,,no IP contract,,80,,17.36,percent of total billed charges,,,,,,,no IP contract,,50,,10.85,percent of total billed charges,,,,,,no IP contract,,,78,,16.93,percent of total billed charges,,,70,,15.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.63,3324,
50268-0185-15 - clindamycin 300 mg Cap,50268-0185-15,NDC,,,,inpatient,1,EA,15.1,9.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.84,percent of total billed charges,,,85,,12.84,percent of total billed charges,,,49,,7.4,percent of total billed charges,,,90,,13.59,percent of total billed charges,,,,,,,no IP contract,,80,,12.08,percent of total billed charges,,,,,,,no IP contract,,50,,7.55,percent of total billed charges,,,,,,no IP contract,,,78,,11.78,percent of total billed charges,,,70,,10.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.4,3324,
cyproheptadine 4 mg Tab,50268-0189-15,NDC,,,,inpatient,1,EA,12.35,7.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.5,percent of total billed charges,,,85,,10.5,percent of total billed charges,,,49,,6.05,percent of total billed charges,,,90,,11.12,percent of total billed charges,,,,,,,no IP contract,,80,,9.88,percent of total billed charges,,,,,,,no IP contract,,50,,6.18,percent of total billed charges,,,,,,no IP contract,,,78,,9.63,percent of total billed charges,,,70,,8.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.05,3324,
cyclobenzaprine 10 mg Tab,50268-0191-15,NDC,,,,inpatient,1,EA,5.5,3.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.68,percent of total billed charges,,,85,,4.68,percent of total billed charges,,,49,,2.7,percent of total billed charges,,,90,,4.95,percent of total billed charges,,,,,,,no IP contract,,80,,4.4,percent of total billed charges,,,,,,,no IP contract,,50,,2.75,percent of total billed charges,,,,,,no IP contract,,,78,,4.29,percent of total billed charges,,,70,,3.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.7,3324,
capsaicin topical 0.025% Cream,50268-0195-60,NDC,,,,inpatient,1,EA,94.2,56.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,76.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,80.07,percent of total billed charges,,,85,,80.07,percent of total billed charges,,,49,,46.16,percent of total billed charges,,,90,,84.78,percent of total billed charges,,,,,,,no IP contract,,80,,75.36,percent of total billed charges,,,,,,,no IP contract,,50,,47.1,percent of total billed charges,,,,,,no IP contract,,,78,,73.48,percent of total billed charges,,,70,,65.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,46.16,3324,
50268-0220-15 - desmopressin 0.1 mg Tab,50268-0220-15,NDC,,,,inpatient,1,EA,27.65,16.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.5,percent of total billed charges,,,85,,23.5,percent of total billed charges,,,49,,13.55,percent of total billed charges,,,90,,24.89,percent of total billed charges,,,,,,,no IP contract,,80,,22.12,percent of total billed charges,,,,,,,no IP contract,,50,,13.83,percent of total billed charges,,,,,,no IP contract,,,78,,21.57,percent of total billed charges,,,70,,19.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.55,3324,
50268-0221-15 - desmopressin 0.2 mg Tab,50268-0221-15,NDC,,,,inpatient,1,EA,37.75,22.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.09,percent of total billed charges,,,85,,32.09,percent of total billed charges,,,49,,18.5,percent of total billed charges,,,90,,33.98,percent of total billed charges,,,,,,,no IP contract,,80,,30.2,percent of total billed charges,,,,,,,no IP contract,,50,,18.88,percent of total billed charges,,,,,,no IP contract,,,78,,29.45,percent of total billed charges,,,70,,26.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.5,3324,
divalproex sodium 250 mg ER Ta,50268-0259-15,NDC,,,,inpatient,1,EA,8.75,5.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.44,percent of total billed charges,,,85,,7.44,percent of total billed charges,,,49,,4.29,percent of total billed charges,,,90,,7.88,percent of total billed charges,,,,,,,no IP contract,,80,,7,percent of total billed charges,,,,,,,no IP contract,,50,,4.38,percent of total billed charges,,,,,,no IP contract,,,78,,6.83,percent of total billed charges,,,70,,6.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.29,3324,
50268-0260-13 - divalproex sodium 500 mg ER Ta,50268-0260-13,NDC,,,,inpatient,1,EA,16.95,10.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.41,percent of total billed charges,,,85,,14.41,percent of total billed charges,,,49,,8.31,percent of total billed charges,,,90,,15.26,percent of total billed charges,,,,,,,no IP contract,,80,,13.56,percent of total billed charges,,,,,,,no IP contract,,50,,8.48,percent of total billed charges,,,,,,no IP contract,,,78,,13.22,percent of total billed charges,,,70,,11.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.31,3324,
50268-0278-15 - doxycycline hyclate 100 mg Cap,50268-0278-15,NDC,,,,inpatient,1,EA,35.6,21.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.26,percent of total billed charges,,,85,,30.26,percent of total billed charges,,,49,,17.44,percent of total billed charges,,,90,,32.04,percent of total billed charges,,,,,,,no IP contract,,80,,28.48,percent of total billed charges,,,,,,,no IP contract,,50,,17.8,percent of total billed charges,,,,,,no IP contract,,,78,,27.77,percent of total billed charges,,,70,,24.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.44,3324,
50268-0282-13 - dutasteride 0.5 mg Cap,50268-0282-13,NDC,,,,inpatient,1,EA,51.9,31.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,42.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,44.12,percent of total billed charges,,,85,,44.12,percent of total billed charges,,,49,,25.43,percent of total billed charges,,,90,,46.71,percent of total billed charges,,,,,,,no IP contract,,80,,41.52,percent of total billed charges,,,,,,,no IP contract,,50,,25.95,percent of total billed charges,,,,,,no IP contract,,,78,,40.48,percent of total billed charges,,,70,,36.33,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.43,3324,
"50268-0297-15 - ergocalciferol 50,000 intl units Cap",50268-0297-15,NDC,,,,inpatient,1,EA,19.1,11.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.24,percent of total billed charges,,,85,,16.24,percent of total billed charges,,,49,,9.36,percent of total billed charges,,,90,,17.19,percent of total billed charges,,,,,,,no IP contract,,80,,15.28,percent of total billed charges,,,,,,,no IP contract,,50,,9.55,percent of total billed charges,,,,,,no IP contract,,,78,,14.9,percent of total billed charges,,,70,,13.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.36,3324,
50268-0299-15 - famotidine 20 mg Tab,50268-0299-15,NDC,,,,inpatient,1,EA,5.2,3.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.42,percent of total billed charges,,,85,,4.42,percent of total billed charges,,,49,,2.55,percent of total billed charges,,,90,,4.68,percent of total billed charges,,,,,,,no IP contract,,80,,4.16,percent of total billed charges,,,,,,,no IP contract,,50,,2.6,percent of total billed charges,,,,,,no IP contract,,,78,,4.06,percent of total billed charges,,,70,,3.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.55,3324,
50268-0314-15 - finasteride 5 mg Tab,50268-0314-15,NDC,,,,inpatient,1,EA,28.7,17.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.4,percent of total billed charges,,,85,,24.4,percent of total billed charges,,,49,,14.06,percent of total billed charges,,,90,,25.83,percent of total billed charges,,,,,,,no IP contract,,80,,22.96,percent of total billed charges,,,,,,,no IP contract,,50,,14.35,percent of total billed charges,,,,,,no IP contract,,,78,,22.39,percent of total billed charges,,,70,,20.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.06,3324,
50268-0330-15 - fludrocortisone 0.1 mg Tab,50268-0330-15,NDC,,,,inpatient,1,EA,16.55,9.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.07,percent of total billed charges,,,85,,14.07,percent of total billed charges,,,49,,8.11,percent of total billed charges,,,90,,14.9,percent of total billed charges,,,,,,,no IP contract,,80,,13.24,percent of total billed charges,,,,,,,no IP contract,,50,,8.28,percent of total billed charges,,,,,,no IP contract,,,78,,12.91,percent of total billed charges,,,70,,11.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.11,3324,
50268-0336-24 - ferrous sulfate 300 mg/5 mL LIQ,50268-0336-24,NDC,,,,inpatient,5,ML,42.5,25.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36.13,percent of total billed charges,,,85,,36.13,percent of total billed charges,,,49,,20.83,percent of total billed charges,,,90,,38.25,percent of total billed charges,,,,,,,no IP contract,,80,,34,percent of total billed charges,,,,,,,no IP contract,,50,,21.25,percent of total billed charges,,,,,,no IP contract,,,78,,33.15,percent of total billed charges,,,70,,29.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.83,3324,
50268-0337-15 - fluconazole 100 mg Tab,50268-0337-15,NDC,,,,inpatient,1,EA,79.6,47.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,64.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,67.66,percent of total billed charges,,,85,,67.66,percent of total billed charges,,,49,,39,percent of total billed charges,,,90,,71.64,percent of total billed charges,,,,,,,no IP contract,,80,,63.68,percent of total billed charges,,,,,,,no IP contract,,50,,39.8,percent of total billed charges,,,,,,no IP contract,,,78,,62.09,percent of total billed charges,,,70,,55.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,39,3324,
50268-0346-15 - folic acid 0.4 mg Tab,50268-0346-15,NDC,,,,inpatient,1,EA,6.05,3.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.14,percent of total billed charges,,,85,,5.14,percent of total billed charges,,,49,,2.96,percent of total billed charges,,,90,,5.45,percent of total billed charges,,,,,,,no IP contract,,80,,4.84,percent of total billed charges,,,,,,,no IP contract,,50,,3.03,percent of total billed charges,,,,,,no IP contract,,,78,,4.72,percent of total billed charges,,,70,,4.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.96,3324,
50268-0348-15 - gabapentin 300 mg Cap,50268-0348-15,NDC,,,,inpatient,1,EA,12.8,7.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.88,percent of total billed charges,,,85,,10.88,percent of total billed charges,,,49,,6.27,percent of total billed charges,,,90,,11.52,percent of total billed charges,,,,,,,no IP contract,,80,,10.24,percent of total billed charges,,,,,,,no IP contract,,50,,6.4,percent of total billed charges,,,,,,no IP contract,,,78,,9.98,percent of total billed charges,,,70,,8.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.27,3324,
gemfibrozil 600 mg Tab,50268-0350-15,NDC,,,,inpatient,1,EA,13.05,7.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.09,percent of total billed charges,,,85,,11.09,percent of total billed charges,,,49,,6.39,percent of total billed charges,,,90,,11.75,percent of total billed charges,,,,,,,no IP contract,,80,,10.44,percent of total billed charges,,,,,,,no IP contract,,50,,6.53,percent of total billed charges,,,,,,no IP contract,,,78,,10.18,percent of total billed charges,,,70,,9.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.39,3324,
glimepiride 1 mg Tab,50268-0358-15,NDC,,,,inpatient,1,EA,11.85,7.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.07,percent of total billed charges,,,85,,10.07,percent of total billed charges,,,49,,5.81,percent of total billed charges,,,90,,10.67,percent of total billed charges,,,,,,,no IP contract,,80,,9.48,percent of total billed charges,,,,,,,no IP contract,,50,,5.93,percent of total billed charges,,,,,,no IP contract,,,78,,9.24,percent of total billed charges,,,70,,8.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.81,3324,
50268-0361-15 - glipiZIDE 5 mg Tab,50268-0361-15,NDC,,,,inpatient,1,EA,7.3,4.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.21,percent of total billed charges,,,85,,6.21,percent of total billed charges,,,49,,3.58,percent of total billed charges,,,90,,6.57,percent of total billed charges,,,,,,,no IP contract,,80,,5.84,percent of total billed charges,,,,,,,no IP contract,,50,,3.65,percent of total billed charges,,,,,,no IP contract,,,78,,5.69,percent of total billed charges,,,70,,5.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.58,3324,
50268-0362-15 - glipiZIDE 10 mg Tab,50268-0362-15,NDC,,,,inpatient,1,EA,9.85,5.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.37,percent of total billed charges,,,85,,8.37,percent of total billed charges,,,49,,4.83,percent of total billed charges,,,90,,8.87,percent of total billed charges,,,,,,,no IP contract,,80,,7.88,percent of total billed charges,,,,,,,no IP contract,,50,,4.93,percent of total billed charges,,,,,,no IP contract,,,78,,7.68,percent of total billed charges,,,70,,6.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.83,3324,
50268-0374-15 - guanFACINE 2 mg Tab,50268-0374-15,NDC,,,,inpatient,1,EA,24.35,14.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.7,percent of total billed charges,,,85,,20.7,percent of total billed charges,,,49,,11.93,percent of total billed charges,,,90,,21.92,percent of total billed charges,,,,,,,no IP contract,,80,,19.48,percent of total billed charges,,,,,,,no IP contract,,50,,12.18,percent of total billed charges,,,,,,no IP contract,,,78,,18.99,percent of total billed charges,,,70,,17.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.93,3324,
50268-0401-15 - acetaminophen-hydrocodone 325 mg-5 mg Tab,50268-0401-15,NDC,,,,inpatient,1,EA,13.75,8.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.69,percent of total billed charges,,,85,,11.69,percent of total billed charges,,,49,,6.74,percent of total billed charges,,,90,,12.38,percent of total billed charges,,,,,,,no IP contract,,80,,11,percent of total billed charges,,,,,,,no IP contract,,50,,6.88,percent of total billed charges,,,,,,no IP contract,,,78,,10.73,percent of total billed charges,,,70,,9.63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.74,3324,
50268-0402-15 - acetaminophen-hydrocodone 325 mg-10 mg Tab,50268-0402-15,NDC,,,,inpatient,1,EA,18.5,11.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.73,percent of total billed charges,,,85,,15.73,percent of total billed charges,,,49,,9.07,percent of total billed charges,,,90,,16.65,percent of total billed charges,,,,,,,no IP contract,,80,,14.8,percent of total billed charges,,,,,,,no IP contract,,50,,9.25,percent of total billed charges,,,,,,no IP contract,,,78,,14.43,percent of total billed charges,,,70,,12.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.07,3324,
hydrocortisone topical 25 mg Supp,50268-0411-24,NDC,,,,inpatient,1,EA,174.75,104.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,141.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,148.54,percent of total billed charges,,,85,,148.54,percent of total billed charges,,,49,,85.63,percent of total billed charges,,,90,,157.28,percent of total billed charges,,,,,,,no IP contract,,80,,139.8,percent of total billed charges,,,,,,,no IP contract,,50,,87.38,percent of total billed charges,,,,,,no IP contract,,,78,,136.31,percent of total billed charges,,,70,,122.33,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,85.63,3324,
50268-0412-15 - hydroxychloroquine 200 mg Tab,50268-0412-15,NDC,,,,inpatient,1,EA,38.4,23.04,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.64,percent of total billed charges,,,85,,32.64,percent of total billed charges,,,49,,18.82,percent of total billed charges,,,90,,34.56,percent of total billed charges,,,,,,,no IP contract,,80,,30.72,percent of total billed charges,,,,,,,no IP contract,,50,,19.2,percent of total billed charges,,,,,,no IP contract,,,78,,29.95,percent of total billed charges,,,70,,26.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.82,3324,
50268-0430-15 - indomethacin 25 mg Cap,50268-0430-15,NDC,,,,inpatient,1,EA,7,4.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.95,percent of total billed charges,,,85,,5.95,percent of total billed charges,,,49,,3.43,percent of total billed charges,,,90,,6.3,percent of total billed charges,,,,,,,no IP contract,,80,,5.6,percent of total billed charges,,,,,,,no IP contract,,50,,3.5,percent of total billed charges,,,,,,no IP contract,,,78,,5.46,percent of total billed charges,,,70,,4.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.43,3324,
50268-0431-15 - indomethacin 50 mg Cap,50268-0431-15,NDC,,,,inpatient,1,EA,9.05,5.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.69,percent of total billed charges,,,85,,7.69,percent of total billed charges,,,49,,4.43,percent of total billed charges,,,90,,8.15,percent of total billed charges,,,,,,,no IP contract,,80,,7.24,percent of total billed charges,,,,,,,no IP contract,,50,,4.53,percent of total billed charges,,,,,,no IP contract,,,78,,7.06,percent of total billed charges,,,70,,6.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.43,3324,
50268-0440-15 - irbesartan 75 mg Tab,50268-0440-15,NDC,,,,inpatient,1,EA,14,8.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.9,percent of total billed charges,,,85,,11.9,percent of total billed charges,,,49,,6.86,percent of total billed charges,,,90,,12.6,percent of total billed charges,,,,,,,no IP contract,,80,,11.2,percent of total billed charges,,,,,,,no IP contract,,50,,7,percent of total billed charges,,,,,,no IP contract,,,78,,10.92,percent of total billed charges,,,70,,9.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.86,3324,
50268-0447-15 - isosorbide dinitrate 5 mg Tab,50268-0447-15,NDC,,,,inpatient,1,EA,12.25,7.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.41,percent of total billed charges,,,85,,10.41,percent of total billed charges,,,49,,6,percent of total billed charges,,,90,,11.03,percent of total billed charges,,,,,,,no IP contract,,80,,9.8,percent of total billed charges,,,,,,,no IP contract,,50,,6.13,percent of total billed charges,,,,,,no IP contract,,,78,,9.56,percent of total billed charges,,,70,,8.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6,3324,
50268-0450-12 - itraconazole 100 mg Cap,50268-0450-12,NDC,,,,inpatient,1,EA,48.8,29.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,39.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,41.48,percent of total billed charges,,,85,,41.48,percent of total billed charges,,,49,,23.91,percent of total billed charges,,,90,,43.92,percent of total billed charges,,,,,,,no IP contract,,80,,39.04,percent of total billed charges,,,,,,,no IP contract,,50,,24.4,percent of total billed charges,,,,,,no IP contract,,,78,,38.06,percent of total billed charges,,,70,,34.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.91,3324,
50268-0459-15 - lamiVUDine 150 mg Tab,50268-0459-15,NDC,,,,inpatient,1,EA,76.75,46.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,62.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,65.24,percent of total billed charges,,,85,,65.24,percent of total billed charges,,,49,,37.61,percent of total billed charges,,,90,,69.08,percent of total billed charges,,,,,,,no IP contract,,80,,61.4,percent of total billed charges,,,,,,,no IP contract,,50,,38.38,percent of total billed charges,,,,,,no IP contract,,,78,,59.87,percent of total billed charges,,,70,,53.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,37.61,3324,
50268-0477-15 - leflunomide 10 mg Tab,50268-0477-15,NDC,,,,inpatient,1,EA,51.5,30.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,41.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,43.78,percent of total billed charges,,,85,,43.78,percent of total billed charges,,,49,,25.24,percent of total billed charges,,,90,,46.35,percent of total billed charges,,,,,,,no IP contract,,80,,41.2,percent of total billed charges,,,,,,,no IP contract,,50,,25.75,percent of total billed charges,,,,,,no IP contract,,,78,,40.17,percent of total billed charges,,,70,,36.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.24,3324,
50268-0489-15 - loratadine 10 mg Tab,50268-0489-15,NDC,,,,inpatient,1,EA,9.4,5.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.99,percent of total billed charges,,,85,,7.99,percent of total billed charges,,,49,,4.61,percent of total billed charges,,,90,,8.46,percent of total billed charges,,,,,,,no IP contract,,80,,7.52,percent of total billed charges,,,,,,,no IP contract,,50,,4.7,percent of total billed charges,,,,,,no IP contract,,,78,,7.33,percent of total billed charges,,,70,,6.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.61,3324,
losartan 25 mg Tab,50268-0504-15,NDC,,,,inpatient,1,EA,8.6,5.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.31,percent of total billed charges,,,85,,7.31,percent of total billed charges,,,49,,4.21,percent of total billed charges,,,90,,7.74,percent of total billed charges,,,,,,,no IP contract,,80,,6.88,percent of total billed charges,,,,,,,no IP contract,,50,,4.3,percent of total billed charges,,,,,,no IP contract,,,78,,6.71,percent of total billed charges,,,70,,6.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.21,3324,
losartan 50 mg Tab,50268-0505-15,NDC,,,,inpatient,1,EA,8.85,5.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.52,percent of total billed charges,,,85,,7.52,percent of total billed charges,,,49,,4.34,percent of total billed charges,,,90,,7.97,percent of total billed charges,,,,,,,no IP contract,,80,,7.08,percent of total billed charges,,,,,,,no IP contract,,50,,4.43,percent of total billed charges,,,,,,no IP contract,,,78,,6.9,percent of total billed charges,,,70,,6.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.34,3324,
methocarbamol 750 mg Tab,50268-0521-15,NDC,,,,inpatient,1,EA,7,4.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.95,percent of total billed charges,,,85,,5.95,percent of total billed charges,,,49,,3.43,percent of total billed charges,,,90,,6.3,percent of total billed charges,,,,,,,no IP contract,,80,,5.6,percent of total billed charges,,,,,,,no IP contract,,50,,3.5,percent of total billed charges,,,,,,no IP contract,,,78,,5.46,percent of total billed charges,,,70,,4.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.43,3324,
50268-0522-15 - meclizine 12.5 mg Tab,50268-0522-15,NDC,,,,inpatient,1,EA,9.7,5.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.25,percent of total billed charges,,,85,,8.25,percent of total billed charges,,,49,,4.75,percent of total billed charges,,,90,,8.73,percent of total billed charges,,,,,,,no IP contract,,80,,7.76,percent of total billed charges,,,,,,,no IP contract,,50,,4.85,percent of total billed charges,,,,,,no IP contract,,,78,,7.57,percent of total billed charges,,,70,,6.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.75,3324,
50268-0524-15 - melatonin 3 mg Tab,50268-0524-15,NDC,,,,inpatient,1,EA,6.95,4.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.91,percent of total billed charges,,,85,,5.91,percent of total billed charges,,,49,,3.41,percent of total billed charges,,,90,,6.26,percent of total billed charges,,,,,,,no IP contract,,80,,5.56,percent of total billed charges,,,,,,,no IP contract,,50,,3.48,percent of total billed charges,,,,,,no IP contract,,,78,,5.42,percent of total billed charges,,,70,,4.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.41,3324,
50268-0525-15 - meloxicam 7.5 mg Tab,50268-0525-15,NDC,,,,inpatient,1,EA,5.1,3.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.34,percent of total billed charges,,,85,,4.34,percent of total billed charges,,,49,,2.5,percent of total billed charges,,,90,,4.59,percent of total billed charges,,,,,,,no IP contract,,80,,4.08,percent of total billed charges,,,,,,,no IP contract,,50,,2.55,percent of total billed charges,,,,,,no IP contract,,,78,,3.98,percent of total billed charges,,,70,,3.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.5,3324,
50268-0526-15 - meloxicam 15 mg Tab,50268-0526-15,NDC,,,,inpatient,1,EA,40.85,24.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34.72,percent of total billed charges,,,85,,34.72,percent of total billed charges,,,49,,20.02,percent of total billed charges,,,90,,36.77,percent of total billed charges,,,,,,,no IP contract,,80,,32.68,percent of total billed charges,,,,,,,no IP contract,,50,,20.43,percent of total billed charges,,,,,,no IP contract,,,78,,31.86,percent of total billed charges,,,70,,28.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.02,3324,
50268-0527-15 - methotrexate 2.5 mg Tab,50268-0527-15,NDC,,,,inpatient,1,EA,32.15,19.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,26.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,27.33,percent of total billed charges,,,85,,27.33,percent of total billed charges,,,49,,15.75,percent of total billed charges,,,90,,28.94,percent of total billed charges,,,,,,,no IP contract,,80,,25.72,percent of total billed charges,,,,,,,no IP contract,,50,,16.08,percent of total billed charges,,,,,,no IP contract,,,78,,25.08,percent of total billed charges,,,70,,22.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.75,3324,
50268-0531-15 - metFORMIN ER 500 mg ER Tablet,50268-0531-15,NDC,,,,inpatient,1,EA,4.2,2.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.57,percent of total billed charges,,,85,,3.57,percent of total billed charges,,,49,,2.06,percent of total billed charges,,,90,,3.78,percent of total billed charges,,,,,,,no IP contract,,80,,3.36,percent of total billed charges,,,,,,,no IP contract,,50,,2.1,percent of total billed charges,,,,,,no IP contract,,,78,,3.28,percent of total billed charges,,,70,,2.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.06,3324,
50268-0532-13 - metFORMIN 750 mg ER Ta,50268-0532-13,NDC,,,,inpatient,1,EA,13.35,8.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.35,percent of total billed charges,,,85,,11.35,percent of total billed charges,,,49,,6.54,percent of total billed charges,,,90,,12.02,percent of total billed charges,,,,,,,no IP contract,,80,,10.68,percent of total billed charges,,,,,,,no IP contract,,50,,6.68,percent of total billed charges,,,,,,no IP contract,,,78,,10.41,percent of total billed charges,,,70,,9.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.54,3324,
metroNIDAZOLE 250 mg Tab,50268-0534-15,NDC,,,,inpatient,1,EA,7.65,4.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.5,percent of total billed charges,,,85,,6.5,percent of total billed charges,,,49,,3.75,percent of total billed charges,,,90,,6.89,percent of total billed charges,,,,,,,no IP contract,,80,,6.12,percent of total billed charges,,,,,,,no IP contract,,50,,3.83,percent of total billed charges,,,,,,no IP contract,,,78,,5.97,percent of total billed charges,,,70,,5.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.75,3324,
metroNIDAZOLE 500 mg Tab,50268-0535-15,NDC,,,,inpatient,1,EA,10.25,6.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.71,percent of total billed charges,,,85,,8.71,percent of total billed charges,,,49,,5.02,percent of total billed charges,,,90,,9.23,percent of total billed charges,,,,,,,no IP contract,,80,,8.2,percent of total billed charges,,,,,,,no IP contract,,50,,5.13,percent of total billed charges,,,,,,no IP contract,,,78,,8,percent of total billed charges,,,70,,7.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.02,3324,
50268-0540-15 - metoprolol 25 mg ER Ta,50268-0540-15,NDC,,,,inpatient,1,EA,12.55,7.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.67,percent of total billed charges,,,85,,10.67,percent of total billed charges,,,49,,6.15,percent of total billed charges,,,90,,11.3,percent of total billed charges,,,,,,,no IP contract,,80,,10.04,percent of total billed charges,,,,,,,no IP contract,,50,,6.28,percent of total billed charges,,,,,,no IP contract,,,78,,9.79,percent of total billed charges,,,70,,8.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.15,3324,
50268-0541-15 - metoprolol 50 mg ER Ta,50268-0541-15,NDC,,,,inpatient,1,EA,12.55,7.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.67,percent of total billed charges,,,85,,10.67,percent of total billed charges,,,49,,6.15,percent of total billed charges,,,90,,11.3,percent of total billed charges,,,,,,,no IP contract,,80,,10.04,percent of total billed charges,,,,,,,no IP contract,,50,,6.28,percent of total billed charges,,,,,,no IP contract,,,78,,9.79,percent of total billed charges,,,70,,8.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.15,3324,
50268-0542-15 - metoprolol 100 mg ER Ta,50268-0542-15,NDC,,,,inpatient,1,EA,17.1,10.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.54,percent of total billed charges,,,85,,14.54,percent of total billed charges,,,49,,8.38,percent of total billed charges,,,90,,15.39,percent of total billed charges,,,,,,,no IP contract,,80,,13.68,percent of total billed charges,,,,,,,no IP contract,,50,,8.55,percent of total billed charges,,,,,,no IP contract,,,78,,13.34,percent of total billed charges,,,70,,11.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.38,3324,
50268-0550-15 - metFORMIN 500 mg ER Ta,50268-0550-15,NDC,,,,inpatient,1,EA,8.75,5.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.44,percent of total billed charges,,,85,,7.44,percent of total billed charges,,,49,,4.29,percent of total billed charges,,,90,,7.88,percent of total billed charges,,,,,,,no IP contract,,80,,7,percent of total billed charges,,,,,,,no IP contract,,50,,4.38,percent of total billed charges,,,,,,no IP contract,,,78,,6.83,percent of total billed charges,,,70,,6.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.29,3324,
metFORMIN 750 mg ER Ta,50268-0551-15,NDC,,,,inpatient,1,EA,13.45,8.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.43,percent of total billed charges,,,85,,11.43,percent of total billed charges,,,49,,6.59,percent of total billed charges,,,90,,12.11,percent of total billed charges,,,,,,,no IP contract,,80,,10.76,percent of total billed charges,,,,,,,no IP contract,,50,,6.73,percent of total billed charges,,,,,,no IP contract,,,78,,10.49,percent of total billed charges,,,70,,9.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.59,3324,
50268-0562-15 - midodrine 5 mg Tab,50268-0562-15,NDC,,,,inpatient,1,EA,12.1,7.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.29,percent of total billed charges,,,85,,10.29,percent of total billed charges,,,49,,5.93,percent of total billed charges,,,90,,10.89,percent of total billed charges,,,,,,,no IP contract,,80,,9.68,percent of total billed charges,,,,,,,no IP contract,,50,,6.05,percent of total billed charges,,,,,,no IP contract,,,78,,9.44,percent of total billed charges,,,70,,8.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.93,3324,
50268-0563-15 - midodrine 10 mg Tab,50268-0563-15,NDC,,,,inpatient,1,EA,17.25,10.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.66,percent of total billed charges,,,85,,14.66,percent of total billed charges,,,49,,8.45,percent of total billed charges,,,90,,15.53,percent of total billed charges,,,,,,,no IP contract,,80,,13.8,percent of total billed charges,,,,,,,no IP contract,,50,,8.63,percent of total billed charges,,,,,,no IP contract,,,78,,13.46,percent of total billed charges,,,70,,12.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.45,3324,
50268-0573-15 - montelukast 4 mg Chew,50268-0573-15,NDC,,,,inpatient,1,EA,32.9,19.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,26.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,27.97,percent of total billed charges,,,85,,27.97,percent of total billed charges,,,49,,16.12,percent of total billed charges,,,90,,29.61,percent of total billed charges,,,,,,,no IP contract,,80,,26.32,percent of total billed charges,,,,,,,no IP contract,,50,,16.45,percent of total billed charges,,,,,,no IP contract,,,78,,25.66,percent of total billed charges,,,70,,23.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.12,3324,
50268-0574-15 - montelukast Chew Tab 5 mg Tab,50268-0574-15,NDC,,,,inpatient,1,EA,36.75,22.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.24,percent of total billed charges,,,85,,31.24,percent of total billed charges,,,49,,18.01,percent of total billed charges,,,90,,33.08,percent of total billed charges,,,,,,,no IP contract,,80,,29.4,percent of total billed charges,,,,,,,no IP contract,,50,,18.38,percent of total billed charges,,,,,,no IP contract,,,78,,28.67,percent of total billed charges,,,70,,25.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.01,3324,
50268-0594-15 - naproxen 250 mg Tab,50268-0594-15,NDC,,,,inpatient,1,EA,10.05,6.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.54,percent of total billed charges,,,85,,8.54,percent of total billed charges,,,49,,4.92,percent of total billed charges,,,90,,9.05,percent of total billed charges,,,,,,,no IP contract,,80,,8.04,percent of total billed charges,,,,,,,no IP contract,,50,,5.03,percent of total billed charges,,,,,,no IP contract,,,78,,7.84,percent of total billed charges,,,70,,7.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.92,3324,
50268-0595-15 - naproxen 375 mg Tab,50268-0595-15,NDC,,,,inpatient,1,EA,11.7,7.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.95,percent of total billed charges,,,85,,9.95,percent of total billed charges,,,49,,5.73,percent of total billed charges,,,90,,10.53,percent of total billed charges,,,,,,,no IP contract,,80,,9.36,percent of total billed charges,,,,,,,no IP contract,,50,,5.85,percent of total billed charges,,,,,,no IP contract,,,78,,9.13,percent of total billed charges,,,70,,8.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.73,3324,
50268-0597-15 - NIFEdipine 30 mg ER Ta,50268-0597-15,NDC,,,,inpatient,1,EA,14.25,8.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.11,percent of total billed charges,,,85,,12.11,percent of total billed charges,,,49,,6.98,percent of total billed charges,,,90,,12.83,percent of total billed charges,,,,,,,no IP contract,,80,,11.4,percent of total billed charges,,,,,,,no IP contract,,50,,7.13,percent of total billed charges,,,,,,no IP contract,,,78,,11.12,percent of total billed charges,,,70,,9.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.98,3324,
50268-0598-15 - NIFEdipine 60 mg ER Ta,50268-0598-15,NDC,,,,inpatient,1,EA,21.7,13.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.45,percent of total billed charges,,,85,,18.45,percent of total billed charges,,,49,,10.63,percent of total billed charges,,,90,,19.53,percent of total billed charges,,,,,,,no IP contract,,80,,17.36,percent of total billed charges,,,,,,,no IP contract,,50,,10.85,percent of total billed charges,,,,,,no IP contract,,,78,,16.93,percent of total billed charges,,,70,,15.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.63,3324,
50268-0599-15 - NIFEdipine 90 mg ER Ta,50268-0599-15,NDC,,,,inpatient,1,EA,23.6,14.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.06,percent of total billed charges,,,85,,20.06,percent of total billed charges,,,49,,11.56,percent of total billed charges,,,90,,21.24,percent of total billed charges,,,,,,,no IP contract,,80,,18.88,percent of total billed charges,,,,,,,no IP contract,,50,,11.8,percent of total billed charges,,,,,,no IP contract,,,78,,18.41,percent of total billed charges,,,70,,16.52,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.56,3324,
50268-0603-15 - nortriptyline 10 mg Cap,50268-0603-15,NDC,,,,inpatient,1,EA,8.6,5.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.31,percent of total billed charges,,,85,,7.31,percent of total billed charges,,,49,,4.21,percent of total billed charges,,,90,,7.74,percent of total billed charges,,,,,,,no IP contract,,80,,6.88,percent of total billed charges,,,,,,,no IP contract,,50,,4.3,percent of total billed charges,,,,,,no IP contract,,,78,,6.71,percent of total billed charges,,,70,,6.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.21,3324,
nortriptyline 25 mg Cap,50268-0604-15,NDC,,,,inpatient,1,EA,8.5,5.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.23,percent of total billed charges,,,85,,7.23,percent of total billed charges,,,49,,4.17,percent of total billed charges,,,90,,7.65,percent of total billed charges,,,,,,,no IP contract,,80,,6.8,percent of total billed charges,,,,,,,no IP contract,,50,,4.25,percent of total billed charges,,,,,,no IP contract,,,78,,6.63,percent of total billed charges,,,70,,5.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.17,3324,
50268-0623-15 - nitrofurantoin macrocrystals 50 mg Cap,50268-0623-15,NDC,,,,inpatient,1,EA,38.95,23.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.11,percent of total billed charges,,,85,,33.11,percent of total billed charges,,,49,,19.09,percent of total billed charges,,,90,,35.06,percent of total billed charges,,,,,,,no IP contract,,80,,31.16,percent of total billed charges,,,,,,,no IP contract,,50,,19.48,percent of total billed charges,,,,,,no IP contract,,,78,,30.38,percent of total billed charges,,,70,,27.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.09,3324,
50268-0628-15 - oxybutynin 10 mg/24 hr ER Ta,50268-0628-15,NDC,,,,inpatient,1,EA,29.4,17.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.99,percent of total billed charges,,,85,,24.99,percent of total billed charges,,,49,,14.41,percent of total billed charges,,,90,,26.46,percent of total billed charges,,,,,,,no IP contract,,80,,23.52,percent of total billed charges,,,,,,,no IP contract,,50,,14.7,percent of total billed charges,,,,,,no IP contract,,,78,,22.93,percent of total billed charges,,,70,,20.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.41,3324,
50268-0631-15 - QUEtiapine 50 mg Tab,50268-0631-15,NDC,,,,inpatient,1,EA,53.05,31.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,42.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,45.09,percent of total billed charges,,,85,,45.09,percent of total billed charges,,,49,,25.99,percent of total billed charges,,,90,,47.75,percent of total billed charges,,,,,,,no IP contract,,80,,42.44,percent of total billed charges,,,,,,,no IP contract,,50,,26.53,percent of total billed charges,,,,,,no IP contract,,,78,,41.38,percent of total billed charges,,,70,,37.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.99,3324,
50268-0639-15 - pantoprazole 40 mg EC Ta,50268-0639-15,NDC,,,,inpatient,1,EA,35.85,21.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.47,percent of total billed charges,,,85,,30.47,percent of total billed charges,,,49,,17.57,percent of total billed charges,,,90,,32.27,percent of total billed charges,,,,,,,no IP contract,,80,,28.68,percent of total billed charges,,,,,,,no IP contract,,50,,17.93,percent of total billed charges,,,,,,no IP contract,,,78,,27.96,percent of total billed charges,,,70,,25.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.57,3324,
50268-0640-15 - PARoxetine 10 mg Tab,50268-0640-15,NDC,,,,inpatient,1,EA,9.95,5.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.46,percent of total billed charges,,,85,,8.46,percent of total billed charges,,,49,,4.88,percent of total billed charges,,,90,,8.96,percent of total billed charges,,,,,,,no IP contract,,80,,7.96,percent of total billed charges,,,,,,,no IP contract,,50,,4.98,percent of total billed charges,,,,,,no IP contract,,,78,,7.76,percent of total billed charges,,,70,,6.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.88,3324,
50268-0644-15 - acetaminophen-oxycodone 325 mg-5 mg Tab,50268-0644-15,NDC,,,,inpatient,1,EA,16.85,10.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.32,percent of total billed charges,,,85,,14.32,percent of total billed charges,,,49,,8.26,percent of total billed charges,,,90,,15.17,percent of total billed charges,,,,,,,no IP contract,,80,,13.48,percent of total billed charges,,,,,,,no IP contract,,50,,8.43,percent of total billed charges,,,,,,no IP contract,,,78,,13.14,percent of total billed charges,,,70,,11.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.26,3324,
propranolol 10 mg Tab,50268-0662-15,NDC,,,,inpatient,1,EA,6.6,3.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.61,percent of total billed charges,,,85,,5.61,percent of total billed charges,,,49,,3.23,percent of total billed charges,,,90,,5.94,percent of total billed charges,,,,,,,no IP contract,,80,,5.28,percent of total billed charges,,,,,,,no IP contract,,50,,3.3,percent of total billed charges,,,,,,no IP contract,,,78,,5.15,percent of total billed charges,,,70,,4.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.23,3324,
propranolol 20 mg Tab,50268-0663-15,NDC,,,,inpatient,1,EA,8.2,4.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.97,percent of total billed charges,,,85,,6.97,percent of total billed charges,,,49,,4.02,percent of total billed charges,,,90,,7.38,percent of total billed charges,,,,,,,no IP contract,,80,,6.56,percent of total billed charges,,,,,,,no IP contract,,50,,4.1,percent of total billed charges,,,,,,no IP contract,,,78,,6.4,percent of total billed charges,,,70,,5.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.02,3324,
50268-0672-15 - Pravastatin 10 mg Tab,50268-0672-15,NDC,,,,inpatient,1,EA,26.8,16.08,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.78,percent of total billed charges,,,85,,22.78,percent of total billed charges,,,49,,13.13,percent of total billed charges,,,90,,24.12,percent of total billed charges,,,,,,,no IP contract,,80,,21.44,percent of total billed charges,,,,,,,no IP contract,,50,,13.4,percent of total billed charges,,,,,,no IP contract,,,78,,20.9,percent of total billed charges,,,70,,18.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.13,3324,
50268-0684-15 - prochlorperazine 5 mg Tab,50268-0684-15,NDC,,,,inpatient,1,EA,16.6,9.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.11,percent of total billed charges,,,85,,14.11,percent of total billed charges,,,49,,8.13,percent of total billed charges,,,90,,14.94,percent of total billed charges,,,,,,,no IP contract,,80,,13.28,percent of total billed charges,,,,,,,no IP contract,,50,,8.3,percent of total billed charges,,,,,,no IP contract,,,78,,12.95,percent of total billed charges,,,70,,11.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.13,3324,
50268-0685-15 - prochlorperazine 10 mg Tab,50268-0685-15,NDC,,,,inpatient,1,EA,17.9,10.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.22,percent of total billed charges,,,85,,15.22,percent of total billed charges,,,49,,8.77,percent of total billed charges,,,90,,16.11,percent of total billed charges,,,,,,,no IP contract,,80,,14.32,percent of total billed charges,,,,,,,no IP contract,,50,,8.95,percent of total billed charges,,,,,,no IP contract,,,78,,13.96,percent of total billed charges,,,70,,12.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.77,3324,
primidone 50 mg Tab,50268-0686-15,NDC,,,,inpatient,1,EA,11.4,6.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.69,percent of total billed charges,,,85,,9.69,percent of total billed charges,,,49,,5.59,percent of total billed charges,,,90,,10.26,percent of total billed charges,,,,,,,no IP contract,,80,,9.12,percent of total billed charges,,,,,,,no IP contract,,50,,5.7,percent of total billed charges,,,,,,no IP contract,,,78,,8.89,percent of total billed charges,,,70,,7.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.59,3324,
50268-0701-15 - propranolol 20 mg Tab,50268-0701-15,NDC,,,,inpatient,1,EA,8.65,5.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.35,percent of total billed charges,,,85,,7.35,percent of total billed charges,,,49,,4.24,percent of total billed charges,,,90,,7.79,percent of total billed charges,,,,,,,no IP contract,,80,,6.92,percent of total billed charges,,,,,,,no IP contract,,50,,4.33,percent of total billed charges,,,,,,no IP contract,,,78,,6.75,percent of total billed charges,,,70,,6.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.24,3324,
50268-0702-15 - propranolol 40 mg Tab,50268-0702-15,NDC,,,,inpatient,1,EA,9,5.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.65,percent of total billed charges,,,85,,7.65,percent of total billed charges,,,49,,4.41,percent of total billed charges,,,90,,8.1,percent of total billed charges,,,,,,,no IP contract,,80,,7.2,percent of total billed charges,,,,,,,no IP contract,,50,,4.5,percent of total billed charges,,,,,,no IP contract,,,78,,7.02,percent of total billed charges,,,70,,6.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.41,3324,
50268-0710-15 - rosuvastatin 20 mg Tab,50268-0710-15,NDC,,,,inpatient,1,EA,15.6,9.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.26,percent of total billed charges,,,85,,13.26,percent of total billed charges,,,49,,7.64,percent of total billed charges,,,90,,14.04,percent of total billed charges,,,,,,,no IP contract,,80,,12.48,percent of total billed charges,,,,,,,no IP contract,,50,,7.8,percent of total billed charges,,,,,,no IP contract,,,78,,12.17,percent of total billed charges,,,70,,10.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.64,3324,
50268-0717-15 - sildenafil 20 mg Tab,50268-0717-15,NDC,,,,inpatient,1,EA,134.85,80.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,109.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,114.62,percent of total billed charges,,,85,,114.62,percent of total billed charges,,,49,,66.08,percent of total billed charges,,,90,,121.37,percent of total billed charges,,,,,,,no IP contract,,80,,107.88,percent of total billed charges,,,,,,,no IP contract,,50,,67.43,percent of total billed charges,,,,,,no IP contract,,,78,,105.18,percent of total billed charges,,,70,,94.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,66.08,3324,
50268-0718-13 - sirolimus 1 mg Tab,50268-0718-13,NDC,,,,inpatient,1,EA,282.8,169.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,229.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,240.38,percent of total billed charges,,,85,,240.38,percent of total billed charges,,,49,,138.57,percent of total billed charges,,,90,,254.52,percent of total billed charges,,,,,,,no IP contract,,80,,226.24,percent of total billed charges,,,,,,,no IP contract,,50,,141.4,percent of total billed charges,,,,,,no IP contract,,,78,,220.58,percent of total billed charges,,,70,,197.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,138.57,3324,
50268-0724-15 - sotalol 80 mg Tab,50268-0724-15,NDC,,,,inpatient,1,EA,22.25,13.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.91,percent of total billed charges,,,85,,18.91,percent of total billed charges,,,49,,10.9,percent of total billed charges,,,90,,20.03,percent of total billed charges,,,,,,,no IP contract,,80,,17.8,percent of total billed charges,,,,,,,no IP contract,,50,,11.13,percent of total billed charges,,,,,,no IP contract,,,78,,17.36,percent of total billed charges,,,70,,15.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.9,3324,
50268-0728-15 - sulfamethoxazole-trimethoprim 400 mg-80 mg Tab,50268-0728-15,NDC,,,,inpatient,1,EA,9.05,5.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.69,percent of total billed charges,,,85,,7.69,percent of total billed charges,,,49,,4.43,percent of total billed charges,,,90,,8.15,percent of total billed charges,,,,,,,no IP contract,,80,,7.24,percent of total billed charges,,,,,,,no IP contract,,50,,4.53,percent of total billed charges,,,,,,no IP contract,,,78,,7.06,percent of total billed charges,,,70,,6.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.43,3324,
50268-0730-15 - sulfaSALAzine 500 mg Tab,50268-0730-15,NDC,,,,inpatient,1,EA,8.3,4.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.06,percent of total billed charges,,,85,,7.06,percent of total billed charges,,,49,,4.07,percent of total billed charges,,,90,,7.47,percent of total billed charges,,,,,,,no IP contract,,80,,6.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.15,percent of total billed charges,,,,,,no IP contract,,,78,,6.47,percent of total billed charges,,,70,,5.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.07,3324,
50268-0740-15 - tamsulosin 0.4 mg Cap,50268-0740-15,NDC,,,,inpatient,1,EA,7.55,4.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.42,percent of total billed charges,,,85,,6.42,percent of total billed charges,,,49,,3.7,percent of total billed charges,,,90,,6.8,percent of total billed charges,,,,,,,no IP contract,,80,,6.04,percent of total billed charges,,,,,,,no IP contract,,50,,3.78,percent of total billed charges,,,,,,no IP contract,,,78,,5.89,percent of total billed charges,,,70,,5.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.7,3324,
valsartan 160 mg Tab,50268-0748-15,NDC,,,,inpatient,1,EA,16.3,9.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.86,percent of total billed charges,,,85,,13.86,percent of total billed charges,,,49,,7.99,percent of total billed charges,,,90,,14.67,percent of total billed charges,,,,,,,no IP contract,,80,,13.04,percent of total billed charges,,,,,,,no IP contract,,50,,8.15,percent of total billed charges,,,,,,no IP contract,,,78,,12.71,percent of total billed charges,,,70,,11.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.99,3324,
50268-0751-15 - topiramate 50 mg Tab,50268-0751-15,NDC,,,,inpatient,1,EA,39.6,23.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.66,percent of total billed charges,,,85,,33.66,percent of total billed charges,,,49,,19.4,percent of total billed charges,,,90,,35.64,percent of total billed charges,,,,,,,no IP contract,,80,,31.68,percent of total billed charges,,,,,,,no IP contract,,50,,19.8,percent of total billed charges,,,,,,no IP contract,,,78,,30.89,percent of total billed charges,,,70,,27.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.4,3324,
50268-0755-15 - torsemide 10 mg Tab,50268-0755-15,NDC,,,,inpatient,1,EA,9.45,5.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.03,percent of total billed charges,,,85,,8.03,percent of total billed charges,,,49,,4.63,percent of total billed charges,,,90,,8.51,percent of total billed charges,,,,,,,no IP contract,,80,,7.56,percent of total billed charges,,,,,,,no IP contract,,50,,4.73,percent of total billed charges,,,,,,no IP contract,,,78,,7.37,percent of total billed charges,,,70,,6.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.63,3324,
50268-0757-15 - torsemide 100 mg Tab,50268-0757-15,NDC,,,,inpatient,1,EA,26.8,16.08,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.78,percent of total billed charges,,,85,,22.78,percent of total billed charges,,,49,,13.13,percent of total billed charges,,,90,,24.12,percent of total billed charges,,,,,,,no IP contract,,80,,21.44,percent of total billed charges,,,,,,,no IP contract,,50,,13.4,percent of total billed charges,,,,,,no IP contract,,,78,,20.9,percent of total billed charges,,,70,,18.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.13,3324,
50268-0759-15 - tiZANidine 2 mg Tab,50268-0759-15,NDC,,,,inpatient,1,EA,17.75,10.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.09,percent of total billed charges,,,85,,15.09,percent of total billed charges,,,49,,8.7,percent of total billed charges,,,90,,15.98,percent of total billed charges,,,,,,,no IP contract,,80,,14.2,percent of total billed charges,,,,,,,no IP contract,,50,,8.88,percent of total billed charges,,,,,,no IP contract,,,78,,13.85,percent of total billed charges,,,70,,12.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.7,3324,
50268-0760-15 - tiZANidine 4 mg Tab,50268-0760-15,NDC,,,,inpatient,1,EA,15.85,9.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.47,percent of total billed charges,,,85,,13.47,percent of total billed charges,,,49,,7.77,percent of total billed charges,,,90,,14.27,percent of total billed charges,,,,,,,no IP contract,,80,,12.68,percent of total billed charges,,,,,,,no IP contract,,50,,7.93,percent of total billed charges,,,,,,no IP contract,,,78,,12.36,percent of total billed charges,,,70,,11.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.77,3324,
50268-0774-15 - acetaminophen-tramadol 325 mg-37.5 mg Tab,50268-0774-15,NDC,,,,inpatient,1,EA,11.45,6.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.73,percent of total billed charges,,,85,,9.73,percent of total billed charges,,,49,,5.61,percent of total billed charges,,,90,,10.31,percent of total billed charges,,,,,,,no IP contract,,80,,9.16,percent of total billed charges,,,,,,,no IP contract,,50,,5.73,percent of total billed charges,,,,,,no IP contract,,,78,,8.93,percent of total billed charges,,,70,,8.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.61,3324,
50268-0785-15 - valsartan 160 mg Tab,50268-0785-15,NDC,,,,inpatient,1,EA,43.5,26.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,35.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36.98,percent of total billed charges,,,85,,36.98,percent of total billed charges,,,49,,21.32,percent of total billed charges,,,90,,39.15,percent of total billed charges,,,,,,,no IP contract,,80,,34.8,percent of total billed charges,,,,,,,no IP contract,,50,,21.75,percent of total billed charges,,,,,,no IP contract,,,78,,33.93,percent of total billed charges,,,70,,30.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.32,3324,
valACYclovir 1 g Tab,50268-0789-15,NDC,,,,inpatient,1,EA,59.25,35.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,47.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,50.36,percent of total billed charges,,,85,,50.36,percent of total billed charges,,,49,,29.03,percent of total billed charges,,,90,,53.33,percent of total billed charges,,,,,,,no IP contract,,80,,47.4,percent of total billed charges,,,,,,,no IP contract,,50,,29.63,percent of total billed charges,,,,,,no IP contract,,,78,,46.22,percent of total billed charges,,,70,,41.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,29.03,3324,
50268-0798-15 - venlafaxine 25 mg Tab,50268-0798-15,NDC,,,,inpatient,1,EA,20.2,12.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.17,percent of total billed charges,,,85,,17.17,percent of total billed charges,,,49,,9.9,percent of total billed charges,,,90,,18.18,percent of total billed charges,,,,,,,no IP contract,,80,,16.16,percent of total billed charges,,,,,,,no IP contract,,50,,10.1,percent of total billed charges,,,,,,no IP contract,,,78,,15.76,percent of total billed charges,,,70,,14.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.9,3324,
50268-0816-15 - zonisamide 100 mg Cap,50268-0816-15,NDC,,,,inpatient,1,EA,17.5,10.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.88,percent of total billed charges,,,85,,14.88,percent of total billed charges,,,49,,8.58,percent of total billed charges,,,90,,15.75,percent of total billed charges,,,,,,,no IP contract,,80,,14,percent of total billed charges,,,,,,,no IP contract,,50,,8.75,percent of total billed charges,,,,,,no IP contract,,,78,,13.65,percent of total billed charges,,,70,,12.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.58,3324,
50268-0851-15 - thiamine 100 mg Tab,50268-0851-15,NDC,,,,inpatient,1,EA,6.3,3.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.36,percent of total billed charges,,,85,,5.36,percent of total billed charges,,,49,,3.09,percent of total billed charges,,,90,,5.67,percent of total billed charges,,,,,,,no IP contract,,80,,5.04,percent of total billed charges,,,,,,,no IP contract,,50,,3.15,percent of total billed charges,,,,,,no IP contract,,,78,,4.91,percent of total billed charges,,,70,,4.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.09,3324,
50268-0852-15 - cyanocobalamin 100 mcg Tab,50268-0852-15,NDC,,,,inpatient,1,EA,6.3,3.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.36,percent of total billed charges,,,85,,5.36,percent of total billed charges,,,49,,3.09,percent of total billed charges,,,90,,5.67,percent of total billed charges,,,,,,,no IP contract,,80,,5.04,percent of total billed charges,,,,,,,no IP contract,,50,,3.15,percent of total billed charges,,,,,,no IP contract,,,78,,4.91,percent of total billed charges,,,70,,4.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.09,3324,
50268-0853-15 - cyanocobalamin 250 mcg Tab,50268-0853-15,NDC,,,,inpatient,1,EA,6.3,3.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.36,percent of total billed charges,,,85,,5.36,percent of total billed charges,,,49,,3.09,percent of total billed charges,,,90,,5.67,percent of total billed charges,,,,,,,no IP contract,,80,,5.04,percent of total billed charges,,,,,,,no IP contract,,50,,3.15,percent of total billed charges,,,,,,no IP contract,,,78,,4.91,percent of total billed charges,,,70,,4.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.09,3324,
50268-0854-15 - cyanocobalamin 500 mcg Tab,50268-0854-15,NDC,,,,inpatient,1,EA,6.35,3.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.4,percent of total billed charges,,,85,,5.4,percent of total billed charges,,,49,,3.11,percent of total billed charges,,,90,,5.72,percent of total billed charges,,,,,,,no IP contract,,80,,5.08,percent of total billed charges,,,,,,,no IP contract,,50,,3.18,percent of total billed charges,,,,,,no IP contract,,,78,,4.95,percent of total billed charges,,,70,,4.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.11,3324,
50268-0855-15 - cyanocobalamin 1000 mcg Tab,50268-0855-15,NDC,,,,inpatient,1,EA,6.7,4.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.7,percent of total billed charges,,,85,,5.7,percent of total billed charges,,,49,,3.28,percent of total billed charges,,,90,,6.03,percent of total billed charges,,,,,,,no IP contract,,80,,5.36,percent of total billed charges,,,,,,,no IP contract,,50,,3.35,percent of total billed charges,,,,,,no IP contract,,,78,,5.23,percent of total billed charges,,,70,,4.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.28,3324,
50268-0858-15 - pyridoxine 50 mg Tab,50268-0858-15,NDC,,,,inpatient,1,EA,6.05,3.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.14,percent of total billed charges,,,85,,5.14,percent of total billed charges,,,49,,2.96,percent of total billed charges,,,90,,5.45,percent of total billed charges,,,,,,,no IP contract,,80,,4.84,percent of total billed charges,,,,,,,no IP contract,,50,,3.03,percent of total billed charges,,,,,,no IP contract,,,78,,4.72,percent of total billed charges,,,70,,4.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.96,3324,
50268-0860-15 - ascorbic acid 250 mg Tab,50268-0860-15,NDC,,,,inpatient,1,EA,6.05,3.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.14,percent of total billed charges,,,85,,5.14,percent of total billed charges,,,49,,2.96,percent of total billed charges,,,90,,5.45,percent of total billed charges,,,,,,,no IP contract,,80,,4.84,percent of total billed charges,,,,,,,no IP contract,,50,,3.03,percent of total billed charges,,,,,,no IP contract,,,78,,4.72,percent of total billed charges,,,70,,4.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.96,3324,
50268-0861-15 - ascorbic acid Chew Tab 500 mg Tab,50268-0861-15,NDC,,,,inpatient,1,EA,7.65,4.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.5,percent of total billed charges,,,85,,6.5,percent of total billed charges,,,49,,3.75,percent of total billed charges,,,90,,6.89,percent of total billed charges,,,,,,,no IP contract,,80,,6.12,percent of total billed charges,,,,,,,no IP contract,,50,,3.83,percent of total billed charges,,,,,,no IP contract,,,78,,5.97,percent of total billed charges,,,70,,5.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.75,3324,
50383-0042-48 - prednisoLONE 15 mg/5 mL Syrup,50383-0042-48,NDC,,,,inpatient,1,ML,8.65,5.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.35,percent of total billed charges,,,85,,7.35,percent of total billed charges,,,49,,4.24,percent of total billed charges,,,90,,7.79,percent of total billed charges,,,,,,,no IP contract,,80,,6.92,percent of total billed charges,,,,,,,no IP contract,,50,,4.33,percent of total billed charges,,,,,,no IP contract,,,78,,6.75,percent of total billed charges,,,70,,6.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.24,3324,
50383-0063-11 - guaiFENesin 100 mg/5 mL LIQ,50383-0063-11,NDC,,,,inpatient,10,ML,10.4,6.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.84,percent of total billed charges,,,85,,8.84,percent of total billed charges,,,49,,5.1,percent of total billed charges,,,90,,9.36,percent of total billed charges,,,,,,,no IP contract,,80,,8.32,percent of total billed charges,,,,,,,no IP contract,,50,,5.2,percent of total billed charges,,,,,,no IP contract,,,78,,8.11,percent of total billed charges,,,70,,7.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.1,3324,
50383-0063-12 - guaiFENesin 100 mg/5 mL LIQ,50383-0063-12,NDC,,,,inpatient,10,ML,10.4,6.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.84,percent of total billed charges,,,85,,8.84,percent of total billed charges,,,49,,5.1,percent of total billed charges,,,90,,9.36,percent of total billed charges,,,,,,,no IP contract,,80,,8.32,percent of total billed charges,,,,,,,no IP contract,,50,,5.2,percent of total billed charges,,,,,,no IP contract,,,78,,8.11,percent of total billed charges,,,70,,7.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.1,3324,
50383-0171-04 - levOCARNitine 100 mg/mL Soln,50383-0171-04,NDC,,,,inpatient,1,ML,7.5,4.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.38,percent of total billed charges,,,85,,6.38,percent of total billed charges,,,49,,3.68,percent of total billed charges,,,90,,6.75,percent of total billed charges,,,,,,,no IP contract,,80,,6,percent of total billed charges,,,,,,,no IP contract,,50,,3.75,percent of total billed charges,,,,,,no IP contract,,,78,,5.85,percent of total billed charges,,,70,,5.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.68,3324,
50383-0172-90 - levocarnitine 330 mg Tab,50383-0172-90,NDC,,,,inpatient,1,EA,10.65,6.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.05,percent of total billed charges,,,85,,9.05,percent of total billed charges,,,49,,5.22,percent of total billed charges,,,90,,9.59,percent of total billed charges,,,,,,,no IP contract,,80,,8.52,percent of total billed charges,,,,,,,no IP contract,,50,,5.33,percent of total billed charges,,,,,,no IP contract,,,78,,8.31,percent of total billed charges,,,70,,7.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.22,3324,
50383-0232-10 - dorzolamide ophthalmic 2% Soln,50383-0232-10,NDC,,,,inpatient,1,UN,565.65,339.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,458.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,480.8,percent of total billed charges,,,85,,480.8,percent of total billed charges,,,49,,277.17,percent of total billed charges,,,90,,509.09,percent of total billed charges,,,,,,,no IP contract,,80,,452.52,percent of total billed charges,,,,,,,no IP contract,,50,,282.83,percent of total billed charges,,,,,,no IP contract,,,78,,441.21,percent of total billed charges,,,70,,395.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,277.17,3324,
50383-0233-10 - dorzolamide-timolol ophthalmic 2%-0.5% Soln,50383-0233-10,NDC,,,,inpatient,1,UN,1030.5,618.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,834.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,875.93,percent of total billed charges,,,85,,875.93,percent of total billed charges,,,49,,504.95,percent of total billed charges,,,90,,927.45,percent of total billed charges,,,,,,,no IP contract,,80,,824.4,percent of total billed charges,,,,,,,no IP contract,,50,,515.25,percent of total billed charges,,,,,,no IP contract,,,78,,803.79,percent of total billed charges,,,70,,721.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,504.95,3324,
50383-0286-04 - levofloxacin 25 mg/mL Soln,50383-0286-04,NDC,,,,inpatient,1,ML,16,9.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.6,percent of total billed charges,,,85,,13.6,percent of total billed charges,,,49,,7.84,percent of total billed charges,,,90,,14.4,percent of total billed charges,,,,,,,no IP contract,,80,,12.8,percent of total billed charges,,,,,,,no IP contract,,50,,8,percent of total billed charges,,,,,,no IP contract,,,78,,12.48,percent of total billed charges,,,70,,11.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.84,3324,
50383-0311-47 - gabapentin 250 mg Soln,50383-0311-47,NDC,,,,inpatient,1,ML,8.1,4.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.89,percent of total billed charges,,,85,,6.89,percent of total billed charges,,,49,,3.97,percent of total billed charges,,,90,,7.29,percent of total billed charges,,,,,,,no IP contract,,80,,6.48,percent of total billed charges,,,,,,,no IP contract,,50,,4.05,percent of total billed charges,,,,,,no IP contract,,,78,,6.32,percent of total billed charges,,,70,,5.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.97,3324,
50383-0349-11 - docusate 10 mg/mL LIQ,50383-0349-11,NDC,,,,inpatient,10,ML,11.25,6.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.56,percent of total billed charges,,,85,,9.56,percent of total billed charges,,,49,,5.51,percent of total billed charges,,,90,,10.13,percent of total billed charges,,,,,,,no IP contract,,80,,9,percent of total billed charges,,,,,,,no IP contract,,50,,5.63,percent of total billed charges,,,,,,no IP contract,,,78,,8.78,percent of total billed charges,,,70,,7.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.51,3324,
50383-0627-50 - ferrous sulfate (as elemental iron) 15 mg/mL LIQ,50383-0627-50,NDC,,,,inpatient,1,ML,6.9,4.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.87,percent of total billed charges,,,85,,5.87,percent of total billed charges,,,49,,3.38,percent of total billed charges,,,90,,6.21,percent of total billed charges,,,,,,,no IP contract,,80,,5.52,percent of total billed charges,,,,,,,no IP contract,,50,,3.45,percent of total billed charges,,,,,,no IP contract,,,78,,5.38,percent of total billed charges,,,70,,4.83,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.38,3324,
50383-0700-16 - fluticasone nasal 0.05 mg/inh Spray,50383-0700-16,NDC,,,,inpatient,1,UN,711.6,426.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,576.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,604.86,percent of total billed charges,,,85,,604.86,percent of total billed charges,,,49,,348.68,percent of total billed charges,,,90,,640.44,percent of total billed charges,,,,,,,no IP contract,,80,,569.28,percent of total billed charges,,,,,,,no IP contract,,50,,355.8,percent of total billed charges,,,,,,no IP contract,,,78,,555.05,percent of total billed charges,,,70,,498.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,348.68,3324,
50383-0775-04 - lidocaine topical 2% Soln,50383-0775-04,NDC,,,,inpatient,15,ML,59.2,35.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,47.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,50.32,percent of total billed charges,,,85,,50.32,percent of total billed charges,,,49,,29.01,percent of total billed charges,,,90,,53.28,percent of total billed charges,,,,,,,no IP contract,,80,,47.36,percent of total billed charges,,,,,,,no IP contract,,50,,29.6,percent of total billed charges,,,,,,no IP contract,,,78,,46.18,percent of total billed charges,,,70,,41.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,29.01,3324,
50383-0779-31 - lactulose 10 g/15 mL Syrup,50383-0779-31,NDC,,,,inpatient,30,ML,15.4,9.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.09,percent of total billed charges,,,85,,13.09,percent of total billed charges,,,49,,7.55,percent of total billed charges,,,90,,13.86,percent of total billed charges,,,,,,,no IP contract,,80,,12.32,percent of total billed charges,,,,,,,no IP contract,,50,,7.7,percent of total billed charges,,,,,,no IP contract,,,78,,12.01,percent of total billed charges,,,70,,10.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.55,3324,
50383-0779-32 - lactulose 10 g/15 mL Syrup,50383-0779-32,NDC,,,,inpatient,1.5,ML,6,3.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.1,percent of total billed charges,,,85,,5.1,percent of total billed charges,,,49,,2.94,percent of total billed charges,,,90,,5.4,percent of total billed charges,,,,,,,no IP contract,,80,,4.8,percent of total billed charges,,,,,,,no IP contract,,50,,3,percent of total billed charges,,,,,,no IP contract,,,78,,4.68,percent of total billed charges,,,70,,4.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.94,3324,
50383-0823-16 - sulfamethoxazole-trimethoprim 200 mg-40 mg/5 mL Susp,50383-0823-16,NDC,,,,inpatient,1,ML,6.4,3.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.44,percent of total billed charges,,,85,,5.44,percent of total billed charges,,,49,,3.14,percent of total billed charges,,,90,,5.76,percent of total billed charges,,,,,,,no IP contract,,80,,5.12,percent of total billed charges,,,,,,,no IP contract,,50,,3.2,percent of total billed charges,,,,,,no IP contract,,,78,,4.99,percent of total billed charges,,,70,,4.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.14,3324,
gadopentetate dimeglumine 46.9% Soln,50419-0188-02,NDC,,,,inpatient,1,ML,848.95,509.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,687.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,721.61,percent of total billed charges,,,85,,721.61,percent of total billed charges,,,49,,415.99,percent of total billed charges,,,90,,764.06,percent of total billed charges,,,,,,,no IP contract,,80,,679.16,percent of total billed charges,,,,,,,no IP contract,,50,,424.48,percent of total billed charges,,,,,,no IP contract,,,78,,662.18,percent of total billed charges,,,70,,594.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,415.99,3324,
gadobutrol 604.72 mg/mL Soln,50419-0325-12,NDC,,,,inpatient,1,mL,93.3,55.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,75.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,79.31,percent of total billed charges,,,85,,79.31,percent of total billed charges,,,49,,45.72,percent of total billed charges,,,90,,83.97,percent of total billed charges,,,,,,,no IP contract,,80,,74.64,percent of total billed charges,,,,,,,no IP contract,,50,,46.65,percent of total billed charges,,,,,,no IP contract,,,78,,72.77,percent of total billed charges,,,70,,65.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,45.72,3324,
gadobutrol 604.72 mg/mL Soln,50419-0325-13,NDC,,,,inpatient,1,mL,93.3,55.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,75.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,79.31,percent of total billed charges,,,85,,79.31,percent of total billed charges,,,49,,45.72,percent of total billed charges,,,90,,83.97,percent of total billed charges,,,,,,,no IP contract,,80,,74.64,percent of total billed charges,,,,,,,no IP contract,,50,,46.65,percent of total billed charges,,,,,,no IP contract,,,78,,72.77,percent of total billed charges,,,70,,65.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,45.72,3324,
gadobutrol 604.72 mg/mL Soln,50419-0325-15,NDC,,,,inpatient,1,mL,848.95,509.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,687.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,721.61,percent of total billed charges,,,85,,721.61,percent of total billed charges,,,49,,415.99,percent of total billed charges,,,90,,764.06,percent of total billed charges,,,,,,,no IP contract,,80,,679.16,percent of total billed charges,,,,,,,no IP contract,,50,,424.48,percent of total billed charges,,,,,,no IP contract,,,78,,662.18,percent of total billed charges,,,70,,594.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,415.99,3324,
50419-0523-35 - interferon beta-1b 0.3 mg Syringe,50419-0523-35,NDC,,,,inpatient,1.2,ML,3102.7,1861.62,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2513.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2637.3,percent of total billed charges,,,85,,2637.3,percent of total billed charges,,,49,,1520.32,percent of total billed charges,,,90,,2792.43,percent of total billed charges,,,,,,,no IP contract,,80,,2482.16,percent of total billed charges,,,,,,,no IP contract,,50,,1551.35,percent of total billed charges,,,,,,no IP contract,,,78,,2420.11,percent of total billed charges,,,70,,2171.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
50419-0777-01 - ciprofloxacin 250 mg Susp,50419-0777-01,NDC,,,,inpatient,1,ML,16.25,9.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.81,percent of total billed charges,,,85,,13.81,percent of total billed charges,,,49,,7.96,percent of total billed charges,,,90,,14.63,percent of total billed charges,,,,,,,no IP contract,,80,,13,percent of total billed charges,,,,,,,no IP contract,,50,,8.13,percent of total billed charges,,,,,,no IP contract,,,78,,12.68,percent of total billed charges,,,70,,11.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.96,3324,
50458-0295-15 - itraconazole 10 mg/mL Soln,50458-0295-15,NDC,,,,inpatient,1,ML,21.75,13.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.49,percent of total billed charges,,,85,,18.49,percent of total billed charges,,,49,,10.66,percent of total billed charges,,,90,,19.58,percent of total billed charges,,,,,,,no IP contract,,80,,17.4,percent of total billed charges,,,,,,,no IP contract,,50,,10.88,percent of total billed charges,,,,,,no IP contract,,,78,,16.97,percent of total billed charges,,,70,,15.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.66,3324,
itraconazole 250 mg Kit,50458-0298-01,NDC,,,,inpatient,1,EA,1883.3,1129.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1525.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1600.81,percent of total billed charges,,,85,,1600.81,percent of total billed charges,,,49,,922.82,percent of total billed charges,,,90,,1694.97,percent of total billed charges,,,,,,,no IP contract,,80,,1506.64,percent of total billed charges,,,,,,,no IP contract,,50,,941.65,percent of total billed charges,,,,,,no IP contract,,,78,,1468.97,percent of total billed charges,,,70,,1318.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,922.82,3324,
50458-0320-01 - risperidone 2 mg Tab,50458-0320-01,NDC,,,,inpatient,1,EA,59.3,35.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,48.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,50.41,percent of total billed charges,,,85,,50.41,percent of total billed charges,,,49,,29.06,percent of total billed charges,,,90,,53.37,percent of total billed charges,,,,,,,no IP contract,,80,,47.44,percent of total billed charges,,,,,,,no IP contract,,50,,29.65,percent of total billed charges,,,,,,no IP contract,,,78,,46.25,percent of total billed charges,,,70,,41.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,29.06,3324,
50458-0398-60 - galantamine 12 mg Tab,50458-0398-60,NDC,,,,inpatient,1,EA,29.35,17.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.95,percent of total billed charges,,,85,,24.95,percent of total billed charges,,,49,,14.38,percent of total billed charges,,,90,,26.42,percent of total billed charges,,,,,,,no IP contract,,80,,23.48,percent of total billed charges,,,,,,,no IP contract,,50,,14.68,percent of total billed charges,,,,,,no IP contract,,,78,,22.89,percent of total billed charges,,,70,,20.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.38,3324,
50458-0400-01 - loperamide 2 mg Cap,50458-0400-01,NDC,,,,inpatient,1,EA,10.65,6.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.05,percent of total billed charges,,,85,,9.05,percent of total billed charges,,,49,,5.22,percent of total billed charges,,,90,,9.59,percent of total billed charges,,,,,,,no IP contract,,80,,8.52,percent of total billed charges,,,,,,,no IP contract,,50,,5.33,percent of total billed charges,,,,,,no IP contract,,,78,,8.31,percent of total billed charges,,,70,,7.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.22,3324,
50458-0577-60 - rivaroxaban 2.5 mg Tab,50458-0577-60,NDC,,,,inpatient,1,EA,78.55,47.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,63.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,66.77,percent of total billed charges,,,85,,66.77,percent of total billed charges,,,49,,38.49,percent of total billed charges,,,90,,70.7,percent of total billed charges,,,,,,,no IP contract,,80,,62.84,percent of total billed charges,,,,,,,no IP contract,,50,,39.28,percent of total billed charges,,,,,,no IP contract,,,78,,61.27,percent of total billed charges,,,70,,54.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,38.49,3324,
50458-0578-10 - rivaroxaban 15 mg Tab,50458-0578-10,NDC,,,,inpatient,1,EA,103.9,62.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,84.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,88.32,percent of total billed charges,,,85,,88.32,percent of total billed charges,,,49,,50.91,percent of total billed charges,,,90,,93.51,percent of total billed charges,,,,,,,no IP contract,,80,,83.12,percent of total billed charges,,,,,,,no IP contract,,50,,51.95,percent of total billed charges,,,,,,no IP contract,,,78,,81.04,percent of total billed charges,,,70,,72.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,50.91,3324,
50458-0578-30 - rivaroxaban 15 mg Tab,50458-0578-30,NDC,,,,inpatient,1,EA,146.3,87.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,118.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,124.36,percent of total billed charges,,,85,,124.36,percent of total billed charges,,,49,,71.69,percent of total billed charges,,,90,,131.67,percent of total billed charges,,,,,,,no IP contract,,80,,117.04,percent of total billed charges,,,,,,,no IP contract,,50,,73.15,percent of total billed charges,,,,,,no IP contract,,,78,,114.11,percent of total billed charges,,,70,,102.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,71.69,3324,
50458-0578-90 - rivaroxaban 15 mg Tab,50458-0578-90,NDC,,,,inpatient,1,EA,87.2,52.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,70.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,74.12,percent of total billed charges,,,85,,74.12,percent of total billed charges,,,49,,42.73,percent of total billed charges,,,90,,78.48,percent of total billed charges,,,,,,,no IP contract,,80,,69.76,percent of total billed charges,,,,,,,no IP contract,,50,,43.6,percent of total billed charges,,,,,,no IP contract,,,78,,68.02,percent of total billed charges,,,70,,61.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,42.73,3324,
50458-0579-10 - rivaroxaban 20 mg Tab,50458-0579-10,NDC,,,,inpatient,1,EA,103.9,62.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,84.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,88.32,percent of total billed charges,,,85,,88.32,percent of total billed charges,,,49,,50.91,percent of total billed charges,,,90,,93.51,percent of total billed charges,,,,,,,no IP contract,,80,,83.12,percent of total billed charges,,,,,,,no IP contract,,50,,51.95,percent of total billed charges,,,,,,no IP contract,,,78,,81.04,percent of total billed charges,,,70,,72.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,50.91,3324,
50458-0580-10 - rivaroxaban 10 mg Tab,50458-0580-10,NDC,,,,inpatient,1,EA,73.4,44.04,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,59.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,62.39,percent of total billed charges,,,85,,62.39,percent of total billed charges,,,49,,35.97,percent of total billed charges,,,90,,66.06,percent of total billed charges,,,,,,,no IP contract,,80,,58.72,percent of total billed charges,,,,,,,no IP contract,,50,,36.7,percent of total billed charges,,,,,,no IP contract,,,78,,57.25,percent of total billed charges,,,70,,51.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,35.97,3324,
50458-0580-30 - rivaroxaban 10 mg Tab,50458-0580-30,NDC,,,,inpatient,1,EA,73.4,44.04,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,59.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,62.39,percent of total billed charges,,,85,,62.39,percent of total billed charges,,,49,,35.97,percent of total billed charges,,,90,,66.06,percent of total billed charges,,,,,,,no IP contract,,80,,58.72,percent of total billed charges,,,,,,,no IP contract,,50,,36.7,percent of total billed charges,,,,,,no IP contract,,,78,,57.25,percent of total billed charges,,,70,,51.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,35.97,3324,
50458-0641-65 - topiramate 100 mg Tab,50458-0641-65,NDC,,,,inpatient,1,EA,65.45,39.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,53.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,55.63,percent of total billed charges,,,85,,55.63,percent of total billed charges,,,49,,32.07,percent of total billed charges,,,90,,58.91,percent of total billed charges,,,,,,,no IP contract,,80,,52.36,percent of total billed charges,,,,,,,no IP contract,,50,,32.73,percent of total billed charges,,,,,,no IP contract,,,78,,51.05,percent of total billed charges,,,70,,45.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.07,3324,
50458-0645-65 - topiramate 25 mg Cap,50458-0645-65,NDC,,,,inpatient,1,EA,29.65,17.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.2,percent of total billed charges,,,85,,25.2,percent of total billed charges,,,49,,14.53,percent of total billed charges,,,90,,26.69,percent of total billed charges,,,,,,,no IP contract,,80,,23.72,percent of total billed charges,,,,,,,no IP contract,,50,,14.83,percent of total billed charges,,,,,,no IP contract,,,78,,23.13,percent of total billed charges,,,70,,20.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.53,3324,
50474-0570-66 - brivaracetam 50 mg Tab,50474-0570-66,NDC,,,,inpatient,1,EA,196.95,118.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,159.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,167.41,percent of total billed charges,,,85,,167.41,percent of total billed charges,,,49,,96.51,percent of total billed charges,,,90,,177.26,percent of total billed charges,,,,,,,no IP contract,,80,,157.56,percent of total billed charges,,,,,,,no IP contract,,50,,98.48,percent of total billed charges,,,,,,no IP contract,,,78,,153.62,percent of total billed charges,,,70,,137.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,96.51,3324,
50474-0770-09 - brivaracetam 100 mg Tab,50474-0770-09,NDC,,,,inpatient,1,EA,185.9,111.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,150.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,158.02,percent of total billed charges,,,85,,158.02,percent of total billed charges,,,49,,91.09,percent of total billed charges,,,90,,167.31,percent of total billed charges,,,,,,,no IP contract,,80,,148.72,percent of total billed charges,,,,,,,no IP contract,,50,,92.95,percent of total billed charges,,,,,,no IP contract,,,78,,145,percent of total billed charges,,,70,,130.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,91.09,3324,
50474-0870-15 - brivaracetam 10 mg/mL LIQ,50474-0870-15,NDC,,,,inpatient,1,ML,43.6,26.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,35.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,37.06,percent of total billed charges,,,85,,37.06,percent of total billed charges,,,49,,21.36,percent of total billed charges,,,90,,39.24,percent of total billed charges,,,,,,,no IP contract,,80,,34.88,percent of total billed charges,,,,,,,no IP contract,,50,,21.8,percent of total billed charges,,,,,,no IP contract,,,78,,34.01,percent of total billed charges,,,70,,30.52,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.36,3324,
50484-0010-30 - collagenase Topical Ointment 250 units/g Ointment,50484-0010-30,NDC,,,,inpatient,1,UN,860.15,516.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,696.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,731.13,percent of total billed charges,,,85,,731.13,percent of total billed charges,,,49,,421.47,percent of total billed charges,,,90,,774.14,percent of total billed charges,,,,,,,no IP contract,,80,,688.12,percent of total billed charges,,,,,,,no IP contract,,50,,430.08,percent of total billed charges,,,,,,no IP contract,,,78,,670.92,percent of total billed charges,,,70,,602.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,421.47,3324,
50486-0550-32 - benzocaine topical 10% Gel,50486-0550-32,NDC,,,,inpatient,1,UN,16.4,9.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.94,percent of total billed charges,,,85,,13.94,percent of total billed charges,,,49,,8.04,percent of total billed charges,,,90,,14.76,percent of total billed charges,,,,,,,no IP contract,,80,,13.12,percent of total billed charges,,,,,,,no IP contract,,50,,8.2,percent of total billed charges,,,,,,no IP contract,,,78,,12.79,percent of total billed charges,,,70,,11.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.04,3324,
loperamide 1 mg/7.5 mL LIQ,50580-0134-44,NDC,,,,inpatient,1,EA,45.4,27.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,38.59,percent of total billed charges,,,85,,38.59,percent of total billed charges,,,49,,22.25,percent of total billed charges,,,90,,40.86,percent of total billed charges,,,,,,,no IP contract,,80,,36.32,percent of total billed charges,,,,,,,no IP contract,,50,,22.7,percent of total billed charges,,,,,,no IP contract,,,78,,35.41,percent of total billed charges,,,70,,31.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.25,3324,
50580-0170-01 - acetaminophen 160 mg/5 mL Susp,50580-0170-01,NDC,,,,inpatient,5,ML,55.4,33.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,44.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,47.09,percent of total billed charges,,,85,,47.09,percent of total billed charges,,,49,,27.15,percent of total billed charges,,,90,,49.86,percent of total billed charges,,,,,,,no IP contract,,80,,44.32,percent of total billed charges,,,,,,,no IP contract,,50,,27.7,percent of total billed charges,,,,,,no IP contract,,,78,,43.21,percent of total billed charges,,,70,,38.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.15,3324,
50580-0296-50 - acetaminophen 160 mg/5 mL Susp,50580-0296-50,NDC,,,,inpatient,5,ML,55.4,33.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,44.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,47.09,percent of total billed charges,,,85,,47.09,percent of total billed charges,,,49,,27.15,percent of total billed charges,,,90,,49.86,percent of total billed charges,,,,,,,no IP contract,,80,,44.32,percent of total billed charges,,,,,,,no IP contract,,50,,27.7,percent of total billed charges,,,,,,no IP contract,,,78,,43.21,percent of total billed charges,,,70,,38.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.15,3324,
50580-0412-02 - acetaminophen 500 mg Tab,50580-0412-02,NDC,,,,inpatient,1,EA,4.4,2.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.74,percent of total billed charges,,,85,,3.74,percent of total billed charges,,,49,,2.16,percent of total billed charges,,,90,,3.96,percent of total billed charges,,,,,,,no IP contract,,80,,3.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.2,percent of total billed charges,,,,,,no IP contract,,,78,,3.43,percent of total billed charges,,,70,,3.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.16,3324,
50580-0424-01 - acetaminophen 160 mg/5 mL Susp,50580-0424-01,NDC,,,,inpatient,5,ML,65.4,39.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,52.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,55.59,percent of total billed charges,,,85,,55.59,percent of total billed charges,,,49,,32.05,percent of total billed charges,,,90,,58.86,percent of total billed charges,,,,,,,no IP contract,,80,,52.32,percent of total billed charges,,,,,,,no IP contract,,50,,32.7,percent of total billed charges,,,,,,no IP contract,,,78,,51.01,percent of total billed charges,,,70,,45.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.05,3324,
50580-0457-11 - acetaminophen 500 mg Tab,50580-0457-11,NDC,,,,inpatient,1,EA,9.65,5.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.2,percent of total billed charges,,,85,,8.2,percent of total billed charges,,,49,,4.73,percent of total billed charges,,,90,,8.69,percent of total billed charges,,,,,,,no IP contract,,80,,7.72,percent of total billed charges,,,,,,,no IP contract,,50,,4.83,percent of total billed charges,,,,,,no IP contract,,,78,,7.53,percent of total billed charges,,,70,,6.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.73,3324,
50580-0458-10 - acetaminophen 325 mg Tab,50580-0458-10,NDC,,,,inpatient,1,EA,4.2,2.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.57,percent of total billed charges,,,85,,3.57,percent of total billed charges,,,49,,2.06,percent of total billed charges,,,90,,3.78,percent of total billed charges,,,,,,,no IP contract,,80,,3.36,percent of total billed charges,,,,,,,no IP contract,,50,,2.1,percent of total billed charges,,,,,,no IP contract,,,78,,3.28,percent of total billed charges,,,70,,2.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.06,3324,
50580-0458-11 - acetaminophen 325 mg Tab,50580-0458-11,NDC,,,,inpatient,1,EA,8.2,4.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.97,percent of total billed charges,,,85,,6.97,percent of total billed charges,,,49,,4.02,percent of total billed charges,,,90,,7.38,percent of total billed charges,,,,,,,no IP contract,,80,,6.56,percent of total billed charges,,,,,,,no IP contract,,50,,4.1,percent of total billed charges,,,,,,no IP contract,,,78,,6.4,percent of total billed charges,,,70,,5.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.02,3324,
50580-0496-60 - acetaminophen 325 mg Tab,50580-0496-60,NDC,,,,inpatient,1,EA,4.45,2.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.78,percent of total billed charges,,,85,,3.78,percent of total billed charges,,,49,,2.18,percent of total billed charges,,,90,,4.01,percent of total billed charges,,,,,,,no IP contract,,80,,3.56,percent of total billed charges,,,,,,,no IP contract,,50,,2.23,percent of total billed charges,,,,,,no IP contract,,,78,,3.47,percent of total billed charges,,,70,,3.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.18,3324,
50580-0579-02 - acetaminophen 160 mg/5 mL Susp,50580-0579-02,NDC,,,,inpatient,5,ML,55.4,33.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,44.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,47.09,percent of total billed charges,,,85,,47.09,percent of total billed charges,,,49,,27.15,percent of total billed charges,,,90,,49.86,percent of total billed charges,,,,,,,no IP contract,,80,,44.32,percent of total billed charges,,,,,,,no IP contract,,50,,27.7,percent of total billed charges,,,,,,no IP contract,,,78,,43.21,percent of total billed charges,,,70,,38.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.15,3324,
50580-0600-02 - acetaminophen 325 mg Tab,50580-0600-02,NDC,,,,inpatient,1,EA,8.2,4.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.97,percent of total billed charges,,,85,,6.97,percent of total billed charges,,,49,,4.02,percent of total billed charges,,,90,,7.38,percent of total billed charges,,,,,,,no IP contract,,80,,6.56,percent of total billed charges,,,,,,,no IP contract,,50,,4.1,percent of total billed charges,,,,,,no IP contract,,,78,,6.4,percent of total billed charges,,,70,,5.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.02,3324,
50580-0601-21 - ibuprofen 100 mg/5 mL Susp,50580-0601-21,NDC,,,,inpatient,1,ML,85.4,51.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,69.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,72.59,percent of total billed charges,,,85,,72.59,percent of total billed charges,,,49,,41.85,percent of total billed charges,,,90,,76.86,percent of total billed charges,,,,,,,no IP contract,,80,,68.32,percent of total billed charges,,,,,,,no IP contract,,50,,42.7,percent of total billed charges,,,,,,no IP contract,,,78,,66.61,percent of total billed charges,,,70,,59.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,41.85,3324,
50580-0612-01 - acetaminophen 160 mg/5 mL Susp,50580-0612-01,NDC,,,,inpatient,5,ML,55.4,33.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,44.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,47.09,percent of total billed charges,,,85,,47.09,percent of total billed charges,,,49,,27.15,percent of total billed charges,,,90,,49.86,percent of total billed charges,,,,,,,no IP contract,,80,,44.32,percent of total billed charges,,,,,,,no IP contract,,50,,27.7,percent of total billed charges,,,,,,no IP contract,,,78,,43.21,percent of total billed charges,,,70,,38.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.15,3324,
50580-0614-01 - acetaminophen 160 mg/5 mL Susp,50580-0614-01,NDC,,,,inpatient,5,ML,65.4,39.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,52.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,55.59,percent of total billed charges,,,85,,55.59,percent of total billed charges,,,49,,32.05,percent of total billed charges,,,90,,58.86,percent of total billed charges,,,,,,,no IP contract,,80,,52.32,percent of total billed charges,,,,,,,no IP contract,,50,,32.7,percent of total billed charges,,,,,,no IP contract,,,78,,51.01,percent of total billed charges,,,70,,45.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.05,3324,
"rabies vaccine, purified chick embryo cell 2.5 intl units REC I",50632-0010-01,NDC,,,,inpatient,1,EA,4196.4,2517.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3399.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3566.94,percent of total billed charges,,,85,,3566.94,percent of total billed charges,,,49,,2056.24,percent of total billed charges,,,90,,3776.76,percent of total billed charges,,,,,,,no IP contract,,80,,3357.12,percent of total billed charges,,,,,,,no IP contract,,50,,2098.2,percent of total billed charges,,,,,,no IP contract,,,78,,3273.19,percent of total billed charges,,,70,,2937.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3776.76,
50742-0112-01 - desipramine 10 mg Tab,50742-0112-01,NDC,,,,inpatient,1,EA,17.1,10.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.54,percent of total billed charges,,,85,,14.54,percent of total billed charges,,,49,,8.38,percent of total billed charges,,,90,,15.39,percent of total billed charges,,,,,,,no IP contract,,80,,13.68,percent of total billed charges,,,,,,,no IP contract,,50,,8.55,percent of total billed charges,,,,,,no IP contract,,,78,,13.34,percent of total billed charges,,,70,,11.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.38,3324,
50742-0113-01 - desipramine 25 mg Tab,50742-0113-01,NDC,,,,inpatient,1,EA,19.7,11.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.75,percent of total billed charges,,,85,,16.75,percent of total billed charges,,,49,,9.65,percent of total billed charges,,,90,,17.73,percent of total billed charges,,,,,,,no IP contract,,80,,15.76,percent of total billed charges,,,,,,,no IP contract,,50,,9.85,percent of total billed charges,,,,,,no IP contract,,,78,,15.37,percent of total billed charges,,,70,,13.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.65,3324,
50742-0142-01 - methenamine hippurate 1 g Tab,50742-0142-01,NDC,,,,inpatient,1,EA,20.45,12.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.38,percent of total billed charges,,,85,,17.38,percent of total billed charges,,,49,,10.02,percent of total billed charges,,,90,,18.41,percent of total billed charges,,,,,,,no IP contract,,80,,16.36,percent of total billed charges,,,,,,,no IP contract,,50,,10.23,percent of total billed charges,,,,,,no IP contract,,,78,,15.95,percent of total billed charges,,,70,,14.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.02,3324,
50742-0176-01 - isosorbide mononitrate 60 mg ER Ta,50742-0176-01,NDC,,,,inpatient,1,EA,37.85,22.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.17,percent of total billed charges,,,85,,32.17,percent of total billed charges,,,49,,18.55,percent of total billed charges,,,90,,34.07,percent of total billed charges,,,,,,,no IP contract,,80,,30.28,percent of total billed charges,,,,,,,no IP contract,,50,,18.93,percent of total billed charges,,,,,,no IP contract,,,78,,29.52,percent of total billed charges,,,70,,26.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.55,3324,
50742-0176-05 - isosorbide mononitrate 60 mg ER Ta,50742-0176-05,NDC,,,,inpatient,1,EA,14.55,8.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.37,percent of total billed charges,,,85,,12.37,percent of total billed charges,,,49,,7.13,percent of total billed charges,,,90,,13.1,percent of total billed charges,,,,,,,no IP contract,,80,,11.64,percent of total billed charges,,,,,,,no IP contract,,50,,7.28,percent of total billed charges,,,,,,no IP contract,,,78,,11.35,percent of total billed charges,,,70,,10.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.13,3324,
50742-0190-01 - cyproheptadine 4 mg Tab,50742-0190-01,NDC,,,,inpatient,1,EA,12.35,7.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.5,percent of total billed charges,,,85,,10.5,percent of total billed charges,,,49,,6.05,percent of total billed charges,,,90,,11.12,percent of total billed charges,,,,,,,no IP contract,,80,,9.88,percent of total billed charges,,,,,,,no IP contract,,50,,6.18,percent of total billed charges,,,,,,no IP contract,,,78,,9.63,percent of total billed charges,,,70,,8.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.05,3324,
50742-0190-10 - cyproheptadine 4 mg Tab,50742-0190-10,NDC,,,,inpatient,1,EA,12.35,7.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.5,percent of total billed charges,,,85,,10.5,percent of total billed charges,,,49,,6.05,percent of total billed charges,,,90,,11.12,percent of total billed charges,,,,,,,no IP contract,,80,,9.88,percent of total billed charges,,,,,,,no IP contract,,50,,6.18,percent of total billed charges,,,,,,no IP contract,,,78,,9.63,percent of total billed charges,,,70,,8.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.05,3324,
50742-0233-01 - acetaZOLAMIDE 500 mg ER Ca,50742-0233-01,NDC,,,,inpatient,1,EA,37.95,22.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.26,percent of total billed charges,,,85,,32.26,percent of total billed charges,,,49,,18.6,percent of total billed charges,,,90,,34.16,percent of total billed charges,,,,,,,no IP contract,,80,,30.36,percent of total billed charges,,,,,,,no IP contract,,50,,18.98,percent of total billed charges,,,,,,no IP contract,,,78,,29.6,percent of total billed charges,,,70,,26.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.6,3324,
50742-0239-01 - mexiletine 150 mg Cap,50742-0239-01,NDC,,,,inpatient,1,EA,24,14.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.4,percent of total billed charges,,,85,,20.4,percent of total billed charges,,,49,,11.76,percent of total billed charges,,,90,,21.6,percent of total billed charges,,,,,,,no IP contract,,80,,19.2,percent of total billed charges,,,,,,,no IP contract,,50,,12,percent of total billed charges,,,,,,no IP contract,,,78,,18.72,percent of total billed charges,,,70,,16.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.76,3324,
50742-0252-90 - dilTIAZem 360 mg/24 hours ER Ca,50742-0252-90,NDC,,,,inpatient,1,EA,85.15,51.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,68.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,72.38,percent of total billed charges,,,85,,72.38,percent of total billed charges,,,49,,41.72,percent of total billed charges,,,90,,76.64,percent of total billed charges,,,,,,,no IP contract,,80,,68.12,percent of total billed charges,,,,,,,no IP contract,,50,,42.58,percent of total billed charges,,,,,,no IP contract,,,78,,66.42,percent of total billed charges,,,70,,59.61,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,41.72,3324,
50742-0260-01 - NIFEdipine 30 mg ER Ta,50742-0260-01,NDC,,,,inpatient,1,EA,14.3,8.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.16,percent of total billed charges,,,85,,12.16,percent of total billed charges,,,49,,7.01,percent of total billed charges,,,90,,12.87,percent of total billed charges,,,,,,,no IP contract,,80,,11.44,percent of total billed charges,,,,,,,no IP contract,,50,,7.15,percent of total billed charges,,,,,,no IP contract,,,78,,11.15,percent of total billed charges,,,70,,10.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.01,3324,
50742-0261-01 - NIFEdipine 60 mg ER Ta,50742-0261-01,NDC,,,,inpatient,1,EA,22.05,13.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.74,percent of total billed charges,,,85,,18.74,percent of total billed charges,,,49,,10.8,percent of total billed charges,,,90,,19.85,percent of total billed charges,,,,,,,no IP contract,,80,,17.64,percent of total billed charges,,,,,,,no IP contract,,50,,11.03,percent of total billed charges,,,,,,no IP contract,,,78,,17.2,percent of total billed charges,,,70,,15.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.8,3324,
50742-0262-01 - NIFEdipine 90 mg ER Ta,50742-0262-01,NDC,,,,inpatient,1,EA,24.2,14.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.57,percent of total billed charges,,,85,,20.57,percent of total billed charges,,,49,,11.86,percent of total billed charges,,,90,,21.78,percent of total billed charges,,,,,,,no IP contract,,80,,19.36,percent of total billed charges,,,,,,,no IP contract,,50,,12.1,percent of total billed charges,,,,,,no IP contract,,,78,,18.88,percent of total billed charges,,,70,,16.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.86,3324,
50742-0349-01 - metOLazone 2.5 mg Tab,50742-0349-01,NDC,,,,inpatient,1,EA,24.35,14.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.7,percent of total billed charges,,,85,,20.7,percent of total billed charges,,,49,,11.93,percent of total billed charges,,,90,,21.92,percent of total billed charges,,,,,,,no IP contract,,80,,19.48,percent of total billed charges,,,,,,,no IP contract,,50,,12.18,percent of total billed charges,,,,,,no IP contract,,,78,,18.99,percent of total billed charges,,,70,,17.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.93,3324,
51079-0003-20 - ascorbic acid 250 mg Tab,51079-0003-20,NDC,,,,inpatient,1,EA,4.2,2.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.57,percent of total billed charges,,,85,,3.57,percent of total billed charges,,,49,,2.06,percent of total billed charges,,,90,,3.78,percent of total billed charges,,,,,,,no IP contract,,80,,3.36,percent of total billed charges,,,,,,,no IP contract,,50,,2.1,percent of total billed charges,,,,,,no IP contract,,,78,,3.28,percent of total billed charges,,,70,,2.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.06,3324,
51079-0007-20 - omeprazole 20 mg DRC,51079-0007-20,NDC,,,,inpatient,1,EA,34.85,20.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.62,percent of total billed charges,,,85,,29.62,percent of total billed charges,,,49,,17.08,percent of total billed charges,,,90,,31.37,percent of total billed charges,,,,,,,no IP contract,,80,,27.88,percent of total billed charges,,,,,,,no IP contract,,50,,17.43,percent of total billed charges,,,,,,no IP contract,,,78,,27.18,percent of total billed charges,,,70,,24.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.08,3324,
51079-0020-03 - budesonide 3 mg EC Capsule,51079-0020-03,NDC,,,,inpatient,1,EA,147,88.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,119.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,124.95,percent of total billed charges,,,85,,124.95,percent of total billed charges,,,49,,72.03,percent of total billed charges,,,90,,132.3,percent of total billed charges,,,,,,,no IP contract,,80,,117.6,percent of total billed charges,,,,,,,no IP contract,,50,,73.5,percent of total billed charges,,,,,,no IP contract,,,78,,114.66,percent of total billed charges,,,70,,102.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,72.03,3324,
51079-0023-20 - metolazone 2.5 mg Tab,51079-0023-20,NDC,,,,inpatient,1,EA,15.6,9.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.26,percent of total billed charges,,,85,,13.26,percent of total billed charges,,,49,,7.64,percent of total billed charges,,,90,,14.04,percent of total billed charges,,,,,,,no IP contract,,80,,12.48,percent of total billed charges,,,,,,,no IP contract,,50,,7.8,percent of total billed charges,,,,,,no IP contract,,,78,,12.17,percent of total billed charges,,,70,,10.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.64,3324,
51079-0025-20 - torsemide 10 mg Tab,51079-0025-20,NDC,,,,inpatient,1,EA,11.05,6.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.39,percent of total billed charges,,,85,,9.39,percent of total billed charges,,,49,,5.41,percent of total billed charges,,,90,,9.95,percent of total billed charges,,,,,,,no IP contract,,80,,8.84,percent of total billed charges,,,,,,,no IP contract,,50,,5.53,percent of total billed charges,,,,,,no IP contract,,,78,,8.62,percent of total billed charges,,,70,,7.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.41,3324,
51079-0026-01 - torsemide 20 mg Tab,51079-0026-01,NDC,,,,inpatient,1,EA,10.8,6.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.18,percent of total billed charges,,,85,,9.18,percent of total billed charges,,,49,,5.29,percent of total billed charges,,,90,,9.72,percent of total billed charges,,,,,,,no IP contract,,80,,8.64,percent of total billed charges,,,,,,,no IP contract,,50,,5.4,percent of total billed charges,,,,,,no IP contract,,,78,,8.42,percent of total billed charges,,,70,,7.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.29,3324,
51079-0026-20 - torsemide 20 mg Tab,51079-0026-20,NDC,,,,inpatient,1,EA,10.8,6.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.18,percent of total billed charges,,,85,,9.18,percent of total billed charges,,,49,,5.29,percent of total billed charges,,,90,,9.72,percent of total billed charges,,,,,,,no IP contract,,80,,8.64,percent of total billed charges,,,,,,,no IP contract,,50,,5.4,percent of total billed charges,,,,,,no IP contract,,,78,,8.42,percent of total billed charges,,,70,,7.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.29,3324,
51079-0028-20 - tacrolimus 5 mg Cap,51079-0028-20,NDC,,,,inpatient,1,EA,181.1,108.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,146.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,153.94,percent of total billed charges,,,85,,153.94,percent of total billed charges,,,49,,88.74,percent of total billed charges,,,90,,162.99,percent of total billed charges,,,,,,,no IP contract,,80,,144.88,percent of total billed charges,,,,,,,no IP contract,,50,,90.55,percent of total billed charges,,,,,,no IP contract,,,78,,141.26,percent of total billed charges,,,70,,126.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,88.74,3324,
51079-0033-17 - prednisone 10 mg EC Capsule,51079-0033-17,NDC,,,,inpatient,1,EA,4.6,2.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.91,percent of total billed charges,,,85,,3.91,percent of total billed charges,,,49,,2.25,percent of total billed charges,,,90,,4.14,percent of total billed charges,,,,,,,no IP contract,,80,,3.68,percent of total billed charges,,,,,,,no IP contract,,50,,2.3,percent of total billed charges,,,,,,no IP contract,,,78,,3.59,percent of total billed charges,,,70,,3.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.25,3324,
51079-0047-20 - buPROPion 150 mg ER Tablet,51079-0047-20,NDC,,,,inpatient,1,EA,45.3,27.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,38.51,percent of total billed charges,,,85,,38.51,percent of total billed charges,,,49,,22.2,percent of total billed charges,,,90,,40.77,percent of total billed charges,,,,,,,no IP contract,,80,,36.24,percent of total billed charges,,,,,,,no IP contract,,50,,22.65,percent of total billed charges,,,,,,no IP contract,,,78,,35.33,percent of total billed charges,,,70,,31.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.2,3324,
51079-0058-01 - chlorthalidone 25 mg Tab,51079-0058-01,NDC,,,,inpatient,1,EA,5.65,3.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.8,percent of total billed charges,,,85,,4.8,percent of total billed charges,,,49,,2.77,percent of total billed charges,,,90,,5.09,percent of total billed charges,,,,,,,no IP contract,,80,,4.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.83,percent of total billed charges,,,,,,no IP contract,,,78,,4.41,percent of total billed charges,,,70,,3.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.77,3324,
51079-0058-20 - chlorthalidone 25 mg Tab,51079-0058-20,NDC,,,,inpatient,1,EA,5.65,3.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.8,percent of total billed charges,,,85,,4.8,percent of total billed charges,,,49,,2.77,percent of total billed charges,,,90,,5.09,percent of total billed charges,,,,,,,no IP contract,,80,,4.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.83,percent of total billed charges,,,,,,no IP contract,,,78,,4.41,percent of total billed charges,,,70,,3.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.77,3324,
51079-0059-01 - chlorthalidone 50 mg Tab,51079-0059-01,NDC,,,,inpatient,1,EA,258.55,155.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,209.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,219.77,percent of total billed charges,,,85,,219.77,percent of total billed charges,,,49,,126.69,percent of total billed charges,,,90,,232.7,percent of total billed charges,,,,,,,no IP contract,,80,,206.84,percent of total billed charges,,,,,,,no IP contract,,50,,129.28,percent of total billed charges,,,,,,no IP contract,,,78,,201.67,percent of total billed charges,,,70,,180.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,126.69,3324,
51079-0059-20 - chlorthalidone 50 mg Tab,51079-0059-20,NDC,,,,inpatient,1,EA,5.25,3.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.46,percent of total billed charges,,,85,,4.46,percent of total billed charges,,,49,,2.57,percent of total billed charges,,,90,,4.73,percent of total billed charges,,,,,,,no IP contract,,80,,4.2,percent of total billed charges,,,,,,,no IP contract,,50,,2.63,percent of total billed charges,,,,,,no IP contract,,,78,,4.1,percent of total billed charges,,,70,,3.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.57,3324,
51079-0072-20 - furosemide 20 mg Tab,51079-0072-20,NDC,,,,inpatient,1,EA,5,3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.25,percent of total billed charges,,,85,,4.25,percent of total billed charges,,,49,,2.45,percent of total billed charges,,,90,,4.5,percent of total billed charges,,,,,,,no IP contract,,80,,4,percent of total billed charges,,,,,,,no IP contract,,50,,2.5,percent of total billed charges,,,,,,no IP contract,,,78,,3.9,percent of total billed charges,,,70,,3.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.45,3324,
51079-0073-20 - furosemide 40 mg Tab,51079-0073-20,NDC,,,,inpatient,1,EA,5.2,3.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.42,percent of total billed charges,,,85,,4.42,percent of total billed charges,,,49,,2.55,percent of total billed charges,,,90,,4.68,percent of total billed charges,,,,,,,no IP contract,,80,,4.16,percent of total billed charges,,,,,,,no IP contract,,50,,2.6,percent of total billed charges,,,,,,no IP contract,,,78,,4.06,percent of total billed charges,,,70,,3.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.55,3324,
hydrALAZINE 10 mg Tab,51079-0074-20,NDC,,,,inpatient,1,EA,4.4,2.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.74,percent of total billed charges,,,85,,3.74,percent of total billed charges,,,49,,2.16,percent of total billed charges,,,90,,3.96,percent of total billed charges,,,,,,,no IP contract,,80,,3.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.2,percent of total billed charges,,,,,,no IP contract,,,78,,3.43,percent of total billed charges,,,70,,3.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.16,3324,
51079-0075-20 - hydrALAZINE 25 mg Tab,51079-0075-20,NDC,,,,inpatient,1,EA,7.9,4.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.72,percent of total billed charges,,,85,,6.72,percent of total billed charges,,,49,,3.87,percent of total billed charges,,,90,,7.11,percent of total billed charges,,,,,,,no IP contract,,80,,6.32,percent of total billed charges,,,,,,,no IP contract,,50,,3.95,percent of total billed charges,,,,,,no IP contract,,,78,,6.16,percent of total billed charges,,,70,,5.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.87,3324,
hydrALAZINE 50 mg Tab,51079-0076-20,NDC,,,,inpatient,1,EA,8.3,4.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.06,percent of total billed charges,,,85,,7.06,percent of total billed charges,,,49,,4.07,percent of total billed charges,,,90,,7.47,percent of total billed charges,,,,,,,no IP contract,,80,,6.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.15,percent of total billed charges,,,,,,no IP contract,,,78,,6.47,percent of total billed charges,,,70,,5.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.07,3324,
51079-0077-20 - hydrOXYzine pamoate 25 mg Cap,51079-0077-20,NDC,,,,inpatient,1,EA,6.2,3.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.27,percent of total billed charges,,,85,,5.27,percent of total billed charges,,,49,,3.04,percent of total billed charges,,,90,,5.58,percent of total billed charges,,,,,,,no IP contract,,80,,4.96,percent of total billed charges,,,,,,,no IP contract,,50,,3.1,percent of total billed charges,,,,,,no IP contract,,,78,,4.84,percent of total billed charges,,,70,,4.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.04,3324,
51079-0082-20 - isoniazid 100 mg Tab,51079-0082-20,NDC,,,,inpatient,1,EA,4.7,2.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4,percent of total billed charges,,,85,,4,percent of total billed charges,,,49,,2.3,percent of total billed charges,,,90,,4.23,percent of total billed charges,,,,,,,no IP contract,,80,,3.76,percent of total billed charges,,,,,,,no IP contract,,50,,2.35,percent of total billed charges,,,,,,no IP contract,,,78,,3.67,percent of total billed charges,,,70,,3.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.3,3324,
51079-0083-01 - isoniazid 300 mg Tab,51079-0083-01,NDC,,,,inpatient,1,EA,6.6,3.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.61,percent of total billed charges,,,85,,5.61,percent of total billed charges,,,49,,3.23,percent of total billed charges,,,90,,5.94,percent of total billed charges,,,,,,,no IP contract,,80,,5.28,percent of total billed charges,,,,,,,no IP contract,,50,,3.3,percent of total billed charges,,,,,,no IP contract,,,78,,5.15,percent of total billed charges,,,70,,4.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.23,3324,
51079-0083-20 - isoniazid 300 mg Tab,51079-0083-20,NDC,,,,inpatient,1,EA,5,3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.25,percent of total billed charges,,,85,,4.25,percent of total billed charges,,,49,,2.45,percent of total billed charges,,,90,,4.5,percent of total billed charges,,,,,,,no IP contract,,80,,4,percent of total billed charges,,,,,,,no IP contract,,50,,2.5,percent of total billed charges,,,,,,no IP contract,,,78,,3.9,percent of total billed charges,,,70,,3.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.45,3324,
51079-0086-20 - mirtazapine 15 mg Tab,51079-0086-20,NDC,,,,inpatient,1,EA,25.45,15.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.63,percent of total billed charges,,,85,,21.63,percent of total billed charges,,,49,,12.47,percent of total billed charges,,,90,,22.91,percent of total billed charges,,,,,,,no IP contract,,80,,20.36,percent of total billed charges,,,,,,,no IP contract,,50,,12.73,percent of total billed charges,,,,,,no IP contract,,,78,,19.85,percent of total billed charges,,,70,,17.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.47,3324,
51079-0087-20 - mirtazapine 30 mg Tab,51079-0087-20,NDC,,,,inpatient,1,EA,26.1,15.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.19,percent of total billed charges,,,85,,22.19,percent of total billed charges,,,49,,12.79,percent of total billed charges,,,90,,23.49,percent of total billed charges,,,,,,,no IP contract,,80,,20.88,percent of total billed charges,,,,,,,no IP contract,,50,,13.05,percent of total billed charges,,,,,,no IP contract,,,78,,20.36,percent of total billed charges,,,70,,18.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.79,3324,
51079-0094-01 - phenobarbital 15 mg Tab,51079-0094-01,NDC,,,,inpatient,1,EA,6,3.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.1,percent of total billed charges,,,85,,5.1,percent of total billed charges,,,49,,2.94,percent of total billed charges,,,90,,5.4,percent of total billed charges,,,,,,,no IP contract,,80,,4.8,percent of total billed charges,,,,,,,no IP contract,,50,,3,percent of total billed charges,,,,,,no IP contract,,,78,,4.68,percent of total billed charges,,,70,,4.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.94,3324,
51079-0103-20 - spironolactone 25 mg Tab,51079-0103-20,NDC,,,,inpatient,1,EA,7.25,4.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.16,percent of total billed charges,,,85,,6.16,percent of total billed charges,,,49,,3.55,percent of total billed charges,,,90,,6.53,percent of total billed charges,,,,,,,no IP contract,,80,,5.8,percent of total billed charges,,,,,,,no IP contract,,50,,3.63,percent of total billed charges,,,,,,no IP contract,,,78,,5.66,percent of total billed charges,,,70,,5.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.55,3324,
51079-0107-20 - amitriptyline 25 mg Tab,51079-0107-20,NDC,,,,inpatient,1,EA,6.75,4.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.74,percent of total billed charges,,,85,,5.74,percent of total billed charges,,,49,,3.31,percent of total billed charges,,,90,,6.08,percent of total billed charges,,,,,,,no IP contract,,80,,5.4,percent of total billed charges,,,,,,,no IP contract,,50,,3.38,percent of total billed charges,,,,,,no IP contract,,,78,,5.27,percent of total billed charges,,,70,,4.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.31,3324,
51079-0109-03 - buPROPion 300 mg/24 hours ER Ta,51079-0109-03,NDC,,,,inpatient,1,EA,53.9,32.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,43.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,45.82,percent of total billed charges,,,85,,45.82,percent of total billed charges,,,49,,26.41,percent of total billed charges,,,90,,48.51,percent of total billed charges,,,,,,,no IP contract,,80,,43.12,percent of total billed charges,,,,,,,no IP contract,,50,,26.95,percent of total billed charges,,,,,,no IP contract,,,78,,42.04,percent of total billed charges,,,70,,37.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.41,3324,
51079-0118-01 - dicyclomine 10 mg Cap,51079-0118-01,NDC,,,,inpatient,1,EA,5.95,3.57,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.06,percent of total billed charges,,,85,,5.06,percent of total billed charges,,,49,,2.92,percent of total billed charges,,,90,,5.36,percent of total billed charges,,,,,,,no IP contract,,80,,4.76,percent of total billed charges,,,,,,,no IP contract,,50,,2.98,percent of total billed charges,,,,,,no IP contract,,,78,,4.64,percent of total billed charges,,,70,,4.17,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.92,3324,
51079-0118-20 - dicyclomine 10 mg Cap,51079-0118-20,NDC,,,,inpatient,1,EA,5.95,3.57,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.06,percent of total billed charges,,,85,,5.06,percent of total billed charges,,,49,,2.92,percent of total billed charges,,,90,,5.36,percent of total billed charges,,,,,,,no IP contract,,80,,4.76,percent of total billed charges,,,,,,,no IP contract,,50,,2.98,percent of total billed charges,,,,,,no IP contract,,,78,,4.64,percent of total billed charges,,,70,,4.17,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.92,3324,
51079-0131-20 - amitriptyline 10 mg Tab,51079-0131-20,NDC,,,,inpatient,1,EA,5.25,3.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.46,percent of total billed charges,,,85,,4.46,percent of total billed charges,,,49,,2.57,percent of total billed charges,,,90,,4.73,percent of total billed charges,,,,,,,no IP contract,,80,,4.2,percent of total billed charges,,,,,,,no IP contract,,50,,2.63,percent of total billed charges,,,,,,no IP contract,,,78,,4.1,percent of total billed charges,,,70,,3.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.57,3324,
51079-0133-20 - amitriptyline 50 mg Tab,51079-0133-20,NDC,,,,inpatient,1,EA,9,5.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.65,percent of total billed charges,,,85,,7.65,percent of total billed charges,,,49,,4.41,percent of total billed charges,,,90,,8.1,percent of total billed charges,,,,,,,no IP contract,,80,,7.2,percent of total billed charges,,,,,,,no IP contract,,50,,4.5,percent of total billed charges,,,,,,no IP contract,,,78,,7.02,percent of total billed charges,,,70,,6.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.41,3324,
51079-0141-20 - chlordiazepoxide 25 mg Cap,51079-0141-20,NDC,,,,inpatient,1,EA,7.35,4.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.25,percent of total billed charges,,,85,,6.25,percent of total billed charges,,,49,,3.6,percent of total billed charges,,,90,,6.62,percent of total billed charges,,,,,,,no IP contract,,80,,5.88,percent of total billed charges,,,,,,,no IP contract,,50,,3.68,percent of total billed charges,,,,,,no IP contract,,,78,,5.73,percent of total billed charges,,,70,,5.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.6,3324,
51079-0145-20 - benazepril 10 mg Tab,51079-0145-20,NDC,,,,inpatient,1,EA,11.4,6.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.69,percent of total billed charges,,,85,,9.69,percent of total billed charges,,,49,,5.59,percent of total billed charges,,,90,,10.26,percent of total billed charges,,,,,,,no IP contract,,80,,9.12,percent of total billed charges,,,,,,,no IP contract,,50,,5.7,percent of total billed charges,,,,,,no IP contract,,,78,,8.89,percent of total billed charges,,,70,,7.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.59,3324,
51079-0147-01 - amitriptyline 75 mg Tab,51079-0147-01,NDC,,,,inpatient,1,EA,11,6.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.35,percent of total billed charges,,,85,,9.35,percent of total billed charges,,,49,,5.39,percent of total billed charges,,,90,,9.9,percent of total billed charges,,,,,,,no IP contract,,80,,8.8,percent of total billed charges,,,,,,,no IP contract,,50,,5.5,percent of total billed charges,,,,,,no IP contract,,,78,,8.58,percent of total billed charges,,,70,,7.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.39,3324,
51079-0147-20 - amitriptyline 75 mg Tab,51079-0147-20,NDC,,,,inpatient,1,EA,11,6.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.35,percent of total billed charges,,,85,,9.35,percent of total billed charges,,,49,,5.39,percent of total billed charges,,,90,,9.9,percent of total billed charges,,,,,,,no IP contract,,80,,8.8,percent of total billed charges,,,,,,,no IP contract,,50,,5.5,percent of total billed charges,,,,,,no IP contract,,,78,,8.58,percent of total billed charges,,,70,,7.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.39,3324,
51079-0149-20 - sertraline 25 mg Tab,51079-0149-20,NDC,,,,inpatient,1,EA,26.5,15.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.53,percent of total billed charges,,,85,,22.53,percent of total billed charges,,,49,,12.99,percent of total billed charges,,,90,,23.85,percent of total billed charges,,,,,,,no IP contract,,80,,21.2,percent of total billed charges,,,,,,,no IP contract,,50,,13.25,percent of total billed charges,,,,,,no IP contract,,,78,,20.67,percent of total billed charges,,,70,,18.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.99,3324,
51079-0161-20 - acetaminophen-codeine 300 mg-30 mg Tab,51079-0161-20,NDC,,,,inpatient,1,EA,8.1,4.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.89,percent of total billed charges,,,85,,6.89,percent of total billed charges,,,49,,3.97,percent of total billed charges,,,90,,7.29,percent of total billed charges,,,,,,,no IP contract,,80,,6.48,percent of total billed charges,,,,,,,no IP contract,,50,,4.05,percent of total billed charges,,,,,,no IP contract,,,78,,6.32,percent of total billed charges,,,70,,5.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.97,3324,
51079-0164-03 - voriconazole 50 mg Tab,51079-0164-03,NDC,,,,inpatient,1,EA,107.5,64.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,87.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,91.38,percent of total billed charges,,,85,,91.38,percent of total billed charges,,,49,,52.68,percent of total billed charges,,,90,,96.75,percent of total billed charges,,,,,,,no IP contract,,80,,86,percent of total billed charges,,,,,,,no IP contract,,50,,53.75,percent of total billed charges,,,,,,no IP contract,,,78,,83.85,percent of total billed charges,,,70,,75.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,52.68,3324,
51079-0180-20 - lithium 300 mg ER Ta,51079-0180-20,NDC,,,,inpatient,1,EA,7.55,4.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.42,percent of total billed charges,,,85,,6.42,percent of total billed charges,,,49,,3.7,percent of total billed charges,,,90,,6.8,percent of total billed charges,,,,,,,no IP contract,,80,,6.04,percent of total billed charges,,,,,,,no IP contract,,50,,3.78,percent of total billed charges,,,,,,no IP contract,,,78,,5.89,percent of total billed charges,,,70,,5.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.7,3324,
51079-0182-20 - ciprofloxacin  500 Tab,51079-0182-20,NDC,,,,inpatient,1,EA,44.35,26.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,35.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,37.7,percent of total billed charges,,,85,,37.7,percent of total billed charges,,,49,,21.73,percent of total billed charges,,,90,,39.92,percent of total billed charges,,,,,,,no IP contract,,80,,35.48,percent of total billed charges,,,,,,,no IP contract,,50,,22.18,percent of total billed charges,,,,,,no IP contract,,,78,,34.59,percent of total billed charges,,,70,,31.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.73,3324,
51079-0190-01 - indomethacin 25 mg Cap,51079-0190-01,NDC,,,,inpatient,1,EA,7,4.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.95,percent of total billed charges,,,85,,5.95,percent of total billed charges,,,49,,3.43,percent of total billed charges,,,90,,6.3,percent of total billed charges,,,,,,,no IP contract,,80,,5.6,percent of total billed charges,,,,,,,no IP contract,,50,,3.5,percent of total billed charges,,,,,,no IP contract,,,78,,5.46,percent of total billed charges,,,70,,4.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.43,3324,
51079-0190-20 - indomethacin 25 mg Cap,51079-0190-20,NDC,,,,inpatient,1,EA,7,4.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.95,percent of total billed charges,,,85,,5.95,percent of total billed charges,,,49,,3.43,percent of total billed charges,,,90,,6.3,percent of total billed charges,,,,,,,no IP contract,,80,,5.6,percent of total billed charges,,,,,,,no IP contract,,50,,3.5,percent of total billed charges,,,,,,no IP contract,,,78,,5.46,percent of total billed charges,,,70,,4.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.43,3324,
51079-0191-20 - indomethacin 50 mg Cap,51079-0191-20,NDC,,,,inpatient,1,EA,9.25,5.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.86,percent of total billed charges,,,85,,7.86,percent of total billed charges,,,49,,4.53,percent of total billed charges,,,90,,8.33,percent of total billed charges,,,,,,,no IP contract,,80,,7.4,percent of total billed charges,,,,,,,no IP contract,,50,,4.63,percent of total billed charges,,,,,,no IP contract,,,78,,7.22,percent of total billed charges,,,70,,6.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.53,3324,
51079-0197-03 - tolterodine 2 mg ER Ca,51079-0197-03,NDC,,,,inpatient,1,EA,100.25,60.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,81.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,85.21,percent of total billed charges,,,85,,85.21,percent of total billed charges,,,49,,49.12,percent of total billed charges,,,90,,90.23,percent of total billed charges,,,,,,,no IP contract,,80,,80.2,percent of total billed charges,,,,,,,no IP contract,,50,,50.13,percent of total billed charges,,,,,,no IP contract,,,78,,78.2,percent of total billed charges,,,70,,70.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,49.12,3324,
51079-0205-20 - allopurinol 100 mg Tab,51079-0205-20,NDC,,,,inpatient,1,EA,5.55,3.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.72,percent of total billed charges,,,85,,4.72,percent of total billed charges,,,49,,2.72,percent of total billed charges,,,90,,5,percent of total billed charges,,,,,,,no IP contract,,80,,4.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.78,percent of total billed charges,,,,,,no IP contract,,,78,,4.33,percent of total billed charges,,,70,,3.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.72,3324,
51079-0206-01 - allopurinol 300 mg Tab,51079-0206-01,NDC,,,,inpatient,1,EA,8.65,5.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.35,percent of total billed charges,,,85,,7.35,percent of total billed charges,,,49,,4.24,percent of total billed charges,,,90,,7.79,percent of total billed charges,,,,,,,no IP contract,,80,,6.92,percent of total billed charges,,,,,,,no IP contract,,50,,4.33,percent of total billed charges,,,,,,no IP contract,,,78,,6.75,percent of total billed charges,,,70,,6.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.24,3324,
51079-0206-20 - allopurinol 300 mg Tab,51079-0206-20,NDC,,,,inpatient,1,EA,8.65,5.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.35,percent of total billed charges,,,85,,7.35,percent of total billed charges,,,49,,4.24,percent of total billed charges,,,90,,7.79,percent of total billed charges,,,,,,,no IP contract,,80,,6.92,percent of total billed charges,,,,,,,no IP contract,,50,,4.33,percent of total billed charges,,,,,,no IP contract,,,78,,6.75,percent of total billed charges,,,70,,6.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.24,3324,
51079-0208-20 - atorvastatin 10 mg Tab,51079-0208-20,NDC,,,,inpatient,1,EA,6.75,4.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.74,percent of total billed charges,,,85,,5.74,percent of total billed charges,,,49,,3.31,percent of total billed charges,,,90,,6.08,percent of total billed charges,,,,,,,no IP contract,,80,,5.4,percent of total billed charges,,,,,,,no IP contract,,50,,3.38,percent of total billed charges,,,,,,no IP contract,,,78,,5.27,percent of total billed charges,,,70,,4.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.31,3324,
51079-0209-20 - atorvastatin 20 mg Tab,51079-0209-20,NDC,,,,inpatient,1,EA,7.95,4.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.76,percent of total billed charges,,,85,,6.76,percent of total billed charges,,,49,,3.9,percent of total billed charges,,,90,,7.16,percent of total billed charges,,,,,,,no IP contract,,80,,6.36,percent of total billed charges,,,,,,,no IP contract,,50,,3.98,percent of total billed charges,,,,,,no IP contract,,,78,,6.2,percent of total billed charges,,,70,,5.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.9,3324,
51079-0210-20 - atorvastatin 40 mg Tab,51079-0210-20,NDC,,,,inpatient,1,EA,8.1,4.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.89,percent of total billed charges,,,85,,6.89,percent of total billed charges,,,49,,3.97,percent of total billed charges,,,90,,7.29,percent of total billed charges,,,,,,,no IP contract,,80,,6.48,percent of total billed charges,,,,,,,no IP contract,,50,,4.05,percent of total billed charges,,,,,,no IP contract,,,78,,6.32,percent of total billed charges,,,70,,5.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.97,3324,
51079-0211-03 - atorvastatin 80 mg Tab,51079-0211-03,NDC,,,,inpatient,1,EA,19.1,11.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.24,percent of total billed charges,,,85,,16.24,percent of total billed charges,,,49,,9.36,percent of total billed charges,,,90,,17.19,percent of total billed charges,,,,,,,no IP contract,,80,,15.28,percent of total billed charges,,,,,,,no IP contract,,50,,9.55,percent of total billed charges,,,,,,no IP contract,,,78,,14.9,percent of total billed charges,,,70,,13.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.36,3324,
51079-0213-20 - cilostazol 100 mg Tab,51079-0213-20,NDC,,,,inpatient,1,EA,18.3,10.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.56,percent of total billed charges,,,85,,15.56,percent of total billed charges,,,49,,8.97,percent of total billed charges,,,90,,16.47,percent of total billed charges,,,,,,,no IP contract,,80,,14.64,percent of total billed charges,,,,,,,no IP contract,,50,,9.15,percent of total billed charges,,,,,,no IP contract,,,78,,14.27,percent of total billed charges,,,70,,12.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.97,3324,
51079-0216-20 - metroNIDAZOLE 250 mg Tab,51079-0216-20,NDC,,,,inpatient,1,EA,8.2,4.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.97,percent of total billed charges,,,85,,6.97,percent of total billed charges,,,49,,4.02,percent of total billed charges,,,90,,7.38,percent of total billed charges,,,,,,,no IP contract,,80,,6.56,percent of total billed charges,,,,,,,no IP contract,,50,,4.1,percent of total billed charges,,,,,,no IP contract,,,78,,6.4,percent of total billed charges,,,70,,5.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.02,3324,
51079-0224-20 - diclofenac sodium 75 mg EC Ta,51079-0224-20,NDC,,,,inpatient,1,EA,17.9,10.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.22,percent of total billed charges,,,85,,15.22,percent of total billed charges,,,49,,8.77,percent of total billed charges,,,90,,16.11,percent of total billed charges,,,,,,,no IP contract,,80,,14.32,percent of total billed charges,,,,,,,no IP contract,,50,,8.95,percent of total billed charges,,,,,,no IP contract,,,78,,13.96,percent of total billed charges,,,70,,12.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.77,3324,
51079-0246-20 - loratadine 10 mg Tab,51079-0246-20,NDC,,,,inpatient,1,EA,10.65,6.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.05,percent of total billed charges,,,85,,9.05,percent of total billed charges,,,49,,5.22,percent of total billed charges,,,90,,9.59,percent of total billed charges,,,,,,,no IP contract,,80,,8.52,percent of total billed charges,,,,,,,no IP contract,,50,,5.33,percent of total billed charges,,,,,,no IP contract,,,78,,8.31,percent of total billed charges,,,70,,7.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.22,3324,
51079-0255-20 - metoprolol 25 mg Tab,51079-0255-20,NDC,,,,inpatient,1,EA,5.75,3.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.89,percent of total billed charges,,,85,,4.89,percent of total billed charges,,,49,,2.82,percent of total billed charges,,,90,,5.18,percent of total billed charges,,,,,,,no IP contract,,80,,4.6,percent of total billed charges,,,,,,,no IP contract,,50,,2.88,percent of total billed charges,,,,,,no IP contract,,,78,,4.49,percent of total billed charges,,,70,,4.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.82,3324,
51079-0265-20 - amoxicillin-clavulanate 500 mg-125 mg Tab,51079-0265-20,NDC,,,,inpatient,1,EA,33.9,20.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.82,percent of total billed charges,,,85,,28.82,percent of total billed charges,,,49,,16.61,percent of total billed charges,,,90,,30.51,percent of total billed charges,,,,,,,no IP contract,,80,,27.12,percent of total billed charges,,,,,,,no IP contract,,50,,16.95,percent of total billed charges,,,,,,no IP contract,,,78,,26.44,percent of total billed charges,,,70,,23.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.61,3324,
51079-0273-03 - entacapone 200 mg Tab,51079-0273-03,NDC,,,,inpatient,1,EA,36.25,21.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.81,percent of total billed charges,,,85,,30.81,percent of total billed charges,,,49,,17.76,percent of total billed charges,,,90,,32.63,percent of total billed charges,,,,,,,no IP contract,,80,,29,percent of total billed charges,,,,,,,no IP contract,,50,,18.13,percent of total billed charges,,,,,,no IP contract,,,78,,28.28,percent of total billed charges,,,70,,25.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.76,3324,
51079-0282-20 - ibuprofen 600 mg Tab,51079-0282-20,NDC,,,,inpatient,1,EA,6.2,3.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.27,percent of total billed charges,,,85,,5.27,percent of total billed charges,,,49,,3.04,percent of total billed charges,,,90,,5.58,percent of total billed charges,,,,,,,no IP contract,,80,,4.96,percent of total billed charges,,,,,,,no IP contract,,50,,3.1,percent of total billed charges,,,,,,no IP contract,,,78,,4.84,percent of total billed charges,,,70,,4.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.04,3324,
51079-0284-20 - diazepam 2 mg Tab,51079-0284-20,NDC,,,,inpatient,1,EA,7.4,4.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.29,percent of total billed charges,,,85,,6.29,percent of total billed charges,,,49,,3.63,percent of total billed charges,,,90,,6.66,percent of total billed charges,,,,,,,no IP contract,,80,,5.92,percent of total billed charges,,,,,,,no IP contract,,50,,3.7,percent of total billed charges,,,,,,no IP contract,,,78,,5.77,percent of total billed charges,,,70,,5.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.63,3324,
51079-0284-21 - diazepam 2 mg Tab,51079-0284-21,NDC,,,,inpatient,1,EA,7.4,4.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.29,percent of total billed charges,,,85,,6.29,percent of total billed charges,,,49,,3.63,percent of total billed charges,,,90,,6.66,percent of total billed charges,,,,,,,no IP contract,,80,,5.92,percent of total billed charges,,,,,,,no IP contract,,50,,3.7,percent of total billed charges,,,,,,no IP contract,,,78,,5.77,percent of total billed charges,,,70,,5.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.63,3324,
51079-0285-20 - diazepam 5 mg Tab,51079-0285-20,NDC,,,,inpatient,1,EA,8.1,4.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.89,percent of total billed charges,,,85,,6.89,percent of total billed charges,,,49,,3.97,percent of total billed charges,,,90,,7.29,percent of total billed charges,,,,,,,no IP contract,,80,,6.48,percent of total billed charges,,,,,,,no IP contract,,50,,4.05,percent of total billed charges,,,,,,no IP contract,,,78,,6.32,percent of total billed charges,,,70,,5.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.97,3324,
51079-0294-20 - tamsulosin 0.4 mg Cap,51079-0294-20,NDC,,,,inpatient,1,EA,37.3,22.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.71,percent of total billed charges,,,85,,31.71,percent of total billed charges,,,49,,18.28,percent of total billed charges,,,90,,33.57,percent of total billed charges,,,,,,,no IP contract,,80,,29.84,percent of total billed charges,,,,,,,no IP contract,,50,,18.65,percent of total billed charges,,,,,,no IP contract,,,78,,29.09,percent of total billed charges,,,70,,26.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.28,3324,
51079-0306-30 - Polyethylene Glycol  17 gm Packet,51079-0306-30,NDC,,,,inpatient,1,EA,18.75,11.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.94,percent of total billed charges,,,85,,15.94,percent of total billed charges,,,49,,9.19,percent of total billed charges,,,90,,16.88,percent of total billed charges,,,,,,,no IP contract,,80,,15,percent of total billed charges,,,,,,,no IP contract,,50,,9.38,percent of total billed charges,,,,,,no IP contract,,,78,,14.63,percent of total billed charges,,,70,,13.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.19,3324,
51079-0335-30 - docusate sodium 150 mg/15 mL LIQ,51079-0335-30,NDC,,,,inpatient,10,ML,8.75,5.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.44,percent of total billed charges,,,85,,7.44,percent of total billed charges,,,49,,4.29,percent of total billed charges,,,90,,7.88,percent of total billed charges,,,,,,,no IP contract,,80,,7,percent of total billed charges,,,,,,,no IP contract,,50,,4.38,percent of total billed charges,,,,,,no IP contract,,,78,,6.83,percent of total billed charges,,,70,,6.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.29,3324,
51079-0374-20 - chlordiazepoxide 5 mg Cap,51079-0374-20,NDC,,,,inpatient,1,EA,7,4.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.95,percent of total billed charges,,,85,,5.95,percent of total billed charges,,,49,,3.43,percent of total billed charges,,,90,,6.3,percent of total billed charges,,,,,,,no IP contract,,80,,5.6,percent of total billed charges,,,,,,,no IP contract,,50,,3.5,percent of total billed charges,,,,,,no IP contract,,,78,,5.46,percent of total billed charges,,,70,,4.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.43,3324,
51079-0379-20 - mycophenolate mofetil 500 mg Tab,51079-0379-20,NDC,,,,inpatient,1,EA,66.85,40.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,54.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.82,percent of total billed charges,,,85,,56.82,percent of total billed charges,,,49,,32.76,percent of total billed charges,,,90,,60.17,percent of total billed charges,,,,,,,no IP contract,,80,,53.48,percent of total billed charges,,,,,,,no IP contract,,50,,33.43,percent of total billed charges,,,,,,no IP contract,,,78,,52.14,percent of total billed charges,,,70,,46.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.76,3324,
51079-0385-20 - carbamazepine 200 mg Tab,51079-0385-20,NDC,,,,inpatient,1,EA,6.7,4.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.7,percent of total billed charges,,,85,,5.7,percent of total billed charges,,,49,,3.28,percent of total billed charges,,,90,,6.03,percent of total billed charges,,,,,,,no IP contract,,80,,5.36,percent of total billed charges,,,,,,,no IP contract,,50,,3.35,percent of total billed charges,,,,,,no IP contract,,,78,,5.23,percent of total billed charges,,,70,,4.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.28,3324,
51079-0386-20 - lorazepam 1 mg Tab,51079-0386-20,NDC,,,,inpatient,1,EA,13,7.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.05,percent of total billed charges,,,85,,11.05,percent of total billed charges,,,49,,6.37,percent of total billed charges,,,90,,11.7,percent of total billed charges,,,,,,,no IP contract,,80,,10.4,percent of total billed charges,,,,,,,no IP contract,,50,,6.5,percent of total billed charges,,,,,,no IP contract,,,78,,10.14,percent of total billed charges,,,70,,9.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.37,3324,
51079-0387-20 - lorazepam 2 mg Tab,51079-0387-20,NDC,,,,inpatient,1,EA,16.4,9.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.94,percent of total billed charges,,,85,,13.94,percent of total billed charges,,,49,,8.04,percent of total billed charges,,,90,,14.76,percent of total billed charges,,,,,,,no IP contract,,80,,13.12,percent of total billed charges,,,,,,,no IP contract,,50,,8.2,percent of total billed charges,,,,,,no IP contract,,,78,,12.79,percent of total billed charges,,,70,,11.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.04,3324,
51079-0392-01 - buPROPion 150 mg/12 hours ER Ta,51079-0392-01,NDC,,,,inpatient,1,EA,7.15,4.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.08,percent of total billed charges,,,85,,6.08,percent of total billed charges,,,49,,3.5,percent of total billed charges,,,90,,6.44,percent of total billed charges,,,,,,,no IP contract,,80,,5.72,percent of total billed charges,,,,,,,no IP contract,,50,,3.58,percent of total billed charges,,,,,,no IP contract,,,78,,5.58,percent of total billed charges,,,70,,5.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.5,3324,
51079-0414-03 - eszopiclone 3 mg Tab,51079-0414-03,NDC,,,,inpatient,1,EA,102.55,61.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,83.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,87.17,percent of total billed charges,,,85,,87.17,percent of total billed charges,,,49,,50.25,percent of total billed charges,,,90,,92.3,percent of total billed charges,,,,,,,no IP contract,,80,,82.04,percent of total billed charges,,,,,,,no IP contract,,50,,51.28,percent of total billed charges,,,,,,no IP contract,,,78,,79.99,percent of total billed charges,,,70,,71.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,50.25,3324,
51079-0417-01 - lorazepam 0.5 mg Tab,51079-0417-01,NDC,,,,inpatient,1,EA,11.25,6.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.56,percent of total billed charges,,,85,,9.56,percent of total billed charges,,,49,,5.51,percent of total billed charges,,,90,,10.13,percent of total billed charges,,,,,,,no IP contract,,80,,9,percent of total billed charges,,,,,,,no IP contract,,50,,5.63,percent of total billed charges,,,,,,no IP contract,,,78,,8.78,percent of total billed charges,,,70,,7.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.51,3324,
51079-0417-20 - lorazepam 0.5 mg Tab,51079-0417-20,NDC,,,,inpatient,1,EA,11.25,6.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.56,percent of total billed charges,,,85,,9.56,percent of total billed charges,,,49,,5.51,percent of total billed charges,,,90,,10.13,percent of total billed charges,,,,,,,no IP contract,,80,,9,percent of total billed charges,,,,,,,no IP contract,,50,,5.63,percent of total billed charges,,,,,,no IP contract,,,78,,8.78,percent of total billed charges,,,70,,7.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.51,3324,
51079-0417-21 - lorazepam 0.5 mg Tab,51079-0417-21,NDC,,,,inpatient,1,EA,11.25,6.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.56,percent of total billed charges,,,85,,9.56,percent of total billed charges,,,49,,5.51,percent of total billed charges,,,90,,10.13,percent of total billed charges,,,,,,,no IP contract,,80,,9,percent of total billed charges,,,,,,,no IP contract,,50,,5.63,percent of total billed charges,,,,,,no IP contract,,,78,,8.78,percent of total billed charges,,,70,,7.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.51,3324,
51079-0418-01 - temazepam 15 mg Cap,51079-0418-01,NDC,,,,inpatient,1,EA,11.35,6.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.65,percent of total billed charges,,,85,,9.65,percent of total billed charges,,,49,,5.56,percent of total billed charges,,,90,,10.22,percent of total billed charges,,,,,,,no IP contract,,80,,9.08,percent of total billed charges,,,,,,,no IP contract,,50,,5.68,percent of total billed charges,,,,,,no IP contract,,,78,,8.85,percent of total billed charges,,,70,,7.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.56,3324,
51079-0418-20 - temazepam 15 mg Cap,51079-0418-20,NDC,,,,inpatient,1,EA,11.35,6.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.65,percent of total billed charges,,,85,,9.65,percent of total billed charges,,,49,,5.56,percent of total billed charges,,,90,,10.22,percent of total billed charges,,,,,,,no IP contract,,80,,9.08,percent of total billed charges,,,,,,,no IP contract,,50,,5.68,percent of total billed charges,,,,,,no IP contract,,,78,,8.85,percent of total billed charges,,,70,,7.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.56,3324,
51079-0425-01 - glimepiride 2 mg Tab,51079-0425-01,NDC,,,,inpatient,1,EA,9,5.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.65,percent of total billed charges,,,85,,7.65,percent of total billed charges,,,49,,4.41,percent of total billed charges,,,90,,8.1,percent of total billed charges,,,,,,,no IP contract,,80,,7.2,percent of total billed charges,,,,,,,no IP contract,,50,,4.5,percent of total billed charges,,,,,,no IP contract,,,78,,7.02,percent of total billed charges,,,70,,6.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.41,3324,
51079-0425-20 - glimepiride 2 mg Tab,51079-0425-20,NDC,,,,inpatient,1,EA,9,5.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.65,percent of total billed charges,,,85,,7.65,percent of total billed charges,,,49,,4.41,percent of total billed charges,,,90,,8.1,percent of total billed charges,,,,,,,no IP contract,,80,,7.2,percent of total billed charges,,,,,,,no IP contract,,50,,4.5,percent of total billed charges,,,,,,no IP contract,,,78,,7.02,percent of total billed charges,,,70,,6.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.41,3324,
51079-0426-01 - glimepiride  4 mg Tab,51079-0426-01,NDC,,,,inpatient,1,EA,13.6,8.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.56,percent of total billed charges,,,85,,11.56,percent of total billed charges,,,49,,6.66,percent of total billed charges,,,90,,12.24,percent of total billed charges,,,,,,,no IP contract,,80,,10.88,percent of total billed charges,,,,,,,no IP contract,,50,,6.8,percent of total billed charges,,,,,,no IP contract,,,78,,10.61,percent of total billed charges,,,70,,9.52,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.66,3324,
51079-0426-20 - glimepiride 4 mg Tab,51079-0426-20,NDC,,,,inpatient,1,EA,13.6,8.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.56,percent of total billed charges,,,85,,11.56,percent of total billed charges,,,49,,6.66,percent of total billed charges,,,90,,12.24,percent of total billed charges,,,,,,,no IP contract,,80,,10.88,percent of total billed charges,,,,,,,no IP contract,,50,,6.8,percent of total billed charges,,,,,,no IP contract,,,78,,10.61,percent of total billed charges,,,70,,9.52,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.66,3324,
51079-0436-01 - doxepin 10 mg Cap,51079-0436-01,NDC,,,,inpatient,1,EA,6.7,4.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.7,percent of total billed charges,,,85,,5.7,percent of total billed charges,,,49,,3.28,percent of total billed charges,,,90,,6.03,percent of total billed charges,,,,,,,no IP contract,,80,,5.36,percent of total billed charges,,,,,,,no IP contract,,50,,3.35,percent of total billed charges,,,,,,no IP contract,,,78,,5.23,percent of total billed charges,,,70,,4.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.28,3324,
51079-0436-20 - doxepin 10 mg Cap,51079-0436-20,NDC,,,,inpatient,1,EA,6.35,3.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.4,percent of total billed charges,,,85,,5.4,percent of total billed charges,,,49,,3.11,percent of total billed charges,,,90,,5.72,percent of total billed charges,,,,,,,no IP contract,,80,,5.08,percent of total billed charges,,,,,,,no IP contract,,50,,3.18,percent of total billed charges,,,,,,no IP contract,,,78,,4.95,percent of total billed charges,,,70,,4.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.11,3324,
51079-0437-01 - doxepin 25 mg Cap,51079-0437-01,NDC,,,,inpatient,1,EA,7.25,4.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.16,percent of total billed charges,,,85,,6.16,percent of total billed charges,,,49,,3.55,percent of total billed charges,,,90,,6.53,percent of total billed charges,,,,,,,no IP contract,,80,,5.8,percent of total billed charges,,,,,,,no IP contract,,50,,3.63,percent of total billed charges,,,,,,no IP contract,,,78,,5.66,percent of total billed charges,,,70,,5.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.55,3324,
51079-0437-20 - doxepin 25 mg Cap,51079-0437-20,NDC,,,,inpatient,1,EA,7.25,4.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.16,percent of total billed charges,,,85,,6.16,percent of total billed charges,,,49,,3.55,percent of total billed charges,,,90,,6.53,percent of total billed charges,,,,,,,no IP contract,,80,,5.8,percent of total billed charges,,,,,,,no IP contract,,50,,3.63,percent of total billed charges,,,,,,no IP contract,,,78,,5.66,percent of total billed charges,,,70,,5.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.55,3324,
51079-0438-01 - doxepin 50 mg Cap,51079-0438-01,NDC,,,,inpatient,1,EA,8.35,5.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.1,percent of total billed charges,,,85,,7.1,percent of total billed charges,,,49,,4.09,percent of total billed charges,,,90,,7.52,percent of total billed charges,,,,,,,no IP contract,,80,,6.68,percent of total billed charges,,,,,,,no IP contract,,50,,4.18,percent of total billed charges,,,,,,no IP contract,,,78,,6.51,percent of total billed charges,,,70,,5.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.09,3324,
51079-0438-20 - doxepin 50 mg Cap,51079-0438-20,NDC,,,,inpatient,1,EA,8.35,5.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.1,percent of total billed charges,,,85,,7.1,percent of total billed charges,,,49,,4.09,percent of total billed charges,,,90,,7.52,percent of total billed charges,,,,,,,no IP contract,,80,,6.68,percent of total billed charges,,,,,,,no IP contract,,50,,4.18,percent of total billed charges,,,,,,no IP contract,,,78,,6.51,percent of total billed charges,,,70,,5.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.09,3324,
51079-0440-20 - levothyroxine 50 mcg (0.05 mg) Tab,51079-0440-20,NDC,,,,inpatient,1,EA,6.55,3.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.57,percent of total billed charges,,,85,,5.57,percent of total billed charges,,,49,,3.21,percent of total billed charges,,,90,,5.9,percent of total billed charges,,,,,,,no IP contract,,80,,5.24,percent of total billed charges,,,,,,,no IP contract,,50,,3.28,percent of total billed charges,,,,,,no IP contract,,,78,,5.11,percent of total billed charges,,,70,,4.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.21,3324,
51079-0441-20 - levothyroxine 75 mcg (0.075 mg) Tab,51079-0441-20,NDC,,,,inpatient,1,EA,6.75,4.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.74,percent of total billed charges,,,85,,5.74,percent of total billed charges,,,49,,3.31,percent of total billed charges,,,90,,6.08,percent of total billed charges,,,,,,,no IP contract,,80,,5.4,percent of total billed charges,,,,,,,no IP contract,,50,,3.38,percent of total billed charges,,,,,,no IP contract,,,78,,5.27,percent of total billed charges,,,70,,4.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.31,3324,
51079-0442-20 - levothyroxine 100 mcg (0.1 mg) Tab,51079-0442-20,NDC,,,,inpatient,1,EA,6.85,4.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.82,percent of total billed charges,,,85,,5.82,percent of total billed charges,,,49,,3.36,percent of total billed charges,,,90,,6.17,percent of total billed charges,,,,,,,no IP contract,,80,,5.48,percent of total billed charges,,,,,,,no IP contract,,50,,3.43,percent of total billed charges,,,,,,no IP contract,,,78,,5.34,percent of total billed charges,,,70,,4.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.36,3324,
51079-0443-01 - levothyroxine 125 mcg (0.125 mg) Tab,51079-0443-01,NDC,,,,inpatient,1,EA,7.4,4.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.29,percent of total billed charges,,,85,,6.29,percent of total billed charges,,,49,,3.63,percent of total billed charges,,,90,,6.66,percent of total billed charges,,,,,,,no IP contract,,80,,5.92,percent of total billed charges,,,,,,,no IP contract,,50,,3.7,percent of total billed charges,,,,,,no IP contract,,,78,,5.77,percent of total billed charges,,,70,,5.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.63,3324,
51079-0444-20 - levothyroxine 25 mcg (0.025 mg) Tab,51079-0444-20,NDC,,,,inpatient,1,EA,6.2,3.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.27,percent of total billed charges,,,85,,5.27,percent of total billed charges,,,49,,3.04,percent of total billed charges,,,90,,5.58,percent of total billed charges,,,,,,,no IP contract,,80,,4.96,percent of total billed charges,,,,,,,no IP contract,,50,,3.1,percent of total billed charges,,,,,,no IP contract,,,78,,4.84,percent of total billed charges,,,70,,4.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.04,3324,
51079-0445-20 - levothyroxine 150 mcg (0.15 mg) Tab,51079-0445-20,NDC,,,,inpatient,1,EA,3.8,2.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.23,percent of total billed charges,,,85,,3.23,percent of total billed charges,,,49,,1.86,percent of total billed charges,,,90,,3.42,percent of total billed charges,,,,,,,no IP contract,,80,,3.04,percent of total billed charges,,,,,,,no IP contract,,50,,1.9,percent of total billed charges,,,,,,no IP contract,,,78,,2.96,percent of total billed charges,,,70,,2.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.86,3324,
51079-0450-20 - amlodipine 2.5 mg Tab,51079-0450-20,NDC,,,,inpatient,1,EA,17.6,10.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.96,percent of total billed charges,,,85,,14.96,percent of total billed charges,,,49,,8.62,percent of total billed charges,,,90,,15.84,percent of total billed charges,,,,,,,no IP contract,,80,,14.08,percent of total billed charges,,,,,,,no IP contract,,50,,8.8,percent of total billed charges,,,,,,no IP contract,,,78,,13.73,percent of total billed charges,,,70,,12.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.62,3324,
51079-0451-20 - amlodipine 5 mg Tab,51079-0451-20,NDC,,,,inpatient,1,EA,17.6,10.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.96,percent of total billed charges,,,85,,14.96,percent of total billed charges,,,49,,8.62,percent of total billed charges,,,90,,15.84,percent of total billed charges,,,,,,,no IP contract,,80,,14.08,percent of total billed charges,,,,,,,no IP contract,,50,,8.8,percent of total billed charges,,,,,,no IP contract,,,78,,13.73,percent of total billed charges,,,70,,12.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.62,3324,
51079-0452-20 - amlodipine 10 mg Tab,51079-0452-20,NDC,,,,inpatient,1,EA,22.65,13.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.25,percent of total billed charges,,,85,,19.25,percent of total billed charges,,,49,,11.1,percent of total billed charges,,,90,,20.39,percent of total billed charges,,,,,,,no IP contract,,80,,18.12,percent of total billed charges,,,,,,,no IP contract,,50,,11.33,percent of total billed charges,,,,,,no IP contract,,,78,,17.67,percent of total billed charges,,,70,,15.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.1,3324,
51079-0453-20 - midodrine 5 mg Tab,51079-0453-20,NDC,,,,inpatient,1,EA,25.35,15.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.55,percent of total billed charges,,,85,,21.55,percent of total billed charges,,,49,,12.42,percent of total billed charges,,,90,,22.82,percent of total billed charges,,,,,,,no IP contract,,80,,20.28,percent of total billed charges,,,,,,,no IP contract,,50,,12.68,percent of total billed charges,,,,,,no IP contract,,,78,,19.77,percent of total billed charges,,,70,,17.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.42,3324,
51079-0454-20 - simvastatin 10 mg Tab,51079-0454-20,NDC,,,,inpatient,1,EA,26,15.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.1,percent of total billed charges,,,85,,22.1,percent of total billed charges,,,49,,12.74,percent of total billed charges,,,90,,23.4,percent of total billed charges,,,,,,,no IP contract,,80,,20.8,percent of total billed charges,,,,,,,no IP contract,,50,,13,percent of total billed charges,,,,,,no IP contract,,,78,,20.28,percent of total billed charges,,,70,,18.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.74,3324,
51079-0455-20 - simvastatin 20 mg Tab,51079-0455-20,NDC,,,,inpatient,1,EA,42.95,25.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36.51,percent of total billed charges,,,85,,36.51,percent of total billed charges,,,49,,21.05,percent of total billed charges,,,90,,38.66,percent of total billed charges,,,,,,,no IP contract,,80,,34.36,percent of total billed charges,,,,,,,no IP contract,,50,,21.48,percent of total billed charges,,,,,,no IP contract,,,78,,33.5,percent of total billed charges,,,70,,30.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.05,3324,
51079-0458-20 - pravastatin 20 mg Tab,51079-0458-20,NDC,,,,inpatient,1,EA,29.8,17.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.33,percent of total billed charges,,,85,,25.33,percent of total billed charges,,,49,,14.6,percent of total billed charges,,,90,,26.82,percent of total billed charges,,,,,,,no IP contract,,80,,23.84,percent of total billed charges,,,,,,,no IP contract,,50,,14.9,percent of total billed charges,,,,,,no IP contract,,,78,,23.24,percent of total billed charges,,,70,,20.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.6,3324,
51079-0460-20 - risperidone 0.25 mg Tab,51079-0460-20,NDC,,,,inpatient,1,EA,34.75,20.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.54,percent of total billed charges,,,85,,29.54,percent of total billed charges,,,49,,17.03,percent of total billed charges,,,90,,31.28,percent of total billed charges,,,,,,,no IP contract,,80,,27.8,percent of total billed charges,,,,,,,no IP contract,,50,,17.38,percent of total billed charges,,,,,,no IP contract,,,78,,27.11,percent of total billed charges,,,70,,24.33,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.03,3324,
51079-0461-20 - risperidone 0.5 mg Tab,51079-0461-20,NDC,,,,inpatient,1,EA,37.75,22.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.09,percent of total billed charges,,,85,,32.09,percent of total billed charges,,,49,,18.5,percent of total billed charges,,,90,,33.98,percent of total billed charges,,,,,,,no IP contract,,80,,30.2,percent of total billed charges,,,,,,,no IP contract,,50,,18.88,percent of total billed charges,,,,,,no IP contract,,,78,,29.45,percent of total billed charges,,,70,,26.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.5,3324,
51079-0462-20 - risperidone 1 mg Tab,51079-0462-20,NDC,,,,inpatient,1,EA,39.9,23.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.92,percent of total billed charges,,,85,,33.92,percent of total billed charges,,,49,,19.55,percent of total billed charges,,,90,,35.91,percent of total billed charges,,,,,,,no IP contract,,80,,31.92,percent of total billed charges,,,,,,,no IP contract,,50,,19.95,percent of total billed charges,,,,,,no IP contract,,,78,,31.12,percent of total billed charges,,,70,,27.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.55,3324,
51079-0463-01 - risperidone 2 mg Tab,51079-0463-01,NDC,,,,inpatient,1,EA,64.15,38.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,51.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,54.53,percent of total billed charges,,,85,,54.53,percent of total billed charges,,,49,,31.43,percent of total billed charges,,,90,,57.74,percent of total billed charges,,,,,,,no IP contract,,80,,51.32,percent of total billed charges,,,,,,,no IP contract,,50,,32.08,percent of total billed charges,,,,,,no IP contract,,,78,,50.04,percent of total billed charges,,,70,,44.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.43,3324,
51079-0463-20 - risperidone 2 mg Tab,51079-0463-20,NDC,,,,inpatient,1,EA,64.15,38.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,51.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,54.53,percent of total billed charges,,,85,,54.53,percent of total billed charges,,,49,,31.43,percent of total billed charges,,,90,,57.74,percent of total billed charges,,,,,,,no IP contract,,80,,51.32,percent of total billed charges,,,,,,,no IP contract,,50,,32.08,percent of total billed charges,,,,,,no IP contract,,,78,,50.04,percent of total billed charges,,,70,,44.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.43,3324,
51079-0474-01 - divalproex 250 mg EC Tablet,51079-0474-01,NDC,,,,inpatient,1,EA,19.4,11.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.49,percent of total billed charges,,,85,,16.49,percent of total billed charges,,,49,,9.51,percent of total billed charges,,,90,,17.46,percent of total billed charges,,,,,,,no IP contract,,80,,15.52,percent of total billed charges,,,,,,,no IP contract,,50,,9.7,percent of total billed charges,,,,,,no IP contract,,,78,,15.13,percent of total billed charges,,,70,,13.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.51,3324,
51079-0474-20 - divalproex 250 mg EC Tablet,51079-0474-20,NDC,,,,inpatient,1,EA,19.4,11.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.49,percent of total billed charges,,,85,,16.49,percent of total billed charges,,,49,,9.51,percent of total billed charges,,,90,,17.46,percent of total billed charges,,,,,,,no IP contract,,80,,15.52,percent of total billed charges,,,,,,,no IP contract,,50,,9.7,percent of total billed charges,,,,,,no IP contract,,,78,,15.13,percent of total billed charges,,,70,,13.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.51,3324,
51079-0481-20 - amantadine 100 mg Cap,51079-0481-20,NDC,,,,inpatient,1,EA,8.6,5.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.31,percent of total billed charges,,,85,,7.31,percent of total billed charges,,,49,,4.21,percent of total billed charges,,,90,,7.74,percent of total billed charges,,,,,,,no IP contract,,80,,6.88,percent of total billed charges,,,,,,,no IP contract,,50,,4.3,percent of total billed charges,,,,,,no IP contract,,,78,,6.71,percent of total billed charges,,,70,,6.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.21,3324,
51079-0482-20 - venlafaxine 75 mg Tab,51079-0482-20,NDC,,,,inpatient,1,EA,21.15,12.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.98,percent of total billed charges,,,85,,17.98,percent of total billed charges,,,49,,10.36,percent of total billed charges,,,90,,19.04,percent of total billed charges,,,,,,,no IP contract,,80,,16.92,percent of total billed charges,,,,,,,no IP contract,,50,,10.58,percent of total billed charges,,,,,,no IP contract,,,78,,16.5,percent of total billed charges,,,70,,14.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.36,3324,
51079-0485-20 - fluPHENAZine 1 mg Tab,51079-0485-20,NDC,,,,inpatient,1,EA,8.45,5.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.18,percent of total billed charges,,,85,,7.18,percent of total billed charges,,,49,,4.14,percent of total billed charges,,,90,,7.61,percent of total billed charges,,,,,,,no IP contract,,80,,6.76,percent of total billed charges,,,,,,,no IP contract,,50,,4.23,percent of total billed charges,,,,,,no IP contract,,,78,,6.59,percent of total billed charges,,,70,,5.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.14,3324,
51079-0486-20 - fluphenazine 2.5 mg Tab,51079-0486-20,NDC,,,,inpatient,1,EA,11,6.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.35,percent of total billed charges,,,85,,9.35,percent of total billed charges,,,49,,5.39,percent of total billed charges,,,90,,9.9,percent of total billed charges,,,,,,,no IP contract,,80,,8.8,percent of total billed charges,,,,,,,no IP contract,,50,,5.5,percent of total billed charges,,,,,,no IP contract,,,78,,8.58,percent of total billed charges,,,70,,7.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.39,3324,
51079-0498-20 - lamotrigine 25 mg Tab,51079-0498-20,NDC,,,,inpatient,1,EA,36.9,22.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.37,percent of total billed charges,,,85,,31.37,percent of total billed charges,,,49,,18.08,percent of total billed charges,,,90,,33.21,percent of total billed charges,,,,,,,no IP contract,,80,,29.52,percent of total billed charges,,,,,,,no IP contract,,50,,18.45,percent of total billed charges,,,,,,no IP contract,,,78,,28.78,percent of total billed charges,,,70,,25.83,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.08,3324,
51079-0508-20 - mycophenolic acid 180 mg EC Ta,51079-0508-20,NDC,,,,inpatient,1,EA,44.05,26.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,35.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,37.44,percent of total billed charges,,,85,,37.44,percent of total billed charges,,,49,,21.58,percent of total billed charges,,,90,,39.65,percent of total billed charges,,,,,,,no IP contract,,80,,35.24,percent of total billed charges,,,,,,,no IP contract,,50,,22.03,percent of total billed charges,,,,,,no IP contract,,,78,,34.36,percent of total billed charges,,,70,,30.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.58,3324,
51079-0518-20 - chlorproMAZINE 10 mg Tab,51079-0518-20,NDC,,,,inpatient,1,EA,6.6,3.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.61,percent of total billed charges,,,85,,5.61,percent of total billed charges,,,49,,3.23,percent of total billed charges,,,90,,5.94,percent of total billed charges,,,,,,,no IP contract,,80,,5.28,percent of total billed charges,,,,,,,no IP contract,,50,,3.3,percent of total billed charges,,,,,,no IP contract,,,78,,5.15,percent of total billed charges,,,70,,4.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.23,3324,
51079-0519-01 - chlorproMAZINE 25 mg Tab,51079-0519-01,NDC,,,,inpatient,1,EA,6.15,3.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.23,percent of total billed charges,,,85,,5.23,percent of total billed charges,,,49,,3.01,percent of total billed charges,,,90,,5.54,percent of total billed charges,,,,,,,no IP contract,,80,,4.92,percent of total billed charges,,,,,,,no IP contract,,50,,3.08,percent of total billed charges,,,,,,no IP contract,,,78,,4.8,percent of total billed charges,,,70,,4.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.01,3324,
51079-0519-20 - chlorproMAZINE 25 mg Tab,51079-0519-20,NDC,,,,inpatient,1,EA,6.05,3.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.14,percent of total billed charges,,,85,,5.14,percent of total billed charges,,,49,,2.96,percent of total billed charges,,,90,,5.45,percent of total billed charges,,,,,,,no IP contract,,80,,4.84,percent of total billed charges,,,,,,,no IP contract,,50,,3.03,percent of total billed charges,,,,,,no IP contract,,,78,,4.72,percent of total billed charges,,,70,,4.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.96,3324,
51079-0524-20 - ondansetron 4 mg Tab,51079-0524-20,NDC,,,,inpatient,1,EA,200.85,120.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,162.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,170.72,percent of total billed charges,,,85,,170.72,percent of total billed charges,,,49,,98.42,percent of total billed charges,,,90,,180.77,percent of total billed charges,,,,,,,no IP contract,,80,,160.68,percent of total billed charges,,,,,,,no IP contract,,50,,100.43,percent of total billed charges,,,,,,no IP contract,,,78,,156.66,percent of total billed charges,,,70,,140.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,98.42,3324,
51079-0538-01 - loratadine 10 mg Tab,51079-0538-01,NDC,,,,inpatient,1,EA,10.65,6.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.05,percent of total billed charges,,,85,,9.05,percent of total billed charges,,,49,,5.22,percent of total billed charges,,,90,,9.59,percent of total billed charges,,,,,,,no IP contract,,80,,8.52,percent of total billed charges,,,,,,,no IP contract,,50,,5.33,percent of total billed charges,,,,,,no IP contract,,,78,,8.31,percent of total billed charges,,,70,,7.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.22,3324,
51079-0538-20 - loratadine 10 mg Tab,51079-0538-20,NDC,,,,inpatient,1,EA,10.65,6.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.05,percent of total billed charges,,,85,,9.05,percent of total billed charges,,,49,,5.22,percent of total billed charges,,,90,,9.59,percent of total billed charges,,,,,,,no IP contract,,80,,8.52,percent of total billed charges,,,,,,,no IP contract,,50,,5.33,percent of total billed charges,,,,,,no IP contract,,,78,,8.31,percent of total billed charges,,,70,,7.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.22,3324,
51079-0541-01 - prochlorperazine 5 mg Tab,51079-0541-01,NDC,,,,inpatient,1,EA,8.65,5.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.35,percent of total billed charges,,,85,,7.35,percent of total billed charges,,,49,,4.24,percent of total billed charges,,,90,,7.79,percent of total billed charges,,,,,,,no IP contract,,80,,6.92,percent of total billed charges,,,,,,,no IP contract,,50,,4.33,percent of total billed charges,,,,,,no IP contract,,,78,,6.75,percent of total billed charges,,,70,,6.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.24,3324,
51079-0541-20 - prochlorperazine 5 mg Tab,51079-0541-20,NDC,,,,inpatient,1,EA,8.65,5.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.35,percent of total billed charges,,,85,,7.35,percent of total billed charges,,,49,,4.24,percent of total billed charges,,,90,,7.79,percent of total billed charges,,,,,,,no IP contract,,80,,6.92,percent of total billed charges,,,,,,,no IP contract,,50,,4.33,percent of total billed charges,,,,,,no IP contract,,,78,,6.75,percent of total billed charges,,,70,,6.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.24,3324,
51079-0542-20 - prochlorperazine 10 mg Tab,51079-0542-20,NDC,,,,inpatient,1,EA,11.15,6.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.48,percent of total billed charges,,,85,,9.48,percent of total billed charges,,,49,,5.46,percent of total billed charges,,,90,,10.04,percent of total billed charges,,,,,,,no IP contract,,80,,8.92,percent of total billed charges,,,,,,,no IP contract,,50,,5.58,percent of total billed charges,,,,,,no IP contract,,,78,,8.7,percent of total billed charges,,,70,,7.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.46,3324,
51079-0543-20 - excitalopram 10 mg Tab,51079-0543-20,NDC,,,,inpatient,1,EA,38.9,23.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.07,percent of total billed charges,,,85,,33.07,percent of total billed charges,,,49,,19.06,percent of total billed charges,,,90,,35.01,percent of total billed charges,,,,,,,no IP contract,,80,,31.12,percent of total billed charges,,,,,,,no IP contract,,50,,19.45,percent of total billed charges,,,,,,no IP contract,,,78,,30.34,percent of total billed charges,,,70,,27.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.06,3324,
51079-0544-01 - escitalopram 20 mg Tab,51079-0544-01,NDC,,,,inpatient,1,EA,40.4,24.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34.34,percent of total billed charges,,,85,,34.34,percent of total billed charges,,,49,,19.8,percent of total billed charges,,,90,,36.36,percent of total billed charges,,,,,,,no IP contract,,80,,32.32,percent of total billed charges,,,,,,,no IP contract,,50,,20.2,percent of total billed charges,,,,,,no IP contract,,,78,,31.51,percent of total billed charges,,,70,,28.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.8,3324,
51079-0544-20 - escitalopram 20 mg Tab,51079-0544-20,NDC,,,,inpatient,1,EA,40.4,24.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34.34,percent of total billed charges,,,85,,34.34,percent of total billed charges,,,49,,19.8,percent of total billed charges,,,90,,36.36,percent of total billed charges,,,,,,,no IP contract,,80,,32.32,percent of total billed charges,,,,,,,no IP contract,,50,,20.2,percent of total billed charges,,,,,,no IP contract,,,78,,31.51,percent of total billed charges,,,70,,28.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.8,3324,
51079-0547-20 - fexofenadine 60 mg Tab,51079-0547-20,NDC,,,,inpatient,1,EA,15.85,9.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.47,percent of total billed charges,,,85,,13.47,percent of total billed charges,,,49,,7.77,percent of total billed charges,,,90,,14.27,percent of total billed charges,,,,,,,no IP contract,,80,,12.68,percent of total billed charges,,,,,,,no IP contract,,50,,7.93,percent of total billed charges,,,,,,no IP contract,,,78,,12.36,percent of total billed charges,,,70,,11.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.77,3324,
51079-0548-20 - fexofenadine 180 mg Tab,51079-0548-20,NDC,,,,inpatient,1,EA,23.15,13.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.68,percent of total billed charges,,,85,,19.68,percent of total billed charges,,,49,,11.34,percent of total billed charges,,,90,,20.84,percent of total billed charges,,,,,,,no IP contract,,80,,18.52,percent of total billed charges,,,,,,,no IP contract,,50,,11.58,percent of total billed charges,,,,,,no IP contract,,,78,,18.06,percent of total billed charges,,,70,,16.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.34,3324,
51079-0555-03 - repaglinide 2 mg Tab,51079-0555-03,NDC,,,,inpatient,1,EA,12.75,7.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.84,percent of total billed charges,,,85,,10.84,percent of total billed charges,,,49,,6.25,percent of total billed charges,,,90,,11.48,percent of total billed charges,,,,,,,no IP contract,,80,,10.2,percent of total billed charges,,,,,,,no IP contract,,50,,6.38,percent of total billed charges,,,,,,no IP contract,,,78,,9.95,percent of total billed charges,,,70,,8.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.25,3324,
51079-0557-20 - clopidogrel 75 mg Tab,51079-0557-20,NDC,,,,inpatient,1,EA,7.1,4.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.04,percent of total billed charges,,,85,,6.04,percent of total billed charges,,,49,,3.48,percent of total billed charges,,,90,,6.39,percent of total billed charges,,,,,,,no IP contract,,80,,5.68,percent of total billed charges,,,,,,,no IP contract,,50,,3.55,percent of total billed charges,,,,,,no IP contract,,,78,,5.54,percent of total billed charges,,,70,,4.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.48,3324,
51079-0559-20 - quinine 325 mg Cap,51079-0559-20,NDC,,,,inpatient,1,EA,5.25,3.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.46,percent of total billed charges,,,85,,4.46,percent of total billed charges,,,49,,2.57,percent of total billed charges,,,90,,4.73,percent of total billed charges,,,,,,,no IP contract,,80,,4.2,percent of total billed charges,,,,,,,no IP contract,,50,,2.63,percent of total billed charges,,,,,,no IP contract,,,78,,4.1,percent of total billed charges,,,70,,3.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.57,3324,
51079-0567-20 - thioridazine 50 mg Tab,51079-0567-20,NDC,,,,inpatient,1,EA,11.4,6.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.69,percent of total billed charges,,,85,,9.69,percent of total billed charges,,,49,,5.59,percent of total billed charges,,,90,,10.26,percent of total billed charges,,,,,,,no IP contract,,80,,9.12,percent of total billed charges,,,,,,,no IP contract,,50,,5.7,percent of total billed charges,,,,,,no IP contract,,,78,,8.89,percent of total billed charges,,,70,,7.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.59,3324,
51079-0581-06 - leucovorin 5 mg Tab,51079-0581-06,NDC,,,,inpatient,1,EA,29.65,17.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.2,percent of total billed charges,,,85,,25.2,percent of total billed charges,,,49,,14.53,percent of total billed charges,,,90,,26.69,percent of total billed charges,,,,,,,no IP contract,,80,,23.72,percent of total billed charges,,,,,,,no IP contract,,50,,14.83,percent of total billed charges,,,,,,no IP contract,,,78,,23.13,percent of total billed charges,,,70,,20.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.53,3324,
51079-0597-20 - cetirizine 10 mg Tab,51079-0597-20,NDC,,,,inpatient,1,EA,23.6,14.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.06,percent of total billed charges,,,85,,20.06,percent of total billed charges,,,49,,11.56,percent of total billed charges,,,90,,21.24,percent of total billed charges,,,,,,,no IP contract,,80,,18.88,percent of total billed charges,,,,,,,no IP contract,,50,,11.8,percent of total billed charges,,,,,,no IP contract,,,78,,18.41,percent of total billed charges,,,70,,16.52,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.56,3324,
51079-0610-01 - dicloxacillin 250 mg Cap,51079-0610-01,NDC,,,,inpatient,1,EA,7.1,4.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.04,percent of total billed charges,,,85,,6.04,percent of total billed charges,,,49,,3.48,percent of total billed charges,,,90,,6.39,percent of total billed charges,,,,,,,no IP contract,,80,,5.68,percent of total billed charges,,,,,,,no IP contract,,50,,3.55,percent of total billed charges,,,,,,no IP contract,,,78,,5.54,percent of total billed charges,,,70,,4.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.48,3324,
51079-0610-20 - dicloxacillin 250 mg Cap,51079-0610-20,NDC,,,,inpatient,1,EA,7.1,4.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.04,percent of total billed charges,,,85,,6.04,percent of total billed charges,,,49,,3.48,percent of total billed charges,,,90,,6.39,percent of total billed charges,,,,,,,no IP contract,,80,,5.68,percent of total billed charges,,,,,,,no IP contract,,50,,3.55,percent of total billed charges,,,,,,no IP contract,,,78,,5.54,percent of total billed charges,,,70,,4.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.48,3324,
51079-0623-81 - mafenide topical 85 mg/g Cream,51079-0623-81,NDC,,,,inpatient,1,UN,439.05,263.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,355.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,373.19,percent of total billed charges,,,85,,373.19,percent of total billed charges,,,49,,215.13,percent of total billed charges,,,90,,395.15,percent of total billed charges,,,,,,,no IP contract,,80,,351.24,percent of total billed charges,,,,,,,no IP contract,,50,,219.53,percent of total billed charges,,,,,,no IP contract,,,78,,342.46,percent of total billed charges,,,70,,307.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,215.13,3324,
51079-0630-20 - prazosin 1 mg Cap,51079-0630-20,NDC,,,,inpatient,1,EA,6.15,3.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.23,percent of total billed charges,,,85,,5.23,percent of total billed charges,,,49,,3.01,percent of total billed charges,,,90,,5.54,percent of total billed charges,,,,,,,no IP contract,,80,,4.92,percent of total billed charges,,,,,,,no IP contract,,50,,3.08,percent of total billed charges,,,,,,no IP contract,,,78,,4.8,percent of total billed charges,,,70,,4.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.01,3324,
51079-0632-20 - prazosin 5 mg Cap,51079-0632-20,NDC,,,,inpatient,1,EA,9,5.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.65,percent of total billed charges,,,85,,7.65,percent of total billed charges,,,49,,4.41,percent of total billed charges,,,90,,8.1,percent of total billed charges,,,,,,,no IP contract,,80,,7.2,percent of total billed charges,,,,,,,no IP contract,,50,,4.5,percent of total billed charges,,,,,,no IP contract,,,78,,7.02,percent of total billed charges,,,70,,6.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.41,3324,
51079-0644-20 - cyclobenzaprine 10 mg Tab,51079-0644-20,NDC,,,,inpatient,1,EA,11.55,6.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.82,percent of total billed charges,,,85,,9.82,percent of total billed charges,,,49,,5.66,percent of total billed charges,,,90,,10.4,percent of total billed charges,,,,,,,no IP contract,,80,,9.24,percent of total billed charges,,,,,,,no IP contract,,50,,5.78,percent of total billed charges,,,,,,no IP contract,,,78,,9.01,percent of total billed charges,,,70,,8.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.66,3324,
51079-0644-20 - cyclobenzaprine 10 mg Tab,51079-0644-20,NDC,,,,inpatient,1,EA,11.55,6.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.82,percent of total billed charges,,,85,,9.82,percent of total billed charges,,,49,,5.66,percent of total billed charges,,,90,,10.4,percent of total billed charges,,,,,,,no IP contract,,80,,9.24,percent of total billed charges,,,,,,,no IP contract,,50,,5.78,percent of total billed charges,,,,,,no IP contract,,,78,,9.01,percent of total billed charges,,,70,,8.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.66,3324,
51079-0682-20 - verapamil 80 mg Tab,51079-0682-20,NDC,,,,inpatient,1,EA,7.15,4.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.08,percent of total billed charges,,,85,,6.08,percent of total billed charges,,,49,,3.5,percent of total billed charges,,,90,,6.44,percent of total billed charges,,,,,,,no IP contract,,80,,5.72,percent of total billed charges,,,,,,,no IP contract,,50,,3.58,percent of total billed charges,,,,,,no IP contract,,,78,,5.58,percent of total billed charges,,,70,,5.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.5,3324,
51079-0683-20 - verapamil 120 mg Tab,51079-0683-20,NDC,,,,inpatient,1,EA,8.3,4.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.06,percent of total billed charges,,,85,,7.06,percent of total billed charges,,,49,,4.07,percent of total billed charges,,,90,,7.47,percent of total billed charges,,,,,,,no IP contract,,80,,6.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.15,percent of total billed charges,,,,,,no IP contract,,,78,,6.47,percent of total billed charges,,,70,,5.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.07,3324,
51079-0684-01 - atenolol 50 mg Tab,51079-0684-01,NDC,,,,inpatient,1,EA,214.5,128.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,173.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,182.33,percent of total billed charges,,,85,,182.33,percent of total billed charges,,,49,,105.11,percent of total billed charges,,,90,,193.05,percent of total billed charges,,,,,,,no IP contract,,80,,171.6,percent of total billed charges,,,,,,,no IP contract,,50,,107.25,percent of total billed charges,,,,,,no IP contract,,,78,,167.31,percent of total billed charges,,,70,,150.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,105.11,3324,
51079-0690-20 - loperamide 2 mg Cap,51079-0690-20,NDC,,,,inpatient,1,EA,9.4,5.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.99,percent of total billed charges,,,85,,7.99,percent of total billed charges,,,49,,4.61,percent of total billed charges,,,90,,8.46,percent of total billed charges,,,,,,,no IP contract,,80,,7.52,percent of total billed charges,,,,,,,no IP contract,,50,,4.7,percent of total billed charges,,,,,,no IP contract,,,78,,7.33,percent of total billed charges,,,70,,6.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.61,3324,
51079-0721-01 - mycophenolate 250 mg Cap,51079-0721-01,NDC,,,,inpatient,1,EA,35.3,21.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.01,percent of total billed charges,,,85,,30.01,percent of total billed charges,,,49,,17.3,percent of total billed charges,,,90,,31.77,percent of total billed charges,,,,,,,no IP contract,,80,,28.24,percent of total billed charges,,,,,,,no IP contract,,50,,17.65,percent of total billed charges,,,,,,no IP contract,,,78,,27.53,percent of total billed charges,,,70,,24.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.3,3324,
51079-0721-20 - mycophenolate mofetil 250 mg Cap,51079-0721-20,NDC,,,,inpatient,1,EA,35.3,21.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.01,percent of total billed charges,,,85,,30.01,percent of total billed charges,,,49,,17.3,percent of total billed charges,,,90,,31.77,percent of total billed charges,,,,,,,no IP contract,,80,,28.24,percent of total billed charges,,,,,,,no IP contract,,50,,17.65,percent of total billed charges,,,,,,no IP contract,,,78,,27.53,percent of total billed charges,,,70,,24.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.3,3324,
51079-0723-20 - oxybutynin 10 mg ER Ta,51079-0723-20,NDC,,,,inpatient,1,EA,30,18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.5,percent of total billed charges,,,85,,25.5,percent of total billed charges,,,49,,14.7,percent of total billed charges,,,90,,27,percent of total billed charges,,,,,,,no IP contract,,80,,24,percent of total billed charges,,,,,,,no IP contract,,50,,15,percent of total billed charges,,,,,,no IP contract,,,78,,23.4,percent of total billed charges,,,70,,21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.7,3324,
51079-0724-20 - zolpidem 5 mg Tab,51079-0724-20,NDC,,,,inpatient,1,EA,43.9,26.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,35.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,37.32,percent of total billed charges,,,85,,37.32,percent of total billed charges,,,49,,21.51,percent of total billed charges,,,90,,39.51,percent of total billed charges,,,,,,,no IP contract,,80,,35.12,percent of total billed charges,,,,,,,no IP contract,,50,,21.95,percent of total billed charges,,,,,,no IP contract,,,78,,34.24,percent of total billed charges,,,70,,30.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.51,3324,
51079-0731-20 - ibuprofen 200 mg Tab,51079-0731-20,NDC,,,,inpatient,1,EA,4.4,2.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.74,percent of total billed charges,,,85,,3.74,percent of total billed charges,,,49,,2.16,percent of total billed charges,,,90,,3.96,percent of total billed charges,,,,,,,no IP contract,,80,,3.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.2,percent of total billed charges,,,,,,no IP contract,,,78,,3.43,percent of total billed charges,,,70,,3.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.16,3324,
51079-0733-01 - haloperidol 0.5 mg Tab,51079-0733-01,NDC,,,,inpatient,1,EA,4.85,2.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.12,percent of total billed charges,,,85,,4.12,percent of total billed charges,,,49,,2.38,percent of total billed charges,,,90,,4.37,percent of total billed charges,,,,,,,no IP contract,,80,,3.88,percent of total billed charges,,,,,,,no IP contract,,50,,2.43,percent of total billed charges,,,,,,no IP contract,,,78,,3.78,percent of total billed charges,,,70,,3.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.38,3324,
51079-0733-20 - haloperidol 0.5 mg Tab,51079-0733-20,NDC,,,,inpatient,1,EA,5.8,3.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.93,percent of total billed charges,,,85,,4.93,percent of total billed charges,,,49,,2.84,percent of total billed charges,,,90,,5.22,percent of total billed charges,,,,,,,no IP contract,,80,,4.64,percent of total billed charges,,,,,,,no IP contract,,50,,2.9,percent of total billed charges,,,,,,no IP contract,,,78,,4.52,percent of total billed charges,,,70,,4.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.84,3324,
51079-0734-01 - haloperidol 1 mg Tab,51079-0734-01,NDC,,,,inpatient,1,EA,5.5,3.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.68,percent of total billed charges,,,85,,4.68,percent of total billed charges,,,49,,2.7,percent of total billed charges,,,90,,4.95,percent of total billed charges,,,,,,,no IP contract,,80,,4.4,percent of total billed charges,,,,,,,no IP contract,,50,,2.75,percent of total billed charges,,,,,,no IP contract,,,78,,4.29,percent of total billed charges,,,70,,3.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.7,3324,
51079-0736-01 - haloperidol 5 mg Tab,51079-0736-01,NDC,,,,inpatient,1,EA,243.85,146.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,197.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,207.27,percent of total billed charges,,,85,,207.27,percent of total billed charges,,,49,,119.49,percent of total billed charges,,,90,,219.47,percent of total billed charges,,,,,,,no IP contract,,80,,195.08,percent of total billed charges,,,,,,,no IP contract,,50,,121.93,percent of total billed charges,,,,,,no IP contract,,,78,,190.2,percent of total billed charges,,,70,,170.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,119.49,3324,
51079-0736-20 - haloperidol 5 mg Tab,51079-0736-20,NDC,,,,inpatient,1,EA,10.05,6.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.54,percent of total billed charges,,,85,,8.54,percent of total billed charges,,,49,,4.92,percent of total billed charges,,,90,,9.05,percent of total billed charges,,,,,,,no IP contract,,80,,8.04,percent of total billed charges,,,,,,,no IP contract,,50,,5.03,percent of total billed charges,,,,,,no IP contract,,,78,,7.84,percent of total billed charges,,,70,,7.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.92,3324,
51079-0745-20 - diltiazem 30 mg Tab,51079-0745-20,NDC,,,,inpatient,1,EA,7.4,4.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.29,percent of total billed charges,,,85,,6.29,percent of total billed charges,,,49,,3.63,percent of total billed charges,,,90,,6.66,percent of total billed charges,,,,,,,no IP contract,,80,,5.92,percent of total billed charges,,,,,,,no IP contract,,50,,3.7,percent of total billed charges,,,,,,no IP contract,,,78,,5.77,percent of total billed charges,,,70,,5.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.63,3324,
51079-0746-20 - diltiazem 60 mg Tab,51079-0746-20,NDC,,,,inpatient,1,EA,9.4,5.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.99,percent of total billed charges,,,85,,7.99,percent of total billed charges,,,49,,4.61,percent of total billed charges,,,90,,8.46,percent of total billed charges,,,,,,,no IP contract,,80,,7.52,percent of total billed charges,,,,,,,no IP contract,,50,,4.7,percent of total billed charges,,,,,,no IP contract,,,78,,7.33,percent of total billed charges,,,70,,6.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.61,3324,
51079-0747-20 - diltiazem 90 mg Tab,51079-0747-20,NDC,,,,inpatient,1,EA,12.6,7.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.71,percent of total billed charges,,,85,,10.71,percent of total billed charges,,,49,,6.17,percent of total billed charges,,,90,,11.34,percent of total billed charges,,,,,,,no IP contract,,80,,10.08,percent of total billed charges,,,,,,,no IP contract,,50,,6.3,percent of total billed charges,,,,,,no IP contract,,,78,,9.83,percent of total billed charges,,,70,,8.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.17,3324,
51079-0753-20 - sucralfate 1 g Tab,51079-0753-20,NDC,,,,inpatient,1,EA,6.85,4.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.82,percent of total billed charges,,,85,,5.82,percent of total billed charges,,,49,,3.36,percent of total billed charges,,,90,,6.17,percent of total billed charges,,,,,,,no IP contract,,80,,5.48,percent of total billed charges,,,,,,,no IP contract,,50,,3.43,percent of total billed charges,,,,,,no IP contract,,,78,,5.34,percent of total billed charges,,,70,,4.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.36,3324,
51079-0755-20 - carbidopa-levodopa 10 mg-100 mg Tab,51079-0755-20,NDC,,,,inpatient,1,EA,9.55,5.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.12,percent of total billed charges,,,85,,8.12,percent of total billed charges,,,49,,4.68,percent of total billed charges,,,90,,8.6,percent of total billed charges,,,,,,,no IP contract,,80,,7.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.78,percent of total billed charges,,,,,,no IP contract,,,78,,7.45,percent of total billed charges,,,70,,6.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.68,3324,
51079-0759-01 - atenolol 25 mg Tab,51079-0759-01,NDC,,,,inpatient,1,EA,10.2,6.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.67,percent of total billed charges,,,85,,8.67,percent of total billed charges,,,49,,5,percent of total billed charges,,,90,,9.18,percent of total billed charges,,,,,,,no IP contract,,80,,8.16,percent of total billed charges,,,,,,,no IP contract,,50,,5.1,percent of total billed charges,,,,,,no IP contract,,,78,,7.96,percent of total billed charges,,,70,,7.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5,3324,
51079-0759-20 - atenolol 25 mg Tab,51079-0759-20,NDC,,,,inpatient,1,EA,10.2,6.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.67,percent of total billed charges,,,85,,8.67,percent of total billed charges,,,49,,5,percent of total billed charges,,,90,,9.18,percent of total billed charges,,,,,,,no IP contract,,80,,8.16,percent of total billed charges,,,,,,,no IP contract,,50,,5.1,percent of total billed charges,,,,,,no IP contract,,,78,,7.96,percent of total billed charges,,,70,,7.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5,3324,
51079-0762-01 - sertraline 25 mg Tab,51079-0762-01,NDC,,,,inpatient,1,EA,26.5,15.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.53,percent of total billed charges,,,85,,22.53,percent of total billed charges,,,49,,12.99,percent of total billed charges,,,90,,23.85,percent of total billed charges,,,,,,,no IP contract,,80,,21.2,percent of total billed charges,,,,,,,no IP contract,,50,,13.25,percent of total billed charges,,,,,,no IP contract,,,78,,20.67,percent of total billed charges,,,70,,18.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.99,3324,
51079-0762-20 - sertraline 25 mg Tab,51079-0762-20,NDC,,,,inpatient,1,EA,26.5,15.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.53,percent of total billed charges,,,85,,22.53,percent of total billed charges,,,49,,12.99,percent of total billed charges,,,90,,23.85,percent of total billed charges,,,,,,,no IP contract,,80,,21.2,percent of total billed charges,,,,,,,no IP contract,,50,,13.25,percent of total billed charges,,,,,,no IP contract,,,78,,20.67,percent of total billed charges,,,70,,18.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.99,3324,
51079-0766-01 - divalproex sodium 250 mg ER Tablet,51079-0766-01,NDC,,,,inpatient,1,EA,15.45,9.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.13,percent of total billed charges,,,85,,13.13,percent of total billed charges,,,49,,7.57,percent of total billed charges,,,90,,13.91,percent of total billed charges,,,,,,,no IP contract,,80,,12.36,percent of total billed charges,,,,,,,no IP contract,,50,,7.73,percent of total billed charges,,,,,,no IP contract,,,78,,12.05,percent of total billed charges,,,70,,10.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.57,3324,
51079-0766-08 - divalproex sodium 250 mg ER Ta,51079-0766-08,NDC,,,,inpatient,1,EA,17.2,10.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.62,percent of total billed charges,,,85,,14.62,percent of total billed charges,,,49,,8.43,percent of total billed charges,,,90,,15.48,percent of total billed charges,,,,,,,no IP contract,,80,,13.76,percent of total billed charges,,,,,,,no IP contract,,50,,8.6,percent of total billed charges,,,,,,no IP contract,,,78,,13.42,percent of total billed charges,,,70,,12.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.43,3324,
51079-0767-01 - divalproex sodium 500 mg ER Tablet,51079-0767-01,NDC,,,,inpatient,1,EA,24.25,14.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.61,percent of total billed charges,,,85,,20.61,percent of total billed charges,,,49,,11.88,percent of total billed charges,,,90,,21.83,percent of total billed charges,,,,,,,no IP contract,,80,,19.4,percent of total billed charges,,,,,,,no IP contract,,50,,12.13,percent of total billed charges,,,,,,no IP contract,,,78,,18.92,percent of total billed charges,,,70,,16.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.88,3324,
51079-0767-08 - divalproex sodium 500 mg ER Ta,51079-0767-08,NDC,,,,inpatient,1,EA,27.3,16.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.21,percent of total billed charges,,,85,,23.21,percent of total billed charges,,,49,,13.38,percent of total billed charges,,,90,,24.57,percent of total billed charges,,,,,,,no IP contract,,80,,21.84,percent of total billed charges,,,,,,,no IP contract,,50,,13.65,percent of total billed charges,,,,,,no IP contract,,,78,,21.29,percent of total billed charges,,,70,,19.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.38,3324,
51079-0768-20 - zonisamide 100 mg Cap,51079-0768-20,NDC,,,,inpatient,1,EA,19.55,11.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.62,percent of total billed charges,,,85,,16.62,percent of total billed charges,,,49,,9.58,percent of total billed charges,,,90,,17.6,percent of total billed charges,,,,,,,no IP contract,,80,,15.64,percent of total billed charges,,,,,,,no IP contract,,50,,9.78,percent of total billed charges,,,,,,no IP contract,,,78,,15.25,percent of total billed charges,,,70,,13.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.58,3324,
51079-0771-20 - carvedilol 3.125 mg Tab,51079-0771-20,NDC,,,,inpatient,1,EA,20.75,12.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.64,percent of total billed charges,,,85,,17.64,percent of total billed charges,,,49,,10.17,percent of total billed charges,,,90,,18.68,percent of total billed charges,,,,,,,no IP contract,,80,,16.6,percent of total billed charges,,,,,,,no IP contract,,50,,10.38,percent of total billed charges,,,,,,no IP contract,,,78,,16.19,percent of total billed charges,,,70,,14.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.17,3324,
51079-0774-20 - paroxetine 20 mg Tab,51079-0774-20,NDC,,,,inpatient,1,EA,25.55,15.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.72,percent of total billed charges,,,85,,21.72,percent of total billed charges,,,49,,12.52,percent of total billed charges,,,90,,23,percent of total billed charges,,,,,,,no IP contract,,80,,20.44,percent of total billed charges,,,,,,,no IP contract,,50,,12.78,percent of total billed charges,,,,,,no IP contract,,,78,,19.93,percent of total billed charges,,,70,,17.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.52,3324,
51079-0779-20 - APAP-HYDROcodone 325 mg-10 mg Tab,51079-0779-20,NDC,,,,inpatient,1,EA,7.6,4.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.46,percent of total billed charges,,,85,,6.46,percent of total billed charges,,,49,,3.72,percent of total billed charges,,,90,,6.84,percent of total billed charges,,,,,,,no IP contract,,80,,6.08,percent of total billed charges,,,,,,,no IP contract,,50,,3.8,percent of total billed charges,,,,,,no IP contract,,,78,,5.93,percent of total billed charges,,,70,,5.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.72,3324,
51079-0782-01 - pravastatin 40 mg Tab,51079-0782-01,NDC,,,,inpatient,1,EA,3796.55,2277.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3075.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3227.07,percent of total billed charges,,,85,,3227.07,percent of total billed charges,,,49,,1860.31,percent of total billed charges,,,90,,3416.9,percent of total billed charges,,,,,,,no IP contract,,80,,3037.24,percent of total billed charges,,,,,,,no IP contract,,50,,1898.28,percent of total billed charges,,,,,,no IP contract,,,78,,2961.31,percent of total billed charges,,,70,,2657.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3416.9,
51079-0782-20 - pravastatin 40 mg Tab,51079-0782-20,NDC,,,,inpatient,1,EA,41.75,25.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,35.49,percent of total billed charges,,,85,,35.49,percent of total billed charges,,,49,,20.46,percent of total billed charges,,,90,,37.58,percent of total billed charges,,,,,,,no IP contract,,80,,33.4,percent of total billed charges,,,,,,,no IP contract,,50,,20.88,percent of total billed charges,,,,,,no IP contract,,,78,,32.57,percent of total billed charges,,,70,,29.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.46,3324,
51079-0789-20 - alprazolam 0.5 mg Tab,51079-0789-20,NDC,,,,inpatient,1,EA,11.75,7.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.99,percent of total billed charges,,,85,,9.99,percent of total billed charges,,,49,,5.76,percent of total billed charges,,,90,,10.58,percent of total billed charges,,,,,,,no IP contract,,80,,9.4,percent of total billed charges,,,,,,,no IP contract,,50,,5.88,percent of total billed charges,,,,,,no IP contract,,,78,,9.17,percent of total billed charges,,,70,,8.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.76,3324,
51079-0801-20 - metoprolol 50 mg Tab,51079-0801-20,NDC,,,,inpatient,1,EA,8.35,5.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.1,percent of total billed charges,,,85,,7.1,percent of total billed charges,,,49,,4.09,percent of total billed charges,,,90,,7.52,percent of total billed charges,,,,,,,no IP contract,,80,,6.68,percent of total billed charges,,,,,,,no IP contract,,50,,4.18,percent of total billed charges,,,,,,no IP contract,,,78,,6.51,percent of total billed charges,,,70,,5.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.09,3324,
51079-0802-20 - metoprolol 100 mg Tab,51079-0802-20,NDC,,,,inpatient,1,EA,10.4,6.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.84,percent of total billed charges,,,85,,8.84,percent of total billed charges,,,49,,5.1,percent of total billed charges,,,90,,9.36,percent of total billed charges,,,,,,,no IP contract,,80,,8.32,percent of total billed charges,,,,,,,no IP contract,,50,,5.2,percent of total billed charges,,,,,,no IP contract,,,78,,8.11,percent of total billed charges,,,70,,7.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.1,3324,
51079-0810-20 - glipiZIDE 5 mg Tab,51079-0810-20,NDC,,,,inpatient,1,EA,6.75,4.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.74,percent of total billed charges,,,85,,5.74,percent of total billed charges,,,49,,3.31,percent of total billed charges,,,90,,6.08,percent of total billed charges,,,,,,,no IP contract,,80,,5.4,percent of total billed charges,,,,,,,no IP contract,,50,,3.38,percent of total billed charges,,,,,,no IP contract,,,78,,5.27,percent of total billed charges,,,70,,4.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.31,3324,
51079-0813-01 - nadolol 40 mg Tab,51079-0813-01,NDC,,,,inpatient,1,EA,12.4,7.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.54,percent of total billed charges,,,85,,10.54,percent of total billed charges,,,49,,6.08,percent of total billed charges,,,90,,11.16,percent of total billed charges,,,,,,,no IP contract,,80,,9.92,percent of total billed charges,,,,,,,no IP contract,,50,,6.2,percent of total billed charges,,,,,,no IP contract,,,78,,9.67,percent of total billed charges,,,70,,8.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.08,3324,
51079-0813-20 - nadolol 40 mg Tab,51079-0813-20,NDC,,,,inpatient,1,EA,12.4,7.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.54,percent of total billed charges,,,85,,10.54,percent of total billed charges,,,49,,6.08,percent of total billed charges,,,90,,11.16,percent of total billed charges,,,,,,,no IP contract,,80,,9.92,percent of total billed charges,,,,,,,no IP contract,,50,,6.2,percent of total billed charges,,,,,,no IP contract,,,78,,9.67,percent of total billed charges,,,70,,8.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.08,3324,
51079-0817-01 - tacrolimus 0.5 mg Cap,51079-0817-01,NDC,,,,inpatient,1,EA,21.55,12.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.32,percent of total billed charges,,,85,,18.32,percent of total billed charges,,,49,,10.56,percent of total billed charges,,,90,,19.4,percent of total billed charges,,,,,,,no IP contract,,80,,17.24,percent of total billed charges,,,,,,,no IP contract,,50,,10.78,percent of total billed charges,,,,,,no IP contract,,,78,,16.81,percent of total billed charges,,,70,,15.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.56,3324,
51079-0817-20 - tacrolimus 0.5 mg Cap,51079-0817-20,NDC,,,,inpatient,1,EA,21.55,12.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.32,percent of total billed charges,,,85,,18.32,percent of total billed charges,,,49,,10.56,percent of total billed charges,,,90,,19.4,percent of total billed charges,,,,,,,no IP contract,,80,,17.24,percent of total billed charges,,,,,,,no IP contract,,50,,10.78,percent of total billed charges,,,,,,no IP contract,,,78,,16.81,percent of total billed charges,,,70,,15.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.56,3324,
51079-0818-20 - tacrolimus 1 mg Cap,51079-0818-20,NDC,,,,inpatient,1,EA,39.3,23.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.41,percent of total billed charges,,,85,,33.41,percent of total billed charges,,,49,,19.26,percent of total billed charges,,,90,,35.37,percent of total billed charges,,,,,,,no IP contract,,80,,31.44,percent of total billed charges,,,,,,,no IP contract,,50,,19.65,percent of total billed charges,,,,,,no IP contract,,,78,,30.65,percent of total billed charges,,,70,,27.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.26,3324,
51079-0820-20 - levetiracetam 250 mg Tab,51079-0820-20,NDC,,,,inpatient,1,EA,539.6,323.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,437.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,458.66,percent of total billed charges,,,85,,458.66,percent of total billed charges,,,49,,264.4,percent of total billed charges,,,90,,485.64,percent of total billed charges,,,,,,,no IP contract,,80,,431.68,percent of total billed charges,,,,,,,no IP contract,,50,,269.8,percent of total billed charges,,,,,,no IP contract,,,78,,420.89,percent of total billed charges,,,70,,377.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,264.4,3324,
51079-0821-20 - levetiracetam 500 mg Tab,51079-0821-20,NDC,,,,inpatient,1,EA,31.75,19.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,25.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.99,percent of total billed charges,,,85,,26.99,percent of total billed charges,,,49,,15.56,percent of total billed charges,,,90,,28.58,percent of total billed charges,,,,,,,no IP contract,,80,,25.4,percent of total billed charges,,,,,,,no IP contract,,50,,15.88,percent of total billed charges,,,,,,no IP contract,,,78,,24.77,percent of total billed charges,,,70,,22.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.56,3324,
51079-0852-03 - galantamine 4 mg Tab,51079-0852-03,NDC,,,,inpatient,1,EA,15.65,9.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.3,percent of total billed charges,,,85,,13.3,percent of total billed charges,,,49,,7.67,percent of total billed charges,,,90,,14.09,percent of total billed charges,,,,,,,no IP contract,,80,,12.52,percent of total billed charges,,,,,,,no IP contract,,50,,7.83,percent of total billed charges,,,,,,no IP contract,,,78,,12.21,percent of total billed charges,,,70,,10.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.67,3324,
51079-0853-03 - galantamine 8 mg Tab,51079-0853-03,NDC,,,,inpatient,1,EA,37.35,22.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.75,percent of total billed charges,,,85,,31.75,percent of total billed charges,,,49,,18.3,percent of total billed charges,,,90,,33.62,percent of total billed charges,,,,,,,no IP contract,,80,,29.88,percent of total billed charges,,,,,,,no IP contract,,50,,18.68,percent of total billed charges,,,,,,no IP contract,,,78,,29.13,percent of total billed charges,,,70,,26.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.3,3324,
51079-0864-01 - captopril 25 mg Tab,51079-0864-01,NDC,,,,inpatient,1,EA,10.05,6.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.54,percent of total billed charges,,,85,,8.54,percent of total billed charges,,,49,,4.92,percent of total billed charges,,,90,,9.05,percent of total billed charges,,,,,,,no IP contract,,80,,8.04,percent of total billed charges,,,,,,,no IP contract,,50,,5.03,percent of total billed charges,,,,,,no IP contract,,,78,,7.84,percent of total billed charges,,,70,,7.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.92,3324,
51079-0864-20 - captopril 25 mg Tab,51079-0864-20,NDC,,,,inpatient,1,EA,10.05,6.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.54,percent of total billed charges,,,85,,8.54,percent of total billed charges,,,49,,4.92,percent of total billed charges,,,90,,9.05,percent of total billed charges,,,,,,,no IP contract,,80,,8.04,percent of total billed charges,,,,,,,no IP contract,,50,,5.03,percent of total billed charges,,,,,,no IP contract,,,78,,7.84,percent of total billed charges,,,70,,7.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.92,3324,
51079-0868-20 - indapamide 2.5 mg Tab,51079-0868-20,NDC,,,,inpatient,1,EA,10.1,6.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.59,percent of total billed charges,,,85,,8.59,percent of total billed charges,,,49,,4.95,percent of total billed charges,,,90,,9.09,percent of total billed charges,,,,,,,no IP contract,,80,,8.08,percent of total billed charges,,,,,,,no IP contract,,50,,5.05,percent of total billed charges,,,,,,no IP contract,,,78,,7.88,percent of total billed charges,,,70,,7.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.95,3324,
51079-0870-20 - carbamazepine 100 mg Chew,51079-0870-20,NDC,,,,inpatient,1,EA,6.15,3.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.23,percent of total billed charges,,,85,,5.23,percent of total billed charges,,,49,,3.01,percent of total billed charges,,,90,,5.54,percent of total billed charges,,,,,,,no IP contract,,80,,4.92,percent of total billed charges,,,,,,,no IP contract,,50,,3.08,percent of total billed charges,,,,,,no IP contract,,,78,,4.8,percent of total billed charges,,,70,,4.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.01,3324,
51079-0881-20 - clonazepam 0.5 mg Tab,51079-0881-20,NDC,,,,inpatient,1,EA,12.1,7.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.29,percent of total billed charges,,,85,,10.29,percent of total billed charges,,,49,,5.93,percent of total billed charges,,,90,,10.89,percent of total billed charges,,,,,,,no IP contract,,80,,9.68,percent of total billed charges,,,,,,,no IP contract,,50,,6.05,percent of total billed charges,,,,,,no IP contract,,,78,,9.44,percent of total billed charges,,,70,,8.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.93,3324,
51079-0882-20 - clonazepam 1 mg Tab,51079-0882-20,NDC,,,,inpatient,1,EA,13,7.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.05,percent of total billed charges,,,85,,11.05,percent of total billed charges,,,49,,6.37,percent of total billed charges,,,90,,11.7,percent of total billed charges,,,,,,,no IP contract,,80,,10.4,percent of total billed charges,,,,,,,no IP contract,,50,,6.5,percent of total billed charges,,,,,,no IP contract,,,78,,10.14,percent of total billed charges,,,70,,9.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.37,3324,
51079-0888-20 - metoclopramide 10 mg Tab,51079-0888-20,NDC,,,,inpatient,1,EA,6.15,3.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.23,percent of total billed charges,,,85,,5.23,percent of total billed charges,,,49,,3.01,percent of total billed charges,,,90,,5.54,percent of total billed charges,,,,,,,no IP contract,,80,,4.92,percent of total billed charges,,,,,,,no IP contract,,50,,3.08,percent of total billed charges,,,,,,no IP contract,,,78,,4.8,percent of total billed charges,,,70,,4.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.01,3324,
51079-0896-20 - NIFEdipine 60 mg ER Ta,51079-0896-20,NDC,,,,inpatient,1,EA,22.05,13.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.74,percent of total billed charges,,,85,,18.74,percent of total billed charges,,,49,,10.8,percent of total billed charges,,,90,,19.85,percent of total billed charges,,,,,,,no IP contract,,80,,17.64,percent of total billed charges,,,,,,,no IP contract,,50,,11.03,percent of total billed charges,,,,,,no IP contract,,,78,,17.2,percent of total billed charges,,,70,,15.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.8,3324,
51079-0899-20 - verapamil 180 mg ER Ta,51079-0899-20,NDC,,,,inpatient,1,EA,23.7,14.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.15,percent of total billed charges,,,85,,20.15,percent of total billed charges,,,49,,11.61,percent of total billed charges,,,90,,21.33,percent of total billed charges,,,,,,,no IP contract,,80,,18.96,percent of total billed charges,,,,,,,no IP contract,,50,,11.85,percent of total billed charges,,,,,,no IP contract,,,78,,18.49,percent of total billed charges,,,70,,16.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.61,3324,
51079-0905-01 - phenytoin 100 mg ER Capsule,51079-0905-01,NDC,,,,inpatient,1,EA,32.6,19.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,26.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,27.71,percent of total billed charges,,,85,,27.71,percent of total billed charges,,,49,,15.97,percent of total billed charges,,,90,,29.34,percent of total billed charges,,,,,,,no IP contract,,80,,26.08,percent of total billed charges,,,,,,,no IP contract,,50,,16.3,percent of total billed charges,,,,,,no IP contract,,,78,,25.43,percent of total billed charges,,,70,,22.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.97,3324,
51079-0905-20 - phenytoin 100 mg ER Ca,51079-0905-20,NDC,,,,inpatient,1,EA,6.6,3.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.61,percent of total billed charges,,,85,,5.61,percent of total billed charges,,,49,,3.23,percent of total billed charges,,,90,,5.94,percent of total billed charges,,,,,,,no IP contract,,80,,5.28,percent of total billed charges,,,,,,,no IP contract,,50,,3.3,percent of total billed charges,,,,,,no IP contract,,,78,,5.15,percent of total billed charges,,,70,,4.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.23,3324,
51079-0921-20 - cloZAPine 25 mg Tab,51079-0921-20,NDC,,,,inpatient,1,EA,14.3,8.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.16,percent of total billed charges,,,85,,12.16,percent of total billed charges,,,49,,7.01,percent of total billed charges,,,90,,12.87,percent of total billed charges,,,,,,,no IP contract,,80,,11.44,percent of total billed charges,,,,,,,no IP contract,,50,,7.15,percent of total billed charges,,,,,,no IP contract,,,78,,11.15,percent of total billed charges,,,70,,10.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.01,3324,
51079-0923-20 - carbidopa-levodopa 50 mg-200 mg ER Ta,51079-0923-20,NDC,,,,inpatient,1,EA,17.65,10.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15,percent of total billed charges,,,85,,15,percent of total billed charges,,,49,,8.65,percent of total billed charges,,,90,,15.89,percent of total billed charges,,,,,,,no IP contract,,80,,14.12,percent of total billed charges,,,,,,,no IP contract,,50,,8.83,percent of total billed charges,,,,,,no IP contract,,,78,,13.77,percent of total billed charges,,,70,,12.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.65,3324,
51079-0930-20 - carvedilol 6.25 mg Tab,51079-0930-20,NDC,,,,inpatient,1,EA,20.75,12.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.64,percent of total billed charges,,,85,,17.64,percent of total billed charges,,,49,,10.17,percent of total billed charges,,,90,,18.68,percent of total billed charges,,,,,,,no IP contract,,80,,16.6,percent of total billed charges,,,,,,,no IP contract,,50,,10.38,percent of total billed charges,,,,,,no IP contract,,,78,,16.19,percent of total billed charges,,,70,,14.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.17,3324,
51079-0931-20 - carvedilol 12.5 mg Tab,51079-0931-20,NDC,,,,inpatient,1,EA,20.75,12.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.64,percent of total billed charges,,,85,,17.64,percent of total billed charges,,,49,,10.17,percent of total billed charges,,,90,,18.68,percent of total billed charges,,,,,,,no IP contract,,80,,16.6,percent of total billed charges,,,,,,,no IP contract,,50,,10.38,percent of total billed charges,,,,,,no IP contract,,,78,,16.19,percent of total billed charges,,,70,,14.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.17,3324,
51079-0932-20 - carvedilol 25 mg Tab,51079-0932-20,NDC,,,,inpatient,1,EA,20.75,12.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.64,percent of total billed charges,,,85,,17.64,percent of total billed charges,,,49,,10.17,percent of total billed charges,,,90,,18.68,percent of total billed charges,,,,,,,no IP contract,,80,,16.6,percent of total billed charges,,,,,,,no IP contract,,50,,10.38,percent of total billed charges,,,,,,no IP contract,,,78,,16.19,percent of total billed charges,,,70,,14.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.17,3324,
51079-0942-05 - alendronate 70 mg Tab,51079-0942-05,NDC,,,,inpatient,1,EA,166.5,99.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,134.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,141.53,percent of total billed charges,,,85,,141.53,percent of total billed charges,,,49,,81.59,percent of total billed charges,,,90,,149.85,percent of total billed charges,,,,,,,no IP contract,,80,,133.2,percent of total billed charges,,,,,,,no IP contract,,50,,83.25,percent of total billed charges,,,,,,no IP contract,,,78,,129.87,percent of total billed charges,,,70,,116.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,81.59,3324,
51079-0943-20 - buPROPion 75 mg Tab,51079-0943-20,NDC,,,,inpatient,1,EA,9.65,5.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.2,percent of total billed charges,,,85,,8.2,percent of total billed charges,,,49,,4.73,percent of total billed charges,,,90,,8.69,percent of total billed charges,,,,,,,no IP contract,,80,,7.72,percent of total billed charges,,,,,,,no IP contract,,50,,4.83,percent of total billed charges,,,,,,no IP contract,,,78,,7.53,percent of total billed charges,,,70,,6.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.73,3324,
51079-0950-01 - enalapril 2.5 mg Tab,51079-0950-01,NDC,,,,inpatient,1,EA,642.2,385.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,520.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,545.87,percent of total billed charges,,,85,,545.87,percent of total billed charges,,,49,,314.68,percent of total billed charges,,,90,,577.98,percent of total billed charges,,,,,,,no IP contract,,80,,513.76,percent of total billed charges,,,,,,,no IP contract,,50,,321.1,percent of total billed charges,,,,,,no IP contract,,,78,,500.92,percent of total billed charges,,,70,,449.54,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,314.68,3324,
51079-0950-20 - enalapril 2.5 mg Tab,51079-0950-20,NDC,,,,inpatient,1,EA,4.95,2.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.21,percent of total billed charges,,,85,,4.21,percent of total billed charges,,,49,,2.43,percent of total billed charges,,,90,,4.46,percent of total billed charges,,,,,,,no IP contract,,80,,3.96,percent of total billed charges,,,,,,,no IP contract,,50,,2.48,percent of total billed charges,,,,,,no IP contract,,,78,,3.86,percent of total billed charges,,,70,,3.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.43,3324,
51079-0951-01 - enalapril 5 mg Tab,51079-0951-01,NDC,,,,inpatient,1,EA,814.7,488.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,659.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,692.5,percent of total billed charges,,,85,,692.5,percent of total billed charges,,,49,,399.2,percent of total billed charges,,,90,,733.23,percent of total billed charges,,,,,,,no IP contract,,80,,651.76,percent of total billed charges,,,,,,,no IP contract,,50,,407.35,percent of total billed charges,,,,,,no IP contract,,,78,,635.47,percent of total billed charges,,,70,,570.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,399.2,3324,
51079-0951-20 - enalapril 5 mg Tab,51079-0951-20,NDC,,,,inpatient,1,EA,5.1,3.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.34,percent of total billed charges,,,85,,4.34,percent of total billed charges,,,49,,2.5,percent of total billed charges,,,90,,4.59,percent of total billed charges,,,,,,,no IP contract,,80,,4.08,percent of total billed charges,,,,,,,no IP contract,,50,,2.55,percent of total billed charges,,,,,,no IP contract,,,78,,3.98,percent of total billed charges,,,70,,3.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.5,3324,
51079-0959-01 - doxazosin mesylate 4 mg Tab,51079-0959-01,NDC,,,,inpatient,1,EA,6.75,4.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.74,percent of total billed charges,,,85,,5.74,percent of total billed charges,,,49,,3.31,percent of total billed charges,,,90,,6.08,percent of total billed charges,,,,,,,no IP contract,,80,,5.4,percent of total billed charges,,,,,,,no IP contract,,50,,3.38,percent of total billed charges,,,,,,no IP contract,,,78,,5.27,percent of total billed charges,,,70,,4.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.31,3324,
51079-0959-20 - doxazosin 4 mg Tab,51079-0959-20,NDC,,,,inpatient,1,EA,11.55,6.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.82,percent of total billed charges,,,85,,9.82,percent of total billed charges,,,49,,5.66,percent of total billed charges,,,90,,10.4,percent of total billed charges,,,,,,,no IP contract,,80,,9.24,percent of total billed charges,,,,,,,no IP contract,,50,,5.78,percent of total billed charges,,,,,,no IP contract,,,78,,9.01,percent of total billed charges,,,70,,8.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.66,3324,
51079-0966-20 - famotidine 20 mg Tab,51079-0966-20,NDC,,,,inpatient,1,EA,17.65,10.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15,percent of total billed charges,,,85,,15,percent of total billed charges,,,49,,8.65,percent of total billed charges,,,90,,15.89,percent of total billed charges,,,,,,,no IP contract,,80,,14.12,percent of total billed charges,,,,,,,no IP contract,,50,,8.83,percent of total billed charges,,,,,,no IP contract,,,78,,13.77,percent of total billed charges,,,70,,12.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.65,3324,
51079-0978-01 - carbidopa/levodopa 25 mg-100 mg CR Tablet,51079-0978-01,NDC,,,,inpatient,1,EA,13.15,7.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.18,percent of total billed charges,,,85,,11.18,percent of total billed charges,,,49,,6.44,percent of total billed charges,,,90,,11.84,percent of total billed charges,,,,,,,no IP contract,,80,,10.52,percent of total billed charges,,,,,,,no IP contract,,50,,6.58,percent of total billed charges,,,,,,no IP contract,,,78,,10.26,percent of total billed charges,,,70,,9.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.44,3324,
51079-0978-20 - carbidopa-levodopa 25 mg-100 mg ER Ta,51079-0978-20,NDC,,,,inpatient,1,EA,11.2,6.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.52,percent of total billed charges,,,85,,9.52,percent of total billed charges,,,49,,5.49,percent of total billed charges,,,90,,10.08,percent of total billed charges,,,,,,,no IP contract,,80,,8.96,percent of total billed charges,,,,,,,no IP contract,,50,,5.6,percent of total billed charges,,,,,,no IP contract,,,78,,8.74,percent of total billed charges,,,70,,7.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.49,3324,
51079-0979-20 - spironolactone 50 mg Tab,51079-0979-20,NDC,,,,inpatient,1,EA,10.8,6.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.18,percent of total billed charges,,,85,,9.18,percent of total billed charges,,,49,,5.29,percent of total billed charges,,,90,,9.72,percent of total billed charges,,,,,,,no IP contract,,80,,8.64,percent of total billed charges,,,,,,,no IP contract,,50,,5.4,percent of total billed charges,,,,,,no IP contract,,,78,,8.42,percent of total billed charges,,,70,,7.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.29,3324,
51079-0982-20 - lisinopril 10 mg Tab,51079-0982-20,NDC,,,,inpatient,1,EA,11.3,6.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.61,percent of total billed charges,,,85,,9.61,percent of total billed charges,,,49,,5.54,percent of total billed charges,,,90,,10.17,percent of total billed charges,,,,,,,no IP contract,,80,,9.04,percent of total billed charges,,,,,,,no IP contract,,50,,5.65,percent of total billed charges,,,,,,no IP contract,,,78,,8.81,percent of total billed charges,,,70,,7.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.54,3324,
51079-0983-20 - lisinopril 20 mg Tab,51079-0983-20,NDC,,,,inpatient,1,EA,11.85,7.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.07,percent of total billed charges,,,85,,10.07,percent of total billed charges,,,49,,5.81,percent of total billed charges,,,90,,10.67,percent of total billed charges,,,,,,,no IP contract,,80,,9.48,percent of total billed charges,,,,,,,no IP contract,,50,,5.93,percent of total billed charges,,,,,,no IP contract,,,78,,9.24,percent of total billed charges,,,70,,8.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.81,3324,
51079-0984-20 - lisinopril 40 mg Tab,51079-0984-20,NDC,,,,inpatient,1,EA,15.6,9.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.26,percent of total billed charges,,,85,,13.26,percent of total billed charges,,,49,,7.64,percent of total billed charges,,,90,,14.04,percent of total billed charges,,,,,,,no IP contract,,80,,12.48,percent of total billed charges,,,,,,,no IP contract,,50,,7.8,percent of total billed charges,,,,,,no IP contract,,,78,,12.17,percent of total billed charges,,,70,,10.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.64,3324,
51079-0985-01 - buspirone 5 mg Tab,51079-0985-01,NDC,,,,inpatient,1,EA,9.95,5.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.46,percent of total billed charges,,,85,,8.46,percent of total billed charges,,,49,,4.88,percent of total billed charges,,,90,,8.96,percent of total billed charges,,,,,,,no IP contract,,80,,7.96,percent of total billed charges,,,,,,,no IP contract,,50,,4.98,percent of total billed charges,,,,,,no IP contract,,,78,,7.76,percent of total billed charges,,,70,,6.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.88,3324,
51079-0985-20 - busPIRone 5 mg Tab,51079-0985-20,NDC,,,,inpatient,1,EA,9.95,5.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.46,percent of total billed charges,,,85,,8.46,percent of total billed charges,,,49,,4.88,percent of total billed charges,,,90,,8.96,percent of total billed charges,,,,,,,no IP contract,,80,,7.96,percent of total billed charges,,,,,,,no IP contract,,50,,4.98,percent of total billed charges,,,,,,no IP contract,,,78,,7.76,percent of total billed charges,,,70,,6.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.88,3324,
51079-0986-20 - busPIRone 10 mg Tab,51079-0986-20,NDC,,,,inpatient,1,EA,14.5,8.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.33,percent of total billed charges,,,85,,12.33,percent of total billed charges,,,49,,7.11,percent of total billed charges,,,90,,13.05,percent of total billed charges,,,,,,,no IP contract,,80,,11.6,percent of total billed charges,,,,,,,no IP contract,,50,,7.25,percent of total billed charges,,,,,,no IP contract,,,78,,11.31,percent of total billed charges,,,70,,10.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.11,3324,
51079-0991-20 - tramadol 50 mg Tab,51079-0991-20,NDC,,,,inpatient,1,EA,10.2,6.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.67,percent of total billed charges,,,85,,8.67,percent of total billed charges,,,49,,5,percent of total billed charges,,,90,,9.18,percent of total billed charges,,,,,,,no IP contract,,80,,8.16,percent of total billed charges,,,,,,,no IP contract,,50,,5.1,percent of total billed charges,,,,,,no IP contract,,,78,,7.96,percent of total billed charges,,,70,,7.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5,3324,
51079-0992-01 - fluvoxamine 50 mg Tab,51079-0992-01,NDC,,,,inpatient,1,EA,991.15,594.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,802.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,842.48,percent of total billed charges,,,85,,842.48,percent of total billed charges,,,49,,485.66,percent of total billed charges,,,90,,892.04,percent of total billed charges,,,,,,,no IP contract,,80,,792.92,percent of total billed charges,,,,,,,no IP contract,,50,,495.58,percent of total billed charges,,,,,,no IP contract,,,78,,773.1,percent of total billed charges,,,70,,693.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,485.66,3324,
51079-0992-20 - fluvoxamine 50 mg Tab,51079-0992-20,NDC,,,,inpatient,1,EA,24.25,14.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.61,percent of total billed charges,,,85,,20.61,percent of total billed charges,,,49,,11.88,percent of total billed charges,,,90,,21.83,percent of total billed charges,,,,,,,no IP contract,,80,,19.4,percent of total billed charges,,,,,,,no IP contract,,50,,12.13,percent of total billed charges,,,,,,no IP contract,,,78,,18.92,percent of total billed charges,,,70,,16.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.88,3324,
51079-0997-20 - fluoxetine 10 mg Cap,51079-0997-20,NDC,,,,inpatient,1,EA,24.5,14.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.83,percent of total billed charges,,,85,,20.83,percent of total billed charges,,,49,,12.01,percent of total billed charges,,,90,,22.05,percent of total billed charges,,,,,,,no IP contract,,80,,19.6,percent of total billed charges,,,,,,,no IP contract,,50,,12.25,percent of total billed charges,,,,,,no IP contract,,,78,,19.11,percent of total billed charges,,,70,,17.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.01,3324,
51079-0998-01 - tizanidine 4 mg tab 4 mg Tab,51079-0998-01,NDC,,,,inpatient,1,EA,15.5,9.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.18,percent of total billed charges,,,85,,13.18,percent of total billed charges,,,49,,7.6,percent of total billed charges,,,90,,13.95,percent of total billed charges,,,,,,,no IP contract,,80,,12.4,percent of total billed charges,,,,,,,no IP contract,,50,,7.75,percent of total billed charges,,,,,,no IP contract,,,78,,12.09,percent of total billed charges,,,70,,10.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.6,3324,
51079-0998-20 - tizanidine 4 mg Tab,51079-0998-20,NDC,,,,inpatient,1,EA,15.5,9.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.18,percent of total billed charges,,,85,,13.18,percent of total billed charges,,,49,,7.6,percent of total billed charges,,,90,,13.95,percent of total billed charges,,,,,,,no IP contract,,80,,12.4,percent of total billed charges,,,,,,,no IP contract,,50,,7.75,percent of total billed charges,,,,,,no IP contract,,,78,,12.09,percent of total billed charges,,,70,,10.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.6,3324,
51224-0007-50 - metFORMIN 500 mg ER Ta,51224-0007-50,NDC,,,,inpatient,1,EA,9.7,5.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.25,percent of total billed charges,,,85,,8.25,percent of total billed charges,,,49,,4.75,percent of total billed charges,,,90,,8.73,percent of total billed charges,,,,,,,no IP contract,,80,,7.76,percent of total billed charges,,,,,,,no IP contract,,50,,4.85,percent of total billed charges,,,,,,no IP contract,,,78,,7.57,percent of total billed charges,,,70,,6.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.75,3324,
51224-0022-30 - azithromycin 250 mg Tab,51224-0022-30,NDC,,,,inpatient,1,EA,65.7,39.42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,53.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,55.85,percent of total billed charges,,,85,,55.85,percent of total billed charges,,,49,,32.19,percent of total billed charges,,,90,,59.13,percent of total billed charges,,,,,,,no IP contract,,80,,52.56,percent of total billed charges,,,,,,,no IP contract,,50,,32.85,percent of total billed charges,,,,,,no IP contract,,,78,,51.25,percent of total billed charges,,,70,,45.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.19,3324,
51224-0162-12 - aluminum sulfate-calcium acetate topical - REC P,51224-0162-12,NDC,,,,inpatient,1,UN,18.65,11.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.85,percent of total billed charges,,,85,,15.85,percent of total billed charges,,,49,,9.14,percent of total billed charges,,,90,,16.79,percent of total billed charges,,,,,,,no IP contract,,80,,14.92,percent of total billed charges,,,,,,,no IP contract,,50,,9.33,percent of total billed charges,,,,,,no IP contract,,,78,,14.55,percent of total billed charges,,,70,,13.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.14,3324,
51224-0222-30 - azithromycin 600 mg Tab,51224-0222-30,NDC,,,,inpatient,1,EA,152.35,91.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,123.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,129.5,percent of total billed charges,,,85,,129.5,percent of total billed charges,,,49,,74.65,percent of total billed charges,,,90,,137.12,percent of total billed charges,,,,,,,no IP contract,,80,,121.88,percent of total billed charges,,,,,,,no IP contract,,50,,76.18,percent of total billed charges,,,,,,no IP contract,,,78,,118.83,percent of total billed charges,,,70,,106.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,74.65,3324,
51224-0301-10 - alendronate 70 mg/75 mL Soln,51224-0301-10,NDC,,,,inpatient,1,ML,8,4.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.8,percent of total billed charges,,,85,,6.8,percent of total billed charges,,,49,,3.92,percent of total billed charges,,,90,,7.2,percent of total billed charges,,,,,,,no IP contract,,80,,6.4,percent of total billed charges,,,,,,,no IP contract,,50,,4,percent of total billed charges,,,,,,no IP contract,,,78,,6.24,percent of total billed charges,,,70,,5.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.92,3324,
51248-0150-03 - solifenacin 5 mg Tab,51248-0150-03,NDC,,,,inpatient,1,EA,74.2,44.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63.07,percent of total billed charges,,,85,,63.07,percent of total billed charges,,,49,,36.36,percent of total billed charges,,,90,,66.78,percent of total billed charges,,,,,,,no IP contract,,80,,59.36,percent of total billed charges,,,,,,,no IP contract,,50,,37.1,percent of total billed charges,,,,,,no IP contract,,,78,,57.88,percent of total billed charges,,,70,,51.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.36,3324,
51248-0150-52 - solifenacin 5 mg Tab,51248-0150-52,NDC,,,,inpatient,1,EA,31.75,19.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,25.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.99,percent of total billed charges,,,85,,26.99,percent of total billed charges,,,49,,15.56,percent of total billed charges,,,90,,28.58,percent of total billed charges,,,,,,,no IP contract,,80,,25.4,percent of total billed charges,,,,,,,no IP contract,,50,,15.88,percent of total billed charges,,,,,,no IP contract,,,78,,24.77,percent of total billed charges,,,70,,22.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.56,3324,
51248-0151-01 - solifenacin 10 mg Tab,51248-0151-01,NDC,,,,inpatient,1,EA,74.2,44.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63.07,percent of total billed charges,,,85,,63.07,percent of total billed charges,,,49,,36.36,percent of total billed charges,,,90,,66.78,percent of total billed charges,,,,,,,no IP contract,,80,,59.36,percent of total billed charges,,,,,,,no IP contract,,50,,37.1,percent of total billed charges,,,,,,no IP contract,,,78,,57.88,percent of total billed charges,,,70,,51.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.36,3324,
51248-0151-52 - solifenacin 10 mg Tab,51248-0151-52,NDC,,,,inpatient,1,EA,31.75,19.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,25.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.99,percent of total billed charges,,,85,,26.99,percent of total billed charges,,,49,,15.56,percent of total billed charges,,,90,,28.58,percent of total billed charges,,,,,,,no IP contract,,80,,25.4,percent of total billed charges,,,,,,,no IP contract,,50,,15.88,percent of total billed charges,,,,,,no IP contract,,,78,,24.77,percent of total billed charges,,,70,,22.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.56,3324,
51285-0060-01 - bisoprolol 5 mg Tab,51285-0060-01,NDC,,,,inpatient,1,EA,23.8,14.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.23,percent of total billed charges,,,85,,20.23,percent of total billed charges,,,49,,11.66,percent of total billed charges,,,90,,21.42,percent of total billed charges,,,,,,,no IP contract,,80,,19.04,percent of total billed charges,,,,,,,no IP contract,,50,,11.9,percent of total billed charges,,,,,,no IP contract,,,78,,18.56,percent of total billed charges,,,70,,16.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.66,3324,
51293-0625-01 - PHENobarbital 16.2 mg Tab,51293-0625-01,NDC,,,,inpatient,1,EA,9.85,5.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.37,percent of total billed charges,,,85,,8.37,percent of total billed charges,,,49,,4.83,percent of total billed charges,,,90,,8.87,percent of total billed charges,,,,,,,no IP contract,,80,,7.88,percent of total billed charges,,,,,,,no IP contract,,50,,4.93,percent of total billed charges,,,,,,no IP contract,,,78,,7.68,percent of total billed charges,,,70,,6.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.83,3324,
51293-0627-01 - PHENobarbital 64.8 mg Tab,51293-0627-01,NDC,,,,inpatient,1,EA,12.4,7.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.54,percent of total billed charges,,,85,,10.54,percent of total billed charges,,,49,,6.08,percent of total billed charges,,,90,,11.16,percent of total billed charges,,,,,,,no IP contract,,80,,9.92,percent of total billed charges,,,,,,,no IP contract,,50,,6.2,percent of total billed charges,,,,,,no IP contract,,,78,,9.67,percent of total billed charges,,,70,,8.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.08,3324,
51293-0691-01 - PHENobarbital 15 mg Tab,51293-0691-01,NDC,,,,inpatient,1,EA,8.25,4.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.01,percent of total billed charges,,,85,,7.01,percent of total billed charges,,,49,,4.04,percent of total billed charges,,,90,,7.43,percent of total billed charges,,,,,,,no IP contract,,80,,6.6,percent of total billed charges,,,,,,,no IP contract,,50,,4.13,percent of total billed charges,,,,,,no IP contract,,,78,,6.44,percent of total billed charges,,,70,,5.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.04,3324,
51293-0694-01 - PHENobarbital 100 mg Tab,51293-0694-01,NDC,,,,inpatient,1,EA,11.6,6.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.86,percent of total billed charges,,,85,,9.86,percent of total billed charges,,,49,,5.68,percent of total billed charges,,,90,,10.44,percent of total billed charges,,,,,,,no IP contract,,80,,9.28,percent of total billed charges,,,,,,,no IP contract,,50,,5.8,percent of total billed charges,,,,,,no IP contract,,,78,,9.05,percent of total billed charges,,,70,,8.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.68,3324,
51293-0810-01 - phenazopyridine 100 mg Tab,51293-0810-01,NDC,,,,inpatient,1,EA,25.3,15.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.51,percent of total billed charges,,,85,,21.51,percent of total billed charges,,,49,,12.4,percent of total billed charges,,,90,,22.77,percent of total billed charges,,,,,,,no IP contract,,80,,20.24,percent of total billed charges,,,,,,,no IP contract,,50,,12.65,percent of total billed charges,,,,,,no IP contract,,,78,,19.73,percent of total billed charges,,,70,,17.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.4,3324,
51293-0838-85 - olopatadine ophthalmic 0.1% Soln,51293-0838-85,NDC,,,,inpatient,1,UN,2145.85,1287.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1738.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1823.97,percent of total billed charges,,,85,,1823.97,percent of total billed charges,,,49,,1051.47,percent of total billed charges,,,90,,1931.27,percent of total billed charges,,,,,,,no IP contract,,80,,1716.68,percent of total billed charges,,,,,,,no IP contract,,50,,1072.93,percent of total billed charges,,,,,,no IP contract,,,78,,1673.76,percent of total billed charges,,,70,,1502.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
51525-0431-01 - felbamate 600 mg Tab,51525-0431-01,NDC,,,,inpatient,1,EA,50.9,30.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,41.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,43.27,percent of total billed charges,,,85,,43.27,percent of total billed charges,,,49,,24.94,percent of total billed charges,,,90,,45.81,percent of total billed charges,,,,,,,no IP contract,,80,,40.72,percent of total billed charges,,,,,,,no IP contract,,50,,25.45,percent of total billed charges,,,,,,no IP contract,,,78,,39.7,percent of total billed charges,,,70,,35.63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.94,3324,
51645-0703-01 - acetaminophen 325 mg Tab,51645-0703-01,NDC,,,,inpatient,1,EA,4,2.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.4,percent of total billed charges,,,85,,3.4,percent of total billed charges,,,49,,1.96,percent of total billed charges,,,90,,3.6,percent of total billed charges,,,,,,,no IP contract,,80,,3.2,percent of total billed charges,,,,,,,no IP contract,,50,,2,percent of total billed charges,,,,,,no IP contract,,,78,,3.12,percent of total billed charges,,,70,,2.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.96,3324,
51645-0827-99 - calcium carbonate 1250 mg Tab,51645-0827-99,NDC,,,,inpatient,1,EA,4.6,2.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.91,percent of total billed charges,,,85,,3.91,percent of total billed charges,,,49,,2.25,percent of total billed charges,,,90,,4.14,percent of total billed charges,,,,,,,no IP contract,,80,,3.68,percent of total billed charges,,,,,,,no IP contract,,50,,2.3,percent of total billed charges,,,,,,no IP contract,,,78,,3.59,percent of total billed charges,,,70,,3.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.25,3324,
51645-0860-01 - simethicone 80 mg Chew,51645-0860-01,NDC,,,,inpatient,1,EA,4.15,2.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.53,percent of total billed charges,,,85,,3.53,percent of total billed charges,,,49,,2.03,percent of total billed charges,,,90,,3.74,percent of total billed charges,,,,,,,no IP contract,,80,,3.32,percent of total billed charges,,,,,,,no IP contract,,50,,2.08,percent of total billed charges,,,,,,no IP contract,,,78,,3.24,percent of total billed charges,,,70,,2.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.03,3324,
51645-0905-99 - thiamine 100 mg Tab,51645-0905-99,NDC,,,,inpatient,1,EA,4.2,2.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.57,percent of total billed charges,,,85,,3.57,percent of total billed charges,,,49,,2.06,percent of total billed charges,,,90,,3.78,percent of total billed charges,,,,,,,no IP contract,,80,,3.36,percent of total billed charges,,,,,,,no IP contract,,50,,2.1,percent of total billed charges,,,,,,no IP contract,,,78,,3.28,percent of total billed charges,,,70,,2.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.06,3324,
51645-0932-01 - folic acid 0.4 mg Tab,51645-0932-01,NDC,,,,inpatient,1,EA,3.9,2.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.32,percent of total billed charges,,,85,,3.32,percent of total billed charges,,,49,,1.91,percent of total billed charges,,,90,,3.51,percent of total billed charges,,,,,,,no IP contract,,80,,3.12,percent of total billed charges,,,,,,,no IP contract,,50,,1.95,percent of total billed charges,,,,,,no IP contract,,,78,,3.04,percent of total billed charges,,,70,,2.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.91,3324,
51660-0141-90 - valsartan 80 mg Tab,51660-0141-90,NDC,,,,inpatient,1,EA,40.8,24.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34.68,percent of total billed charges,,,85,,34.68,percent of total billed charges,,,49,,19.99,percent of total billed charges,,,90,,36.72,percent of total billed charges,,,,,,,no IP contract,,80,,32.64,percent of total billed charges,,,,,,,no IP contract,,50,,20.4,percent of total billed charges,,,,,,no IP contract,,,78,,31.82,percent of total billed charges,,,70,,28.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.99,3324,
51660-0200-30 - ezetimibe 10 mg Tab,51660-0200-30,NDC,,,,inpatient,1,EA,85.55,51.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,69.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,72.72,percent of total billed charges,,,85,,72.72,percent of total billed charges,,,49,,41.92,percent of total billed charges,,,90,,77,percent of total billed charges,,,,,,,no IP contract,,80,,68.44,percent of total billed charges,,,,,,,no IP contract,,50,,42.78,percent of total billed charges,,,,,,no IP contract,,,78,,66.73,percent of total billed charges,,,70,,59.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,41.92,3324,
51660-0200-90 - ezetimibe 10 mg Tab,51660-0200-90,NDC,,,,inpatient,1,EA,85.55,51.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,69.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,72.72,percent of total billed charges,,,85,,72.72,percent of total billed charges,,,49,,41.92,percent of total billed charges,,,90,,77,percent of total billed charges,,,,,,,no IP contract,,80,,68.44,percent of total billed charges,,,,,,,no IP contract,,50,,42.78,percent of total billed charges,,,,,,no IP contract,,,78,,66.73,percent of total billed charges,,,70,,59.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,41.92,3324,
51672-1258-01 - clobetasol topical 0.05% Cream,51672-1258-01,NDC,,,,inpatient,1,UN,1077.55,646.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,872.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,915.92,percent of total billed charges,,,85,,915.92,percent of total billed charges,,,49,,528,percent of total billed charges,,,90,,969.8,percent of total billed charges,,,,,,,no IP contract,,80,,862.04,percent of total billed charges,,,,,,,no IP contract,,50,,538.78,percent of total billed charges,,,,,,no IP contract,,,78,,840.49,percent of total billed charges,,,70,,754.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,528,3324,
51672-1259-02 - clobetasol topical 0.05% Ointm,51672-1259-02,NDC,,,,inpatient,1,UN,2173.35,1304.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1760.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1847.35,percent of total billed charges,,,85,,1847.35,percent of total billed charges,,,49,,1064.94,percent of total billed charges,,,90,,1956.02,percent of total billed charges,,,,,,,no IP contract,,80,,1738.68,percent of total billed charges,,,,,,,no IP contract,,50,,1086.68,percent of total billed charges,,,,,,no IP contract,,,78,,1695.21,percent of total billed charges,,,70,,1521.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
51672-1263-01 - nystatin-triamcinolone topical 100000 units/g-0.1% Cream,51672-1263-01,NDC,,,,inpatient,1,UN,81.7,49.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,66.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,69.45,percent of total billed charges,,,85,,69.45,percent of total billed charges,,,49,,40.03,percent of total billed charges,,,90,,73.53,percent of total billed charges,,,,,,,no IP contract,,80,,65.36,percent of total billed charges,,,,,,,no IP contract,,50,,40.85,percent of total billed charges,,,,,,no IP contract,,,78,,63.73,percent of total billed charges,,,70,,57.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,40.03,3324,
51672-1263-02 - nystatin-triamcinolone topical 100000 units/g-0.1% Cream,51672-1263-02,NDC,,,,inpatient,1,UN,1338.7,803.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1084.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1137.9,percent of total billed charges,,,85,,1137.9,percent of total billed charges,,,49,,655.96,percent of total billed charges,,,90,,1204.83,percent of total billed charges,,,,,,,no IP contract,,80,,1070.96,percent of total billed charges,,,,,,,no IP contract,,50,,669.35,percent of total billed charges,,,,,,no IP contract,,,78,,1044.19,percent of total billed charges,,,70,,937.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,655.96,3324,
51672-1267-05 - triamcinolone topical 0.1% Paste,51672-1267-05,NDC,,,,inpatient,1,UN,680.6,408.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,551.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,578.51,percent of total billed charges,,,85,,578.51,percent of total billed charges,,,49,,333.49,percent of total billed charges,,,90,,612.54,percent of total billed charges,,,,,,,no IP contract,,80,,544.48,percent of total billed charges,,,,,,,no IP contract,,50,,340.3,percent of total billed charges,,,,,,no IP contract,,,78,,530.87,percent of total billed charges,,,70,,476.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,333.49,3324,
51672-1271-03 - desoximetasone topical 0.05% Cream,51672-1271-03,NDC,,,,inpatient,1,UN,569,341.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,460.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,483.65,percent of total billed charges,,,85,,483.65,percent of total billed charges,,,49,,278.81,percent of total billed charges,,,90,,512.1,percent of total billed charges,,,,,,,no IP contract,,80,,455.2,percent of total billed charges,,,,,,,no IP contract,,50,,284.5,percent of total billed charges,,,,,,no IP contract,,,78,,443.82,percent of total billed charges,,,70,,398.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,278.81,3324,
51672-1272-01 - nystatin-triamcinolone topical 100000 units/g-0.1% Ointm,51672-1272-01,NDC,,,,inpatient,1,UN,81.7,49.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,66.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,69.45,percent of total billed charges,,,85,,69.45,percent of total billed charges,,,49,,40.03,percent of total billed charges,,,90,,73.53,percent of total billed charges,,,,,,,no IP contract,,80,,65.36,percent of total billed charges,,,,,,,no IP contract,,50,,40.85,percent of total billed charges,,,,,,no IP contract,,,78,,63.73,percent of total billed charges,,,70,,57.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,40.03,3324,
51672-1272-02 - nystatin-triamcinolone topical 100000 units/g-0.1% Ointm,51672-1272-02,NDC,,,,inpatient,1,UN,64.2,38.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,54.57,percent of total billed charges,,,85,,54.57,percent of total billed charges,,,49,,31.46,percent of total billed charges,,,90,,57.78,percent of total billed charges,,,,,,,no IP contract,,80,,51.36,percent of total billed charges,,,,,,,no IP contract,,50,,32.1,percent of total billed charges,,,,,,no IP contract,,,78,,50.08,percent of total billed charges,,,70,,44.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.46,3324,
51672-1273-04 - fluocinonide topical 0.05% Soln,51672-1273-04,NDC,,,,inpatient,1,UN,234.15,140.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,189.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,199.03,percent of total billed charges,,,85,,199.03,percent of total billed charges,,,49,,114.73,percent of total billed charges,,,90,,210.74,percent of total billed charges,,,,,,,no IP contract,,80,,187.32,percent of total billed charges,,,,,,,no IP contract,,50,,117.08,percent of total billed charges,,,,,,no IP contract,,,78,,182.64,percent of total billed charges,,,70,,163.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,114.73,3324,
51672-1275-02 - clotrimazole topical 1% Cream,51672-1275-02,NDC,,,,inpatient,1,UN,101.7,61.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,82.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,86.45,percent of total billed charges,,,85,,86.45,percent of total billed charges,,,49,,49.83,percent of total billed charges,,,90,,91.53,percent of total billed charges,,,,,,,no IP contract,,80,,81.36,percent of total billed charges,,,,,,,no IP contract,,50,,50.85,percent of total billed charges,,,,,,no IP contract,,,78,,79.33,percent of total billed charges,,,70,,71.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,49.83,3324,
51672-1280-03 - desonide topical 0.05% Cream,51672-1280-03,NDC,,,,inpatient,1,UN,2683.15,1609.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2173.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2280.68,percent of total billed charges,,,85,,2280.68,percent of total billed charges,,,49,,1314.74,percent of total billed charges,,,90,,2414.84,percent of total billed charges,,,,,,,no IP contract,,80,,2146.52,percent of total billed charges,,,,,,,no IP contract,,50,,1341.58,percent of total billed charges,,,,,,no IP contract,,,78,,2092.86,percent of total billed charges,,,70,,1878.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
51672-1298-02 - ketoconazole topical 2% Cream,51672-1298-02,NDC,,,,inpatient,1,UN,444.05,266.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,359.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,377.44,percent of total billed charges,,,85,,377.44,percent of total billed charges,,,49,,217.58,percent of total billed charges,,,90,,399.65,percent of total billed charges,,,,,,,no IP contract,,80,,355.24,percent of total billed charges,,,,,,,no IP contract,,50,,222.03,percent of total billed charges,,,,,,no IP contract,,,78,,346.36,percent of total billed charges,,,70,,310.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,217.58,3324,
51672-1303-02 - econazole topical 1% Cream,51672-1303-02,NDC,,,,inpatient,1,UN,1821,1092.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1475.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1547.85,percent of total billed charges,,,85,,1547.85,percent of total billed charges,,,49,,892.29,percent of total billed charges,,,90,,1638.9,percent of total billed charges,,,,,,,no IP contract,,80,,1456.8,percent of total billed charges,,,,,,,no IP contract,,50,,910.5,percent of total billed charges,,,,,,no IP contract,,,78,,1420.38,percent of total billed charges,,,70,,1274.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,892.29,3324,
51672-1316-03 - alclometasone topical 0.05% Ointm,51672-1316-03,NDC,,,,inpatient,1,UN,324.1,194.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,262.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,275.49,percent of total billed charges,,,85,,275.49,percent of total billed charges,,,49,,158.81,percent of total billed charges,,,90,,291.69,percent of total billed charges,,,,,,,no IP contract,,80,,259.28,percent of total billed charges,,,,,,,no IP contract,,50,,162.05,percent of total billed charges,,,,,,no IP contract,,,78,,252.8,percent of total billed charges,,,70,,226.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,158.81,3324,
ciclopirox topical 0.77% Cream,51672-1318-08,NDC,,,,inpatient,1,EA,653.95,392.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,529.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,555.86,percent of total billed charges,,,85,,555.86,percent of total billed charges,,,49,,320.44,percent of total billed charges,,,90,,588.56,percent of total billed charges,,,,,,,no IP contract,,80,,523.16,percent of total billed charges,,,,,,,no IP contract,,50,,326.98,percent of total billed charges,,,,,,no IP contract,,,78,,510.08,percent of total billed charges,,,70,,457.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,320.44,3324,
51672-1365-04 - fluocinolone topical 0.01% Soln,51672-1365-04,NDC,,,,inpatient,1,UN,1568.6,941.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1270.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1333.31,percent of total billed charges,,,85,,1333.31,percent of total billed charges,,,49,,768.61,percent of total billed charges,,,90,,1411.74,percent of total billed charges,,,,,,,no IP contract,,80,,1254.88,percent of total billed charges,,,,,,,no IP contract,,50,,784.3,percent of total billed charges,,,,,,no IP contract,,,78,,1223.51,percent of total billed charges,,,70,,1098.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,768.61,3324,
mupirocin topical 2% Cream,51672-1370-02,NDC,,,,inpatient,1,EA,3470.35,2082.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2810.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2949.8,percent of total billed charges,,,85,,2949.8,percent of total billed charges,,,49,,1700.47,percent of total billed charges,,,90,,3123.32,percent of total billed charges,,,,,,,no IP contract,,80,,2776.28,percent of total billed charges,,,,,,,no IP contract,,50,,1735.18,percent of total billed charges,,,,,,no IP contract,,,78,,2706.87,percent of total billed charges,,,70,,2429.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
51672-2003-06 - clotrimazole topical 1% Cream,51672-2003-06,NDC,,,,inpatient,1,UN,76.7,46.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,62.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,65.2,percent of total billed charges,,,85,,65.2,percent of total billed charges,,,49,,37.58,percent of total billed charges,,,90,,69.03,percent of total billed charges,,,,,,,no IP contract,,80,,61.36,percent of total billed charges,,,,,,,no IP contract,,50,,38.35,percent of total billed charges,,,,,,no IP contract,,,78,,59.83,percent of total billed charges,,,70,,53.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,37.58,3324,
51672-2010-02 - hydrocortisone topical 0.5% Cream,51672-2010-02,NDC,,,,inpatient,1,UN,54.2,32.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,43.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,46.07,percent of total billed charges,,,85,,46.07,percent of total billed charges,,,49,,26.56,percent of total billed charges,,,90,,48.78,percent of total billed charges,,,,,,,no IP contract,,80,,43.36,percent of total billed charges,,,,,,,no IP contract,,50,,27.1,percent of total billed charges,,,,,,no IP contract,,,78,,42.28,percent of total billed charges,,,70,,37.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.56,3324,
51672-2035-06 - miconazole topical 2% Cream,51672-2035-06,NDC,,,,inpatient,1,UN,93.25,55.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,75.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,79.26,percent of total billed charges,,,85,,79.26,percent of total billed charges,,,49,,45.69,percent of total billed charges,,,90,,83.93,percent of total billed charges,,,,,,,no IP contract,,80,,74.6,percent of total billed charges,,,,,,,no IP contract,,50,,46.63,percent of total billed charges,,,,,,no IP contract,,,78,,72.74,percent of total billed charges,,,70,,65.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,45.69,3324,
51672-2044-02 - bacitracin-polymyxin B topical 500 units-10000 units/g Ointm,51672-2044-02,NDC,,,,inpatient,1,UN,66.7,40.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,54.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.7,percent of total billed charges,,,85,,56.7,percent of total billed charges,,,49,,32.68,percent of total billed charges,,,90,,60.03,percent of total billed charges,,,,,,,no IP contract,,80,,53.36,percent of total billed charges,,,,,,,no IP contract,,50,,33.35,percent of total billed charges,,,,,,no IP contract,,,78,,52.03,percent of total billed charges,,,70,,46.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.68,3324,
51672-2066-02 - diphenhydrAMINE topical 2% Cream,51672-2066-02,NDC,,,,inpatient,1,UN,44.2,26.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,35.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,37.57,percent of total billed charges,,,85,,37.57,percent of total billed charges,,,49,,21.66,percent of total billed charges,,,90,,39.78,percent of total billed charges,,,,,,,no IP contract,,80,,35.36,percent of total billed charges,,,,,,,no IP contract,,50,,22.1,percent of total billed charges,,,,,,no IP contract,,,78,,34.48,percent of total billed charges,,,70,,30.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.66,3324,
51672-2080-02 - terbinafine topical 1% Cream,51672-2080-02,NDC,,,,inpatient,1,UN,11.65,6.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.9,percent of total billed charges,,,85,,9.9,percent of total billed charges,,,49,,5.71,percent of total billed charges,,,90,,10.49,percent of total billed charges,,,,,,,no IP contract,,80,,9.32,percent of total billed charges,,,,,,,no IP contract,,50,,5.83,percent of total billed charges,,,,,,no IP contract,,,78,,9.09,percent of total billed charges,,,70,,8.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.71,3324,
cetirizine 1 mg/mL Syrup,51672-2102-08,NDC,,,,inpatient,1,mL,6.1,3.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.19,percent of total billed charges,,,85,,5.19,percent of total billed charges,,,49,,2.99,percent of total billed charges,,,90,,5.49,percent of total billed charges,,,,,,,no IP contract,,80,,4.88,percent of total billed charges,,,,,,,no IP contract,,50,,3.05,percent of total billed charges,,,,,,no IP contract,,,78,,4.76,percent of total billed charges,,,70,,4.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.99,3324,
51672-2115-02 - acetaminophen 120 mg Supp,51672-2115-02,NDC,,,,inpatient,1,UN,10.2,6.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.67,percent of total billed charges,,,85,,8.67,percent of total billed charges,,,49,,5,percent of total billed charges,,,90,,9.18,percent of total billed charges,,,,,,,no IP contract,,80,,8.16,percent of total billed charges,,,,,,,no IP contract,,50,,5.1,percent of total billed charges,,,,,,no IP contract,,,78,,7.96,percent of total billed charges,,,70,,7.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5,3324,
51672-2130-08 - ibuprofen 100 mg/5 mL Susp,51672-2130-08,NDC,,,,inpatient,1,ML,35.4,21.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.09,percent of total billed charges,,,85,,30.09,percent of total billed charges,,,49,,17.35,percent of total billed charges,,,90,,31.86,percent of total billed charges,,,,,,,no IP contract,,80,,28.32,percent of total billed charges,,,,,,,no IP contract,,50,,17.7,percent of total billed charges,,,,,,no IP contract,,,78,,27.61,percent of total billed charges,,,70,,24.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.35,3324,
51672-3003-02 - hydrocortisone topical 2.5% Cream,51672-3003-02,NDC,,,,inpatient,1,UN,94.2,56.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,76.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,80.07,percent of total billed charges,,,85,,80.07,percent of total billed charges,,,49,,46.16,percent of total billed charges,,,90,,84.78,percent of total billed charges,,,,,,,no IP contract,,80,,75.36,percent of total billed charges,,,,,,,no IP contract,,50,,47.1,percent of total billed charges,,,,,,no IP contract,,,78,,73.48,percent of total billed charges,,,70,,65.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,46.16,3324,
51672-4002-01 - nortriptyline 25 mg Cap,51672-4002-01,NDC,,,,inpatient,1,EA,15.5,9.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.18,percent of total billed charges,,,85,,13.18,percent of total billed charges,,,49,,7.6,percent of total billed charges,,,90,,13.95,percent of total billed charges,,,,,,,no IP contract,,80,,12.4,percent of total billed charges,,,,,,,no IP contract,,50,,7.75,percent of total billed charges,,,,,,no IP contract,,,78,,12.09,percent of total billed charges,,,70,,10.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.6,3324,
51672-4005-01 - carBAMazepine 200 mg Tab,51672-4005-01,NDC,,,,inpatient,1,EA,16.55,9.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.07,percent of total billed charges,,,85,,14.07,percent of total billed charges,,,49,,8.11,percent of total billed charges,,,90,,14.9,percent of total billed charges,,,,,,,no IP contract,,80,,13.24,percent of total billed charges,,,,,,,no IP contract,,50,,8.28,percent of total billed charges,,,,,,no IP contract,,,78,,12.91,percent of total billed charges,,,70,,11.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.11,3324,
51672-4023-01 - acetaZOLAMIDE 250 mg Tab,51672-4023-01,NDC,,,,inpatient,1,EA,7.3,4.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.21,percent of total billed charges,,,85,,6.21,percent of total billed charges,,,49,,3.58,percent of total billed charges,,,90,,6.57,percent of total billed charges,,,,,,,no IP contract,,80,,5.84,percent of total billed charges,,,,,,,no IP contract,,50,,3.65,percent of total billed charges,,,,,,no IP contract,,,78,,5.69,percent of total billed charges,,,70,,5.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.58,3324,
51672-4026-06 - ketoconazole 200 mg Tab,51672-4026-06,NDC,,,,inpatient,1,EA,28.95,17.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.61,percent of total billed charges,,,85,,24.61,percent of total billed charges,,,49,,14.19,percent of total billed charges,,,90,,26.06,percent of total billed charges,,,,,,,no IP contract,,80,,23.16,percent of total billed charges,,,,,,,no IP contract,,50,,14.48,percent of total billed charges,,,,,,no IP contract,,,78,,22.58,percent of total billed charges,,,70,,20.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.19,3324,
51672-4027-01 - warfarin 1 mg Tab,51672-4027-01,NDC,,,,inpatient,1,EA,8.65,5.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.35,percent of total billed charges,,,85,,7.35,percent of total billed charges,,,49,,4.24,percent of total billed charges,,,90,,7.79,percent of total billed charges,,,,,,,no IP contract,,80,,6.92,percent of total billed charges,,,,,,,no IP contract,,50,,4.33,percent of total billed charges,,,,,,no IP contract,,,78,,6.75,percent of total billed charges,,,70,,6.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.24,3324,
51672-4030-01 - warfarin 3 mg Tab,51672-4030-01,NDC,,,,inpatient,1,EA,9.05,5.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.69,percent of total billed charges,,,85,,7.69,percent of total billed charges,,,49,,4.43,percent of total billed charges,,,90,,8.15,percent of total billed charges,,,,,,,no IP contract,,80,,7.24,percent of total billed charges,,,,,,,no IP contract,,50,,4.53,percent of total billed charges,,,,,,no IP contract,,,78,,7.06,percent of total billed charges,,,70,,6.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.43,3324,
51672-4034-01 - warfarin 7.5 mg Tab,51672-4034-01,NDC,,,,inpatient,1,EA,11.45,6.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.73,percent of total billed charges,,,85,,9.73,percent of total billed charges,,,49,,5.61,percent of total billed charges,,,90,,10.31,percent of total billed charges,,,,,,,no IP contract,,80,,9.16,percent of total billed charges,,,,,,,no IP contract,,50,,5.73,percent of total billed charges,,,,,,no IP contract,,,78,,8.93,percent of total billed charges,,,70,,8.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.61,3324,
51672-4035-01 - warfarin 10 mg Tab,51672-4035-01,NDC,,,,inpatient,1,EA,11.75,7.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.99,percent of total billed charges,,,85,,9.99,percent of total billed charges,,,49,,5.76,percent of total billed charges,,,90,,10.58,percent of total billed charges,,,,,,,no IP contract,,80,,9.4,percent of total billed charges,,,,,,,no IP contract,,50,,5.88,percent of total billed charges,,,,,,no IP contract,,,78,,9.17,percent of total billed charges,,,70,,8.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.76,3324,
enalapril 2.5 mg Tab,51672-4037-01,NDC,,,,inpatient,1,EA,15.45,9.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.13,percent of total billed charges,,,85,,13.13,percent of total billed charges,,,49,,7.57,percent of total billed charges,,,90,,13.91,percent of total billed charges,,,,,,,no IP contract,,80,,12.36,percent of total billed charges,,,,,,,no IP contract,,50,,7.73,percent of total billed charges,,,,,,no IP contract,,,78,,12.05,percent of total billed charges,,,70,,10.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.57,3324,
enalapril 5 mg Tab,51672-4038-01,NDC,,,,inpatient,1,EA,18.55,11.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.77,percent of total billed charges,,,85,,15.77,percent of total billed charges,,,49,,9.09,percent of total billed charges,,,90,,16.7,percent of total billed charges,,,,,,,no IP contract,,80,,14.84,percent of total billed charges,,,,,,,no IP contract,,50,,9.28,percent of total billed charges,,,,,,no IP contract,,,78,,14.47,percent of total billed charges,,,70,,12.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.09,3324,
51672-4040-01 - enalapril 20 mg Tab,51672-4040-01,NDC,,,,inpatient,1,EA,25.85,15.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.97,percent of total billed charges,,,85,,21.97,percent of total billed charges,,,49,,12.67,percent of total billed charges,,,90,,23.27,percent of total billed charges,,,,,,,no IP contract,,80,,20.68,percent of total billed charges,,,,,,,no IP contract,,50,,12.93,percent of total billed charges,,,,,,no IP contract,,,78,,20.16,percent of total billed charges,,,70,,18.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.67,3324,
51672-4047-09 - carbamazepine 100 mg/5 mL Susp,51672-4047-09,NDC,,,,inpatient,1,ML,7.1,4.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.04,percent of total billed charges,,,85,,6.04,percent of total billed charges,,,49,,3.48,percent of total billed charges,,,90,,6.39,percent of total billed charges,,,,,,,no IP contract,,80,,5.68,percent of total billed charges,,,,,,,no IP contract,,50,,3.55,percent of total billed charges,,,,,,no IP contract,,,78,,5.54,percent of total billed charges,,,70,,4.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.48,3324,
51672-4069-01 - phenytoin 125 mg/5 mL Susp,51672-4069-01,NDC,,,,inpatient,1,ML,6.75,4.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.74,percent of total billed charges,,,85,,5.74,percent of total billed charges,,,49,,3.31,percent of total billed charges,,,90,,6.08,percent of total billed charges,,,,,,,no IP contract,,80,,5.4,percent of total billed charges,,,,,,,no IP contract,,50,,3.38,percent of total billed charges,,,,,,no IP contract,,,78,,5.27,percent of total billed charges,,,70,,4.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.31,3324,
51672-4070-08 - cetirizine 1 mg/mL Syrup,51672-4070-08,NDC,,,,inpatient,1,ML,7.9,4.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.72,percent of total billed charges,,,85,,6.72,percent of total billed charges,,,49,,3.87,percent of total billed charges,,,90,,7.11,percent of total billed charges,,,,,,,no IP contract,,80,,6.32,percent of total billed charges,,,,,,,no IP contract,,50,,3.95,percent of total billed charges,,,,,,no IP contract,,,78,,6.16,percent of total billed charges,,,70,,5.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.87,3324,
51672-4091-03 - ondansetron 4 mg/5 mL Soln,51672-4091-03,NDC,,,,inpatient,1,ML,45.4,27.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,38.59,percent of total billed charges,,,85,,38.59,percent of total billed charges,,,49,,22.25,percent of total billed charges,,,90,,40.86,percent of total billed charges,,,,,,,no IP contract,,80,,36.32,percent of total billed charges,,,,,,,no IP contract,,50,,22.7,percent of total billed charges,,,,,,no IP contract,,,78,,35.41,percent of total billed charges,,,70,,31.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.25,3324,
51672-4111-01 - phenytoin 100 mg ER Ca,51672-4111-01,NDC,,,,inpatient,1,EA,6.55,3.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.57,percent of total billed charges,,,85,,5.57,percent of total billed charges,,,49,,3.21,percent of total billed charges,,,90,,5.9,percent of total billed charges,,,,,,,no IP contract,,80,,5.24,percent of total billed charges,,,,,,,no IP contract,,50,,3.28,percent of total billed charges,,,,,,no IP contract,,,78,,5.11,percent of total billed charges,,,70,,4.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.21,3324,
51672-4111-03 - phenytoin 100 mg ER Ca,51672-4111-03,NDC,,,,inpatient,1,EA,6.55,3.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.57,percent of total billed charges,,,85,,5.57,percent of total billed charges,,,49,,3.21,percent of total billed charges,,,90,,5.9,percent of total billed charges,,,,,,,no IP contract,,80,,5.24,percent of total billed charges,,,,,,,no IP contract,,50,,3.28,percent of total billed charges,,,,,,no IP contract,,,78,,5.11,percent of total billed charges,,,70,,4.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.21,3324,
51672-4116-06 - metronidazole topical 0.75% Gel,51672-4116-06,NDC,,,,inpatient,1,UN,601.5,360.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,487.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,511.28,percent of total billed charges,,,85,,511.28,percent of total billed charges,,,49,,294.74,percent of total billed charges,,,90,,541.35,percent of total billed charges,,,,,,,no IP contract,,80,,481.2,percent of total billed charges,,,,,,,no IP contract,,50,,300.75,percent of total billed charges,,,,,,no IP contract,,,78,,469.17,percent of total billed charges,,,70,,421.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,294.74,3324,
51672-4124-01 - carbamazepine 200 mg ER Ta,51672-4124-01,NDC,,,,inpatient,1,EA,11.7,7.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.95,percent of total billed charges,,,85,,9.95,percent of total billed charges,,,49,,5.73,percent of total billed charges,,,90,,10.53,percent of total billed charges,,,,,,,no IP contract,,80,,9.36,percent of total billed charges,,,,,,,no IP contract,,50,,5.85,percent of total billed charges,,,,,,no IP contract,,,78,,9.13,percent of total billed charges,,,70,,8.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.73,3324,
51672-5205-03 - desoximetasone topical 0.05% Cream,51672-5205-03,NDC,,,,inpatient,1,UN,748.95,449.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,606.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,636.61,percent of total billed charges,,,85,,636.61,percent of total billed charges,,,49,,366.99,percent of total billed charges,,,90,,674.06,percent of total billed charges,,,,,,,no IP contract,,80,,599.16,percent of total billed charges,,,,,,,no IP contract,,50,,374.48,percent of total billed charges,,,,,,no IP contract,,,78,,584.18,percent of total billed charges,,,70,,524.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,366.99,3324,
51801-0012-30 - citric acid-potassium bicarbonate 20 mEq EFF T,51801-0012-30,NDC,,,,inpatient,1,EA,7.8,4.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.63,percent of total billed charges,,,85,,6.63,percent of total billed charges,,,49,,3.82,percent of total billed charges,,,90,,7.02,percent of total billed charges,,,,,,,no IP contract,,80,,6.24,percent of total billed charges,,,,,,,no IP contract,,50,,3.9,percent of total billed charges,,,,,,no IP contract,,,78,,6.08,percent of total billed charges,,,70,,5.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.82,3324,
51862-0070-01 - estazolam 2 mg Tab,51862-0070-01,NDC,,,,inpatient,1,EA,54.75,32.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,44.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,46.54,percent of total billed charges,,,85,,46.54,percent of total billed charges,,,49,,26.83,percent of total billed charges,,,90,,49.28,percent of total billed charges,,,,,,,no IP contract,,80,,43.8,percent of total billed charges,,,,,,,no IP contract,,50,,27.38,percent of total billed charges,,,,,,no IP contract,,,78,,42.71,percent of total billed charges,,,70,,38.33,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.83,3324,
51862-0180-15 - pramoxine topical 1% Foam,51862-0180-15,NDC,,,,inpatient,1,UN,421.2,252.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,341.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,358.02,percent of total billed charges,,,85,,358.02,percent of total billed charges,,,49,,206.39,percent of total billed charges,,,90,,379.08,percent of total billed charges,,,,,,,no IP contract,,80,,336.96,percent of total billed charges,,,,,,,no IP contract,,50,,210.6,percent of total billed charges,,,,,,no IP contract,,,78,,328.54,percent of total billed charges,,,70,,294.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,206.39,3324,
51862-0333-01 - estradiol 1 mg Tab,51862-0333-01,NDC,,,,inpatient,1,EA,9.25,5.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.86,percent of total billed charges,,,85,,7.86,percent of total billed charges,,,49,,4.53,percent of total billed charges,,,90,,8.33,percent of total billed charges,,,,,,,no IP contract,,80,,7.4,percent of total billed charges,,,,,,,no IP contract,,50,,4.63,percent of total billed charges,,,,,,no IP contract,,,78,,7.22,percent of total billed charges,,,70,,6.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.53,3324,
51862-0453-04 - cloNIDine Patch 0.1 mg/24 hr Patch,51862-0453-04,NDC,,,,inpatient,1,UN,285.45,171.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,231.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,242.63,percent of total billed charges,,,85,,242.63,percent of total billed charges,,,49,,139.87,percent of total billed charges,,,90,,256.91,percent of total billed charges,,,,,,,no IP contract,,80,,228.36,percent of total billed charges,,,,,,,no IP contract,,50,,142.73,percent of total billed charges,,,,,,no IP contract,,,78,,222.65,percent of total billed charges,,,70,,199.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,139.87,3324,
51862-0454-04 - cloNIDine Patch 0.2 mg/24 hr Patch,51862-0454-04,NDC,,,,inpatient,1,UN,474.2,284.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,384.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,403.07,percent of total billed charges,,,85,,403.07,percent of total billed charges,,,49,,232.36,percent of total billed charges,,,90,,426.78,percent of total billed charges,,,,,,,no IP contract,,80,,379.36,percent of total billed charges,,,,,,,no IP contract,,50,,237.1,percent of total billed charges,,,,,,no IP contract,,,78,,369.88,percent of total billed charges,,,70,,331.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,232.36,3324,
51862-0455-04 - cloNIDine Patch 0.3 mg/24 hr Patch,51862-0455-04,NDC,,,,inpatient,1,UN,654.4,392.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,530.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,556.24,percent of total billed charges,,,85,,556.24,percent of total billed charges,,,49,,320.66,percent of total billed charges,,,90,,588.96,percent of total billed charges,,,,,,,no IP contract,,80,,523.52,percent of total billed charges,,,,,,,no IP contract,,50,,327.2,percent of total billed charges,,,,,,no IP contract,,,78,,510.43,percent of total billed charges,,,70,,458.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,320.66,3324,
51862-0486-01 - trimethoprim 100 mg Tab,51862-0486-01,NDC,,,,inpatient,1,EA,22.35,13.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19,percent of total billed charges,,,85,,19,percent of total billed charges,,,49,,10.95,percent of total billed charges,,,90,,20.12,percent of total billed charges,,,,,,,no IP contract,,80,,17.88,percent of total billed charges,,,,,,,no IP contract,,50,,11.18,percent of total billed charges,,,,,,no IP contract,,,78,,17.43,percent of total billed charges,,,70,,15.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.95,3324,
51862-0855-01 - carbidopa-levodopa 10 mg-100 mg Tab,51862-0855-01,NDC,,,,inpatient,1,EA,9.95,5.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.46,percent of total billed charges,,,85,,8.46,percent of total billed charges,,,49,,4.88,percent of total billed charges,,,90,,8.96,percent of total billed charges,,,,,,,no IP contract,,80,,7.96,percent of total billed charges,,,,,,,no IP contract,,50,,4.98,percent of total billed charges,,,,,,no IP contract,,,78,,7.76,percent of total billed charges,,,70,,6.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.88,3324,
51862-0856-01 - carbidopa-levodopa 25 mg-100 mg Tab,51862-0856-01,NDC,,,,inpatient,1,EA,10.75,6.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.14,percent of total billed charges,,,85,,9.14,percent of total billed charges,,,49,,5.27,percent of total billed charges,,,90,,9.68,percent of total billed charges,,,,,,,no IP contract,,80,,8.6,percent of total billed charges,,,,,,,no IP contract,,50,,5.38,percent of total billed charges,,,,,,no IP contract,,,78,,8.39,percent of total billed charges,,,70,,7.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.27,3324,
51991-0384-90 - multivitamin Vitamin B Complex with Folic Acid Tab,51991-0384-90,NDC,,,,inpatient,1,EA,9.65,5.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.2,percent of total billed charges,,,85,,8.2,percent of total billed charges,,,49,,4.73,percent of total billed charges,,,90,,8.69,percent of total billed charges,,,,,,,no IP contract,,80,,7.72,percent of total billed charges,,,,,,,no IP contract,,50,,4.83,percent of total billed charges,,,,,,no IP contract,,,78,,7.53,percent of total billed charges,,,70,,6.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.73,3324,
51991-0526-01 - terbinafine 250 mg Tab,51991-0526-01,NDC,,,,inpatient,1,EA,107.8,64.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,87.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,91.63,percent of total billed charges,,,85,,91.63,percent of total billed charges,,,49,,52.82,percent of total billed charges,,,90,,97.02,percent of total billed charges,,,,,,,no IP contract,,80,,86.24,percent of total billed charges,,,,,,,no IP contract,,50,,53.9,percent of total billed charges,,,,,,no IP contract,,,78,,84.08,percent of total billed charges,,,70,,75.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,52.82,3324,
51991-0620-33 - anastrozole 1 mg Tab,51991-0620-33,NDC,,,,inpatient,1,EA,109.95,65.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,89.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,93.46,percent of total billed charges,,,85,,93.46,percent of total billed charges,,,49,,53.88,percent of total billed charges,,,90,,98.96,percent of total billed charges,,,,,,,no IP contract,,80,,87.96,percent of total billed charges,,,,,,,no IP contract,,50,,54.98,percent of total billed charges,,,,,,no IP contract,,,78,,85.76,percent of total billed charges,,,70,,76.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,53.88,3324,
51991-0748-90 - DULoxetine 60 mg DR Ca,51991-0748-90,NDC,,,,inpatient,1,EA,63.75,38.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,51.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,54.19,percent of total billed charges,,,85,,54.19,percent of total billed charges,,,49,,31.24,percent of total billed charges,,,90,,57.38,percent of total billed charges,,,,,,,no IP contract,,80,,51,percent of total billed charges,,,,,,,no IP contract,,50,,31.88,percent of total billed charges,,,,,,no IP contract,,,78,,49.73,percent of total billed charges,,,70,,44.63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.24,3324,
51991-0793-06 - rivastigmine 1.5 mg Cap,51991-0793-06,NDC,,,,inpatient,1,EA,37.55,22.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.92,percent of total billed charges,,,85,,31.92,percent of total billed charges,,,49,,18.4,percent of total billed charges,,,90,,33.8,percent of total billed charges,,,,,,,no IP contract,,80,,30.04,percent of total billed charges,,,,,,,no IP contract,,50,,18.78,percent of total billed charges,,,,,,no IP contract,,,78,,29.29,percent of total billed charges,,,70,,26.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.4,3324,
propranolol 80 mg ER Ca,51991-0818-01,NDC,,,,inpatient,1,EA,23,13.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.55,percent of total billed charges,,,85,,19.55,percent of total billed charges,,,49,,11.27,percent of total billed charges,,,90,,20.7,percent of total billed charges,,,,,,,no IP contract,,80,,18.4,percent of total billed charges,,,,,,,no IP contract,,50,,11.5,percent of total billed charges,,,,,,no IP contract,,,78,,17.94,percent of total billed charges,,,70,,16.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.27,3324,
51991-0838-01 - cyproheptadine 4 mg Tab,51991-0838-01,NDC,,,,inpatient,1,EA,12.35,7.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.5,percent of total billed charges,,,85,,10.5,percent of total billed charges,,,49,,6.05,percent of total billed charges,,,90,,11.12,percent of total billed charges,,,,,,,no IP contract,,80,,9.88,percent of total billed charges,,,,,,,no IP contract,,50,,6.18,percent of total billed charges,,,,,,no IP contract,,,78,,9.63,percent of total billed charges,,,70,,8.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.05,3324,
51991-0877-33 - eplerenone 25 mg Tab,51991-0877-33,NDC,,,,inpatient,1,EA,37,22.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.45,percent of total billed charges,,,85,,31.45,percent of total billed charges,,,49,,18.13,percent of total billed charges,,,90,,33.3,percent of total billed charges,,,,,,,no IP contract,,80,,29.6,percent of total billed charges,,,,,,,no IP contract,,50,,18.5,percent of total billed charges,,,,,,no IP contract,,,78,,28.86,percent of total billed charges,,,70,,25.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.13,3324,
51991-0897-30 - rivastigmine 4.6 mg/24 hr ER Fi,51991-0897-30,NDC,,,,inpatient,1,UN,150,90,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,121.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,127.5,percent of total billed charges,,,85,,127.5,percent of total billed charges,,,49,,73.5,percent of total billed charges,,,90,,135,percent of total billed charges,,,,,,,no IP contract,,80,,120,percent of total billed charges,,,,,,,no IP contract,,50,,75,percent of total billed charges,,,,,,no IP contract,,,78,,117,percent of total billed charges,,,70,,105,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,73.5,3324,
51991-0907-01 - tetracycline 500 mg Cap,51991-0907-01,NDC,,,,inpatient,1,EA,129.05,77.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,104.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,109.69,percent of total billed charges,,,85,,109.69,percent of total billed charges,,,49,,63.23,percent of total billed charges,,,90,,116.15,percent of total billed charges,,,,,,,no IP contract,,80,,103.24,percent of total billed charges,,,,,,,no IP contract,,50,,64.53,percent of total billed charges,,,,,,no IP contract,,,78,,100.66,percent of total billed charges,,,70,,90.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,63.23,3324,
52015-0080-01 - fidaxomicin 200 mg Tab,52015-0080-01,NDC,,,,inpatient,1,EA,1492.3,895.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1208.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1268.46,percent of total billed charges,,,85,,1268.46,percent of total billed charges,,,49,,731.23,percent of total billed charges,,,90,,1343.07,percent of total billed charges,,,,,,,no IP contract,,80,,1193.84,percent of total billed charges,,,,,,,no IP contract,,50,,746.15,percent of total billed charges,,,,,,no IP contract,,,78,,1163.99,percent of total billed charges,,,70,,1044.61,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,731.23,3324,
52152-0264-01 - isradipine 5 mg Cap,52152-0264-01,NDC,,,,inpatient,1,EA,2,1.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1.7,percent of total billed charges,,,85,,1.7,percent of total billed charges,,,49,,0.98,percent of total billed charges,,,90,,1.8,percent of total billed charges,,,,,,,no IP contract,,80,,1.6,percent of total billed charges,,,,,,,no IP contract,,50,,1,percent of total billed charges,,,,,,no IP contract,,,78,,1.56,percent of total billed charges,,,70,,1.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,0.98,3324,
52152-0341-02 - desipramine 10 mg Tab,52152-0341-02,NDC,,,,inpatient,1,EA,7,4.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.95,percent of total billed charges,,,85,,5.95,percent of total billed charges,,,49,,3.43,percent of total billed charges,,,90,,6.3,percent of total billed charges,,,,,,,no IP contract,,80,,5.6,percent of total billed charges,,,,,,,no IP contract,,50,,3.5,percent of total billed charges,,,,,,no IP contract,,,78,,5.46,percent of total billed charges,,,70,,4.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.43,3324,
52152-0342-02 - desipramine 25 mg Tab,52152-0342-02,NDC,,,,inpatient,1,EA,7.7,4.62,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.55,percent of total billed charges,,,85,,6.55,percent of total billed charges,,,49,,3.77,percent of total billed charges,,,90,,6.93,percent of total billed charges,,,,,,,no IP contract,,80,,6.16,percent of total billed charges,,,,,,,no IP contract,,50,,3.85,percent of total billed charges,,,,,,no IP contract,,,78,,6.01,percent of total billed charges,,,70,,5.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.77,3324,
52244-0100-10 - theophylline 100 mg/24 hours ER Ca,52244-0100-10,NDC,,,,inpatient,1,EA,34.35,20.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.2,percent of total billed charges,,,85,,29.2,percent of total billed charges,,,49,,16.83,percent of total billed charges,,,90,,30.92,percent of total billed charges,,,,,,,no IP contract,,80,,27.48,percent of total billed charges,,,,,,,no IP contract,,50,,17.18,percent of total billed charges,,,,,,no IP contract,,,78,,26.79,percent of total billed charges,,,70,,24.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.83,3324,
52244-0200-10 - theophylline 200 mg/24 hours ER Ca,52244-0200-10,NDC,,,,inpatient,1,EA,49.2,29.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,39.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,41.82,percent of total billed charges,,,85,,41.82,percent of total billed charges,,,49,,24.11,percent of total billed charges,,,90,,44.28,percent of total billed charges,,,,,,,no IP contract,,80,,39.36,percent of total billed charges,,,,,,,no IP contract,,50,,24.6,percent of total billed charges,,,,,,no IP contract,,,78,,38.38,percent of total billed charges,,,70,,34.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.11,3324,
52268-0100-01 - polyethylene glycol 3350 with electrolytes - REC Powder,52268-0100-01,NDC,,,,inpatient,4000,ML,5.4,3.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.59,percent of total billed charges,,,85,,4.59,percent of total billed charges,,,49,,2.65,percent of total billed charges,,,90,,4.86,percent of total billed charges,,,,,,,no IP contract,,80,,4.32,percent of total billed charges,,,,,,,no IP contract,,50,,2.7,percent of total billed charges,,,,,,no IP contract,,,78,,4.21,percent of total billed charges,,,70,,3.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.65,3324,
52268-0800-02 - polyethylene glycol 3350 - REC P,52268-0800-02,NDC,,,,inpatient,1,EA,196.6,117.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,159.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,167.11,percent of total billed charges,,,85,,167.11,percent of total billed charges,,,49,,96.33,percent of total billed charges,,,90,,176.94,percent of total billed charges,,,,,,,no IP contract,,80,,157.28,percent of total billed charges,,,,,,,no IP contract,,50,,98.3,percent of total billed charges,,,,,,no IP contract,,,78,,153.35,percent of total billed charges,,,70,,137.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,96.33,3324,
52536-0134-13 - erythromycin ethylsuccinate 200 mg/5 mL REC G,52536-0134-13,NDC,,,,inpatient,1,ML,38,22.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.3,percent of total billed charges,,,85,,32.3,percent of total billed charges,,,49,,18.62,percent of total billed charges,,,90,,34.2,percent of total billed charges,,,,,,,no IP contract,,80,,30.4,percent of total billed charges,,,,,,,no IP contract,,50,,19,percent of total billed charges,,,,,,no IP contract,,,78,,29.64,percent of total billed charges,,,70,,26.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.62,3324,
52544-0151-30 - silodosin 4 mg Cap,52544-0151-30,NDC,,,,inpatient,1,EA,41.1,24.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34.94,percent of total billed charges,,,85,,34.94,percent of total billed charges,,,49,,20.14,percent of total billed charges,,,90,,36.99,percent of total billed charges,,,,,,,no IP contract,,80,,32.88,percent of total billed charges,,,,,,,no IP contract,,50,,20.55,percent of total billed charges,,,,,,no IP contract,,,78,,32.06,percent of total billed charges,,,70,,28.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.14,3324,
52544-0152-30 - silodosin 8 mg Cap,52544-0152-30,NDC,,,,inpatient,1,EA,37.05,22.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.49,percent of total billed charges,,,85,,31.49,percent of total billed charges,,,49,,18.15,percent of total billed charges,,,90,,33.35,percent of total billed charges,,,,,,,no IP contract,,80,,29.64,percent of total billed charges,,,,,,,no IP contract,,50,,18.53,percent of total billed charges,,,,,,no IP contract,,,78,,28.9,percent of total billed charges,,,70,,25.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.15,3324,
52544-0930-01 - ursodiol 300 mg Cap,52544-0930-01,NDC,,,,inpatient,1,EA,40,24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34,percent of total billed charges,,,85,,34,percent of total billed charges,,,49,,19.6,percent of total billed charges,,,90,,36,percent of total billed charges,,,,,,,no IP contract,,80,,32,percent of total billed charges,,,,,,,no IP contract,,50,,20,percent of total billed charges,,,,,,no IP contract,,,78,,31.2,percent of total billed charges,,,70,,28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.6,3324,
52565-0012-59 - fluocinolone topical 0.01% Soln,52565-0012-59,NDC,,,,inpatient,1,UN,1513.6,908.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1226.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1286.56,percent of total billed charges,,,85,,1286.56,percent of total billed charges,,,49,,741.66,percent of total billed charges,,,90,,1362.24,percent of total billed charges,,,,,,,no IP contract,,80,,1210.88,percent of total billed charges,,,,,,,no IP contract,,50,,756.8,percent of total billed charges,,,,,,no IP contract,,,78,,1180.61,percent of total billed charges,,,70,,1059.52,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,741.66,3324,
52565-0051-15 - clobetasol 0.05% Cream 0.05% Cream,52565-0051-15,NDC,,,,inpatient,1,UN,1076.3,645.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,871.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,914.86,percent of total billed charges,,,85,,914.86,percent of total billed charges,,,49,,527.39,percent of total billed charges,,,90,,968.67,percent of total billed charges,,,,,,,no IP contract,,80,,861.04,percent of total billed charges,,,,,,,no IP contract,,50,,538.15,percent of total billed charges,,,,,,no IP contract,,,78,,839.51,percent of total billed charges,,,70,,753.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,527.39,3324,
52652-2001-01 - methotrexate 2.5 mg/mL Soln,52652-2001-01,NDC,,,,inpatient,1,ML,163.35,98.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,132.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,138.85,percent of total billed charges,,,85,,138.85,percent of total billed charges,,,49,,80.04,percent of total billed charges,,,90,,147.02,percent of total billed charges,,,,,,,no IP contract,,80,,130.68,percent of total billed charges,,,,,,,no IP contract,,50,,81.68,percent of total billed charges,,,,,,no IP contract,,,78,,127.41,percent of total billed charges,,,70,,114.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,80.04,3324,
52652-6001-01 - baclofen 5 mg/mL Susp,52652-6001-01,NDC,,,,inpatient,1,ML,65.9,39.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,53.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.02,percent of total billed charges,,,85,,56.02,percent of total billed charges,,,49,,32.29,percent of total billed charges,,,90,,59.31,percent of total billed charges,,,,,,,no IP contract,,80,,52.72,percent of total billed charges,,,,,,,no IP contract,,50,,32.95,percent of total billed charges,,,,,,no IP contract,,,78,,51.4,percent of total billed charges,,,70,,46.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.29,3324,
52652-8001-01 - zonisamide 100 mg/5 mL Susp,52652-8001-01,NDC,,,,inpatient,1,ML,28.75,17.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.44,percent of total billed charges,,,85,,24.44,percent of total billed charges,,,49,,14.09,percent of total billed charges,,,90,,25.88,percent of total billed charges,,,,,,,no IP contract,,80,,23,percent of total billed charges,,,,,,,no IP contract,,50,,14.38,percent of total billed charges,,,,,,no IP contract,,,78,,22.43,percent of total billed charges,,,70,,20.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.09,3324,
52652-9001-03 - topiramate 25 mg/mL Soln,52652-9001-03,NDC,,,,inpatient,1,ML,28.6,17.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.31,percent of total billed charges,,,85,,24.31,percent of total billed charges,,,49,,14.01,percent of total billed charges,,,90,,25.74,percent of total billed charges,,,,,,,no IP contract,,80,,22.88,percent of total billed charges,,,,,,,no IP contract,,50,,14.3,percent of total billed charges,,,,,,no IP contract,,,78,,22.31,percent of total billed charges,,,70,,20.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.01,3324,
52817-0319-10 - baclofen 5 mg Tab,52817-0319-10,NDC,,,,inpatient,1,EA,13.7,8.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.65,percent of total billed charges,,,85,,11.65,percent of total billed charges,,,49,,6.71,percent of total billed charges,,,90,,12.33,percent of total billed charges,,,,,,,no IP contract,,80,,10.96,percent of total billed charges,,,,,,,no IP contract,,50,,6.85,percent of total billed charges,,,,,,no IP contract,,,78,,10.69,percent of total billed charges,,,70,,9.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.71,3324,
cyclobenzaprine 10 mg Tab,52817-0332-10,NDC,,,,inpatient,1,EA,13.05,7.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.09,percent of total billed charges,,,85,,11.09,percent of total billed charges,,,49,,6.39,percent of total billed charges,,,90,,11.75,percent of total billed charges,,,,,,,no IP contract,,80,,10.44,percent of total billed charges,,,,,,,no IP contract,,50,,6.53,percent of total billed charges,,,,,,no IP contract,,,78,,10.18,percent of total billed charges,,,70,,9.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.39,3324,
52817-0364-10 - triamterene 50 mg Cap,52817-0364-10,NDC,,,,inpatient,1,EA,98.75,59.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,79.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,83.94,percent of total billed charges,,,85,,83.94,percent of total billed charges,,,49,,48.39,percent of total billed charges,,,90,,88.88,percent of total billed charges,,,,,,,no IP contract,,80,,79,percent of total billed charges,,,,,,,no IP contract,,50,,49.38,percent of total billed charges,,,,,,no IP contract,,,78,,77.03,percent of total billed charges,,,70,,69.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,48.39,3324,
52959-0029-20 - cefuroxime 250 mg Tab,52959-0029-20,NDC,,,,inpatient,1,EA,41.75,25.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,35.49,percent of total billed charges,,,85,,35.49,percent of total billed charges,,,49,,20.46,percent of total billed charges,,,90,,37.58,percent of total billed charges,,,,,,,no IP contract,,80,,33.4,percent of total billed charges,,,,,,,no IP contract,,50,,20.88,percent of total billed charges,,,,,,no IP contract,,,78,,32.57,percent of total billed charges,,,70,,29.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.46,3324,
"53191-0362-01 - cholecalciferol 50,000 intl units Cap",53191-0362-01,NDC,,,,inpatient,1,EA,6.2,3.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.27,percent of total billed charges,,,85,,5.27,percent of total billed charges,,,49,,3.04,percent of total billed charges,,,90,,5.58,percent of total billed charges,,,,,,,no IP contract,,80,,4.96,percent of total billed charges,,,,,,,no IP contract,,50,,3.1,percent of total billed charges,,,,,,no IP contract,,,78,,4.84,percent of total billed charges,,,70,,4.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.04,3324,
"53329-0068-01 - petrolatum, white 100% Ointment",53329-0068-01,NDC,,,,inpatient,1,UN,32.9,19.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,26.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,27.97,percent of total billed charges,,,85,,27.97,percent of total billed charges,,,49,,16.12,percent of total billed charges,,,90,,29.61,percent of total billed charges,,,,,,,no IP contract,,80,,26.32,percent of total billed charges,,,,,,,no IP contract,,50,,16.45,percent of total billed charges,,,,,,no IP contract,,,78,,25.66,percent of total billed charges,,,70,,23.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.12,3324,
53489-0138-01 - predniSONE 5 mg Tab,53489-0138-01,NDC,,,,inpatient,1,EA,4.2,2.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.57,percent of total billed charges,,,85,,3.57,percent of total billed charges,,,49,,2.06,percent of total billed charges,,,90,,3.78,percent of total billed charges,,,,,,,no IP contract,,80,,3.36,percent of total billed charges,,,,,,,no IP contract,,50,,2.1,percent of total billed charges,,,,,,no IP contract,,,78,,3.28,percent of total billed charges,,,70,,2.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.06,3324,
53489-0138-01 - predniSONE 5 mg Tab,53489-0138-01,NDC,,,,inpatient,1,EA,4.2,2.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.57,percent of total billed charges,,,85,,3.57,percent of total billed charges,,,49,,2.06,percent of total billed charges,,,90,,3.78,percent of total billed charges,,,,,,,no IP contract,,80,,3.36,percent of total billed charges,,,,,,,no IP contract,,50,,2.1,percent of total billed charges,,,,,,no IP contract,,,78,,3.28,percent of total billed charges,,,70,,2.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.06,3324,
53489-0148-01 - thioridazine 10 mg Tab,53489-0148-01,NDC,,,,inpatient,1,EA,6.45,3.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.48,percent of total billed charges,,,85,,5.48,percent of total billed charges,,,49,,3.16,percent of total billed charges,,,90,,5.81,percent of total billed charges,,,,,,,no IP contract,,80,,5.16,percent of total billed charges,,,,,,,no IP contract,,50,,3.23,percent of total billed charges,,,,,,no IP contract,,,78,,5.03,percent of total billed charges,,,70,,4.52,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.16,3324,
allopurinol 100 mg Tab,53489-0156-01,NDC,,,,inpatient,1,EA,7.65,4.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.5,percent of total billed charges,,,85,,6.5,percent of total billed charges,,,49,,3.75,percent of total billed charges,,,90,,6.89,percent of total billed charges,,,,,,,no IP contract,,80,,6.12,percent of total billed charges,,,,,,,no IP contract,,50,,3.83,percent of total billed charges,,,,,,no IP contract,,,78,,5.97,percent of total billed charges,,,70,,5.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.75,3324,
53489-0330-01 - imipramine 10 mg Tab,53489-0330-01,NDC,,,,inpatient,1,EA,7.25,4.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.16,percent of total billed charges,,,85,,6.16,percent of total billed charges,,,49,,3.55,percent of total billed charges,,,90,,6.53,percent of total billed charges,,,,,,,no IP contract,,80,,5.8,percent of total billed charges,,,,,,,no IP contract,,50,,3.63,percent of total billed charges,,,,,,no IP contract,,,78,,5.66,percent of total billed charges,,,70,,5.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.55,3324,
53489-0332-01 - imipramine 50 mg Tab,53489-0332-01,NDC,,,,inpatient,1,EA,13.5,8.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.48,percent of total billed charges,,,85,,11.48,percent of total billed charges,,,49,,6.62,percent of total billed charges,,,90,,12.15,percent of total billed charges,,,,,,,no IP contract,,80,,10.8,percent of total billed charges,,,,,,,no IP contract,,50,,6.75,percent of total billed charges,,,,,,no IP contract,,,78,,10.53,percent of total billed charges,,,70,,9.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.62,3324,
trimethobenzamide 300 mg Cap,53489-0376-01,NDC,,,,inpatient,1,EA,16.7,10.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.2,percent of total billed charges,,,85,,14.2,percent of total billed charges,,,49,,8.18,percent of total billed charges,,,90,,15.03,percent of total billed charges,,,,,,,no IP contract,,80,,13.36,percent of total billed charges,,,,,,,no IP contract,,50,,8.35,percent of total billed charges,,,,,,no IP contract,,,78,,13.03,percent of total billed charges,,,70,,11.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.18,3324,
53489-0511-01 - traZODone 100 mg Tab,53489-0511-01,NDC,,,,inpatient,1,EA,9.65,5.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.2,percent of total billed charges,,,85,,8.2,percent of total billed charges,,,49,,4.73,percent of total billed charges,,,90,,8.69,percent of total billed charges,,,,,,,no IP contract,,80,,7.72,percent of total billed charges,,,,,,,no IP contract,,50,,4.83,percent of total billed charges,,,,,,no IP contract,,,78,,7.53,percent of total billed charges,,,70,,6.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.73,3324,
53746-0271-01 - sulfamethoxazole-trimethoprim 400 mg-80 mg Tab,53746-0271-01,NDC,,,,inpatient,1,EA,10.05,6.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.54,percent of total billed charges,,,85,,8.54,percent of total billed charges,,,49,,4.92,percent of total billed charges,,,90,,9.05,percent of total billed charges,,,,,,,no IP contract,,80,,8.04,percent of total billed charges,,,,,,,no IP contract,,50,,5.03,percent of total billed charges,,,,,,no IP contract,,,78,,7.84,percent of total billed charges,,,70,,7.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.92,3324,
folic acid 1 mg Tab,53746-0361-01,NDC,,,,inpatient,1,EA,6.45,3.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.48,percent of total billed charges,,,85,,5.48,percent of total billed charges,,,49,,3.16,percent of total billed charges,,,90,,5.81,percent of total billed charges,,,,,,,no IP contract,,80,,5.16,percent of total billed charges,,,,,,,no IP contract,,50,,3.23,percent of total billed charges,,,,,,no IP contract,,,78,,5.03,percent of total billed charges,,,70,,4.52,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.16,3324,
53746-0545-01 - primidone 250 mg Tab,53746-0545-01,NDC,,,,inpatient,1,EA,11.75,7.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.99,percent of total billed charges,,,85,,9.99,percent of total billed charges,,,49,,5.76,percent of total billed charges,,,90,,10.58,percent of total billed charges,,,,,,,no IP contract,,80,,9.4,percent of total billed charges,,,,,,,no IP contract,,50,,5.88,percent of total billed charges,,,,,,no IP contract,,,78,,9.17,percent of total billed charges,,,70,,8.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.76,3324,
53746-0554-01 - demeclocycline 150 mg Tab,53746-0554-01,NDC,,,,inpatient,1,EA,78.55,47.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,63.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,66.77,percent of total billed charges,,,85,,66.77,percent of total billed charges,,,49,,38.49,percent of total billed charges,,,90,,70.7,percent of total billed charges,,,,,,,no IP contract,,80,,62.84,percent of total billed charges,,,,,,,no IP contract,,50,,39.28,percent of total billed charges,,,,,,no IP contract,,,78,,61.27,percent of total billed charges,,,70,,54.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,38.49,3324,
53746-0617-01 - acetaminophen-tramadol 325 mg-37.5 mg Tab,53746-0617-01,NDC,,,,inpatient,1,EA,11.95,7.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.16,percent of total billed charges,,,85,,10.16,percent of total billed charges,,,49,,5.86,percent of total billed charges,,,90,,10.76,percent of total billed charges,,,,,,,no IP contract,,80,,9.56,percent of total billed charges,,,,,,,no IP contract,,50,,5.98,percent of total billed charges,,,,,,no IP contract,,,78,,9.32,percent of total billed charges,,,70,,8.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.86,3324,
benazepril 5 mg Tab,53746-0751-01,NDC,,,,inpatient,1,EA,12.15,7.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.33,percent of total billed charges,,,85,,10.33,percent of total billed charges,,,49,,5.95,percent of total billed charges,,,90,,10.94,percent of total billed charges,,,,,,,no IP contract,,80,,9.72,percent of total billed charges,,,,,,,no IP contract,,50,,6.08,percent of total billed charges,,,,,,no IP contract,,,78,,9.48,percent of total billed charges,,,70,,8.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.95,3324,
54023-9373-01 - ubiquinone 90 mg/mL LIQ,54023-9373-01,NDC,,,,inpatient,1,ML,13.5,8.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.48,percent of total billed charges,,,85,,11.48,percent of total billed charges,,,49,,6.62,percent of total billed charges,,,90,,12.15,percent of total billed charges,,,,,,,no IP contract,,80,,10.8,percent of total billed charges,,,,,,,no IP contract,,50,,6.75,percent of total billed charges,,,,,,no IP contract,,,78,,10.53,percent of total billed charges,,,70,,9.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.62,3324,
54092-0173-12 - carbamazepine 300 mg ER Cap,54092-0173-12,NDC,,,,inpatient,1,EA,13.45,8.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.43,percent of total billed charges,,,85,,11.43,percent of total billed charges,,,49,,6.59,percent of total billed charges,,,90,,12.11,percent of total billed charges,,,,,,,no IP contract,,80,,10.76,percent of total billed charges,,,,,,,no IP contract,,50,,6.73,percent of total billed charges,,,,,,no IP contract,,,78,,10.49,percent of total billed charges,,,70,,9.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.59,3324,
54092-0191-12 - mesalamine 500 mg ER Ca,54092-0191-12,NDC,,,,inpatient,1,EA,21.95,13.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.66,percent of total billed charges,,,85,,18.66,percent of total billed charges,,,49,,10.76,percent of total billed charges,,,90,,19.76,percent of total billed charges,,,,,,,no IP contract,,80,,17.56,percent of total billed charges,,,,,,,no IP contract,,50,,10.98,percent of total billed charges,,,,,,no IP contract,,,78,,17.12,percent of total billed charges,,,70,,15.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.76,3324,
54092-0247-01 - lanthanum carbonate 250 mg Chew Tab,54092-0247-01,NDC,,,,inpatient,1,EA,13.3,7.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.31,percent of total billed charges,,,85,,11.31,percent of total billed charges,,,49,,6.52,percent of total billed charges,,,90,,11.97,percent of total billed charges,,,,,,,no IP contract,,80,,10.64,percent of total billed charges,,,,,,,no IP contract,,50,,6.65,percent of total billed charges,,,,,,no IP contract,,,78,,10.37,percent of total billed charges,,,70,,9.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.52,3324,
54092-0383-01 - amphetamine-dextroamphetamine 10 mg ER Ca,54092-0383-01,NDC,,,,inpatient,1,EA,38.65,23.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.85,percent of total billed charges,,,85,,32.85,percent of total billed charges,,,49,,18.94,percent of total billed charges,,,90,,34.79,percent of total billed charges,,,,,,,no IP contract,,80,,30.92,percent of total billed charges,,,,,,,no IP contract,,50,,19.33,percent of total billed charges,,,,,,no IP contract,,,78,,30.15,percent of total billed charges,,,70,,27.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.94,3324,
54092-0476-12 - mesalamine 1.2 g EC Ta,54092-0476-12,NDC,,,,inpatient,1,EA,50.35,30.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,40.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,42.8,percent of total billed charges,,,85,,42.8,percent of total billed charges,,,49,,24.67,percent of total billed charges,,,90,,45.32,percent of total billed charges,,,,,,,no IP contract,,80,,40.28,percent of total billed charges,,,,,,,no IP contract,,50,,25.18,percent of total billed charges,,,,,,no IP contract,,,78,,39.27,percent of total billed charges,,,70,,35.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.67,3324,
54162-0007-08 - senna 8.8 mg/5 mL Syrup,54162-0007-08,NDC,,,,inpatient,1,ML,5.9,3.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.02,percent of total billed charges,,,85,,5.02,percent of total billed charges,,,49,,2.89,percent of total billed charges,,,90,,5.31,percent of total billed charges,,,,,,,no IP contract,,80,,4.72,percent of total billed charges,,,,,,,no IP contract,,50,,2.95,percent of total billed charges,,,,,,no IP contract,,,78,,4.6,percent of total billed charges,,,70,,4.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.89,3324,
54162-0190-16 - mineral oil 100% LIQ,54162-0190-16,NDC,,,,inpatient,1,ML,5.5,3.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.68,percent of total billed charges,,,85,,4.68,percent of total billed charges,,,49,,2.7,percent of total billed charges,,,90,,4.95,percent of total billed charges,,,,,,,no IP contract,,80,,4.4,percent of total billed charges,,,,,,,no IP contract,,50,,2.75,percent of total billed charges,,,,,,no IP contract,,,78,,4.29,percent of total billed charges,,,70,,3.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.7,3324,
54288-0125-30 - potassium chloride 20 mEq REC P,54288-0125-30,NDC,,,,inpatient,1,UN,88.65,53.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,71.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,75.35,percent of total billed charges,,,85,,75.35,percent of total billed charges,,,49,,43.44,percent of total billed charges,,,90,,79.79,percent of total billed charges,,,,,,,no IP contract,,80,,70.92,percent of total billed charges,,,,,,,no IP contract,,50,,44.33,percent of total billed charges,,,,,,no IP contract,,,78,,69.15,percent of total billed charges,,,70,,62.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,43.44,3324,
54288-0135-01 - tacrolimus  1 mg Cap,54288-0135-01,NDC,,,,inpatient,1,EA,59.1,35.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,47.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,50.24,percent of total billed charges,,,85,,50.24,percent of total billed charges,,,49,,28.96,percent of total billed charges,,,90,,53.19,percent of total billed charges,,,,,,,no IP contract,,80,,47.28,percent of total billed charges,,,,,,,no IP contract,,50,,29.55,percent of total billed charges,,,,,,no IP contract,,,78,,46.1,percent of total billed charges,,,70,,41.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,28.96,3324,
54482-0144-07 - levocarnitine 330 mg Tab,54482-0144-07,NDC,,,,inpatient,1,EA,11.55,6.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.82,percent of total billed charges,,,85,,9.82,percent of total billed charges,,,49,,5.66,percent of total billed charges,,,90,,10.4,percent of total billed charges,,,,,,,no IP contract,,80,,9.24,percent of total billed charges,,,,,,,no IP contract,,50,,5.78,percent of total billed charges,,,,,,no IP contract,,,78,,9.01,percent of total billed charges,,,70,,8.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.66,3324,
54482-0147-01 - levOCARNitine 200 mg/mL Soln,54482-0147-01,NDC,,,,inpatient,1,ML,76.35,45.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,61.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,64.9,percent of total billed charges,,,85,,64.9,percent of total billed charges,,,49,,37.41,percent of total billed charges,,,90,,68.72,percent of total billed charges,,,,,,,no IP contract,,80,,61.08,percent of total billed charges,,,,,,,no IP contract,,50,,38.18,percent of total billed charges,,,,,,no IP contract,,,78,,59.55,percent of total billed charges,,,70,,53.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,37.41,3324,
ascorbic acid 500 mg Chew,54629-0700-01,NDC,,,,inpatient,1,EA,4.05,2.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.44,percent of total billed charges,,,85,,3.44,percent of total billed charges,,,49,,1.98,percent of total billed charges,,,90,,3.65,percent of total billed charges,,,,,,,no IP contract,,80,,3.24,percent of total billed charges,,,,,,,no IP contract,,50,,2.03,percent of total billed charges,,,,,,no IP contract,,,78,,3.16,percent of total billed charges,,,70,,2.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.98,3324,
54643-5646-01 - multivitamin Pediatric Multiple Vitamins Soln,54643-5646-01,NDC,,,,inpatient,1,ML,1224.5,734.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,991.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1040.83,percent of total billed charges,,,85,,1040.83,percent of total billed charges,,,49,,600.01,percent of total billed charges,,,90,,1102.05,percent of total billed charges,,,,,,,no IP contract,,80,,979.6,percent of total billed charges,,,,,,,no IP contract,,50,,612.25,percent of total billed charges,,,,,,no IP contract,,,78,,955.11,percent of total billed charges,,,70,,857.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,600.01,3324,
54643-5647-00 - multivitamin Pediatric Multiple Vitamins Soln,54643-5647-00,NDC,,,,inpatient,1,ML,1224.5,734.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,991.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1040.83,percent of total billed charges,,,85,,1040.83,percent of total billed charges,,,49,,600.01,percent of total billed charges,,,90,,1102.05,percent of total billed charges,,,,,,,no IP contract,,80,,979.6,percent of total billed charges,,,,,,,no IP contract,,50,,612.25,percent of total billed charges,,,,,,no IP contract,,,78,,955.11,percent of total billed charges,,,70,,857.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,600.01,3324,
54643-5650-02 - multivitamin Multiple Vitamins Soln,54643-5650-02,NDC,,,,inpatient,1,ML,18,10.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.3,percent of total billed charges,,,85,,15.3,percent of total billed charges,,,49,,8.82,percent of total billed charges,,,90,,16.2,percent of total billed charges,,,,,,,no IP contract,,80,,14.4,percent of total billed charges,,,,,,,no IP contract,,50,,9,percent of total billed charges,,,,,,no IP contract,,,78,,14.04,percent of total billed charges,,,70,,12.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.82,3324,
54838-0005-30 - vitamin E 15 intl units/0.3 mL Soln,54838-0005-30,NDC,,,,inpatient,0.3,ML,16.65,9.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.15,percent of total billed charges,,,85,,14.15,percent of total billed charges,,,49,,8.16,percent of total billed charges,,,90,,14.99,percent of total billed charges,,,,,,,no IP contract,,80,,13.32,percent of total billed charges,,,,,,,no IP contract,,50,,8.33,percent of total billed charges,,,,,,no IP contract,,,78,,12.99,percent of total billed charges,,,70,,11.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.16,3324,
54838-0011-50 - ferrous sulfate (as elemental iron) 15 mg/mL LIQ,54838-0011-50,NDC,,,,inpatient,1,ML,6.4,3.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.44,percent of total billed charges,,,85,,5.44,percent of total billed charges,,,49,,3.14,percent of total billed charges,,,90,,5.76,percent of total billed charges,,,,,,,no IP contract,,80,,5.12,percent of total billed charges,,,,,,,no IP contract,,50,,3.2,percent of total billed charges,,,,,,no IP contract,,,78,,4.99,percent of total billed charges,,,70,,4.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.14,3324,
54838-0116-80 - docusate 10 mg/mL LIQ,54838-0116-80,NDC,,,,inpatient,1,ML,5.65,3.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.8,percent of total billed charges,,,85,,4.8,percent of total billed charges,,,49,,2.77,percent of total billed charges,,,90,,5.09,percent of total billed charges,,,,,,,no IP contract,,80,,4.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.83,percent of total billed charges,,,,,,no IP contract,,,78,,4.41,percent of total billed charges,,,70,,3.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.77,3324,
54838-0209-40 - dextromethorphan-guaifenesin 10 mg-100 mg/5 mL LIQ,54838-0209-40,NDC,,,,inpatient,10,ML,45.4,27.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,38.59,percent of total billed charges,,,85,,38.59,percent of total billed charges,,,49,,22.25,percent of total billed charges,,,90,,40.86,percent of total billed charges,,,,,,,no IP contract,,80,,36.32,percent of total billed charges,,,,,,,no IP contract,,50,,22.7,percent of total billed charges,,,,,,no IP contract,,,78,,35.41,percent of total billed charges,,,70,,31.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.25,3324,
54838-0523-40 - fluoxetine 20 mg/5 mL Soln,54838-0523-40,NDC,,,,inpatient,1,ML,13.6,8.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.56,percent of total billed charges,,,85,,11.56,percent of total billed charges,,,49,,6.66,percent of total billed charges,,,90,,12.24,percent of total billed charges,,,,,,,no IP contract,,80,,10.88,percent of total billed charges,,,,,,,no IP contract,,50,,6.8,percent of total billed charges,,,,,,no IP contract,,,78,,10.61,percent of total billed charges,,,70,,9.52,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.66,3324,
54838-0548-80 - levetiracetam 100 mg Soln,54838-0548-80,NDC,,,,inpatient,1,ML,10.5,6.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.93,percent of total billed charges,,,85,,8.93,percent of total billed charges,,,49,,5.15,percent of total billed charges,,,90,,9.45,percent of total billed charges,,,,,,,no IP contract,,80,,8.4,percent of total billed charges,,,,,,,no IP contract,,50,,5.25,percent of total billed charges,,,,,,no IP contract,,,78,,8.19,percent of total billed charges,,,70,,7.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.15,3324,
54838-0551-70 - escitalopram 5 mg/5 mL Soln,54838-0551-70,NDC,,,,inpatient,1,ML,17.65,10.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15,percent of total billed charges,,,85,,15,percent of total billed charges,,,49,,8.65,percent of total billed charges,,,90,,15.89,percent of total billed charges,,,,,,,no IP contract,,80,,14.12,percent of total billed charges,,,,,,,no IP contract,,50,,8.83,percent of total billed charges,,,,,,no IP contract,,,78,,13.77,percent of total billed charges,,,70,,12.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.65,3324,
54838-0555-50 - ondansetron  4 mg / 5 mL Soln,54838-0555-50,NDC,,,,inpatient,1,ML,45.25,27.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,38.46,percent of total billed charges,,,85,,38.46,percent of total billed charges,,,49,,22.17,percent of total billed charges,,,90,,40.73,percent of total billed charges,,,,,,,no IP contract,,80,,36.2,percent of total billed charges,,,,,,,no IP contract,,50,,22.63,percent of total billed charges,,,,,,no IP contract,,,78,,35.3,percent of total billed charges,,,70,,31.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.17,3324,
54879-0007-16 - sulfamethoxazole-trimethoprim 200 mg-40 mg/5 mL Susp,54879-0007-16,NDC,,,,inpatient,1,ML,5.6,3.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.76,percent of total billed charges,,,85,,4.76,percent of total billed charges,,,49,,2.74,percent of total billed charges,,,90,,5.04,percent of total billed charges,,,,,,,no IP contract,,80,,4.48,percent of total billed charges,,,,,,,no IP contract,,50,,2.8,percent of total billed charges,,,,,,no IP contract,,,78,,4.37,percent of total billed charges,,,70,,3.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.74,3324,
55111-0123-90 - atorvastatin 40 mg Tab,55111-0123-90,NDC,,,,inpatient,1,EA,47.45,28.47,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,38.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,40.33,percent of total billed charges,,,85,,40.33,percent of total billed charges,,,49,,23.25,percent of total billed charges,,,90,,42.71,percent of total billed charges,,,,,,,no IP contract,,80,,37.96,percent of total billed charges,,,,,,,no IP contract,,50,,23.73,percent of total billed charges,,,,,,no IP contract,,,78,,37.01,percent of total billed charges,,,70,,33.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.25,3324,
55111-0127-01 - ciprofloxacin 500 mg Tab,55111-0127-01,NDC,,,,inpatient,1,EA,45.1,27.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,38.34,percent of total billed charges,,,85,,38.34,percent of total billed charges,,,49,,22.1,percent of total billed charges,,,90,,40.59,percent of total billed charges,,,,,,,no IP contract,,80,,36.08,percent of total billed charges,,,,,,,no IP contract,,50,,22.55,percent of total billed charges,,,,,,no IP contract,,,78,,35.18,percent of total billed charges,,,70,,31.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.1,3324,
55111-0128-50 - ciprofloxacin 750 mg Tab,55111-0128-50,NDC,,,,inpatient,1,EA,47.15,28.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,38.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,40.08,percent of total billed charges,,,85,,40.08,percent of total billed charges,,,49,,23.1,percent of total billed charges,,,90,,42.44,percent of total billed charges,,,,,,,no IP contract,,80,,37.72,percent of total billed charges,,,,,,,no IP contract,,50,,23.58,percent of total billed charges,,,,,,no IP contract,,,78,,36.78,percent of total billed charges,,,70,,33.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.1,3324,
55111-0144-30 - fluconazole 100 mg Tab,55111-0144-30,NDC,,,,inpatient,1,EA,73.4,44.04,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,59.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,62.39,percent of total billed charges,,,85,,62.39,percent of total billed charges,,,49,,35.97,percent of total billed charges,,,90,,66.06,percent of total billed charges,,,,,,,no IP contract,,80,,58.72,percent of total billed charges,,,,,,,no IP contract,,50,,36.7,percent of total billed charges,,,,,,no IP contract,,,78,,57.25,percent of total billed charges,,,70,,51.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,35.97,3324,
55111-0167-30 - OLANZapine 15 mg Tab,55111-0167-30,NDC,,,,inpatient,1,EA,18.05,10.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.34,percent of total billed charges,,,85,,15.34,percent of total billed charges,,,49,,8.84,percent of total billed charges,,,90,,16.25,percent of total billed charges,,,,,,,no IP contract,,80,,14.44,percent of total billed charges,,,,,,,no IP contract,,50,,9.03,percent of total billed charges,,,,,,no IP contract,,,78,,14.08,percent of total billed charges,,,70,,12.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.84,3324,
55111-0199-90 - simvastatin 20 mg Tab,55111-0199-90,NDC,,,,inpatient,1,EA,42.7,25.62,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36.3,percent of total billed charges,,,85,,36.3,percent of total billed charges,,,49,,20.92,percent of total billed charges,,,90,,38.43,percent of total billed charges,,,,,,,no IP contract,,80,,34.16,percent of total billed charges,,,,,,,no IP contract,,50,,21.35,percent of total billed charges,,,,,,no IP contract,,,78,,33.31,percent of total billed charges,,,70,,29.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.92,3324,
55111-0263-81 - OLANZapine 10 mg DIS T,55111-0263-81,NDC,,,,inpatient,1,EA,28.05,16.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.84,percent of total billed charges,,,85,,23.84,percent of total billed charges,,,49,,13.74,percent of total billed charges,,,90,,25.25,percent of total billed charges,,,,,,,no IP contract,,80,,22.44,percent of total billed charges,,,,,,,no IP contract,,50,,14.03,percent of total billed charges,,,,,,no IP contract,,,78,,21.88,percent of total billed charges,,,70,,19.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.74,3324,
55111-0521-30 - atomoxetine 40 mg Cap,55111-0521-30,NDC,,,,inpatient,1,EA,126.8,76.08,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,102.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,107.78,percent of total billed charges,,,85,,107.78,percent of total billed charges,,,49,,62.13,percent of total billed charges,,,90,,114.12,percent of total billed charges,,,,,,,no IP contract,,80,,101.44,percent of total billed charges,,,,,,,no IP contract,,50,,63.4,percent of total billed charges,,,,,,no IP contract,,,78,,98.9,percent of total billed charges,,,70,,88.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,62.13,3324,
55111-0525-01 - tacrolimus 0.5 mg Cap,55111-0525-01,NDC,,,,inpatient,1,EA,21.55,12.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.32,percent of total billed charges,,,85,,18.32,percent of total billed charges,,,49,,10.56,percent of total billed charges,,,90,,19.4,percent of total billed charges,,,,,,,no IP contract,,80,,17.24,percent of total billed charges,,,,,,,no IP contract,,50,,10.78,percent of total billed charges,,,,,,no IP contract,,,78,,16.81,percent of total billed charges,,,70,,15.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.56,3324,
55111-0526-01 - tacrolimus 1 mg Cap,55111-0526-01,NDC,,,,inpatient,1,EA,39.3,23.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.41,percent of total billed charges,,,85,,33.41,percent of total billed charges,,,49,,19.26,percent of total billed charges,,,90,,35.37,percent of total billed charges,,,,,,,no IP contract,,80,,31.44,percent of total billed charges,,,,,,,no IP contract,,50,,19.65,percent of total billed charges,,,,,,no IP contract,,,78,,30.65,percent of total billed charges,,,70,,27.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.26,3324,
55111-0532-01 - divalproex sodium 125 mg DRC,55111-0532-01,NDC,,,,inpatient,1,EA,12.75,7.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.84,percent of total billed charges,,,85,,10.84,percent of total billed charges,,,49,,6.25,percent of total billed charges,,,90,,11.48,percent of total billed charges,,,,,,,no IP contract,,80,,10.2,percent of total billed charges,,,,,,,no IP contract,,50,,6.38,percent of total billed charges,,,,,,no IP contract,,,78,,9.95,percent of total billed charges,,,70,,8.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.25,3324,
55111-0629-30 - eszopiclone 1 mg Tab,55111-0629-30,NDC,,,,inpatient,1,EA,102.65,61.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,83.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,87.25,percent of total billed charges,,,85,,87.25,percent of total billed charges,,,49,,50.3,percent of total billed charges,,,90,,92.39,percent of total billed charges,,,,,,,no IP contract,,80,,82.12,percent of total billed charges,,,,,,,no IP contract,,50,,51.33,percent of total billed charges,,,,,,no IP contract,,,78,,80.07,percent of total billed charges,,,70,,71.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,50.3,3324,
55111-0678-10 - fondaparinux 2.5 mg/0.5 mL Soln,55111-0678-10,NDC,,,,inpatient,0.5,ML,930.7,558.42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,753.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,791.1,percent of total billed charges,,,85,,791.1,percent of total billed charges,,,49,,456.04,percent of total billed charges,,,90,,837.63,percent of total billed charges,,,,,,,no IP contract,,80,,744.56,percent of total billed charges,,,,,,,no IP contract,,50,,465.35,percent of total billed charges,,,,,,no IP contract,,,78,,725.95,percent of total billed charges,,,70,,651.49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,456.04,3324,
55111-0679-10 - fondaparinux 5 mg/0.4 mL Soln,55111-0679-10,NDC,,,,inpatient,0.4,ML,2719.8,1631.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2203.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2311.83,percent of total billed charges,,,85,,2311.83,percent of total billed charges,,,49,,1332.7,percent of total billed charges,,,90,,2447.82,percent of total billed charges,,,,,,,no IP contract,,80,,2175.84,percent of total billed charges,,,,,,,no IP contract,,50,,1359.9,percent of total billed charges,,,,,,no IP contract,,,78,,2121.44,percent of total billed charges,,,70,,1903.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
55111-0680-10 - fondaparinux 7.5 mg/0.6 mL Soln,55111-0680-10,NDC,,,,inpatient,0.6,ML,1816.3,1089.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1471.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1543.86,percent of total billed charges,,,85,,1543.86,percent of total billed charges,,,49,,889.99,percent of total billed charges,,,90,,1634.67,percent of total billed charges,,,,,,,no IP contract,,80,,1453.04,percent of total billed charges,,,,,,,no IP contract,,50,,908.15,percent of total billed charges,,,,,,no IP contract,,,78,,1416.71,percent of total billed charges,,,70,,1271.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,889.99,3324,
55111-0681-02 - fondaparinux 10 mg/0.8 mL Soln,55111-0681-02,NDC,,,,inpatient,0.8,ML,1440.3,864.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1166.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1224.26,percent of total billed charges,,,85,,1224.26,percent of total billed charges,,,49,,705.75,percent of total billed charges,,,90,,1296.27,percent of total billed charges,,,,,,,no IP contract,,80,,1152.24,percent of total billed charges,,,,,,,no IP contract,,50,,720.15,percent of total billed charges,,,,,,no IP contract,,,78,,1123.43,percent of total billed charges,,,70,,1008.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,705.75,3324,
55111-0681-10 - fondaparinux 10 mg/0.8 mL Soln,55111-0681-10,NDC,,,,inpatient,0.8,ML,1364.55,818.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1105.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1159.87,percent of total billed charges,,,85,,1159.87,percent of total billed charges,,,49,,668.63,percent of total billed charges,,,90,,1228.1,percent of total billed charges,,,,,,,no IP contract,,80,,1091.64,percent of total billed charges,,,,,,,no IP contract,,50,,682.28,percent of total billed charges,,,,,,no IP contract,,,78,,1064.35,percent of total billed charges,,,70,,955.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,668.63,3324,
55111-0683-05 - ibuprofen 600 mg Tab,55111-0683-05,NDC,,,,inpatient,1,EA,5.75,3.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.89,percent of total billed charges,,,85,,4.89,percent of total billed charges,,,49,,2.82,percent of total billed charges,,,90,,5.18,percent of total billed charges,,,,,,,no IP contract,,80,,4.6,percent of total billed charges,,,,,,,no IP contract,,50,,2.88,percent of total billed charges,,,,,,no IP contract,,,78,,4.49,percent of total billed charges,,,70,,4.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.82,3324,
55111-0731-30 - valsartan 40 mg Tab,55111-0731-30,NDC,,,,inpatient,1,EA,16.7,10.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.2,percent of total billed charges,,,85,,14.2,percent of total billed charges,,,49,,8.18,percent of total billed charges,,,90,,15.03,percent of total billed charges,,,,,,,no IP contract,,80,,13.36,percent of total billed charges,,,,,,,no IP contract,,50,,8.35,percent of total billed charges,,,,,,no IP contract,,,78,,13.03,percent of total billed charges,,,70,,11.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.18,3324,
55111-0732-90 - valsartan 80 mg Tab,55111-0732-90,NDC,,,,inpatient,1,EA,19.25,11.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.36,percent of total billed charges,,,85,,16.36,percent of total billed charges,,,49,,9.43,percent of total billed charges,,,90,,17.33,percent of total billed charges,,,,,,,no IP contract,,80,,15.4,percent of total billed charges,,,,,,,no IP contract,,50,,9.63,percent of total billed charges,,,,,,no IP contract,,,78,,15.02,percent of total billed charges,,,70,,13.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.43,3324,
55111-0733-90 - valsartan 160 mg Tab,55111-0733-90,NDC,,,,inpatient,1,EA,20.35,12.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.3,percent of total billed charges,,,85,,17.3,percent of total billed charges,,,49,,9.97,percent of total billed charges,,,90,,18.32,percent of total billed charges,,,,,,,no IP contract,,80,,16.28,percent of total billed charges,,,,,,,no IP contract,,50,,10.18,percent of total billed charges,,,,,,no IP contract,,,78,,15.87,percent of total billed charges,,,70,,14.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.97,3324,
55111-0762-60 - valganciclovir 450 mg Tab,55111-0762-60,NDC,,,,inpatient,1,EA,515.8,309.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,417.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,438.43,percent of total billed charges,,,85,,438.43,percent of total billed charges,,,49,,252.74,percent of total billed charges,,,90,,464.22,percent of total billed charges,,,,,,,no IP contract,,80,,412.64,percent of total billed charges,,,,,,,no IP contract,,50,,257.9,percent of total billed charges,,,,,,no IP contract,,,78,,402.32,percent of total billed charges,,,70,,361.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,252.74,3324,
fexofenadine 60 mg Tab,55111-0783-01,NDC,,,,inpatient,1,EA,5.25,3.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.46,percent of total billed charges,,,85,,4.46,percent of total billed charges,,,49,,2.57,percent of total billed charges,,,90,,4.73,percent of total billed charges,,,,,,,no IP contract,,80,,4.2,percent of total billed charges,,,,,,,no IP contract,,50,,2.63,percent of total billed charges,,,,,,no IP contract,,,78,,4.1,percent of total billed charges,,,70,,3.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.57,3324,
fexofenadine 180 mg Tab,55111-0784-01,NDC,,,,inpatient,1,EA,5.8,3.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.93,percent of total billed charges,,,85,,4.93,percent of total billed charges,,,49,,2.84,percent of total billed charges,,,90,,5.22,percent of total billed charges,,,,,,,no IP contract,,80,,4.64,percent of total billed charges,,,,,,,no IP contract,,50,,2.9,percent of total billed charges,,,,,,no IP contract,,,78,,4.52,percent of total billed charges,,,70,,4.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.84,3324,
55150-0113-10 - ampicillin 1 g REC I,55150-0113-10,NDC,,,,inpatient,1,EA,143.5,86.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,116.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,121.98,percent of total billed charges,,,85,,121.98,percent of total billed charges,,,49,,70.32,percent of total billed charges,,,90,,129.15,percent of total billed charges,,,,,,,no IP contract,,80,,114.8,percent of total billed charges,,,,,,,no IP contract,,50,,71.75,percent of total billed charges,,,,,,no IP contract,,,78,,111.93,percent of total billed charges,,,70,,100.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,70.32,3324,
55150-0114-20 - ampicillin 2 g REC I,55150-0114-20,NDC,,,,inpatient,1,EA,207.75,124.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,168.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,176.59,percent of total billed charges,,,85,,176.59,percent of total billed charges,,,49,,101.8,percent of total billed charges,,,90,,186.98,percent of total billed charges,,,,,,,no IP contract,,80,,166.2,percent of total billed charges,,,,,,,no IP contract,,50,,103.88,percent of total billed charges,,,,,,no IP contract,,,78,,162.05,percent of total billed charges,,,70,,145.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,101.8,3324,
55150-0116-20 - ampicillin-sulbactam 1 g-0.5 g REC I,55150-0116-20,NDC,,,,inpatient,1,EA,139.6,83.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,113.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,118.66,percent of total billed charges,,,85,,118.66,percent of total billed charges,,,49,,68.4,percent of total billed charges,,,90,,125.64,percent of total billed charges,,,,,,,no IP contract,,80,,111.68,percent of total billed charges,,,,,,,no IP contract,,50,,69.8,percent of total billed charges,,,,,,no IP contract,,,78,,108.89,percent of total billed charges,,,70,,97.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,68.4,3324,
55150-0117-20 - ampicillin-sulbactam 2 g-1 g REC I,55150-0117-20,NDC,,,,inpatient,8,ML,132.4,79.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,107.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,112.54,percent of total billed charges,,,85,,112.54,percent of total billed charges,,,49,,64.88,percent of total billed charges,,,90,,119.16,percent of total billed charges,,,,,,,no IP contract,,80,,105.92,percent of total billed charges,,,,,,,no IP contract,,50,,66.2,percent of total billed charges,,,,,,no IP contract,,,78,,103.27,percent of total billed charges,,,70,,92.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,64.88,3324,
55150-0119-30 - piperacillin-tazobactam 2 g-0.25 g REC I,55150-0119-30,NDC,,,,inpatient,1,EA,131.55,78.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,106.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,111.82,percent of total billed charges,,,85,,111.82,percent of total billed charges,,,49,,64.46,percent of total billed charges,,,90,,118.4,percent of total billed charges,,,,,,,no IP contract,,80,,105.24,percent of total billed charges,,,,,,,no IP contract,,50,,65.78,percent of total billed charges,,,,,,no IP contract,,,78,,102.61,percent of total billed charges,,,70,,92.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,64.46,3324,
55150-0128-24 - oxacillin 2 g REC I,55150-0128-24,NDC,,,,inpatient,1,EA,247.75,148.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,200.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,210.59,percent of total billed charges,,,85,,210.59,percent of total billed charges,,,49,,121.4,percent of total billed charges,,,90,,222.98,percent of total billed charges,,,,,,,no IP contract,,80,,198.2,percent of total billed charges,,,,,,,no IP contract,,50,,123.88,percent of total billed charges,,,,,,no IP contract,,,78,,193.25,percent of total billed charges,,,70,,173.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,121.4,3324,
55150-0128-25 - oxacillin 2 gm REC Injection,55150-0128-25,NDC,,,,inpatient,1,EA,247.75,148.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,200.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,210.59,percent of total billed charges,,,85,,210.59,percent of total billed charges,,,49,,121.4,percent of total billed charges,,,90,,222.98,percent of total billed charges,,,,,,,no IP contract,,80,,198.2,percent of total billed charges,,,,,,,no IP contract,,50,,123.88,percent of total billed charges,,,,,,no IP contract,,,78,,193.25,percent of total billed charges,,,70,,173.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,121.4,3324,
55150-0167-10 - bupivacaine 0.25% preservative-free Soln,55150-0167-10,NDC,,,,inpatient,10,ML,25.35,15.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.55,percent of total billed charges,,,85,,21.55,percent of total billed charges,,,49,,12.42,percent of total billed charges,,,90,,22.82,percent of total billed charges,,,,,,,no IP contract,,80,,20.28,percent of total billed charges,,,,,,,no IP contract,,50,,12.68,percent of total billed charges,,,,,,no IP contract,,,78,,19.77,percent of total billed charges,,,70,,17.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.42,3324,
SUMAtriptan 6 mg/0.5 mL Soln,55150-0173-01,NDC,,,,inpatient,1,EA,120.6,72.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,97.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,102.51,percent of total billed charges,,,85,,102.51,percent of total billed charges,,,49,,59.09,percent of total billed charges,,,90,,108.54,percent of total billed charges,,,,,,,no IP contract,,80,,96.48,percent of total billed charges,,,,,,,no IP contract,,50,,60.3,percent of total billed charges,,,,,,no IP contract,,,78,,94.07,percent of total billed charges,,,70,,84.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,59.09,3324,
fondaparinux 2.5 mg/0.5 mL Soln,55150-0230-10,NDC,,,,inpatient,1,EA,616.3,369.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,499.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,523.86,percent of total billed charges,,,85,,523.86,percent of total billed charges,,,49,,301.99,percent of total billed charges,,,90,,554.67,percent of total billed charges,,,,,,,no IP contract,,80,,493.04,percent of total billed charges,,,,,,,no IP contract,,50,,308.15,percent of total billed charges,,,,,,no IP contract,,,78,,480.71,percent of total billed charges,,,70,,431.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,301.99,3324,
fondaparinux 7.5 mg/0.6 mL Soln,55150-0232-10,NDC,,,,inpatient,1,EA,1231.65,738.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,997.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1046.9,percent of total billed charges,,,85,,1046.9,percent of total billed charges,,,49,,603.51,percent of total billed charges,,,90,,1108.49,percent of total billed charges,,,,,,,no IP contract,,80,,985.32,percent of total billed charges,,,,,,,no IP contract,,50,,615.83,percent of total billed charges,,,,,,no IP contract,,,78,,960.69,percent of total billed charges,,,70,,862.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,603.51,3324,
fondaparinux 10 mg/0.8 mL Soln,55150-0233-10,NDC,,,,inpatient,1,EA,927.7,556.62,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,751.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,788.55,percent of total billed charges,,,85,,788.55,percent of total billed charges,,,49,,454.57,percent of total billed charges,,,90,,834.93,percent of total billed charges,,,,,,,no IP contract,,80,,742.16,percent of total billed charges,,,,,,,no IP contract,,50,,463.85,percent of total billed charges,,,,,,no IP contract,,,78,,723.61,percent of total billed charges,,,70,,649.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,454.57,3324,
55150-0282-09 - ertapenem 1 gm REC Injection,55150-0282-09,NDC,,,,inpatient,10,ML,1324.6,794.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1072.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1125.91,percent of total billed charges,,,85,,1125.91,percent of total billed charges,,,49,,649.05,percent of total billed charges,,,90,,1192.14,percent of total billed charges,,,,,,,no IP contract,,80,,1059.68,percent of total billed charges,,,,,,,no IP contract,,50,,662.3,percent of total billed charges,,,,,,no IP contract,,,78,,1033.19,percent of total billed charges,,,70,,927.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,649.05,3324,
ertapenem 1 g REC I,55150-0282-20,NDC,,,,inpatient,1,EA,674.9,404.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,546.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,573.67,percent of total billed charges,,,85,,573.67,percent of total billed charges,,,49,,330.7,percent of total billed charges,,,90,,607.41,percent of total billed charges,,,,,,,no IP contract,,80,,539.92,percent of total billed charges,,,,,,,no IP contract,,50,,337.45,percent of total billed charges,,,,,,no IP contract,,,78,,526.42,percent of total billed charges,,,70,,472.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,330.7,3324,
55150-0308-01 - OLANZapine 10 mg REC I,55150-0308-01,NDC,,,,inpatient,2,ML,367.85,220.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,297.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,312.67,percent of total billed charges,,,85,,312.67,percent of total billed charges,,,49,,180.25,percent of total billed charges,,,90,,331.07,percent of total billed charges,,,,,,,no IP contract,,80,,294.28,percent of total billed charges,,,,,,,no IP contract,,50,,183.93,percent of total billed charges,,,,,,no IP contract,,,78,,286.92,percent of total billed charges,,,70,,257.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,180.25,3324,
55150-0359-50 - doxercalciferol 2 mcg/mL Soln,55150-0359-50,NDC,,,,inpatient,2,ML,54.85,32.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,44.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,46.62,percent of total billed charges,,,85,,46.62,percent of total billed charges,,,49,,26.88,percent of total billed charges,,,90,,49.37,percent of total billed charges,,,,,,,no IP contract,,80,,43.88,percent of total billed charges,,,,,,,no IP contract,,50,,27.43,percent of total billed charges,,,,,,no IP contract,,,78,,42.78,percent of total billed charges,,,70,,38.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.88,3324,
55390-0027-01 - famotidine 10 mg/mL Soln,55390-0027-01,NDC,,,,inpatient,1,ML,15.55,9.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.22,percent of total billed charges,,,85,,13.22,percent of total billed charges,,,49,,7.62,percent of total billed charges,,,90,,14,percent of total billed charges,,,,,,,no IP contract,,80,,12.44,percent of total billed charges,,,,,,,no IP contract,,50,,7.78,percent of total billed charges,,,,,,no IP contract,,,78,,12.13,percent of total billed charges,,,70,,10.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.62,3324,
55390-0073-10 - metoprolol 1 mg/mL Soln,55390-0073-10,NDC,,,,inpatient,5,ML,30.4,18.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.84,percent of total billed charges,,,85,,25.84,percent of total billed charges,,,49,,14.9,percent of total billed charges,,,90,,27.36,percent of total billed charges,,,,,,,no IP contract,,80,,24.32,percent of total billed charges,,,,,,,no IP contract,,50,,15.2,percent of total billed charges,,,,,,no IP contract,,,78,,23.71,percent of total billed charges,,,70,,21.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.9,3324,
55390-0077-10 - prochlorperazine 5 mg/mL Soln,55390-0077-10,NDC,,,,inpatient,1,ML,41,24.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34.85,percent of total billed charges,,,85,,34.85,percent of total billed charges,,,49,,20.09,percent of total billed charges,,,90,,36.9,percent of total billed charges,,,,,,,no IP contract,,80,,32.8,percent of total billed charges,,,,,,,no IP contract,,50,,20.5,percent of total billed charges,,,,,,no IP contract,,,78,,31.98,percent of total billed charges,,,70,,28.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.09,3324,
55390-0139-01 - polymyxin B sulfate 500000 units REC I,55390-0139-01,NDC,,,,inpatient,1,EA,150.1,90.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,121.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,127.59,percent of total billed charges,,,85,,127.59,percent of total billed charges,,,49,,73.55,percent of total billed charges,,,90,,135.09,percent of total billed charges,,,,,,,no IP contract,,80,,120.08,percent of total billed charges,,,,,,,no IP contract,,50,,75.05,percent of total billed charges,,,,,,no IP contract,,,78,,117.08,percent of total billed charges,,,70,,105.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,73.55,3324,
55390-0139-10 - polymyxin B sulfate 500000 units REC I,55390-0139-10,NDC,,,,inpatient,1,EA,207.4,124.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,167.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,176.29,percent of total billed charges,,,85,,176.29,percent of total billed charges,,,49,,101.63,percent of total billed charges,,,90,,186.66,percent of total billed charges,,,,,,,no IP contract,,80,,165.92,percent of total billed charges,,,,,,,no IP contract,,50,,103.7,percent of total billed charges,,,,,,no IP contract,,,78,,161.77,percent of total billed charges,,,70,,145.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,101.63,3324,
55390-0481-02 - ketorolac 30 mg/mL Soln,55390-0481-02,NDC,,,,inpatient,1,ML,17.75,10.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.09,percent of total billed charges,,,85,,15.09,percent of total billed charges,,,49,,8.7,percent of total billed charges,,,90,,15.98,percent of total billed charges,,,,,,,no IP contract,,80,,14.2,percent of total billed charges,,,,,,,no IP contract,,50,,8.88,percent of total billed charges,,,,,,no IP contract,,,78,,13.85,percent of total billed charges,,,70,,12.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.7,3324,
55390-0500-02 - bumetanide 0.25 mg/mL Soln,55390-0500-02,NDC,,,,inpatient,1,ML,81,48.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,65.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,68.85,percent of total billed charges,,,85,,68.85,percent of total billed charges,,,49,,39.69,percent of total billed charges,,,90,,72.9,percent of total billed charges,,,,,,,no IP contract,,80,,64.8,percent of total billed charges,,,,,,,no IP contract,,50,,40.5,percent of total billed charges,,,,,,no IP contract,,,78,,63.18,percent of total billed charges,,,70,,56.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,39.69,3324,
55513-0073-30 - cinacalcet 30 mg Tab,55513-0073-30,NDC,,,,inpatient,1,EA,136.5,81.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,110.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,116.03,percent of total billed charges,,,85,,116.03,percent of total billed charges,,,49,,66.89,percent of total billed charges,,,90,,122.85,percent of total billed charges,,,,,,,no IP contract,,80,,109.2,percent of total billed charges,,,,,,,no IP contract,,50,,68.25,percent of total billed charges,,,,,,no IP contract,,,78,,106.47,percent of total billed charges,,,70,,95.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,66.89,3324,
55513-0126-01 - epoetin alfa 2000 units/mL preservative-free Soln,55513-0126-01,NDC,,,,inpatient,1,ML,252.2,151.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,204.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,214.37,percent of total billed charges,,,85,,214.37,percent of total billed charges,,,49,,123.58,percent of total billed charges,,,90,,226.98,percent of total billed charges,,,,,,,no IP contract,,80,,201.76,percent of total billed charges,,,,,,,no IP contract,,50,,126.1,percent of total billed charges,,,,,,no IP contract,,,78,,196.72,percent of total billed charges,,,70,,176.54,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,123.58,3324,
epoetin alfa 2000 units/mL Soln,55513-0126-10,NDC,,,,inpatient,1,EA,302.1,181.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,244.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,256.79,percent of total billed charges,,,85,,256.79,percent of total billed charges,,,49,,148.03,percent of total billed charges,,,90,,271.89,percent of total billed charges,,,,,,,no IP contract,,80,,241.68,percent of total billed charges,,,,,,,no IP contract,,50,,151.05,percent of total billed charges,,,,,,no IP contract,,,78,,235.64,percent of total billed charges,,,70,,211.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,148.03,3324,
"55513-0144-01 - epoetin alfa 10,000 units/mL preservative-free Soln",55513-0144-01,NDC,,,,inpatient,1,ML,1228.3,736.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,994.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1044.06,percent of total billed charges,,,85,,1044.06,percent of total billed charges,,,49,,601.87,percent of total billed charges,,,90,,1105.47,percent of total billed charges,,,,,,,no IP contract,,80,,982.64,percent of total billed charges,,,,,,,no IP contract,,50,,614.15,percent of total billed charges,,,,,,no IP contract,,,78,,958.07,percent of total billed charges,,,70,,859.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,601.87,3324,
epoetin alfa 10000 units/mL Soln,55513-0144-10,NDC,,,,inpatient,1,EA,1473.1,883.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1193.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1252.14,percent of total billed charges,,,85,,1252.14,percent of total billed charges,,,49,,721.82,percent of total billed charges,,,90,,1325.79,percent of total billed charges,,,,,,,no IP contract,,80,,1178.48,percent of total billed charges,,,,,,,no IP contract,,50,,736.55,percent of total billed charges,,,,,,no IP contract,,,78,,1149.02,percent of total billed charges,,,70,,1031.17,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,721.82,3324,
55513-0148-10 - epoetin alfa 4000 units/mL Soln,55513-0148-10,NDC,,,,inpatient,1,ML,594.85,356.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,481.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,505.62,percent of total billed charges,,,85,,505.62,percent of total billed charges,,,49,,291.48,percent of total billed charges,,,90,,535.37,percent of total billed charges,,,,,,,no IP contract,,80,,475.88,percent of total billed charges,,,,,,,no IP contract,,50,,297.43,percent of total billed charges,,,,,,no IP contract,,,78,,463.98,percent of total billed charges,,,70,,416.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,291.48,3324,
55513-0221-01 - romiPLOStim 250 mcg REC I,55513-0221-01,NDC,,,,inpatient,0.75,ML,11795.5,7077.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9554.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10026.18,percent of total billed charges,,,85,,10026.18,percent of total billed charges,,,49,,5779.8,percent of total billed charges,,,90,,10615.95,percent of total billed charges,,,,,,,no IP contract,,80,,9436.4,percent of total billed charges,,,,,,,no IP contract,,50,,5897.75,percent of total billed charges,,,,,,no IP contract,,,78,,9200.49,percent of total billed charges,,,70,,8256.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,10615.95,
55513-0267-01 - epoetin alfa 3000 units/mL preservative-free Soln,55513-0267-01,NDC,,,,inpatient,1,ML,370.05,222.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,299.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,314.54,percent of total billed charges,,,85,,314.54,percent of total billed charges,,,49,,181.32,percent of total billed charges,,,90,,333.05,percent of total billed charges,,,,,,,no IP contract,,80,,296.04,percent of total billed charges,,,,,,,no IP contract,,50,,185.03,percent of total billed charges,,,,,,no IP contract,,,78,,288.64,percent of total billed charges,,,70,,259.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,181.32,3324,
55513-0267-10 - epoetin alfa 3000 units/mL Soln,55513-0267-10,NDC,,,,inpatient,1,ML,448.45,269.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,363.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,381.18,percent of total billed charges,,,85,,381.18,percent of total billed charges,,,49,,219.74,percent of total billed charges,,,90,,403.61,percent of total billed charges,,,,,,,no IP contract,,80,,358.76,percent of total billed charges,,,,,,,no IP contract,,50,,224.23,percent of total billed charges,,,,,,no IP contract,,,78,,349.79,percent of total billed charges,,,70,,313.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,219.74,3324,
55513-0478-10 - epoetin alfa 20000 units/mL Soln,55513-0478-10,NDC,,,,inpatient,1,ML,2938.6,1763.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2380.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2497.81,percent of total billed charges,,,85,,2497.81,percent of total billed charges,,,49,,1439.91,percent of total billed charges,,,90,,2644.74,percent of total billed charges,,,,,,,no IP contract,,80,,2350.88,percent of total billed charges,,,,,,,no IP contract,,50,,1469.3,percent of total billed charges,,,,,,no IP contract,,,78,,2292.11,percent of total billed charges,,,70,,2057.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
55513-0530-10 - filgrastim 300 mcg/mL Soln,55513-0530-10,NDC,,,,inpatient,1,ML,2969.25,1781.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2405.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2523.86,percent of total billed charges,,,85,,2523.86,percent of total billed charges,,,49,,1454.93,percent of total billed charges,,,90,,2672.33,percent of total billed charges,,,,,,,no IP contract,,80,,2375.4,percent of total billed charges,,,,,,,no IP contract,,50,,1484.63,percent of total billed charges,,,,,,no IP contract,,,78,,2316.02,percent of total billed charges,,,70,,2078.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
55513-0546-10 - filgrastim 480 mcg/1.6 mL Soln,55513-0546-10,NDC,,,,inpatient,1.6,ML,4722.45,2833.47,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3825.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4014.08,percent of total billed charges,,,85,,4014.08,percent of total billed charges,,,49,,2314,percent of total billed charges,,,90,,4250.21,percent of total billed charges,,,,,,,no IP contract,,80,,3777.96,percent of total billed charges,,,,,,,no IP contract,,50,,2361.23,percent of total billed charges,,,,,,no IP contract,,,78,,3683.51,percent of total billed charges,,,70,,3305.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4250.21,
55513-0823-10 - epoetin alfa 40000 units/mL Soln,55513-0823-10,NDC,,,,inpatient,1,ML,5241.25,3144.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4245.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4455.06,percent of total billed charges,,,85,,4455.06,percent of total billed charges,,,49,,2568.21,percent of total billed charges,,,90,,4717.13,percent of total billed charges,,,,,,,no IP contract,,80,,4193,percent of total billed charges,,,,,,,no IP contract,,50,,2620.63,percent of total billed charges,,,,,,no IP contract,,,78,,4088.18,percent of total billed charges,,,70,,3668.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4717.13,
romosozumab 105 mg/1.17 mL Soln,55513-0880-02,NDC,,,,inpatient,1,EA,9240.2,5544.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7484.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7854.17,percent of total billed charges,,,85,,7854.17,percent of total billed charges,,,49,,4527.7,percent of total billed charges,,,90,,8316.18,percent of total billed charges,,,,,,,no IP contract,,80,,7392.16,percent of total billed charges,,,,,,,no IP contract,,50,,4620.1,percent of total billed charges,,,,,,no IP contract,,,78,,7207.36,percent of total billed charges,,,70,,6468.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,8316.18,
sodium hyaluronate 10 mg/mL Soln,55566-4100-01,NDC,,,,inpatient,1,EA,1399.7,839.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1133.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1189.75,percent of total billed charges,,,85,,1189.75,percent of total billed charges,,,49,,685.85,percent of total billed charges,,,90,,1259.73,percent of total billed charges,,,,,,,no IP contract,,80,,1119.76,percent of total billed charges,,,,,,,no IP contract,,50,,699.85,percent of total billed charges,,,,,,no IP contract,,,78,,1091.77,percent of total billed charges,,,70,,979.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,685.85,3324,
57237-0005-11 - fluconazole 150 mg Tab,57237-0005-11,NDC,,,,inpatient,1,EA,114.55,68.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,92.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,97.37,percent of total billed charges,,,85,,97.37,percent of total billed charges,,,49,,56.13,percent of total billed charges,,,90,,103.1,percent of total billed charges,,,,,,,no IP contract,,80,,91.64,percent of total billed charges,,,,,,,no IP contract,,50,,57.28,percent of total billed charges,,,,,,no IP contract,,,78,,89.35,percent of total billed charges,,,70,,80.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,56.13,3324,
fluconazole 200 mg Tab,57237-0006-30,NDC,,,,inpatient,1,EA,117.75,70.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,95.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,100.09,percent of total billed charges,,,85,,100.09,percent of total billed charges,,,49,,57.7,percent of total billed charges,,,90,,105.98,percent of total billed charges,,,,,,,no IP contract,,80,,94.2,percent of total billed charges,,,,,,,no IP contract,,50,,58.88,percent of total billed charges,,,,,,no IP contract,,,78,,91.85,percent of total billed charges,,,70,,82.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,57.7,3324,
57237-0011-06 - mirtazapine 15 mg DIS T,57237-0011-06,NDC,,,,inpatient,1,EA,22.5,13.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.13,percent of total billed charges,,,85,,19.13,percent of total billed charges,,,49,,11.03,percent of total billed charges,,,90,,20.25,percent of total billed charges,,,,,,,no IP contract,,80,,18,percent of total billed charges,,,,,,,no IP contract,,50,,11.25,percent of total billed charges,,,,,,no IP contract,,,78,,17.55,percent of total billed charges,,,70,,15.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.03,3324,
57237-0012-06 - mirtazapine 30 mg DIS T,57237-0012-06,NDC,,,,inpatient,1,EA,23.15,13.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.68,percent of total billed charges,,,85,,19.68,percent of total billed charges,,,49,,11.34,percent of total billed charges,,,90,,20.84,percent of total billed charges,,,,,,,no IP contract,,80,,18.52,percent of total billed charges,,,,,,,no IP contract,,50,,11.58,percent of total billed charges,,,,,,no IP contract,,,78,,18.06,percent of total billed charges,,,70,,16.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.34,3324,
57237-0031-01 - amoxicillin 500 mg Cap,57237-0031-01,NDC,,,,inpatient,1,EA,7.25,4.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.16,percent of total billed charges,,,85,,6.16,percent of total billed charges,,,49,,3.55,percent of total billed charges,,,90,,6.53,percent of total billed charges,,,,,,,no IP contract,,80,,5.8,percent of total billed charges,,,,,,,no IP contract,,50,,3.63,percent of total billed charges,,,,,,no IP contract,,,78,,5.66,percent of total billed charges,,,70,,5.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.55,3324,
57237-0040-01 - penicillin V potassium 250 mg Tab,57237-0040-01,NDC,,,,inpatient,1,EA,10.6,6.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.01,percent of total billed charges,,,85,,9.01,percent of total billed charges,,,49,,5.19,percent of total billed charges,,,90,,9.54,percent of total billed charges,,,,,,,no IP contract,,80,,8.48,percent of total billed charges,,,,,,,no IP contract,,50,,5.3,percent of total billed charges,,,,,,no IP contract,,,78,,8.27,percent of total billed charges,,,70,,7.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.19,3324,
57237-0050-60 - galantamine 8 mg Tab,57237-0050-60,NDC,,,,inpatient,1,EA,29.1,17.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.74,percent of total billed charges,,,85,,24.74,percent of total billed charges,,,49,,14.26,percent of total billed charges,,,90,,26.19,percent of total billed charges,,,,,,,no IP contract,,80,,23.28,percent of total billed charges,,,,,,,no IP contract,,50,,14.55,percent of total billed charges,,,,,,no IP contract,,,78,,22.7,percent of total billed charges,,,70,,20.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.26,3324,
57237-0075-30 - ondansetron 4 mg Tab,57237-0075-30,NDC,,,,inpatient,1,EA,200.85,120.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,162.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,170.72,percent of total billed charges,,,85,,170.72,percent of total billed charges,,,49,,98.42,percent of total billed charges,,,90,,180.77,percent of total billed charges,,,,,,,no IP contract,,80,,160.68,percent of total billed charges,,,,,,,no IP contract,,50,,100.43,percent of total billed charges,,,,,,no IP contract,,,78,,156.66,percent of total billed charges,,,70,,140.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,98.42,3324,
57237-0077-10 - ondansetron 4 mg DIS T,57237-0077-10,NDC,,,,inpatient,1,EA,180.95,108.57,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,146.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,153.81,percent of total billed charges,,,85,,153.81,percent of total billed charges,,,49,,88.67,percent of total billed charges,,,90,,162.86,percent of total billed charges,,,,,,,no IP contract,,80,,144.76,percent of total billed charges,,,,,,,no IP contract,,50,,90.48,percent of total billed charges,,,,,,no IP contract,,,78,,141.14,percent of total billed charges,,,70,,126.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,88.67,3324,
57237-0099-60 - cefdinir 300 mg Cap,57237-0099-60,NDC,,,,inpatient,1,EA,44.45,26.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,37.78,percent of total billed charges,,,85,,37.78,percent of total billed charges,,,49,,21.78,percent of total billed charges,,,90,,40.01,percent of total billed charges,,,,,,,no IP contract,,80,,35.56,percent of total billed charges,,,,,,,no IP contract,,50,,22.23,percent of total billed charges,,,,,,no IP contract,,,78,,34.67,percent of total billed charges,,,70,,31.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.78,3324,
57237-0150-35 - fluconazole 40 mg/mL REC P,57237-0150-35,NDC,,,,inpatient,1,ML,36.5,21.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.03,percent of total billed charges,,,85,,31.03,percent of total billed charges,,,49,,17.89,percent of total billed charges,,,90,,32.85,percent of total billed charges,,,,,,,no IP contract,,80,,29.2,percent of total billed charges,,,,,,,no IP contract,,50,,18.25,percent of total billed charges,,,,,,no IP contract,,,78,,28.47,percent of total billed charges,,,70,,25.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.89,3324,
57237-0169-90 - rosuvastatin 10 mg Tab,57237-0169-90,NDC,,,,inpatient,1,EA,75,45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63.75,percent of total billed charges,,,85,,63.75,percent of total billed charges,,,49,,36.75,percent of total billed charges,,,90,,67.5,percent of total billed charges,,,,,,,no IP contract,,80,,60,percent of total billed charges,,,,,,,no IP contract,,50,,37.5,percent of total billed charges,,,,,,no IP contract,,,78,,58.5,percent of total billed charges,,,70,,52.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.75,3324,
57237-0170-90 - rosuvastatin 20 mg Tab,57237-0170-90,NDC,,,,inpatient,1,EA,75,45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63.75,percent of total billed charges,,,85,,63.75,percent of total billed charges,,,49,,36.75,percent of total billed charges,,,90,,67.5,percent of total billed charges,,,,,,,no IP contract,,80,,60,percent of total billed charges,,,,,,,no IP contract,,50,,37.5,percent of total billed charges,,,,,,no IP contract,,,78,,58.5,percent of total billed charges,,,70,,52.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.75,3324,
57237-0172-01 - venlafaxine 25 mg Tab,57237-0172-01,NDC,,,,inpatient,1,EA,19.25,11.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.36,percent of total billed charges,,,85,,16.36,percent of total billed charges,,,49,,9.43,percent of total billed charges,,,90,,17.33,percent of total billed charges,,,,,,,no IP contract,,80,,15.4,percent of total billed charges,,,,,,,no IP contract,,50,,9.63,percent of total billed charges,,,,,,no IP contract,,,78,,15.02,percent of total billed charges,,,70,,13.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.43,3324,
57237-0173-01 - venlafaxine 37.5 mg Tab,57237-0173-01,NDC,,,,inpatient,1,EA,19.7,11.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.75,percent of total billed charges,,,85,,16.75,percent of total billed charges,,,49,,9.65,percent of total billed charges,,,90,,17.73,percent of total billed charges,,,,,,,no IP contract,,80,,15.76,percent of total billed charges,,,,,,,no IP contract,,50,,9.85,percent of total billed charges,,,,,,no IP contract,,,78,,15.37,percent of total billed charges,,,70,,13.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.65,3324,
pramipexole 1 mg Tab,57237-0184-90,NDC,,,,inpatient,1,EA,27.3,16.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.21,percent of total billed charges,,,85,,23.21,percent of total billed charges,,,49,,13.38,percent of total billed charges,,,90,,24.57,percent of total billed charges,,,,,,,no IP contract,,80,,21.84,percent of total billed charges,,,,,,,no IP contract,,50,,13.65,percent of total billed charges,,,,,,no IP contract,,,78,,21.29,percent of total billed charges,,,70,,19.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.38,3324,
pramipexole 1.5 mg Tab,57237-0185-90,NDC,,,,inpatient,1,EA,27.3,16.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.21,percent of total billed charges,,,85,,23.21,percent of total billed charges,,,49,,13.38,percent of total billed charges,,,90,,24.57,percent of total billed charges,,,,,,,no IP contract,,80,,21.84,percent of total billed charges,,,,,,,no IP contract,,50,,13.65,percent of total billed charges,,,,,,no IP contract,,,78,,21.29,percent of total billed charges,,,70,,19.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.38,3324,
57237-0223-01 - ramipril 2.5 mg Cap,57237-0223-01,NDC,,,,inpatient,1,EA,18.2,10.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.47,percent of total billed charges,,,85,,15.47,percent of total billed charges,,,49,,8.92,percent of total billed charges,,,90,,16.38,percent of total billed charges,,,,,,,no IP contract,,80,,14.56,percent of total billed charges,,,,,,,no IP contract,,50,,9.1,percent of total billed charges,,,,,,no IP contract,,,78,,14.2,percent of total billed charges,,,70,,12.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.92,3324,
57237-0239-01 - zaleplon 5 mg Cap,57237-0239-01,NDC,,,,inpatient,1,EA,36.15,21.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.73,percent of total billed charges,,,85,,30.73,percent of total billed charges,,,49,,17.71,percent of total billed charges,,,90,,32.54,percent of total billed charges,,,,,,,no IP contract,,80,,28.92,percent of total billed charges,,,,,,,no IP contract,,50,,18.08,percent of total billed charges,,,,,,no IP contract,,,78,,28.2,percent of total billed charges,,,70,,25.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.71,3324,
57648-0002-01 - bisacodyl 10 mg Supp,57648-0002-01,NDC,,,,inpatient,1,UN,6.95,4.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.91,percent of total billed charges,,,85,,5.91,percent of total billed charges,,,49,,3.41,percent of total billed charges,,,90,,6.26,percent of total billed charges,,,,,,,no IP contract,,80,,5.56,percent of total billed charges,,,,,,,no IP contract,,50,,3.48,percent of total billed charges,,,,,,no IP contract,,,78,,5.42,percent of total billed charges,,,70,,4.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.41,3324,
57664-0116-88 - verapamil 120 mg/12 hours ER Ta,57664-0116-88,NDC,,,,inpatient,1,EA,18.05,10.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.34,percent of total billed charges,,,85,,15.34,percent of total billed charges,,,49,,8.84,percent of total billed charges,,,90,,16.25,percent of total billed charges,,,,,,,no IP contract,,80,,14.44,percent of total billed charges,,,,,,,no IP contract,,50,,9.03,percent of total billed charges,,,,,,no IP contract,,,78,,14.08,percent of total billed charges,,,70,,12.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.84,3324,
57664-0117-88 - verapamil 180 mg/12 hours ER Ta,57664-0117-88,NDC,,,,inpatient,1,EA,21.85,13.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.57,percent of total billed charges,,,85,,18.57,percent of total billed charges,,,49,,10.71,percent of total billed charges,,,90,,19.67,percent of total billed charges,,,,,,,no IP contract,,80,,17.48,percent of total billed charges,,,,,,,no IP contract,,50,,10.93,percent of total billed charges,,,,,,no IP contract,,,78,,17.04,percent of total billed charges,,,70,,15.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.71,3324,
57664-0146-34 - promethazine 6.25 mg/5 mL Syrup,57664-0146-34,NDC,,,,inpatient,5,ML,5.85,3.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.97,percent of total billed charges,,,85,,4.97,percent of total billed charges,,,49,,2.87,percent of total billed charges,,,90,,5.27,percent of total billed charges,,,,,,,no IP contract,,80,,4.68,percent of total billed charges,,,,,,,no IP contract,,50,,2.93,percent of total billed charges,,,,,,no IP contract,,,78,,4.56,percent of total billed charges,,,70,,4.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.87,3324,
57664-0166-52 - metoprolol 50 mg Tab,57664-0166-52,NDC,,,,inpatient,1,EA,8.3,4.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.06,percent of total billed charges,,,85,,7.06,percent of total billed charges,,,49,,4.07,percent of total billed charges,,,90,,7.47,percent of total billed charges,,,,,,,no IP contract,,80,,6.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.15,percent of total billed charges,,,,,,no IP contract,,,78,,6.47,percent of total billed charges,,,70,,5.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.07,3324,
57664-0228-88 - methylphenidate 5 mg Tab,57664-0228-88,NDC,,,,inpatient,1,EA,11.6,6.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.86,percent of total billed charges,,,85,,9.86,percent of total billed charges,,,49,,5.68,percent of total billed charges,,,90,,10.44,percent of total billed charges,,,,,,,no IP contract,,80,,9.28,percent of total billed charges,,,,,,,no IP contract,,50,,5.8,percent of total billed charges,,,,,,no IP contract,,,78,,9.05,percent of total billed charges,,,70,,8.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.68,3324,
57664-0264-88 - atenolol 25 mg Tab,57664-0264-88,NDC,,,,inpatient,1,EA,10.25,6.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.71,percent of total billed charges,,,85,,8.71,percent of total billed charges,,,49,,5.02,percent of total billed charges,,,90,,9.23,percent of total billed charges,,,,,,,no IP contract,,80,,8.2,percent of total billed charges,,,,,,,no IP contract,,50,,5.13,percent of total billed charges,,,,,,no IP contract,,,78,,8,percent of total billed charges,,,70,,7.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.02,3324,
57664-0392-88 - venlafaxine 25 mg Tab,57664-0392-88,NDC,,,,inpatient,1,EA,19.25,11.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.36,percent of total billed charges,,,85,,16.36,percent of total billed charges,,,49,,9.43,percent of total billed charges,,,90,,17.33,percent of total billed charges,,,,,,,no IP contract,,80,,15.4,percent of total billed charges,,,,,,,no IP contract,,50,,9.63,percent of total billed charges,,,,,,no IP contract,,,78,,15.02,percent of total billed charges,,,70,,13.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.43,3324,
57664-0502-89 - tiZANidine 2 mg Tab,57664-0502-89,NDC,,,,inpatient,1,EA,13.5,8.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.48,percent of total billed charges,,,85,,11.48,percent of total billed charges,,,49,,6.62,percent of total billed charges,,,90,,12.15,percent of total billed charges,,,,,,,no IP contract,,80,,10.8,percent of total billed charges,,,,,,,no IP contract,,50,,6.75,percent of total billed charges,,,,,,no IP contract,,,78,,10.53,percent of total billed charges,,,70,,9.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.62,3324,
57664-0506-52 - metoprolol 25 mg Tab,57664-0506-52,NDC,,,,inpatient,1,EA,5.95,3.57,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.06,percent of total billed charges,,,85,,5.06,percent of total billed charges,,,49,,2.92,percent of total billed charges,,,90,,5.36,percent of total billed charges,,,,,,,no IP contract,,80,,4.76,percent of total billed charges,,,,,,,no IP contract,,50,,2.98,percent of total billed charges,,,,,,no IP contract,,,78,,4.64,percent of total billed charges,,,70,,4.17,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.92,3324,
chlorthalidone 25 mg Tab,57664-0648-88,NDC,,,,inpatient,1,EA,13.45,8.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.43,percent of total billed charges,,,85,,11.43,percent of total billed charges,,,49,,6.59,percent of total billed charges,,,90,,12.11,percent of total billed charges,,,,,,,no IP contract,,80,,10.76,percent of total billed charges,,,,,,,no IP contract,,50,,6.73,percent of total billed charges,,,,,,no IP contract,,,78,,10.49,percent of total billed charges,,,70,,9.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.59,3324,
57664-0683-57 - linezolid 2 mg/mL-D5% Soln,57664-0683-57,NDC,,,,inpatient,300,ML,666.85,400.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,540.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,566.82,percent of total billed charges,,,85,,566.82,percent of total billed charges,,,49,,326.76,percent of total billed charges,,,90,,600.17,percent of total billed charges,,,,,,,no IP contract,,80,,533.48,percent of total billed charges,,,,,,,no IP contract,,50,,333.43,percent of total billed charges,,,,,,no IP contract,,,78,,520.14,percent of total billed charges,,,70,,466.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,326.76,3324,
57664-0808-88 - phenytoin 100 mg ER Ca,57664-0808-88,NDC,,,,inpatient,1,EA,6.55,3.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.57,percent of total billed charges,,,85,,5.57,percent of total billed charges,,,49,,3.21,percent of total billed charges,,,90,,5.9,percent of total billed charges,,,,,,,no IP contract,,80,,5.24,percent of total billed charges,,,,,,,no IP contract,,50,,3.28,percent of total billed charges,,,,,,no IP contract,,,78,,5.11,percent of total billed charges,,,70,,4.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.21,3324,
57665-0101-41 - amphotericin B lipid complex 5 mg/mL Susp,57665-0101-41,NDC,,,,inpatient,20,ML,2032.5,1219.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1646.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1727.63,percent of total billed charges,,,85,,1727.63,percent of total billed charges,,,49,,995.93,percent of total billed charges,,,90,,1829.25,percent of total billed charges,,,,,,,no IP contract,,80,,1626,percent of total billed charges,,,,,,,no IP contract,,50,,1016.25,percent of total billed charges,,,,,,no IP contract,,,78,,1585.35,percent of total billed charges,,,70,,1422.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
57782-0397-26 - cromolyn nasal 5.2 mg/inh Spray,57782-0397-26,NDC,,,,inpatient,1,UN,117.5,70.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,95.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,99.88,percent of total billed charges,,,85,,99.88,percent of total billed charges,,,49,,57.58,percent of total billed charges,,,90,,105.75,percent of total billed charges,,,,,,,no IP contract,,80,,94,percent of total billed charges,,,,,,,no IP contract,,50,,58.75,percent of total billed charges,,,,,,no IP contract,,,78,,91.65,percent of total billed charges,,,70,,82.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,57.58,3324,
57841-1300-01 - naloxegol 12.5 mg Tab,57841-1300-01,NDC,,,,inpatient,1,EA,116.85,70.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,94.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,99.32,percent of total billed charges,,,85,,99.32,percent of total billed charges,,,49,,57.26,percent of total billed charges,,,90,,105.17,percent of total billed charges,,,,,,,no IP contract,,80,,93.48,percent of total billed charges,,,,,,,no IP contract,,50,,58.43,percent of total billed charges,,,,,,no IP contract,,,78,,91.14,percent of total billed charges,,,70,,81.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,57.26,3324,
57841-1301-01 - naloxegol 25 mg Tab,57841-1301-01,NDC,,,,inpatient,1,EA,116.85,70.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,94.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,99.32,percent of total billed charges,,,85,,99.32,percent of total billed charges,,,49,,57.26,percent of total billed charges,,,90,,105.17,percent of total billed charges,,,,,,,no IP contract,,80,,93.48,percent of total billed charges,,,,,,,no IP contract,,50,,58.43,percent of total billed charges,,,,,,no IP contract,,,78,,91.14,percent of total billed charges,,,70,,81.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,57.26,3324,
57896-0102-05 - acetaminophen 325 mg Tab,57896-0102-05,NDC,,,,inpatient,1,EA,4.15,2.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.53,percent of total billed charges,,,85,,3.53,percent of total billed charges,,,49,,2.03,percent of total billed charges,,,90,,3.74,percent of total billed charges,,,,,,,no IP contract,,80,,3.32,percent of total billed charges,,,,,,,no IP contract,,50,,2.08,percent of total billed charges,,,,,,no IP contract,,,78,,3.24,percent of total billed charges,,,70,,2.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.03,3324,
57896-0104-10 - acetaminophen 325 mg Tab,57896-0104-10,NDC,,,,inpatient,1,EA,3.9,2.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.32,percent of total billed charges,,,85,,3.32,percent of total billed charges,,,49,,1.91,percent of total billed charges,,,90,,3.51,percent of total billed charges,,,,,,,no IP contract,,80,,3.12,percent of total billed charges,,,,,,,no IP contract,,50,,1.95,percent of total billed charges,,,,,,no IP contract,,,78,,3.04,percent of total billed charges,,,70,,2.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.91,3324,
benzocaine topical 20% Gel,57896-0139-05,NDC,,,,inpatient,1,EA,19.15,11.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.28,percent of total billed charges,,,85,,16.28,percent of total billed charges,,,49,,9.38,percent of total billed charges,,,90,,17.24,percent of total billed charges,,,,,,,no IP contract,,80,,15.32,percent of total billed charges,,,,,,,no IP contract,,50,,9.58,percent of total billed charges,,,,,,no IP contract,,,78,,14.94,percent of total billed charges,,,70,,13.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.38,3324,
57896-0421-01 - docusate 100 mg Tab,57896-0421-01,NDC,,,,inpatient,1,EA,4.15,2.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.53,percent of total billed charges,,,85,,3.53,percent of total billed charges,,,49,,2.03,percent of total billed charges,,,90,,3.74,percent of total billed charges,,,,,,,no IP contract,,80,,3.32,percent of total billed charges,,,,,,,no IP contract,,50,,2.08,percent of total billed charges,,,,,,no IP contract,,,78,,3.24,percent of total billed charges,,,70,,2.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.03,3324,
57896-0454-01 - senna 8.6 mg Tab,57896-0454-01,NDC,,,,inpatient,1,EA,4.05,2.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.44,percent of total billed charges,,,85,,3.44,percent of total billed charges,,,49,,1.98,percent of total billed charges,,,90,,3.65,percent of total billed charges,,,,,,,no IP contract,,80,,3.24,percent of total billed charges,,,,,,,no IP contract,,50,,2.03,percent of total billed charges,,,,,,no IP contract,,,78,,3.16,percent of total billed charges,,,70,,2.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.98,3324,
57896-0458-01 - docusate-senna 50 mg-8.6 mg Tab,57896-0458-01,NDC,,,,inpatient,1,EA,4.05,2.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.44,percent of total billed charges,,,85,,3.44,percent of total billed charges,,,49,,1.98,percent of total billed charges,,,90,,3.65,percent of total billed charges,,,,,,,no IP contract,,80,,3.24,percent of total billed charges,,,,,,,no IP contract,,50,,2.03,percent of total billed charges,,,,,,no IP contract,,,78,,3.16,percent of total billed charges,,,70,,2.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.98,3324,
calcium-vitamin D 500 mg-5 mcg Tab,57896-0742-01,NDC,,,,inpatient,1,EA,4.05,2.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.44,percent of total billed charges,,,85,,3.44,percent of total billed charges,,,49,,1.98,percent of total billed charges,,,90,,3.65,percent of total billed charges,,,,,,,no IP contract,,80,,3.24,percent of total billed charges,,,,,,,no IP contract,,50,,2.03,percent of total billed charges,,,,,,no IP contract,,,78,,3.16,percent of total billed charges,,,70,,2.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.98,3324,
57896-0799-01 - simethicone 80 mg Chew,57896-0799-01,NDC,,,,inpatient,1,EA,4,2.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.4,percent of total billed charges,,,85,,3.4,percent of total billed charges,,,49,,1.96,percent of total billed charges,,,90,,3.6,percent of total billed charges,,,,,,,no IP contract,,80,,3.2,percent of total billed charges,,,,,,,no IP contract,,50,,2,percent of total billed charges,,,,,,no IP contract,,,78,,3.12,percent of total billed charges,,,70,,2.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.96,3324,
57896-0841-01 - ascorbic acid 500 mg Tab,57896-0841-01,NDC,,,,inpatient,1,EA,4.05,2.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.44,percent of total billed charges,,,85,,3.44,percent of total billed charges,,,49,,1.98,percent of total billed charges,,,90,,3.65,percent of total billed charges,,,,,,,no IP contract,,80,,3.24,percent of total billed charges,,,,,,,no IP contract,,50,,2.03,percent of total billed charges,,,,,,no IP contract,,,78,,3.16,percent of total billed charges,,,70,,2.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.98,3324,
57896-0845-01 - cranberry - Tab,57896-0845-01,NDC,,,,inpatient,1,EA,4.15,2.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.53,percent of total billed charges,,,85,,3.53,percent of total billed charges,,,49,,2.03,percent of total billed charges,,,90,,3.74,percent of total billed charges,,,,,,,no IP contract,,80,,3.32,percent of total billed charges,,,,,,,no IP contract,,50,,2.08,percent of total billed charges,,,,,,no IP contract,,,78,,3.24,percent of total billed charges,,,70,,2.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.03,3324,
saccharomyces boulardii lyo 250 mg Cap,57896-0869-05,NDC,,,,inpatient,1,EA,7.65,4.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.5,percent of total billed charges,,,85,,6.5,percent of total billed charges,,,49,,3.75,percent of total billed charges,,,90,,6.89,percent of total billed charges,,,,,,,no IP contract,,80,,6.12,percent of total billed charges,,,,,,,no IP contract,,50,,3.83,percent of total billed charges,,,,,,no IP contract,,,78,,5.97,percent of total billed charges,,,70,,5.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.75,3324,
57896-0901-01 - aspirin 325 mg Tab,57896-0901-01,NDC,,,,inpatient,1,EA,3.9,2.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.32,percent of total billed charges,,,85,,3.32,percent of total billed charges,,,49,,1.91,percent of total billed charges,,,90,,3.51,percent of total billed charges,,,,,,,no IP contract,,80,,3.12,percent of total billed charges,,,,,,,no IP contract,,50,,1.95,percent of total billed charges,,,,,,no IP contract,,,78,,3.04,percent of total billed charges,,,70,,2.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.91,3324,
57896-0921-01 - aspirin 325 mg EC Ta,57896-0921-01,NDC,,,,inpatient,1,EA,4,2.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.4,percent of total billed charges,,,85,,3.4,percent of total billed charges,,,49,,1.96,percent of total billed charges,,,90,,3.6,percent of total billed charges,,,,,,,no IP contract,,80,,3.2,percent of total billed charges,,,,,,,no IP contract,,50,,2,percent of total billed charges,,,,,,no IP contract,,,78,,3.12,percent of total billed charges,,,70,,2.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.96,3324,
58063-0705-10 - pilocarpine 5 mg Tab,58063-0705-10,NDC,,,,inpatient,1,EA,18.15,10.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.43,percent of total billed charges,,,85,,15.43,percent of total billed charges,,,49,,8.89,percent of total billed charges,,,90,,16.34,percent of total billed charges,,,,,,,no IP contract,,80,,14.52,percent of total billed charges,,,,,,,no IP contract,,50,,9.08,percent of total billed charges,,,,,,no IP contract,,,78,,14.16,percent of total billed charges,,,70,,12.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.89,3324,
58160-0820-52 - hepatitis B pediatric vaccine 10 mcg/0.5 mL Susp,58160-0820-52,NDC,,,,inpatient,0.5,ML,214.15,128.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,173.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,182.03,percent of total billed charges,,,85,,182.03,percent of total billed charges,,,49,,104.93,percent of total billed charges,,,90,,192.74,percent of total billed charges,,,,,,,no IP contract,,80,,171.32,percent of total billed charges,,,,,,,no IP contract,,50,,107.08,percent of total billed charges,,,,,,no IP contract,,,78,,167.04,percent of total billed charges,,,70,,149.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,104.93,3324,
58160-0821-52 - hepatitis B adult vaccine 20 mcg/mL Susp,58160-0821-52,NDC,,,,inpatient,1,ML,532,319.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,430.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,452.2,percent of total billed charges,,,85,,452.2,percent of total billed charges,,,49,,260.68,percent of total billed charges,,,90,,478.8,percent of total billed charges,,,,,,,no IP contract,,80,,425.6,percent of total billed charges,,,,,,,no IP contract,,50,,266,percent of total billed charges,,,,,,no IP contract,,,78,,414.96,percent of total billed charges,,,70,,372.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,260.68,3324,
"influenza virus vaccine, inactivated preservative-free trivalent Susp",58160-0884-52,NDC,,,,inpatient,1,EA,405.95,243.57,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,328.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,345.06,percent of total billed charges,,,85,,345.06,percent of total billed charges,,,49,,198.92,percent of total billed charges,,,90,,365.36,percent of total billed charges,,,,,,,no IP contract,,80,,324.76,percent of total billed charges,,,,,,,no IP contract,,50,,202.98,percent of total billed charges,,,,,,no IP contract,,,78,,316.64,percent of total billed charges,,,70,,284.17,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,198.92,3324,
"58160-0976-20 - meningococcal group B vaccine recombinant, OMV, adjuvanted Susp",58160-0976-20,NDC,,,,inpatient,0.5,ML,1821.35,1092.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1475.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1548.15,percent of total billed charges,,,85,,1548.15,percent of total billed charges,,,49,,892.46,percent of total billed charges,,,90,,1639.22,percent of total billed charges,,,,,,,no IP contract,,80,,1457.08,percent of total billed charges,,,,,,,no IP contract,,50,,910.68,percent of total billed charges,,,,,,no IP contract,,,78,,1420.65,percent of total billed charges,,,70,,1274.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,892.46,3324,
58177-0301-04 - ketorolac 10 mg Tab,58177-0301-04,NDC,,,,inpatient,1,EA,11.2,6.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.52,percent of total billed charges,,,85,,9.52,percent of total billed charges,,,49,,5.49,percent of total billed charges,,,90,,10.08,percent of total billed charges,,,,,,,no IP contract,,80,,8.96,percent of total billed charges,,,,,,,no IP contract,,50,,5.6,percent of total billed charges,,,,,,no IP contract,,,78,,8.74,percent of total billed charges,,,70,,7.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.49,3324,
58177-0363-22 - ondansetron 4 mg DIS Tablet,58177-0363-22,NDC,,,,inpatient,1,EA,5310.45,3186.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4301.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4513.88,percent of total billed charges,,,85,,4513.88,percent of total billed charges,,,49,,2602.12,percent of total billed charges,,,90,,4779.41,percent of total billed charges,,,,,,,no IP contract,,80,,4248.36,percent of total billed charges,,,,,,,no IP contract,,50,,2655.23,percent of total billed charges,,,,,,no IP contract,,,78,,4142.15,percent of total billed charges,,,70,,3717.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4779.41,
58177-0886-56 - morphine 20 mg/mL Conc,58177-0886-56,NDC,,,,inpatient,0.1,ML,21.5,12.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.28,percent of total billed charges,,,85,,18.28,percent of total billed charges,,,49,,10.54,percent of total billed charges,,,90,,19.35,percent of total billed charges,,,,,,,no IP contract,,80,,17.2,percent of total billed charges,,,,,,,no IP contract,,50,,10.75,percent of total billed charges,,,,,,no IP contract,,,78,,16.77,percent of total billed charges,,,70,,15.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.54,3324,
58177-3633-75 - ondansetron 4 mg Tab,58177-3633-75,NDC,,,,inpatient,1,EA,5310.45,3186.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4301.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4513.88,percent of total billed charges,,,85,,4513.88,percent of total billed charges,,,49,,2602.12,percent of total billed charges,,,90,,4779.41,percent of total billed charges,,,,,,,no IP contract,,80,,4248.36,percent of total billed charges,,,,,,,no IP contract,,50,,2655.23,percent of total billed charges,,,,,,no IP contract,,,78,,4142.15,percent of total billed charges,,,70,,3717.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4779.41,
58232-0721-03 - zinc oxide topical 40% Paste,58232-0721-03,NDC,,,,inpatient,1,EA,42.45,25.47,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36.08,percent of total billed charges,,,85,,36.08,percent of total billed charges,,,49,,20.8,percent of total billed charges,,,90,,38.21,percent of total billed charges,,,,,,,no IP contract,,80,,33.96,percent of total billed charges,,,,,,,no IP contract,,50,,21.23,percent of total billed charges,,,,,,no IP contract,,,78,,33.11,percent of total billed charges,,,70,,29.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.8,3324,
baclofen 0.05 mg/mL Soln,58281-0562-01,NDC,,,,inpatient,1,mL,226.9,136.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,183.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,192.87,percent of total billed charges,,,85,,192.87,percent of total billed charges,,,49,,111.18,percent of total billed charges,,,90,,204.21,percent of total billed charges,,,,,,,no IP contract,,80,,181.52,percent of total billed charges,,,,,,,no IP contract,,50,,113.45,percent of total billed charges,,,,,,no IP contract,,,78,,176.98,percent of total billed charges,,,70,,158.83,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,111.18,3324,
etanercept 25 mg REC Inj,58406-0425-34,NDC,,,,inpatient,1,EA,1667.1,1000.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1350.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1417.04,percent of total billed charges,,,85,,1417.04,percent of total billed charges,,,49,,816.88,percent of total billed charges,,,90,,1500.39,percent of total billed charges,,,,,,,no IP contract,,80,,1333.68,percent of total billed charges,,,,,,,no IP contract,,50,,833.55,percent of total billed charges,,,,,,no IP contract,,,78,,1300.34,percent of total billed charges,,,70,,1166.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,816.88,3324,
58406-0435-04 - etanercept 50 mg/mL Soln,58406-0435-04,NDC,,,,inpatient,1,ML,4902,2941.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3970.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4166.7,percent of total billed charges,,,85,,4166.7,percent of total billed charges,,,49,,2401.98,percent of total billed charges,,,90,,4411.8,percent of total billed charges,,,,,,,no IP contract,,80,,3921.6,percent of total billed charges,,,,,,,no IP contract,,50,,2451,percent of total billed charges,,,,,,no IP contract,,,78,,3823.56,percent of total billed charges,,,70,,3431.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4411.8,
58468-0020-01 - sevelamer 400 mg Tab,58468-0020-01,NDC,,,,inpatient,1,EA,12.35,7.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.5,percent of total billed charges,,,85,,10.5,percent of total billed charges,,,49,,6.05,percent of total billed charges,,,90,,11.12,percent of total billed charges,,,,,,,no IP contract,,80,,9.88,percent of total billed charges,,,,,,,no IP contract,,50,,6.18,percent of total billed charges,,,,,,no IP contract,,,78,,9.63,percent of total billed charges,,,70,,8.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.05,3324,
58468-0021-01 - sevelamer 800 mg Tab,58468-0021-01,NDC,,,,inpatient,1,EA,51.05,30.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,41.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,43.39,percent of total billed charges,,,85,,43.39,percent of total billed charges,,,49,,25.01,percent of total billed charges,,,90,,45.95,percent of total billed charges,,,,,,,no IP contract,,80,,40.84,percent of total billed charges,,,,,,,no IP contract,,50,,25.53,percent of total billed charges,,,,,,no IP contract,,,78,,39.82,percent of total billed charges,,,70,,35.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.01,3324,
hylan G-F 20 8 mg/mL Soln,58468-0090-01,NDC,,,,inpatient,1,EA,1822.4,1093.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1476.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1549.04,percent of total billed charges,,,85,,1549.04,percent of total billed charges,,,49,,892.98,percent of total billed charges,,,90,,1640.16,percent of total billed charges,,,,,,,no IP contract,,80,,1457.92,percent of total billed charges,,,,,,,no IP contract,,50,,911.2,percent of total billed charges,,,,,,no IP contract,,,78,,1421.47,percent of total billed charges,,,70,,1275.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,892.98,3324,
hylan G-F 20 8 mg/mL Soln,58468-0090-03,NDC,,,,inpatient,1,EA,5449.1,3269.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4413.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4631.74,percent of total billed charges,,,85,,4631.74,percent of total billed charges,,,49,,2670.06,percent of total billed charges,,,90,,4904.19,percent of total billed charges,,,,,,,no IP contract,,80,,4359.28,percent of total billed charges,,,,,,,no IP contract,,50,,2724.55,percent of total billed charges,,,,,,no IP contract,,,78,,4250.3,percent of total billed charges,,,70,,3814.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4904.19,
58468-0131-02 - sevelamer carbonate 2.4 gm Packet,58468-0131-02,NDC,,,,inpatient,60,ML,74.5,44.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63.33,percent of total billed charges,,,85,,63.33,percent of total billed charges,,,49,,36.51,percent of total billed charges,,,90,,67.05,percent of total billed charges,,,,,,,no IP contract,,80,,59.6,percent of total billed charges,,,,,,,no IP contract,,50,,37.25,percent of total billed charges,,,,,,no IP contract,,,78,,58.11,percent of total billed charges,,,70,,52.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.51,3324,
58468-0132-02 - sevelamer carbonate 0.8 g REC P,58468-0132-02,NDC,,,,inpatient,30,ML,64.4,38.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,52.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,54.74,percent of total billed charges,,,85,,54.74,percent of total billed charges,,,49,,31.56,percent of total billed charges,,,90,,57.96,percent of total billed charges,,,,,,,no IP contract,,80,,51.52,percent of total billed charges,,,,,,,no IP contract,,50,,32.2,percent of total billed charges,,,,,,no IP contract,,,78,,50.23,percent of total billed charges,,,70,,45.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.56,3324,
58526-0005-37 - ascorbic acid Chew Tab 500 mg Chew tab,58526-0005-37,NDC,,,,inpatient,1,EA,13.9,8.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.82,percent of total billed charges,,,85,,11.82,percent of total billed charges,,,49,,6.81,percent of total billed charges,,,90,,12.51,percent of total billed charges,,,,,,,no IP contract,,80,,11.12,percent of total billed charges,,,,,,,no IP contract,,50,,6.95,percent of total billed charges,,,,,,no IP contract,,,78,,10.84,percent of total billed charges,,,70,,9.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.81,3324,
58526-0005-41 - multivitamin Vitamin B Complex with C and Folic Acid Cap 1 cap(s) Cap,58526-0005-41,NDC,,,,inpatient,1,EA,11.3,6.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.61,percent of total billed charges,,,85,,9.61,percent of total billed charges,,,49,,5.54,percent of total billed charges,,,90,,10.17,percent of total billed charges,,,,,,,no IP contract,,80,,9.04,percent of total billed charges,,,,,,,no IP contract,,50,,5.65,percent of total billed charges,,,,,,no IP contract,,,78,,8.81,percent of total billed charges,,,70,,7.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.54,3324,
diclofenac topical 1% Gel,58602-0604-07,NDC,,,,inpatient,1,EA,109.2,65.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,88.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,92.82,percent of total billed charges,,,85,,92.82,percent of total billed charges,,,49,,53.51,percent of total billed charges,,,90,,98.28,percent of total billed charges,,,,,,,no IP contract,,80,,87.36,percent of total billed charges,,,,,,,no IP contract,,50,,54.6,percent of total billed charges,,,,,,no IP contract,,,78,,85.18,percent of total billed charges,,,70,,76.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,53.51,3324,
58768-0790-36 - ocular lubricant - Gel,58768-0790-36,NDC,,,,inpatient,1,UN,76.7,46.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,62.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,65.2,percent of total billed charges,,,85,,65.2,percent of total billed charges,,,49,,37.58,percent of total billed charges,,,90,,69.03,percent of total billed charges,,,,,,,no IP contract,,80,,61.36,percent of total billed charges,,,,,,,no IP contract,,50,,38.35,percent of total billed charges,,,,,,no IP contract,,,78,,59.83,percent of total billed charges,,,70,,53.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,37.58,3324,
58790-0003-30 - carboxymethylcellulose [Celluvisc] - Drops,58790-0003-30,NDC,,,,inpatient,1,UN,12.8,7.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.88,percent of total billed charges,,,85,,10.88,percent of total billed charges,,,49,,6.27,percent of total billed charges,,,90,,11.52,percent of total billed charges,,,,,,,no IP contract,,80,,10.24,percent of total billed charges,,,,,,,no IP contract,,50,,6.4,percent of total billed charges,,,,,,no IP contract,,,78,,9.98,percent of total billed charges,,,70,,8.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.27,3324,
58887-0027-30 - carbamazepine 200 mg Tab,58887-0027-30,NDC,,,,inpatient,1,EA,6.85,4.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.82,percent of total billed charges,,,85,,5.82,percent of total billed charges,,,49,,3.36,percent of total billed charges,,,90,,6.17,percent of total billed charges,,,,,,,no IP contract,,80,,5.48,percent of total billed charges,,,,,,,no IP contract,,50,,3.43,percent of total billed charges,,,,,,no IP contract,,,78,,5.34,percent of total billed charges,,,70,,4.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.36,3324,
58887-0052-32 - carbamazepine 100 mg Chew Tab,58887-0052-32,NDC,,,,inpatient,1,EA,5.55,3.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.72,percent of total billed charges,,,85,,4.72,percent of total billed charges,,,49,,2.72,percent of total billed charges,,,90,,5,percent of total billed charges,,,,,,,no IP contract,,80,,4.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.78,percent of total billed charges,,,,,,no IP contract,,,78,,4.33,percent of total billed charges,,,70,,3.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.72,3324,
58914-0015-16 - dicyclomine 10 mg/5 mL Syrup,58914-0015-16,NDC,,,,inpatient,1,ML,6.25,3.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.31,percent of total billed charges,,,85,,5.31,percent of total billed charges,,,49,,3.06,percent of total billed charges,,,90,,5.63,percent of total billed charges,,,,,,,no IP contract,,80,,5,percent of total billed charges,,,,,,,no IP contract,,50,,3.13,percent of total billed charges,,,,,,no IP contract,,,78,,4.88,percent of total billed charges,,,70,,4.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.06,3324,
"58914-0112-10 - pancrelipase 10,440 units-39,150 units-39,150 units Tab",58914-0112-10,NDC,,,,inpatient,1,EA,27.05,16.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.99,percent of total billed charges,,,85,,22.99,percent of total billed charges,,,49,,13.25,percent of total billed charges,,,90,,24.35,percent of total billed charges,,,,,,,no IP contract,,80,,21.64,percent of total billed charges,,,,,,,no IP contract,,50,,13.53,percent of total billed charges,,,,,,no IP contract,,,78,,21.1,percent of total billed charges,,,70,,18.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.25,3324,
"58914-0214-60 - multivitamin with minerals Antioxidant Multiple Vitamins (A,D,E,K-intensive) and Min",58914-0214-60,NDC,,,,inpatient,1,ML,8.4,5.04,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.14,percent of total billed charges,,,85,,7.14,percent of total billed charges,,,49,,4.12,percent of total billed charges,,,90,,7.56,percent of total billed charges,,,,,,,no IP contract,,80,,6.72,percent of total billed charges,,,,,,,no IP contract,,50,,4.2,percent of total billed charges,,,,,,no IP contract,,,78,,6.55,percent of total billed charges,,,70,,5.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.12,3324,
58914-0501-56 - mesalamine 1000 mg Supp,58914-0501-56,NDC,,,,inpatient,1,UN,90.5,54.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,73.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,76.93,percent of total billed charges,,,85,,76.93,percent of total billed charges,,,49,,44.35,percent of total billed charges,,,90,,81.45,percent of total billed charges,,,,,,,no IP contract,,80,,72.4,percent of total billed charges,,,,,,,no IP contract,,50,,45.25,percent of total billed charges,,,,,,no IP contract,,,78,,70.59,percent of total billed charges,,,70,,63.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,44.35,3324,
58980-0610-30 - urea topical 20% Cream,58980-0610-30,NDC,,,,inpatient,1,UN,106.7,64.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,86.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,90.7,percent of total billed charges,,,85,,90.7,percent of total billed charges,,,49,,52.28,percent of total billed charges,,,90,,96.03,percent of total billed charges,,,,,,,no IP contract,,80,,85.36,percent of total billed charges,,,,,,,no IP contract,,50,,53.35,percent of total billed charges,,,,,,no IP contract,,,78,,83.23,percent of total billed charges,,,70,,74.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,52.28,3324,
59011-0109-25 - oxycodone 160 mg ER Tab,59011-0109-25,NDC,,,,inpatient,1,EA,143.3,85.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,116.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,121.81,percent of total billed charges,,,85,,121.81,percent of total billed charges,,,49,,70.22,percent of total billed charges,,,90,,128.97,percent of total billed charges,,,,,,,no IP contract,,80,,114.64,percent of total billed charges,,,,,,,no IP contract,,50,,71.65,percent of total billed charges,,,,,,no IP contract,,,78,,111.77,percent of total billed charges,,,70,,100.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,70.22,3324,
59011-0410-10 - oxycodone 10 mg ER Tablet,59011-0410-10,NDC,,,,inpatient,1,EA,32.25,19.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,26.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,27.41,percent of total billed charges,,,85,,27.41,percent of total billed charges,,,49,,15.8,percent of total billed charges,,,90,,29.03,percent of total billed charges,,,,,,,no IP contract,,80,,25.8,percent of total billed charges,,,,,,,no IP contract,,50,,16.13,percent of total billed charges,,,,,,no IP contract,,,78,,25.16,percent of total billed charges,,,70,,22.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.8,3324,
59011-0410-20 - oxycodone 10 mg CR Tablet,59011-0410-20,NDC,,,,inpatient,1,EA,32.9,19.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,26.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,27.97,percent of total billed charges,,,85,,27.97,percent of total billed charges,,,49,,16.12,percent of total billed charges,,,90,,29.61,percent of total billed charges,,,,,,,no IP contract,,80,,26.32,percent of total billed charges,,,,,,,no IP contract,,50,,16.45,percent of total billed charges,,,,,,no IP contract,,,78,,25.66,percent of total billed charges,,,70,,23.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.12,3324,
59011-0415-10 - oxycodone 15 mg ER Tablet,59011-0415-10,NDC,,,,inpatient,1,EA,44.9,26.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,38.17,percent of total billed charges,,,85,,38.17,percent of total billed charges,,,49,,22,percent of total billed charges,,,90,,40.41,percent of total billed charges,,,,,,,no IP contract,,80,,35.92,percent of total billed charges,,,,,,,no IP contract,,50,,22.45,percent of total billed charges,,,,,,no IP contract,,,78,,35.02,percent of total billed charges,,,70,,31.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22,3324,
59011-0415-20 - oxyCODONE 15 mg ER Ta,59011-0415-20,NDC,,,,inpatient,1,EA,45.9,27.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,37.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,39.02,percent of total billed charges,,,85,,39.02,percent of total billed charges,,,49,,22.49,percent of total billed charges,,,90,,41.31,percent of total billed charges,,,,,,,no IP contract,,80,,36.72,percent of total billed charges,,,,,,,no IP contract,,50,,22.95,percent of total billed charges,,,,,,no IP contract,,,78,,35.8,percent of total billed charges,,,70,,32.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.49,3324,
59011-0420-10 - oxycodone CR 20 mg Tab,59011-0420-10,NDC,,,,inpatient,1,EA,55.4,33.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,44.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,47.09,percent of total billed charges,,,85,,47.09,percent of total billed charges,,,49,,27.15,percent of total billed charges,,,90,,49.86,percent of total billed charges,,,,,,,no IP contract,,80,,44.32,percent of total billed charges,,,,,,,no IP contract,,50,,27.7,percent of total billed charges,,,,,,no IP contract,,,78,,43.21,percent of total billed charges,,,70,,38.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.15,3324,
59011-0420-20 - oxycodone 20 mg ER Ta,59011-0420-20,NDC,,,,inpatient,1,EA,56.65,33.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,45.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,48.15,percent of total billed charges,,,85,,48.15,percent of total billed charges,,,49,,27.76,percent of total billed charges,,,90,,50.99,percent of total billed charges,,,,,,,no IP contract,,80,,45.32,percent of total billed charges,,,,,,,no IP contract,,50,,28.33,percent of total billed charges,,,,,,no IP contract,,,78,,44.19,percent of total billed charges,,,70,,39.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.76,3324,
59011-0440-10 - oxycodone cr 40 mg ER Tablet,59011-0440-10,NDC,,,,inpatient,1,EA,66.15,39.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,53.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.23,percent of total billed charges,,,85,,56.23,percent of total billed charges,,,49,,32.41,percent of total billed charges,,,90,,59.54,percent of total billed charges,,,,,,,no IP contract,,80,,52.92,percent of total billed charges,,,,,,,no IP contract,,50,,33.08,percent of total billed charges,,,,,,no IP contract,,,78,,51.6,percent of total billed charges,,,70,,46.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.41,3324,
59011-0440-20 - oxyCODONE 40 mg ER Ta,59011-0440-20,NDC,,,,inpatient,1,EA,75.4,45.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,61.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,64.09,percent of total billed charges,,,85,,64.09,percent of total billed charges,,,49,,36.95,percent of total billed charges,,,90,,67.86,percent of total billed charges,,,,,,,no IP contract,,80,,60.32,percent of total billed charges,,,,,,,no IP contract,,50,,37.7,percent of total billed charges,,,,,,no IP contract,,,78,,58.81,percent of total billed charges,,,70,,52.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.95,3324,
59011-0458-10 - HYDROmorphone 8 mg Tab,59011-0458-10,NDC,,,,inpatient,1,EA,34.5,20.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.33,percent of total billed charges,,,85,,29.33,percent of total billed charges,,,49,,16.91,percent of total billed charges,,,90,,31.05,percent of total billed charges,,,,,,,no IP contract,,80,,27.6,percent of total billed charges,,,,,,,no IP contract,,50,,17.25,percent of total billed charges,,,,,,no IP contract,,,78,,26.91,percent of total billed charges,,,70,,24.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.91,3324,
59011-0460-10 - oxycodone cr 60 mg ER Tablet,59011-0460-10,NDC,,,,inpatient,1,EA,119.4,71.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,96.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,101.49,percent of total billed charges,,,85,,101.49,percent of total billed charges,,,49,,58.51,percent of total billed charges,,,90,,107.46,percent of total billed charges,,,,,,,no IP contract,,80,,95.52,percent of total billed charges,,,,,,,no IP contract,,50,,59.7,percent of total billed charges,,,,,,no IP contract,,,78,,93.13,percent of total billed charges,,,70,,83.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.51,3324,
59016-0420-17 - magnesium lactate 84 mg ER Ta,59016-0420-17,NDC,,,,inpatient,1,EA,5.8,3.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.93,percent of total billed charges,,,85,,4.93,percent of total billed charges,,,49,,2.84,percent of total billed charges,,,90,,5.22,percent of total billed charges,,,,,,,no IP contract,,80,,4.64,percent of total billed charges,,,,,,,no IP contract,,50,,2.9,percent of total billed charges,,,,,,no IP contract,,,78,,4.52,percent of total billed charges,,,70,,4.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.84,3324,
59016-0420-19 - magnesium lactate 84 mg ER Ta,59016-0420-19,NDC,,,,inpatient,1,EA,5.8,3.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.93,percent of total billed charges,,,85,,4.93,percent of total billed charges,,,49,,2.84,percent of total billed charges,,,90,,5.22,percent of total billed charges,,,,,,,no IP contract,,80,,4.64,percent of total billed charges,,,,,,,no IP contract,,50,,2.9,percent of total billed charges,,,,,,no IP contract,,,78,,4.52,percent of total billed charges,,,70,,4.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.84,3324,
59148-0013-15 - aripiprazole 1 mg/mL Soln,59148-0013-15,NDC,,,,inpatient,1,ML,70.8,42.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,57.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,60.18,percent of total billed charges,,,85,,60.18,percent of total billed charges,,,49,,34.69,percent of total billed charges,,,90,,63.72,percent of total billed charges,,,,,,,no IP contract,,80,,56.64,percent of total billed charges,,,,,,,no IP contract,,50,,35.4,percent of total billed charges,,,,,,no IP contract,,,78,,55.22,percent of total billed charges,,,70,,49.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,34.69,3324,
59310-0204-12 - beclomethasone 80 mcg/inh Aeros,59310-0204-12,NDC,,,,inpatient,1,UN,1706.5,1023.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1382.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1450.53,percent of total billed charges,,,85,,1450.53,percent of total billed charges,,,49,,836.19,percent of total billed charges,,,90,,1535.85,percent of total billed charges,,,,,,,no IP contract,,80,,1365.2,percent of total billed charges,,,,,,,no IP contract,,50,,853.25,percent of total billed charges,,,,,,no IP contract,,,78,,1331.07,percent of total billed charges,,,70,,1194.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,836.19,3324,
59310-0302-40 - beclomethasone [QVar 40] 40 mcg / 1 INH Aerosol,59310-0302-40,NDC,,,,inpatient,1,UN,1701,1020.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1377.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1445.85,percent of total billed charges,,,85,,1445.85,percent of total billed charges,,,49,,833.49,percent of total billed charges,,,90,,1530.9,percent of total billed charges,,,,,,,no IP contract,,80,,1360.8,percent of total billed charges,,,,,,,no IP contract,,50,,850.5,percent of total billed charges,,,,,,no IP contract,,,78,,1326.78,percent of total billed charges,,,70,,1190.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,833.49,3324,
59310-0579-22 - albuterol CFC free 90 mcg/inh Aeros,59310-0579-22,NDC,,,,inpatient,1,UN,830.55,498.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,672.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,705.97,percent of total billed charges,,,85,,705.97,percent of total billed charges,,,49,,406.97,percent of total billed charges,,,90,,747.5,percent of total billed charges,,,,,,,no IP contract,,80,,664.44,percent of total billed charges,,,,,,,no IP contract,,50,,415.28,percent of total billed charges,,,,,,no IP contract,,,78,,647.83,percent of total billed charges,,,70,,581.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,406.97,3324,
59627-0002-05 - interferon beta-1a 30 mcg/0.5 mL Kit,59627-0002-05,NDC,,,,inpatient,0.5,ML,48282.9,28969.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,39109.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,41040.47,percent of total billed charges,,,85,,41040.47,percent of total billed charges,,,49,,23658.62,percent of total billed charges,,,90,,43454.61,percent of total billed charges,,,,,,,no IP contract,,80,,38626.32,percent of total billed charges,,,,,,,no IP contract,,50,,24141.45,percent of total billed charges,,,,,,no IP contract,,,78,,37660.66,percent of total billed charges,,,70,,33798.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,31035.48,100% of Medicare,,,,,31035.48,100% of Medicare,,,,,31035.48,100% of Medicare,,,,,31035.48,100% of Medicare,,,,,31035.48,100% of Medicare,,,,,31035.48,100% of Medicare,,,,,31035.48,100% of Medicare,,,,,31035.48,100% of Medicare,,,,,31035.48,100% of Medicare,,,,,31035.48,100% of Medicare,,,,,31035.48,100% of Medicare,,,,,,31035.48,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,43454.61,
cefiderocol 1 g REC I,59630-0266-10,NDC,,,,inpatient,1,EA,1971.85,1183.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1597.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1676.07,percent of total billed charges,,,85,,1676.07,percent of total billed charges,,,49,,966.21,percent of total billed charges,,,90,,1774.67,percent of total billed charges,,,,,,,no IP contract,,80,,1577.48,percent of total billed charges,,,,,,,no IP contract,,50,,985.93,percent of total billed charges,,,,,,no IP contract,,,78,,1538.04,percent of total billed charges,,,70,,1380.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,966.21,3324,
59651-0026-75 - amoxicillin-clavulanate 250 mg-62.5 mg/5 mL REC P,59651-0026-75,NDC,,,,inpatient,1,ML,12.6,7.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.71,percent of total billed charges,,,85,,10.71,percent of total billed charges,,,49,,6.17,percent of total billed charges,,,90,,11.34,percent of total billed charges,,,,,,,no IP contract,,80,,10.08,percent of total billed charges,,,,,,,no IP contract,,50,,6.3,percent of total billed charges,,,,,,no IP contract,,,78,,9.83,percent of total billed charges,,,70,,8.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.17,3324,
59651-0052-90 - ezetimibe 10 mg Tab,59651-0052-90,NDC,,,,inpatient,1,EA,85.55,51.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,69.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,72.72,percent of total billed charges,,,85,,72.72,percent of total billed charges,,,49,,41.92,percent of total billed charges,,,90,,77,percent of total billed charges,,,,,,,no IP contract,,80,,68.44,percent of total billed charges,,,,,,,no IP contract,,50,,42.78,percent of total billed charges,,,,,,no IP contract,,,78,,66.73,percent of total billed charges,,,70,,59.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,41.92,3324,
59651-0119-60 - dofetilide 250 mcg Cap,59651-0119-60,NDC,,,,inpatient,1,EA,71.9,43.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,58.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,61.12,percent of total billed charges,,,85,,61.12,percent of total billed charges,,,49,,35.23,percent of total billed charges,,,90,,64.71,percent of total billed charges,,,,,,,no IP contract,,80,,57.52,percent of total billed charges,,,,,,,no IP contract,,50,,35.95,percent of total billed charges,,,,,,no IP contract,,,78,,56.08,percent of total billed charges,,,70,,50.33,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,35.23,3324,
nebivolol 5 mg Tab,59651-0138-30,NDC,,,,inpatient,1,EA,41.5,24.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,35.28,percent of total billed charges,,,85,,35.28,percent of total billed charges,,,49,,20.34,percent of total billed charges,,,90,,37.35,percent of total billed charges,,,,,,,no IP contract,,80,,33.2,percent of total billed charges,,,,,,,no IP contract,,50,,20.75,percent of total billed charges,,,,,,no IP contract,,,78,,32.37,percent of total billed charges,,,70,,29.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.34,3324,
59651-0270-01 - glipiZIDE 10 mg ER Ta,59651-0270-01,NDC,,,,inpatient,1,EA,10.25,6.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.71,percent of total billed charges,,,85,,8.71,percent of total billed charges,,,49,,5.02,percent of total billed charges,,,90,,9.23,percent of total billed charges,,,,,,,no IP contract,,80,,8.2,percent of total billed charges,,,,,,,no IP contract,,50,,5.13,percent of total billed charges,,,,,,no IP contract,,,78,,8,percent of total billed charges,,,70,,7.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.02,3324,
59651-0300-30 - tamoxifen 20 mg Tab,59651-0300-30,NDC,,,,inpatient,1,EA,33.95,20.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.86,percent of total billed charges,,,85,,28.86,percent of total billed charges,,,49,,16.64,percent of total billed charges,,,90,,30.56,percent of total billed charges,,,,,,,no IP contract,,80,,27.16,percent of total billed charges,,,,,,,no IP contract,,50,,16.98,percent of total billed charges,,,,,,no IP contract,,,78,,26.48,percent of total billed charges,,,70,,23.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.64,3324,
59651-0421-01 - ursodiol 300 mg Cap,59651-0421-01,NDC,,,,inpatient,1,EA,62.25,37.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,50.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,52.91,percent of total billed charges,,,85,,52.91,percent of total billed charges,,,49,,30.5,percent of total billed charges,,,90,,56.03,percent of total billed charges,,,,,,,no IP contract,,80,,49.8,percent of total billed charges,,,,,,,no IP contract,,50,,31.13,percent of total billed charges,,,,,,no IP contract,,,78,,48.56,percent of total billed charges,,,70,,43.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,30.5,3324,
59651-0426-01 - spironolactone 25 mg Tab,59651-0426-01,NDC,,,,inpatient,1,EA,7.5,4.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.38,percent of total billed charges,,,85,,6.38,percent of total billed charges,,,49,,3.68,percent of total billed charges,,,90,,6.75,percent of total billed charges,,,,,,,no IP contract,,80,,6,percent of total billed charges,,,,,,,no IP contract,,50,,3.75,percent of total billed charges,,,,,,no IP contract,,,78,,5.85,percent of total billed charges,,,70,,5.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.68,3324,
carbidopa-levodopa 10 mg-100 mg Tab,59651-0456-01,NDC,,,,inpatient,1,EA,9.45,5.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.03,percent of total billed charges,,,85,,8.03,percent of total billed charges,,,49,,4.63,percent of total billed charges,,,90,,8.51,percent of total billed charges,,,,,,,no IP contract,,80,,7.56,percent of total billed charges,,,,,,,no IP contract,,50,,4.73,percent of total billed charges,,,,,,no IP contract,,,78,,7.37,percent of total billed charges,,,70,,6.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.63,3324,
predniSONE 1 mg Tab,59651-0484-01,NDC,,,,inpatient,1,EA,5.8,3.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.93,percent of total billed charges,,,85,,4.93,percent of total billed charges,,,49,,2.84,percent of total billed charges,,,90,,5.22,percent of total billed charges,,,,,,,no IP contract,,80,,4.64,percent of total billed charges,,,,,,,no IP contract,,50,,2.9,percent of total billed charges,,,,,,no IP contract,,,78,,4.52,percent of total billed charges,,,70,,4.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.84,3324,
predniSONE 50 mg Tab,59651-0489-01,NDC,,,,inpatient,1,EA,7.1,4.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.04,percent of total billed charges,,,85,,6.04,percent of total billed charges,,,49,,3.48,percent of total billed charges,,,90,,6.39,percent of total billed charges,,,,,,,no IP contract,,80,,5.68,percent of total billed charges,,,,,,,no IP contract,,50,,3.55,percent of total billed charges,,,,,,no IP contract,,,78,,5.54,percent of total billed charges,,,70,,4.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.48,3324,
exemestane 25 mg Tab,59651-0516-30,NDC,,,,inpatient,1,EA,164.65,98.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,133.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,139.95,percent of total billed charges,,,85,,139.95,percent of total billed charges,,,49,,80.68,percent of total billed charges,,,90,,148.19,percent of total billed charges,,,,,,,no IP contract,,80,,131.72,percent of total billed charges,,,,,,,no IP contract,,50,,82.33,percent of total billed charges,,,,,,no IP contract,,,78,,128.43,percent of total billed charges,,,70,,115.26,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,80.68,3324,
glipiZIDE 5 mg ER Ta,59651-0781-01,NDC,,,,inpatient,1,EA,7.1,4.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.04,percent of total billed charges,,,85,,6.04,percent of total billed charges,,,49,,3.48,percent of total billed charges,,,90,,6.39,percent of total billed charges,,,,,,,no IP contract,,80,,5.68,percent of total billed charges,,,,,,,no IP contract,,50,,3.55,percent of total billed charges,,,,,,no IP contract,,,78,,5.54,percent of total billed charges,,,70,,4.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.48,3324,
hyaluronan 30 mg/2 mL Soln,59676-0360-01,NDC,,,,inpatient,1,EA,1907.65,1144.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1545.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1621.5,percent of total billed charges,,,85,,1621.5,percent of total billed charges,,,49,,934.75,percent of total billed charges,,,90,,1716.89,percent of total billed charges,,,,,,,no IP contract,,80,,1526.12,percent of total billed charges,,,,,,,no IP contract,,50,,953.83,percent of total billed charges,,,,,,no IP contract,,,78,,1487.97,percent of total billed charges,,,70,,1335.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,934.75,3324,
59676-0562-01 - darunavir 600 mg Tab,59676-0562-01,NDC,,,,inpatient,1,EA,149.85,89.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,121.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,127.37,percent of total billed charges,,,85,,127.37,percent of total billed charges,,,49,,73.43,percent of total billed charges,,,90,,134.87,percent of total billed charges,,,,,,,no IP contract,,80,,119.88,percent of total billed charges,,,,,,,no IP contract,,50,,74.93,percent of total billed charges,,,,,,no IP contract,,,78,,116.88,percent of total billed charges,,,70,,104.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,73.43,3324,
59676-0566-30 - darunavir 800 mg Tab,59676-0566-30,NDC,,,,inpatient,1,EA,367.55,220.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,297.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,312.42,percent of total billed charges,,,85,,312.42,percent of total billed charges,,,49,,180.1,percent of total billed charges,,,90,,330.8,percent of total billed charges,,,,,,,no IP contract,,80,,294.04,percent of total billed charges,,,,,,,no IP contract,,50,,183.78,percent of total billed charges,,,,,,no IP contract,,,78,,286.69,percent of total billed charges,,,70,,257.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,180.1,3324,
hyaluronan 88 mg/4 mL Soln,59676-0820-01,NDC,,,,inpatient,1,EA,15183.3,9109.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12298.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12905.81,percent of total billed charges,,,85,,12905.81,percent of total billed charges,,,49,,7439.82,percent of total billed charges,,,90,,13664.97,percent of total billed charges,,,,,,,no IP contract,,80,,12146.64,percent of total billed charges,,,,,,,no IP contract,,50,,7591.65,percent of total billed charges,,,,,,no IP contract,,,78,,11842.97,percent of total billed charges,,,70,,10628.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,13664.97,
59730-6401-01 - calcium acetate 667 mg Tab,59730-6401-01,NDC,,,,inpatient,1,EA,5.75,3.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.89,percent of total billed charges,,,85,,4.89,percent of total billed charges,,,49,,2.82,percent of total billed charges,,,90,,5.18,percent of total billed charges,,,,,,,no IP contract,,80,,4.6,percent of total billed charges,,,,,,,no IP contract,,50,,2.88,percent of total billed charges,,,,,,no IP contract,,,78,,4.49,percent of total billed charges,,,70,,4.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.82,3324,
59746-0003-14 - methylPREDNISolone 16 mg Tab,59746-0003-14,NDC,,,,inpatient,1,EA,28.55,17.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.27,percent of total billed charges,,,85,,24.27,percent of total billed charges,,,49,,13.99,percent of total billed charges,,,90,,25.7,percent of total billed charges,,,,,,,no IP contract,,80,,22.84,percent of total billed charges,,,,,,,no IP contract,,50,,14.28,percent of total billed charges,,,,,,no IP contract,,,78,,22.27,percent of total billed charges,,,70,,19.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.99,3324,
59746-0113-06 - prochlorperazine 5 mg Tab,59746-0113-06,NDC,,,,inpatient,1,EA,8.5,5.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.23,percent of total billed charges,,,85,,7.23,percent of total billed charges,,,49,,4.17,percent of total billed charges,,,90,,7.65,percent of total billed charges,,,,,,,no IP contract,,80,,6.8,percent of total billed charges,,,,,,,no IP contract,,50,,4.25,percent of total billed charges,,,,,,no IP contract,,,78,,6.63,percent of total billed charges,,,70,,5.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.17,3324,
59746-0115-06 - prochlorperazine 10 mg Tab,59746-0115-06,NDC,,,,inpatient,1,EA,10.9,6.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.27,percent of total billed charges,,,85,,9.27,percent of total billed charges,,,49,,5.34,percent of total billed charges,,,90,,9.81,percent of total billed charges,,,,,,,no IP contract,,80,,8.72,percent of total billed charges,,,,,,,no IP contract,,50,,5.45,percent of total billed charges,,,,,,no IP contract,,,78,,8.5,percent of total billed charges,,,70,,7.63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.34,3324,
59746-0173-06 - predniSONE 10 mg Tab,59746-0173-06,NDC,,,,inpatient,1,EA,11.05,6.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.39,percent of total billed charges,,,85,,9.39,percent of total billed charges,,,49,,5.41,percent of total billed charges,,,90,,9.95,percent of total billed charges,,,,,,,no IP contract,,80,,8.84,percent of total billed charges,,,,,,,no IP contract,,50,,5.53,percent of total billed charges,,,,,,no IP contract,,,78,,8.62,percent of total billed charges,,,70,,7.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.41,3324,
59746-0175-06 - predniSONE 20 mg Tab,59746-0175-06,NDC,,,,inpatient,1,EA,15.75,9.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.39,percent of total billed charges,,,85,,13.39,percent of total billed charges,,,49,,7.72,percent of total billed charges,,,90,,14.18,percent of total billed charges,,,,,,,no IP contract,,80,,12.6,percent of total billed charges,,,,,,,no IP contract,,50,,7.88,percent of total billed charges,,,,,,no IP contract,,,78,,12.29,percent of total billed charges,,,70,,11.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.72,3324,
59746-0216-01 - spironolactone 25 mg Tab,59746-0216-01,NDC,,,,inpatient,1,EA,7.5,4.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.38,percent of total billed charges,,,85,,6.38,percent of total billed charges,,,49,,3.68,percent of total billed charges,,,90,,6.75,percent of total billed charges,,,,,,,no IP contract,,80,,6,percent of total billed charges,,,,,,,no IP contract,,50,,3.75,percent of total billed charges,,,,,,no IP contract,,,78,,5.85,percent of total billed charges,,,70,,5.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.68,3324,
59746-0217-01 - spironolactone 50 mg Tab,59746-0217-01,NDC,,,,inpatient,1,EA,10.35,6.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.8,percent of total billed charges,,,85,,8.8,percent of total billed charges,,,49,,5.07,percent of total billed charges,,,90,,9.32,percent of total billed charges,,,,,,,no IP contract,,80,,8.28,percent of total billed charges,,,,,,,no IP contract,,50,,5.18,percent of total billed charges,,,,,,no IP contract,,,78,,8.07,percent of total billed charges,,,70,,7.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.07,3324,
59746-0306-32 - OLANZapine 5 mg DIS T,59746-0306-32,NDC,,,,inpatient,1,EA,117.25,70.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,94.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,99.66,percent of total billed charges,,,85,,99.66,percent of total billed charges,,,49,,57.45,percent of total billed charges,,,90,,105.53,percent of total billed charges,,,,,,,no IP contract,,80,,93.8,percent of total billed charges,,,,,,,no IP contract,,50,,58.63,percent of total billed charges,,,,,,no IP contract,,,78,,91.46,percent of total billed charges,,,70,,82.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,57.45,3324,
59746-0307-32 - OLANZapine 10 mg DIS T,59746-0307-32,NDC,,,,inpatient,1,EA,35.15,21.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.88,percent of total billed charges,,,85,,29.88,percent of total billed charges,,,49,,17.22,percent of total billed charges,,,90,,31.64,percent of total billed charges,,,,,,,no IP contract,,80,,28.12,percent of total billed charges,,,,,,,no IP contract,,50,,17.58,percent of total billed charges,,,,,,no IP contract,,,78,,27.42,percent of total billed charges,,,70,,24.61,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.22,3324,
59746-0330-90 - donepezil 10 mg Tab,59746-0330-90,NDC,,,,inpatient,1,EA,72.6,43.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,58.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,61.71,percent of total billed charges,,,85,,61.71,percent of total billed charges,,,49,,35.57,percent of total billed charges,,,90,,65.34,percent of total billed charges,,,,,,,no IP contract,,80,,58.08,percent of total billed charges,,,,,,,no IP contract,,50,,36.3,percent of total billed charges,,,,,,no IP contract,,,78,,56.63,percent of total billed charges,,,70,,50.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,35.57,3324,
59746-0361-90 - valsartan 80 mg Tab,59746-0361-90,NDC,,,,inpatient,1,EA,40.4,24.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34.34,percent of total billed charges,,,85,,34.34,percent of total billed charges,,,49,,19.8,percent of total billed charges,,,90,,36.36,percent of total billed charges,,,,,,,no IP contract,,80,,32.32,percent of total billed charges,,,,,,,no IP contract,,50,,20.2,percent of total billed charges,,,,,,no IP contract,,,78,,31.51,percent of total billed charges,,,70,,28.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.8,3324,
59746-0362-90 - valsartan 160 mg Tab,59746-0362-90,NDC,,,,inpatient,1,EA,43.2,25.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36.72,percent of total billed charges,,,85,,36.72,percent of total billed charges,,,49,,21.17,percent of total billed charges,,,90,,38.88,percent of total billed charges,,,,,,,no IP contract,,80,,34.56,percent of total billed charges,,,,,,,no IP contract,,50,,21.6,percent of total billed charges,,,,,,no IP contract,,,78,,33.7,percent of total billed charges,,,70,,30.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.17,3324,
59746-0783-01 - predniSONE 50 mg Tab,59746-0783-01,NDC,,,,inpatient,1,EA,7.1,4.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.04,percent of total billed charges,,,85,,6.04,percent of total billed charges,,,49,,3.48,percent of total billed charges,,,90,,6.39,percent of total billed charges,,,,,,,no IP contract,,80,,5.68,percent of total billed charges,,,,,,,no IP contract,,50,,3.55,percent of total billed charges,,,,,,no IP contract,,,78,,5.54,percent of total billed charges,,,70,,4.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.48,3324,
carBAMazepine 200 mg ER Ta,59746-0790-01,NDC,,,,inpatient,1,EA,20.35,12.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.3,percent of total billed charges,,,85,,17.3,percent of total billed charges,,,49,,9.97,percent of total billed charges,,,90,,18.32,percent of total billed charges,,,,,,,no IP contract,,80,,16.28,percent of total billed charges,,,,,,,no IP contract,,50,,10.18,percent of total billed charges,,,,,,no IP contract,,,78,,15.87,percent of total billed charges,,,70,,14.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.97,3324,
59762-0047-01 - tolterodine 2 mg ER Ca,59762-0047-01,NDC,,,,inpatient,1,EA,79.75,47.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,64.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,67.79,percent of total billed charges,,,85,,67.79,percent of total billed charges,,,49,,39.08,percent of total billed charges,,,90,,71.78,percent of total billed charges,,,,,,,no IP contract,,80,,63.8,percent of total billed charges,,,,,,,no IP contract,,50,,39.88,percent of total billed charges,,,,,,no IP contract,,,78,,62.21,percent of total billed charges,,,70,,55.83,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,39.08,3324,
59762-0056-01 - medroxyPROGESTERone 10 mg Tab,59762-0056-01,NDC,,,,inpatient,1,EA,7.7,4.62,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.55,percent of total billed charges,,,85,,6.55,percent of total billed charges,,,49,,3.77,percent of total billed charges,,,90,,6.93,percent of total billed charges,,,,,,,no IP contract,,80,,6.16,percent of total billed charges,,,,,,,no IP contract,,50,,3.85,percent of total billed charges,,,,,,no IP contract,,,78,,6.01,percent of total billed charges,,,70,,5.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.77,3324,
59762-0073-01 - hydrocortisone 5 mg Tab,59762-0073-01,NDC,,,,inpatient,1,EA,6.55,3.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.57,percent of total billed charges,,,85,,5.57,percent of total billed charges,,,49,,3.21,percent of total billed charges,,,90,,5.9,percent of total billed charges,,,,,,,no IP contract,,80,,5.24,percent of total billed charges,,,,,,,no IP contract,,50,,3.28,percent of total billed charges,,,,,,no IP contract,,,78,,5.11,percent of total billed charges,,,70,,4.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.21,3324,
59762-0074-01 - hydrocortisone 10 mg Tab,59762-0074-01,NDC,,,,inpatient,1,EA,6.55,3.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.57,percent of total billed charges,,,85,,5.57,percent of total billed charges,,,49,,3.21,percent of total billed charges,,,90,,5.9,percent of total billed charges,,,,,,,no IP contract,,80,,5.24,percent of total billed charges,,,,,,,no IP contract,,50,,3.28,percent of total billed charges,,,,,,no IP contract,,,78,,5.11,percent of total billed charges,,,70,,4.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.21,3324,
59762-0104-01 - sulfasalazine 500 mg EC Ta,59762-0104-01,NDC,,,,inpatient,1,EA,6.85,4.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.82,percent of total billed charges,,,85,,5.82,percent of total billed charges,,,49,,3.36,percent of total billed charges,,,90,,6.17,percent of total billed charges,,,,,,,no IP contract,,80,,5.48,percent of total billed charges,,,,,,,no IP contract,,50,,3.43,percent of total billed charges,,,,,,no IP contract,,,78,,5.34,percent of total billed charges,,,70,,4.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.36,3324,
59762-0104-05 - sulfaSALAzine 500 mg EC Ta,59762-0104-05,NDC,,,,inpatient,1,EA,7.3,4.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.21,percent of total billed charges,,,85,,6.21,percent of total billed charges,,,49,,3.58,percent of total billed charges,,,90,,6.57,percent of total billed charges,,,,,,,no IP contract,,80,,5.84,percent of total billed charges,,,,,,,no IP contract,,50,,3.65,percent of total billed charges,,,,,,no IP contract,,,78,,5.69,percent of total billed charges,,,70,,5.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.58,3324,
59762-0117-01 - mesalamine 400 mg DR Ca,59762-0117-01,NDC,,,,inpatient,1,EA,37.15,22.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.58,percent of total billed charges,,,85,,31.58,percent of total billed charges,,,49,,18.2,percent of total billed charges,,,90,,33.44,percent of total billed charges,,,,,,,no IP contract,,80,,29.72,percent of total billed charges,,,,,,,no IP contract,,50,,18.58,percent of total billed charges,,,,,,no IP contract,,,78,,28.98,percent of total billed charges,,,70,,26.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.2,3324,
59762-0131-04 - silver sulfADIAZINE topical 1% Cream,59762-0131-04,NDC,,,,inpatient,1,UN,542.35,325.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,439.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,461,percent of total billed charges,,,85,,461,percent of total billed charges,,,49,,265.75,percent of total billed charges,,,90,,488.12,percent of total billed charges,,,,,,,no IP contract,,80,,433.88,percent of total billed charges,,,,,,,no IP contract,,50,,271.18,percent of total billed charges,,,,,,no IP contract,,,78,,423.03,percent of total billed charges,,,70,,379.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,265.75,3324,
59762-0131-05 - silver sulfADIAZINE topical 1% Cream,59762-0131-05,NDC,,,,inpatient,1,UN,134.15,80.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,108.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,114.03,percent of total billed charges,,,85,,114.03,percent of total billed charges,,,49,,65.73,percent of total billed charges,,,90,,120.74,percent of total billed charges,,,,,,,no IP contract,,80,,107.32,percent of total billed charges,,,,,,,no IP contract,,50,,67.08,percent of total billed charges,,,,,,no IP contract,,,78,,104.64,percent of total billed charges,,,70,,93.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,65.73,3324,
59762-0131-06 - silver sulfADIAZINE topical 1% Cream,59762-0131-06,NDC,,,,inpatient,1,UN,134.15,80.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,108.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,114.03,percent of total billed charges,,,85,,114.03,percent of total billed charges,,,49,,65.73,percent of total billed charges,,,90,,120.74,percent of total billed charges,,,,,,,no IP contract,,80,,107.32,percent of total billed charges,,,,,,,no IP contract,,50,,67.08,percent of total billed charges,,,,,,no IP contract,,,78,,104.64,percent of total billed charges,,,70,,93.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,65.73,3324,
59762-0180-02 - venlafaxine 37.5 mg ER Ca,59762-0180-02,NDC,,,,inpatient,1,EA,36.9,22.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.37,percent of total billed charges,,,85,,31.37,percent of total billed charges,,,49,,18.08,percent of total billed charges,,,90,,33.21,percent of total billed charges,,,,,,,no IP contract,,80,,29.52,percent of total billed charges,,,,,,,no IP contract,,50,,18.45,percent of total billed charges,,,,,,no IP contract,,,78,,28.78,percent of total billed charges,,,70,,25.83,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.08,3324,
59762-0450-01 - colestipol 1 g Tab,59762-0450-01,NDC,,,,inpatient,1,EA,9.05,5.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.69,percent of total billed charges,,,85,,7.69,percent of total billed charges,,,49,,4.43,percent of total billed charges,,,90,,8.15,percent of total billed charges,,,,,,,no IP contract,,80,,7.24,percent of total billed charges,,,,,,,no IP contract,,50,,4.53,percent of total billed charges,,,,,,no IP contract,,,78,,7.06,percent of total billed charges,,,70,,6.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.43,3324,
59762-0531-01 - phenytoin 25 mg/mL Susp,59762-0531-01,NDC,,,,inpatient,1,ML,6.75,4.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.74,percent of total billed charges,,,85,,5.74,percent of total billed charges,,,49,,3.31,percent of total billed charges,,,90,,6.08,percent of total billed charges,,,,,,,no IP contract,,80,,5.4,percent of total billed charges,,,,,,,no IP contract,,50,,3.38,percent of total billed charges,,,,,,no IP contract,,,78,,5.27,percent of total billed charges,,,70,,4.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.31,3324,
59762-0800-02 - tolterodine 2 mg Tab,59762-0800-02,NDC,,,,inpatient,1,EA,30.85,18.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.22,percent of total billed charges,,,85,,26.22,percent of total billed charges,,,49,,15.12,percent of total billed charges,,,90,,27.77,percent of total billed charges,,,,,,,no IP contract,,80,,24.68,percent of total billed charges,,,,,,,no IP contract,,50,,15.43,percent of total billed charges,,,,,,no IP contract,,,78,,24.06,percent of total billed charges,,,70,,21.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.12,3324,
59762-1050-05 - amoxicillin 875 mg Tab,59762-1050-05,NDC,,,,inpatient,1,EA,10.75,6.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.14,percent of total billed charges,,,85,,9.14,percent of total billed charges,,,49,,5.27,percent of total billed charges,,,90,,9.68,percent of total billed charges,,,,,,,no IP contract,,80,,8.6,percent of total billed charges,,,,,,,no IP contract,,50,,5.38,percent of total billed charges,,,,,,no IP contract,,,78,,8.39,percent of total billed charges,,,70,,7.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.27,3324,
59762-1061-01 - atropine-diphenoxylate 0.025 mg-2.5 mg Tab,59762-1061-01,NDC,,,,inpatient,1,EA,11.25,6.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.56,percent of total billed charges,,,85,,9.56,percent of total billed charges,,,49,,5.51,percent of total billed charges,,,90,,10.13,percent of total billed charges,,,,,,,no IP contract,,80,,9,percent of total billed charges,,,,,,,no IP contract,,50,,5.63,percent of total billed charges,,,,,,no IP contract,,,78,,8.78,percent of total billed charges,,,70,,7.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.51,3324,
linezolid 600 mg Tab,59762-1307-02,NDC,,,,inpatient,1,EA,1464,878.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1185.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1244.4,percent of total billed charges,,,85,,1244.4,percent of total billed charges,,,49,,717.36,percent of total billed charges,,,90,,1317.6,percent of total billed charges,,,,,,,no IP contract,,80,,1171.2,percent of total billed charges,,,,,,,no IP contract,,50,,732,percent of total billed charges,,,,,,no IP contract,,,78,,1141.92,percent of total billed charges,,,70,,1024.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,717.36,3324,
59762-1350-01 - rifabutin 150 mg Cap,59762-1350-01,NDC,,,,inpatient,1,EA,142.85,85.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,115.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,121.42,percent of total billed charges,,,85,,121.42,percent of total billed charges,,,49,,70,percent of total billed charges,,,90,,128.57,percent of total billed charges,,,,,,,no IP contract,,80,,114.28,percent of total billed charges,,,,,,,no IP contract,,50,,71.43,percent of total billed charges,,,,,,no IP contract,,,78,,111.42,percent of total billed charges,,,70,,100,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,70,3324,
59762-1710-01 - eplerenone 25 mg Tab,59762-1710-01,NDC,,,,inpatient,1,EA,36.4,21.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.94,percent of total billed charges,,,85,,30.94,percent of total billed charges,,,49,,17.84,percent of total billed charges,,,90,,32.76,percent of total billed charges,,,,,,,no IP contract,,80,,29.12,percent of total billed charges,,,,,,,no IP contract,,50,,18.2,percent of total billed charges,,,,,,no IP contract,,,78,,28.39,percent of total billed charges,,,70,,25.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.84,3324,
59762-2350-06 - ethosuximide 250 mg/5 mL Syrup,59762-2350-06,NDC,,,,inpatient,1,ML,10.6,6.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.01,percent of total billed charges,,,85,,9.01,percent of total billed charges,,,49,,5.19,percent of total billed charges,,,90,,9.54,percent of total billed charges,,,,,,,no IP contract,,80,,8.48,percent of total billed charges,,,,,,,no IP contract,,50,,5.3,percent of total billed charges,,,,,,no IP contract,,,78,,8.27,percent of total billed charges,,,70,,7.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.19,3324,
59762-2380-06 - doxazosin 8 mg Tab,59762-2380-06,NDC,,,,inpatient,1,EA,15.65,9.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.3,percent of total billed charges,,,85,,13.3,percent of total billed charges,,,49,,7.67,percent of total billed charges,,,90,,14.09,percent of total billed charges,,,,,,,no IP contract,,80,,12.52,percent of total billed charges,,,,,,,no IP contract,,50,,7.83,percent of total billed charges,,,,,,no IP contract,,,78,,12.21,percent of total billed charges,,,70,,10.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.67,3324,
59762-3720-01 - ALPRAZolam 0.5 mg Tab,59762-3720-01,NDC,,,,inpatient,1,EA,5.85,3.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.97,percent of total billed charges,,,85,,4.97,percent of total billed charges,,,49,,2.87,percent of total billed charges,,,90,,5.27,percent of total billed charges,,,,,,,no IP contract,,80,,4.68,percent of total billed charges,,,,,,,no IP contract,,50,,2.93,percent of total billed charges,,,,,,no IP contract,,,78,,4.56,percent of total billed charges,,,70,,4.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.87,3324,
59762-3728-02 - clindamycin topical 1% Soln,59762-3728-02,NDC,,,,inpatient,1,UN,663.95,398.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,537.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,564.36,percent of total billed charges,,,85,,564.36,percent of total billed charges,,,49,,325.34,percent of total billed charges,,,90,,597.56,percent of total billed charges,,,,,,,no IP contract,,80,,531.16,percent of total billed charges,,,,,,,no IP contract,,50,,331.98,percent of total billed charges,,,,,,no IP contract,,,78,,517.88,percent of total billed charges,,,70,,464.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,325.34,3324,
59762-3740-01 - medroxyPROGESTERone 2.5 mg Tab,59762-3740-01,NDC,,,,inpatient,1,EA,6.2,3.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.27,percent of total billed charges,,,85,,5.27,percent of total billed charges,,,49,,3.04,percent of total billed charges,,,90,,5.58,percent of total billed charges,,,,,,,no IP contract,,80,,4.96,percent of total billed charges,,,,,,,no IP contract,,50,,3.1,percent of total billed charges,,,,,,no IP contract,,,78,,4.84,percent of total billed charges,,,70,,4.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.04,3324,
59762-3744-01 - clindamycin topical 1% Lotio,59762-3744-01,NDC,,,,inpatient,1,UN,1008.8,605.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,817.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,857.48,percent of total billed charges,,,85,,857.48,percent of total billed charges,,,49,,494.31,percent of total billed charges,,,90,,907.92,percent of total billed charges,,,,,,,no IP contract,,80,,807.04,percent of total billed charges,,,,,,,no IP contract,,50,,504.4,percent of total billed charges,,,,,,no IP contract,,,78,,786.86,percent of total billed charges,,,70,,706.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,494.31,3324,
59762-4440-03 - methylPREDNISolone 4 mg Tab,59762-4440-03,NDC,,,,inpatient,1,EA,15.2,9.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.92,percent of total billed charges,,,85,,12.92,percent of total billed charges,,,49,,7.45,percent of total billed charges,,,90,,13.68,percent of total billed charges,,,,,,,no IP contract,,80,,12.16,percent of total billed charges,,,,,,,no IP contract,,50,,7.6,percent of total billed charges,,,,,,no IP contract,,,78,,11.86,percent of total billed charges,,,70,,10.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.45,3324,
59762-4900-03 - sertraline 50 mg Tab,59762-4900-03,NDC,,,,inpatient,1,EA,25.35,15.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.55,percent of total billed charges,,,85,,21.55,percent of total billed charges,,,49,,12.42,percent of total billed charges,,,90,,22.82,percent of total billed charges,,,,,,,no IP contract,,80,,20.28,percent of total billed charges,,,,,,,no IP contract,,50,,12.68,percent of total billed charges,,,,,,no IP contract,,,78,,19.77,percent of total billed charges,,,70,,17.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.42,3324,
59762-4940-01 - sertraline 20 mg/mL Conc,59762-4940-01,NDC,,,,inpatient,1,ML,14.75,8.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.54,percent of total billed charges,,,85,,12.54,percent of total billed charges,,,49,,7.23,percent of total billed charges,,,90,,13.28,percent of total billed charges,,,,,,,no IP contract,,80,,11.8,percent of total billed charges,,,,,,,no IP contract,,50,,7.38,percent of total billed charges,,,,,,no IP contract,,,78,,11.51,percent of total billed charges,,,70,,10.33,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.23,3324,
59762-4960-01 - sertraline 25 mg Tab,59762-4960-01,NDC,,,,inpatient,1,EA,25.35,15.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.55,percent of total billed charges,,,85,,21.55,percent of total billed charges,,,49,,12.42,percent of total billed charges,,,90,,22.82,percent of total billed charges,,,,,,,no IP contract,,80,,20.28,percent of total billed charges,,,,,,,no IP contract,,50,,12.68,percent of total billed charges,,,,,,no IP contract,,,78,,19.77,percent of total billed charges,,,70,,17.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.42,3324,
59762-5000-05 - sulfaSALAzine 500 mg Tab,59762-5000-05,NDC,,,,inpatient,1,EA,5.75,3.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.89,percent of total billed charges,,,85,,4.89,percent of total billed charges,,,49,,2.82,percent of total billed charges,,,90,,5.18,percent of total billed charges,,,,,,,no IP contract,,80,,4.6,percent of total billed charges,,,,,,,no IP contract,,50,,2.88,percent of total billed charges,,,,,,no IP contract,,,78,,4.49,percent of total billed charges,,,70,,4.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.82,3324,
59762-5007-01 - misoprostol 100 mcg Tab,59762-5007-01,NDC,,,,inpatient,1,EA,10.35,6.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.8,percent of total billed charges,,,85,,8.8,percent of total billed charges,,,49,,5.07,percent of total billed charges,,,90,,9.32,percent of total billed charges,,,,,,,no IP contract,,80,,8.28,percent of total billed charges,,,,,,,no IP contract,,50,,5.18,percent of total billed charges,,,,,,no IP contract,,,78,,8.07,percent of total billed charges,,,70,,7.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.07,3324,
59762-5017-01 - fluconazole 150 mg Tab,59762-5017-01,NDC,,,,inpatient,1,EA,114.55,68.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,92.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,97.37,percent of total billed charges,,,85,,97.37,percent of total billed charges,,,49,,56.13,percent of total billed charges,,,90,,103.1,percent of total billed charges,,,,,,,no IP contract,,80,,91.64,percent of total billed charges,,,,,,,no IP contract,,50,,57.28,percent of total billed charges,,,,,,no IP contract,,,78,,89.35,percent of total billed charges,,,70,,80.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,56.13,3324,
59762-5030-01 - fluconazole 40 mg/mL REC P,59762-5030-01,NDC,,,,inpatient,1,ML,35.35,21.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.05,percent of total billed charges,,,85,,30.05,percent of total billed charges,,,49,,17.32,percent of total billed charges,,,90,,31.82,percent of total billed charges,,,,,,,no IP contract,,80,,28.28,percent of total billed charges,,,,,,,no IP contract,,50,,17.68,percent of total billed charges,,,,,,no IP contract,,,78,,27.57,percent of total billed charges,,,70,,24.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.32,3324,
59762-5031-01 - glipiZIDE 2.5 mg ER Ta,59762-5031-01,NDC,,,,inpatient,1,EA,7.1,4.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.04,percent of total billed charges,,,85,,6.04,percent of total billed charges,,,49,,3.48,percent of total billed charges,,,90,,6.39,percent of total billed charges,,,,,,,no IP contract,,80,,5.68,percent of total billed charges,,,,,,,no IP contract,,50,,3.55,percent of total billed charges,,,,,,no IP contract,,,78,,5.54,percent of total billed charges,,,70,,4.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.48,3324,
59762-5032-01 - glipiZIDE 5 mg ER Ta,59762-5032-01,NDC,,,,inpatient,1,EA,7.1,4.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.04,percent of total billed charges,,,85,,6.04,percent of total billed charges,,,49,,3.48,percent of total billed charges,,,90,,6.39,percent of total billed charges,,,,,,,no IP contract,,80,,5.68,percent of total billed charges,,,,,,,no IP contract,,50,,3.55,percent of total billed charges,,,,,,no IP contract,,,78,,5.54,percent of total billed charges,,,70,,4.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.48,3324,
59762-5032-01 - glipiZIDE 5 mg ER Ta,59762-5032-01,NDC,,,,inpatient,1,EA,7.1,4.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.04,percent of total billed charges,,,85,,6.04,percent of total billed charges,,,49,,3.48,percent of total billed charges,,,90,,6.39,percent of total billed charges,,,,,,,no IP contract,,80,,5.68,percent of total billed charges,,,,,,,no IP contract,,50,,3.55,percent of total billed charges,,,,,,no IP contract,,,78,,5.54,percent of total billed charges,,,70,,4.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.48,3324,
59762-5033-01 - glipiZIDE 10 mg ER Ta,59762-5033-01,NDC,,,,inpatient,1,EA,10.25,6.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.71,percent of total billed charges,,,85,,8.71,percent of total billed charges,,,49,,5.02,percent of total billed charges,,,90,,9.23,percent of total billed charges,,,,,,,no IP contract,,80,,8.2,percent of total billed charges,,,,,,,no IP contract,,50,,5.13,percent of total billed charges,,,,,,no IP contract,,,78,,8,percent of total billed charges,,,70,,7.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.02,3324,
59762-5033-01 - glipiZIDE 10 mg ER Ta,59762-5033-01,NDC,,,,inpatient,1,EA,10.25,6.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.71,percent of total billed charges,,,85,,8.71,percent of total billed charges,,,49,,5.02,percent of total billed charges,,,90,,9.23,percent of total billed charges,,,,,,,no IP contract,,80,,8.2,percent of total billed charges,,,,,,,no IP contract,,50,,5.13,percent of total billed charges,,,,,,no IP contract,,,78,,8,percent of total billed charges,,,70,,7.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.02,3324,
59762-7379-01 - ibuprofen 600 mg Tab,59762-7379-01,NDC,,,,inpatient,1,EA,6.15,3.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.23,percent of total billed charges,,,85,,5.23,percent of total billed charges,,,49,,3.01,percent of total billed charges,,,90,,5.54,percent of total billed charges,,,,,,,no IP contract,,80,,4.92,percent of total billed charges,,,,,,,no IP contract,,50,,3.08,percent of total billed charges,,,,,,no IP contract,,,78,,4.8,percent of total billed charges,,,70,,4.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.01,3324,
60219-1679-01 - fluPHENAZine 2.5 mg Tab,60219-1679-01,NDC,,,,inpatient,1,EA,57.9,34.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,46.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,49.22,percent of total billed charges,,,85,,49.22,percent of total billed charges,,,49,,28.37,percent of total billed charges,,,90,,52.11,percent of total billed charges,,,,,,,no IP contract,,80,,46.32,percent of total billed charges,,,,,,,no IP contract,,50,,28.95,percent of total billed charges,,,,,,no IP contract,,,78,,45.16,percent of total billed charges,,,70,,40.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,28.37,3324,
60219-1748-02 - atropine ophthalmic 1% Soln,60219-1748-02,NDC,,,,inpatient,1,UN,1005.9,603.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,814.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,855.02,percent of total billed charges,,,85,,855.02,percent of total billed charges,,,49,,492.89,percent of total billed charges,,,90,,905.31,percent of total billed charges,,,,,,,no IP contract,,80,,804.72,percent of total billed charges,,,,,,,no IP contract,,50,,502.95,percent of total billed charges,,,,,,no IP contract,,,78,,784.6,percent of total billed charges,,,70,,704.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,492.89,3324,
60219-1749-03 - atropine ophthalmic 1% Soln,60219-1749-03,NDC,,,,inpatient,1,UN,495.7,297.42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,401.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,421.35,percent of total billed charges,,,85,,421.35,percent of total billed charges,,,49,,242.89,percent of total billed charges,,,90,,446.13,percent of total billed charges,,,,,,,no IP contract,,80,,396.56,percent of total billed charges,,,,,,,no IP contract,,50,,247.85,percent of total billed charges,,,,,,no IP contract,,,78,,386.65,percent of total billed charges,,,70,,346.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,242.89,3324,
60219-2056-01 - dexamethasone 2 mg Tab,60219-2056-01,NDC,,,,inpatient,1,EA,8.5,5.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.23,percent of total billed charges,,,85,,7.23,percent of total billed charges,,,49,,4.17,percent of total billed charges,,,90,,7.65,percent of total billed charges,,,,,,,no IP contract,,80,,6.8,percent of total billed charges,,,,,,,no IP contract,,50,,4.25,percent of total billed charges,,,,,,no IP contract,,,78,,6.63,percent of total billed charges,,,70,,5.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.17,3324,
60219-2135-01 - mycophenolate mofetil 500 mg Tab,60219-2135-01,NDC,,,,inpatient,1,EA,66.85,40.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,54.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.82,percent of total billed charges,,,85,,56.82,percent of total billed charges,,,49,,32.76,percent of total billed charges,,,90,,60.17,percent of total billed charges,,,,,,,no IP contract,,80,,53.48,percent of total billed charges,,,,,,,no IP contract,,50,,33.43,percent of total billed charges,,,,,,no IP contract,,,78,,52.14,percent of total billed charges,,,70,,46.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.76,3324,
60258-0001-16 - citric acid-sodium citrate 334 mg-500 mg/5 mL Soln,60258-0001-16,NDC,,,,inpatient,1,ML,5.6,3.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.76,percent of total billed charges,,,85,,4.76,percent of total billed charges,,,49,,2.74,percent of total billed charges,,,90,,5.04,percent of total billed charges,,,,,,,no IP contract,,80,,4.48,percent of total billed charges,,,,,,,no IP contract,,50,,2.8,percent of total billed charges,,,,,,no IP contract,,,78,,4.37,percent of total billed charges,,,70,,3.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.74,3324,
60258-0003-16 - citric acid-potassium citrate 334 mg-1100 mg/5 mL LIQ,60258-0003-16,NDC,,,,inpatient,1,ML,5.75,3.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.89,percent of total billed charges,,,85,,4.89,percent of total billed charges,,,49,,2.82,percent of total billed charges,,,90,,5.18,percent of total billed charges,,,,,,,no IP contract,,80,,4.6,percent of total billed charges,,,,,,,no IP contract,,50,,2.88,percent of total billed charges,,,,,,no IP contract,,,78,,4.49,percent of total billed charges,,,70,,4.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.82,3324,
60258-0005-01 - citric acid-potassium citrate 30 mEq REC P,60258-0005-01,NDC,,,,inpatient,1,UN,10.65,6.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.05,percent of total billed charges,,,85,,9.05,percent of total billed charges,,,49,,5.22,percent of total billed charges,,,90,,9.59,percent of total billed charges,,,,,,,no IP contract,,80,,8.52,percent of total billed charges,,,,,,,no IP contract,,50,,5.33,percent of total billed charges,,,,,,no IP contract,,,78,,8.31,percent of total billed charges,,,70,,7.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.22,3324,
60258-0006-01 - potassium phosphate-sodium phosphate 250 mg-278 mg-164 mg REC P,60258-0006-01,NDC,,,,inpatient,1,UN,6.95,4.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.91,percent of total billed charges,,,85,,5.91,percent of total billed charges,,,49,,3.41,percent of total billed charges,,,90,,6.26,percent of total billed charges,,,,,,,no IP contract,,80,,5.56,percent of total billed charges,,,,,,,no IP contract,,50,,3.48,percent of total billed charges,,,,,,no IP contract,,,78,,5.42,percent of total billed charges,,,70,,4.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.41,3324,
60258-0161-01 - multivitamin Vitamin B Complex with C and Folic Acid Tab,60258-0161-01,NDC,,,,inpatient,1,EA,7.3,4.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.21,percent of total billed charges,,,85,,6.21,percent of total billed charges,,,49,,3.58,percent of total billed charges,,,90,,6.57,percent of total billed charges,,,,,,,no IP contract,,80,,5.84,percent of total billed charges,,,,,,,no IP contract,,50,,3.65,percent of total billed charges,,,,,,no IP contract,,,78,,5.69,percent of total billed charges,,,70,,5.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.58,3324,
60258-0162-01 - multivitamin Vitamin B Complex with C and Folic Acid Cap,60258-0162-01,NDC,,,,inpatient,1,EA,9.15,5.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.78,percent of total billed charges,,,85,,7.78,percent of total billed charges,,,49,,4.48,percent of total billed charges,,,90,,8.24,percent of total billed charges,,,,,,,no IP contract,,80,,7.32,percent of total billed charges,,,,,,,no IP contract,,50,,4.58,percent of total billed charges,,,,,,no IP contract,,,78,,7.14,percent of total billed charges,,,70,,6.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.48,3324,
60258-0171-01 - magnesium oxide 400 mg Tab,60258-0171-01,NDC,,,,inpatient,1,EA,5,3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.25,percent of total billed charges,,,85,,4.25,percent of total billed charges,,,49,,2.45,percent of total billed charges,,,90,,4.5,percent of total billed charges,,,,,,,no IP contract,,80,,4,percent of total billed charges,,,,,,,no IP contract,,50,,2.5,percent of total billed charges,,,,,,no IP contract,,,78,,3.9,percent of total billed charges,,,70,,3.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.45,3324,
60267-0705-50 - sodium thiosulfate 25% Soln,60267-0705-50,NDC,,,,inpatient,1,ML,73.85,44.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,59.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,62.77,percent of total billed charges,,,85,,62.77,percent of total billed charges,,,49,,36.19,percent of total billed charges,,,90,,66.47,percent of total billed charges,,,,,,,no IP contract,,80,,59.08,percent of total billed charges,,,,,,,no IP contract,,50,,36.93,percent of total billed charges,,,,,,no IP contract,,,78,,57.6,percent of total billed charges,,,70,,51.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.19,3324,
60432-0093-16 - amantadine 50 mg/5 mL Syrup,60432-0093-16,NDC,,,,inpatient,1,ML,6.65,3.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.65,percent of total billed charges,,,85,,5.65,percent of total billed charges,,,49,,3.26,percent of total billed charges,,,90,,5.99,percent of total billed charges,,,,,,,no IP contract,,80,,5.32,percent of total billed charges,,,,,,,no IP contract,,50,,3.33,percent of total billed charges,,,,,,no IP contract,,,78,,5.19,percent of total billed charges,,,70,,4.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.26,3324,
60432-0133-50 - clobetasol topical 0.05% Soln,60432-0133-50,NDC,,,,inpatient,1,UN,338.25,202.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,273.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,287.51,percent of total billed charges,,,85,,287.51,percent of total billed charges,,,49,,165.74,percent of total billed charges,,,90,,304.43,percent of total billed charges,,,,,,,no IP contract,,80,,270.6,percent of total billed charges,,,,,,,no IP contract,,50,,169.13,percent of total billed charges,,,,,,no IP contract,,,78,,263.84,percent of total billed charges,,,70,,236.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,165.74,3324,
60432-0150-04 - hydrOXYzine hydrochloride 10 mg/5 mL Syrup,60432-0150-04,NDC,,,,inpatient,1,ML,6.85,4.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.82,percent of total billed charges,,,85,,5.82,percent of total billed charges,,,49,,3.36,percent of total billed charges,,,90,,6.17,percent of total billed charges,,,,,,,no IP contract,,80,,5.48,percent of total billed charges,,,,,,,no IP contract,,50,,3.43,percent of total billed charges,,,,,,no IP contract,,,78,,5.34,percent of total billed charges,,,70,,4.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.36,3324,
60432-0150-16 - hydrOXYzine hydrochloride 10 mg/5 mL Syrup,60432-0150-16,NDC,,,,inpatient,1,ML,6.1,3.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.19,percent of total billed charges,,,85,,5.19,percent of total billed charges,,,49,,2.99,percent of total billed charges,,,90,,5.49,percent of total billed charges,,,,,,,no IP contract,,80,,4.88,percent of total billed charges,,,,,,,no IP contract,,50,,3.05,percent of total billed charges,,,,,,no IP contract,,,78,,4.76,percent of total billed charges,,,70,,4.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.99,3324,
60432-0608-16 - promethazine 6.25 mg/5 mL Syrup,60432-0608-16,NDC,,,,inpatient,5,ML,5.85,3.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.97,percent of total billed charges,,,85,,4.97,percent of total billed charges,,,49,,2.87,percent of total billed charges,,,90,,5.27,percent of total billed charges,,,,,,,no IP contract,,80,,4.68,percent of total billed charges,,,,,,,no IP contract,,50,,2.93,percent of total billed charges,,,,,,no IP contract,,,78,,4.56,percent of total billed charges,,,70,,4.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.87,3324,
60432-0613-60 - furosemide 10 mg/mL LIQ,60432-0613-60,NDC,,,,inpatient,1,ML,6.85,4.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.82,percent of total billed charges,,,85,,5.82,percent of total billed charges,,,49,,3.36,percent of total billed charges,,,90,,6.17,percent of total billed charges,,,,,,,no IP contract,,80,,5.48,percent of total billed charges,,,,,,,no IP contract,,50,,3.43,percent of total billed charges,,,,,,no IP contract,,,78,,5.34,percent of total billed charges,,,70,,4.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.36,3324,
60432-0621-16 - valproic acid 250 mg/5 mL Syrup,60432-0621-16,NDC,,,,inpatient,1,ML,6.65,3.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.65,percent of total billed charges,,,85,,5.65,percent of total billed charges,,,49,,3.26,percent of total billed charges,,,90,,5.99,percent of total billed charges,,,,,,,no IP contract,,80,,5.32,percent of total billed charges,,,,,,,no IP contract,,50,,3.33,percent of total billed charges,,,,,,no IP contract,,,78,,5.19,percent of total billed charges,,,70,,4.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.26,3324,
60505-0065-07 - omeprazole 20 mg DR Ca,60505-0065-07,NDC,,,,inpatient,1,EA,37,22.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.45,percent of total billed charges,,,85,,31.45,percent of total billed charges,,,49,,18.13,percent of total billed charges,,,90,,33.3,percent of total billed charges,,,,,,,no IP contract,,80,,29.6,percent of total billed charges,,,,,,,no IP contract,,50,,18.5,percent of total billed charges,,,,,,no IP contract,,,78,,28.86,percent of total billed charges,,,70,,25.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.13,3324,
doxazosin 1 mg Tab,60505-0093-00,NDC,,,,inpatient,1,EA,14.55,8.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.37,percent of total billed charges,,,85,,12.37,percent of total billed charges,,,49,,7.13,percent of total billed charges,,,90,,13.1,percent of total billed charges,,,,,,,no IP contract,,80,,11.64,percent of total billed charges,,,,,,,no IP contract,,50,,7.28,percent of total billed charges,,,,,,no IP contract,,,78,,11.35,percent of total billed charges,,,70,,10.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.13,3324,
60505-0096-00 - doxazosin 8 mg Tab,60505-0096-00,NDC,,,,inpatient,1,EA,12.15,7.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.33,percent of total billed charges,,,85,,10.33,percent of total billed charges,,,49,,5.95,percent of total billed charges,,,90,,10.94,percent of total billed charges,,,,,,,no IP contract,,80,,9.72,percent of total billed charges,,,,,,,no IP contract,,50,,6.08,percent of total billed charges,,,,,,no IP contract,,,78,,9.48,percent of total billed charges,,,70,,8.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.95,3324,
60505-0112-00 - gabapentin 100 mg Cap,60505-0112-00,NDC,,,,inpatient,1,EA,8.2,4.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.97,percent of total billed charges,,,85,,6.97,percent of total billed charges,,,49,,4.02,percent of total billed charges,,,90,,7.38,percent of total billed charges,,,,,,,no IP contract,,80,,6.56,percent of total billed charges,,,,,,,no IP contract,,50,,4.1,percent of total billed charges,,,,,,no IP contract,,,78,,6.4,percent of total billed charges,,,70,,5.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.02,3324,
60505-0113-00 - gabapentin 300 mg Cap,60505-0113-00,NDC,,,,inpatient,1,EA,14.55,8.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.37,percent of total billed charges,,,85,,12.37,percent of total billed charges,,,49,,7.13,percent of total billed charges,,,90,,13.1,percent of total billed charges,,,,,,,no IP contract,,80,,11.64,percent of total billed charges,,,,,,,no IP contract,,50,,7.28,percent of total billed charges,,,,,,no IP contract,,,78,,11.35,percent of total billed charges,,,70,,10.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.13,3324,
60505-0113-01 - gabapentin 300 mg Cap,60505-0113-01,NDC,,,,inpatient,1,EA,14.4,8.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.24,percent of total billed charges,,,85,,12.24,percent of total billed charges,,,49,,7.06,percent of total billed charges,,,90,,12.96,percent of total billed charges,,,,,,,no IP contract,,80,,11.52,percent of total billed charges,,,,,,,no IP contract,,50,,7.2,percent of total billed charges,,,,,,no IP contract,,,78,,11.23,percent of total billed charges,,,70,,10.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.06,3324,
60505-0114-00 - gabapentin 400 mg Cap,60505-0114-00,NDC,,,,inpatient,1,EA,16.7,10.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.2,percent of total billed charges,,,85,,14.2,percent of total billed charges,,,49,,8.18,percent of total billed charges,,,90,,15.03,percent of total billed charges,,,,,,,no IP contract,,80,,13.36,percent of total billed charges,,,,,,,no IP contract,,50,,8.35,percent of total billed charges,,,,,,no IP contract,,,78,,13.03,percent of total billed charges,,,70,,11.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.18,3324,
60505-0132-01 - carbidopa-levodopa 50 mg-200 mg ER Ta,60505-0132-01,NDC,,,,inpatient,1,EA,18.2,10.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.47,percent of total billed charges,,,85,,15.47,percent of total billed charges,,,49,,8.92,percent of total billed charges,,,90,,16.38,percent of total billed charges,,,,,,,no IP contract,,80,,14.56,percent of total billed charges,,,,,,,no IP contract,,50,,9.1,percent of total billed charges,,,,,,no IP contract,,,78,,14.2,percent of total billed charges,,,70,,12.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.92,3324,
60505-0141-00 - glipiZIDE 5 mg Tab,60505-0141-00,NDC,,,,inpatient,1,EA,6.7,4.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.7,percent of total billed charges,,,85,,5.7,percent of total billed charges,,,49,,3.28,percent of total billed charges,,,90,,6.03,percent of total billed charges,,,,,,,no IP contract,,80,,5.36,percent of total billed charges,,,,,,,no IP contract,,50,,3.35,percent of total billed charges,,,,,,no IP contract,,,78,,5.23,percent of total billed charges,,,70,,4.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.28,3324,
60505-0165-01 - fluvoxamine 50 mg Tab,60505-0165-01,NDC,,,,inpatient,1,EA,24.25,14.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.61,percent of total billed charges,,,85,,20.61,percent of total billed charges,,,49,,11.88,percent of total billed charges,,,90,,21.83,percent of total billed charges,,,,,,,no IP contract,,80,,19.4,percent of total billed charges,,,,,,,no IP contract,,50,,12.13,percent of total billed charges,,,,,,no IP contract,,,78,,18.92,percent of total billed charges,,,70,,16.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.88,3324,
60505-0168-09 - pravastatin 10 mg Tab,60505-0168-09,NDC,,,,inpatient,1,EA,29.35,17.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.95,percent of total billed charges,,,85,,24.95,percent of total billed charges,,,49,,14.38,percent of total billed charges,,,90,,26.42,percent of total billed charges,,,,,,,no IP contract,,80,,23.48,percent of total billed charges,,,,,,,no IP contract,,50,,14.68,percent of total billed charges,,,,,,no IP contract,,,78,,22.89,percent of total billed charges,,,70,,20.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.38,3324,
60505-0183-00 - carBAMazepine 200 mg Tab,60505-0183-00,NDC,,,,inpatient,1,EA,16.55,9.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.07,percent of total billed charges,,,85,,14.07,percent of total billed charges,,,49,,8.11,percent of total billed charges,,,90,,14.9,percent of total billed charges,,,,,,,no IP contract,,80,,13.24,percent of total billed charges,,,,,,,no IP contract,,50,,8.28,percent of total billed charges,,,,,,no IP contract,,,78,,12.91,percent of total billed charges,,,70,,11.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.11,3324,
60505-0235-01 - torsemide 100 mg Tab,60505-0235-01,NDC,,,,inpatient,1,EA,28,16.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.8,percent of total billed charges,,,85,,23.8,percent of total billed charges,,,49,,13.72,percent of total billed charges,,,90,,25.2,percent of total billed charges,,,,,,,no IP contract,,80,,22.4,percent of total billed charges,,,,,,,no IP contract,,50,,14,percent of total billed charges,,,,,,no IP contract,,,78,,21.84,percent of total billed charges,,,70,,19.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.72,3324,
60505-0257-01 - desmopressin 0.1 mg Tab,60505-0257-01,NDC,,,,inpatient,1,EA,27.85,16.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.67,percent of total billed charges,,,85,,23.67,percent of total billed charges,,,49,,13.65,percent of total billed charges,,,90,,25.07,percent of total billed charges,,,,,,,no IP contract,,80,,22.28,percent of total billed charges,,,,,,,no IP contract,,50,,13.93,percent of total billed charges,,,,,,no IP contract,,,78,,21.72,percent of total billed charges,,,70,,19.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.65,3324,
60505-0258-01 - desmopressin 0.2 mg Tab,60505-0258-01,NDC,,,,inpatient,1,EA,38.4,23.04,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.64,percent of total billed charges,,,85,,32.64,percent of total billed charges,,,49,,18.82,percent of total billed charges,,,90,,34.56,percent of total billed charges,,,,,,,no IP contract,,80,,30.72,percent of total billed charges,,,,,,,no IP contract,,50,,19.2,percent of total billed charges,,,,,,no IP contract,,,78,,29.95,percent of total billed charges,,,70,,26.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.82,3324,
60505-0402-05 - PARoxetine 10 mg/5 mL Susp,60505-0402-05,NDC,,,,inpatient,1,ML,14.9,8.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.67,percent of total billed charges,,,85,,12.67,percent of total billed charges,,,49,,7.3,percent of total billed charges,,,90,,13.41,percent of total billed charges,,,,,,,no IP contract,,80,,11.92,percent of total billed charges,,,,,,,no IP contract,,50,,7.45,percent of total billed charges,,,,,,no IP contract,,,78,,11.62,percent of total billed charges,,,70,,10.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.3,3324,
60505-0564-01 - brimonidine  0.15% Soln,60505-0564-01,NDC,,,,inpatient,1,UN,1606.1,963.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1300.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1365.19,percent of total billed charges,,,85,,1365.19,percent of total billed charges,,,49,,786.99,percent of total billed charges,,,90,,1445.49,percent of total billed charges,,,,,,,no IP contract,,80,,1284.88,percent of total billed charges,,,,,,,no IP contract,,50,,803.05,percent of total billed charges,,,,,,no IP contract,,,78,,1252.76,percent of total billed charges,,,70,,1124.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,786.99,3324,
60505-0575-01 - olopatadine ophthalmic 0.1% Soln,60505-0575-01,NDC,,,,inpatient,1,UN,2145.85,1287.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1738.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1823.97,percent of total billed charges,,,85,,1823.97,percent of total billed charges,,,49,,1051.47,percent of total billed charges,,,90,,1931.27,percent of total billed charges,,,,,,,no IP contract,,80,,1716.68,percent of total billed charges,,,,,,,no IP contract,,50,,1072.93,percent of total billed charges,,,,,,no IP contract,,,78,,1673.76,percent of total billed charges,,,70,,1502.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
60505-0589-01 - brimonidine-timolol ophthalmic 0.2%-0.5% Soln,60505-0589-01,NDC,,,,inpatient,1,UN,1855.55,1113.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1503,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1577.22,percent of total billed charges,,,85,,1577.22,percent of total billed charges,,,49,,909.22,percent of total billed charges,,,90,,1670,percent of total billed charges,,,,,,,no IP contract,,80,,1484.44,percent of total billed charges,,,,,,,no IP contract,,50,,927.78,percent of total billed charges,,,,,,no IP contract,,,78,,1447.33,percent of total billed charges,,,70,,1298.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,909.22,3324,
60505-0681-04 - cefepime 2 g REC I,60505-0681-04,NDC,,,,inpatient,1,EA,411.3,246.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,333.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,349.61,percent of total billed charges,,,85,,349.61,percent of total billed charges,,,49,,201.54,percent of total billed charges,,,90,,370.17,percent of total billed charges,,,,,,,no IP contract,,80,,329.04,percent of total billed charges,,,,,,,no IP contract,,50,,205.65,percent of total billed charges,,,,,,no IP contract,,,78,,320.81,percent of total billed charges,,,70,,287.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,201.54,3324,
60505-0686-04 - piperacillin-tazobactam 2 g-0.25 g REC I,60505-0686-04,NDC,,,,inpatient,1,EA,105.85,63.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,85.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,89.97,percent of total billed charges,,,85,,89.97,percent of total billed charges,,,49,,51.87,percent of total billed charges,,,90,,95.27,percent of total billed charges,,,,,,,no IP contract,,80,,84.68,percent of total billed charges,,,,,,,no IP contract,,50,,52.93,percent of total billed charges,,,,,,no IP contract,,,78,,82.56,percent of total billed charges,,,70,,74.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,51.87,3324,
60505-0687-04 - piperacillin-tazobactam 3 g-0.375 g REC I,60505-0687-04,NDC,,,,inpatient,1,EA,190.3,114.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,154.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,161.76,percent of total billed charges,,,85,,161.76,percent of total billed charges,,,49,,93.25,percent of total billed charges,,,90,,171.27,percent of total billed charges,,,,,,,no IP contract,,80,,152.24,percent of total billed charges,,,,,,,no IP contract,,50,,95.15,percent of total billed charges,,,,,,no IP contract,,,78,,148.43,percent of total billed charges,,,70,,133.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,93.25,3324,
60505-0688-04 - piperacillin-tazobactam 4 g-0.5 g REC I,60505-0688-04,NDC,,,,inpatient,1,EA,256.3,153.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,207.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,217.86,percent of total billed charges,,,85,,217.86,percent of total billed charges,,,49,,125.59,percent of total billed charges,,,90,,230.67,percent of total billed charges,,,,,,,no IP contract,,80,,205.04,percent of total billed charges,,,,,,,no IP contract,,50,,128.15,percent of total billed charges,,,,,,no IP contract,,,78,,199.91,percent of total billed charges,,,70,,179.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,125.59,3324,
60505-0796-00 - enoxaparin 120 mg/0.8 mL Soln,60505-0796-00,NDC,,,,inpatient,0.8,ML,236.95,142.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,191.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,201.41,percent of total billed charges,,,85,,201.41,percent of total billed charges,,,49,,116.11,percent of total billed charges,,,90,,213.26,percent of total billed charges,,,,,,,no IP contract,,80,,189.56,percent of total billed charges,,,,,,,no IP contract,,50,,118.48,percent of total billed charges,,,,,,no IP contract,,,78,,184.82,percent of total billed charges,,,70,,165.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,116.11,3324,
60505-0823-06 - calcitonin 200 intl units/inh Spray,60505-0823-06,NDC,,,,inpatient,1,UN,996.75,598.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,807.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,847.24,percent of total billed charges,,,85,,847.24,percent of total billed charges,,,49,,488.41,percent of total billed charges,,,90,,897.08,percent of total billed charges,,,,,,,no IP contract,,80,,797.4,percent of total billed charges,,,,,,,no IP contract,,50,,498.38,percent of total billed charges,,,,,,no IP contract,,,78,,777.47,percent of total billed charges,,,70,,697.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,488.41,3324,
60505-0829-01 - fluticasone nasal 0.05 mg/inh Spray,60505-0829-01,NDC,,,,inpatient,1,UN,719.6,431.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,582.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,611.66,percent of total billed charges,,,85,,611.66,percent of total billed charges,,,49,,352.6,percent of total billed charges,,,90,,647.64,percent of total billed charges,,,,,,,no IP contract,,80,,575.68,percent of total billed charges,,,,,,,no IP contract,,50,,359.8,percent of total billed charges,,,,,,no IP contract,,,78,,561.29,percent of total billed charges,,,70,,503.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,352.6,3324,
60505-0833-05 - azelastine nasal 137 mcg/inh Spray,60505-0833-05,NDC,,,,inpatient,1,UN,886.35,531.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,717.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,753.4,percent of total billed charges,,,85,,753.4,percent of total billed charges,,,49,,434.31,percent of total billed charges,,,90,,797.72,percent of total billed charges,,,,,,,no IP contract,,80,,709.08,percent of total billed charges,,,,,,,no IP contract,,50,,443.18,percent of total billed charges,,,,,,no IP contract,,,78,,691.35,percent of total billed charges,,,70,,620.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,434.31,3324,
60505-1003-01 - ketorolac ophthalmic 0.5% Soln,60505-1003-01,NDC,,,,inpatient,1,UN,899.3,539.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,728.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,764.41,percent of total billed charges,,,85,,764.41,percent of total billed charges,,,49,,440.66,percent of total billed charges,,,90,,809.37,percent of total billed charges,,,,,,,no IP contract,,80,,719.44,percent of total billed charges,,,,,,,no IP contract,,50,,449.65,percent of total billed charges,,,,,,no IP contract,,,78,,701.45,percent of total billed charges,,,70,,629.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,440.66,3324,
60505-1317-03 - PARoxetine 25 mg ER Ta,60505-1317-03,NDC,,,,inpatient,1,EA,50.1,30.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,40.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,42.59,percent of total billed charges,,,85,,42.59,percent of total billed charges,,,49,,24.55,percent of total billed charges,,,90,,45.09,percent of total billed charges,,,,,,,no IP contract,,80,,40.08,percent of total billed charges,,,,,,,no IP contract,,50,,25.05,percent of total billed charges,,,,,,no IP contract,,,78,,39.08,percent of total billed charges,,,70,,35.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.55,3324,
60505-1321-01 - midodrine 5 mg Tab,60505-1321-01,NDC,,,,inpatient,1,EA,23.15,13.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.68,percent of total billed charges,,,85,,19.68,percent of total billed charges,,,49,,11.34,percent of total billed charges,,,90,,20.84,percent of total billed charges,,,,,,,no IP contract,,80,,18.52,percent of total billed charges,,,,,,,no IP contract,,50,,11.58,percent of total billed charges,,,,,,no IP contract,,,78,,18.06,percent of total billed charges,,,70,,16.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.34,3324,
60505-1325-01 - midodrine 10 mg Tab,60505-1325-01,NDC,,,,inpatient,1,EA,42.45,25.47,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36.08,percent of total billed charges,,,85,,36.08,percent of total billed charges,,,49,,20.8,percent of total billed charges,,,90,,38.21,percent of total billed charges,,,,,,,no IP contract,,80,,33.96,percent of total billed charges,,,,,,,no IP contract,,50,,21.23,percent of total billed charges,,,,,,no IP contract,,,78,,33.11,percent of total billed charges,,,70,,29.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.8,3324,
60505-2502-01 - leflunomide 10 mg Tab,60505-2502-01,NDC,,,,inpatient,1,EA,134.3,80.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,108.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,114.16,percent of total billed charges,,,85,,114.16,percent of total billed charges,,,49,,65.81,percent of total billed charges,,,90,,120.87,percent of total billed charges,,,,,,,no IP contract,,80,,107.44,percent of total billed charges,,,,,,,no IP contract,,50,,67.15,percent of total billed charges,,,,,,no IP contract,,,78,,104.75,percent of total billed charges,,,70,,94.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,65.81,3324,
60505-2526-03 - modafinil 100 mg Tab,60505-2526-03,NDC,,,,inpatient,1,EA,225.15,135.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,182.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,191.38,percent of total billed charges,,,85,,191.38,percent of total billed charges,,,49,,110.32,percent of total billed charges,,,90,,202.64,percent of total billed charges,,,,,,,no IP contract,,80,,180.12,percent of total billed charges,,,,,,,no IP contract,,50,,112.58,percent of total billed charges,,,,,,no IP contract,,,78,,175.62,percent of total billed charges,,,70,,157.61,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,110.32,3324,
60505-2528-06 - ziprasidone 20 mg Cap,60505-2528-06,NDC,,,,inpatient,1,EA,75.05,45.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63.79,percent of total billed charges,,,85,,63.79,percent of total billed charges,,,49,,36.77,percent of total billed charges,,,90,,67.55,percent of total billed charges,,,,,,,no IP contract,,80,,60.04,percent of total billed charges,,,,,,,no IP contract,,50,,37.53,percent of total billed charges,,,,,,no IP contract,,,78,,58.54,percent of total billed charges,,,70,,52.54,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.77,3324,
60505-2575-07 - balsalazide 750 mg Cap,60505-2575-07,NDC,,,,inpatient,1,EA,16.55,9.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.07,percent of total billed charges,,,85,,14.07,percent of total billed charges,,,49,,8.11,percent of total billed charges,,,90,,14.9,percent of total billed charges,,,,,,,no IP contract,,80,,13.24,percent of total billed charges,,,,,,,no IP contract,,50,,8.28,percent of total billed charges,,,,,,no IP contract,,,78,,12.91,percent of total billed charges,,,70,,11.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.11,3324,
60505-2578-09 - atorvastatin 10 mg Tab,60505-2578-09,NDC,,,,inpatient,1,EA,36,21.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.6,percent of total billed charges,,,85,,30.6,percent of total billed charges,,,49,,17.64,percent of total billed charges,,,90,,32.4,percent of total billed charges,,,,,,,no IP contract,,80,,28.8,percent of total billed charges,,,,,,,no IP contract,,50,,18,percent of total billed charges,,,,,,no IP contract,,,78,,28.08,percent of total billed charges,,,70,,25.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.64,3324,
60505-2580-09 - atorvastatin 40 mg Tab,60505-2580-09,NDC,,,,inpatient,1,EA,49.7,29.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,40.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,42.25,percent of total billed charges,,,85,,42.25,percent of total billed charges,,,49,,24.35,percent of total billed charges,,,90,,44.73,percent of total billed charges,,,,,,,no IP contract,,80,,39.76,percent of total billed charges,,,,,,,no IP contract,,50,,24.85,percent of total billed charges,,,,,,no IP contract,,,78,,38.77,percent of total billed charges,,,70,,34.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.35,3324,
60505-2654-01 - traZODone 100 mg Tab,60505-2654-01,NDC,,,,inpatient,1,EA,9.65,5.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.2,percent of total billed charges,,,85,,8.2,percent of total billed charges,,,49,,4.73,percent of total billed charges,,,90,,8.69,percent of total billed charges,,,,,,,no IP contract,,80,,7.72,percent of total billed charges,,,,,,,no IP contract,,50,,4.83,percent of total billed charges,,,,,,no IP contract,,,78,,7.53,percent of total billed charges,,,70,,6.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.73,3324,
60505-2671-09 - atorvastatin 80 mg Tab,60505-2671-09,NDC,,,,inpatient,1,EA,49.7,29.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,40.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,42.25,percent of total billed charges,,,85,,42.25,percent of total billed charges,,,49,,24.35,percent of total billed charges,,,90,,44.73,percent of total billed charges,,,,,,,no IP contract,,80,,39.76,percent of total billed charges,,,,,,,no IP contract,,50,,24.85,percent of total billed charges,,,,,,no IP contract,,,78,,38.77,percent of total billed charges,,,70,,34.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.35,3324,
60505-2673-03 - aripiprazole 5 mg Tab,60505-2673-03,NDC,,,,inpatient,1,EA,259.1,155.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,209.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,220.24,percent of total billed charges,,,85,,220.24,percent of total billed charges,,,49,,126.96,percent of total billed charges,,,90,,233.19,percent of total billed charges,,,,,,,no IP contract,,80,,207.28,percent of total billed charges,,,,,,,no IP contract,,50,,129.55,percent of total billed charges,,,,,,no IP contract,,,78,,202.1,percent of total billed charges,,,70,,181.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,126.96,3324,
60505-2805-07 - carBAMazepine 100 mg ER Ca,60505-2805-07,NDC,,,,inpatient,1,EA,19,11.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.15,percent of total billed charges,,,85,,16.15,percent of total billed charges,,,49,,9.31,percent of total billed charges,,,90,,17.1,percent of total billed charges,,,,,,,no IP contract,,80,,15.2,percent of total billed charges,,,,,,,no IP contract,,50,,9.5,percent of total billed charges,,,,,,no IP contract,,,78,,14.82,percent of total billed charges,,,70,,13.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.31,3324,
60505-2807-07 - carBAMazepine 300 mg ER Ca,60505-2807-07,NDC,,,,inpatient,1,EA,19,11.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.15,percent of total billed charges,,,85,,16.15,percent of total billed charges,,,49,,9.31,percent of total billed charges,,,90,,17.1,percent of total billed charges,,,,,,,no IP contract,,80,,15.2,percent of total billed charges,,,,,,,no IP contract,,50,,9.5,percent of total billed charges,,,,,,no IP contract,,,78,,14.82,percent of total billed charges,,,70,,13.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.31,3324,
60505-2966-07 - mycophenolic acid 360 mg EC Ta,60505-2966-07,NDC,,,,inpatient,1,EA,76.5,45.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,61.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,65.03,percent of total billed charges,,,85,,65.03,percent of total billed charges,,,49,,37.49,percent of total billed charges,,,90,,68.85,percent of total billed charges,,,,,,,no IP contract,,80,,61.2,percent of total billed charges,,,,,,,no IP contract,,50,,38.25,percent of total billed charges,,,,,,no IP contract,,,78,,59.67,percent of total billed charges,,,70,,53.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,37.49,3324,
60505-3110-00 - OLANZapine 2.5 mg Tab,60505-3110-00,NDC,,,,inpatient,1,EA,92.85,55.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,75.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,78.92,percent of total billed charges,,,85,,78.92,percent of total billed charges,,,49,,45.5,percent of total billed charges,,,90,,83.57,percent of total billed charges,,,,,,,no IP contract,,80,,74.28,percent of total billed charges,,,,,,,no IP contract,,50,,46.43,percent of total billed charges,,,,,,no IP contract,,,78,,72.42,percent of total billed charges,,,70,,65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,45.5,3324,
60505-3111-00 - OLANZapine 5 mg Tab,60505-3111-00,NDC,,,,inpatient,1,EA,108.9,65.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,88.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,92.57,percent of total billed charges,,,85,,92.57,percent of total billed charges,,,49,,53.36,percent of total billed charges,,,90,,98.01,percent of total billed charges,,,,,,,no IP contract,,80,,87.12,percent of total billed charges,,,,,,,no IP contract,,50,,54.45,percent of total billed charges,,,,,,no IP contract,,,78,,84.94,percent of total billed charges,,,70,,76.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,53.36,3324,
60505-3113-00 - OLANZapine 10 mg Tab,60505-3113-00,NDC,,,,inpatient,1,EA,162.2,97.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,131.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,137.87,percent of total billed charges,,,85,,137.87,percent of total billed charges,,,49,,79.48,percent of total billed charges,,,90,,145.98,percent of total billed charges,,,,,,,no IP contract,,80,,129.76,percent of total billed charges,,,,,,,no IP contract,,50,,81.1,percent of total billed charges,,,,,,no IP contract,,,78,,126.52,percent of total billed charges,,,70,,113.54,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,79.48,3324,
60505-3250-06 - lamiVUDine 100 mg Tab,60505-3250-06,NDC,,,,inpatient,1,EA,131.9,79.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,106.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,112.12,percent of total billed charges,,,85,,112.12,percent of total billed charges,,,49,,64.63,percent of total billed charges,,,90,,118.71,percent of total billed charges,,,,,,,no IP contract,,80,,105.52,percent of total billed charges,,,,,,,no IP contract,,50,,65.95,percent of total billed charges,,,,,,no IP contract,,,78,,102.88,percent of total billed charges,,,70,,92.33,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,64.63,3324,
60505-3275-00 - OLANZapine 5 mg DIS T,60505-3275-00,NDC,,,,inpatient,1,EA,117.25,70.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,94.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,99.66,percent of total billed charges,,,85,,99.66,percent of total billed charges,,,49,,57.45,percent of total billed charges,,,90,,105.53,percent of total billed charges,,,,,,,no IP contract,,80,,93.8,percent of total billed charges,,,,,,,no IP contract,,50,,58.63,percent of total billed charges,,,,,,no IP contract,,,78,,91.46,percent of total billed charges,,,70,,82.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,57.45,3324,
60505-3275-03 - OLANZapine 5 mg DIS T,60505-3275-03,NDC,,,,inpatient,1,EA,117.25,70.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,94.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,99.66,percent of total billed charges,,,85,,99.66,percent of total billed charges,,,49,,57.45,percent of total billed charges,,,90,,105.53,percent of total billed charges,,,,,,,no IP contract,,80,,93.8,percent of total billed charges,,,,,,,no IP contract,,50,,58.63,percent of total billed charges,,,,,,no IP contract,,,78,,91.46,percent of total billed charges,,,70,,82.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,57.45,3324,
60505-3614-05 - varenicline 1 mg Tab,60505-3614-05,NDC,,,,inpatient,1,EA,77.6,46.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,62.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,65.96,percent of total billed charges,,,85,,65.96,percent of total billed charges,,,49,,38.02,percent of total billed charges,,,90,,69.84,percent of total billed charges,,,,,,,no IP contract,,80,,62.08,percent of total billed charges,,,,,,,no IP contract,,50,,38.8,percent of total billed charges,,,,,,no IP contract,,,78,,60.53,percent of total billed charges,,,70,,54.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,38.02,3324,
60505-3673-03 - PARoxetine 12.5 mg ER Ta,60505-3673-03,NDC,,,,inpatient,1,EA,48.2,28.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,39.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,40.97,percent of total billed charges,,,85,,40.97,percent of total billed charges,,,49,,23.62,percent of total billed charges,,,90,,43.38,percent of total billed charges,,,,,,,no IP contract,,80,,38.56,percent of total billed charges,,,,,,,no IP contract,,50,,24.1,percent of total billed charges,,,,,,no IP contract,,,78,,37.6,percent of total billed charges,,,70,,33.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.62,3324,
60505-3674-03 - PARoxetine 25 mg ER Ta,60505-3674-03,NDC,,,,inpatient,1,EA,50.1,30.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,40.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,42.59,percent of total billed charges,,,85,,42.59,percent of total billed charges,,,49,,24.55,percent of total billed charges,,,90,,45.09,percent of total billed charges,,,,,,,no IP contract,,80,,40.08,percent of total billed charges,,,,,,,no IP contract,,50,,25.05,percent of total billed charges,,,,,,no IP contract,,,78,,39.08,percent of total billed charges,,,70,,35.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.55,3324,
60505-4630-03 - cycloSPORINE modified 25 mg Cap,60505-4630-03,NDC,,,,inpatient,1,EA,14.8,8.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.58,percent of total billed charges,,,85,,12.58,percent of total billed charges,,,49,,7.25,percent of total billed charges,,,90,,13.32,percent of total billed charges,,,,,,,no IP contract,,80,,11.84,percent of total billed charges,,,,,,,no IP contract,,50,,7.4,percent of total billed charges,,,,,,no IP contract,,,78,,11.54,percent of total billed charges,,,70,,10.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.25,3324,
60505-4632-03 - cycloSPORINE modified 100 mg Cap,60505-4632-03,NDC,,,,inpatient,1,EA,47.55,28.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,38.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,40.42,percent of total billed charges,,,85,,40.42,percent of total billed charges,,,49,,23.3,percent of total billed charges,,,90,,42.8,percent of total billed charges,,,,,,,no IP contract,,80,,38.04,percent of total billed charges,,,,,,,no IP contract,,50,,23.78,percent of total billed charges,,,,,,no IP contract,,,78,,37.09,percent of total billed charges,,,70,,33.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.3,3324,
60505-4702-03 - solifenacin 5 mg Tab,60505-4702-03,NDC,,,,inpatient,1,EA,114.15,68.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,92.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,97.03,percent of total billed charges,,,85,,97.03,percent of total billed charges,,,49,,55.93,percent of total billed charges,,,90,,102.74,percent of total billed charges,,,,,,,no IP contract,,80,,91.32,percent of total billed charges,,,,,,,no IP contract,,50,,57.08,percent of total billed charges,,,,,,no IP contract,,,78,,89.04,percent of total billed charges,,,70,,79.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,55.93,3324,
60505-4766-06 - varenicline 1 mg Tab,60505-4766-06,NDC,,,,inpatient,1,EA,77.6,46.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,62.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,65.96,percent of total billed charges,,,85,,65.96,percent of total billed charges,,,49,,38.02,percent of total billed charges,,,90,,69.84,percent of total billed charges,,,,,,,no IP contract,,80,,62.08,percent of total billed charges,,,,,,,no IP contract,,50,,38.8,percent of total billed charges,,,,,,no IP contract,,,78,,60.53,percent of total billed charges,,,70,,54.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,38.02,3324,
60505-6030-04 - cefepime 1 g REC I,60505-6030-04,NDC,,,,inpatient,1,EA,180.7,108.42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,146.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,153.6,percent of total billed charges,,,85,,153.6,percent of total billed charges,,,49,,88.54,percent of total billed charges,,,90,,162.63,percent of total billed charges,,,,,,,no IP contract,,80,,144.56,percent of total billed charges,,,,,,,no IP contract,,50,,90.35,percent of total billed charges,,,,,,no IP contract,,,78,,140.95,percent of total billed charges,,,70,,126.49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,88.54,3324,
60505-6144-00 - cefepime 1 g REC I,60505-6144-00,NDC,,,,inpatient,1,EA,180.7,108.42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,146.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,153.6,percent of total billed charges,,,85,,153.6,percent of total billed charges,,,49,,88.54,percent of total billed charges,,,90,,162.63,percent of total billed charges,,,,,,,no IP contract,,80,,144.56,percent of total billed charges,,,,,,,no IP contract,,50,,90.35,percent of total billed charges,,,,,,no IP contract,,,78,,140.95,percent of total billed charges,,,70,,126.49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,88.54,3324,
60505-6145-00 - cefepime 2 g REC I,60505-6145-00,NDC,,,,inpatient,1,EA,411.3,246.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,333.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,349.61,percent of total billed charges,,,85,,349.61,percent of total billed charges,,,49,,201.54,percent of total billed charges,,,90,,370.17,percent of total billed charges,,,,,,,no IP contract,,80,,329.04,percent of total billed charges,,,,,,,no IP contract,,50,,205.65,percent of total billed charges,,,,,,no IP contract,,,78,,320.81,percent of total billed charges,,,70,,287.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,201.54,3324,
60505-6147-00 - cefePIME 2 gm REC Injection,60505-6147-00,NDC,,,,inpatient,1,EA,108.8,65.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,88.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,92.48,percent of total billed charges,,,85,,92.48,percent of total billed charges,,,49,,53.31,percent of total billed charges,,,90,,97.92,percent of total billed charges,,,,,,,no IP contract,,80,,87.04,percent of total billed charges,,,,,,,no IP contract,,50,,54.4,percent of total billed charges,,,,,,no IP contract,,,78,,84.86,percent of total billed charges,,,70,,76.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,53.31,3324,
60505-6231-00 - ceFAZolin 2 g REC I,60505-6231-00,NDC,,,,inpatient,1,EA,96.3,57.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,81.86,percent of total billed charges,,,85,,81.86,percent of total billed charges,,,49,,47.19,percent of total billed charges,,,90,,86.67,percent of total billed charges,,,,,,,no IP contract,,80,,77.04,percent of total billed charges,,,,,,,no IP contract,,50,,48.15,percent of total billed charges,,,,,,no IP contract,,,78,,75.11,percent of total billed charges,,,70,,67.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,47.19,3324,
60505-7006-02 - fentaNYL 25 mcg/hr ER Fi,60505-7006-02,NDC,,,,inpatient,1,UN,182.6,109.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,147.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,155.21,percent of total billed charges,,,85,,155.21,percent of total billed charges,,,49,,89.47,percent of total billed charges,,,90,,164.34,percent of total billed charges,,,,,,,no IP contract,,80,,146.08,percent of total billed charges,,,,,,,no IP contract,,50,,91.3,percent of total billed charges,,,,,,no IP contract,,,78,,142.43,percent of total billed charges,,,70,,127.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,89.47,3324,
60505-7007-02 - fentaNYL 50 mcg/hr ER Fi,60505-7007-02,NDC,,,,inpatient,1,UN,329.3,197.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,266.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,279.91,percent of total billed charges,,,85,,279.91,percent of total billed charges,,,49,,161.36,percent of total billed charges,,,90,,296.37,percent of total billed charges,,,,,,,no IP contract,,80,,263.44,percent of total billed charges,,,,,,,no IP contract,,50,,164.65,percent of total billed charges,,,,,,no IP contract,,,78,,256.85,percent of total billed charges,,,70,,230.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,161.36,3324,
60505-7008-02 - fentaNYL 75 mcg/hr ER Fi,60505-7008-02,NDC,,,,inpatient,1,UN,499.5,299.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,404.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,424.58,percent of total billed charges,,,85,,424.58,percent of total billed charges,,,49,,244.76,percent of total billed charges,,,90,,449.55,percent of total billed charges,,,,,,,no IP contract,,80,,399.6,percent of total billed charges,,,,,,,no IP contract,,50,,249.75,percent of total billed charges,,,,,,no IP contract,,,78,,389.61,percent of total billed charges,,,70,,349.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,244.76,3324,
60598-0003-01 - niacin 1000 mg ER Ta,60598-0003-01,NDC,,,,inpatient,1,EA,35.7,21.42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.35,percent of total billed charges,,,85,,30.35,percent of total billed charges,,,49,,17.49,percent of total billed charges,,,90,,32.13,percent of total billed charges,,,,,,,no IP contract,,80,,28.56,percent of total billed charges,,,,,,,no IP contract,,50,,17.85,percent of total billed charges,,,,,,no IP contract,,,78,,27.85,percent of total billed charges,,,70,,24.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.49,3324,
60687-0112-21 - anastrozole 1 mg Tab,60687-0112-21,NDC,,,,inpatient,1,EA,20.3,12.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.26,percent of total billed charges,,,85,,17.26,percent of total billed charges,,,49,,9.95,percent of total billed charges,,,90,,18.27,percent of total billed charges,,,,,,,no IP contract,,80,,16.24,percent of total billed charges,,,,,,,no IP contract,,50,,10.15,percent of total billed charges,,,,,,no IP contract,,,78,,15.83,percent of total billed charges,,,70,,14.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.95,3324,
60687-0113-01 - cloNIDine 0.1 mg Tab,60687-0113-01,NDC,,,,inpatient,1,EA,6.35,3.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.4,percent of total billed charges,,,85,,5.4,percent of total billed charges,,,49,,3.11,percent of total billed charges,,,90,,5.72,percent of total billed charges,,,,,,,no IP contract,,80,,5.08,percent of total billed charges,,,,,,,no IP contract,,50,,3.18,percent of total billed charges,,,,,,no IP contract,,,78,,4.95,percent of total billed charges,,,70,,4.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.11,3324,
60687-0114-01 - labetalol 100 mg Tab,60687-0114-01,NDC,,,,inpatient,1,EA,8.2,4.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.97,percent of total billed charges,,,85,,6.97,percent of total billed charges,,,49,,4.02,percent of total billed charges,,,90,,7.38,percent of total billed charges,,,,,,,no IP contract,,80,,6.56,percent of total billed charges,,,,,,,no IP contract,,50,,4.1,percent of total billed charges,,,,,,no IP contract,,,78,,6.4,percent of total billed charges,,,70,,5.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.02,3324,
60687-0118-21 - doxycycline hyclate 100 mg Cap,60687-0118-21,NDC,,,,inpatient,1,EA,22.05,13.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.74,percent of total billed charges,,,85,,18.74,percent of total billed charges,,,49,,10.8,percent of total billed charges,,,90,,19.85,percent of total billed charges,,,,,,,no IP contract,,80,,17.64,percent of total billed charges,,,,,,,no IP contract,,50,,11.03,percent of total billed charges,,,,,,no IP contract,,,78,,17.2,percent of total billed charges,,,70,,15.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.8,3324,
60687-0119-25 - candesartan 8 mg Tab,60687-0119-25,NDC,,,,inpatient,1,EA,41.6,24.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,35.36,percent of total billed charges,,,85,,35.36,percent of total billed charges,,,49,,20.38,percent of total billed charges,,,90,,37.44,percent of total billed charges,,,,,,,no IP contract,,80,,33.28,percent of total billed charges,,,,,,,no IP contract,,50,,20.8,percent of total billed charges,,,,,,no IP contract,,,78,,32.45,percent of total billed charges,,,70,,29.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.38,3324,
60687-0122-01 - predniSONE 5 mg Tab,60687-0122-01,NDC,,,,inpatient,1,EA,5.5,3.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.68,percent of total billed charges,,,85,,4.68,percent of total billed charges,,,49,,2.7,percent of total billed charges,,,90,,4.95,percent of total billed charges,,,,,,,no IP contract,,80,,4.4,percent of total billed charges,,,,,,,no IP contract,,50,,2.75,percent of total billed charges,,,,,,no IP contract,,,78,,4.29,percent of total billed charges,,,70,,3.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.7,3324,
cloNIDine 0.2 mg Tab,60687-0124-01,NDC,,,,inpatient,1,EA,6.75,4.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.74,percent of total billed charges,,,85,,5.74,percent of total billed charges,,,49,,3.31,percent of total billed charges,,,90,,6.08,percent of total billed charges,,,,,,,no IP contract,,80,,5.4,percent of total billed charges,,,,,,,no IP contract,,50,,3.38,percent of total billed charges,,,,,,no IP contract,,,78,,5.27,percent of total billed charges,,,70,,4.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.31,3324,
60687-0127-65 - omega-3 polyunsaturated fatty acids ethyl esters 1000 mg Cap,60687-0127-65,NDC,,,,inpatient,1,EA,32.85,19.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,26.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,27.92,percent of total billed charges,,,85,,27.92,percent of total billed charges,,,49,,16.1,percent of total billed charges,,,90,,29.57,percent of total billed charges,,,,,,,no IP contract,,80,,26.28,percent of total billed charges,,,,,,,no IP contract,,50,,16.43,percent of total billed charges,,,,,,no IP contract,,,78,,25.62,percent of total billed charges,,,70,,23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.1,3324,
60687-0128-01 - valsartan 80 mg Tab,60687-0128-01,NDC,,,,inpatient,1,EA,10.5,6.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.93,percent of total billed charges,,,85,,8.93,percent of total billed charges,,,49,,5.15,percent of total billed charges,,,90,,9.45,percent of total billed charges,,,,,,,no IP contract,,80,,8.4,percent of total billed charges,,,,,,,no IP contract,,50,,5.25,percent of total billed charges,,,,,,no IP contract,,,78,,8.19,percent of total billed charges,,,70,,7.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.15,3324,
60687-0129-01 - docusate sodium 100 mg Cap,60687-0129-01,NDC,,,,inpatient,1,EA,4.95,2.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.21,percent of total billed charges,,,85,,4.21,percent of total billed charges,,,49,,2.43,percent of total billed charges,,,90,,4.46,percent of total billed charges,,,,,,,no IP contract,,80,,3.96,percent of total billed charges,,,,,,,no IP contract,,50,,2.48,percent of total billed charges,,,,,,no IP contract,,,78,,3.86,percent of total billed charges,,,70,,3.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.43,3324,
60687-0134-01 - predniSONE 10 mg Tab,60687-0134-01,NDC,,,,inpatient,1,EA,5.5,3.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.68,percent of total billed charges,,,85,,4.68,percent of total billed charges,,,49,,2.7,percent of total billed charges,,,90,,4.95,percent of total billed charges,,,,,,,no IP contract,,80,,4.4,percent of total billed charges,,,,,,,no IP contract,,50,,2.75,percent of total billed charges,,,,,,no IP contract,,,78,,4.29,percent of total billed charges,,,70,,3.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.7,3324,
60687-0136-01 - labetalol 300 mg Tab,60687-0136-01,NDC,,,,inpatient,1,EA,9.45,5.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.03,percent of total billed charges,,,85,,8.03,percent of total billed charges,,,49,,4.63,percent of total billed charges,,,90,,8.51,percent of total billed charges,,,,,,,no IP contract,,80,,7.56,percent of total billed charges,,,,,,,no IP contract,,50,,4.73,percent of total billed charges,,,,,,no IP contract,,,78,,7.37,percent of total billed charges,,,70,,6.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.63,3324,
60687-0139-01 - valsartan 160 mg Tab,60687-0139-01,NDC,,,,inpatient,1,EA,43.55,26.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,35.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,37.02,percent of total billed charges,,,85,,37.02,percent of total billed charges,,,49,,21.34,percent of total billed charges,,,90,,39.2,percent of total billed charges,,,,,,,no IP contract,,80,,34.84,percent of total billed charges,,,,,,,no IP contract,,50,,21.78,percent of total billed charges,,,,,,no IP contract,,,78,,33.97,percent of total billed charges,,,70,,30.49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.34,3324,
60687-0143-01 - metFORMIN 850 mg Tab,60687-0143-01,NDC,,,,inpatient,1,EA,13.35,8.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.35,percent of total billed charges,,,85,,11.35,percent of total billed charges,,,49,,6.54,percent of total billed charges,,,90,,12.02,percent of total billed charges,,,,,,,no IP contract,,80,,10.68,percent of total billed charges,,,,,,,no IP contract,,50,,6.68,percent of total billed charges,,,,,,no IP contract,,,78,,10.41,percent of total billed charges,,,70,,9.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.54,3324,
60687-0145-01 - predniSONE 20 mg Tab,60687-0145-01,NDC,,,,inpatient,1,EA,5.75,3.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.89,percent of total billed charges,,,85,,4.89,percent of total billed charges,,,49,,2.82,percent of total billed charges,,,90,,5.18,percent of total billed charges,,,,,,,no IP contract,,80,,4.6,percent of total billed charges,,,,,,,no IP contract,,50,,2.88,percent of total billed charges,,,,,,no IP contract,,,78,,4.49,percent of total billed charges,,,70,,4.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.82,3324,
60687-0152-01 - cephalexin 250 mg Cap,60687-0152-01,NDC,,,,inpatient,1,EA,9.45,5.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.03,percent of total billed charges,,,85,,8.03,percent of total billed charges,,,49,,4.63,percent of total billed charges,,,90,,8.51,percent of total billed charges,,,,,,,no IP contract,,80,,7.56,percent of total billed charges,,,,,,,no IP contract,,50,,4.73,percent of total billed charges,,,,,,no IP contract,,,78,,7.37,percent of total billed charges,,,70,,6.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.63,3324,
60687-0155-01 - metFORMIN 500 mg Tab,60687-0155-01,NDC,,,,inpatient,1,EA,9.4,5.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.99,percent of total billed charges,,,85,,7.99,percent of total billed charges,,,49,,4.61,percent of total billed charges,,,90,,8.46,percent of total billed charges,,,,,,,no IP contract,,80,,7.52,percent of total billed charges,,,,,,,no IP contract,,50,,4.7,percent of total billed charges,,,,,,no IP contract,,,78,,7.33,percent of total billed charges,,,70,,6.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.61,3324,
60687-0156-25 - phenytoin 50 mg Chew,60687-0156-25,NDC,,,,inpatient,1,EA,13.35,8.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.35,percent of total billed charges,,,85,,11.35,percent of total billed charges,,,49,,6.54,percent of total billed charges,,,90,,12.02,percent of total billed charges,,,,,,,no IP contract,,80,,10.68,percent of total billed charges,,,,,,,no IP contract,,50,,6.68,percent of total billed charges,,,,,,no IP contract,,,78,,10.41,percent of total billed charges,,,70,,9.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.54,3324,
60687-0161-01 - haloperidol 5 mg Tab,60687-0161-01,NDC,,,,inpatient,1,EA,10.05,6.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.54,percent of total billed charges,,,85,,8.54,percent of total billed charges,,,49,,4.92,percent of total billed charges,,,90,,9.05,percent of total billed charges,,,,,,,no IP contract,,80,,8.04,percent of total billed charges,,,,,,,no IP contract,,50,,5.03,percent of total billed charges,,,,,,no IP contract,,,78,,7.84,percent of total billed charges,,,70,,7.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.92,3324,
60687-0163-01 - cepHALexin 500 mg Cap,60687-0163-01,NDC,,,,inpatient,1,EA,6.2,3.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.27,percent of total billed charges,,,85,,5.27,percent of total billed charges,,,49,,3.04,percent of total billed charges,,,90,,5.58,percent of total billed charges,,,,,,,no IP contract,,80,,4.96,percent of total billed charges,,,,,,,no IP contract,,50,,3.1,percent of total billed charges,,,,,,no IP contract,,,78,,4.84,percent of total billed charges,,,70,,4.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.04,3324,
60687-0165-01 - cetirizine 10 mg Tab,60687-0165-01,NDC,,,,inpatient,1,EA,23.55,14.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.02,percent of total billed charges,,,85,,20.02,percent of total billed charges,,,49,,11.54,percent of total billed charges,,,90,,21.2,percent of total billed charges,,,,,,,no IP contract,,80,,18.84,percent of total billed charges,,,,,,,no IP contract,,50,,11.78,percent of total billed charges,,,,,,no IP contract,,,78,,18.37,percent of total billed charges,,,70,,16.49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.54,3324,
60687-0169-01 - pravastatin 10 mg Tab,60687-0169-01,NDC,,,,inpatient,1,EA,29.25,17.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.86,percent of total billed charges,,,85,,24.86,percent of total billed charges,,,49,,14.33,percent of total billed charges,,,90,,26.33,percent of total billed charges,,,,,,,no IP contract,,80,,23.4,percent of total billed charges,,,,,,,no IP contract,,50,,14.63,percent of total billed charges,,,,,,no IP contract,,,78,,22.82,percent of total billed charges,,,70,,20.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.33,3324,
60687-0171-01 - donepezil 5 mg Tab,60687-0171-01,NDC,,,,inpatient,1,EA,10.05,6.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.54,percent of total billed charges,,,85,,8.54,percent of total billed charges,,,49,,4.92,percent of total billed charges,,,90,,9.05,percent of total billed charges,,,,,,,no IP contract,,80,,8.04,percent of total billed charges,,,,,,,no IP contract,,50,,5.03,percent of total billed charges,,,,,,no IP contract,,,78,,7.84,percent of total billed charges,,,70,,7.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.92,3324,
pravastatin 20 mg Tab,60687-0178-01,NDC,,,,inpatient,1,EA,29.65,17.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.2,percent of total billed charges,,,85,,25.2,percent of total billed charges,,,49,,14.53,percent of total billed charges,,,90,,26.69,percent of total billed charges,,,,,,,no IP contract,,80,,23.72,percent of total billed charges,,,,,,,no IP contract,,50,,14.83,percent of total billed charges,,,,,,no IP contract,,,78,,23.13,percent of total billed charges,,,70,,20.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.53,3324,
60687-0179-01 - aripiprazole 10 mg Tab,60687-0179-01,NDC,,,,inpatient,1,EA,242.65,145.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,196.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,206.25,percent of total billed charges,,,85,,206.25,percent of total billed charges,,,49,,118.9,percent of total billed charges,,,90,,218.39,percent of total billed charges,,,,,,,no IP contract,,80,,194.12,percent of total billed charges,,,,,,,no IP contract,,50,,121.33,percent of total billed charges,,,,,,no IP contract,,,78,,189.27,percent of total billed charges,,,70,,169.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,118.9,3324,
60687-0182-01 - donepezil 10 mg Tab,60687-0182-01,NDC,,,,inpatient,1,EA,10.05,6.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.54,percent of total billed charges,,,85,,8.54,percent of total billed charges,,,49,,4.92,percent of total billed charges,,,90,,9.05,percent of total billed charges,,,,,,,no IP contract,,80,,8.04,percent of total billed charges,,,,,,,no IP contract,,50,,5.03,percent of total billed charges,,,,,,no IP contract,,,78,,7.84,percent of total billed charges,,,70,,7.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.92,3324,
60687-0184-57 - memantine 10 mg Tab,60687-0184-57,NDC,,,,inpatient,1,EA,10.2,6.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.67,percent of total billed charges,,,85,,8.67,percent of total billed charges,,,49,,5,percent of total billed charges,,,90,,9.18,percent of total billed charges,,,,,,,no IP contract,,80,,8.16,percent of total billed charges,,,,,,,no IP contract,,50,,5.1,percent of total billed charges,,,,,,no IP contract,,,78,,7.96,percent of total billed charges,,,70,,7.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5,3324,
60687-0188-21 - entacapone 200 mg Tab,60687-0188-21,NDC,,,,inpatient,1,EA,43.1,25.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36.64,percent of total billed charges,,,85,,36.64,percent of total billed charges,,,49,,21.12,percent of total billed charges,,,90,,38.79,percent of total billed charges,,,,,,,no IP contract,,80,,34.48,percent of total billed charges,,,,,,,no IP contract,,50,,21.55,percent of total billed charges,,,,,,no IP contract,,,78,,33.62,percent of total billed charges,,,70,,30.17,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.12,3324,
60687-0190-01 - pravastatin 40 mg Tab,60687-0190-01,NDC,,,,inpatient,1,EA,41.75,25.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,35.49,percent of total billed charges,,,85,,35.49,percent of total billed charges,,,49,,20.46,percent of total billed charges,,,90,,37.58,percent of total billed charges,,,,,,,no IP contract,,80,,33.4,percent of total billed charges,,,,,,,no IP contract,,50,,20.88,percent of total billed charges,,,,,,no IP contract,,,78,,32.57,percent of total billed charges,,,70,,29.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.46,3324,
60687-0195-01 - diltiazem ER (Once-a-Day) 120 mg/24 hours Cap,60687-0195-01,NDC,,,,inpatient,1,EA,7.25,4.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.16,percent of total billed charges,,,85,,6.16,percent of total billed charges,,,49,,3.55,percent of total billed charges,,,90,,6.53,percent of total billed charges,,,,,,,no IP contract,,80,,5.8,percent of total billed charges,,,,,,,no IP contract,,50,,3.63,percent of total billed charges,,,,,,no IP contract,,,78,,5.66,percent of total billed charges,,,70,,5.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.55,3324,
meloxicam 15 mg Tab,60687-0199-01,NDC,,,,inpatient,1,EA,41.85,25.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,35.57,percent of total billed charges,,,85,,35.57,percent of total billed charges,,,49,,20.51,percent of total billed charges,,,90,,37.67,percent of total billed charges,,,,,,,no IP contract,,80,,33.48,percent of total billed charges,,,,,,,no IP contract,,50,,20.93,percent of total billed charges,,,,,,no IP contract,,,78,,32.64,percent of total billed charges,,,70,,29.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.51,3324,
60687-0206-01 - diltiazem 180 mg/24 hours ER Ca,60687-0206-01,NDC,,,,inpatient,1,EA,7.9,4.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.72,percent of total billed charges,,,85,,6.72,percent of total billed charges,,,49,,3.87,percent of total billed charges,,,90,,7.11,percent of total billed charges,,,,,,,no IP contract,,80,,6.32,percent of total billed charges,,,,,,,no IP contract,,50,,3.95,percent of total billed charges,,,,,,no IP contract,,,78,,6.16,percent of total billed charges,,,70,,5.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.87,3324,
60687-0206-90 - diltiazem ER (Once-a-Day) 180 mg/24 hours ER Capsule,60687-0206-90,NDC,,,,inpatient,1,EA,7.9,4.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.72,percent of total billed charges,,,85,,6.72,percent of total billed charges,,,49,,3.87,percent of total billed charges,,,90,,7.11,percent of total billed charges,,,,,,,no IP contract,,80,,6.32,percent of total billed charges,,,,,,,no IP contract,,50,,3.95,percent of total billed charges,,,,,,no IP contract,,,78,,6.16,percent of total billed charges,,,70,,5.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.87,3324,
60687-0210-01 - simvastatin 40 mg Tab,60687-0210-01,NDC,,,,inpatient,1,EA,42.95,25.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36.51,percent of total billed charges,,,85,,36.51,percent of total billed charges,,,49,,21.05,percent of total billed charges,,,90,,38.66,percent of total billed charges,,,,,,,no IP contract,,80,,34.36,percent of total billed charges,,,,,,,no IP contract,,50,,21.48,percent of total billed charges,,,,,,no IP contract,,,78,,33.5,percent of total billed charges,,,70,,30.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.05,3324,
60687-0211-21 - divalproex sodium 125 mg EC Ta,60687-0211-21,NDC,,,,inpatient,1,EA,10.9,6.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.27,percent of total billed charges,,,85,,9.27,percent of total billed charges,,,49,,5.34,percent of total billed charges,,,90,,9.81,percent of total billed charges,,,,,,,no IP contract,,80,,8.72,percent of total billed charges,,,,,,,no IP contract,,50,,5.45,percent of total billed charges,,,,,,no IP contract,,,78,,8.5,percent of total billed charges,,,70,,7.63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.34,3324,
60687-0214-01 - methadone 5 mg Tab,60687-0214-01,NDC,,,,inpatient,1,EA,8.65,5.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.35,percent of total billed charges,,,85,,7.35,percent of total billed charges,,,49,,4.24,percent of total billed charges,,,90,,7.79,percent of total billed charges,,,,,,,no IP contract,,80,,6.92,percent of total billed charges,,,,,,,no IP contract,,50,,4.33,percent of total billed charges,,,,,,no IP contract,,,78,,6.75,percent of total billed charges,,,70,,6.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.24,3324,
60687-0217-01 - diltiazem ER (Once-a-Day) 240 mg/24 hours ER Capsule,60687-0217-01,NDC,,,,inpatient,1,EA,10.2,6.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.67,percent of total billed charges,,,85,,8.67,percent of total billed charges,,,49,,5,percent of total billed charges,,,90,,9.18,percent of total billed charges,,,,,,,no IP contract,,80,,8.16,percent of total billed charges,,,,,,,no IP contract,,50,,5.1,percent of total billed charges,,,,,,no IP contract,,,78,,7.96,percent of total billed charges,,,70,,7.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5,3324,
60687-0224-01 - gemfibrozil 600 mg Tab,60687-0224-01,NDC,,,,inpatient,1,EA,22.2,13.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.87,percent of total billed charges,,,85,,18.87,percent of total billed charges,,,49,,10.88,percent of total billed charges,,,90,,19.98,percent of total billed charges,,,,,,,no IP contract,,80,,17.76,percent of total billed charges,,,,,,,no IP contract,,50,,11.1,percent of total billed charges,,,,,,no IP contract,,,78,,17.32,percent of total billed charges,,,70,,15.54,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.88,3324,
60687-0227-94 - leucovorin 25 mg Tab,60687-0227-94,NDC,,,,inpatient,1,EA,106,63.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,85.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,90.1,percent of total billed charges,,,85,,90.1,percent of total billed charges,,,49,,51.94,percent of total billed charges,,,90,,95.4,percent of total billed charges,,,,,,,no IP contract,,80,,84.8,percent of total billed charges,,,,,,,no IP contract,,50,,53,percent of total billed charges,,,,,,no IP contract,,,78,,82.68,percent of total billed charges,,,70,,74.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,51.94,3324,
60687-0228-01 - dilTIAZem 300 mg/24 hours ER Ca,60687-0228-01,NDC,,,,inpatient,1,EA,25.15,15.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.38,percent of total billed charges,,,85,,21.38,percent of total billed charges,,,49,,12.32,percent of total billed charges,,,90,,22.64,percent of total billed charges,,,,,,,no IP contract,,80,,20.12,percent of total billed charges,,,,,,,no IP contract,,50,,12.58,percent of total billed charges,,,,,,no IP contract,,,78,,19.62,percent of total billed charges,,,70,,17.61,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.32,3324,
60687-0229-01 - loperamide 2 mg Cap,60687-0229-01,NDC,,,,inpatient,1,EA,10.8,6.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.18,percent of total billed charges,,,85,,9.18,percent of total billed charges,,,49,,5.29,percent of total billed charges,,,90,,9.72,percent of total billed charges,,,,,,,no IP contract,,80,,8.64,percent of total billed charges,,,,,,,no IP contract,,50,,5.4,percent of total billed charges,,,,,,no IP contract,,,78,,8.42,percent of total billed charges,,,70,,7.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.29,3324,
60687-0230-65 - zonisamide 100 mg Cap,60687-0230-65,NDC,,,,inpatient,1,EA,18.2,10.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.47,percent of total billed charges,,,85,,15.47,percent of total billed charges,,,49,,8.92,percent of total billed charges,,,90,,16.38,percent of total billed charges,,,,,,,no IP contract,,80,,14.56,percent of total billed charges,,,,,,,no IP contract,,50,,9.1,percent of total billed charges,,,,,,no IP contract,,,78,,14.2,percent of total billed charges,,,70,,12.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.92,3324,
60687-0231-01 - sertraline 25 mg Tab,60687-0231-01,NDC,,,,inpatient,1,EA,7,4.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.95,percent of total billed charges,,,85,,5.95,percent of total billed charges,,,49,,3.43,percent of total billed charges,,,90,,6.3,percent of total billed charges,,,,,,,no IP contract,,80,,5.6,percent of total billed charges,,,,,,,no IP contract,,50,,3.5,percent of total billed charges,,,,,,no IP contract,,,78,,5.46,percent of total billed charges,,,70,,4.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.43,3324,
60687-0234-01 - rosuvastatin 5 mg Tab,60687-0234-01,NDC,,,,inpatient,1,EA,60.6,36.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,49.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,51.51,percent of total billed charges,,,85,,51.51,percent of total billed charges,,,49,,29.69,percent of total billed charges,,,90,,54.54,percent of total billed charges,,,,,,,no IP contract,,80,,48.48,percent of total billed charges,,,,,,,no IP contract,,50,,30.3,percent of total billed charges,,,,,,no IP contract,,,78,,47.27,percent of total billed charges,,,70,,42.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,29.69,3324,
60687-0239-56 - amantadine 50 mg/5 mL Syrup,60687-0239-56,NDC,,,,inpatient,10,ML,27.1,16.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.04,percent of total billed charges,,,85,,23.04,percent of total billed charges,,,49,,13.28,percent of total billed charges,,,90,,24.39,percent of total billed charges,,,,,,,no IP contract,,80,,21.68,percent of total billed charges,,,,,,,no IP contract,,50,,13.55,percent of total billed charges,,,,,,no IP contract,,,78,,21.14,percent of total billed charges,,,70,,18.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.28,3324,
60687-0242-01 - sertraline 50 mg Tab,60687-0242-01,NDC,,,,inpatient,1,EA,7,4.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.95,percent of total billed charges,,,85,,5.95,percent of total billed charges,,,49,,3.43,percent of total billed charges,,,90,,6.3,percent of total billed charges,,,,,,,no IP contract,,80,,5.6,percent of total billed charges,,,,,,,no IP contract,,50,,3.5,percent of total billed charges,,,,,,no IP contract,,,78,,5.46,percent of total billed charges,,,70,,4.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.43,3324,
60687-0249-67 - levETIRAcetam 100 mg/mL Soln,60687-0249-67,NDC,,,,inpatient,5,ML,63.3,37.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,51.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,53.81,percent of total billed charges,,,85,,53.81,percent of total billed charges,,,49,,31.02,percent of total billed charges,,,90,,56.97,percent of total billed charges,,,,,,,no IP contract,,80,,50.64,percent of total billed charges,,,,,,,no IP contract,,50,,31.65,percent of total billed charges,,,,,,no IP contract,,,78,,49.37,percent of total billed charges,,,70,,44.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.02,3324,
60687-0253-01 - sertraline 100 mg Tab,60687-0253-01,NDC,,,,inpatient,1,EA,7,4.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.95,percent of total billed charges,,,85,,5.95,percent of total billed charges,,,49,,3.43,percent of total billed charges,,,90,,6.3,percent of total billed charges,,,,,,,no IP contract,,80,,5.6,percent of total billed charges,,,,,,,no IP contract,,50,,3.5,percent of total billed charges,,,,,,no IP contract,,,78,,5.46,percent of total billed charges,,,70,,4.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.43,3324,
60687-0256-01 - rosuvastatin 20 mg Tab,60687-0256-01,NDC,,,,inpatient,1,EA,60.6,36.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,49.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,51.51,percent of total billed charges,,,85,,51.51,percent of total billed charges,,,49,,29.69,percent of total billed charges,,,90,,54.54,percent of total billed charges,,,,,,,no IP contract,,80,,48.48,percent of total billed charges,,,,,,,no IP contract,,50,,30.3,percent of total billed charges,,,,,,no IP contract,,,78,,47.27,percent of total billed charges,,,70,,42.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,29.69,3324,
60687-0263-01 - amLODIPine 5 mg Tab,60687-0263-01,NDC,,,,inpatient,1,EA,7,4.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.95,percent of total billed charges,,,85,,5.95,percent of total billed charges,,,49,,3.43,percent of total billed charges,,,90,,6.3,percent of total billed charges,,,,,,,no IP contract,,80,,5.6,percent of total billed charges,,,,,,,no IP contract,,50,,3.5,percent of total billed charges,,,,,,no IP contract,,,78,,5.46,percent of total billed charges,,,70,,4.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.43,3324,
60687-0268-01 - naproxen 500 mg Tab,60687-0268-01,NDC,,,,inpatient,1,EA,14.5,8.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.33,percent of total billed charges,,,85,,12.33,percent of total billed charges,,,49,,7.11,percent of total billed charges,,,90,,13.05,percent of total billed charges,,,,,,,no IP contract,,80,,11.6,percent of total billed charges,,,,,,,no IP contract,,50,,7.25,percent of total billed charges,,,,,,no IP contract,,,78,,11.31,percent of total billed charges,,,70,,10.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.11,3324,
60687-0270-01 - glycopyrrolate 1 mg Tab,60687-0270-01,NDC,,,,inpatient,1,EA,13.75,8.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.69,percent of total billed charges,,,85,,11.69,percent of total billed charges,,,49,,6.74,percent of total billed charges,,,90,,12.38,percent of total billed charges,,,,,,,no IP contract,,80,,11,percent of total billed charges,,,,,,,no IP contract,,50,,6.88,percent of total billed charges,,,,,,no IP contract,,,78,,10.73,percent of total billed charges,,,70,,9.63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.74,3324,
60687-0272-94 - cefuroxime 250 mg Tab,60687-0272-94,NDC,,,,inpatient,1,EA,36.6,21.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.11,percent of total billed charges,,,85,,31.11,percent of total billed charges,,,49,,17.93,percent of total billed charges,,,90,,32.94,percent of total billed charges,,,,,,,no IP contract,,80,,29.28,percent of total billed charges,,,,,,,no IP contract,,50,,18.3,percent of total billed charges,,,,,,no IP contract,,,78,,28.55,percent of total billed charges,,,70,,25.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.93,3324,
60687-0273-21 - voriconazole 200 mg Tab,60687-0273-21,NDC,,,,inpatient,1,EA,376.75,226.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,305.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,320.24,percent of total billed charges,,,85,,320.24,percent of total billed charges,,,49,,184.61,percent of total billed charges,,,90,,339.08,percent of total billed charges,,,,,,,no IP contract,,80,,301.4,percent of total billed charges,,,,,,,no IP contract,,50,,188.38,percent of total billed charges,,,,,,no IP contract,,,78,,293.87,percent of total billed charges,,,70,,263.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,184.61,3324,
60687-0274-01 - amLODIPine 10 mg Tab,60687-0274-01,NDC,,,,inpatient,1,EA,8.35,5.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.1,percent of total billed charges,,,85,,7.1,percent of total billed charges,,,49,,4.09,percent of total billed charges,,,90,,7.52,percent of total billed charges,,,,,,,no IP contract,,80,,6.68,percent of total billed charges,,,,,,,no IP contract,,50,,4.18,percent of total billed charges,,,,,,no IP contract,,,78,,6.51,percent of total billed charges,,,70,,5.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.09,3324,
60687-0281-01 - nortriptyline 10 mg Cap,60687-0281-01,NDC,,,,inpatient,1,EA,7.3,4.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.21,percent of total billed charges,,,85,,6.21,percent of total billed charges,,,49,,3.58,percent of total billed charges,,,90,,6.57,percent of total billed charges,,,,,,,no IP contract,,80,,5.84,percent of total billed charges,,,,,,,no IP contract,,50,,3.65,percent of total billed charges,,,,,,no IP contract,,,78,,5.69,percent of total billed charges,,,70,,5.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.58,3324,
60687-0282-01 - azithromycin 250 mg Tab,60687-0282-01,NDC,,,,inpatient,1,EA,37.35,22.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.75,percent of total billed charges,,,85,,31.75,percent of total billed charges,,,49,,18.3,percent of total billed charges,,,90,,33.62,percent of total billed charges,,,,,,,no IP contract,,80,,29.88,percent of total billed charges,,,,,,,no IP contract,,50,,18.68,percent of total billed charges,,,,,,no IP contract,,,78,,29.13,percent of total billed charges,,,70,,26.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.3,3324,
60687-0282-65 - azithromycin 250 mg Tab,60687-0282-65,NDC,,,,inpatient,1,EA,18.7,11.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.9,percent of total billed charges,,,85,,15.9,percent of total billed charges,,,49,,9.16,percent of total billed charges,,,90,,16.83,percent of total billed charges,,,,,,,no IP contract,,80,,14.96,percent of total billed charges,,,,,,,no IP contract,,50,,9.35,percent of total billed charges,,,,,,no IP contract,,,78,,14.59,percent of total billed charges,,,70,,13.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.16,3324,
60687-0285-01 - amLODIPine 2.5 mg Tab,60687-0285-01,NDC,,,,inpatient,1,EA,7,4.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.95,percent of total billed charges,,,85,,5.95,percent of total billed charges,,,49,,3.43,percent of total billed charges,,,90,,6.3,percent of total billed charges,,,,,,,no IP contract,,80,,5.6,percent of total billed charges,,,,,,,no IP contract,,50,,3.5,percent of total billed charges,,,,,,no IP contract,,,78,,5.46,percent of total billed charges,,,70,,4.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.43,3324,
60687-0286-21 - bromocriptine 2.5 mg Tab,60687-0286-21,NDC,,,,inpatient,1,EA,50.55,30.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,40.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,42.97,percent of total billed charges,,,85,,42.97,percent of total billed charges,,,49,,24.77,percent of total billed charges,,,90,,45.5,percent of total billed charges,,,,,,,no IP contract,,80,,40.44,percent of total billed charges,,,,,,,no IP contract,,50,,25.28,percent of total billed charges,,,,,,no IP contract,,,78,,39.43,percent of total billed charges,,,70,,35.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.77,3324,
60687-0292-01 - donepezil 5 mg Tab,60687-0292-01,NDC,,,,inpatient,1,EA,10.05,6.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.54,percent of total billed charges,,,85,,8.54,percent of total billed charges,,,49,,4.92,percent of total billed charges,,,90,,9.05,percent of total billed charges,,,,,,,no IP contract,,80,,8.04,percent of total billed charges,,,,,,,no IP contract,,50,,5.03,percent of total billed charges,,,,,,no IP contract,,,78,,7.84,percent of total billed charges,,,70,,7.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.92,3324,
60687-0293-01 - nortriptyline 25 mg Cap,60687-0293-01,NDC,,,,inpatient,1,EA,10.8,6.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.18,percent of total billed charges,,,85,,9.18,percent of total billed charges,,,49,,5.29,percent of total billed charges,,,90,,9.72,percent of total billed charges,,,,,,,no IP contract,,80,,8.64,percent of total billed charges,,,,,,,no IP contract,,50,,5.4,percent of total billed charges,,,,,,no IP contract,,,78,,8.42,percent of total billed charges,,,70,,7.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.29,3324,
60687-0294-21 - voriconazole 50 mg Tab,60687-0294-21,NDC,,,,inpatient,1,EA,97.4,58.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,78.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,82.79,percent of total billed charges,,,85,,82.79,percent of total billed charges,,,49,,47.73,percent of total billed charges,,,90,,87.66,percent of total billed charges,,,,,,,no IP contract,,80,,77.92,percent of total billed charges,,,,,,,no IP contract,,50,,48.7,percent of total billed charges,,,,,,no IP contract,,,78,,75.97,percent of total billed charges,,,70,,68.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,47.73,3324,
60687-0295-01 - propranolol 40 mg Tab,60687-0295-01,NDC,,,,inpatient,1,EA,14.15,8.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.03,percent of total billed charges,,,85,,12.03,percent of total billed charges,,,49,,6.93,percent of total billed charges,,,90,,12.74,percent of total billed charges,,,,,,,no IP contract,,80,,11.32,percent of total billed charges,,,,,,,no IP contract,,50,,7.08,percent of total billed charges,,,,,,no IP contract,,,78,,11.04,percent of total billed charges,,,70,,9.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.93,3324,
60687-0299-25 - itraconazole 100 mg Cap,60687-0299-25,NDC,,,,inpatient,1,EA,35.6,21.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.26,percent of total billed charges,,,85,,30.26,percent of total billed charges,,,49,,17.44,percent of total billed charges,,,90,,32.04,percent of total billed charges,,,,,,,no IP contract,,80,,28.48,percent of total billed charges,,,,,,,no IP contract,,50,,17.8,percent of total billed charges,,,,,,no IP contract,,,78,,27.77,percent of total billed charges,,,70,,24.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.44,3324,
60687-0303-01 - donepezil 10 mg Tab,60687-0303-01,NDC,,,,inpatient,1,EA,10.05,6.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.54,percent of total billed charges,,,85,,8.54,percent of total billed charges,,,49,,4.92,percent of total billed charges,,,90,,9.05,percent of total billed charges,,,,,,,no IP contract,,80,,8.04,percent of total billed charges,,,,,,,no IP contract,,50,,5.03,percent of total billed charges,,,,,,no IP contract,,,78,,7.84,percent of total billed charges,,,70,,7.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.92,3324,
60687-0304-21 - captopril 12.5 mg Tab,60687-0304-21,NDC,,,,inpatient,1,EA,17.35,10.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.75,percent of total billed charges,,,85,,14.75,percent of total billed charges,,,49,,8.5,percent of total billed charges,,,90,,15.62,percent of total billed charges,,,,,,,no IP contract,,80,,13.88,percent of total billed charges,,,,,,,no IP contract,,50,,8.68,percent of total billed charges,,,,,,no IP contract,,,78,,13.53,percent of total billed charges,,,70,,12.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.5,3324,
60687-0305-32 - aspirin-dipyridamole 25 mg-200 mg ER Ca,60687-0305-32,NDC,,,,inpatient,1,EA,104,62.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,84.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,88.4,percent of total billed charges,,,85,,88.4,percent of total billed charges,,,49,,50.96,percent of total billed charges,,,90,,93.6,percent of total billed charges,,,,,,,no IP contract,,80,,83.2,percent of total billed charges,,,,,,,no IP contract,,50,,52,percent of total billed charges,,,,,,no IP contract,,,78,,81.12,percent of total billed charges,,,70,,72.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,50.96,3324,
60687-0306-01 - propranolol 20 mg Tab,60687-0306-01,NDC,,,,inpatient,1,EA,4.8,2.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.08,percent of total billed charges,,,85,,4.08,percent of total billed charges,,,49,,2.35,percent of total billed charges,,,90,,4.32,percent of total billed charges,,,,,,,no IP contract,,80,,3.84,percent of total billed charges,,,,,,,no IP contract,,50,,2.4,percent of total billed charges,,,,,,no IP contract,,,78,,3.74,percent of total billed charges,,,70,,3.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.35,3324,
60687-0309-21 - linezolid 600 mg Tab,60687-0309-21,NDC,,,,inpatient,1,EA,1008.25,604.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,816.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,857.01,percent of total billed charges,,,85,,857.01,percent of total billed charges,,,49,,494.04,percent of total billed charges,,,90,,907.43,percent of total billed charges,,,,,,,no IP contract,,80,,806.6,percent of total billed charges,,,,,,,no IP contract,,50,,504.13,percent of total billed charges,,,,,,no IP contract,,,78,,786.44,percent of total billed charges,,,70,,705.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,494.04,3324,
60687-0312-01 - buPROPion 150 mg/24 hours ER Ta,60687-0312-01,NDC,,,,inpatient,1,EA,40.85,24.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34.72,percent of total billed charges,,,85,,34.72,percent of total billed charges,,,49,,20.02,percent of total billed charges,,,90,,36.77,percent of total billed charges,,,,,,,no IP contract,,80,,32.68,percent of total billed charges,,,,,,,no IP contract,,50,,20.43,percent of total billed charges,,,,,,no IP contract,,,78,,31.86,percent of total billed charges,,,70,,28.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.02,3324,
60687-0314-25 - azithromycin 600 mg Tab,60687-0314-25,NDC,,,,inpatient,1,EA,39.9,23.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.92,percent of total billed charges,,,85,,33.92,percent of total billed charges,,,49,,19.55,percent of total billed charges,,,90,,35.91,percent of total billed charges,,,,,,,no IP contract,,80,,31.92,percent of total billed charges,,,,,,,no IP contract,,50,,19.95,percent of total billed charges,,,,,,no IP contract,,,78,,31.12,percent of total billed charges,,,70,,27.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.55,3324,
60687-0315-21 - captopril 25 mg Tab,60687-0315-21,NDC,,,,inpatient,1,EA,18.55,11.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.77,percent of total billed charges,,,85,,15.77,percent of total billed charges,,,49,,9.09,percent of total billed charges,,,90,,16.7,percent of total billed charges,,,,,,,no IP contract,,80,,14.84,percent of total billed charges,,,,,,,no IP contract,,50,,9.28,percent of total billed charges,,,,,,no IP contract,,,78,,14.47,percent of total billed charges,,,70,,12.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.09,3324,
60687-0317-25 - chlorthalidone 25 mg Tab,60687-0317-25,NDC,,,,inpatient,1,EA,22.1,13.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.79,percent of total billed charges,,,85,,18.79,percent of total billed charges,,,49,,10.83,percent of total billed charges,,,90,,19.89,percent of total billed charges,,,,,,,no IP contract,,80,,17.68,percent of total billed charges,,,,,,,no IP contract,,50,,11.05,percent of total billed charges,,,,,,no IP contract,,,78,,17.24,percent of total billed charges,,,70,,15.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.83,3324,
60687-0319-21 - tolterodine 2 mg ER Ca,60687-0319-21,NDC,,,,inpatient,1,EA,99.6,59.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,80.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,84.66,percent of total billed charges,,,85,,84.66,percent of total billed charges,,,49,,48.8,percent of total billed charges,,,90,,89.64,percent of total billed charges,,,,,,,no IP contract,,80,,79.68,percent of total billed charges,,,,,,,no IP contract,,50,,49.8,percent of total billed charges,,,,,,no IP contract,,,78,,77.69,percent of total billed charges,,,70,,69.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,48.8,3324,
60687-0325-01 - lisinopril 10 mg Tab,60687-0325-01,NDC,,,,inpatient,1,EA,5,3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.25,percent of total billed charges,,,85,,4.25,percent of total billed charges,,,49,,2.45,percent of total billed charges,,,90,,4.5,percent of total billed charges,,,,,,,no IP contract,,80,,4,percent of total billed charges,,,,,,,no IP contract,,50,,2.5,percent of total billed charges,,,,,,no IP contract,,,78,,3.9,percent of total billed charges,,,70,,3.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.45,3324,
60687-0326-25 - atomoxetine 40 mg Cap,60687-0326-25,NDC,,,,inpatient,1,EA,64.15,38.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,51.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,54.53,percent of total billed charges,,,85,,54.53,percent of total billed charges,,,49,,31.43,percent of total billed charges,,,90,,57.74,percent of total billed charges,,,,,,,no IP contract,,80,,51.32,percent of total billed charges,,,,,,,no IP contract,,50,,32.08,percent of total billed charges,,,,,,no IP contract,,,78,,50.04,percent of total billed charges,,,70,,44.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.43,3324,
60687-0327-01 - QUEtiapine 25 mg Tab,60687-0327-01,NDC,,,,inpatient,1,EA,33.9,20.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.82,percent of total billed charges,,,85,,28.82,percent of total billed charges,,,49,,16.61,percent of total billed charges,,,90,,30.51,percent of total billed charges,,,,,,,no IP contract,,80,,27.12,percent of total billed charges,,,,,,,no IP contract,,50,,16.95,percent of total billed charges,,,,,,no IP contract,,,78,,26.44,percent of total billed charges,,,70,,23.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.61,3324,
60687-0330-21 - tolterodine 4 mg ER Ca,60687-0330-21,NDC,,,,inpatient,1,EA,99.6,59.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,80.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,84.66,percent of total billed charges,,,85,,84.66,percent of total billed charges,,,49,,48.8,percent of total billed charges,,,90,,89.64,percent of total billed charges,,,,,,,no IP contract,,80,,79.68,percent of total billed charges,,,,,,,no IP contract,,50,,49.8,percent of total billed charges,,,,,,no IP contract,,,78,,77.69,percent of total billed charges,,,70,,69.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,48.8,3324,
60687-0333-01 - lisinopril 20 mg Tab,60687-0333-01,NDC,,,,inpatient,1,EA,5,3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.25,percent of total billed charges,,,85,,4.25,percent of total billed charges,,,49,,2.45,percent of total billed charges,,,90,,4.5,percent of total billed charges,,,,,,,no IP contract,,80,,4,percent of total billed charges,,,,,,,no IP contract,,50,,2.5,percent of total billed charges,,,,,,no IP contract,,,78,,3.9,percent of total billed charges,,,70,,3.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.45,3324,
60687-0336-65 - minocycline 100 mg Cap,60687-0336-65,NDC,,,,inpatient,1,EA,14.3,8.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.16,percent of total billed charges,,,85,,12.16,percent of total billed charges,,,49,,7.01,percent of total billed charges,,,90,,12.87,percent of total billed charges,,,,,,,no IP contract,,80,,11.44,percent of total billed charges,,,,,,,no IP contract,,50,,7.15,percent of total billed charges,,,,,,no IP contract,,,78,,11.15,percent of total billed charges,,,70,,10.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.01,3324,
60687-0338-01 - quetiapine 50 mg Tab,60687-0338-01,NDC,,,,inpatient,1,EA,53.1,31.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,43.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,45.14,percent of total billed charges,,,85,,45.14,percent of total billed charges,,,49,,26.02,percent of total billed charges,,,90,,47.79,percent of total billed charges,,,,,,,no IP contract,,80,,42.48,percent of total billed charges,,,,,,,no IP contract,,50,,26.55,percent of total billed charges,,,,,,no IP contract,,,78,,41.42,percent of total billed charges,,,70,,37.17,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.02,3324,
60687-0340-01 - buPROPion  75 mg Tab,60687-0340-01,NDC,,,,inpatient,1,EA,14.25,8.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.11,percent of total billed charges,,,85,,12.11,percent of total billed charges,,,49,,6.98,percent of total billed charges,,,90,,12.83,percent of total billed charges,,,,,,,no IP contract,,80,,11.4,percent of total billed charges,,,,,,,no IP contract,,50,,7.13,percent of total billed charges,,,,,,no IP contract,,,78,,11.12,percent of total billed charges,,,70,,9.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.98,3324,
60687-0345-01 - calcitriol 0.25 mcg Cap,60687-0345-01,NDC,,,,inpatient,1,EA,9.95,5.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.46,percent of total billed charges,,,85,,8.46,percent of total billed charges,,,49,,4.88,percent of total billed charges,,,90,,8.96,percent of total billed charges,,,,,,,no IP contract,,80,,7.96,percent of total billed charges,,,,,,,no IP contract,,50,,4.98,percent of total billed charges,,,,,,no IP contract,,,78,,7.76,percent of total billed charges,,,70,,6.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.88,3324,
60687-0346-01 - benzonatate 100 mg Cap,60687-0346-01,NDC,,,,inpatient,1,EA,9.65,5.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.2,percent of total billed charges,,,85,,8.2,percent of total billed charges,,,49,,4.73,percent of total billed charges,,,90,,8.69,percent of total billed charges,,,,,,,no IP contract,,80,,7.72,percent of total billed charges,,,,,,,no IP contract,,50,,4.83,percent of total billed charges,,,,,,no IP contract,,,78,,7.53,percent of total billed charges,,,70,,6.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.73,3324,
60687-0349-01 - quetiapine 100 mg Tab,60687-0349-01,NDC,,,,inpatient,1,EA,55.35,33.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,44.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,47.05,percent of total billed charges,,,85,,47.05,percent of total billed charges,,,49,,27.12,percent of total billed charges,,,90,,49.82,percent of total billed charges,,,,,,,no IP contract,,80,,44.28,percent of total billed charges,,,,,,,no IP contract,,50,,27.68,percent of total billed charges,,,,,,no IP contract,,,78,,43.17,percent of total billed charges,,,70,,38.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.12,3324,
60687-0351-01 - buPROPion 100 mg Tab,60687-0351-01,NDC,,,,inpatient,1,EA,18.05,10.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.34,percent of total billed charges,,,85,,15.34,percent of total billed charges,,,49,,8.84,percent of total billed charges,,,90,,16.25,percent of total billed charges,,,,,,,no IP contract,,80,,14.44,percent of total billed charges,,,,,,,no IP contract,,50,,9.03,percent of total billed charges,,,,,,no IP contract,,,78,,14.08,percent of total billed charges,,,70,,12.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.84,3324,
60687-0354-01 - ramipril 10 mg Cap,60687-0354-01,NDC,,,,inpatient,1,EA,8.5,5.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.23,percent of total billed charges,,,85,,7.23,percent of total billed charges,,,49,,4.17,percent of total billed charges,,,90,,7.65,percent of total billed charges,,,,,,,no IP contract,,80,,6.8,percent of total billed charges,,,,,,,no IP contract,,50,,4.25,percent of total billed charges,,,,,,no IP contract,,,78,,6.63,percent of total billed charges,,,70,,5.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.17,3324,
60687-0355-01 - LORazepam 1 mg Tab,60687-0355-01,NDC,,,,inpatient,1,EA,6.85,4.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.82,percent of total billed charges,,,85,,5.82,percent of total billed charges,,,49,,3.36,percent of total billed charges,,,90,,6.17,percent of total billed charges,,,,,,,no IP contract,,80,,5.48,percent of total billed charges,,,,,,,no IP contract,,50,,3.43,percent of total billed charges,,,,,,no IP contract,,,78,,5.34,percent of total billed charges,,,70,,4.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.36,3324,
60687-0362-21 - lamiVUDine 150 mg Tab,60687-0362-21,NDC,,,,inpatient,1,EA,69.55,41.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,56.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,59.12,percent of total billed charges,,,85,,59.12,percent of total billed charges,,,49,,34.08,percent of total billed charges,,,90,,62.6,percent of total billed charges,,,,,,,no IP contract,,80,,55.64,percent of total billed charges,,,,,,,no IP contract,,50,,34.78,percent of total billed charges,,,,,,no IP contract,,,78,,54.25,percent of total billed charges,,,70,,48.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,34.08,3324,
60687-0364-25 - ritonavir 100 mg Tab,60687-0364-25,NDC,,,,inpatient,1,EA,93.25,55.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,75.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,79.26,percent of total billed charges,,,85,,79.26,percent of total billed charges,,,49,,45.69,percent of total billed charges,,,90,,83.93,percent of total billed charges,,,,,,,no IP contract,,80,,74.6,percent of total billed charges,,,,,,,no IP contract,,50,,46.63,percent of total billed charges,,,,,,no IP contract,,,78,,72.74,percent of total billed charges,,,70,,65.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,45.69,3324,
60687-0366-25 - tenofovir 300 mg Tab,60687-0366-25,NDC,,,,inpatient,1,EA,16.8,10.08,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.28,percent of total billed charges,,,85,,14.28,percent of total billed charges,,,49,,8.23,percent of total billed charges,,,90,,15.12,percent of total billed charges,,,,,,,no IP contract,,80,,13.44,percent of total billed charges,,,,,,,no IP contract,,50,,8.4,percent of total billed charges,,,,,,no IP contract,,,78,,13.1,percent of total billed charges,,,70,,11.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.23,3324,
60687-0368-01 - benztropine 1 mg Tab,60687-0368-01,NDC,,,,inpatient,1,EA,8.5,5.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.23,percent of total billed charges,,,85,,7.23,percent of total billed charges,,,49,,4.17,percent of total billed charges,,,90,,7.65,percent of total billed charges,,,,,,,no IP contract,,80,,6.8,percent of total billed charges,,,,,,,no IP contract,,50,,4.25,percent of total billed charges,,,,,,no IP contract,,,78,,6.63,percent of total billed charges,,,70,,5.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.17,3324,
60687-0369-01 - dicyclomine 10 mg Cap,60687-0369-01,NDC,,,,inpatient,1,EA,8.1,4.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.89,percent of total billed charges,,,85,,6.89,percent of total billed charges,,,49,,3.97,percent of total billed charges,,,90,,7.29,percent of total billed charges,,,,,,,no IP contract,,80,,6.48,percent of total billed charges,,,,,,,no IP contract,,50,,4.05,percent of total billed charges,,,,,,no IP contract,,,78,,6.32,percent of total billed charges,,,70,,5.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.97,3324,
60687-0373-21 - ezetimibe 10 mg Tab,60687-0373-21,NDC,,,,inpatient,1,EA,101.6,60.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,82.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,86.36,percent of total billed charges,,,85,,86.36,percent of total billed charges,,,49,,49.78,percent of total billed charges,,,90,,91.44,percent of total billed charges,,,,,,,no IP contract,,80,,81.28,percent of total billed charges,,,,,,,no IP contract,,50,,50.8,percent of total billed charges,,,,,,no IP contract,,,78,,79.25,percent of total billed charges,,,70,,71.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,49.78,3324,
60687-0375-01 - dronabinol 2.5 mg Cap,60687-0375-01,NDC,,,,inpatient,1,EA,49.55,29.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,40.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,42.12,percent of total billed charges,,,85,,42.12,percent of total billed charges,,,49,,24.28,percent of total billed charges,,,90,,44.6,percent of total billed charges,,,,,,,no IP contract,,80,,39.64,percent of total billed charges,,,,,,,no IP contract,,50,,24.78,percent of total billed charges,,,,,,no IP contract,,,78,,38.65,percent of total billed charges,,,70,,34.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.28,3324,
ALPRAZolam 0.25 mg Tab,60687-0377-01,NDC,,,,inpatient,1,EA,8.4,5.04,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.14,percent of total billed charges,,,85,,7.14,percent of total billed charges,,,49,,4.12,percent of total billed charges,,,90,,7.56,percent of total billed charges,,,,,,,no IP contract,,80,,6.72,percent of total billed charges,,,,,,,no IP contract,,50,,4.2,percent of total billed charges,,,,,,no IP contract,,,78,,6.55,percent of total billed charges,,,70,,5.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.12,3324,
60687-0379-01 - benztropine 2 mg Tab,60687-0379-01,NDC,,,,inpatient,1,EA,9.15,5.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.78,percent of total billed charges,,,85,,7.78,percent of total billed charges,,,49,,4.48,percent of total billed charges,,,90,,8.24,percent of total billed charges,,,,,,,no IP contract,,80,,7.32,percent of total billed charges,,,,,,,no IP contract,,50,,4.58,percent of total billed charges,,,,,,no IP contract,,,78,,7.14,percent of total billed charges,,,70,,6.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.48,3324,
60687-0384-01 - bumetanide 1 mg Tab,60687-0384-01,NDC,,,,inpatient,1,EA,14.15,8.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.03,percent of total billed charges,,,85,,12.03,percent of total billed charges,,,49,,6.93,percent of total billed charges,,,90,,12.74,percent of total billed charges,,,,,,,no IP contract,,80,,11.32,percent of total billed charges,,,,,,,no IP contract,,50,,7.08,percent of total billed charges,,,,,,no IP contract,,,78,,11.04,percent of total billed charges,,,70,,9.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.93,3324,
60687-0384-25 - bumetadine 1 mg Tab,60687-0384-25,NDC,,,,inpatient,1,EA,19.4,11.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.49,percent of total billed charges,,,85,,16.49,percent of total billed charges,,,49,,9.51,percent of total billed charges,,,90,,17.46,percent of total billed charges,,,,,,,no IP contract,,80,,15.52,percent of total billed charges,,,,,,,no IP contract,,50,,9.7,percent of total billed charges,,,,,,no IP contract,,,78,,15.13,percent of total billed charges,,,70,,13.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.51,3324,
droNABinol 5 mg Cap,60687-0386-94,NDC,,,,inpatient,1,EA,148.55,89.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,120.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,126.27,percent of total billed charges,,,85,,126.27,percent of total billed charges,,,49,,72.79,percent of total billed charges,,,90,,133.7,percent of total billed charges,,,,,,,no IP contract,,80,,118.84,percent of total billed charges,,,,,,,no IP contract,,50,,74.28,percent of total billed charges,,,,,,no IP contract,,,78,,115.87,percent of total billed charges,,,70,,103.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,72.79,3324,
60687-0387-01 - midodrine 2.5 mg Tab,60687-0387-01,NDC,,,,inpatient,1,EA,4.95,2.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.21,percent of total billed charges,,,85,,4.21,percent of total billed charges,,,49,,2.43,percent of total billed charges,,,90,,4.46,percent of total billed charges,,,,,,,no IP contract,,80,,3.96,percent of total billed charges,,,,,,,no IP contract,,50,,2.48,percent of total billed charges,,,,,,no IP contract,,,78,,3.86,percent of total billed charges,,,70,,3.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.43,3324,
ALPRAZolam 0.5 mg Tab,60687-0388-01,NDC,,,,inpatient,1,EA,9.1,5.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.74,percent of total billed charges,,,85,,7.74,percent of total billed charges,,,49,,4.46,percent of total billed charges,,,90,,8.19,percent of total billed charges,,,,,,,no IP contract,,80,,7.28,percent of total billed charges,,,,,,,no IP contract,,50,,4.55,percent of total billed charges,,,,,,no IP contract,,,78,,7.1,percent of total billed charges,,,70,,6.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.46,3324,
60687-0389-21 - colchicine 0.6 mg Tab,60687-0389-21,NDC,,,,inpatient,1,EA,92.45,55.47,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,74.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,78.58,percent of total billed charges,,,85,,78.58,percent of total billed charges,,,49,,45.3,percent of total billed charges,,,90,,83.21,percent of total billed charges,,,,,,,no IP contract,,80,,73.96,percent of total billed charges,,,,,,,no IP contract,,50,,46.23,percent of total billed charges,,,,,,no IP contract,,,78,,72.11,percent of total billed charges,,,70,,64.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,45.3,3324,
60687-0390-01 - metoprolol SUCCINATE  25 mg ER Tablet,60687-0390-01,NDC,,,,inpatient,1,EA,12.65,7.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.75,percent of total billed charges,,,85,,10.75,percent of total billed charges,,,49,,6.2,percent of total billed charges,,,90,,11.39,percent of total billed charges,,,,,,,no IP contract,,80,,10.12,percent of total billed charges,,,,,,,no IP contract,,50,,6.33,percent of total billed charges,,,,,,no IP contract,,,78,,9.87,percent of total billed charges,,,70,,8.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.2,3324,
60687-0391-01 - pioglitazone 15 mg Tab,60687-0391-01,NDC,,,,inpatient,1,EA,13.85,8.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.77,percent of total billed charges,,,85,,11.77,percent of total billed charges,,,49,,6.79,percent of total billed charges,,,90,,12.47,percent of total billed charges,,,,,,,no IP contract,,80,,11.08,percent of total billed charges,,,,,,,no IP contract,,50,,6.93,percent of total billed charges,,,,,,no IP contract,,,78,,10.8,percent of total billed charges,,,70,,9.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.79,3324,
60687-0394-83 - ipratropium 500 mcg/2.5 mL Soln,60687-0394-83,NDC,,,,inpatient,2.5,ML,11.3,6.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.61,percent of total billed charges,,,85,,9.61,percent of total billed charges,,,49,,5.54,percent of total billed charges,,,90,,10.17,percent of total billed charges,,,,,,,no IP contract,,80,,9.04,percent of total billed charges,,,,,,,no IP contract,,50,,5.65,percent of total billed charges,,,,,,no IP contract,,,78,,8.81,percent of total billed charges,,,70,,7.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.54,3324,
60687-0395-83 - albuterol 2.5 mg/3 mL (0.083%) Soln,60687-0395-83,NDC,,,,inpatient,3,ML,11.2,6.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.52,percent of total billed charges,,,85,,9.52,percent of total billed charges,,,49,,5.49,percent of total billed charges,,,90,,10.08,percent of total billed charges,,,,,,,no IP contract,,80,,8.96,percent of total billed charges,,,,,,,no IP contract,,50,,5.6,percent of total billed charges,,,,,,no IP contract,,,78,,8.74,percent of total billed charges,,,70,,7.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.49,3324,
60687-0396-01 - acetaminophen-HYDROcodone 325 mg-5 mg Tab,60687-0396-01,NDC,,,,inpatient,1,EA,10.6,6.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.01,percent of total billed charges,,,85,,9.01,percent of total billed charges,,,49,,5.19,percent of total billed charges,,,90,,9.54,percent of total billed charges,,,,,,,no IP contract,,80,,8.48,percent of total billed charges,,,,,,,no IP contract,,50,,5.3,percent of total billed charges,,,,,,no IP contract,,,78,,8.27,percent of total billed charges,,,70,,7.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.19,3324,
60687-0397-25 - mesalamine 1.2 g EC Ta,60687-0397-25,NDC,,,,inpatient,1,EA,103.05,61.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,83.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,87.59,percent of total billed charges,,,85,,87.59,percent of total billed charges,,,49,,50.49,percent of total billed charges,,,90,,92.75,percent of total billed charges,,,,,,,no IP contract,,80,,82.44,percent of total billed charges,,,,,,,no IP contract,,50,,51.53,percent of total billed charges,,,,,,no IP contract,,,78,,80.38,percent of total billed charges,,,70,,72.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,50.49,3324,
60687-0398-01 - midodrine 5 mg Tab,60687-0398-01,NDC,,,,inpatient,1,EA,11,6.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.35,percent of total billed charges,,,85,,9.35,percent of total billed charges,,,49,,5.39,percent of total billed charges,,,90,,9.9,percent of total billed charges,,,,,,,no IP contract,,80,,8.8,percent of total billed charges,,,,,,,no IP contract,,50,,5.5,percent of total billed charges,,,,,,no IP contract,,,78,,8.58,percent of total billed charges,,,70,,7.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.39,3324,
60687-0401-01 - LORazepam 0.5 mg Tab,60687-0401-01,NDC,,,,inpatient,1,EA,6.85,4.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.82,percent of total billed charges,,,85,,5.82,percent of total billed charges,,,49,,3.36,percent of total billed charges,,,90,,6.17,percent of total billed charges,,,,,,,no IP contract,,80,,5.48,percent of total billed charges,,,,,,,no IP contract,,50,,3.43,percent of total billed charges,,,,,,no IP contract,,,78,,5.34,percent of total billed charges,,,70,,4.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.36,3324,
60687-0402-01 - metoprolol SUCCINATE  50 mg ER Tablet,60687-0402-01,NDC,,,,inpatient,1,EA,12.65,7.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.75,percent of total billed charges,,,85,,10.75,percent of total billed charges,,,49,,6.2,percent of total billed charges,,,90,,11.39,percent of total billed charges,,,,,,,no IP contract,,80,,10.12,percent of total billed charges,,,,,,,no IP contract,,50,,6.33,percent of total billed charges,,,,,,no IP contract,,,78,,9.87,percent of total billed charges,,,70,,8.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.2,3324,
60687-0405-83 - albuterol-ipratropium 2.5 mg-0.5 mg/3 mL Soln,60687-0405-83,NDC,,,,inpatient,3,ML,14.45,8.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.28,percent of total billed charges,,,85,,12.28,percent of total billed charges,,,49,,7.08,percent of total billed charges,,,90,,13.01,percent of total billed charges,,,,,,,no IP contract,,80,,11.56,percent of total billed charges,,,,,,,no IP contract,,50,,7.23,percent of total billed charges,,,,,,no IP contract,,,78,,11.27,percent of total billed charges,,,70,,10.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.08,3324,
60687-0406-77 - oxyCODONE 5 mg/5 mL Soln,60687-0406-77,NDC,,,,inpatient,5,ML,64.55,38.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,52.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,54.87,percent of total billed charges,,,85,,54.87,percent of total billed charges,,,49,,31.63,percent of total billed charges,,,90,,58.1,percent of total billed charges,,,,,,,no IP contract,,80,,51.64,percent of total billed charges,,,,,,,no IP contract,,50,,32.28,percent of total billed charges,,,,,,no IP contract,,,78,,50.35,percent of total billed charges,,,70,,45.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.63,3324,
60687-0409-25 - midodrine 10 mg Tab,60687-0409-25,NDC,,,,inpatient,1,EA,17.25,10.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.66,percent of total billed charges,,,85,,14.66,percent of total billed charges,,,49,,8.45,percent of total billed charges,,,90,,15.53,percent of total billed charges,,,,,,,no IP contract,,80,,13.8,percent of total billed charges,,,,,,,no IP contract,,50,,8.63,percent of total billed charges,,,,,,no IP contract,,,78,,13.46,percent of total billed charges,,,70,,12.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.45,3324,
60687-0413-01 - metoprolol SUCCINATE 100 mg ER Tablet,60687-0413-01,NDC,,,,inpatient,1,EA,17.2,10.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.62,percent of total billed charges,,,85,,14.62,percent of total billed charges,,,49,,8.43,percent of total billed charges,,,90,,15.48,percent of total billed charges,,,,,,,no IP contract,,80,,13.76,percent of total billed charges,,,,,,,no IP contract,,50,,8.6,percent of total billed charges,,,,,,no IP contract,,,78,,13.42,percent of total billed charges,,,70,,12.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.43,3324,
60687-0415-01 - clozapine 100 mg Tab,60687-0415-01,NDC,,,,inpatient,1,EA,31.35,18.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,25.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.65,percent of total billed charges,,,85,,26.65,percent of total billed charges,,,49,,15.36,percent of total billed charges,,,90,,28.22,percent of total billed charges,,,,,,,no IP contract,,80,,25.08,percent of total billed charges,,,,,,,no IP contract,,50,,15.68,percent of total billed charges,,,,,,no IP contract,,,78,,24.45,percent of total billed charges,,,70,,21.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.36,3324,
60687-0416-21 - sildenafil 20 mg Tab 20 mg Tab,60687-0416-21,NDC,,,,inpatient,1,EA,164.4,98.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,133.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,139.74,percent of total billed charges,,,85,,139.74,percent of total billed charges,,,49,,80.56,percent of total billed charges,,,90,,147.96,percent of total billed charges,,,,,,,no IP contract,,80,,131.52,percent of total billed charges,,,,,,,no IP contract,,50,,82.2,percent of total billed charges,,,,,,no IP contract,,,78,,128.23,percent of total billed charges,,,70,,115.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,80.56,3324,
60687-0418-01 - acetaminophen-hydrocodone 325 mg-10 mg Tab,60687-0418-01,NDC,,,,inpatient,1,EA,14.6,8.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.41,percent of total billed charges,,,85,,12.41,percent of total billed charges,,,49,,7.15,percent of total billed charges,,,90,,13.14,percent of total billed charges,,,,,,,no IP contract,,80,,11.68,percent of total billed charges,,,,,,,no IP contract,,50,,7.3,percent of total billed charges,,,,,,no IP contract,,,78,,11.39,percent of total billed charges,,,70,,10.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.15,3324,
60687-0422-01 - amantadine 100 mg Cap,60687-0422-01,NDC,,,,inpatient,1,EA,21.15,12.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.98,percent of total billed charges,,,85,,17.98,percent of total billed charges,,,49,,10.36,percent of total billed charges,,,90,,19.04,percent of total billed charges,,,,,,,no IP contract,,80,,16.92,percent of total billed charges,,,,,,,no IP contract,,50,,10.58,percent of total billed charges,,,,,,no IP contract,,,78,,16.5,percent of total billed charges,,,70,,14.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.36,3324,
cloBAZam 10 mg Tab,60687-0423-21,NDC,,,,inpatient,1,EA,28.65,17.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.35,percent of total billed charges,,,85,,24.35,percent of total billed charges,,,49,,14.04,percent of total billed charges,,,90,,25.79,percent of total billed charges,,,,,,,no IP contract,,80,,22.92,percent of total billed charges,,,,,,,no IP contract,,50,,14.33,percent of total billed charges,,,,,,no IP contract,,,78,,22.35,percent of total billed charges,,,70,,20.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.04,3324,
60687-0424-01 - metroNIDAZOLE 500 mg Tab,60687-0424-01,NDC,,,,inpatient,1,EA,11.15,6.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.48,percent of total billed charges,,,85,,9.48,percent of total billed charges,,,49,,5.46,percent of total billed charges,,,90,,10.04,percent of total billed charges,,,,,,,no IP contract,,80,,8.92,percent of total billed charges,,,,,,,no IP contract,,50,,5.58,percent of total billed charges,,,,,,no IP contract,,,78,,8.7,percent of total billed charges,,,70,,7.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.46,3324,
60687-0428-01 - finasteride 5 mg Tab,60687-0428-01,NDC,,,,inpatient,1,EA,12.4,7.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.54,percent of total billed charges,,,85,,10.54,percent of total billed charges,,,49,,6.08,percent of total billed charges,,,90,,11.16,percent of total billed charges,,,,,,,no IP contract,,80,,9.92,percent of total billed charges,,,,,,,no IP contract,,50,,6.2,percent of total billed charges,,,,,,no IP contract,,,78,,9.67,percent of total billed charges,,,70,,8.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.08,3324,
60687-0429-76 - magnesium hydroxide 8% Susp,60687-0429-76,NDC,,,,inpatient,30,ML,25.4,15.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.59,percent of total billed charges,,,85,,21.59,percent of total billed charges,,,49,,12.45,percent of total billed charges,,,90,,22.86,percent of total billed charges,,,,,,,no IP contract,,80,,20.32,percent of total billed charges,,,,,,,no IP contract,,50,,12.7,percent of total billed charges,,,,,,no IP contract,,,78,,19.81,percent of total billed charges,,,70,,17.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.45,3324,
60687-0433-01 - amitriptyline 25 mg Tab,60687-0433-01,NDC,,,,inpatient,1,EA,7.95,4.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.76,percent of total billed charges,,,85,,6.76,percent of total billed charges,,,49,,3.9,percent of total billed charges,,,90,,7.16,percent of total billed charges,,,,,,,no IP contract,,80,,6.36,percent of total billed charges,,,,,,,no IP contract,,50,,3.98,percent of total billed charges,,,,,,no IP contract,,,78,,6.2,percent of total billed charges,,,70,,5.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.9,3324,
60687-0436-01 - celecoxib 100 mg Cap,60687-0436-01,NDC,,,,inpatient,1,EA,40.55,24.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34.47,percent of total billed charges,,,85,,34.47,percent of total billed charges,,,49,,19.87,percent of total billed charges,,,90,,36.5,percent of total billed charges,,,,,,,no IP contract,,80,,32.44,percent of total billed charges,,,,,,,no IP contract,,50,,20.28,percent of total billed charges,,,,,,no IP contract,,,78,,31.63,percent of total billed charges,,,70,,28.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.87,3324,
60687-0437-01 - amiodarone 200 mg Tab,60687-0437-01,NDC,,,,inpatient,1,EA,8.65,5.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.35,percent of total billed charges,,,85,,7.35,percent of total billed charges,,,49,,4.24,percent of total billed charges,,,90,,7.79,percent of total billed charges,,,,,,,no IP contract,,80,,6.92,percent of total billed charges,,,,,,,no IP contract,,50,,4.33,percent of total billed charges,,,,,,no IP contract,,,78,,6.75,percent of total billed charges,,,70,,6.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.24,3324,
60687-0438-01 - mycophenoLATE mofetil [Cellcept] 500 mg Tab,60687-0438-01,NDC,,,,inpatient,1,EA,16.25,9.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.81,percent of total billed charges,,,85,,13.81,percent of total billed charges,,,49,,7.96,percent of total billed charges,,,90,,14.63,percent of total billed charges,,,,,,,no IP contract,,80,,13,percent of total billed charges,,,,,,,no IP contract,,50,,8.13,percent of total billed charges,,,,,,no IP contract,,,78,,12.68,percent of total billed charges,,,70,,11.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.96,3324,
60687-0439-01 - labetalol 100 mg Tab,60687-0439-01,NDC,,,,inpatient,1,EA,8.1,4.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.89,percent of total billed charges,,,85,,6.89,percent of total billed charges,,,49,,3.97,percent of total billed charges,,,90,,7.29,percent of total billed charges,,,,,,,no IP contract,,80,,6.48,percent of total billed charges,,,,,,,no IP contract,,50,,4.05,percent of total billed charges,,,,,,no IP contract,,,78,,6.32,percent of total billed charges,,,70,,5.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.97,3324,
60687-0443-01 - traZODone 50 mg Tab,60687-0443-01,NDC,,,,inpatient,1,EA,5.1,3.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.34,percent of total billed charges,,,85,,4.34,percent of total billed charges,,,49,,2.5,percent of total billed charges,,,90,,4.59,percent of total billed charges,,,,,,,no IP contract,,80,,4.08,percent of total billed charges,,,,,,,no IP contract,,50,,2.55,percent of total billed charges,,,,,,no IP contract,,,78,,3.98,percent of total billed charges,,,70,,3.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.5,3324,
60687-0444-01 - amitriptyline 50 mg Tab,60687-0444-01,NDC,,,,inpatient,1,EA,9.4,5.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.99,percent of total billed charges,,,85,,7.99,percent of total billed charges,,,49,,4.61,percent of total billed charges,,,90,,8.46,percent of total billed charges,,,,,,,no IP contract,,80,,7.52,percent of total billed charges,,,,,,,no IP contract,,50,,4.7,percent of total billed charges,,,,,,no IP contract,,,78,,7.33,percent of total billed charges,,,70,,6.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.61,3324,
60687-0446-01 - ibuprofen 400 mg Tab,60687-0446-01,NDC,,,,inpatient,1,EA,5.9,3.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.02,percent of total billed charges,,,85,,5.02,percent of total billed charges,,,49,,2.89,percent of total billed charges,,,90,,5.31,percent of total billed charges,,,,,,,no IP contract,,80,,4.72,percent of total billed charges,,,,,,,no IP contract,,50,,2.95,percent of total billed charges,,,,,,no IP contract,,,78,,4.6,percent of total billed charges,,,70,,4.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.89,3324,
60687-0447-01 - celecoxib 200 mg Cap,60687-0447-01,NDC,,,,inpatient,1,EA,23.15,13.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.68,percent of total billed charges,,,85,,19.68,percent of total billed charges,,,49,,11.34,percent of total billed charges,,,90,,20.84,percent of total billed charges,,,,,,,no IP contract,,80,,18.52,percent of total billed charges,,,,,,,no IP contract,,50,,11.58,percent of total billed charges,,,,,,no IP contract,,,78,,18.06,percent of total billed charges,,,70,,16.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.34,3324,
60687-0450-01 - labetalol 200 mg Tab,60687-0450-01,NDC,,,,inpatient,1,EA,9.4,5.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.99,percent of total billed charges,,,85,,7.99,percent of total billed charges,,,49,,4.61,percent of total billed charges,,,90,,8.46,percent of total billed charges,,,,,,,no IP contract,,80,,7.52,percent of total billed charges,,,,,,,no IP contract,,50,,4.7,percent of total billed charges,,,,,,no IP contract,,,78,,7.33,percent of total billed charges,,,70,,6.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.61,3324,
60687-0451-21 - eplerenone 25 mg Tab,60687-0451-21,NDC,,,,inpatient,1,EA,43.55,26.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,35.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,37.02,percent of total billed charges,,,85,,37.02,percent of total billed charges,,,49,,21.34,percent of total billed charges,,,90,,39.2,percent of total billed charges,,,,,,,no IP contract,,80,,34.84,percent of total billed charges,,,,,,,no IP contract,,50,,21.78,percent of total billed charges,,,,,,no IP contract,,,78,,33.97,percent of total billed charges,,,70,,30.49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.34,3324,
levothyroxine 25 mcg (0.025 mg) Tab,60687-0453-01,NDC,,,,inpatient,1,EA,8.3,4.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.06,percent of total billed charges,,,85,,7.06,percent of total billed charges,,,49,,4.07,percent of total billed charges,,,90,,7.47,percent of total billed charges,,,,,,,no IP contract,,80,,6.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.15,percent of total billed charges,,,,,,no IP contract,,,78,,6.47,percent of total billed charges,,,70,,5.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.07,3324,
60687-0454-01 - traZODone 100 mg Tab,60687-0454-01,NDC,,,,inpatient,1,EA,5.55,3.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.72,percent of total billed charges,,,85,,4.72,percent of total billed charges,,,49,,2.72,percent of total billed charges,,,90,,5,percent of total billed charges,,,,,,,no IP contract,,80,,4.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.78,percent of total billed charges,,,,,,no IP contract,,,78,,4.33,percent of total billed charges,,,70,,3.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.72,3324,
60687-0457-01 - ibuprofen 600 mg Tab,60687-0457-01,NDC,,,,inpatient,1,EA,6.7,4.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.7,percent of total billed charges,,,85,,5.7,percent of total billed charges,,,49,,3.28,percent of total billed charges,,,90,,6.03,percent of total billed charges,,,,,,,no IP contract,,80,,5.36,percent of total billed charges,,,,,,,no IP contract,,50,,3.35,percent of total billed charges,,,,,,no IP contract,,,78,,5.23,percent of total billed charges,,,70,,4.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.28,3324,
60687-0458-01 - glycopyrrolate 1 mg Tab,60687-0458-01,NDC,,,,inpatient,1,EA,13.7,8.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.65,percent of total billed charges,,,85,,11.65,percent of total billed charges,,,49,,6.71,percent of total billed charges,,,90,,12.33,percent of total billed charges,,,,,,,no IP contract,,80,,10.96,percent of total billed charges,,,,,,,no IP contract,,50,,6.85,percent of total billed charges,,,,,,no IP contract,,,78,,10.69,percent of total billed charges,,,70,,9.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.71,3324,
60687-0461-01 - labetalol 300 mg Tab,60687-0461-01,NDC,,,,inpatient,1,EA,13.3,7.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.31,percent of total billed charges,,,85,,11.31,percent of total billed charges,,,49,,6.52,percent of total billed charges,,,90,,11.97,percent of total billed charges,,,,,,,no IP contract,,80,,10.64,percent of total billed charges,,,,,,,no IP contract,,50,,6.65,percent of total billed charges,,,,,,no IP contract,,,78,,10.37,percent of total billed charges,,,70,,9.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.52,3324,
60687-0464-01 - levothyroxine 50 mcg (0.05 mg) Tab,60687-0464-01,NDC,,,,inpatient,1,EA,8.3,4.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.06,percent of total billed charges,,,85,,7.06,percent of total billed charges,,,49,,4.07,percent of total billed charges,,,90,,7.47,percent of total billed charges,,,,,,,no IP contract,,80,,6.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.15,percent of total billed charges,,,,,,no IP contract,,,78,,6.47,percent of total billed charges,,,70,,5.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.07,3324,
60687-0465-01 - spironolactone 25 mg Tab,60687-0465-01,NDC,,,,inpatient,1,EA,5.65,3.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.8,percent of total billed charges,,,85,,4.8,percent of total billed charges,,,49,,2.77,percent of total billed charges,,,90,,5.09,percent of total billed charges,,,,,,,no IP contract,,80,,4.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.83,percent of total billed charges,,,,,,no IP contract,,,78,,4.41,percent of total billed charges,,,70,,3.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.77,3324,
60687-0466-01 - potassium chloride 10 mEq ER Tablet,60687-0466-01,NDC,,,,inpatient,1,EA,8.65,5.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.35,percent of total billed charges,,,85,,7.35,percent of total billed charges,,,49,,4.24,percent of total billed charges,,,90,,7.79,percent of total billed charges,,,,,,,no IP contract,,80,,6.92,percent of total billed charges,,,,,,,no IP contract,,50,,4.33,percent of total billed charges,,,,,,no IP contract,,,78,,6.75,percent of total billed charges,,,70,,6.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.24,3324,
60687-0472-01 - nitrofurantoin macrocrystals 50 mg Cap,60687-0472-01,NDC,,,,inpatient,1,EA,38.95,23.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.11,percent of total billed charges,,,85,,33.11,percent of total billed charges,,,49,,19.09,percent of total billed charges,,,90,,35.06,percent of total billed charges,,,,,,,no IP contract,,80,,31.16,percent of total billed charges,,,,,,,no IP contract,,50,,19.48,percent of total billed charges,,,,,,no IP contract,,,78,,30.38,percent of total billed charges,,,70,,27.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.09,3324,
60687-0473-01 - pregabalin 25 mg Cap,60687-0473-01,NDC,,,,inpatient,1,EA,18.9,11.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.07,percent of total billed charges,,,85,,16.07,percent of total billed charges,,,49,,9.26,percent of total billed charges,,,90,,17.01,percent of total billed charges,,,,,,,no IP contract,,80,,15.12,percent of total billed charges,,,,,,,no IP contract,,50,,9.45,percent of total billed charges,,,,,,no IP contract,,,78,,14.74,percent of total billed charges,,,70,,13.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.26,3324,
60687-0475-01 - levothyroxine 75 mcg (0.075 mg) Tab,60687-0475-01,NDC,,,,inpatient,1,EA,9.4,5.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.99,percent of total billed charges,,,85,,7.99,percent of total billed charges,,,49,,4.61,percent of total billed charges,,,90,,8.46,percent of total billed charges,,,,,,,no IP contract,,80,,7.52,percent of total billed charges,,,,,,,no IP contract,,50,,4.7,percent of total billed charges,,,,,,no IP contract,,,78,,7.33,percent of total billed charges,,,70,,6.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.61,3324,
60687-0476-01 - spironolactone 50 mg Tab,60687-0476-01,NDC,,,,inpatient,1,EA,8.2,4.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.97,percent of total billed charges,,,85,,6.97,percent of total billed charges,,,49,,4.02,percent of total billed charges,,,90,,7.38,percent of total billed charges,,,,,,,no IP contract,,80,,6.56,percent of total billed charges,,,,,,,no IP contract,,50,,4.1,percent of total billed charges,,,,,,no IP contract,,,78,,6.4,percent of total billed charges,,,70,,5.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.02,3324,
60687-0484-01 - pregabalin 50 mg Cap,60687-0484-01,NDC,,,,inpatient,1,EA,18.9,11.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.07,percent of total billed charges,,,85,,16.07,percent of total billed charges,,,49,,9.26,percent of total billed charges,,,90,,17.01,percent of total billed charges,,,,,,,no IP contract,,80,,15.12,percent of total billed charges,,,,,,,no IP contract,,50,,9.45,percent of total billed charges,,,,,,no IP contract,,,78,,14.74,percent of total billed charges,,,70,,13.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.26,3324,
60687-0486-01 - levothyroxine 88 mcg tab 88 mcg Tab,60687-0486-01,NDC,,,,inpatient,1,EA,9.4,5.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.99,percent of total billed charges,,,85,,7.99,percent of total billed charges,,,49,,4.61,percent of total billed charges,,,90,,8.46,percent of total billed charges,,,,,,,no IP contract,,80,,7.52,percent of total billed charges,,,,,,,no IP contract,,50,,4.7,percent of total billed charges,,,,,,no IP contract,,,78,,7.33,percent of total billed charges,,,70,,6.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.61,3324,
60687-0488-01 - amLODIPine 5 mg Tab,60687-0488-01,NDC,,,,inpatient,1,EA,4.8,2.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.08,percent of total billed charges,,,85,,4.08,percent of total billed charges,,,49,,2.35,percent of total billed charges,,,90,,4.32,percent of total billed charges,,,,,,,no IP contract,,80,,3.84,percent of total billed charges,,,,,,,no IP contract,,50,,2.4,percent of total billed charges,,,,,,no IP contract,,,78,,3.74,percent of total billed charges,,,70,,3.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.35,3324,
60687-0491-01 - naproxen 500 mg Tab,60687-0491-01,NDC,,,,inpatient,1,EA,14.5,8.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.33,percent of total billed charges,,,85,,12.33,percent of total billed charges,,,49,,7.11,percent of total billed charges,,,90,,13.05,percent of total billed charges,,,,,,,no IP contract,,80,,11.6,percent of total billed charges,,,,,,,no IP contract,,50,,7.25,percent of total billed charges,,,,,,no IP contract,,,78,,11.31,percent of total billed charges,,,70,,10.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.11,3324,
60687-0494-01 - mycophenolate mofetil 250 mg Cap,60687-0494-01,NDC,,,,inpatient,1,EA,9.8,5.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.33,percent of total billed charges,,,85,,8.33,percent of total billed charges,,,49,,4.8,percent of total billed charges,,,90,,8.82,percent of total billed charges,,,,,,,no IP contract,,80,,7.84,percent of total billed charges,,,,,,,no IP contract,,50,,4.9,percent of total billed charges,,,,,,no IP contract,,,78,,7.64,percent of total billed charges,,,70,,6.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.8,3324,
60687-0495-01 - pregabalin 75 mg Cap,60687-0495-01,NDC,,,,inpatient,1,EA,16.7,10.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.2,percent of total billed charges,,,85,,14.2,percent of total billed charges,,,49,,8.18,percent of total billed charges,,,90,,15.03,percent of total billed charges,,,,,,,no IP contract,,80,,13.36,percent of total billed charges,,,,,,,no IP contract,,50,,8.35,percent of total billed charges,,,,,,no IP contract,,,78,,13.03,percent of total billed charges,,,70,,11.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.18,3324,
60687-0496-01 - amLODIPine 10 mg Tab,60687-0496-01,NDC,,,,inpatient,1,EA,4.8,2.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.08,percent of total billed charges,,,85,,4.08,percent of total billed charges,,,49,,2.35,percent of total billed charges,,,90,,4.32,percent of total billed charges,,,,,,,no IP contract,,80,,3.84,percent of total billed charges,,,,,,,no IP contract,,50,,2.4,percent of total billed charges,,,,,,no IP contract,,,78,,3.74,percent of total billed charges,,,70,,3.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.35,3324,
60687-0499-21 - solifenacin 5 mg Tab,60687-0499-21,NDC,,,,inpatient,1,EA,18.95,11.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.11,percent of total billed charges,,,85,,16.11,percent of total billed charges,,,49,,9.29,percent of total billed charges,,,90,,17.06,percent of total billed charges,,,,,,,no IP contract,,80,,15.16,percent of total billed charges,,,,,,,no IP contract,,50,,9.48,percent of total billed charges,,,,,,no IP contract,,,78,,14.78,percent of total billed charges,,,70,,13.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.29,3324,
"60687-0500-01 - ergocalciferol  50,000 unit(s) Cap",60687-0500-01,NDC,,,,inpatient,1,EA,19.1,11.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.24,percent of total billed charges,,,85,,16.24,percent of total billed charges,,,49,,9.36,percent of total billed charges,,,90,,17.19,percent of total billed charges,,,,,,,no IP contract,,80,,15.28,percent of total billed charges,,,,,,,no IP contract,,50,,9.55,percent of total billed charges,,,,,,no IP contract,,,78,,14.9,percent of total billed charges,,,70,,13.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.36,3324,
60687-0503-01 - baclofen 10 mg Tab,60687-0503-01,NDC,,,,inpatient,1,EA,9.7,5.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.25,percent of total billed charges,,,85,,8.25,percent of total billed charges,,,49,,4.75,percent of total billed charges,,,90,,8.73,percent of total billed charges,,,,,,,no IP contract,,80,,7.76,percent of total billed charges,,,,,,,no IP contract,,50,,4.85,percent of total billed charges,,,,,,no IP contract,,,78,,7.57,percent of total billed charges,,,70,,6.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.75,3324,
60687-0506-01 - pregabalin 100 mg Cap,60687-0506-01,NDC,,,,inpatient,1,EA,18.9,11.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.07,percent of total billed charges,,,85,,16.07,percent of total billed charges,,,49,,9.26,percent of total billed charges,,,90,,17.01,percent of total billed charges,,,,,,,no IP contract,,80,,15.12,percent of total billed charges,,,,,,,no IP contract,,50,,9.45,percent of total billed charges,,,,,,no IP contract,,,78,,14.74,percent of total billed charges,,,70,,13.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.26,3324,
60687-0508-01 - levothyroxine 112 mcg (0.112 mg) Tab,60687-0508-01,NDC,,,,inpatient,1,EA,10.35,6.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.8,percent of total billed charges,,,85,,8.8,percent of total billed charges,,,49,,5.07,percent of total billed charges,,,90,,9.32,percent of total billed charges,,,,,,,no IP contract,,80,,8.28,percent of total billed charges,,,,,,,no IP contract,,50,,5.18,percent of total billed charges,,,,,,no IP contract,,,78,,8.07,percent of total billed charges,,,70,,7.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.07,3324,
60687-0511-01 - hydroCORTisone 10 mg Tab,60687-0511-01,NDC,,,,inpatient,1,EA,17.65,10.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15,percent of total billed charges,,,85,,15,percent of total billed charges,,,49,,8.65,percent of total billed charges,,,90,,15.89,percent of total billed charges,,,,,,,no IP contract,,80,,14.12,percent of total billed charges,,,,,,,no IP contract,,50,,8.83,percent of total billed charges,,,,,,no IP contract,,,78,,13.77,percent of total billed charges,,,70,,12.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.65,3324,
60687-0514-01 - baclofen 20 mg Tab,60687-0514-01,NDC,,,,inpatient,1,EA,13.45,8.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.43,percent of total billed charges,,,85,,11.43,percent of total billed charges,,,49,,6.59,percent of total billed charges,,,90,,12.11,percent of total billed charges,,,,,,,no IP contract,,80,,10.76,percent of total billed charges,,,,,,,no IP contract,,50,,6.73,percent of total billed charges,,,,,,no IP contract,,,78,,10.49,percent of total billed charges,,,70,,9.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.59,3324,
60687-0517-01 - pregabalin 150 mg Cap,60687-0517-01,NDC,,,,inpatient,1,EA,16.7,10.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.2,percent of total billed charges,,,85,,14.2,percent of total billed charges,,,49,,8.18,percent of total billed charges,,,90,,15.03,percent of total billed charges,,,,,,,no IP contract,,80,,13.36,percent of total billed charges,,,,,,,no IP contract,,50,,8.35,percent of total billed charges,,,,,,no IP contract,,,78,,13.03,percent of total billed charges,,,70,,11.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.18,3324,
60687-0518-01 - gabapentin 800 mg Tab,60687-0518-01,NDC,,,,inpatient,1,EA,26.95,16.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.91,percent of total billed charges,,,85,,22.91,percent of total billed charges,,,49,,13.21,percent of total billed charges,,,90,,24.26,percent of total billed charges,,,,,,,no IP contract,,80,,21.56,percent of total billed charges,,,,,,,no IP contract,,50,,13.48,percent of total billed charges,,,,,,no IP contract,,,78,,21.02,percent of total billed charges,,,70,,18.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.21,3324,
60687-0519-01 - levothyroxine 125 mcg (0.125 mg) Tab,60687-0519-01,NDC,,,,inpatient,1,EA,10.6,6.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.01,percent of total billed charges,,,85,,9.01,percent of total billed charges,,,49,,5.19,percent of total billed charges,,,90,,9.54,percent of total billed charges,,,,,,,no IP contract,,80,,8.48,percent of total billed charges,,,,,,,no IP contract,,50,,5.3,percent of total billed charges,,,,,,no IP contract,,,78,,8.27,percent of total billed charges,,,70,,7.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.19,3324,
60687-0525-21 - cinacalcet $31.00 Tab,60687-0525-21,NDC,,,,inpatient,1,EA,242.3,145.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,196.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,205.96,percent of total billed charges,,,85,,205.96,percent of total billed charges,,,49,,118.73,percent of total billed charges,,,90,,218.07,percent of total billed charges,,,,,,,no IP contract,,80,,193.84,percent of total billed charges,,,,,,,no IP contract,,50,,121.15,percent of total billed charges,,,,,,no IP contract,,,78,,188.99,percent of total billed charges,,,70,,169.61,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,118.73,3324,
60687-0526-01 - metroNIDAZOLE 250 mg Tab,60687-0526-01,NDC,,,,inpatient,1,EA,7.7,4.62,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.55,percent of total billed charges,,,85,,6.55,percent of total billed charges,,,49,,3.77,percent of total billed charges,,,90,,6.93,percent of total billed charges,,,,,,,no IP contract,,80,,6.16,percent of total billed charges,,,,,,,no IP contract,,50,,3.85,percent of total billed charges,,,,,,no IP contract,,,78,,6.01,percent of total billed charges,,,70,,5.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.77,3324,
60687-0530-01 - levothyroxine 150 mcg (0.15 mg) Tab,60687-0530-01,NDC,,,,inpatient,1,EA,10.75,6.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.14,percent of total billed charges,,,85,,9.14,percent of total billed charges,,,49,,5.27,percent of total billed charges,,,90,,9.68,percent of total billed charges,,,,,,,no IP contract,,80,,8.6,percent of total billed charges,,,,,,,no IP contract,,50,,5.38,percent of total billed charges,,,,,,no IP contract,,,78,,8.39,percent of total billed charges,,,70,,7.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.27,3324,
60687-0535-01 - bumetanide 2 mg Tab,60687-0535-01,NDC,,,,inpatient,1,EA,17.9,10.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.22,percent of total billed charges,,,85,,15.22,percent of total billed charges,,,49,,8.77,percent of total billed charges,,,90,,16.11,percent of total billed charges,,,,,,,no IP contract,,80,,14.32,percent of total billed charges,,,,,,,no IP contract,,50,,8.95,percent of total billed charges,,,,,,no IP contract,,,78,,13.96,percent of total billed charges,,,70,,12.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.77,3324,
60687-0540-01 - digoxin 125 mcg (0.125 mg) Tab,60687-0540-01,NDC,,,,inpatient,1,EA,14.9,8.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.67,percent of total billed charges,,,85,,12.67,percent of total billed charges,,,49,,7.3,percent of total billed charges,,,90,,13.41,percent of total billed charges,,,,,,,no IP contract,,80,,11.92,percent of total billed charges,,,,,,,no IP contract,,50,,7.45,percent of total billed charges,,,,,,no IP contract,,,78,,11.62,percent of total billed charges,,,70,,10.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.3,3324,
60687-0542-21 - sulfamethoxazole-trimethoprim 400 mg-80 mg Tab,60687-0542-21,NDC,,,,inpatient,1,EA,9.95,5.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.46,percent of total billed charges,,,85,,8.46,percent of total billed charges,,,49,,4.88,percent of total billed charges,,,90,,8.96,percent of total billed charges,,,,,,,no IP contract,,80,,7.96,percent of total billed charges,,,,,,,no IP contract,,50,,4.98,percent of total billed charges,,,,,,no IP contract,,,78,,7.76,percent of total billed charges,,,70,,6.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.88,3324,
60687-0544-01 - clonazePAM 0.5 mg Tab,60687-0544-01,NDC,,,,inpatient,1,EA,7.75,4.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.59,percent of total billed charges,,,85,,6.59,percent of total billed charges,,,49,,3.8,percent of total billed charges,,,90,,6.98,percent of total billed charges,,,,,,,no IP contract,,80,,6.2,percent of total billed charges,,,,,,,no IP contract,,50,,3.88,percent of total billed charges,,,,,,no IP contract,,,78,,6.05,percent of total billed charges,,,70,,5.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.8,3324,
60687-0550-01 - metroNIDAZOLE 500 mg Tab,60687-0550-01,NDC,,,,inpatient,1,EA,11.15,6.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.48,percent of total billed charges,,,85,,9.48,percent of total billed charges,,,49,,5.46,percent of total billed charges,,,90,,10.04,percent of total billed charges,,,,,,,no IP contract,,80,,8.92,percent of total billed charges,,,,,,,no IP contract,,50,,5.58,percent of total billed charges,,,,,,no IP contract,,,78,,8.7,percent of total billed charges,,,70,,7.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.46,3324,
60687-0551-01 - digoxin 250 mcg (0.25 mg) Tab,60687-0551-01,NDC,,,,inpatient,1,EA,14.9,8.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.67,percent of total billed charges,,,85,,12.67,percent of total billed charges,,,49,,7.3,percent of total billed charges,,,90,,13.41,percent of total billed charges,,,,,,,no IP contract,,80,,11.92,percent of total billed charges,,,,,,,no IP contract,,50,,7.45,percent of total billed charges,,,,,,no IP contract,,,78,,11.62,percent of total billed charges,,,70,,10.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.3,3324,
60687-0552-01 - levothyroxine 200 mcg (0.2 mg) Tab,60687-0552-01,NDC,,,,inpatient,1,EA,18.15,10.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.43,percent of total billed charges,,,85,,15.43,percent of total billed charges,,,49,,8.89,percent of total billed charges,,,90,,16.34,percent of total billed charges,,,,,,,no IP contract,,80,,14.52,percent of total billed charges,,,,,,,no IP contract,,50,,9.08,percent of total billed charges,,,,,,no IP contract,,,78,,14.16,percent of total billed charges,,,70,,12.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.89,3324,
60687-0553-01 - isoniazid 300 mg Tab,60687-0553-01,NDC,,,,inpatient,1,EA,14.3,8.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.16,percent of total billed charges,,,85,,12.16,percent of total billed charges,,,49,,7.01,percent of total billed charges,,,90,,12.87,percent of total billed charges,,,,,,,no IP contract,,80,,11.44,percent of total billed charges,,,,,,,no IP contract,,50,,7.15,percent of total billed charges,,,,,,no IP contract,,,78,,11.15,percent of total billed charges,,,70,,10.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.01,3324,
60687-0555-01 - clonazePAM 1 mg Tab,60687-0555-01,NDC,,,,inpatient,1,EA,11.35,6.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.65,percent of total billed charges,,,85,,9.65,percent of total billed charges,,,49,,5.56,percent of total billed charges,,,90,,10.22,percent of total billed charges,,,,,,,no IP contract,,80,,9.08,percent of total billed charges,,,,,,,no IP contract,,50,,5.68,percent of total billed charges,,,,,,no IP contract,,,78,,8.85,percent of total billed charges,,,70,,7.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.56,3324,
60687-0558-01 - cyclobenzaprine 10 mg Tab,60687-0558-01,NDC,,,,inpatient,1,EA,5.5,3.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.68,percent of total billed charges,,,85,,4.68,percent of total billed charges,,,49,,2.7,percent of total billed charges,,,90,,4.95,percent of total billed charges,,,,,,,no IP contract,,80,,4.4,percent of total billed charges,,,,,,,no IP contract,,50,,2.75,percent of total billed charges,,,,,,no IP contract,,,78,,4.29,percent of total billed charges,,,70,,3.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.7,3324,
60687-0559-01 - methocarbamol 500 mg Tab,60687-0559-01,NDC,,,,inpatient,1,EA,6.2,3.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.27,percent of total billed charges,,,85,,5.27,percent of total billed charges,,,49,,3.04,percent of total billed charges,,,90,,5.58,percent of total billed charges,,,,,,,no IP contract,,80,,4.96,percent of total billed charges,,,,,,,no IP contract,,50,,3.1,percent of total billed charges,,,,,,no IP contract,,,78,,4.84,percent of total billed charges,,,70,,4.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.04,3324,
60687-0562-01 - dilTIAZem 30 mg Tab,60687-0562-01,NDC,,,,inpatient,1,EA,7.1,4.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.04,percent of total billed charges,,,85,,6.04,percent of total billed charges,,,49,,3.48,percent of total billed charges,,,90,,6.39,percent of total billed charges,,,,,,,no IP contract,,80,,5.68,percent of total billed charges,,,,,,,no IP contract,,50,,3.55,percent of total billed charges,,,,,,no IP contract,,,78,,5.54,percent of total billed charges,,,70,,4.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.48,3324,
60687-0563-01 - levothyroxine 137 mcg Tab,60687-0563-01,NDC,,,,inpatient,1,EA,10.65,6.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.05,percent of total billed charges,,,85,,9.05,percent of total billed charges,,,49,,5.22,percent of total billed charges,,,90,,9.59,percent of total billed charges,,,,,,,no IP contract,,80,,8.52,percent of total billed charges,,,,,,,no IP contract,,50,,5.33,percent of total billed charges,,,,,,no IP contract,,,78,,8.31,percent of total billed charges,,,70,,7.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.22,3324,
60687-0568-01 - methocarbamol 750 mg Tab,60687-0568-01,NDC,,,,inpatient,1,EA,6.75,4.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.74,percent of total billed charges,,,85,,5.74,percent of total billed charges,,,49,,3.31,percent of total billed charges,,,90,,6.08,percent of total billed charges,,,,,,,no IP contract,,80,,5.4,percent of total billed charges,,,,,,,no IP contract,,50,,3.38,percent of total billed charges,,,,,,no IP contract,,,78,,5.27,percent of total billed charges,,,70,,4.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.31,3324,
60687-0569-01 - atropine-diphenoxylate 0.025 mg-2.5 mg Tab,60687-0569-01,NDC,,,,inpatient,1,EA,15.1,9.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.84,percent of total billed charges,,,85,,12.84,percent of total billed charges,,,49,,7.4,percent of total billed charges,,,90,,13.59,percent of total billed charges,,,,,,,no IP contract,,80,,12.08,percent of total billed charges,,,,,,,no IP contract,,50,,7.55,percent of total billed charges,,,,,,no IP contract,,,78,,11.78,percent of total billed charges,,,70,,10.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.4,3324,
60687-0570-01 - pramipexole 0.25 mg Tab,60687-0570-01,NDC,,,,inpatient,1,EA,6.7,4.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.7,percent of total billed charges,,,85,,5.7,percent of total billed charges,,,49,,3.28,percent of total billed charges,,,90,,6.03,percent of total billed charges,,,,,,,no IP contract,,80,,5.36,percent of total billed charges,,,,,,,no IP contract,,50,,3.35,percent of total billed charges,,,,,,no IP contract,,,78,,5.23,percent of total billed charges,,,70,,4.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.28,3324,
60687-0571-56 - acetaminophen 650 mg/20.3 mL LIQ,60687-0571-56,NDC,,,,inpatient,20.3,ML,20.4,12.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.34,percent of total billed charges,,,85,,17.34,percent of total billed charges,,,49,,10,percent of total billed charges,,,90,,18.36,percent of total billed charges,,,,,,,no IP contract,,80,,16.32,percent of total billed charges,,,,,,,no IP contract,,50,,10.2,percent of total billed charges,,,,,,no IP contract,,,78,,15.91,percent of total billed charges,,,70,,14.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10,3324,
60687-0573-01 - dilTIAZem 60 mg Tab,60687-0573-01,NDC,,,,inpatient,1,EA,8.1,4.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.89,percent of total billed charges,,,85,,6.89,percent of total billed charges,,,49,,3.97,percent of total billed charges,,,90,,7.29,percent of total billed charges,,,,,,,no IP contract,,80,,6.48,percent of total billed charges,,,,,,,no IP contract,,50,,4.05,percent of total billed charges,,,,,,no IP contract,,,78,,6.32,percent of total billed charges,,,70,,5.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.97,3324,
60687-0575-21 - rifAMPin 150 mg Cap,60687-0575-21,NDC,,,,inpatient,1,EA,19.65,11.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.7,percent of total billed charges,,,85,,16.7,percent of total billed charges,,,49,,9.63,percent of total billed charges,,,90,,17.69,percent of total billed charges,,,,,,,no IP contract,,80,,15.72,percent of total billed charges,,,,,,,no IP contract,,50,,9.83,percent of total billed charges,,,,,,no IP contract,,,78,,15.33,percent of total billed charges,,,70,,13.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.63,3324,
60687-0577-01 - rOPINIRole 0.25 mg Tab,60687-0577-01,NDC,,,,inpatient,1,EA,9.05,5.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.69,percent of total billed charges,,,85,,7.69,percent of total billed charges,,,49,,4.43,percent of total billed charges,,,90,,8.15,percent of total billed charges,,,,,,,no IP contract,,80,,7.24,percent of total billed charges,,,,,,,no IP contract,,50,,4.53,percent of total billed charges,,,,,,no IP contract,,,78,,7.06,percent of total billed charges,,,70,,6.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.43,3324,
60687-0579-01 - HYDROmorphone 2 mg Tab,60687-0579-01,NDC,,,,inpatient,1,EA,11.35,6.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.65,percent of total billed charges,,,85,,9.65,percent of total billed charges,,,49,,5.56,percent of total billed charges,,,90,,10.22,percent of total billed charges,,,,,,,no IP contract,,80,,9.08,percent of total billed charges,,,,,,,no IP contract,,50,,5.68,percent of total billed charges,,,,,,no IP contract,,,78,,8.85,percent of total billed charges,,,70,,7.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.56,3324,
60687-0580-01 - gabapentin 100 mg Cap,60687-0580-01,NDC,,,,inpatient,1,EA,8.45,5.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.18,percent of total billed charges,,,85,,7.18,percent of total billed charges,,,49,,4.14,percent of total billed charges,,,90,,7.61,percent of total billed charges,,,,,,,no IP contract,,80,,6.76,percent of total billed charges,,,,,,,no IP contract,,50,,4.23,percent of total billed charges,,,,,,no IP contract,,,78,,6.59,percent of total billed charges,,,70,,5.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.14,3324,
60687-0586-01 - rifAMPin 300 mg Cap,60687-0586-01,NDC,,,,inpatient,1,EA,14.65,8.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.45,percent of total billed charges,,,85,,12.45,percent of total billed charges,,,49,,7.18,percent of total billed charges,,,90,,13.19,percent of total billed charges,,,,,,,no IP contract,,80,,11.72,percent of total billed charges,,,,,,,no IP contract,,50,,7.33,percent of total billed charges,,,,,,no IP contract,,,78,,11.43,percent of total billed charges,,,70,,10.26,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.18,3324,
60687-0587-01 - propranolol 10 mg Tab,60687-0587-01,NDC,,,,inpatient,1,EA,6.2,3.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.27,percent of total billed charges,,,85,,5.27,percent of total billed charges,,,49,,3.04,percent of total billed charges,,,90,,5.58,percent of total billed charges,,,,,,,no IP contract,,80,,4.96,percent of total billed charges,,,,,,,no IP contract,,50,,3.1,percent of total billed charges,,,,,,no IP contract,,,78,,4.84,percent of total billed charges,,,70,,4.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.04,3324,
60687-0590-01 - HYDROmorphone 4 mg Tab,60687-0590-01,NDC,,,,inpatient,1,EA,11.35,6.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.65,percent of total billed charges,,,85,,9.65,percent of total billed charges,,,49,,5.56,percent of total billed charges,,,90,,10.22,percent of total billed charges,,,,,,,no IP contract,,80,,9.08,percent of total billed charges,,,,,,,no IP contract,,50,,5.68,percent of total billed charges,,,,,,no IP contract,,,78,,8.85,percent of total billed charges,,,70,,7.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.56,3324,
60687-0591-01 - gabapentin 300 mg Cap,60687-0591-01,NDC,,,,inpatient,1,EA,14.8,8.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.58,percent of total billed charges,,,85,,12.58,percent of total billed charges,,,49,,7.25,percent of total billed charges,,,90,,13.32,percent of total billed charges,,,,,,,no IP contract,,80,,11.84,percent of total billed charges,,,,,,,no IP contract,,50,,7.4,percent of total billed charges,,,,,,no IP contract,,,78,,11.54,percent of total billed charges,,,70,,10.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.25,3324,
60687-0593-01 - hydroCHLOROthiazide 25 mg Tab,60687-0593-01,NDC,,,,inpatient,1,EA,5.8,3.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.93,percent of total billed charges,,,85,,4.93,percent of total billed charges,,,49,,2.84,percent of total billed charges,,,90,,5.22,percent of total billed charges,,,,,,,no IP contract,,80,,4.64,percent of total billed charges,,,,,,,no IP contract,,50,,2.9,percent of total billed charges,,,,,,no IP contract,,,78,,4.52,percent of total billed charges,,,70,,4.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.84,3324,
60687-0595-01 - famotidine 20 mg Tab,60687-0595-01,NDC,,,,inpatient,1,EA,5.75,3.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.89,percent of total billed charges,,,85,,4.89,percent of total billed charges,,,49,,2.82,percent of total billed charges,,,90,,5.18,percent of total billed charges,,,,,,,no IP contract,,80,,4.6,percent of total billed charges,,,,,,,no IP contract,,50,,2.88,percent of total billed charges,,,,,,no IP contract,,,78,,4.49,percent of total billed charges,,,70,,4.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.82,3324,
budesonide 3 mg DR Ca,60687-0596-32,NDC,,,,inpatient,1,EA,132.6,79.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,107.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,112.71,percent of total billed charges,,,85,,112.71,percent of total billed charges,,,49,,64.97,percent of total billed charges,,,90,,119.34,percent of total billed charges,,,,,,,no IP contract,,80,,106.08,percent of total billed charges,,,,,,,no IP contract,,50,,66.3,percent of total billed charges,,,,,,no IP contract,,,78,,103.43,percent of total billed charges,,,70,,92.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,64.97,3324,
60687-0598-01 - propranolol 20 mg Tab,60687-0598-01,NDC,,,,inpatient,1,EA,8.2,4.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.97,percent of total billed charges,,,85,,6.97,percent of total billed charges,,,49,,4.02,percent of total billed charges,,,90,,7.38,percent of total billed charges,,,,,,,no IP contract,,80,,6.56,percent of total billed charges,,,,,,,no IP contract,,50,,4.1,percent of total billed charges,,,,,,no IP contract,,,78,,6.4,percent of total billed charges,,,70,,5.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.02,3324,
60687-0602-01 - gabapentin 400 mg Cap,60687-0602-01,NDC,,,,inpatient,1,EA,13.5,8.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.48,percent of total billed charges,,,85,,11.48,percent of total billed charges,,,49,,6.62,percent of total billed charges,,,90,,12.15,percent of total billed charges,,,,,,,no IP contract,,80,,10.8,percent of total billed charges,,,,,,,no IP contract,,50,,6.75,percent of total billed charges,,,,,,no IP contract,,,78,,10.53,percent of total billed charges,,,70,,9.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.62,3324,
sulfamethoxazole-trimethoprim 400 mg-80 mg Tab,60687-0603-65,NDC,,,,inpatient,1,EA,6.75,4.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.74,percent of total billed charges,,,85,,5.74,percent of total billed charges,,,49,,3.31,percent of total billed charges,,,90,,6.08,percent of total billed charges,,,,,,,no IP contract,,80,,5.4,percent of total billed charges,,,,,,,no IP contract,,50,,3.38,percent of total billed charges,,,,,,no IP contract,,,78,,5.27,percent of total billed charges,,,70,,4.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.31,3324,
60687-0609-01 - propranolol 40 mg Tab,60687-0609-01,NDC,,,,inpatient,1,EA,9.15,5.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.78,percent of total billed charges,,,85,,7.78,percent of total billed charges,,,49,,4.48,percent of total billed charges,,,90,,8.24,percent of total billed charges,,,,,,,no IP contract,,80,,7.32,percent of total billed charges,,,,,,,no IP contract,,50,,4.58,percent of total billed charges,,,,,,no IP contract,,,78,,7.14,percent of total billed charges,,,70,,6.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.48,3324,
60687-0617-01 - morphine 15 mg Tab,60687-0617-01,NDC,,,,inpatient,1,EA,15.75,9.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.39,percent of total billed charges,,,85,,13.39,percent of total billed charges,,,49,,7.72,percent of total billed charges,,,90,,14.18,percent of total billed charges,,,,,,,no IP contract,,80,,12.6,percent of total billed charges,,,,,,,no IP contract,,50,,7.88,percent of total billed charges,,,,,,no IP contract,,,78,,12.29,percent of total billed charges,,,70,,11.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.72,3324,
60687-0618-21 - fenofibrate 48 mg Tab,60687-0618-21,NDC,,,,inpatient,1,EA,19,11.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.15,percent of total billed charges,,,85,,16.15,percent of total billed charges,,,49,,9.31,percent of total billed charges,,,90,,17.1,percent of total billed charges,,,,,,,no IP contract,,80,,15.2,percent of total billed charges,,,,,,,no IP contract,,50,,9.5,percent of total billed charges,,,,,,no IP contract,,,78,,14.82,percent of total billed charges,,,70,,13.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.31,3324,
60687-0622-01 - docusate-senna 50 mg-8.6 mg Tab,60687-0622-01,NDC,,,,inpatient,1,EA,5.2,3.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.42,percent of total billed charges,,,85,,4.42,percent of total billed charges,,,49,,2.55,percent of total billed charges,,,90,,4.68,percent of total billed charges,,,,,,,no IP contract,,80,,4.16,percent of total billed charges,,,,,,,no IP contract,,50,,2.6,percent of total billed charges,,,,,,no IP contract,,,78,,4.06,percent of total billed charges,,,70,,3.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.55,3324,
60687-0623-01 - valsartan 80 mg Tab,60687-0623-01,NDC,,,,inpatient,1,EA,14.1,8.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.99,percent of total billed charges,,,85,,11.99,percent of total billed charges,,,49,,6.91,percent of total billed charges,,,90,,12.69,percent of total billed charges,,,,,,,no IP contract,,80,,11.28,percent of total billed charges,,,,,,,no IP contract,,50,,7.05,percent of total billed charges,,,,,,no IP contract,,,78,,11,percent of total billed charges,,,70,,9.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.91,3324,
60687-0627-01 - LORazepam 0.5 mg Tab,60687-0627-01,NDC,,,,inpatient,1,EA,6.85,4.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.82,percent of total billed charges,,,85,,5.82,percent of total billed charges,,,49,,3.36,percent of total billed charges,,,90,,6.17,percent of total billed charges,,,,,,,no IP contract,,80,,5.48,percent of total billed charges,,,,,,,no IP contract,,50,,3.43,percent of total billed charges,,,,,,no IP contract,,,78,,5.34,percent of total billed charges,,,70,,4.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.36,3324,
60687-0631-01 - metoclopramide 10 mg Tab,60687-0631-01,NDC,,,,inpatient,1,EA,9.55,5.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.12,percent of total billed charges,,,85,,8.12,percent of total billed charges,,,49,,4.68,percent of total billed charges,,,90,,8.6,percent of total billed charges,,,,,,,no IP contract,,80,,7.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.78,percent of total billed charges,,,,,,no IP contract,,,78,,7.45,percent of total billed charges,,,70,,6.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.68,3324,
60687-0633-65 - nitrofurantoin macrocrystals-monohydrate 100 mg Cap,60687-0633-65,NDC,,,,inpatient,1,EA,37.95,22.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.26,percent of total billed charges,,,85,,32.26,percent of total billed charges,,,49,,18.6,percent of total billed charges,,,90,,34.16,percent of total billed charges,,,,,,,no IP contract,,80,,30.36,percent of total billed charges,,,,,,,no IP contract,,50,,18.98,percent of total billed charges,,,,,,no IP contract,,,78,,29.6,percent of total billed charges,,,70,,26.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.6,3324,
valsartan 160 mg Tab,60687-0634-01,NDC,,,,inpatient,1,EA,15.35,9.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.05,percent of total billed charges,,,85,,13.05,percent of total billed charges,,,49,,7.52,percent of total billed charges,,,90,,13.82,percent of total billed charges,,,,,,,no IP contract,,80,,12.28,percent of total billed charges,,,,,,,no IP contract,,50,,7.68,percent of total billed charges,,,,,,no IP contract,,,78,,11.97,percent of total billed charges,,,70,,10.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.52,3324,
60687-0636-01 - ondansetron 4 mg Tab,60687-0636-01,NDC,,,,inpatient,1,EA,194.15,116.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,157.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,165.03,percent of total billed charges,,,85,,165.03,percent of total billed charges,,,49,,95.13,percent of total billed charges,,,90,,174.74,percent of total billed charges,,,,,,,no IP contract,,80,,155.32,percent of total billed charges,,,,,,,no IP contract,,50,,97.08,percent of total billed charges,,,,,,no IP contract,,,78,,151.44,percent of total billed charges,,,70,,135.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,95.13,3324,
60687-0638-01 - LORazepam 1 mg Tab,60687-0638-01,NDC,,,,inpatient,1,EA,6.85,4.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.82,percent of total billed charges,,,85,,5.82,percent of total billed charges,,,49,,3.36,percent of total billed charges,,,90,,6.17,percent of total billed charges,,,,,,,no IP contract,,80,,5.48,percent of total billed charges,,,,,,,no IP contract,,50,,3.43,percent of total billed charges,,,,,,no IP contract,,,78,,5.34,percent of total billed charges,,,70,,4.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.36,3324,
60687-0640-01 - metFORMIN 500 mg ER Ta,60687-0640-01,NDC,,,,inpatient,1,EA,8.75,5.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.44,percent of total billed charges,,,85,,7.44,percent of total billed charges,,,49,,4.29,percent of total billed charges,,,90,,7.88,percent of total billed charges,,,,,,,no IP contract,,80,,7,percent of total billed charges,,,,,,,no IP contract,,50,,4.38,percent of total billed charges,,,,,,no IP contract,,,78,,6.83,percent of total billed charges,,,70,,6.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.29,3324,
60687-0642-01 - acetaminophen-oxycodone 325 mg-5 mg Tab,60687-0642-01,NDC,,,,inpatient,1,EA,17,10.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.45,percent of total billed charges,,,85,,14.45,percent of total billed charges,,,49,,8.33,percent of total billed charges,,,90,,15.3,percent of total billed charges,,,,,,,no IP contract,,80,,13.6,percent of total billed charges,,,,,,,no IP contract,,50,,8.5,percent of total billed charges,,,,,,no IP contract,,,78,,13.26,percent of total billed charges,,,70,,11.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.33,3324,
60687-0647-01 - ondansetron 8 mg Tab,60687-0647-01,NDC,,,,inpatient,1,EA,321.45,192.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,260.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,273.23,percent of total billed charges,,,85,,273.23,percent of total billed charges,,,49,,157.51,percent of total billed charges,,,90,,289.31,percent of total billed charges,,,,,,,no IP contract,,80,,257.16,percent of total billed charges,,,,,,,no IP contract,,50,,160.73,percent of total billed charges,,,,,,no IP contract,,,78,,250.73,percent of total billed charges,,,70,,225.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,157.51,3324,
60687-0648-21 - varenicline 1 mg Tab,60687-0648-21,NDC,,,,inpatient,1,EA,128,76.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,103.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,108.8,percent of total billed charges,,,85,,108.8,percent of total billed charges,,,49,,62.72,percent of total billed charges,,,90,,115.2,percent of total billed charges,,,,,,,no IP contract,,80,,102.4,percent of total billed charges,,,,,,,no IP contract,,50,,64,percent of total billed charges,,,,,,no IP contract,,,78,,99.84,percent of total billed charges,,,70,,89.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,62.72,3324,
60687-0657-01 - levETIRAcetam 500 mg Tab,60687-0657-01,NDC,,,,inpatient,1,EA,9.55,5.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.12,percent of total billed charges,,,85,,8.12,percent of total billed charges,,,49,,4.68,percent of total billed charges,,,90,,8.6,percent of total billed charges,,,,,,,no IP contract,,80,,7.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.78,percent of total billed charges,,,,,,no IP contract,,,78,,7.45,percent of total billed charges,,,70,,6.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.68,3324,
diclofenac sodium 75 mg EC Ta,60687-0658-01,NDC,,,,inpatient,1,EA,10.2,6.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.67,percent of total billed charges,,,85,,8.67,percent of total billed charges,,,49,,5,percent of total billed charges,,,90,,9.18,percent of total billed charges,,,,,,,no IP contract,,80,,8.16,percent of total billed charges,,,,,,,no IP contract,,50,,5.1,percent of total billed charges,,,,,,no IP contract,,,78,,7.96,percent of total billed charges,,,70,,7.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5,3324,
60687-0660-01 - promethazine 12.5 mg Tab,60687-0660-01,NDC,,,,inpatient,1,EA,8.3,4.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.06,percent of total billed charges,,,85,,7.06,percent of total billed charges,,,49,,4.07,percent of total billed charges,,,90,,7.47,percent of total billed charges,,,,,,,no IP contract,,80,,6.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.15,percent of total billed charges,,,,,,no IP contract,,,78,,6.47,percent of total billed charges,,,70,,5.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.07,3324,
60687-0661-01 - carbidopa-levodopa 25 mg-100 mg Tab,60687-0661-01,NDC,,,,inpatient,1,EA,10.35,6.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.8,percent of total billed charges,,,85,,8.8,percent of total billed charges,,,49,,5.07,percent of total billed charges,,,90,,9.32,percent of total billed charges,,,,,,,no IP contract,,80,,8.28,percent of total billed charges,,,,,,,no IP contract,,50,,5.18,percent of total billed charges,,,,,,no IP contract,,,78,,8.07,percent of total billed charges,,,70,,7.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.07,3324,
60687-0664-01 - hydrOXYzine hydrochloride 10 mg Tab,60687-0664-01,NDC,,,,inpatient,1,EA,6.05,3.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.14,percent of total billed charges,,,85,,5.14,percent of total billed charges,,,49,,2.96,percent of total billed charges,,,90,,5.45,percent of total billed charges,,,,,,,no IP contract,,80,,4.84,percent of total billed charges,,,,,,,no IP contract,,50,,3.03,percent of total billed charges,,,,,,no IP contract,,,78,,4.72,percent of total billed charges,,,70,,4.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.96,3324,
lisinopril 5 mg Tab,60687-0667-01,NDC,,,,inpatient,1,EA,10.75,6.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.14,percent of total billed charges,,,85,,9.14,percent of total billed charges,,,49,,5.27,percent of total billed charges,,,90,,9.68,percent of total billed charges,,,,,,,no IP contract,,80,,8.6,percent of total billed charges,,,,,,,no IP contract,,50,,5.38,percent of total billed charges,,,,,,no IP contract,,,78,,8.39,percent of total billed charges,,,70,,7.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.27,3324,
60687-0669-01 - methIMAzole 5 mg Tab,60687-0669-01,NDC,,,,inpatient,1,EA,8.6,5.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.31,percent of total billed charges,,,85,,7.31,percent of total billed charges,,,49,,4.21,percent of total billed charges,,,90,,7.74,percent of total billed charges,,,,,,,no IP contract,,80,,6.88,percent of total billed charges,,,,,,,no IP contract,,50,,4.3,percent of total billed charges,,,,,,no IP contract,,,78,,6.71,percent of total billed charges,,,70,,6.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.21,3324,
60687-0670-01 - oxybutynin 5 mg Tab,60687-0670-01,NDC,,,,inpatient,1,EA,7.8,4.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.63,percent of total billed charges,,,85,,6.63,percent of total billed charges,,,49,,3.82,percent of total billed charges,,,90,,7.02,percent of total billed charges,,,,,,,no IP contract,,80,,6.24,percent of total billed charges,,,,,,,no IP contract,,50,,3.9,percent of total billed charges,,,,,,no IP contract,,,78,,6.08,percent of total billed charges,,,70,,5.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.82,3324,
acetaminophen/butalbital/caffeine 325 mg-50 mg-40 mg Tab,60687-0672-65,NDC,,,,inpatient,1,EA,19.35,11.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.45,percent of total billed charges,,,85,,16.45,percent of total billed charges,,,49,,9.48,percent of total billed charges,,,90,,17.42,percent of total billed charges,,,,,,,no IP contract,,80,,15.48,percent of total billed charges,,,,,,,no IP contract,,50,,9.68,percent of total billed charges,,,,,,no IP contract,,,78,,15.09,percent of total billed charges,,,70,,13.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.48,3324,
60687-0675-01 - hydrOXYzine hydrochloride 25 mg Tab,60687-0675-01,NDC,,,,inpatient,1,EA,6.95,4.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.91,percent of total billed charges,,,85,,5.91,percent of total billed charges,,,49,,3.41,percent of total billed charges,,,90,,6.26,percent of total billed charges,,,,,,,no IP contract,,80,,5.56,percent of total billed charges,,,,,,,no IP contract,,50,,3.48,percent of total billed charges,,,,,,no IP contract,,,78,,5.42,percent of total billed charges,,,70,,4.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.41,3324,
60687-0677-01 - allopurinol 100 mg Tab,60687-0677-01,NDC,,,,inpatient,1,EA,7.8,4.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.63,percent of total billed charges,,,85,,6.63,percent of total billed charges,,,49,,3.82,percent of total billed charges,,,90,,7.02,percent of total billed charges,,,,,,,no IP contract,,80,,6.24,percent of total billed charges,,,,,,,no IP contract,,50,,3.9,percent of total billed charges,,,,,,no IP contract,,,78,,6.08,percent of total billed charges,,,70,,5.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.82,3324,
60687-0678-01 - lisinopril 40 mg Tab,60687-0678-01,NDC,,,,inpatient,1,EA,8.65,5.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.35,percent of total billed charges,,,85,,7.35,percent of total billed charges,,,49,,4.24,percent of total billed charges,,,90,,7.79,percent of total billed charges,,,,,,,no IP contract,,80,,6.92,percent of total billed charges,,,,,,,no IP contract,,50,,4.33,percent of total billed charges,,,,,,no IP contract,,,78,,6.75,percent of total billed charges,,,70,,6.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.24,3324,
bisoprolol 5 mg Tab,60687-0679-21,NDC,,,,inpatient,1,EA,16.25,9.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.81,percent of total billed charges,,,85,,13.81,percent of total billed charges,,,49,,7.96,percent of total billed charges,,,90,,14.63,percent of total billed charges,,,,,,,no IP contract,,80,,13,percent of total billed charges,,,,,,,no IP contract,,50,,8.13,percent of total billed charges,,,,,,no IP contract,,,78,,12.68,percent of total billed charges,,,70,,11.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.96,3324,
60687-0681-01 - folic acid 1 mg Tab,60687-0681-01,NDC,,,,inpatient,1,EA,5.5,3.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.68,percent of total billed charges,,,85,,4.68,percent of total billed charges,,,49,,2.7,percent of total billed charges,,,90,,4.95,percent of total billed charges,,,,,,,no IP contract,,80,,4.4,percent of total billed charges,,,,,,,no IP contract,,50,,2.75,percent of total billed charges,,,,,,no IP contract,,,78,,4.29,percent of total billed charges,,,70,,3.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.7,3324,
60687-0683-01 - hydroCHLOROthiazide 12.5 mg Cap,60687-0683-01,NDC,,,,inpatient,1,EA,5.4,3.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.59,percent of total billed charges,,,85,,4.59,percent of total billed charges,,,49,,2.65,percent of total billed charges,,,90,,4.86,percent of total billed charges,,,,,,,no IP contract,,80,,4.32,percent of total billed charges,,,,,,,no IP contract,,50,,2.7,percent of total billed charges,,,,,,no IP contract,,,78,,4.21,percent of total billed charges,,,70,,3.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.65,3324,
60687-0687-57 - lacosamide 100 mg Tab,60687-0687-57,NDC,,,,inpatient,1,EA,36.1,21.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.69,percent of total billed charges,,,85,,30.69,percent of total billed charges,,,49,,17.69,percent of total billed charges,,,90,,32.49,percent of total billed charges,,,,,,,no IP contract,,80,,28.88,percent of total billed charges,,,,,,,no IP contract,,50,,18.05,percent of total billed charges,,,,,,no IP contract,,,78,,28.16,percent of total billed charges,,,70,,25.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.69,3324,
60687-0689-01 - bethanechol 10 mg Tab,60687-0689-01,NDC,,,,inpatient,1,EA,14.15,8.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.03,percent of total billed charges,,,85,,12.03,percent of total billed charges,,,49,,6.93,percent of total billed charges,,,90,,12.74,percent of total billed charges,,,,,,,no IP contract,,80,,11.32,percent of total billed charges,,,,,,,no IP contract,,50,,7.08,percent of total billed charges,,,,,,no IP contract,,,78,,11.04,percent of total billed charges,,,70,,9.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.93,3324,
sucralfate 1 g Tab,60687-0695-01,NDC,,,,inpatient,1,EA,7.5,4.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.38,percent of total billed charges,,,85,,6.38,percent of total billed charges,,,49,,3.68,percent of total billed charges,,,90,,6.75,percent of total billed charges,,,,,,,no IP contract,,80,,6,percent of total billed charges,,,,,,,no IP contract,,50,,3.75,percent of total billed charges,,,,,,no IP contract,,,78,,5.85,percent of total billed charges,,,70,,5.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.68,3324,
hydrOXYzine pamoate 25 mg Cap,60687-0696-01,NDC,,,,inpatient,1,EA,8.45,5.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.18,percent of total billed charges,,,85,,7.18,percent of total billed charges,,,49,,4.14,percent of total billed charges,,,90,,7.61,percent of total billed charges,,,,,,,no IP contract,,80,,6.76,percent of total billed charges,,,,,,,no IP contract,,50,,4.23,percent of total billed charges,,,,,,no IP contract,,,78,,6.59,percent of total billed charges,,,70,,5.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.14,3324,
60687-0704-01 - lamoTRIgine 200 mg Tab,60687-0704-01,NDC,,,,inpatient,1,EA,8.05,4.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.84,percent of total billed charges,,,85,,6.84,percent of total billed charges,,,49,,3.94,percent of total billed charges,,,90,,7.25,percent of total billed charges,,,,,,,no IP contract,,80,,6.44,percent of total billed charges,,,,,,,no IP contract,,50,,4.03,percent of total billed charges,,,,,,no IP contract,,,78,,6.28,percent of total billed charges,,,70,,5.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.94,3324,
60687-0708-09 - potassium chloride 10 mEq ER Ta,60687-0708-09,NDC,,,,inpatient,1,EA,5.9,3.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.02,percent of total billed charges,,,85,,5.02,percent of total billed charges,,,49,,2.89,percent of total billed charges,,,90,,5.31,percent of total billed charges,,,,,,,no IP contract,,80,,4.72,percent of total billed charges,,,,,,,no IP contract,,50,,2.95,percent of total billed charges,,,,,,no IP contract,,,78,,4.6,percent of total billed charges,,,70,,4.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.89,3324,
60687-0711-01 - OXcarbazepine 150 mg Tab,60687-0711-01,NDC,,,,inpatient,1,EA,15.85,9.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.47,percent of total billed charges,,,85,,13.47,percent of total billed charges,,,49,,7.77,percent of total billed charges,,,90,,14.27,percent of total billed charges,,,,,,,no IP contract,,80,,12.68,percent of total billed charges,,,,,,,no IP contract,,50,,7.93,percent of total billed charges,,,,,,no IP contract,,,78,,12.36,percent of total billed charges,,,70,,11.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.77,3324,
60687-0718-01 - dexAMETHasone 4 mg Tab,60687-0718-01,NDC,,,,inpatient,1,EA,13.45,8.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.43,percent of total billed charges,,,85,,11.43,percent of total billed charges,,,49,,6.59,percent of total billed charges,,,90,,12.11,percent of total billed charges,,,,,,,no IP contract,,80,,10.76,percent of total billed charges,,,,,,,no IP contract,,50,,6.73,percent of total billed charges,,,,,,no IP contract,,,78,,10.49,percent of total billed charges,,,70,,9.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.59,3324,
emtricitabine-tenofovir 200 mg-300 mg Tab,60687-0719-25,NDC,,,,inpatient,1,EA,22.45,13.47,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.08,percent of total billed charges,,,85,,19.08,percent of total billed charges,,,49,,11,percent of total billed charges,,,90,,20.21,percent of total billed charges,,,,,,,no IP contract,,80,,17.96,percent of total billed charges,,,,,,,no IP contract,,50,,11.23,percent of total billed charges,,,,,,no IP contract,,,78,,17.51,percent of total billed charges,,,70,,15.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11,3324,
60687-0722-01 - OXcarbazepine 300 mg Tab,60687-0722-01,NDC,,,,inpatient,1,EA,25.7,15.42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.85,percent of total billed charges,,,85,,21.85,percent of total billed charges,,,49,,12.59,percent of total billed charges,,,90,,23.13,percent of total billed charges,,,,,,,no IP contract,,80,,20.56,percent of total billed charges,,,,,,,no IP contract,,50,,12.85,percent of total billed charges,,,,,,no IP contract,,,78,,20.05,percent of total billed charges,,,70,,17.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.59,3324,
60687-0723-21 - DULoxetine 20 mg DR Ca,60687-0723-21,NDC,,,,inpatient,1,EA,68.7,41.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,55.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,58.4,percent of total billed charges,,,85,,58.4,percent of total billed charges,,,49,,33.66,percent of total billed charges,,,90,,61.83,percent of total billed charges,,,,,,,no IP contract,,80,,54.96,percent of total billed charges,,,,,,,no IP contract,,50,,34.35,percent of total billed charges,,,,,,no IP contract,,,78,,53.59,percent of total billed charges,,,70,,48.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,33.66,3324,
60687-0730-01 - meclizine 25 mg Tab,60687-0730-01,NDC,,,,inpatient,1,EA,10.65,6.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.05,percent of total billed charges,,,85,,9.05,percent of total billed charges,,,49,,5.22,percent of total billed charges,,,90,,9.59,percent of total billed charges,,,,,,,no IP contract,,80,,8.52,percent of total billed charges,,,,,,,no IP contract,,50,,5.33,percent of total billed charges,,,,,,no IP contract,,,78,,8.31,percent of total billed charges,,,70,,7.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.22,3324,
60687-0734-01 - DULoxetine 30 mg DRC,60687-0734-01,NDC,,,,inpatient,1,EA,65.6,39.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,53.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,55.76,percent of total billed charges,,,85,,55.76,percent of total billed charges,,,49,,32.14,percent of total billed charges,,,90,,59.04,percent of total billed charges,,,,,,,no IP contract,,80,,52.48,percent of total billed charges,,,,,,,no IP contract,,50,,32.8,percent of total billed charges,,,,,,no IP contract,,,78,,51.17,percent of total billed charges,,,70,,45.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.14,3324,
60687-0736-65 - pantoprazole 40 mg EC Ta,60687-0736-65,NDC,,,,inpatient,1,EA,5.9,3.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.02,percent of total billed charges,,,85,,5.02,percent of total billed charges,,,49,,2.89,percent of total billed charges,,,90,,5.31,percent of total billed charges,,,,,,,no IP contract,,80,,4.72,percent of total billed charges,,,,,,,no IP contract,,50,,2.95,percent of total billed charges,,,,,,no IP contract,,,78,,4.6,percent of total billed charges,,,70,,4.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.89,3324,
60687-0740-37 - acetaminophen 650 mg/20.3 mL LIQ,60687-0740-37,NDC,,,,inpatient,20.3,ML,25.4,15.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.59,percent of total billed charges,,,85,,21.59,percent of total billed charges,,,49,,12.45,percent of total billed charges,,,90,,22.86,percent of total billed charges,,,,,,,no IP contract,,80,,20.32,percent of total billed charges,,,,,,,no IP contract,,50,,12.7,percent of total billed charges,,,,,,no IP contract,,,78,,19.81,percent of total billed charges,,,70,,17.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.45,3324,
60687-0745-01 - DULoxetine 60 mg DR Ca,60687-0745-01,NDC,,,,inpatient,1,EA,65.05,39.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,52.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,55.29,percent of total billed charges,,,85,,55.29,percent of total billed charges,,,49,,31.87,percent of total billed charges,,,90,,58.55,percent of total billed charges,,,,,,,no IP contract,,80,,52.04,percent of total billed charges,,,,,,,no IP contract,,50,,32.53,percent of total billed charges,,,,,,no IP contract,,,78,,50.74,percent of total billed charges,,,70,,45.54,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.87,3324,
isosorbide mononitrate 60 mg ER Ta,60687-0794-01,NDC,,,,inpatient,1,EA,7.8,4.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.63,percent of total billed charges,,,85,,6.63,percent of total billed charges,,,49,,3.82,percent of total billed charges,,,90,,7.02,percent of total billed charges,,,,,,,no IP contract,,80,,6.24,percent of total billed charges,,,,,,,no IP contract,,50,,3.9,percent of total billed charges,,,,,,no IP contract,,,78,,6.08,percent of total billed charges,,,70,,5.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.82,3324,
traMADol 50 mg Tab,60687-0795-01,NDC,,,,inpatient,1,EA,5.25,3.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.46,percent of total billed charges,,,85,,4.46,percent of total billed charges,,,49,,2.57,percent of total billed charges,,,90,,4.73,percent of total billed charges,,,,,,,no IP contract,,80,,4.2,percent of total billed charges,,,,,,,no IP contract,,50,,2.63,percent of total billed charges,,,,,,no IP contract,,,78,,4.1,percent of total billed charges,,,70,,3.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.57,3324,
hydrALAZINE 25 mg Tab,60687-0822-01,NDC,,,,inpatient,1,EA,5.8,3.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.93,percent of total billed charges,,,85,,4.93,percent of total billed charges,,,49,,2.84,percent of total billed charges,,,90,,5.22,percent of total billed charges,,,,,,,no IP contract,,80,,4.64,percent of total billed charges,,,,,,,no IP contract,,50,,2.9,percent of total billed charges,,,,,,no IP contract,,,78,,4.52,percent of total billed charges,,,70,,4.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.84,3324,
carbidopa-levodopa 25 mg-250 mg Tab,60687-0836-01,NDC,,,,inpatient,1,EA,7.3,4.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.21,percent of total billed charges,,,85,,6.21,percent of total billed charges,,,49,,3.58,percent of total billed charges,,,90,,6.57,percent of total billed charges,,,,,,,no IP contract,,80,,5.84,percent of total billed charges,,,,,,,no IP contract,,50,,3.65,percent of total billed charges,,,,,,no IP contract,,,78,,5.69,percent of total billed charges,,,70,,5.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.58,3324,
60758-0188-05 - gentamicin ophthalmic 0.3% Soln,60758-0188-05,NDC,,,,inpatient,1,UN,82.1,49.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,66.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,69.79,percent of total billed charges,,,85,,69.79,percent of total billed charges,,,49,,40.23,percent of total billed charges,,,90,,73.89,percent of total billed charges,,,,,,,no IP contract,,80,,65.68,percent of total billed charges,,,,,,,no IP contract,,50,,41.05,percent of total billed charges,,,,,,no IP contract,,,78,,64.04,percent of total billed charges,,,70,,57.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,40.23,3324,
60758-0801-05 - timolol ophthalmic maleate 0.5% Soln,60758-0801-05,NDC,,,,inpatient,1,UN,63.8,38.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,51.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,54.23,percent of total billed charges,,,85,,54.23,percent of total billed charges,,,49,,31.26,percent of total billed charges,,,90,,57.42,percent of total billed charges,,,,,,,no IP contract,,80,,51.04,percent of total billed charges,,,,,,,no IP contract,,50,,31.9,percent of total billed charges,,,,,,no IP contract,,,78,,49.76,percent of total billed charges,,,70,,44.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.26,3324,
60758-0802-10 - timolol ophthalmic maleate 0.25% Soln,60758-0802-10,NDC,,,,inpatient,1,UN,70.85,42.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,57.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,60.22,percent of total billed charges,,,85,,60.22,percent of total billed charges,,,49,,34.72,percent of total billed charges,,,90,,63.77,percent of total billed charges,,,,,,,no IP contract,,80,,56.68,percent of total billed charges,,,,,,,no IP contract,,50,,35.43,percent of total billed charges,,,,,,no IP contract,,,78,,55.26,percent of total billed charges,,,70,,49.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,34.72,3324,
fluorometholone ophthalmic 0.1% Susp,60758-0880-10,NDC,,,,inpatient,1,EA,75.85,45.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,61.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,64.47,percent of total billed charges,,,85,,64.47,percent of total billed charges,,,49,,37.17,percent of total billed charges,,,90,,68.27,percent of total billed charges,,,,,,,no IP contract,,80,,60.68,percent of total billed charges,,,,,,,no IP contract,,50,,37.93,percent of total billed charges,,,,,,no IP contract,,,78,,59.16,percent of total billed charges,,,70,,53.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,37.17,3324,
60758-0908-10 - polymyxin B-trimethoprim ophthalmic 10000 units-1 mg/mL Soln,60758-0908-10,NDC,,,,inpatient,1,UN,118.35,71.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,95.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,100.6,percent of total billed charges,,,85,,100.6,percent of total billed charges,,,49,,57.99,percent of total billed charges,,,90,,106.52,percent of total billed charges,,,,,,,no IP contract,,80,,94.68,percent of total billed charges,,,,,,,no IP contract,,50,,59.18,percent of total billed charges,,,,,,no IP contract,,,78,,92.31,percent of total billed charges,,,70,,82.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,57.99,3324,
60793-0105-01 - methimazole 10 mg Tab,60793-0105-01,NDC,,,,inpatient,1,EA,13.35,8.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.35,percent of total billed charges,,,85,,11.35,percent of total billed charges,,,49,,6.54,percent of total billed charges,,,90,,12.02,percent of total billed charges,,,,,,,no IP contract,,80,,10.68,percent of total billed charges,,,,,,,no IP contract,,50,,6.68,percent of total billed charges,,,,,,no IP contract,,,78,,10.41,percent of total billed charges,,,70,,9.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.54,3324,
60793-0115-01 - liothyronine 5 mcg Tab,60793-0115-01,NDC,,,,inpatient,1,EA,9.65,5.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.2,percent of total billed charges,,,85,,8.2,percent of total billed charges,,,49,,4.73,percent of total billed charges,,,90,,8.69,percent of total billed charges,,,,,,,no IP contract,,80,,7.72,percent of total billed charges,,,,,,,no IP contract,,50,,4.83,percent of total billed charges,,,,,,no IP contract,,,78,,7.53,percent of total billed charges,,,70,,6.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.73,3324,
60793-0145-01 - zaleplon 5 mg Cap,60793-0145-01,NDC,,,,inpatient,1,EA,36.75,22.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.24,percent of total billed charges,,,85,,31.24,percent of total billed charges,,,49,,18.01,percent of total billed charges,,,90,,33.08,percent of total billed charges,,,,,,,no IP contract,,80,,29.4,percent of total billed charges,,,,,,,no IP contract,,50,,18.38,percent of total billed charges,,,,,,no IP contract,,,78,,28.67,percent of total billed charges,,,70,,25.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.01,3324,
60793-0411-30 - diclofenac epolamine 1.3% patch(es) Patch,60793-0411-30,NDC,,,,inpatient,1,UN,90.6,54.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,73.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,77.01,percent of total billed charges,,,85,,77.01,percent of total billed charges,,,49,,44.39,percent of total billed charges,,,90,,81.54,percent of total billed charges,,,,,,,no IP contract,,80,,72.48,percent of total billed charges,,,,,,,no IP contract,,50,,45.3,percent of total billed charges,,,,,,no IP contract,,,78,,70.67,percent of total billed charges,,,70,,63.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,44.39,3324,
"60793-0701-10 - penicillin G benzathine 1,200,000 units/2 mL Susp",60793-0701-10,NDC,,,,inpatient,2,ML,482.1,289.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,390.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,409.79,percent of total billed charges,,,85,,409.79,percent of total billed charges,,,49,,236.23,percent of total billed charges,,,90,,433.89,percent of total billed charges,,,,,,,no IP contract,,80,,385.68,percent of total billed charges,,,,,,,no IP contract,,50,,241.05,percent of total billed charges,,,,,,no IP contract,,,78,,376.04,percent of total billed charges,,,70,,337.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,236.23,3324,
61269-0345-56 - hydrocortisone topical 1% Ointm,61269-0345-56,NDC,,,,inpatient,1,UN,23.2,13.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.72,percent of total billed charges,,,85,,19.72,percent of total billed charges,,,49,,11.37,percent of total billed charges,,,90,,20.88,percent of total billed charges,,,,,,,no IP contract,,80,,18.56,percent of total billed charges,,,,,,,no IP contract,,50,,11.6,percent of total billed charges,,,,,,no IP contract,,,78,,18.1,percent of total billed charges,,,70,,16.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.37,3324,
budesonide 180 mcg/inh Powde,61269-0518-12,NDC,,,,inpatient,1,EA,2654.15,1592.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2149.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2256.03,percent of total billed charges,,,85,,2256.03,percent of total billed charges,,,49,,1300.53,percent of total billed charges,,,90,,2388.74,percent of total billed charges,,,,,,,no IP contract,,80,,2123.32,percent of total billed charges,,,,,,,no IP contract,,50,,1327.08,percent of total billed charges,,,,,,no IP contract,,,78,,2070.24,percent of total billed charges,,,70,,1857.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
miconazole topical 2% Cream,61269-0735-56,NDC,,,,inpatient,1,EA,32.9,19.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,26.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,27.97,percent of total billed charges,,,85,,27.97,percent of total billed charges,,,49,,16.12,percent of total billed charges,,,90,,29.61,percent of total billed charges,,,,,,,no IP contract,,80,,26.32,percent of total billed charges,,,,,,,no IP contract,,50,,16.45,percent of total billed charges,,,,,,no IP contract,,,78,,25.66,percent of total billed charges,,,70,,23.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.12,3324,
61269-0981-35 - docosanol topical 10% Cream,61269-0981-35,NDC,,,,inpatient,1,UN,142.85,85.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,115.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,121.42,percent of total billed charges,,,85,,121.42,percent of total billed charges,,,49,,70,percent of total billed charges,,,90,,128.57,percent of total billed charges,,,,,,,no IP contract,,80,,114.28,percent of total billed charges,,,,,,,no IP contract,,50,,71.43,percent of total billed charges,,,,,,no IP contract,,,78,,111.42,percent of total billed charges,,,70,,100,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,70,3324,
61314-0014-25 - diclofenac ophthalmic 0.1% Soln,61314-0014-25,NDC,,,,inpatient,1,UN,382.2,229.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,309.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,324.87,percent of total billed charges,,,85,,324.87,percent of total billed charges,,,49,,187.28,percent of total billed charges,,,90,,343.98,percent of total billed charges,,,,,,,no IP contract,,80,,305.76,percent of total billed charges,,,,,,,no IP contract,,50,,191.1,percent of total billed charges,,,,,,no IP contract,,,78,,298.12,percent of total billed charges,,,70,,267.54,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,187.28,3324,
61314-0015-05 - ofloxacin otic 0.3% Soln,61314-0015-05,NDC,,,,inpatient,1,UN,625.65,375.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,506.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,531.8,percent of total billed charges,,,85,,531.8,percent of total billed charges,,,49,,306.57,percent of total billed charges,,,90,,563.09,percent of total billed charges,,,,,,,no IP contract,,80,,500.52,percent of total billed charges,,,,,,,no IP contract,,50,,312.83,percent of total billed charges,,,,,,no IP contract,,,78,,488.01,percent of total billed charges,,,70,,437.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,306.57,3324,
61314-0019-10 - dorzolamide ophthalmic 2% Soln,61314-0019-10,NDC,,,,inpatient,1,UN,565.65,339.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,458.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,480.8,percent of total billed charges,,,85,,480.8,percent of total billed charges,,,49,,277.17,percent of total billed charges,,,90,,509.09,percent of total billed charges,,,,,,,no IP contract,,80,,452.52,percent of total billed charges,,,,,,,no IP contract,,50,,282.83,percent of total billed charges,,,,,,no IP contract,,,78,,441.21,percent of total billed charges,,,70,,395.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,277.17,3324,
61314-0144-05 - brimonidine ophthalmic 0.15% Soln,61314-0144-05,NDC,,,,inpatient,1,UN,1468.65,881.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1189.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1248.35,percent of total billed charges,,,85,,1248.35,percent of total billed charges,,,49,,719.64,percent of total billed charges,,,90,,1321.79,percent of total billed charges,,,,,,,no IP contract,,80,,1174.92,percent of total billed charges,,,,,,,no IP contract,,50,,734.33,percent of total billed charges,,,,,,no IP contract,,,78,,1145.55,percent of total billed charges,,,70,,1028.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,719.64,3324,
61314-0203-15 - pilocarpine ophthalmic 1% Soln,61314-0203-15,NDC,,,,inpatient,1,UN,85.45,51.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,69.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,72.63,percent of total billed charges,,,85,,72.63,percent of total billed charges,,,49,,41.87,percent of total billed charges,,,90,,76.91,percent of total billed charges,,,,,,,no IP contract,,80,,68.36,percent of total billed charges,,,,,,,no IP contract,,50,,42.73,percent of total billed charges,,,,,,no IP contract,,,78,,66.65,percent of total billed charges,,,70,,59.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,41.87,3324,
61314-0226-10 - timolol ophthalmic maleate 0.25% Soln,61314-0226-10,NDC,,,,inpatient,1,UN,239.95,143.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,194.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,203.96,percent of total billed charges,,,85,,203.96,percent of total billed charges,,,49,,117.58,percent of total billed charges,,,90,,215.96,percent of total billed charges,,,,,,,no IP contract,,80,,191.96,percent of total billed charges,,,,,,,no IP contract,,50,,119.98,percent of total billed charges,,,,,,no IP contract,,,78,,187.16,percent of total billed charges,,,70,,167.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,117.58,3324,
61314-0226-15 - timolol ophthalmic 0.25% Soln,61314-0226-15,NDC,,,,inpatient,1,UN,242.45,145.47,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,196.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,206.08,percent of total billed charges,,,85,,206.08,percent of total billed charges,,,49,,118.8,percent of total billed charges,,,90,,218.21,percent of total billed charges,,,,,,,no IP contract,,80,,193.96,percent of total billed charges,,,,,,,no IP contract,,50,,121.23,percent of total billed charges,,,,,,no IP contract,,,78,,189.11,percent of total billed charges,,,70,,169.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,118.8,3324,
61314-0227-05 - timolol ophthalmic 0.5% Soln,61314-0227-05,NDC,,,,inpatient,1,UN,150.85,90.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,122.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,128.22,percent of total billed charges,,,85,,128.22,percent of total billed charges,,,49,,73.92,percent of total billed charges,,,90,,135.77,percent of total billed charges,,,,,,,no IP contract,,80,,120.68,percent of total billed charges,,,,,,,no IP contract,,50,,75.43,percent of total billed charges,,,,,,no IP contract,,,78,,117.66,percent of total billed charges,,,70,,105.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,73.92,3324,
61314-0308-02 - azelastine ophthalmic 0.05% Soln,61314-0308-02,NDC,,,,inpatient,1,UN,875.9,525.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,709.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,744.52,percent of total billed charges,,,85,,744.52,percent of total billed charges,,,49,,429.19,percent of total billed charges,,,90,,788.31,percent of total billed charges,,,,,,,no IP contract,,80,,700.72,percent of total billed charges,,,,,,,no IP contract,,50,,437.95,percent of total billed charges,,,,,,no IP contract,,,78,,683.2,percent of total billed charges,,,70,,613.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,429.19,3324,
61314-0318-10 - filgrastim sndz 300 mcg/0.5 mL Soln,61314-0318-10,NDC,,,,inpatient,0.5,ML,2784.8,1670.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2255.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2367.08,percent of total billed charges,,,85,,2367.08,percent of total billed charges,,,49,,1364.55,percent of total billed charges,,,90,,2506.32,percent of total billed charges,,,,,,,no IP contract,,80,,2227.84,percent of total billed charges,,,,,,,no IP contract,,50,,1392.4,percent of total billed charges,,,,,,no IP contract,,,78,,2172.14,percent of total billed charges,,,70,,1949.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
61314-0326-10 - filgrastim sndz 480 mcg/0.8 mL Soln,61314-0326-10,NDC,,,,inpatient,0.8,ML,4450.05,2670.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3604.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3782.54,percent of total billed charges,,,85,,3782.54,percent of total billed charges,,,49,,2180.52,percent of total billed charges,,,90,,4005.05,percent of total billed charges,,,,,,,no IP contract,,80,,3560.04,percent of total billed charges,,,,,,,no IP contract,,50,,2225.03,percent of total billed charges,,,,,,no IP contract,,,78,,3471.04,percent of total billed charges,,,70,,3115.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4005.05,
61314-0547-01 - latanoprost ophthalmic 0.005% Soln,61314-0547-01,NDC,,,,inpatient,1,UN,800.55,480.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,648.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,680.47,percent of total billed charges,,,85,,680.47,percent of total billed charges,,,49,,392.27,percent of total billed charges,,,90,,720.5,percent of total billed charges,,,,,,,no IP contract,,80,,640.44,percent of total billed charges,,,,,,,no IP contract,,50,,400.28,percent of total billed charges,,,,,,no IP contract,,,78,,624.43,percent of total billed charges,,,70,,560.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,392.27,3324,
61314-0547-03 - latanoprost ophthalmic 0.005% Soln,61314-0547-03,NDC,,,,inpatient,1,UN,800.55,480.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,648.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,680.47,percent of total billed charges,,,85,,680.47,percent of total billed charges,,,49,,392.27,percent of total billed charges,,,90,,720.5,percent of total billed charges,,,,,,,no IP contract,,80,,640.44,percent of total billed charges,,,,,,,no IP contract,,50,,400.28,percent of total billed charges,,,,,,no IP contract,,,78,,624.43,percent of total billed charges,,,70,,560.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,392.27,3324,
61314-0628-10 - polymyxin B-trimethoprim ophthalmic 10000 units-1 mg/mL Soln,61314-0628-10,NDC,,,,inpatient,1,UN,154.15,92.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,124.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,131.03,percent of total billed charges,,,85,,131.03,percent of total billed charges,,,49,,75.53,percent of total billed charges,,,90,,138.74,percent of total billed charges,,,,,,,no IP contract,,80,,123.32,percent of total billed charges,,,,,,,no IP contract,,50,,77.08,percent of total billed charges,,,,,,no IP contract,,,78,,120.24,percent of total billed charges,,,70,,107.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,75.53,3324,
61314-0631-36 - dexamethasone/neomycin/polymyxin B ophthalmic 1 mg-3.5 mg-10000 units/g Ointm,61314-0631-36,NDC,,,,inpatient,1,UN,375.7,225.42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,304.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,319.35,percent of total billed charges,,,85,,319.35,percent of total billed charges,,,49,,184.09,percent of total billed charges,,,90,,338.13,percent of total billed charges,,,,,,,no IP contract,,80,,300.56,percent of total billed charges,,,,,,,no IP contract,,50,,187.85,percent of total billed charges,,,,,,no IP contract,,,78,,293.05,percent of total billed charges,,,70,,262.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,184.09,3324,
gentamicin ophthalmic 0.3% Soln,61314-0633-05,NDC,,,,inpatient,1,EA,59.2,35.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,47.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,50.32,percent of total billed charges,,,85,,50.32,percent of total billed charges,,,49,,29.01,percent of total billed charges,,,90,,53.28,percent of total billed charges,,,,,,,no IP contract,,80,,47.36,percent of total billed charges,,,,,,,no IP contract,,50,,29.6,percent of total billed charges,,,,,,no IP contract,,,78,,46.18,percent of total billed charges,,,70,,41.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,29.01,3324,
61314-0637-05 - prednisoLONE ophthalmic acetate 1% Susp,61314-0637-05,NDC,,,,inpatient,1,UN,930.5,558.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,753.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,790.93,percent of total billed charges,,,85,,790.93,percent of total billed charges,,,49,,455.95,percent of total billed charges,,,90,,837.45,percent of total billed charges,,,,,,,no IP contract,,80,,744.4,percent of total billed charges,,,,,,,no IP contract,,50,,465.25,percent of total billed charges,,,,,,no IP contract,,,78,,725.79,percent of total billed charges,,,70,,651.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,455.95,3324,
61314-0637-10 - prednisoLONE ophthalmic acetate 1% Susp,61314-0637-10,NDC,,,,inpatient,1,UN,250.8,150.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,203.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,213.18,percent of total billed charges,,,85,,213.18,percent of total billed charges,,,49,,122.89,percent of total billed charges,,,90,,225.72,percent of total billed charges,,,,,,,no IP contract,,80,,200.64,percent of total billed charges,,,,,,,no IP contract,,50,,125.4,percent of total billed charges,,,,,,no IP contract,,,78,,195.62,percent of total billed charges,,,70,,175.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,122.89,3324,
61314-0643-05 - tobramycin ophthalmic 0.3% Soln,61314-0643-05,NDC,,,,inpatient,1,UN,292.45,175.47,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,236.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,248.58,percent of total billed charges,,,85,,248.58,percent of total billed charges,,,49,,143.3,percent of total billed charges,,,90,,263.21,percent of total billed charges,,,,,,,no IP contract,,80,,233.96,percent of total billed charges,,,,,,,no IP contract,,50,,146.23,percent of total billed charges,,,,,,no IP contract,,,78,,228.11,percent of total billed charges,,,70,,204.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,143.3,3324,
61314-0646-10 - hydrocortisone/neomycin/polymyxin B otic 1%-0.35%-10000 units/mL Soln,61314-0646-10,NDC,,,,inpatient,1,UN,265.8,159.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,215.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,225.93,percent of total billed charges,,,85,,225.93,percent of total billed charges,,,49,,130.24,percent of total billed charges,,,90,,239.22,percent of total billed charges,,,,,,,no IP contract,,80,,212.64,percent of total billed charges,,,,,,,no IP contract,,50,,132.9,percent of total billed charges,,,,,,no IP contract,,,78,,207.32,percent of total billed charges,,,70,,186.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,130.24,3324,
61314-0647-05 - dexamethasone-tobramycin ophthalmic 0.1%-0.3% Susp,61314-0647-05,NDC,,,,inpatient,1,UN,1372,823.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1111.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1166.2,percent of total billed charges,,,85,,1166.2,percent of total billed charges,,,49,,672.28,percent of total billed charges,,,90,,1234.8,percent of total billed charges,,,,,,,no IP contract,,80,,1097.6,percent of total billed charges,,,,,,,no IP contract,,50,,686,percent of total billed charges,,,,,,no IP contract,,,78,,1070.16,percent of total billed charges,,,70,,960.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,672.28,3324,
61314-0656-05 - ciprofloxacin ophthalmic 0.3% Soln,61314-0656-05,NDC,,,,inpatient,1,UN,403.25,241.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,326.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,342.76,percent of total billed charges,,,85,,342.76,percent of total billed charges,,,49,,197.59,percent of total billed charges,,,90,,362.93,percent of total billed charges,,,,,,,no IP contract,,80,,322.6,percent of total billed charges,,,,,,,no IP contract,,50,,201.63,percent of total billed charges,,,,,,no IP contract,,,78,,314.54,percent of total billed charges,,,70,,282.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,197.59,3324,
61570-0031-50 - bacitracin/HC/neomycin/polymyxin B Topical 400 units-10 mg-3.5 mg-10000 units/g Oint,61570-0031-50,NDC,,,,inpatient,1,UN,946.35,567.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,766.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,804.4,percent of total billed charges,,,85,,804.4,percent of total billed charges,,,49,,463.71,percent of total billed charges,,,90,,851.72,percent of total billed charges,,,,,,,no IP contract,,80,,757.08,percent of total billed charges,,,,,,,no IP contract,,50,,473.18,percent of total billed charges,,,,,,no IP contract,,,78,,738.15,percent of total billed charges,,,70,,662.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,463.71,3324,
61570-0032-75 - hydrocortisone/neomycin/polymyxin B Topical 0.5%-0.35%-10000 units/g Cream,61570-0032-75,NDC,,,,inpatient,1,UN,694.6,416.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,562.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,590.41,percent of total billed charges,,,85,,590.41,percent of total billed charges,,,49,,340.35,percent of total billed charges,,,90,,625.14,percent of total billed charges,,,,,,,no IP contract,,80,,555.68,percent of total billed charges,,,,,,,no IP contract,,50,,347.3,percent of total billed charges,,,,,,no IP contract,,,78,,541.79,percent of total billed charges,,,70,,486.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,340.35,3324,
61570-0034-10 - hydrocortisone/neomycin/polymyxin B otic 1%-0.35%-10000 units/mL Soln,61570-0034-10,NDC,,,,inpatient,1,UN,576.5,345.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,466.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,490.03,percent of total billed charges,,,85,,490.03,percent of total billed charges,,,49,,282.49,percent of total billed charges,,,90,,518.85,percent of total billed charges,,,,,,,no IP contract,,80,,461.2,percent of total billed charges,,,,,,,no IP contract,,50,,288.25,percent of total billed charges,,,,,,no IP contract,,,78,,449.67,percent of total billed charges,,,70,,403.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,282.49,3324,
61570-0079-01 - trimethobenzamide 300 mg Cap,61570-0079-01,NDC,,,,inpatient,1,EA,15.2,9.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.92,percent of total billed charges,,,85,,12.92,percent of total billed charges,,,49,,7.45,percent of total billed charges,,,90,,13.68,percent of total billed charges,,,,,,,no IP contract,,80,,12.16,percent of total billed charges,,,,,,,no IP contract,,50,,7.6,percent of total billed charges,,,,,,no IP contract,,,78,,11.86,percent of total billed charges,,,70,,10.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.45,3324,
61570-0111-56 - ramipril 2.5 mg Cap,61570-0111-56,NDC,,,,inpatient,1,EA,16.7,10.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.2,percent of total billed charges,,,85,,14.2,percent of total billed charges,,,49,,8.18,percent of total billed charges,,,90,,15.03,percent of total billed charges,,,,,,,no IP contract,,80,,13.36,percent of total billed charges,,,,,,,no IP contract,,50,,8.35,percent of total billed charges,,,,,,no IP contract,,,78,,13.03,percent of total billed charges,,,70,,11.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.18,3324,
61570-0112-01 - ramipril 5 mg Cap,61570-0112-01,NDC,,,,inpatient,1,EA,20.6,12.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.51,percent of total billed charges,,,85,,17.51,percent of total billed charges,,,49,,10.09,percent of total billed charges,,,90,,18.54,percent of total billed charges,,,,,,,no IP contract,,80,,16.48,percent of total billed charges,,,,,,,no IP contract,,50,,10.3,percent of total billed charges,,,,,,no IP contract,,,78,,16.07,percent of total billed charges,,,70,,14.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.09,3324,
61570-0112-56 - ramipril 5 mg Cap,61570-0112-56,NDC,,,,inpatient,1,EA,17.65,10.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15,percent of total billed charges,,,85,,15,percent of total billed charges,,,49,,8.65,percent of total billed charges,,,90,,15.89,percent of total billed charges,,,,,,,no IP contract,,80,,14.12,percent of total billed charges,,,,,,,no IP contract,,50,,8.83,percent of total billed charges,,,,,,no IP contract,,,78,,13.77,percent of total billed charges,,,70,,12.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.65,3324,
61570-0131-40 - silver sulfADIAZINE Topical 1% Cream,61570-0131-40,NDC,,,,inpatient,1,UN,609,365.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,493.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,517.65,percent of total billed charges,,,85,,517.65,percent of total billed charges,,,49,,298.41,percent of total billed charges,,,90,,548.1,percent of total billed charges,,,,,,,no IP contract,,80,,487.2,percent of total billed charges,,,,,,,no IP contract,,50,,304.5,percent of total billed charges,,,,,,no IP contract,,,78,,475.02,percent of total billed charges,,,70,,426.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,298.41,3324,
61570-0131-55 - silver sulfADIAZINE topical 1% Cream,61570-0131-55,NDC,,,,inpatient,1,UN,138.35,83.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,112.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,117.6,percent of total billed charges,,,85,,117.6,percent of total billed charges,,,49,,67.79,percent of total billed charges,,,90,,124.52,percent of total billed charges,,,,,,,no IP contract,,80,,110.68,percent of total billed charges,,,,,,,no IP contract,,50,,69.18,percent of total billed charges,,,,,,no IP contract,,,78,,107.91,percent of total billed charges,,,70,,96.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,67.79,3324,
61570-0504-50 - benzocaine-trimethobenzamide 2%-200 mg Supp,61570-0504-50,NDC,,,,inpatient,1,UN,30.8,18.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.18,percent of total billed charges,,,85,,26.18,percent of total billed charges,,,49,,15.09,percent of total billed charges,,,90,,27.72,percent of total billed charges,,,,,,,no IP contract,,80,,24.64,percent of total billed charges,,,,,,,no IP contract,,50,,15.4,percent of total billed charges,,,,,,no IP contract,,,78,,24.02,percent of total billed charges,,,70,,21.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.09,3324,
61703-0324-18 - pamidronate 3 mg/mL Soln,61703-0324-18,NDC,,,,inpatient,10,ML,202.55,121.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,164.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,172.17,percent of total billed charges,,,85,,172.17,percent of total billed charges,,,49,,99.25,percent of total billed charges,,,90,,182.3,percent of total billed charges,,,,,,,no IP contract,,80,,162.04,percent of total billed charges,,,,,,,no IP contract,,50,,101.28,percent of total billed charges,,,,,,no IP contract,,,78,,157.99,percent of total billed charges,,,70,,141.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,99.25,3324,
61703-0326-18 - pamidronate 9 mg/mL Soln,61703-0326-18,NDC,,,,inpatient,10,ML,446.85,268.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,361.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,379.82,percent of total billed charges,,,85,,379.82,percent of total billed charges,,,49,,218.96,percent of total billed charges,,,90,,402.17,percent of total billed charges,,,,,,,no IP contract,,80,,357.48,percent of total billed charges,,,,,,,no IP contract,,50,,223.43,percent of total billed charges,,,,,,no IP contract,,,78,,348.54,percent of total billed charges,,,70,,312.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,218.96,3324,
61703-0350-38 - methotrexate 25 mg/mL Soln,61703-0350-38,NDC,,,,inpatient,1,ML,53.1,31.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,43.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,45.14,percent of total billed charges,,,85,,45.14,percent of total billed charges,,,49,,26.02,percent of total billed charges,,,90,,47.79,percent of total billed charges,,,,,,,no IP contract,,80,,42.48,percent of total billed charges,,,,,,,no IP contract,,50,,26.55,percent of total billed charges,,,,,,no IP contract,,,78,,41.42,percent of total billed charges,,,70,,37.17,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.02,3324,
61703-0423-83 - multivitamin Multiple Vitamins Soln,61703-0423-83,NDC,,,,inpatient,1,ML,17.4,10.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.79,percent of total billed charges,,,85,,14.79,percent of total billed charges,,,49,,8.53,percent of total billed charges,,,90,,15.66,percent of total billed charges,,,,,,,no IP contract,,80,,13.92,percent of total billed charges,,,,,,,no IP contract,,50,,8.7,percent of total billed charges,,,,,,no IP contract,,,78,,13.57,percent of total billed charges,,,70,,12.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.53,3324,
61748-0012-06 - pyrazinamide 500 mg Tab,61748-0012-06,NDC,,,,inpatient,1,EA,13.5,8.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.48,percent of total billed charges,,,85,,11.48,percent of total billed charges,,,49,,6.62,percent of total billed charges,,,90,,12.15,percent of total billed charges,,,,,,,no IP contract,,80,,10.8,percent of total billed charges,,,,,,,no IP contract,,50,,6.75,percent of total billed charges,,,,,,no IP contract,,,78,,10.53,percent of total billed charges,,,70,,9.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.62,3324,
61748-0012-09 - pyrazinamide 500 mg Tab,61748-0012-09,NDC,,,,inpatient,1,EA,13.5,8.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.48,percent of total billed charges,,,85,,11.48,percent of total billed charges,,,49,,6.62,percent of total billed charges,,,90,,12.15,percent of total billed charges,,,,,,,no IP contract,,80,,10.8,percent of total billed charges,,,,,,,no IP contract,,50,,6.75,percent of total billed charges,,,,,,no IP contract,,,78,,10.53,percent of total billed charges,,,70,,9.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.62,3324,
61748-0012-11 - pyrazinamide 500 mg Tab,61748-0012-11,NDC,,,,inpatient,1,EA,13.85,8.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.77,percent of total billed charges,,,85,,11.77,percent of total billed charges,,,49,,6.79,percent of total billed charges,,,90,,12.47,percent of total billed charges,,,,,,,no IP contract,,80,,11.08,percent of total billed charges,,,,,,,no IP contract,,50,,6.93,percent of total billed charges,,,,,,no IP contract,,,78,,10.8,percent of total billed charges,,,70,,9.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.79,3324,
61748-0015-30 - rifampin 150 mg Cap,61748-0015-30,NDC,,,,inpatient,1,EA,16.4,9.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.94,percent of total billed charges,,,85,,13.94,percent of total billed charges,,,49,,8.04,percent of total billed charges,,,90,,14.76,percent of total billed charges,,,,,,,no IP contract,,80,,13.12,percent of total billed charges,,,,,,,no IP contract,,50,,8.2,percent of total billed charges,,,,,,no IP contract,,,78,,12.79,percent of total billed charges,,,70,,11.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.04,3324,
61748-0018-60 - rifAMPin 300 mg Cap,61748-0018-60,NDC,,,,inpatient,1,EA,19.8,11.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.83,percent of total billed charges,,,85,,16.83,percent of total billed charges,,,49,,9.7,percent of total billed charges,,,90,,17.82,percent of total billed charges,,,,,,,no IP contract,,80,,15.84,percent of total billed charges,,,,,,,no IP contract,,50,,9.9,percent of total billed charges,,,,,,no IP contract,,,78,,15.44,percent of total billed charges,,,70,,13.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.7,3324,
61748-0025-01 - ethosuximide 250 mg Cap,61748-0025-01,NDC,,,,inpatient,1,EA,14.4,8.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.24,percent of total billed charges,,,85,,12.24,percent of total billed charges,,,49,,7.06,percent of total billed charges,,,90,,12.96,percent of total billed charges,,,,,,,no IP contract,,80,,11.52,percent of total billed charges,,,,,,,no IP contract,,50,,7.2,percent of total billed charges,,,,,,no IP contract,,,78,,11.23,percent of total billed charges,,,70,,10.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.06,3324,
61748-0054-16 - trihexyphenidyl 2 mg/5 mL Elixi,61748-0054-16,NDC,,,,inpatient,1,ML,5.85,3.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.97,percent of total billed charges,,,85,,4.97,percent of total billed charges,,,49,,2.87,percent of total billed charges,,,90,,5.27,percent of total billed charges,,,,,,,no IP contract,,80,,4.68,percent of total billed charges,,,,,,,no IP contract,,50,,2.93,percent of total billed charges,,,,,,no IP contract,,,78,,4.56,percent of total billed charges,,,70,,4.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.87,3324,
61958-0601-01 - emtricitabine 200 mg Cap,61958-0601-01,NDC,,,,inpatient,1,EA,137.45,82.47,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,111.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,116.83,percent of total billed charges,,,85,,116.83,percent of total billed charges,,,49,,67.35,percent of total billed charges,,,90,,123.71,percent of total billed charges,,,,,,,no IP contract,,80,,109.96,percent of total billed charges,,,,,,,no IP contract,,50,,68.73,percent of total billed charges,,,,,,no IP contract,,,78,,107.21,percent of total billed charges,,,70,,96.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,67.35,3324,
61958-0701-01 - emtricitabine-tenofovir 200 mg-300 mg Tab,61958-0701-01,NDC,,,,inpatient,1,EA,355.45,213.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,287.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,302.13,percent of total billed charges,,,85,,302.13,percent of total billed charges,,,49,,174.17,percent of total billed charges,,,90,,319.91,percent of total billed charges,,,,,,,no IP contract,,80,,284.36,percent of total billed charges,,,,,,,no IP contract,,50,,177.73,percent of total billed charges,,,,,,no IP contract,,,78,,277.25,percent of total billed charges,,,70,,248.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,174.17,3324,
61958-1003-01 - ranolazine 500 mg ER Ta,61958-1003-01,NDC,,,,inpatient,1,EA,38,22.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.3,percent of total billed charges,,,85,,32.3,percent of total billed charges,,,49,,18.62,percent of total billed charges,,,90,,34.2,percent of total billed charges,,,,,,,no IP contract,,80,,30.4,percent of total billed charges,,,,,,,no IP contract,,50,,19,percent of total billed charges,,,,,,no IP contract,,,78,,29.64,percent of total billed charges,,,70,,26.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.62,3324,
61958-2002-02 - emtricitabine-tenofovir 200 mg-25 mg Tab,61958-2002-02,NDC,,,,inpatient,1,EA,652.15,391.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,528.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,554.33,percent of total billed charges,,,85,,554.33,percent of total billed charges,,,49,,319.55,percent of total billed charges,,,90,,586.94,percent of total billed charges,,,,,,,no IP contract,,80,,521.72,percent of total billed charges,,,,,,,no IP contract,,50,,326.08,percent of total billed charges,,,,,,no IP contract,,,78,,508.68,percent of total billed charges,,,70,,456.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,319.55,3324,
61958-2301-01 - tenofovir 25 mg Tab,61958-2301-01,NDC,,,,inpatient,1,EA,416.5,249.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,337.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,354.03,percent of total billed charges,,,85,,354.03,percent of total billed charges,,,49,,204.09,percent of total billed charges,,,90,,374.85,percent of total billed charges,,,,,,,no IP contract,,80,,333.2,percent of total billed charges,,,,,,,no IP contract,,50,,208.25,percent of total billed charges,,,,,,no IP contract,,,78,,324.87,percent of total billed charges,,,70,,291.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,204.09,3324,
61958-2901-02 - remdesivir 100 mg REC I,61958-2901-02,NDC,,,,inpatient,1,EA,5273.05,3163.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4271.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4482.09,percent of total billed charges,,,85,,4482.09,percent of total billed charges,,,49,,2583.79,percent of total billed charges,,,90,,4745.75,percent of total billed charges,,,,,,,no IP contract,,80,,4218.44,percent of total billed charges,,,,,,,no IP contract,,50,,2636.53,percent of total billed charges,,,,,,no IP contract,,,78,,4112.98,percent of total billed charges,,,70,,3691.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4745.75,
62107-0047-01 - multivitamin 1 tab(s) Tab,62107-0047-01,NDC,,,,inpatient,1,EA,48.9,29.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,39.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,41.57,percent of total billed charges,,,85,,41.57,percent of total billed charges,,,49,,23.96,percent of total billed charges,,,90,,44.01,percent of total billed charges,,,,,,,no IP contract,,80,,39.12,percent of total billed charges,,,,,,,no IP contract,,50,,24.45,percent of total billed charges,,,,,,no IP contract,,,78,,38.14,percent of total billed charges,,,70,,34.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.96,3324,
62135-0191-22 - calcium acetate 667 mg Cap,62135-0191-22,NDC,,,,inpatient,1,EA,12,7.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.2,percent of total billed charges,,,85,,10.2,percent of total billed charges,,,49,,5.88,percent of total billed charges,,,90,,10.8,percent of total billed charges,,,,,,,no IP contract,,80,,9.6,percent of total billed charges,,,,,,,no IP contract,,50,,6,percent of total billed charges,,,,,,no IP contract,,,78,,9.36,percent of total billed charges,,,70,,8.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.88,3324,
62135-0502-47 - hydrOXYzine hydrochloride 10 mg/5 mL Syrup,62135-0502-47,NDC,,,,inpatient,1,ML,16,9.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.6,percent of total billed charges,,,85,,13.6,percent of total billed charges,,,49,,7.84,percent of total billed charges,,,90,,14.4,percent of total billed charges,,,,,,,no IP contract,,80,,12.8,percent of total billed charges,,,,,,,no IP contract,,50,,8,percent of total billed charges,,,,,,no IP contract,,,78,,12.48,percent of total billed charges,,,70,,11.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.84,3324,
62135-0712-42 - lidocaine VISCOUS 2% 1 app Soln,62135-0712-42,NDC,,,,inpatient,15,ML,992.15,595.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,803.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,843.33,percent of total billed charges,,,85,,843.33,percent of total billed charges,,,49,,486.15,percent of total billed charges,,,90,,892.94,percent of total billed charges,,,,,,,no IP contract,,80,,793.72,percent of total billed charges,,,,,,,no IP contract,,50,,496.08,percent of total billed charges,,,,,,no IP contract,,,78,,773.88,percent of total billed charges,,,70,,694.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,486.15,3324,
62135-0773-30 - trimethobenzamide 300 mg Cap,62135-0773-30,NDC,,,,inpatient,1,EA,175.55,105.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,142.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,149.22,percent of total billed charges,,,85,,149.22,percent of total billed charges,,,49,,86.02,percent of total billed charges,,,90,,158,percent of total billed charges,,,,,,,no IP contract,,80,,140.44,percent of total billed charges,,,,,,,no IP contract,,50,,87.78,percent of total billed charges,,,,,,no IP contract,,,78,,136.93,percent of total billed charges,,,70,,122.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,86.02,3324,
62175-0107-01 - isosorbide mononitrate 20 mg Tab,62175-0107-01,NDC,,,,inpatient,1,EA,10.25,6.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.71,percent of total billed charges,,,85,,8.71,percent of total billed charges,,,49,,5.02,percent of total billed charges,,,90,,9.23,percent of total billed charges,,,,,,,no IP contract,,80,,8.2,percent of total billed charges,,,,,,,no IP contract,,50,,5.13,percent of total billed charges,,,,,,no IP contract,,,78,,8,percent of total billed charges,,,70,,7.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.02,3324,
62175-0114-37 - omeprazole 10 mg DRC,62175-0114-37,NDC,,,,inpatient,1,EA,32.5,19.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,26.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,27.63,percent of total billed charges,,,85,,27.63,percent of total billed charges,,,49,,15.93,percent of total billed charges,,,90,,29.25,percent of total billed charges,,,,,,,no IP contract,,80,,26,percent of total billed charges,,,,,,,no IP contract,,50,,16.25,percent of total billed charges,,,,,,no IP contract,,,78,,25.35,percent of total billed charges,,,70,,22.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.93,3324,
62175-0119-37 - isosorbide mononitrate 60 mg ER Ta,62175-0119-37,NDC,,,,inpatient,1,EA,15.9,9.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.52,percent of total billed charges,,,85,,13.52,percent of total billed charges,,,49,,7.79,percent of total billed charges,,,90,,14.31,percent of total billed charges,,,,,,,no IP contract,,80,,12.72,percent of total billed charges,,,,,,,no IP contract,,50,,7.95,percent of total billed charges,,,,,,no IP contract,,,78,,12.4,percent of total billed charges,,,70,,11.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.79,3324,
62175-0270-37 - oxybutynin 5 mg/24 hours ER Ta,62175-0270-37,NDC,,,,inpatient,1,EA,28.25,16.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.01,percent of total billed charges,,,85,,24.01,percent of total billed charges,,,49,,13.84,percent of total billed charges,,,90,,25.43,percent of total billed charges,,,,,,,no IP contract,,80,,22.6,percent of total billed charges,,,,,,,no IP contract,,50,,14.13,percent of total billed charges,,,,,,no IP contract,,,78,,22.04,percent of total billed charges,,,70,,19.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.84,3324,
62175-0271-37 - oxybutynin 10 mg/24 hr ER Ta,62175-0271-37,NDC,,,,inpatient,1,EA,28.3,16.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.06,percent of total billed charges,,,85,,24.06,percent of total billed charges,,,49,,13.87,percent of total billed charges,,,90,,25.47,percent of total billed charges,,,,,,,no IP contract,,80,,22.64,percent of total billed charges,,,,,,,no IP contract,,50,,14.15,percent of total billed charges,,,,,,no IP contract,,,78,,22.07,percent of total billed charges,,,70,,19.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.87,3324,
62175-0485-37 - verapamil 100 mg/24 hours ER Ca,62175-0485-37,NDC,,,,inpatient,1,EA,2,1.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1.7,percent of total billed charges,,,85,,1.7,percent of total billed charges,,,49,,0.98,percent of total billed charges,,,90,,1.8,percent of total billed charges,,,,,,,no IP contract,,80,,1.6,percent of total billed charges,,,,,,,no IP contract,,50,,1,percent of total billed charges,,,,,,no IP contract,,,78,,1.56,percent of total billed charges,,,70,,1.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,0.98,3324,
62332-0030-31 - rOPINIRole 0.25 mg Tab,62332-0030-31,NDC,,,,inpatient,1,EA,23.7,14.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.15,percent of total billed charges,,,85,,20.15,percent of total billed charges,,,49,,11.61,percent of total billed charges,,,90,,21.33,percent of total billed charges,,,,,,,no IP contract,,80,,18.96,percent of total billed charges,,,,,,,no IP contract,,50,,11.85,percent of total billed charges,,,,,,no IP contract,,,78,,18.49,percent of total billed charges,,,70,,16.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.61,3324,
62332-0032-31 - rOPINIRole 1 mg Tab,62332-0032-31,NDC,,,,inpatient,1,EA,23.7,14.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.15,percent of total billed charges,,,85,,20.15,percent of total billed charges,,,49,,11.61,percent of total billed charges,,,90,,21.33,percent of total billed charges,,,,,,,no IP contract,,80,,18.96,percent of total billed charges,,,,,,,no IP contract,,50,,11.85,percent of total billed charges,,,,,,no IP contract,,,78,,18.49,percent of total billed charges,,,70,,16.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.61,3324,
62332-0042-30 - irbesartan 150 mg Tab,62332-0042-30,NDC,,,,inpatient,1,EA,28.25,16.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.01,percent of total billed charges,,,85,,24.01,percent of total billed charges,,,49,,13.84,percent of total billed charges,,,90,,25.43,percent of total billed charges,,,,,,,no IP contract,,80,,22.6,percent of total billed charges,,,,,,,no IP contract,,50,,14.13,percent of total billed charges,,,,,,no IP contract,,,78,,22.04,percent of total billed charges,,,70,,19.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.84,3324,
62332-0042-90 - irbesartan 150 mg Tab,62332-0042-90,NDC,,,,inpatient,1,EA,28.25,16.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.01,percent of total billed charges,,,85,,24.01,percent of total billed charges,,,49,,13.84,percent of total billed charges,,,90,,25.43,percent of total billed charges,,,,,,,no IP contract,,80,,22.6,percent of total billed charges,,,,,,,no IP contract,,50,,14.13,percent of total billed charges,,,,,,no IP contract,,,78,,22.04,percent of total billed charges,,,70,,19.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.84,3324,
62332-0046-90 - valsartan 160 mg Tab,62332-0046-90,NDC,,,,inpatient,1,EA,43.55,26.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,35.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,37.02,percent of total billed charges,,,85,,37.02,percent of total billed charges,,,49,,21.34,percent of total billed charges,,,90,,39.2,percent of total billed charges,,,,,,,no IP contract,,80,,34.84,percent of total billed charges,,,,,,,no IP contract,,50,,21.78,percent of total billed charges,,,,,,no IP contract,,,78,,33.97,percent of total billed charges,,,70,,30.49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.34,3324,
62332-0054-91 - cloNIDine 0.1 mg Tab,62332-0054-91,NDC,,,,inpatient,1,EA,5.5,3.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.68,percent of total billed charges,,,85,,4.68,percent of total billed charges,,,49,,2.7,percent of total billed charges,,,90,,4.95,percent of total billed charges,,,,,,,no IP contract,,80,,4.4,percent of total billed charges,,,,,,,no IP contract,,50,,2.75,percent of total billed charges,,,,,,no IP contract,,,78,,4.29,percent of total billed charges,,,70,,3.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.7,3324,
62332-0061-30 - leflunomide 10 mg Tab,62332-0061-30,NDC,,,,inpatient,1,EA,134.3,80.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,108.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,114.16,percent of total billed charges,,,85,,114.16,percent of total billed charges,,,49,,65.81,percent of total billed charges,,,90,,120.87,percent of total billed charges,,,,,,,no IP contract,,80,,107.44,percent of total billed charges,,,,,,,no IP contract,,50,,67.15,percent of total billed charges,,,,,,no IP contract,,,78,,104.75,percent of total billed charges,,,70,,94.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,65.81,3324,
62332-0097-30 - ARIPiprazole 2 mg Tab,62332-0097-30,NDC,,,,inpatient,1,EA,258.2,154.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,209.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,219.47,percent of total billed charges,,,85,,219.47,percent of total billed charges,,,49,,126.52,percent of total billed charges,,,90,,232.38,percent of total billed charges,,,,,,,no IP contract,,80,,206.56,percent of total billed charges,,,,,,,no IP contract,,50,,129.1,percent of total billed charges,,,,,,no IP contract,,,78,,201.4,percent of total billed charges,,,70,,180.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,126.52,3324,
62332-0098-30 - ARIPiprazole 5 mg Tab,62332-0098-30,NDC,,,,inpatient,1,EA,258.2,154.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,209.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,219.47,percent of total billed charges,,,85,,219.47,percent of total billed charges,,,49,,126.52,percent of total billed charges,,,90,,232.38,percent of total billed charges,,,,,,,no IP contract,,80,,206.56,percent of total billed charges,,,,,,,no IP contract,,50,,129.1,percent of total billed charges,,,,,,no IP contract,,,78,,201.4,percent of total billed charges,,,70,,180.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,126.52,3324,
62332-0098-31 - ARIPiprazole 5 mg Tab,62332-0098-31,NDC,,,,inpatient,1,EA,258.85,155.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,209.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,220.02,percent of total billed charges,,,85,,220.02,percent of total billed charges,,,49,,126.84,percent of total billed charges,,,90,,232.97,percent of total billed charges,,,,,,,no IP contract,,80,,207.08,percent of total billed charges,,,,,,,no IP contract,,50,,129.43,percent of total billed charges,,,,,,no IP contract,,,78,,201.9,percent of total billed charges,,,70,,181.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,126.84,3324,
62332-0099-30 - ARIPiprazole 10 mg Tab,62332-0099-30,NDC,,,,inpatient,1,EA,258.2,154.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,209.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,219.47,percent of total billed charges,,,85,,219.47,percent of total billed charges,,,49,,126.52,percent of total billed charges,,,90,,232.38,percent of total billed charges,,,,,,,no IP contract,,80,,206.56,percent of total billed charges,,,,,,,no IP contract,,50,,129.1,percent of total billed charges,,,,,,no IP contract,,,78,,201.4,percent of total billed charges,,,70,,180.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,126.52,3324,
62332-0099-31 - ARIPiprazole 10 mg Tab,62332-0099-31,NDC,,,,inpatient,1,EA,258.85,155.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,209.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,220.02,percent of total billed charges,,,85,,220.02,percent of total billed charges,,,49,,126.84,percent of total billed charges,,,90,,232.97,percent of total billed charges,,,,,,,no IP contract,,80,,207.08,percent of total billed charges,,,,,,,no IP contract,,50,,129.43,percent of total billed charges,,,,,,no IP contract,,,78,,201.9,percent of total billed charges,,,70,,181.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,126.84,3324,
62332-0132-30 - olmesartan 20 mg Tab,62332-0132-30,NDC,,,,inpatient,1,EA,53.75,32.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,43.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,45.69,percent of total billed charges,,,85,,45.69,percent of total billed charges,,,49,,26.34,percent of total billed charges,,,90,,48.38,percent of total billed charges,,,,,,,no IP contract,,80,,43,percent of total billed charges,,,,,,,no IP contract,,50,,26.88,percent of total billed charges,,,,,,no IP contract,,,78,,41.93,percent of total billed charges,,,70,,37.63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.34,3324,
62332-0142-31 - celecoxib 200 mg Cap,62332-0142-31,NDC,,,,inpatient,1,EA,64,38.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,51.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,54.4,percent of total billed charges,,,85,,54.4,percent of total billed charges,,,49,,31.36,percent of total billed charges,,,90,,57.6,percent of total billed charges,,,,,,,no IP contract,,80,,51.2,percent of total billed charges,,,,,,,no IP contract,,50,,32,percent of total billed charges,,,,,,no IP contract,,,78,,49.92,percent of total billed charges,,,70,,44.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.36,3324,
azithromycin 600 mg Tab,62332-0253-30,NDC,,,,inpatient,1,EA,152.35,91.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,123.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,129.5,percent of total billed charges,,,85,,129.5,percent of total billed charges,,,49,,74.65,percent of total billed charges,,,90,,137.12,percent of total billed charges,,,,,,,no IP contract,,80,,121.88,percent of total billed charges,,,,,,,no IP contract,,50,,76.18,percent of total billed charges,,,,,,no IP contract,,,78,,118.83,percent of total billed charges,,,70,,106.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,74.65,3324,
candesartan 8 mg Tab,62332-0342-30,NDC,,,,inpatient,1,EA,28.15,16.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.93,percent of total billed charges,,,85,,23.93,percent of total billed charges,,,49,,13.79,percent of total billed charges,,,90,,25.34,percent of total billed charges,,,,,,,no IP contract,,80,,22.52,percent of total billed charges,,,,,,,no IP contract,,50,,14.08,percent of total billed charges,,,,,,no IP contract,,,78,,21.96,percent of total billed charges,,,70,,19.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.79,3324,
62332-0352-31 - doxycycline 20 mg Tab,62332-0352-31,NDC,,,,inpatient,1,EA,13.3,7.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.31,percent of total billed charges,,,85,,11.31,percent of total billed charges,,,49,,6.52,percent of total billed charges,,,90,,11.97,percent of total billed charges,,,,,,,no IP contract,,80,,10.64,percent of total billed charges,,,,,,,no IP contract,,50,,6.65,percent of total billed charges,,,,,,no IP contract,,,78,,10.37,percent of total billed charges,,,70,,9.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.52,3324,
62332-0364-06 - clonazePAM 0.125 mg DIS T,62332-0364-06,NDC,,,,inpatient,1,EA,14.15,8.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.03,percent of total billed charges,,,85,,12.03,percent of total billed charges,,,49,,6.93,percent of total billed charges,,,90,,12.74,percent of total billed charges,,,,,,,no IP contract,,80,,11.32,percent of total billed charges,,,,,,,no IP contract,,50,,7.08,percent of total billed charges,,,,,,no IP contract,,,78,,11.04,percent of total billed charges,,,70,,9.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.93,3324,
62332-0366-06 - clonazePAM 0.5 mg DIS T,62332-0366-06,NDC,,,,inpatient,1,EA,16.25,9.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.81,percent of total billed charges,,,85,,13.81,percent of total billed charges,,,49,,7.96,percent of total billed charges,,,90,,14.63,percent of total billed charges,,,,,,,no IP contract,,80,,13,percent of total billed charges,,,,,,,no IP contract,,50,,8.13,percent of total billed charges,,,,,,no IP contract,,,78,,12.68,percent of total billed charges,,,70,,11.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.96,3324,
62332-0582-31 - lidocaine-prilocaine topical 2.5%-2.5% Cream,62332-0582-31,NDC,,,,inpatient,1,UN,806.4,483.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,653.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,685.44,percent of total billed charges,,,85,,685.44,percent of total billed charges,,,49,,395.14,percent of total billed charges,,,90,,725.76,percent of total billed charges,,,,,,,no IP contract,,80,,645.12,percent of total billed charges,,,,,,,no IP contract,,50,,403.2,percent of total billed charges,,,,,,no IP contract,,,78,,628.99,percent of total billed charges,,,70,,564.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,395.14,3324,
mercaptopurine 100 mg/5 mL Susp,62484-0020-02,NDC,,,,inpatient,1,mL,92.9,55.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,75.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,78.97,percent of total billed charges,,,85,,78.97,percent of total billed charges,,,49,,45.52,percent of total billed charges,,,90,,83.61,percent of total billed charges,,,,,,,no IP contract,,80,,74.32,percent of total billed charges,,,,,,,no IP contract,,50,,46.45,percent of total billed charges,,,,,,no IP contract,,,78,,72.46,percent of total billed charges,,,70,,65.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,45.52,3324,
62559-0153-04 - opium 10% (equivalent to morphine 10 mg/mL) Tinct,62559-0153-04,NDC,,,,inpatient,0.1,ML,57.65,34.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,46.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,49,percent of total billed charges,,,85,,49,percent of total billed charges,,,49,,28.25,percent of total billed charges,,,90,,51.89,percent of total billed charges,,,,,,,no IP contract,,80,,46.12,percent of total billed charges,,,,,,,no IP contract,,50,,28.83,percent of total billed charges,,,,,,no IP contract,,,78,,44.97,percent of total billed charges,,,70,,40.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,28.25,3324,
62559-0159-01 - fluvoxaMINE 50 mg Tab,62559-0159-01,NDC,,,,inpatient,1,EA,24.25,14.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.61,percent of total billed charges,,,85,,20.61,percent of total billed charges,,,49,,11.88,percent of total billed charges,,,90,,21.83,percent of total billed charges,,,,,,,no IP contract,,80,,19.4,percent of total billed charges,,,,,,,no IP contract,,50,,12.13,percent of total billed charges,,,,,,no IP contract,,,78,,18.92,percent of total billed charges,,,70,,16.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.88,3324,
62559-0210-31 - nimodipine 30 mg Cap,62559-0210-31,NDC,,,,inpatient,1,EA,135.4,81.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,109.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,115.09,percent of total billed charges,,,85,,115.09,percent of total billed charges,,,49,,66.35,percent of total billed charges,,,90,,121.86,percent of total billed charges,,,,,,,no IP contract,,80,,108.32,percent of total billed charges,,,,,,,no IP contract,,50,,67.7,percent of total billed charges,,,,,,no IP contract,,,78,,105.61,percent of total billed charges,,,70,,94.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,66.35,3324,
62559-0230-01 - propafenone 150 mg Tab,62559-0230-01,NDC,,,,inpatient,1,EA,16.85,10.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.32,percent of total billed charges,,,85,,14.32,percent of total billed charges,,,49,,8.26,percent of total billed charges,,,90,,15.17,percent of total billed charges,,,,,,,no IP contract,,80,,13.48,percent of total billed charges,,,,,,,no IP contract,,50,,8.43,percent of total billed charges,,,,,,no IP contract,,,78,,13.14,percent of total billed charges,,,70,,11.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.26,3324,
62559-0291-01 - potassium citrate 10 mEq ER Ta,62559-0291-01,NDC,,,,inpatient,1,EA,23.3,13.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.81,percent of total billed charges,,,85,,19.81,percent of total billed charges,,,49,,11.42,percent of total billed charges,,,90,,20.97,percent of total billed charges,,,,,,,no IP contract,,80,,18.64,percent of total billed charges,,,,,,,no IP contract,,50,,11.65,percent of total billed charges,,,,,,no IP contract,,,78,,18.17,percent of total billed charges,,,70,,16.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.42,3324,
62559-0381-01 - flecainide 100 mg Tab,62559-0381-01,NDC,,,,inpatient,1,EA,25.55,15.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.72,percent of total billed charges,,,85,,21.72,percent of total billed charges,,,49,,12.52,percent of total billed charges,,,90,,23,percent of total billed charges,,,,,,,no IP contract,,80,,20.44,percent of total billed charges,,,,,,,no IP contract,,50,,12.78,percent of total billed charges,,,,,,no IP contract,,,78,,19.93,percent of total billed charges,,,70,,17.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.52,3324,
62559-0391-20 - vancomycin 250 mg Cap,62559-0391-20,NDC,,,,inpatient,1,EA,462.7,277.62,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,374.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,393.3,percent of total billed charges,,,85,,393.3,percent of total billed charges,,,49,,226.72,percent of total billed charges,,,90,,416.43,percent of total billed charges,,,,,,,no IP contract,,80,,370.16,percent of total billed charges,,,,,,,no IP contract,,50,,231.35,percent of total billed charges,,,,,,no IP contract,,,78,,360.91,percent of total billed charges,,,70,,323.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,226.72,3324,
62559-0490-01 - atropine-diphenoxylate Tab 0.025 mg-2.5 mg Tab,62559-0490-01,NDC,,,,inpatient,1,EA,11.25,6.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.56,percent of total billed charges,,,85,,9.56,percent of total billed charges,,,49,,5.51,percent of total billed charges,,,90,,10.13,percent of total billed charges,,,,,,,no IP contract,,80,,9,percent of total billed charges,,,,,,,no IP contract,,50,,5.63,percent of total billed charges,,,,,,no IP contract,,,78,,8.78,percent of total billed charges,,,70,,7.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.51,3324,
62559-0630-01 - erythromycin ethylsuccinate 200 mg/5 mL REC G,62559-0630-01,NDC,,,,inpatient,1,ML,39.15,23.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.28,percent of total billed charges,,,85,,33.28,percent of total billed charges,,,49,,19.18,percent of total billed charges,,,90,,35.24,percent of total billed charges,,,,,,,no IP contract,,80,,31.32,percent of total billed charges,,,,,,,no IP contract,,50,,19.58,percent of total billed charges,,,,,,no IP contract,,,78,,30.54,percent of total billed charges,,,70,,27.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.18,3324,
62576-0240-64 - ondansetron 4 mg Tab,62576-0240-64,NDC,,,,inpatient,1,EA,5310.45,3186.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4301.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4513.88,percent of total billed charges,,,85,,4513.88,percent of total billed charges,,,49,,2602.12,percent of total billed charges,,,90,,4779.41,percent of total billed charges,,,,,,,no IP contract,,80,,4248.36,percent of total billed charges,,,,,,,no IP contract,,50,,2655.23,percent of total billed charges,,,,,,no IP contract,,,78,,4142.15,percent of total billed charges,,,70,,3717.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4779.41,
62584-0259-01 - metformin 500 mg Tab,62584-0259-01,NDC,,,,inpatient,1,EA,9.4,5.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.99,percent of total billed charges,,,85,,7.99,percent of total billed charges,,,49,,4.61,percent of total billed charges,,,90,,8.46,percent of total billed charges,,,,,,,no IP contract,,80,,7.52,percent of total billed charges,,,,,,,no IP contract,,50,,4.7,percent of total billed charges,,,,,,no IP contract,,,78,,7.33,percent of total billed charges,,,70,,6.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.61,3324,
62584-0265-01 - metoprolol 25 mg Tab,62584-0265-01,NDC,,,,inpatient,1,EA,4.7,2.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4,percent of total billed charges,,,85,,4,percent of total billed charges,,,49,,2.3,percent of total billed charges,,,90,,4.23,percent of total billed charges,,,,,,,no IP contract,,80,,3.76,percent of total billed charges,,,,,,,no IP contract,,50,,2.35,percent of total billed charges,,,,,,no IP contract,,,78,,3.67,percent of total billed charges,,,70,,3.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.3,3324,
62584-0266-01 - metoprolol 50 mg Tab,62584-0266-01,NDC,,,,inpatient,1,EA,4.4,2.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.74,percent of total billed charges,,,85,,3.74,percent of total billed charges,,,49,,2.16,percent of total billed charges,,,90,,3.96,percent of total billed charges,,,,,,,no IP contract,,80,,3.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.2,percent of total billed charges,,,,,,no IP contract,,,78,,3.43,percent of total billed charges,,,70,,3.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.16,3324,
62584-0267-01 - metoprolol 100 mg Tab,62584-0267-01,NDC,,,,inpatient,1,EA,4.7,2.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4,percent of total billed charges,,,85,,4,percent of total billed charges,,,49,,2.3,percent of total billed charges,,,90,,4.23,percent of total billed charges,,,,,,,no IP contract,,80,,3.76,percent of total billed charges,,,,,,,no IP contract,,50,,2.35,percent of total billed charges,,,,,,no IP contract,,,78,,3.67,percent of total billed charges,,,70,,3.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.3,3324,
62584-0467-01 - atenolol 50 mg Tab,62584-0467-01,NDC,,,,inpatient,1,EA,12.8,7.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.88,percent of total billed charges,,,85,,10.88,percent of total billed charges,,,49,,6.27,percent of total billed charges,,,90,,11.52,percent of total billed charges,,,,,,,no IP contract,,80,,10.24,percent of total billed charges,,,,,,,no IP contract,,50,,6.4,percent of total billed charges,,,,,,no IP contract,,,78,,9.98,percent of total billed charges,,,70,,8.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.27,3324,
62584-0713-01 - allopurinol 300 mg Tab,62584-0713-01,NDC,,,,inpatient,1,EA,9.4,5.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.99,percent of total billed charges,,,85,,7.99,percent of total billed charges,,,49,,4.61,percent of total billed charges,,,90,,8.46,percent of total billed charges,,,,,,,no IP contract,,80,,7.52,percent of total billed charges,,,,,,,no IP contract,,50,,4.7,percent of total billed charges,,,,,,no IP contract,,,78,,7.33,percent of total billed charges,,,70,,6.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.61,3324,
62584-0733-01 - hydrALAZINE 25 mg Tab,62584-0733-01,NDC,,,,inpatient,1,EA,5.8,3.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.93,percent of total billed charges,,,85,,4.93,percent of total billed charges,,,49,,2.84,percent of total billed charges,,,90,,5.22,percent of total billed charges,,,,,,,no IP contract,,80,,4.64,percent of total billed charges,,,,,,,no IP contract,,50,,2.9,percent of total billed charges,,,,,,no IP contract,,,78,,4.52,percent of total billed charges,,,70,,4.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.84,3324,
62584-0747-01 - ibuprofen 600 mg Tab,62584-0747-01,NDC,,,,inpatient,1,EA,6.7,4.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.7,percent of total billed charges,,,85,,5.7,percent of total billed charges,,,49,,3.28,percent of total billed charges,,,90,,6.03,percent of total billed charges,,,,,,,no IP contract,,80,,5.36,percent of total billed charges,,,,,,,no IP contract,,50,,3.35,percent of total billed charges,,,,,,no IP contract,,,78,,5.23,percent of total billed charges,,,70,,4.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.28,3324,
62584-0747-11 - ibuprofen 600 mg Tab,62584-0747-11,NDC,,,,inpatient,1,EA,6.7,4.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.7,percent of total billed charges,,,85,,5.7,percent of total billed charges,,,49,,3.28,percent of total billed charges,,,90,,6.03,percent of total billed charges,,,,,,,no IP contract,,80,,5.36,percent of total billed charges,,,,,,,no IP contract,,50,,3.35,percent of total billed charges,,,,,,no IP contract,,,78,,5.23,percent of total billed charges,,,70,,4.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.28,3324,
62584-0897-01 - folic acid 1 mg Tab,62584-0897-01,NDC,,,,inpatient,1,EA,6.7,4.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.7,percent of total billed charges,,,85,,5.7,percent of total billed charges,,,49,,3.28,percent of total billed charges,,,90,,6.03,percent of total billed charges,,,,,,,no IP contract,,80,,5.36,percent of total billed charges,,,,,,,no IP contract,,50,,3.35,percent of total billed charges,,,,,,no IP contract,,,78,,5.23,percent of total billed charges,,,70,,4.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.28,3324,
62584-0984-01 - warfarin 2 mg Tab,62584-0984-01,NDC,,,,inpatient,1,EA,8.75,5.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.44,percent of total billed charges,,,85,,7.44,percent of total billed charges,,,49,,4.29,percent of total billed charges,,,90,,7.88,percent of total billed charges,,,,,,,no IP contract,,80,,7,percent of total billed charges,,,,,,,no IP contract,,50,,4.38,percent of total billed charges,,,,,,no IP contract,,,78,,6.83,percent of total billed charges,,,70,,6.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.29,3324,
62584-0994-01 - warfarin 5 mg Tab,62584-0994-01,NDC,,,,inpatient,1,EA,3.8,2.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.23,percent of total billed charges,,,85,,3.23,percent of total billed charges,,,49,,1.86,percent of total billed charges,,,90,,3.42,percent of total billed charges,,,,,,,no IP contract,,80,,3.04,percent of total billed charges,,,,,,,no IP contract,,50,,1.9,percent of total billed charges,,,,,,no IP contract,,,78,,2.96,percent of total billed charges,,,70,,2.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.86,3324,
62584-0994-11 - warfarin 5 mg Tab,62584-0994-11,NDC,,,,inpatient,1,EA,8.9,5.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.57,percent of total billed charges,,,85,,7.57,percent of total billed charges,,,49,,4.36,percent of total billed charges,,,90,,8.01,percent of total billed charges,,,,,,,no IP contract,,80,,7.12,percent of total billed charges,,,,,,,no IP contract,,50,,4.45,percent of total billed charges,,,,,,no IP contract,,,78,,6.94,percent of total billed charges,,,70,,6.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.36,3324,
62756-0015-40 - testosterone cypionate 200 mg/mL Soln,62756-0015-40,NDC,,,,inpatient,1,ML,198.25,118.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,160.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,168.51,percent of total billed charges,,,85,,168.51,percent of total billed charges,,,49,,97.14,percent of total billed charges,,,90,,178.43,percent of total billed charges,,,,,,,no IP contract,,80,,158.6,percent of total billed charges,,,,,,,no IP contract,,50,,99.13,percent of total billed charges,,,,,,no IP contract,,,78,,154.64,percent of total billed charges,,,70,,138.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,97.14,3324,
62756-0071-64 - pantoprazole 40 mg ECGR,62756-0071-64,NDC,,,,inpatient,1,UN,138.9,83.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,112.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,118.07,percent of total billed charges,,,85,,118.07,percent of total billed charges,,,49,,68.06,percent of total billed charges,,,90,,125.01,percent of total billed charges,,,,,,,no IP contract,,80,,111.12,percent of total billed charges,,,,,,,no IP contract,,50,,69.45,percent of total billed charges,,,,,,no IP contract,,,78,,108.34,percent of total billed charges,,,70,,97.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,68.06,3324,
62756-0142-01 - metFORMIN 500 mg ER Ta,62756-0142-01,NDC,,,,inpatient,1,EA,9.7,5.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.25,percent of total billed charges,,,85,,8.25,percent of total billed charges,,,49,,4.75,percent of total billed charges,,,90,,8.73,percent of total billed charges,,,,,,,no IP contract,,80,,7.76,percent of total billed charges,,,,,,,no IP contract,,50,,4.85,percent of total billed charges,,,,,,no IP contract,,,78,,7.57,percent of total billed charges,,,70,,6.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.75,3324,
62756-0143-01 - metformin 750 mg ER Ta,62756-0143-01,NDC,,,,inpatient,1,EA,13.35,8.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.35,percent of total billed charges,,,85,,11.35,percent of total billed charges,,,49,,6.54,percent of total billed charges,,,90,,12.02,percent of total billed charges,,,,,,,no IP contract,,80,,10.68,percent of total billed charges,,,,,,,no IP contract,,50,,6.68,percent of total billed charges,,,,,,no IP contract,,,78,,10.41,percent of total billed charges,,,70,,9.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.54,3324,
62756-0183-88 - OXcarbazepine 150 mg Tab,62756-0183-88,NDC,,,,inpatient,1,EA,15.35,9.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.05,percent of total billed charges,,,85,,13.05,percent of total billed charges,,,49,,7.52,percent of total billed charges,,,90,,13.82,percent of total billed charges,,,,,,,no IP contract,,80,,12.28,percent of total billed charges,,,,,,,no IP contract,,50,,7.68,percent of total billed charges,,,,,,no IP contract,,,78,,11.97,percent of total billed charges,,,70,,10.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.52,3324,
62756-0184-88 - oxcarbazepine 300 mg Tab,62756-0184-88,NDC,,,,inpatient,1,EA,24.8,14.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.08,percent of total billed charges,,,85,,21.08,percent of total billed charges,,,49,,12.15,percent of total billed charges,,,90,,22.32,percent of total billed charges,,,,,,,no IP contract,,80,,19.84,percent of total billed charges,,,,,,,no IP contract,,50,,12.4,percent of total billed charges,,,,,,no IP contract,,,78,,19.34,percent of total billed charges,,,70,,17.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.15,3324,
62756-0259-02 - zonisamide 50 mg Cap,62756-0259-02,NDC,,,,inpatient,1,EA,12.55,7.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.67,percent of total billed charges,,,85,,10.67,percent of total billed charges,,,49,,6.15,percent of total billed charges,,,90,,11.3,percent of total billed charges,,,,,,,no IP contract,,80,,10.04,percent of total billed charges,,,,,,,no IP contract,,50,,6.28,percent of total billed charges,,,,,,no IP contract,,,78,,9.79,percent of total billed charges,,,70,,8.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.15,3324,
62756-0427-90 - ciprofloxacin-dexamethasone otic 0.3%-0.1% Susp,62756-0427-90,NDC,,,,inpatient,1,UN,2343.3,1405.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1898.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1991.81,percent of total billed charges,,,85,,1991.81,percent of total billed charges,,,49,,1148.22,percent of total billed charges,,,90,,2108.97,percent of total billed charges,,,,,,,no IP contract,,80,,1874.64,percent of total billed charges,,,,,,,no IP contract,,50,,1171.65,percent of total billed charges,,,,,,no IP contract,,,78,,1827.77,percent of total billed charges,,,70,,1640.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
62756-0457-88 - carbidopa-levodopa 50 mg-200 mg ER Ta,62756-0457-88,NDC,,,,inpatient,1,EA,18.2,10.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.47,percent of total billed charges,,,85,,15.47,percent of total billed charges,,,49,,8.92,percent of total billed charges,,,90,,16.38,percent of total billed charges,,,,,,,no IP contract,,80,,14.56,percent of total billed charges,,,,,,,no IP contract,,50,,9.1,percent of total billed charges,,,,,,no IP contract,,,78,,14.2,percent of total billed charges,,,70,,12.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.92,3324,
62756-0512-44 - azithromycin 500 mg REC I,62756-0512-44,NDC,,,,inpatient,5,ML,70,42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,56.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,59.5,percent of total billed charges,,,85,,59.5,percent of total billed charges,,,49,,34.3,percent of total billed charges,,,90,,63,percent of total billed charges,,,,,,,no IP contract,,80,,56,percent of total billed charges,,,,,,,no IP contract,,50,,35,percent of total billed charges,,,,,,no IP contract,,,78,,54.6,percent of total billed charges,,,70,,49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,34.3,3324,
62756-0520-69 - sumatriptan 25 mg Tab,62756-0520-69,NDC,,,,inpatient,1,EA,218.85,131.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,177.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,186.02,percent of total billed charges,,,85,,186.02,percent of total billed charges,,,49,,107.24,percent of total billed charges,,,90,,196.97,percent of total billed charges,,,,,,,no IP contract,,80,,175.08,percent of total billed charges,,,,,,,no IP contract,,50,,109.43,percent of total billed charges,,,,,,no IP contract,,,78,,170.7,percent of total billed charges,,,70,,153.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,107.24,3324,
62756-0538-86 - riluzole 50 mg Tab,62756-0538-86,NDC,,,,inpatient,1,EA,300.6,180.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,243.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,255.51,percent of total billed charges,,,85,,255.51,percent of total billed charges,,,49,,147.29,percent of total billed charges,,,90,,270.54,percent of total billed charges,,,,,,,no IP contract,,80,,240.48,percent of total billed charges,,,,,,,no IP contract,,50,,150.3,percent of total billed charges,,,,,,no IP contract,,,78,,234.47,percent of total billed charges,,,70,,210.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,147.29,3324,
62756-0762-88 - torsemide 10 mg Tab,62756-0762-88,NDC,,,,inpatient,1,EA,9.4,5.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.99,percent of total billed charges,,,85,,7.99,percent of total billed charges,,,49,,4.61,percent of total billed charges,,,90,,8.46,percent of total billed charges,,,,,,,no IP contract,,80,,7.52,percent of total billed charges,,,,,,,no IP contract,,50,,4.7,percent of total billed charges,,,,,,no IP contract,,,78,,7.33,percent of total billed charges,,,70,,6.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.61,3324,
62756-0763-88 - torsemide 20 mg Tab,62756-0763-88,NDC,,,,inpatient,1,EA,10.4,6.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.84,percent of total billed charges,,,85,,8.84,percent of total billed charges,,,49,,5.1,percent of total billed charges,,,90,,9.36,percent of total billed charges,,,,,,,no IP contract,,80,,8.32,percent of total billed charges,,,,,,,no IP contract,,50,,5.2,percent of total billed charges,,,,,,no IP contract,,,78,,8.11,percent of total billed charges,,,70,,7.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.1,3324,
62756-0764-88 - torsemide 100 mg Tab,62756-0764-88,NDC,,,,inpatient,1,EA,28,16.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.8,percent of total billed charges,,,85,,23.8,percent of total billed charges,,,49,,13.72,percent of total billed charges,,,90,,25.2,percent of total billed charges,,,,,,,no IP contract,,80,,22.4,percent of total billed charges,,,,,,,no IP contract,,50,,14,percent of total billed charges,,,,,,no IP contract,,,78,,21.84,percent of total billed charges,,,70,,19.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.72,3324,
62756-0798-88 - divalproex sodium 500 mg EC Ta,62756-0798-88,NDC,,,,inpatient,1,EA,29.35,17.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.95,percent of total billed charges,,,85,,24.95,percent of total billed charges,,,49,,14.38,percent of total billed charges,,,90,,26.42,percent of total billed charges,,,,,,,no IP contract,,80,,23.48,percent of total billed charges,,,,,,,no IP contract,,50,,14.68,percent of total billed charges,,,,,,no IP contract,,,78,,22.89,percent of total billed charges,,,70,,20.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.38,3324,
62756-0955-01 - mexiletine 150 mg Cap,62756-0955-01,NDC,,,,inpatient,1,EA,24,14.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.4,percent of total billed charges,,,85,,20.4,percent of total billed charges,,,49,,11.76,percent of total billed charges,,,90,,21.6,percent of total billed charges,,,,,,,no IP contract,,80,,19.2,percent of total billed charges,,,,,,,no IP contract,,50,,12,percent of total billed charges,,,,,,no IP contract,,,78,,18.72,percent of total billed charges,,,70,,16.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.76,3324,
62756-0956-01 - mexiletine 200 mg Cap,62756-0956-01,NDC,,,,inpatient,1,EA,27.9,16.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.72,percent of total billed charges,,,85,,23.72,percent of total billed charges,,,49,,13.67,percent of total billed charges,,,90,,25.11,percent of total billed charges,,,,,,,no IP contract,,80,,22.32,percent of total billed charges,,,,,,,no IP contract,,50,,13.95,percent of total billed charges,,,,,,no IP contract,,,78,,21.76,percent of total billed charges,,,70,,19.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.67,3324,
62856-0272-30 - perampanel 2 mg Tab,62856-0272-30,NDC,,,,inpatient,1,EA,130.35,78.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,105.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,110.8,percent of total billed charges,,,85,,110.8,percent of total billed charges,,,49,,63.87,percent of total billed charges,,,90,,117.32,percent of total billed charges,,,,,,,no IP contract,,80,,104.28,percent of total billed charges,,,,,,,no IP contract,,50,,65.18,percent of total billed charges,,,,,,no IP contract,,,78,,101.67,percent of total billed charges,,,70,,91.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,63.87,3324,
62856-0278-30 - perampanel 8 mg Tab,62856-0278-30,NDC,,,,inpatient,1,EA,177.7,106.62,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,143.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,151.05,percent of total billed charges,,,85,,151.05,percent of total billed charges,,,49,,87.07,percent of total billed charges,,,90,,159.93,percent of total billed charges,,,,,,,no IP contract,,80,,142.16,percent of total billed charges,,,,,,,no IP contract,,50,,88.85,percent of total billed charges,,,,,,no IP contract,,,78,,138.61,percent of total billed charges,,,70,,124.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,87.07,3324,
62856-0282-30 - perampanel 12 mg Tab,62856-0282-30,NDC,,,,inpatient,1,EA,194.95,116.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,157.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,165.71,percent of total billed charges,,,85,,165.71,percent of total billed charges,,,49,,95.53,percent of total billed charges,,,90,,175.46,percent of total billed charges,,,,,,,no IP contract,,80,,155.96,percent of total billed charges,,,,,,,no IP contract,,50,,97.48,percent of total billed charges,,,,,,no IP contract,,,78,,152.06,percent of total billed charges,,,70,,136.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,95.53,3324,
62856-0681-10 - zonisamide 25 mg Cap,62856-0681-10,NDC,,,,inpatient,1,EA,9.05,5.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.69,percent of total billed charges,,,85,,7.69,percent of total billed charges,,,49,,4.43,percent of total billed charges,,,90,,8.15,percent of total billed charges,,,,,,,no IP contract,,80,,7.24,percent of total billed charges,,,,,,,no IP contract,,50,,4.53,percent of total billed charges,,,,,,no IP contract,,,78,,7.06,percent of total billed charges,,,70,,6.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.43,3324,
63090-0100-30 - pimavanserin 10 mg Tab,63090-0100-30,NDC,,,,inpatient,1,EA,887.25,532.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,718.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,754.16,percent of total billed charges,,,85,,754.16,percent of total billed charges,,,49,,434.75,percent of total billed charges,,,90,,798.53,percent of total billed charges,,,,,,,no IP contract,,80,,709.8,percent of total billed charges,,,,,,,no IP contract,,50,,443.63,percent of total billed charges,,,,,,no IP contract,,,78,,692.06,percent of total billed charges,,,70,,621.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,434.75,3324,
63090-0340-30 - pimavanserin 34 mg Cap,63090-0340-30,NDC,,,,inpatient,1,EA,887.25,532.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,718.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,754.16,percent of total billed charges,,,85,,754.16,percent of total billed charges,,,49,,434.75,percent of total billed charges,,,90,,798.53,percent of total billed charges,,,,,,,no IP contract,,80,,709.8,percent of total billed charges,,,,,,,no IP contract,,50,,443.63,percent of total billed charges,,,,,,no IP contract,,,78,,692.06,percent of total billed charges,,,70,,621.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,434.75,3324,
63304-0089-13 - mesalamine 500 mg CR Capsule,63304-0089-13,NDC,,,,inpatient,1,EA,56,33.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,45.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,47.6,percent of total billed charges,,,85,,47.6,percent of total billed charges,,,49,,27.44,percent of total billed charges,,,90,,50.4,percent of total billed charges,,,,,,,no IP contract,,80,,44.8,percent of total billed charges,,,,,,,no IP contract,,50,,28,percent of total billed charges,,,,,,no IP contract,,,78,,43.68,percent of total billed charges,,,70,,39.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.44,3324,
63304-0143-01 - chlorproMAZINE 25 mg Tab,63304-0143-01,NDC,,,,inpatient,1,EA,64.55,38.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,52.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,54.87,percent of total billed charges,,,85,,54.87,percent of total billed charges,,,49,,31.63,percent of total billed charges,,,90,,58.1,percent of total billed charges,,,,,,,no IP contract,,80,,51.64,percent of total billed charges,,,,,,,no IP contract,,50,,32.28,percent of total billed charges,,,,,,no IP contract,,,78,,50.35,percent of total billed charges,,,70,,45.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.63,3324,
63304-0158-01 - bromocriptine 5 mg Cap,63304-0158-01,NDC,,,,inpatient,1,EA,77.85,46.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,63.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,66.17,percent of total billed charges,,,85,,66.17,percent of total billed charges,,,49,,38.15,percent of total billed charges,,,90,,70.07,percent of total billed charges,,,,,,,no IP contract,,80,,62.28,percent of total billed charges,,,,,,,no IP contract,,50,,38.93,percent of total billed charges,,,,,,no IP contract,,,78,,60.72,percent of total billed charges,,,70,,54.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,38.15,3324,
63304-0158-30 - bromocriptine 5 mg Cap,63304-0158-30,NDC,,,,inpatient,1,EA,77.85,46.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,63.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,66.17,percent of total billed charges,,,85,,66.17,percent of total billed charges,,,49,,38.15,percent of total billed charges,,,90,,70.07,percent of total billed charges,,,,,,,no IP contract,,80,,62.28,percent of total billed charges,,,,,,,no IP contract,,50,,38.93,percent of total billed charges,,,,,,no IP contract,,,78,,60.72,percent of total billed charges,,,70,,54.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,38.15,3324,
63304-0175-13 - mesalamine 1.2 g EC Ta,63304-0175-13,NDC,,,,inpatient,1,EA,84.2,50.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,68.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,71.57,percent of total billed charges,,,85,,71.57,percent of total billed charges,,,49,,41.26,percent of total billed charges,,,90,,75.78,percent of total billed charges,,,,,,,no IP contract,,80,,67.36,percent of total billed charges,,,,,,,no IP contract,,50,,42.1,percent of total billed charges,,,,,,no IP contract,,,78,,65.68,percent of total billed charges,,,70,,58.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,41.26,3324,
63304-0241-59 - calcitriol 1 mcg/mL LIQ,63304-0241-59,NDC,,,,inpatient,1,ML,104.8,62.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,84.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,89.08,percent of total billed charges,,,85,,89.08,percent of total billed charges,,,49,,51.35,percent of total billed charges,,,90,,94.32,percent of total billed charges,,,,,,,no IP contract,,80,,83.84,percent of total billed charges,,,,,,,no IP contract,,50,,52.4,percent of total billed charges,,,,,,no IP contract,,,78,,81.74,percent of total billed charges,,,70,,73.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,51.35,3324,
63304-0296-01 - hydroxychloroquine 200 mg Tab,63304-0296-01,NDC,,,,inpatient,1,EA,13.6,8.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.56,percent of total billed charges,,,85,,11.56,percent of total billed charges,,,49,,6.66,percent of total billed charges,,,90,,12.24,percent of total billed charges,,,,,,,no IP contract,,80,,10.88,percent of total billed charges,,,,,,,no IP contract,,50,,6.8,percent of total billed charges,,,,,,no IP contract,,,78,,10.61,percent of total billed charges,,,70,,9.52,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.66,3324,
63304-0459-30 - ondansetron 8 mg Tab,63304-0459-30,NDC,,,,inpatient,1,EA,331.9,199.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,268.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,282.12,percent of total billed charges,,,85,,282.12,percent of total billed charges,,,49,,162.63,percent of total billed charges,,,90,,298.71,percent of total billed charges,,,,,,,no IP contract,,80,,265.52,percent of total billed charges,,,,,,,no IP contract,,50,,165.95,percent of total billed charges,,,,,,no IP contract,,,78,,258.88,percent of total billed charges,,,70,,232.33,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,162.63,3324,
63304-0504-01 - acyclovir 400 mg Tab,63304-0504-01,NDC,,,,inpatient,1,EA,21.1,12.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.94,percent of total billed charges,,,85,,17.94,percent of total billed charges,,,49,,10.34,percent of total billed charges,,,90,,18.99,percent of total billed charges,,,,,,,no IP contract,,80,,16.88,percent of total billed charges,,,,,,,no IP contract,,50,,10.55,percent of total billed charges,,,,,,no IP contract,,,78,,16.46,percent of total billed charges,,,70,,14.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.34,3324,
63304-0521-20 - cefpodoxime 200 mg Tab,63304-0521-20,NDC,,,,inpatient,1,EA,57.5,34.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,46.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,48.88,percent of total billed charges,,,85,,48.88,percent of total billed charges,,,49,,28.18,percent of total billed charges,,,90,,51.75,percent of total billed charges,,,,,,,no IP contract,,80,,46,percent of total billed charges,,,,,,,no IP contract,,50,,28.75,percent of total billed charges,,,,,,no IP contract,,,78,,44.85,percent of total billed charges,,,70,,40.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,28.18,3324,
63304-0683-01 - oxyCODONE CR 40 mg ER Tablet,63304-0683-01,NDC,,,,inpatient,1,EA,87.9,52.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,71.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,74.72,percent of total billed charges,,,85,,74.72,percent of total billed charges,,,49,,43.07,percent of total billed charges,,,90,,79.11,percent of total billed charges,,,,,,,no IP contract,,80,,70.32,percent of total billed charges,,,,,,,no IP contract,,50,,43.95,percent of total billed charges,,,,,,no IP contract,,,78,,68.56,percent of total billed charges,,,70,,61.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,43.07,3324,
63304-0693-01 - clindamycin 300 mg Cap,63304-0693-01,NDC,,,,inpatient,1,EA,33.4,20.04,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.39,percent of total billed charges,,,85,,28.39,percent of total billed charges,,,49,,16.37,percent of total billed charges,,,90,,30.06,percent of total billed charges,,,,,,,no IP contract,,80,,26.72,percent of total billed charges,,,,,,,no IP contract,,50,,16.7,percent of total billed charges,,,,,,no IP contract,,,78,,26.05,percent of total billed charges,,,70,,23.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.37,3324,
63304-0721-90 - dilTIAZem 300 mg/24 hours ER Ca,63304-0721-90,NDC,,,,inpatient,1,EA,24.95,14.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.21,percent of total billed charges,,,85,,21.21,percent of total billed charges,,,49,,12.23,percent of total billed charges,,,90,,22.46,percent of total billed charges,,,,,,,no IP contract,,80,,19.96,percent of total billed charges,,,,,,,no IP contract,,50,,12.48,percent of total billed charges,,,,,,no IP contract,,,78,,19.46,percent of total billed charges,,,70,,17.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.23,3324,
63304-0835-01 - enalapril 5 mg Tab,63304-0835-01,NDC,,,,inpatient,1,EA,11.95,7.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.16,percent of total billed charges,,,85,,10.16,percent of total billed charges,,,49,,5.86,percent of total billed charges,,,90,,10.76,percent of total billed charges,,,,,,,no IP contract,,80,,9.56,percent of total billed charges,,,,,,,no IP contract,,50,,5.98,percent of total billed charges,,,,,,no IP contract,,,78,,9.32,percent of total billed charges,,,70,,8.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.86,3324,
63304-0835-01 - enalapril 5 mg Tab,63304-0835-01,NDC,,,,inpatient,1,EA,11.95,7.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.16,percent of total billed charges,,,85,,10.16,percent of total billed charges,,,49,,5.86,percent of total billed charges,,,90,,10.76,percent of total billed charges,,,,,,,no IP contract,,80,,9.56,percent of total billed charges,,,,,,,no IP contract,,50,,5.98,percent of total billed charges,,,,,,no IP contract,,,78,,9.32,percent of total billed charges,,,70,,8.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.86,3324,
63304-0904-30 - valacyclovir 500 mg Tab,63304-0904-30,NDC,,,,inpatient,1,EA,21.1,12.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.94,percent of total billed charges,,,85,,17.94,percent of total billed charges,,,49,,10.34,percent of total billed charges,,,90,,18.99,percent of total billed charges,,,,,,,no IP contract,,80,,16.88,percent of total billed charges,,,,,,,no IP contract,,50,,10.55,percent of total billed charges,,,,,,no IP contract,,,78,,16.46,percent of total billed charges,,,70,,14.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.34,3324,
63304-0904-90 - valACYclovir 500 mg Tab,63304-0904-90,NDC,,,,inpatient,1,EA,61.2,36.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,49.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,52.02,percent of total billed charges,,,85,,52.02,percent of total billed charges,,,49,,29.99,percent of total billed charges,,,90,,55.08,percent of total billed charges,,,,,,,no IP contract,,80,,48.96,percent of total billed charges,,,,,,,no IP contract,,50,,30.6,percent of total billed charges,,,,,,no IP contract,,,78,,47.74,percent of total billed charges,,,70,,42.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,29.99,3324,
63304-0905-30 - valacyclovir 1 g Tab,63304-0905-30,NDC,,,,inpatient,1,EA,104.3,62.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,84.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,88.66,percent of total billed charges,,,85,,88.66,percent of total billed charges,,,49,,51.11,percent of total billed charges,,,90,,93.87,percent of total billed charges,,,,,,,no IP contract,,80,,83.44,percent of total billed charges,,,,,,,no IP contract,,50,,52.15,percent of total billed charges,,,,,,no IP contract,,,78,,81.35,percent of total billed charges,,,70,,73.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,51.11,3324,
63304-0905-90 - valACYclovir 1 g Tab,63304-0905-90,NDC,,,,inpatient,1,EA,104.3,62.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,84.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,88.66,percent of total billed charges,,,85,,88.66,percent of total billed charges,,,49,,51.11,percent of total billed charges,,,90,,93.87,percent of total billed charges,,,,,,,no IP contract,,80,,83.44,percent of total billed charges,,,,,,,no IP contract,,50,,52.15,percent of total billed charges,,,,,,no IP contract,,,78,,81.35,percent of total billed charges,,,70,,73.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,51.11,3324,
63304-0962-01 - bromocriptine 2.5 mg Tab,63304-0962-01,NDC,,,,inpatient,1,EA,22.6,13.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.21,percent of total billed charges,,,85,,19.21,percent of total billed charges,,,49,,11.07,percent of total billed charges,,,90,,20.34,percent of total billed charges,,,,,,,no IP contract,,80,,18.08,percent of total billed charges,,,,,,,no IP contract,,50,,11.3,percent of total billed charges,,,,,,no IP contract,,,78,,17.63,percent of total billed charges,,,70,,15.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.07,3324,
63304-0962-30 - bromocriptine 2.5 mg Tab,63304-0962-30,NDC,,,,inpatient,1,EA,36.75,22.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.24,percent of total billed charges,,,85,,31.24,percent of total billed charges,,,49,,18.01,percent of total billed charges,,,90,,33.08,percent of total billed charges,,,,,,,no IP contract,,80,,29.4,percent of total billed charges,,,,,,,no IP contract,,50,,18.38,percent of total billed charges,,,,,,no IP contract,,,78,,28.67,percent of total billed charges,,,70,,25.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.01,3324,
63323-0010-02 - gentamicin 40 mg/mL Soln,63323-0010-02,NDC,,,,inpatient,1,ML,88.05,52.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,71.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,74.84,percent of total billed charges,,,85,,74.84,percent of total billed charges,,,49,,43.14,percent of total billed charges,,,90,,79.25,percent of total billed charges,,,,,,,no IP contract,,80,,70.44,percent of total billed charges,,,,,,,no IP contract,,50,,44.03,percent of total billed charges,,,,,,no IP contract,,,78,,68.68,percent of total billed charges,,,70,,61.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,43.14,3324,
63323-0010-20 - gentamicin 40 mg/mL Soln,63323-0010-20,NDC,,,,inpatient,1,ML,80.3,48.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,65.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,68.26,percent of total billed charges,,,85,,68.26,percent of total billed charges,,,49,,39.35,percent of total billed charges,,,90,,72.27,percent of total billed charges,,,,,,,no IP contract,,80,,64.24,percent of total billed charges,,,,,,,no IP contract,,50,,40.15,percent of total billed charges,,,,,,no IP contract,,,78,,62.63,percent of total billed charges,,,70,,56.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,39.35,3324,
63323-0013-02 - thiamine 100 mg/mL Soln,63323-0013-02,NDC,,,,inpatient,2,ML,114.2,68.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,92.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,97.07,percent of total billed charges,,,85,,97.07,percent of total billed charges,,,49,,55.96,percent of total billed charges,,,90,,102.78,percent of total billed charges,,,,,,,no IP contract,,80,,91.36,percent of total billed charges,,,,,,,no IP contract,,50,,57.1,percent of total billed charges,,,,,,no IP contract,,,78,,89.08,percent of total billed charges,,,70,,79.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,55.96,3324,
63323-0013-09 - thiamine 100 mg/mL Soln,63323-0013-09,NDC,,,,inpatient,2,ML,114.2,68.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,92.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,97.07,percent of total billed charges,,,85,,97.07,percent of total billed charges,,,49,,55.96,percent of total billed charges,,,90,,102.78,percent of total billed charges,,,,,,,no IP contract,,80,,91.36,percent of total billed charges,,,,,,,no IP contract,,50,,57.1,percent of total billed charges,,,,,,no IP contract,,,78,,89.08,percent of total billed charges,,,70,,79.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,55.96,3324,
63323-0021-01 - hydrOXYzine hydrochloride 25 mg/mL Soln,63323-0021-01,NDC,,,,inpatient,2,ML,35.1,21.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.84,percent of total billed charges,,,85,,29.84,percent of total billed charges,,,49,,17.2,percent of total billed charges,,,90,,31.59,percent of total billed charges,,,,,,,no IP contract,,80,,28.08,percent of total billed charges,,,,,,,no IP contract,,50,,17.55,percent of total billed charges,,,,,,no IP contract,,,78,,27.38,percent of total billed charges,,,70,,24.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.2,3324,
63323-0044-01 - cyanocobalamin 1000 mcg/mL Soln,63323-0044-01,NDC,,,,inpatient,1,ML,48.85,29.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,39.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,41.52,percent of total billed charges,,,85,,41.52,percent of total billed charges,,,49,,23.94,percent of total billed charges,,,90,,43.97,percent of total billed charges,,,,,,,no IP contract,,80,,39.08,percent of total billed charges,,,,,,,no IP contract,,50,,24.43,percent of total billed charges,,,,,,no IP contract,,,78,,38.1,percent of total billed charges,,,70,,34.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.94,3324,
63323-0064-02 - magnesium sulfate 50% Soln,63323-0064-02,NDC,,,,inpatient,1,ML,14.7,8.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.5,percent of total billed charges,,,85,,12.5,percent of total billed charges,,,49,,7.2,percent of total billed charges,,,90,,13.23,percent of total billed charges,,,,,,,no IP contract,,80,,11.76,percent of total billed charges,,,,,,,no IP contract,,50,,7.35,percent of total billed charges,,,,,,no IP contract,,,78,,11.47,percent of total billed charges,,,70,,10.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.2,3324,
magnesium sulfate 50% Soln,63323-0064-11,NDC,,,,inpatient,1,mL,11.85,7.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.07,percent of total billed charges,,,85,,10.07,percent of total billed charges,,,49,,5.81,percent of total billed charges,,,90,,10.67,percent of total billed charges,,,,,,,no IP contract,,80,,9.48,percent of total billed charges,,,,,,,no IP contract,,50,,5.93,percent of total billed charges,,,,,,no IP contract,,,78,,9.24,percent of total billed charges,,,70,,8.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.81,3324,
63323-0086-05 - potassium phosphate 3 mmol/mL Soln,63323-0086-05,NDC,,,,inpatient,1,ML,39.25,23.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.36,percent of total billed charges,,,85,,33.36,percent of total billed charges,,,49,,19.23,percent of total billed charges,,,90,,35.33,percent of total billed charges,,,,,,,no IP contract,,80,,31.4,percent of total billed charges,,,,,,,no IP contract,,50,,19.63,percent of total billed charges,,,,,,no IP contract,,,78,,30.62,percent of total billed charges,,,70,,27.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.23,3324,
63323-0086-15 - potassium phosphate 3 mmol/mL Soln,63323-0086-15,NDC,,,,inpatient,1,ML,23,13.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.55,percent of total billed charges,,,85,,19.55,percent of total billed charges,,,49,,11.27,percent of total billed charges,,,90,,20.7,percent of total billed charges,,,,,,,no IP contract,,80,,18.4,percent of total billed charges,,,,,,,no IP contract,,50,,11.5,percent of total billed charges,,,,,,no IP contract,,,78,,17.94,percent of total billed charges,,,70,,16.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.27,3324,
63323-0088-61 - sodium chloride 23.4% Soln,63323-0088-61,NDC,,,,inpatient,1,ML,11,6.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.35,percent of total billed charges,,,85,,9.35,percent of total billed charges,,,49,,5.39,percent of total billed charges,,,90,,9.9,percent of total billed charges,,,,,,,no IP contract,,80,,8.8,percent of total billed charges,,,,,,,no IP contract,,50,,5.5,percent of total billed charges,,,,,,no IP contract,,,78,,8.58,percent of total billed charges,,,70,,7.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.39,3324,
63323-0139-40 - sodium chloride 14.6% Soln,63323-0139-40,NDC,,,,inpatient,1,ML,10.4,6.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.84,percent of total billed charges,,,85,,8.84,percent of total billed charges,,,49,,5.1,percent of total billed charges,,,90,,9.36,percent of total billed charges,,,,,,,no IP contract,,80,,8.32,percent of total billed charges,,,,,,,no IP contract,,50,,5.2,percent of total billed charges,,,,,,no IP contract,,,78,,8.11,percent of total billed charges,,,70,,7.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.1,3324,
63323-0165-01 - dexamethasone 4 mg/mL Soln,63323-0165-01,NDC,,,,inpatient,1,ML,26.45,15.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.48,percent of total billed charges,,,85,,22.48,percent of total billed charges,,,49,,12.96,percent of total billed charges,,,90,,23.81,percent of total billed charges,,,,,,,no IP contract,,80,,21.16,percent of total billed charges,,,,,,,no IP contract,,50,,13.23,percent of total billed charges,,,,,,no IP contract,,,78,,20.63,percent of total billed charges,,,70,,18.52,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.96,3324,
63323-0165-30 - dexamethasone 4 mg/mL Soln,63323-0165-30,NDC,,,,inpatient,1,ML,231.9,139.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,187.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,197.12,percent of total billed charges,,,85,,197.12,percent of total billed charges,,,49,,113.63,percent of total billed charges,,,90,,208.71,percent of total billed charges,,,,,,,no IP contract,,80,,185.52,percent of total billed charges,,,,,,,no IP contract,,50,,115.95,percent of total billed charges,,,,,,no IP contract,,,78,,180.88,percent of total billed charges,,,70,,162.33,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,113.63,3324,
63323-0170-05 - sodium phosphate 3 mmol/mL Soln,63323-0170-05,NDC,,,,inpatient,1,ML,26,15.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.1,percent of total billed charges,,,85,,22.1,percent of total billed charges,,,49,,12.74,percent of total billed charges,,,90,,23.4,percent of total billed charges,,,,,,,no IP contract,,80,,20.8,percent of total billed charges,,,,,,,no IP contract,,50,,13,percent of total billed charges,,,,,,no IP contract,,,78,,20.28,percent of total billed charges,,,70,,18.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.74,3324,
63323-0170-15 - sodium phosphate 3 mmol/mL Soln,63323-0170-15,NDC,,,,inpatient,1,ML,29.75,17.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.29,percent of total billed charges,,,85,,25.29,percent of total billed charges,,,49,,14.58,percent of total billed charges,,,90,,26.78,percent of total billed charges,,,,,,,no IP contract,,80,,23.8,percent of total billed charges,,,,,,,no IP contract,,50,,14.88,percent of total billed charges,,,,,,no IP contract,,,78,,23.21,percent of total billed charges,,,70,,20.83,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.58,3324,
63323-0184-10 - folic acid 5 mg/mL Soln,63323-0184-10,NDC,,,,inpatient,1,ML,36.3,21.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.86,percent of total billed charges,,,85,,30.86,percent of total billed charges,,,49,,17.79,percent of total billed charges,,,90,,32.67,percent of total billed charges,,,,,,,no IP contract,,80,,29.04,percent of total billed charges,,,,,,,no IP contract,,50,,18.15,percent of total billed charges,,,,,,no IP contract,,,78,,28.31,percent of total billed charges,,,70,,25.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.79,3324,
63323-0185-10 - sterile water - Soln,63323-0185-10,NDC,,,,inpatient,10,ML,16.9,10.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.37,percent of total billed charges,,,85,,14.37,percent of total billed charges,,,49,,8.28,percent of total billed charges,,,90,,15.21,percent of total billed charges,,,,,,,no IP contract,,80,,13.52,percent of total billed charges,,,,,,,no IP contract,,50,,8.45,percent of total billed charges,,,,,,no IP contract,,,78,,13.18,percent of total billed charges,,,70,,11.83,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.28,3324,
63323-0186-10 - sodium chloride 0.9% Soln,63323-0186-10,NDC,,,,inpatient,10,ML,16.9,10.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.37,percent of total billed charges,,,85,,14.37,percent of total billed charges,,,49,,8.28,percent of total billed charges,,,90,,15.21,percent of total billed charges,,,,,,,no IP contract,,80,,13.52,percent of total billed charges,,,,,,,no IP contract,,50,,8.45,percent of total billed charges,,,,,,no IP contract,,,78,,13.18,percent of total billed charges,,,70,,11.83,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.28,3324,
63323-0221-10 - vancomycin 500 mg REC I,63323-0221-10,NDC,,,,inpatient,5,ML,145.1,87.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,117.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,123.34,percent of total billed charges,,,85,,123.34,percent of total billed charges,,,49,,71.1,percent of total billed charges,,,90,,130.59,percent of total billed charges,,,,,,,no IP contract,,80,,116.08,percent of total billed charges,,,,,,,no IP contract,,50,,72.55,percent of total billed charges,,,,,,no IP contract,,,78,,113.18,percent of total billed charges,,,70,,101.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,71.1,3324,
63323-0262-01 - heparin 5000 units/mL Soln,63323-0262-01,NDC,,,,inpatient,1,ML,53.15,31.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,43.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,45.18,percent of total billed charges,,,85,,45.18,percent of total billed charges,,,49,,26.04,percent of total billed charges,,,90,,47.84,percent of total billed charges,,,,,,,no IP contract,,80,,42.52,percent of total billed charges,,,,,,,no IP contract,,50,,26.58,percent of total billed charges,,,,,,no IP contract,,,78,,41.46,percent of total billed charges,,,70,,37.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.04,3324,
63323-0262-01 - heparin 5000 units/mL Soln,63323-0262-01,NDC,,,,inpatient,1,ML,53.15,31.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,43.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,45.18,percent of total billed charges,,,85,,45.18,percent of total billed charges,,,49,,26.04,percent of total billed charges,,,90,,47.84,percent of total billed charges,,,,,,,no IP contract,,80,,42.52,percent of total billed charges,,,,,,,no IP contract,,50,,26.58,percent of total billed charges,,,,,,no IP contract,,,78,,41.46,percent of total billed charges,,,70,,37.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.04,3324,
63323-0262-06 - heparin 5000 units/mL Soln,63323-0262-06,NDC,,,,inpatient,1,ML,51.4,30.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,41.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,43.69,percent of total billed charges,,,85,,43.69,percent of total billed charges,,,49,,25.19,percent of total billed charges,,,90,,46.26,percent of total billed charges,,,,,,,no IP contract,,80,,41.12,percent of total billed charges,,,,,,,no IP contract,,50,,25.7,percent of total billed charges,,,,,,no IP contract,,,78,,40.09,percent of total billed charges,,,70,,35.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.19,3324,
63323-0262-26 - heparin 5000 units/mL Soln,63323-0262-26,NDC,,,,inpatient,1,ML,29.55,17.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.12,percent of total billed charges,,,85,,25.12,percent of total billed charges,,,49,,14.48,percent of total billed charges,,,90,,26.6,percent of total billed charges,,,,,,,no IP contract,,80,,23.64,percent of total billed charges,,,,,,,no IP contract,,50,,14.78,percent of total billed charges,,,,,,no IP contract,,,78,,23.05,percent of total billed charges,,,70,,20.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.48,3324,
63323-0262-55 - heparin 5000 units/mL Soln,63323-0262-55,NDC,,,,inpatient,1,ML,53.15,31.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,43.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,45.18,percent of total billed charges,,,85,,45.18,percent of total billed charges,,,49,,26.04,percent of total billed charges,,,90,,47.84,percent of total billed charges,,,,,,,no IP contract,,80,,42.52,percent of total billed charges,,,,,,,no IP contract,,50,,26.58,percent of total billed charges,,,,,,no IP contract,,,78,,41.46,percent of total billed charges,,,70,,37.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.04,3324,
63323-0265-30 - methylPREDNISolone 1 g REC I,63323-0265-30,NDC,,,,inpatient,1,ML,355.45,213.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,287.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,302.13,percent of total billed charges,,,85,,302.13,percent of total billed charges,,,49,,174.17,percent of total billed charges,,,90,,319.91,percent of total billed charges,,,,,,,no IP contract,,80,,284.36,percent of total billed charges,,,,,,,no IP contract,,50,,177.73,percent of total billed charges,,,,,,no IP contract,,,78,,277.25,percent of total billed charges,,,70,,248.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,174.17,3324,
63323-0284-20 - vancomycin 1 g REC I,63323-0284-20,NDC,,,,inpatient,10,ML,210.5,126.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,170.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,178.93,percent of total billed charges,,,85,,178.93,percent of total billed charges,,,49,,103.15,percent of total billed charges,,,90,,189.45,percent of total billed charges,,,,,,,no IP contract,,80,,168.4,percent of total billed charges,,,,,,,no IP contract,,50,,105.25,percent of total billed charges,,,,,,no IP contract,,,78,,164.19,percent of total billed charges,,,70,,147.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,103.15,3324,
ropivacaine 0.2% Soln,63323-0285-10,NDC,,,,inpatient,1,EA,56.55,33.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,45.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,48.07,percent of total billed charges,,,85,,48.07,percent of total billed charges,,,49,,27.71,percent of total billed charges,,,90,,50.9,percent of total billed charges,,,,,,,no IP contract,,80,,45.24,percent of total billed charges,,,,,,,no IP contract,,50,,28.28,percent of total billed charges,,,,,,no IP contract,,,78,,44.11,percent of total billed charges,,,70,,39.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.71,3324,
ropivacaine 0.5% Soln,63323-0286-30,NDC,,,,inpatient,1,EA,229.35,137.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,185.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,194.95,percent of total billed charges,,,85,,194.95,percent of total billed charges,,,49,,112.38,percent of total billed charges,,,90,,206.42,percent of total billed charges,,,,,,,no IP contract,,80,,183.48,percent of total billed charges,,,,,,,no IP contract,,50,,114.68,percent of total billed charges,,,,,,no IP contract,,,78,,178.89,percent of total billed charges,,,70,,160.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,112.38,3324,
63323-0300-30 - piperacillin-tazobactam 3 g-0.375 g REC I,63323-0300-30,NDC,,,,inpatient,1,EA,75.1,45.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63.84,percent of total billed charges,,,85,,63.84,percent of total billed charges,,,49,,36.8,percent of total billed charges,,,90,,67.59,percent of total billed charges,,,,,,,no IP contract,,80,,60.08,percent of total billed charges,,,,,,,no IP contract,,50,,37.55,percent of total billed charges,,,,,,no IP contract,,,78,,58.58,percent of total billed charges,,,70,,52.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.8,3324,
63323-0306-30 - tobramycin 40 mg/mL Soln,63323-0306-30,NDC,,,,inpatient,30,ML,231.9,139.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,187.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,197.12,percent of total billed charges,,,85,,197.12,percent of total billed charges,,,49,,113.63,percent of total billed charges,,,90,,208.71,percent of total billed charges,,,,,,,no IP contract,,80,,185.52,percent of total billed charges,,,,,,,no IP contract,,50,,115.95,percent of total billed charges,,,,,,no IP contract,,,78,,180.88,percent of total billed charges,,,70,,162.33,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,113.63,3324,
63323-0311-19 - calcium gluconate 100 mg/mL Injection,63323-0311-19,NDC,,,,inpatient,1,ML,12.85,7.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.92,percent of total billed charges,,,85,,10.92,percent of total billed charges,,,49,,6.3,percent of total billed charges,,,90,,11.57,percent of total billed charges,,,,,,,no IP contract,,80,,10.28,percent of total billed charges,,,,,,,no IP contract,,50,,6.43,percent of total billed charges,,,,,,no IP contract,,,78,,10.02,percent of total billed charges,,,70,,9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.3,3324,
63323-0315-10 - ganciclovir 500 mg REC I,63323-0315-10,NDC,,,,inpatient,10,ML,885.4,531.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,717.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,752.59,percent of total billed charges,,,85,,752.59,percent of total billed charges,,,49,,433.85,percent of total billed charges,,,90,,796.86,percent of total billed charges,,,,,,,no IP contract,,80,,708.32,percent of total billed charges,,,,,,,no IP contract,,50,,442.7,percent of total billed charges,,,,,,no IP contract,,,78,,690.61,percent of total billed charges,,,70,,619.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,433.85,3324,
63323-0320-50 - piperacillin-tazobactam 4 g-0.5 g REC I,63323-0320-50,NDC,,,,inpatient,1,EA,213.05,127.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,172.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,181.09,percent of total billed charges,,,85,,181.09,percent of total billed charges,,,49,,104.39,percent of total billed charges,,,90,,191.75,percent of total billed charges,,,,,,,no IP contract,,80,,170.44,percent of total billed charges,,,,,,,no IP contract,,50,,106.53,percent of total billed charges,,,,,,no IP contract,,,78,,166.18,percent of total billed charges,,,70,,149.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,104.39,3324,
63323-0325-20 - acyclovir 50 mg/mL Soln,63323-0325-20,NDC,,,,inpatient,1,ML,75.9,45.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,61.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,64.52,percent of total billed charges,,,85,,64.52,percent of total billed charges,,,49,,37.19,percent of total billed charges,,,90,,68.31,percent of total billed charges,,,,,,,no IP contract,,80,,60.72,percent of total billed charges,,,,,,,no IP contract,,50,,37.95,percent of total billed charges,,,,,,no IP contract,,,78,,59.2,percent of total billed charges,,,70,,53.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,37.19,3324,
63323-0340-20 - cefepime 2 g REC I,63323-0340-20,NDC,,,,inpatient,1,EA,174.1,104.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,141.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,147.99,percent of total billed charges,,,85,,147.99,percent of total billed charges,,,49,,85.31,percent of total billed charges,,,90,,156.69,percent of total billed charges,,,,,,,no IP contract,,80,,139.28,percent of total billed charges,,,,,,,no IP contract,,50,,87.05,percent of total billed charges,,,,,,no IP contract,,,78,,135.8,percent of total billed charges,,,70,,121.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,85.31,3324,
63323-0360-19 - calcium gluconate 100 mg/mL Soln,63323-0360-19,NDC,,,,inpatient,1,ML,18.6,11.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.81,percent of total billed charges,,,85,,15.81,percent of total billed charges,,,49,,9.11,percent of total billed charges,,,90,,16.74,percent of total billed charges,,,,,,,no IP contract,,80,,14.88,percent of total billed charges,,,,,,,no IP contract,,50,,9.3,percent of total billed charges,,,,,,no IP contract,,,78,,14.51,percent of total billed charges,,,70,,13.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.11,3324,
63323-0365-01 - octreotide 50 mcg/mL Soln,63323-0365-01,NDC,,,,inpatient,1,ML,60.5,36.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,49.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,51.43,percent of total billed charges,,,85,,51.43,percent of total billed charges,,,49,,29.65,percent of total billed charges,,,90,,54.45,percent of total billed charges,,,,,,,no IP contract,,80,,48.4,percent of total billed charges,,,,,,,no IP contract,,50,,30.25,percent of total billed charges,,,,,,no IP contract,,,78,,47.19,percent of total billed charges,,,70,,42.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,29.65,3324,
63323-0369-20 - ampicillin-sulbactam 2 g-1 g REC I,63323-0369-20,NDC,,,,inpatient,8,ML,87.3,52.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,70.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,74.21,percent of total billed charges,,,85,,74.21,percent of total billed charges,,,49,,42.78,percent of total billed charges,,,90,,78.57,percent of total billed charges,,,,,,,no IP contract,,80,,69.84,percent of total billed charges,,,,,,,no IP contract,,50,,43.65,percent of total billed charges,,,,,,no IP contract,,,78,,68.09,percent of total billed charges,,,70,,61.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,42.78,3324,
63323-0371-19 - DAPTOmycin 500 mg REC I,63323-0371-19,NDC,,,,inpatient,10,ML,4528.2,2716.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3667.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3848.97,percent of total billed charges,,,85,,3848.97,percent of total billed charges,,,49,,2218.82,percent of total billed charges,,,90,,4075.38,percent of total billed charges,,,,,,,no IP contract,,80,,3622.56,percent of total billed charges,,,,,,,no IP contract,,50,,2264.1,percent of total billed charges,,,,,,no IP contract,,,78,,3532,percent of total billed charges,,,70,,3169.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4075.38,
63323-0376-01 - octreotide 100 mcg/mL Soln,63323-0376-01,NDC,,,,inpatient,1,ML,89.75,53.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,72.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,76.29,percent of total billed charges,,,85,,76.29,percent of total billed charges,,,49,,43.98,percent of total billed charges,,,90,,80.78,percent of total billed charges,,,,,,,no IP contract,,80,,71.8,percent of total billed charges,,,,,,,no IP contract,,50,,44.88,percent of total billed charges,,,,,,no IP contract,,,78,,70.01,percent of total billed charges,,,70,,62.83,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,43.98,3324,
63323-0389-10 - ampicillin 1 g REC I,63323-0389-10,NDC,,,,inpatient,1,EA,134.1,80.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,108.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,113.99,percent of total billed charges,,,85,,113.99,percent of total billed charges,,,49,,65.71,percent of total billed charges,,,90,,120.69,percent of total billed charges,,,,,,,no IP contract,,80,,107.28,percent of total billed charges,,,,,,,no IP contract,,50,,67.05,percent of total billed charges,,,,,,no IP contract,,,78,,104.6,percent of total billed charges,,,70,,93.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,65.71,3324,
63323-0398-10 - azithromycin 500 mg REC I,63323-0398-10,NDC,,,,inpatient,5,ML,84.5,50.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,68.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,71.83,percent of total billed charges,,,85,,71.83,percent of total billed charges,,,49,,41.41,percent of total billed charges,,,90,,76.05,percent of total billed charges,,,,,,,no IP contract,,80,,67.6,percent of total billed charges,,,,,,,no IP contract,,50,,42.25,percent of total billed charges,,,,,,no IP contract,,,78,,65.91,percent of total billed charges,,,70,,59.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,41.41,3324,
63323-0399-23 - ampicillin 2 g REC I,63323-0399-23,NDC,,,,inpatient,1,EA,154.5,92.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,125.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,131.33,percent of total billed charges,,,85,,131.33,percent of total billed charges,,,49,,75.71,percent of total billed charges,,,90,,139.05,percent of total billed charges,,,,,,,no IP contract,,80,,123.6,percent of total billed charges,,,,,,,no IP contract,,50,,77.25,percent of total billed charges,,,,,,no IP contract,,,78,,120.51,percent of total billed charges,,,70,,108.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,75.71,3324,
63323-0401-20 - aztreonam 1 gm Injection,63323-0401-20,NDC,,,,inpatient,10,ML,342.65,205.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,277.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,291.25,percent of total billed charges,,,85,,291.25,percent of total billed charges,,,49,,167.9,percent of total billed charges,,,90,,308.39,percent of total billed charges,,,,,,,no IP contract,,80,,274.12,percent of total billed charges,,,,,,,no IP contract,,50,,171.33,percent of total billed charges,,,,,,no IP contract,,,78,,267.27,percent of total billed charges,,,70,,239.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,167.9,3324,
63323-0401-26 - aztreonam 1 g REC I,63323-0401-26,NDC,,,,inpatient,10,ML,342.65,205.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,277.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,291.25,percent of total billed charges,,,85,,291.25,percent of total billed charges,,,49,,167.9,percent of total billed charges,,,90,,308.39,percent of total billed charges,,,,,,,no IP contract,,80,,274.12,percent of total billed charges,,,,,,,no IP contract,,50,,171.33,percent of total billed charges,,,,,,no IP contract,,,78,,267.27,percent of total billed charges,,,70,,239.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,167.9,3324,
63323-0402-20 - aztreonam 2 gm Injection,63323-0402-20,NDC,,,,inpatient,20,ML,686.6,411.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,556.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,583.61,percent of total billed charges,,,85,,583.61,percent of total billed charges,,,49,,336.43,percent of total billed charges,,,90,,617.94,percent of total billed charges,,,,,,,no IP contract,,80,,549.28,percent of total billed charges,,,,,,,no IP contract,,50,,343.3,percent of total billed charges,,,,,,no IP contract,,,78,,535.55,percent of total billed charges,,,70,,480.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,336.43,3324,
63323-0402-30 - aztreonam 2 gm REC Injection,63323-0402-30,NDC,,,,inpatient,20,ML,561.85,337.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,455.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,477.57,percent of total billed charges,,,85,,477.57,percent of total billed charges,,,49,,275.31,percent of total billed charges,,,90,,505.67,percent of total billed charges,,,,,,,no IP contract,,80,,449.48,percent of total billed charges,,,,,,,no IP contract,,50,,280.93,percent of total billed charges,,,,,,no IP contract,,,78,,438.24,percent of total billed charges,,,70,,393.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,275.31,3324,
63323-0464-17 - bupivacaine 0.25% preservative-free Soln,63323-0464-17,NDC,,,,inpatient,10,ML,66.65,39.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,53.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.65,percent of total billed charges,,,85,,56.65,percent of total billed charges,,,49,,32.66,percent of total billed charges,,,90,,59.99,percent of total billed charges,,,,,,,no IP contract,,80,,53.32,percent of total billed charges,,,,,,,no IP contract,,50,,33.33,percent of total billed charges,,,,,,no IP contract,,,78,,51.99,percent of total billed charges,,,70,,46.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.66,3324,
lidocaine 1% preservative-free Soln,63323-0492-27,NDC,,,,inpatient,1,EA,30.05,18.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.54,percent of total billed charges,,,85,,25.54,percent of total billed charges,,,49,,14.72,percent of total billed charges,,,90,,27.05,percent of total billed charges,,,,,,,no IP contract,,80,,24.04,percent of total billed charges,,,,,,,no IP contract,,50,,15.03,percent of total billed charges,,,,,,no IP contract,,,78,,23.44,percent of total billed charges,,,70,,21.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.72,3324,
lidocaine 1% preservative-free Soln,63323-0492-57,NDC,,,,inpatient,1,EA,43.45,26.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,35.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36.93,percent of total billed charges,,,85,,36.93,percent of total billed charges,,,49,,21.29,percent of total billed charges,,,90,,39.11,percent of total billed charges,,,,,,,no IP contract,,80,,34.76,percent of total billed charges,,,,,,,no IP contract,,50,,21.73,percent of total billed charges,,,,,,no IP contract,,,78,,33.89,percent of total billed charges,,,70,,30.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.29,3324,
63323-0495-05 - lidocaine 5 mL Injection,63323-0495-05,NDC,,,,inpatient,5,ML,129.05,77.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,104.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,109.69,percent of total billed charges,,,85,,109.69,percent of total billed charges,,,49,,63.23,percent of total billed charges,,,90,,116.15,percent of total billed charges,,,,,,,no IP contract,,80,,103.24,percent of total billed charges,,,,,,,no IP contract,,50,,64.53,percent of total billed charges,,,,,,no IP contract,,,78,,100.66,percent of total billed charges,,,70,,90.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,63.23,3324,
lidocaine 2% preservative-free Soln,63323-0495-07,NDC,,,,inpatient,1,EA,38,22.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.3,percent of total billed charges,,,85,,32.3,percent of total billed charges,,,49,,18.62,percent of total billed charges,,,90,,34.2,percent of total billed charges,,,,,,,no IP contract,,80,,30.4,percent of total billed charges,,,,,,,no IP contract,,50,,19,percent of total billed charges,,,,,,no IP contract,,,78,,29.64,percent of total billed charges,,,70,,26.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.62,3324,
63323-0495-27 - lidocaine 2% preservative-free Soln,63323-0495-27,NDC,,,,inpatient,2,ML,35.1,21.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.84,percent of total billed charges,,,85,,29.84,percent of total billed charges,,,49,,17.2,percent of total billed charges,,,90,,31.59,percent of total billed charges,,,,,,,no IP contract,,80,,28.08,percent of total billed charges,,,,,,,no IP contract,,50,,17.55,percent of total billed charges,,,,,,no IP contract,,,78,,27.38,percent of total billed charges,,,70,,24.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.2,3324,
dexamethasone 10 mg/mL preservative-free Soln,63323-0506-01,NDC,,,,inpatient,1,ML,50.2,30.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,40.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,42.67,percent of total billed charges,,,85,,42.67,percent of total billed charges,,,49,,24.6,percent of total billed charges,,,90,,45.18,percent of total billed charges,,,,,,,no IP contract,,80,,40.16,percent of total billed charges,,,,,,,no IP contract,,50,,25.1,percent of total billed charges,,,,,,no IP contract,,,78,,39.16,percent of total billed charges,,,70,,35.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.6,3324,
63323-0508-30 - meropenem 1000 mg REC I,63323-0508-30,NDC,,,,inpatient,1,EA,229.05,137.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,185.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,194.69,percent of total billed charges,,,85,,194.69,percent of total billed charges,,,49,,112.23,percent of total billed charges,,,90,,206.15,percent of total billed charges,,,,,,,no IP contract,,80,,183.24,percent of total billed charges,,,,,,,no IP contract,,50,,114.53,percent of total billed charges,,,,,,no IP contract,,,78,,178.66,percent of total billed charges,,,70,,160.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,112.23,3324,
63323-0508-31 - meropenem 1000 mg REC I,63323-0508-31,NDC,,,,inpatient,1,EA,275.05,165.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,222.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,233.79,percent of total billed charges,,,85,,233.79,percent of total billed charges,,,49,,134.77,percent of total billed charges,,,90,,247.55,percent of total billed charges,,,,,,,no IP contract,,80,,220.04,percent of total billed charges,,,,,,,no IP contract,,50,,137.53,percent of total billed charges,,,,,,no IP contract,,,78,,214.54,percent of total billed charges,,,70,,192.54,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,134.77,3324,
63323-0531-90 - enoxaparin 80 mg/0.8 mL Soln,63323-0531-90,NDC,,,,inpatient,0.8,ML,84.25,50.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,68.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,71.61,percent of total billed charges,,,85,,71.61,percent of total billed charges,,,49,,41.28,percent of total billed charges,,,90,,75.83,percent of total billed charges,,,,,,,no IP contract,,80,,67.4,percent of total billed charges,,,,,,,no IP contract,,50,,42.13,percent of total billed charges,,,,,,no IP contract,,,78,,65.72,percent of total billed charges,,,70,,58.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,41.28,3324,
63323-0531-98 - eNOXaparin  80 MG / 0.8 ML Injection,63323-0531-98,NDC,,,,inpatient,0.8,ML,557.25,334.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,451.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,473.66,percent of total billed charges,,,85,,473.66,percent of total billed charges,,,49,,273.05,percent of total billed charges,,,90,,501.53,percent of total billed charges,,,,,,,no IP contract,,80,,445.8,percent of total billed charges,,,,,,,no IP contract,,50,,278.63,percent of total billed charges,,,,,,no IP contract,,,78,,434.66,percent of total billed charges,,,70,,390.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,273.05,3324,
63323-0533-83 - eNOXaparin  30 MG / 0.3 ML Injection,63323-0533-83,NDC,,,,inpatient,0.3,ML,83.95,50.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,71.36,percent of total billed charges,,,85,,71.36,percent of total billed charges,,,49,,41.14,percent of total billed charges,,,90,,75.56,percent of total billed charges,,,,,,,no IP contract,,80,,67.16,percent of total billed charges,,,,,,,no IP contract,,50,,41.98,percent of total billed charges,,,,,,no IP contract,,,78,,65.48,percent of total billed charges,,,70,,58.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,41.14,3324,
63323-0533-93 - eNOXaparin 30 MG / 0.3 ML Injection,63323-0533-93,NDC,,,,inpatient,0.3,ML,313.8,188.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,254.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,266.73,percent of total billed charges,,,85,,266.73,percent of total billed charges,,,49,,153.76,percent of total billed charges,,,90,,282.42,percent of total billed charges,,,,,,,no IP contract,,80,,251.04,percent of total billed charges,,,,,,,no IP contract,,50,,156.9,percent of total billed charges,,,,,,no IP contract,,,78,,244.76,percent of total billed charges,,,70,,219.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,153.76,3324,
63323-0535-87 - enoxaparin 40 mg/0.4 mL Soln,63323-0535-87,NDC,,,,inpatient,0.4,ML,210.15,126.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,170.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,178.63,percent of total billed charges,,,85,,178.63,percent of total billed charges,,,49,,102.97,percent of total billed charges,,,90,,189.14,percent of total billed charges,,,,,,,no IP contract,,80,,168.12,percent of total billed charges,,,,,,,no IP contract,,50,,105.08,percent of total billed charges,,,,,,no IP contract,,,78,,163.92,percent of total billed charges,,,70,,147.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,102.97,3324,
63323-0535-98 - eNOXaparin [Lovenox] 40 MG / 0.4 ML Injection,63323-0535-98,NDC,,,,inpatient,0.4,ML,414.8,248.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,335.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,352.58,percent of total billed charges,,,85,,352.58,percent of total billed charges,,,49,,203.25,percent of total billed charges,,,90,,373.32,percent of total billed charges,,,,,,,no IP contract,,80,,331.84,percent of total billed charges,,,,,,,no IP contract,,50,,207.4,percent of total billed charges,,,,,,no IP contract,,,78,,323.54,percent of total billed charges,,,70,,290.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,203.25,3324,
63323-0537-84 - enoxaparin 150 mg/mL Soln,63323-0537-84,NDC,,,,inpatient,1,ML,310.85,186.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,251.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,264.22,percent of total billed charges,,,85,,264.22,percent of total billed charges,,,49,,152.32,percent of total billed charges,,,90,,279.77,percent of total billed charges,,,,,,,no IP contract,,80,,248.68,percent of total billed charges,,,,,,,no IP contract,,50,,155.43,percent of total billed charges,,,,,,no IP contract,,,78,,242.46,percent of total billed charges,,,70,,217.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,152.32,3324,
63323-0540-11 - heparin 1000 units/mL Soln,63323-0540-11,NDC,,,,inpatient,10,ML,86.05,51.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,69.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,73.14,percent of total billed charges,,,85,,73.14,percent of total billed charges,,,49,,42.16,percent of total billed charges,,,90,,77.45,percent of total billed charges,,,,,,,no IP contract,,80,,68.84,percent of total billed charges,,,,,,,no IP contract,,50,,43.03,percent of total billed charges,,,,,,no IP contract,,,78,,67.12,percent of total billed charges,,,70,,60.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,42.16,3324,
63323-0540-15 - heparin 1000 units/mL Soln,63323-0540-15,NDC,,,,inpatient,10,ML,82.65,49.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,66.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,70.25,percent of total billed charges,,,85,,70.25,percent of total billed charges,,,49,,40.5,percent of total billed charges,,,90,,74.39,percent of total billed charges,,,,,,,no IP contract,,80,,66.12,percent of total billed charges,,,,,,,no IP contract,,50,,41.33,percent of total billed charges,,,,,,no IP contract,,,78,,64.47,percent of total billed charges,,,70,,57.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,40.5,3324,
heparin 1000 units/mL Soln,63323-0540-67,NDC,,,,inpatient,1,EA,86.05,51.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,69.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,73.14,percent of total billed charges,,,85,,73.14,percent of total billed charges,,,49,,42.16,percent of total billed charges,,,90,,77.45,percent of total billed charges,,,,,,,no IP contract,,80,,68.84,percent of total billed charges,,,,,,,no IP contract,,50,,43.03,percent of total billed charges,,,,,,no IP contract,,,78,,67.12,percent of total billed charges,,,70,,60.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,42.16,3324,
63323-0559-65 - enoxaparin 30 mg/0.3 mL Soln,63323-0559-65,NDC,,,,inpatient,0.3,ML,110.8,66.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,89.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,94.18,percent of total billed charges,,,85,,94.18,percent of total billed charges,,,49,,54.29,percent of total billed charges,,,90,,99.72,percent of total billed charges,,,,,,,no IP contract,,80,,88.64,percent of total billed charges,,,,,,,no IP contract,,50,,55.4,percent of total billed charges,,,,,,no IP contract,,,78,,86.42,percent of total billed charges,,,70,,77.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,54.29,3324,
63323-0559-93 - enoxaparin 30 mg/0.3 mL Soln,63323-0559-93,NDC,,,,inpatient,0.3,ML,210.65,126.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,170.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,179.05,percent of total billed charges,,,85,,179.05,percent of total billed charges,,,49,,103.22,percent of total billed charges,,,90,,189.59,percent of total billed charges,,,,,,,no IP contract,,80,,168.52,percent of total billed charges,,,,,,,no IP contract,,50,,105.33,percent of total billed charges,,,,,,no IP contract,,,78,,164.31,percent of total billed charges,,,70,,147.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,103.22,3324,
63323-0564-65 - eNOXaparin 40 mg / 0.4 mL Injection,63323-0564-65,NDC,,,,inpatient,0.4,ML,110.5,66.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,89.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,93.93,percent of total billed charges,,,85,,93.93,percent of total billed charges,,,49,,54.15,percent of total billed charges,,,90,,99.45,percent of total billed charges,,,,,,,no IP contract,,80,,88.4,percent of total billed charges,,,,,,,no IP contract,,50,,55.25,percent of total billed charges,,,,,,no IP contract,,,78,,86.19,percent of total billed charges,,,70,,77.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,54.15,3324,
63323-0564-97 - enoxaparin 40 mg/0.4 mL Soln,63323-0564-97,NDC,,,,inpatient,0.4,ML,210.15,126.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,170.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,178.63,percent of total billed charges,,,85,,178.63,percent of total billed charges,,,49,,102.97,percent of total billed charges,,,90,,189.14,percent of total billed charges,,,,,,,no IP contract,,80,,168.12,percent of total billed charges,,,,,,,no IP contract,,50,,105.08,percent of total billed charges,,,,,,no IP contract,,,78,,163.92,percent of total billed charges,,,70,,147.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,102.97,3324,
63323-0565-93 - enoxaparin 300 mg/3 mL Soln,63323-0565-93,NDC,,,,inpatient,0.01,ML,11.7,7.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.95,percent of total billed charges,,,85,,9.95,percent of total billed charges,,,49,,5.73,percent of total billed charges,,,90,,10.53,percent of total billed charges,,,,,,,no IP contract,,80,,9.36,percent of total billed charges,,,,,,,no IP contract,,50,,5.85,percent of total billed charges,,,,,,no IP contract,,,78,,9.13,percent of total billed charges,,,70,,8.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.73,3324,
63323-0566-65 - eNOXaparin 60 mg / 0.6 mL Injection,63323-0566-65,NDC,,,,inpatient,0.6,ML,110.8,66.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,89.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,94.18,percent of total billed charges,,,85,,94.18,percent of total billed charges,,,49,,54.29,percent of total billed charges,,,90,,99.72,percent of total billed charges,,,,,,,no IP contract,,80,,88.64,percent of total billed charges,,,,,,,no IP contract,,50,,55.4,percent of total billed charges,,,,,,no IP contract,,,78,,86.42,percent of total billed charges,,,70,,77.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,54.29,3324,
63323-0568-83 - enoxaparin 30 mg/0.3 mL Soln,63323-0568-83,NDC,,,,inpatient,0.3,ML,251.95,151.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,204.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,214.16,percent of total billed charges,,,85,,214.16,percent of total billed charges,,,49,,123.46,percent of total billed charges,,,90,,226.76,percent of total billed charges,,,,,,,no IP contract,,80,,201.56,percent of total billed charges,,,,,,,no IP contract,,50,,125.98,percent of total billed charges,,,,,,no IP contract,,,78,,196.52,percent of total billed charges,,,70,,176.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,123.46,3324,
63323-0568-87 - enoxaparin 40 mg/0.4 mL Soln,63323-0568-87,NDC,,,,inpatient,0.4,ML,210.15,126.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,170.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,178.63,percent of total billed charges,,,85,,178.63,percent of total billed charges,,,49,,102.97,percent of total billed charges,,,90,,189.14,percent of total billed charges,,,,,,,no IP contract,,80,,168.12,percent of total billed charges,,,,,,,no IP contract,,50,,105.08,percent of total billed charges,,,,,,no IP contract,,,78,,163.92,percent of total billed charges,,,70,,147.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,102.97,3324,
63323-0568-95 - enoxaparin Inj 100 mg/mL Injection,63323-0568-95,NDC,,,,inpatient,1,ML,110.9,66.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,89.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,94.27,percent of total billed charges,,,85,,94.27,percent of total billed charges,,,49,,54.34,percent of total billed charges,,,90,,99.81,percent of total billed charges,,,,,,,no IP contract,,80,,88.72,percent of total billed charges,,,,,,,no IP contract,,50,,55.45,percent of total billed charges,,,,,,no IP contract,,,78,,86.5,percent of total billed charges,,,70,,77.63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,54.34,3324,
63323-0568-96 - enoxaparin 40 mg/0.4 mL Soln,63323-0568-96,NDC,,,,inpatient,0.4,ML,414.8,248.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,335.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,352.58,percent of total billed charges,,,85,,352.58,percent of total billed charges,,,49,,203.25,percent of total billed charges,,,90,,373.32,percent of total billed charges,,,,,,,no IP contract,,80,,331.84,percent of total billed charges,,,,,,,no IP contract,,50,,207.4,percent of total billed charges,,,,,,no IP contract,,,78,,323.54,percent of total billed charges,,,70,,290.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,203.25,3324,
63323-0568-98 - enoxaparin 60 mg/0.6 mL Soln,63323-0568-98,NDC,,,,inpatient,0.6,ML,617.95,370.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,500.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,525.26,percent of total billed charges,,,85,,525.26,percent of total billed charges,,,49,,302.8,percent of total billed charges,,,90,,556.16,percent of total billed charges,,,,,,,no IP contract,,80,,494.36,percent of total billed charges,,,,,,,no IP contract,,50,,308.98,percent of total billed charges,,,,,,no IP contract,,,78,,482,percent of total billed charges,,,70,,432.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,302.8,3324,
63323-0568-99 - enoxaparin Inj 80 mg / 0.8 mL Injection,63323-0568-99,NDC,,,,inpatient,0.8,ML,109.05,65.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,88.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,92.69,percent of total billed charges,,,85,,92.69,percent of total billed charges,,,49,,53.43,percent of total billed charges,,,90,,98.15,percent of total billed charges,,,,,,,no IP contract,,80,,87.24,percent of total billed charges,,,,,,,no IP contract,,50,,54.53,percent of total billed charges,,,,,,no IP contract,,,78,,85.06,percent of total billed charges,,,70,,76.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,53.43,3324,
63323-0569-90 - enoxaparin 120 mg/0.8 mL Soln,63323-0569-90,NDC,,,,inpatient,0.8,ML,310.85,186.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,251.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,264.22,percent of total billed charges,,,85,,264.22,percent of total billed charges,,,49,,152.32,percent of total billed charges,,,90,,279.77,percent of total billed charges,,,,,,,no IP contract,,80,,248.68,percent of total billed charges,,,,,,,no IP contract,,50,,155.43,percent of total billed charges,,,,,,no IP contract,,,78,,242.46,percent of total billed charges,,,70,,217.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,152.32,3324,
63323-0569-95 - enoxaparin Inj 150 mg/mL Injection,63323-0569-95,NDC,,,,inpatient,1,ML,161.65,96.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,130.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,137.4,percent of total billed charges,,,85,,137.4,percent of total billed charges,,,49,,79.21,percent of total billed charges,,,90,,145.49,percent of total billed charges,,,,,,,no IP contract,,80,,129.32,percent of total billed charges,,,,,,,no IP contract,,50,,80.83,percent of total billed charges,,,,,,no IP contract,,,78,,126.09,percent of total billed charges,,,70,,113.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,79.21,3324,
63323-0569-99 - enoxaparin 120 mg/0.8 mL Soln,63323-0569-99,NDC,,,,inpatient,0.8,ML,1228.3,736.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,994.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1044.06,percent of total billed charges,,,85,,1044.06,percent of total billed charges,,,49,,601.87,percent of total billed charges,,,90,,1105.47,percent of total billed charges,,,,,,,no IP contract,,80,,982.64,percent of total billed charges,,,,,,,no IP contract,,50,,614.15,percent of total billed charges,,,,,,no IP contract,,,78,,958.07,percent of total billed charges,,,70,,859.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,601.87,3324,
63323-0584-99 - enoxaparin 80 mg/0.8 mL Soln,63323-0584-99,NDC,,,,inpatient,0.8,ML,210.4,126.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,170.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,178.84,percent of total billed charges,,,85,,178.84,percent of total billed charges,,,49,,103.1,percent of total billed charges,,,90,,189.36,percent of total billed charges,,,,,,,no IP contract,,80,,168.32,percent of total billed charges,,,,,,,no IP contract,,50,,105.2,percent of total billed charges,,,,,,no IP contract,,,78,,164.11,percent of total billed charges,,,70,,147.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,103.1,3324,
63323-0594-03 - glucagon 1 mg REC I,63323-0594-03,NDC,,,,inpatient,1,ML,1648.1,988.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1334.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1400.89,percent of total billed charges,,,85,,1400.89,percent of total billed charges,,,49,,807.57,percent of total billed charges,,,90,,1483.29,percent of total billed charges,,,,,,,no IP contract,,80,,1318.48,percent of total billed charges,,,,,,,no IP contract,,50,,824.05,percent of total billed charges,,,,,,no IP contract,,,78,,1285.52,percent of total billed charges,,,70,,1153.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,807.57,3324,
63323-0605-84 - eNOXaparin 100 mg/mL Injection,63323-0605-84,NDC,,,,inpatient,1,ML,210.45,126.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,170.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,178.88,percent of total billed charges,,,85,,178.88,percent of total billed charges,,,49,,103.12,percent of total billed charges,,,90,,189.41,percent of total billed charges,,,,,,,no IP contract,,80,,168.36,percent of total billed charges,,,,,,,no IP contract,,50,,105.23,percent of total billed charges,,,,,,no IP contract,,,78,,164.15,percent of total billed charges,,,70,,147.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,103.12,3324,
63323-0605-94 - eNOXaparin  100 mg/mL Injection,63323-0605-94,NDC,,,,inpatient,1,ML,1024.95,614.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,830.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,871.21,percent of total billed charges,,,85,,871.21,percent of total billed charges,,,49,,502.23,percent of total billed charges,,,90,,922.46,percent of total billed charges,,,,,,,no IP contract,,80,,819.96,percent of total billed charges,,,,,,,no IP contract,,50,,512.48,percent of total billed charges,,,,,,no IP contract,,,78,,799.46,percent of total billed charges,,,70,,717.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,502.23,3324,
63323-0607-88 - enoxaparin 60 mg/0.6 mL Soln,63323-0607-88,NDC,,,,inpatient,0.6,ML,210.45,126.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,170.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,178.88,percent of total billed charges,,,85,,178.88,percent of total billed charges,,,49,,103.12,percent of total billed charges,,,90,,189.41,percent of total billed charges,,,,,,,no IP contract,,80,,168.36,percent of total billed charges,,,,,,,no IP contract,,50,,105.23,percent of total billed charges,,,,,,no IP contract,,,78,,164.15,percent of total billed charges,,,70,,147.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,103.12,3324,
63323-0607-98 - enoxaparin 60 mg/0.6 mL Soln,63323-0607-98,NDC,,,,inpatient,0.6,ML,110.8,66.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,89.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,94.18,percent of total billed charges,,,85,,94.18,percent of total billed charges,,,49,,54.29,percent of total billed charges,,,90,,99.72,percent of total billed charges,,,,,,,no IP contract,,80,,88.64,percent of total billed charges,,,,,,,no IP contract,,50,,55.4,percent of total billed charges,,,,,,no IP contract,,,78,,86.42,percent of total billed charges,,,70,,77.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,54.29,3324,
63323-0609-90 - eNOXaparin 120 mg Injection,63323-0609-90,NDC,,,,inpatient,0.8,ML,310.85,186.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,251.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,264.22,percent of total billed charges,,,85,,264.22,percent of total billed charges,,,49,,152.32,percent of total billed charges,,,90,,279.77,percent of total billed charges,,,,,,,no IP contract,,80,,248.68,percent of total billed charges,,,,,,,no IP contract,,50,,155.43,percent of total billed charges,,,,,,no IP contract,,,78,,242.46,percent of total billed charges,,,70,,217.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,152.32,3324,
63323-0614-01 - hydrALAZINE 20 mg/mL Soln,63323-0614-01,NDC,,,,inpatient,1,ML,130.7,78.42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,105.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,111.1,percent of total billed charges,,,85,,111.1,percent of total billed charges,,,49,,64.04,percent of total billed charges,,,90,,117.63,percent of total billed charges,,,,,,,no IP contract,,80,,104.56,percent of total billed charges,,,,,,,no IP contract,,50,,65.35,percent of total billed charges,,,,,,no IP contract,,,78,,101.95,percent of total billed charges,,,70,,91.49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,64.04,3324,
63323-0616-03 - amiodarone 50 mg/mL Soln,63323-0616-03,NDC,,,,inpatient,1,ML,14.05,8.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.94,percent of total billed charges,,,85,,11.94,percent of total billed charges,,,49,,6.88,percent of total billed charges,,,90,,12.65,percent of total billed charges,,,,,,,no IP contract,,80,,11.24,percent of total billed charges,,,,,,,no IP contract,,50,,7.03,percent of total billed charges,,,,,,no IP contract,,,78,,10.96,percent of total billed charges,,,70,,9.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.88,3324,
63323-0623-75 - LVP solution Sodium Chloride 0.9% Soln,63323-0623-75,NDC,,,,inpatient,500,ML,77.05,46.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,62.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,65.49,percent of total billed charges,,,85,,65.49,percent of total billed charges,,,49,,37.75,percent of total billed charges,,,90,,69.35,percent of total billed charges,,,,,,,no IP contract,,80,,61.64,percent of total billed charges,,,,,,,no IP contract,,50,,38.53,percent of total billed charges,,,,,,no IP contract,,,78,,60.1,percent of total billed charges,,,70,,53.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,37.75,3324,
63323-0623-76 - LVP solution Sodium Chloride 0.9% Soln,63323-0623-76,NDC,,,,inpatient,1000,ML,118.7,71.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,96.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,100.9,percent of total billed charges,,,85,,100.9,percent of total billed charges,,,49,,58.16,percent of total billed charges,,,90,,106.83,percent of total billed charges,,,,,,,no IP contract,,80,,94.96,percent of total billed charges,,,,,,,no IP contract,,50,,59.35,percent of total billed charges,,,,,,no IP contract,,,78,,92.59,percent of total billed charges,,,70,,83.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.16,3324,
63323-0624-61 - LVP solution Dextrose 5% in Water Soln,63323-0624-61,NDC,,,,inpatient,100,ML,46.25,27.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,37.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,39.31,percent of total billed charges,,,85,,39.31,percent of total billed charges,,,49,,22.66,percent of total billed charges,,,90,,41.63,percent of total billed charges,,,,,,,no IP contract,,80,,37,percent of total billed charges,,,,,,,no IP contract,,50,,23.13,percent of total billed charges,,,,,,no IP contract,,,78,,36.08,percent of total billed charges,,,70,,32.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.66,3324,
63323-0626-10 - LVP solution Sodium Chloride 0.45% Soln,63323-0626-10,NDC,,,,inpatient,1000,ML,118.7,71.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,96.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,100.9,percent of total billed charges,,,85,,100.9,percent of total billed charges,,,49,,58.16,percent of total billed charges,,,90,,106.83,percent of total billed charges,,,,,,,no IP contract,,80,,94.96,percent of total billed charges,,,,,,,no IP contract,,50,,59.35,percent of total billed charges,,,,,,no IP contract,,,78,,92.59,percent of total billed charges,,,70,,83.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.16,3324,
63323-0651-02 - adenosine 3 mg/mL Soln,63323-0651-02,NDC,,,,inpatient,2,ML,120.1,72.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,97.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,102.09,percent of total billed charges,,,85,,102.09,percent of total billed charges,,,49,,58.85,percent of total billed charges,,,90,,108.09,percent of total billed charges,,,,,,,no IP contract,,80,,96.08,percent of total billed charges,,,,,,,no IP contract,,50,,60.05,percent of total billed charges,,,,,,no IP contract,,,78,,93.68,percent of total billed charges,,,70,,84.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.85,3324,
63323-0655-99 - enoxaparin 120 mg/0.8 mL Soln,63323-0655-99,NDC,,,,inpatient,0.8,ML,310.85,186.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,251.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,264.22,percent of total billed charges,,,85,,264.22,percent of total billed charges,,,49,,152.32,percent of total billed charges,,,90,,279.77,percent of total billed charges,,,,,,,no IP contract,,80,,248.68,percent of total billed charges,,,,,,,no IP contract,,50,,155.43,percent of total billed charges,,,,,,no IP contract,,,78,,242.46,percent of total billed charges,,,70,,217.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,152.32,3324,
63323-0690-30 - acetylcysteine 20% Soln,63323-0690-30,NDC,,,,inpatient,1,ML,14.8,8.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.58,percent of total billed charges,,,85,,12.58,percent of total billed charges,,,49,,7.25,percent of total billed charges,,,90,,13.32,percent of total billed charges,,,,,,,no IP contract,,80,,11.84,percent of total billed charges,,,,,,,no IP contract,,50,,7.4,percent of total billed charges,,,,,,no IP contract,,,78,,11.54,percent of total billed charges,,,70,,10.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.25,3324,
63323-0693-10 - acetylcysteine 10% Soln,63323-0693-10,NDC,,,,inpatient,1,ML,21.4,12.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.19,percent of total billed charges,,,85,,18.19,percent of total billed charges,,,49,,10.49,percent of total billed charges,,,90,,19.26,percent of total billed charges,,,,,,,no IP contract,,80,,17.12,percent of total billed charges,,,,,,,no IP contract,,50,,10.7,percent of total billed charges,,,,,,no IP contract,,,78,,16.69,percent of total billed charges,,,70,,14.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.49,3324,
63323-0728-10 - micafungin 50 mg REC I,63323-0728-10,NDC,,,,inpatient,5,ML,993.05,595.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,804.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,844.09,percent of total billed charges,,,85,,844.09,percent of total billed charges,,,49,,486.59,percent of total billed charges,,,90,,893.75,percent of total billed charges,,,,,,,no IP contract,,80,,794.44,percent of total billed charges,,,,,,,no IP contract,,50,,496.53,percent of total billed charges,,,,,,no IP contract,,,78,,774.58,percent of total billed charges,,,70,,695.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,486.59,3324,
63323-0729-10 - micafungin 100 mg REC I,63323-0729-10,NDC,,,,inpatient,5,ML,1944.4,1166.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1574.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1652.74,percent of total billed charges,,,85,,1652.74,percent of total billed charges,,,49,,952.76,percent of total billed charges,,,90,,1749.96,percent of total billed charges,,,,,,,no IP contract,,80,,1555.52,percent of total billed charges,,,,,,,no IP contract,,50,,972.2,percent of total billed charges,,,,,,no IP contract,,,78,,1516.63,percent of total billed charges,,,70,,1361.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,952.76,3324,
63323-0738-09 - famotidine 10 mg/mL Soln,63323-0738-09,NDC,,,,inpatient,1,ML,13.9,8.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.82,percent of total billed charges,,,85,,11.82,percent of total billed charges,,,49,,6.81,percent of total billed charges,,,90,,12.51,percent of total billed charges,,,,,,,no IP contract,,80,,11.12,percent of total billed charges,,,,,,,no IP contract,,50,,6.95,percent of total billed charges,,,,,,no IP contract,,,78,,10.84,percent of total billed charges,,,70,,9.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.81,3324,
63323-0812-20 - oxacillin 2 g REC I,63323-0812-20,NDC,,,,inpatient,1,EA,245.6,147.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,198.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,208.76,percent of total billed charges,,,85,,208.76,percent of total billed charges,,,49,,120.34,percent of total billed charges,,,90,,221.04,percent of total billed charges,,,,,,,no IP contract,,80,,196.48,percent of total billed charges,,,,,,,no IP contract,,50,,122.8,percent of total billed charges,,,,,,no IP contract,,,78,,191.57,percent of total billed charges,,,70,,171.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,120.34,3324,
"63323-0820-00 - fat emulsion, intravenous with fish, medium chain, olive, and soy oil 20% Emuls",63323-0820-00,NDC,,,,inpatient,100,ML,275,165,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,222.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,233.75,percent of total billed charges,,,85,,233.75,percent of total billed charges,,,49,,134.75,percent of total billed charges,,,90,,247.5,percent of total billed charges,,,,,,,no IP contract,,80,,220,percent of total billed charges,,,,,,,no IP contract,,50,,137.5,percent of total billed charges,,,,,,no IP contract,,,78,,214.5,percent of total billed charges,,,70,,192.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,134.75,3324,
"63323-0820-50 - fat emulsion, intravenous with fish, medium chain, olive, and soy oil 20% Emuls",63323-0820-50,NDC,,,,inpatient,500,ML,349.95,209.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,283.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,297.46,percent of total billed charges,,,85,,297.46,percent of total billed charges,,,49,,171.48,percent of total billed charges,,,90,,314.96,percent of total billed charges,,,,,,,no IP contract,,80,,279.96,percent of total billed charges,,,,,,,no IP contract,,50,,174.98,percent of total billed charges,,,,,,no IP contract,,,78,,272.96,percent of total billed charges,,,70,,244.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,171.48,3324,
"63323-0820-74 - fat emulsion, intravenous with fish, medium chain, olive, and soy oil 20% Emuls",63323-0820-74,NDC,,,,inpatient,250,ML,287.5,172.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,232.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,244.38,percent of total billed charges,,,85,,244.38,percent of total billed charges,,,49,,140.88,percent of total billed charges,,,90,,258.75,percent of total billed charges,,,,,,,no IP contract,,80,,230,percent of total billed charges,,,,,,,no IP contract,,50,,143.75,percent of total billed charges,,,,,,no IP contract,,,78,,224.25,percent of total billed charges,,,70,,201.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,140.88,3324,
63323-0871-15 - daptomycin 500 mg REC Injection,63323-0871-15,NDC,,,,inpatient,10,ML,4273.45,2564.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3461.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3632.43,percent of total billed charges,,,85,,3632.43,percent of total billed charges,,,49,,2093.99,percent of total billed charges,,,90,,3846.11,percent of total billed charges,,,,,,,no IP contract,,80,,3418.76,percent of total billed charges,,,,,,,no IP contract,,50,,2136.73,percent of total billed charges,,,,,,no IP contract,,,78,,3333.29,percent of total billed charges,,,70,,2991.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3846.11,
63323-0884-06 - sodium phosphate 3 mmol/mL Soln,63323-0884-06,NDC,,,,inpatient,1,ML,43.8,26.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,35.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,37.23,percent of total billed charges,,,85,,37.23,percent of total billed charges,,,49,,21.46,percent of total billed charges,,,90,,39.42,percent of total billed charges,,,,,,,no IP contract,,80,,35.04,percent of total billed charges,,,,,,,no IP contract,,50,,21.9,percent of total billed charges,,,,,,no IP contract,,,78,,34.16,percent of total billed charges,,,70,,30.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.46,3324,
63323-0960-10 - tigecycline 50 mg REC I,63323-0960-10,NDC,,,,inpatient,5,ML,1634.5,980.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1323.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1389.33,percent of total billed charges,,,85,,1389.33,percent of total billed charges,,,49,,800.91,percent of total billed charges,,,90,,1471.05,percent of total billed charges,,,,,,,no IP contract,,80,,1307.6,percent of total billed charges,,,,,,,no IP contract,,50,,817.25,percent of total billed charges,,,,,,no IP contract,,,78,,1274.91,percent of total billed charges,,,70,,1144.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,800.91,3324,
potassium chloride 2 mEq/mL Soln,63323-0965-10,NDC,,,,inpatient,1,EA,19.45,11.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.53,percent of total billed charges,,,85,,16.53,percent of total billed charges,,,49,,9.53,percent of total billed charges,,,90,,17.51,percent of total billed charges,,,,,,,no IP contract,,80,,15.56,percent of total billed charges,,,,,,,no IP contract,,50,,9.73,percent of total billed charges,,,,,,no IP contract,,,78,,15.17,percent of total billed charges,,,70,,13.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.53,3324,
63323-0983-21 - piperacillin-tazobactam 3 g-0.375 g REC I,63323-0983-21,NDC,,,,inpatient,1,EA,149.6,89.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,121.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,127.16,percent of total billed charges,,,85,,127.16,percent of total billed charges,,,49,,73.3,percent of total billed charges,,,90,,134.64,percent of total billed charges,,,,,,,no IP contract,,80,,119.68,percent of total billed charges,,,,,,,no IP contract,,50,,74.8,percent of total billed charges,,,,,,no IP contract,,,78,,116.69,percent of total billed charges,,,70,,104.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,73.3,3324,
63395-0101-05 - ofloxacin otic 0.3% Soln,63395-0101-05,NDC,,,,inpatient,1,UN,461.15,276.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,373.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,391.98,percent of total billed charges,,,85,,391.98,percent of total billed charges,,,49,,225.96,percent of total billed charges,,,90,,415.04,percent of total billed charges,,,,,,,no IP contract,,80,,368.92,percent of total billed charges,,,,,,,no IP contract,,50,,230.58,percent of total billed charges,,,,,,no IP contract,,,78,,359.7,percent of total billed charges,,,70,,322.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,225.96,3324,
63402-0510-01 - levalbuterol CFC free 45 mcg/inh Aeros,63402-0510-01,NDC,,,,inpatient,1,UN,524,314.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,424.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,445.4,percent of total billed charges,,,85,,445.4,percent of total billed charges,,,49,,256.76,percent of total billed charges,,,90,,471.6,percent of total billed charges,,,,,,,no IP contract,,80,,419.2,percent of total billed charges,,,,,,,no IP contract,,50,,262,percent of total billed charges,,,,,,no IP contract,,,78,,408.72,percent of total billed charges,,,70,,366.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,256.76,3324,
63402-0911-30 - arformoterol 15 mcg/2 mL Soln,63402-0911-30,NDC,,,,inpatient,2,ML,109,65.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,88.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,92.65,percent of total billed charges,,,85,,92.65,percent of total billed charges,,,49,,53.41,percent of total billed charges,,,90,,98.1,percent of total billed charges,,,,,,,no IP contract,,80,,87.2,percent of total billed charges,,,,,,,no IP contract,,50,,54.5,percent of total billed charges,,,,,,no IP contract,,,78,,85.02,percent of total billed charges,,,70,,76.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,53.41,3324,
arformoterol 15 mcg/2 mL Soln,63402-0911-64,NDC,,,,inpatient,1,EA,206.15,123.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,166.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,175.23,percent of total billed charges,,,85,,175.23,percent of total billed charges,,,49,,101.01,percent of total billed charges,,,90,,185.54,percent of total billed charges,,,,,,,no IP contract,,80,,164.92,percent of total billed charges,,,,,,,no IP contract,,50,,103.08,percent of total billed charges,,,,,,no IP contract,,,78,,160.8,percent of total billed charges,,,70,,144.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,101.01,3324,
63459-0205-30 - armodafinil 50 mg Tab,63459-0205-30,NDC,,,,inpatient,1,EA,65.75,39.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,53.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,55.89,percent of total billed charges,,,85,,55.89,percent of total billed charges,,,49,,32.22,percent of total billed charges,,,90,,59.18,percent of total billed charges,,,,,,,no IP contract,,80,,52.6,percent of total billed charges,,,,,,,no IP contract,,50,,32.88,percent of total billed charges,,,,,,no IP contract,,,78,,51.29,percent of total billed charges,,,70,,46.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.22,3324,
63459-0225-30 - armodafinil 250 mg Tab,63459-0225-30,NDC,,,,inpatient,1,EA,189.7,113.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,153.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,161.25,percent of total billed charges,,,85,,161.25,percent of total billed charges,,,49,,92.95,percent of total billed charges,,,90,,170.73,percent of total billed charges,,,,,,,no IP contract,,80,,151.76,percent of total billed charges,,,,,,,no IP contract,,50,,94.85,percent of total billed charges,,,,,,no IP contract,,,78,,147.97,percent of total billed charges,,,70,,132.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,92.95,3324,
63481-0205-16 - amantadine 50 mg/5 mL Syrup,63481-0205-16,NDC,,,,inpatient,10,ML,30.4,18.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.84,percent of total billed charges,,,85,,25.84,percent of total billed charges,,,49,,14.9,percent of total billed charges,,,90,,27.36,percent of total billed charges,,,,,,,no IP contract,,80,,24.32,percent of total billed charges,,,,,,,no IP contract,,50,,15.2,percent of total billed charges,,,,,,no IP contract,,,78,,23.71,percent of total billed charges,,,70,,21.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.9,3324,
63481-0674-70 - oxymorphone 10 mg ER Ta,63481-0674-70,NDC,,,,inpatient,1,EA,36.6,21.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.11,percent of total billed charges,,,85,,31.11,percent of total billed charges,,,49,,17.93,percent of total billed charges,,,90,,32.94,percent of total billed charges,,,,,,,no IP contract,,80,,29.28,percent of total billed charges,,,,,,,no IP contract,,50,,18.3,percent of total billed charges,,,,,,no IP contract,,,78,,28.55,percent of total billed charges,,,70,,25.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.93,3324,
63481-0684-47 - diclofenac topical 1% Gel,63481-0684-47,NDC,,,,inpatient,1,EA,309.1,185.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,250.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,262.74,percent of total billed charges,,,85,,262.74,percent of total billed charges,,,49,,151.46,percent of total billed charges,,,90,,278.19,percent of total billed charges,,,,,,,no IP contract,,80,,247.28,percent of total billed charges,,,,,,,no IP contract,,50,,154.55,percent of total billed charges,,,,,,no IP contract,,,78,,241.1,percent of total billed charges,,,70,,216.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,151.46,3324,
63481-0814-60 - oxymorphone 10 mg ER Ta,63481-0814-60,NDC,,,,inpatient,1,EA,43.15,25.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36.68,percent of total billed charges,,,85,,36.68,percent of total billed charges,,,49,,21.14,percent of total billed charges,,,90,,38.84,percent of total billed charges,,,,,,,no IP contract,,80,,34.52,percent of total billed charges,,,,,,,no IP contract,,50,,21.58,percent of total billed charges,,,,,,no IP contract,,,78,,33.66,percent of total billed charges,,,70,,30.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.14,3324,
63481-0818-60 - oxymorphone 40 mg ER Ta,63481-0818-60,NDC,,,,inpatient,1,EA,154.2,92.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,124.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,131.07,percent of total billed charges,,,85,,131.07,percent of total billed charges,,,49,,75.56,percent of total billed charges,,,90,,138.78,percent of total billed charges,,,,,,,no IP contract,,80,,123.36,percent of total billed charges,,,,,,,no IP contract,,50,,77.1,percent of total billed charges,,,,,,no IP contract,,,78,,120.28,percent of total billed charges,,,70,,107.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,75.56,3324,
hydrocortisone topical 2.5% Cream,63629-8847-01,NDC,,,,inpatient,1,EA,736.45,441.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,596.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,625.98,percent of total billed charges,,,85,,625.98,percent of total billed charges,,,49,,360.86,percent of total billed charges,,,90,,662.81,percent of total billed charges,,,,,,,no IP contract,,80,,589.16,percent of total billed charges,,,,,,,no IP contract,,50,,368.23,percent of total billed charges,,,,,,no IP contract,,,78,,574.43,percent of total billed charges,,,70,,515.52,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,360.86,3324,
63736-0024-03 - permethrin topical 1% Lotio,63736-0024-03,NDC,,,,inpatient,1,UN,92.75,55.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,75.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,78.84,percent of total billed charges,,,85,,78.84,percent of total billed charges,,,49,,45.45,percent of total billed charges,,,90,,83.48,percent of total billed charges,,,,,,,no IP contract,,80,,74.2,percent of total billed charges,,,,,,,no IP contract,,50,,46.38,percent of total billed charges,,,,,,no IP contract,,,78,,72.35,percent of total billed charges,,,70,,64.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,45.45,3324,
63736-0024-04 - permethrin topical 1% Lotio,63736-0024-04,NDC,,,,inpatient,1,UN,78.05,46.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,63.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,66.34,percent of total billed charges,,,85,,66.34,percent of total billed charges,,,49,,38.24,percent of total billed charges,,,90,,70.25,percent of total billed charges,,,,,,,no IP contract,,80,,62.44,percent of total billed charges,,,,,,,no IP contract,,50,,39.03,percent of total billed charges,,,,,,no IP contract,,,78,,60.88,percent of total billed charges,,,70,,54.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,38.24,3324,
63739-0023-01 - aspirin 325 mg EC Ta,63739-0023-01,NDC,,,,inpatient,1,EA,4.3,2.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.66,percent of total billed charges,,,85,,3.66,percent of total billed charges,,,49,,2.11,percent of total billed charges,,,90,,3.87,percent of total billed charges,,,,,,,no IP contract,,80,,3.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.15,percent of total billed charges,,,,,,no IP contract,,,78,,3.35,percent of total billed charges,,,70,,3.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.11,3324,
63739-0046-10 - carbidopa-levodopa 10 mg-100 mg Tab,63739-0046-10,NDC,,,,inpatient,1,EA,12.95,7.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.01,percent of total billed charges,,,85,,11.01,percent of total billed charges,,,49,,6.35,percent of total billed charges,,,90,,11.66,percent of total billed charges,,,,,,,no IP contract,,80,,10.36,percent of total billed charges,,,,,,,no IP contract,,50,,6.48,percent of total billed charges,,,,,,no IP contract,,,78,,10.1,percent of total billed charges,,,70,,9.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.35,3324,
63739-0047-10 - carbidopa-levodopa 25 mg-100 mg Tab,63739-0047-10,NDC,,,,inpatient,1,EA,13.9,8.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.82,percent of total billed charges,,,85,,11.82,percent of total billed charges,,,49,,6.81,percent of total billed charges,,,90,,12.51,percent of total billed charges,,,,,,,no IP contract,,80,,11.12,percent of total billed charges,,,,,,,no IP contract,,50,,6.95,percent of total billed charges,,,,,,no IP contract,,,78,,10.84,percent of total billed charges,,,70,,9.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.81,3324,
63739-0048-10 - carbidopa-levodopa 25 mg-250 mg Tab,63739-0048-10,NDC,,,,inpatient,1,EA,16.6,9.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.11,percent of total billed charges,,,85,,14.11,percent of total billed charges,,,49,,8.13,percent of total billed charges,,,90,,14.94,percent of total billed charges,,,,,,,no IP contract,,80,,13.28,percent of total billed charges,,,,,,,no IP contract,,50,,8.3,percent of total billed charges,,,,,,no IP contract,,,78,,12.95,percent of total billed charges,,,70,,11.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.13,3324,
63739-0059-10 - clindamycin 150 mg Cap,63739-0059-10,NDC,,,,inpatient,1,EA,9.25,5.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.86,percent of total billed charges,,,85,,7.86,percent of total billed charges,,,49,,4.53,percent of total billed charges,,,90,,8.33,percent of total billed charges,,,,,,,no IP contract,,80,,7.4,percent of total billed charges,,,,,,,no IP contract,,50,,4.63,percent of total billed charges,,,,,,no IP contract,,,78,,7.22,percent of total billed charges,,,70,,6.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.53,3324,
sildenafil 20 mg Tab,63739-0072-33,NDC,,,,inpatient,1,EA,8.65,5.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.35,percent of total billed charges,,,85,,7.35,percent of total billed charges,,,49,,4.24,percent of total billed charges,,,90,,7.79,percent of total billed charges,,,,,,,no IP contract,,80,,6.92,percent of total billed charges,,,,,,,no IP contract,,50,,4.33,percent of total billed charges,,,,,,no IP contract,,,78,,6.75,percent of total billed charges,,,70,,6.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.24,3324,
valACYclovir 500 mg Tab,63739-0077-10,NDC,,,,inpatient,1,EA,16.85,10.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.32,percent of total billed charges,,,85,,14.32,percent of total billed charges,,,49,,8.26,percent of total billed charges,,,90,,15.17,percent of total billed charges,,,,,,,no IP contract,,80,,13.48,percent of total billed charges,,,,,,,no IP contract,,50,,8.43,percent of total billed charges,,,,,,no IP contract,,,78,,13.14,percent of total billed charges,,,70,,11.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.26,3324,
63739-0079-10 - diltiazem 30 mg Tab,63739-0079-10,NDC,,,,inpatient,1,EA,7.4,4.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.29,percent of total billed charges,,,85,,6.29,percent of total billed charges,,,49,,3.63,percent of total billed charges,,,90,,6.66,percent of total billed charges,,,,,,,no IP contract,,80,,5.92,percent of total billed charges,,,,,,,no IP contract,,50,,3.7,percent of total billed charges,,,,,,no IP contract,,,78,,5.77,percent of total billed charges,,,70,,5.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.63,3324,
63739-0080-10 - diltiazem 60 mg Tab,63739-0080-10,NDC,,,,inpatient,1,EA,9.55,5.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.12,percent of total billed charges,,,85,,8.12,percent of total billed charges,,,49,,4.68,percent of total billed charges,,,90,,8.6,percent of total billed charges,,,,,,,no IP contract,,80,,7.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.78,percent of total billed charges,,,,,,no IP contract,,,78,,7.45,percent of total billed charges,,,70,,6.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.68,3324,
63739-0086-10 - valproic acid 250 mg Cap,63739-0086-10,NDC,,,,inpatient,1,EA,7.9,4.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.72,percent of total billed charges,,,85,,6.72,percent of total billed charges,,,49,,3.87,percent of total billed charges,,,90,,7.11,percent of total billed charges,,,,,,,no IP contract,,80,,6.32,percent of total billed charges,,,,,,,no IP contract,,50,,3.95,percent of total billed charges,,,,,,no IP contract,,,78,,6.16,percent of total billed charges,,,70,,5.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.87,3324,
63739-0107-10 - carbidopa-levodopa 10 mg-100 mg Tab,63739-0107-10,NDC,,,,inpatient,1,EA,6.85,4.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.82,percent of total billed charges,,,85,,5.82,percent of total billed charges,,,49,,3.36,percent of total billed charges,,,90,,6.17,percent of total billed charges,,,,,,,no IP contract,,80,,5.48,percent of total billed charges,,,,,,,no IP contract,,50,,3.43,percent of total billed charges,,,,,,no IP contract,,,78,,5.34,percent of total billed charges,,,70,,4.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.36,3324,
63739-0126-10 - hydrALAZINE 25 mg Tab,63739-0126-10,NDC,,,,inpatient,1,EA,8.75,5.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.44,percent of total billed charges,,,85,,7.44,percent of total billed charges,,,49,,4.29,percent of total billed charges,,,90,,7.88,percent of total billed charges,,,,,,,no IP contract,,80,,7,percent of total billed charges,,,,,,,no IP contract,,50,,4.38,percent of total billed charges,,,,,,no IP contract,,,78,,6.83,percent of total billed charges,,,70,,6.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.29,3324,
63739-0127-10 - hydralazine 50 mg Tab,63739-0127-10,NDC,,,,inpatient,1,EA,9.3,5.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.91,percent of total billed charges,,,85,,7.91,percent of total billed charges,,,49,,4.56,percent of total billed charges,,,90,,8.37,percent of total billed charges,,,,,,,no IP contract,,80,,7.44,percent of total billed charges,,,,,,,no IP contract,,50,,4.65,percent of total billed charges,,,,,,no IP contract,,,78,,7.25,percent of total billed charges,,,70,,6.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.56,3324,
63739-0134-01 - ibuprofen 200 mg Tab,63739-0134-01,NDC,,,,inpatient,1,EA,4.4,2.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.74,percent of total billed charges,,,85,,3.74,percent of total billed charges,,,49,,2.16,percent of total billed charges,,,90,,3.96,percent of total billed charges,,,,,,,no IP contract,,80,,3.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.2,percent of total billed charges,,,,,,no IP contract,,,78,,3.43,percent of total billed charges,,,70,,3.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.16,3324,
63739-0145-10 - midodrine 5 mg Tab,63739-0145-10,NDC,,,,inpatient,1,EA,7.9,4.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.72,percent of total billed charges,,,85,,6.72,percent of total billed charges,,,49,,3.87,percent of total billed charges,,,90,,7.11,percent of total billed charges,,,,,,,no IP contract,,80,,6.32,percent of total billed charges,,,,,,,no IP contract,,50,,3.95,percent of total billed charges,,,,,,no IP contract,,,78,,6.16,percent of total billed charges,,,70,,5.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.87,3324,
63739-0157-10 - ferrous sulfate 300 mg/5 mL LIQ,63739-0157-10,NDC,,,,inpatient,5,ML,34.6,20.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.41,percent of total billed charges,,,85,,29.41,percent of total billed charges,,,49,,16.95,percent of total billed charges,,,90,,31.14,percent of total billed charges,,,,,,,no IP contract,,80,,27.68,percent of total billed charges,,,,,,,no IP contract,,50,,17.3,percent of total billed charges,,,,,,no IP contract,,,78,,26.99,percent of total billed charges,,,70,,24.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.95,3324,
63739-0158-32 - levETIRAcetam 100 mg/mL Soln,63739-0158-32,NDC,,,,inpatient,5,ML,32.9,19.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,26.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,27.97,percent of total billed charges,,,85,,27.97,percent of total billed charges,,,49,,16.12,percent of total billed charges,,,90,,29.61,percent of total billed charges,,,,,,,no IP contract,,80,,26.32,percent of total billed charges,,,,,,,no IP contract,,50,,16.45,percent of total billed charges,,,,,,no IP contract,,,78,,25.66,percent of total billed charges,,,70,,23.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.12,3324,
63739-0160-10 - nystatin 100000 units/mL Susp,63739-0160-10,NDC,,,,inpatient,5,ML,19.15,11.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.28,percent of total billed charges,,,85,,16.28,percent of total billed charges,,,49,,9.38,percent of total billed charges,,,90,,17.24,percent of total billed charges,,,,,,,no IP contract,,80,,15.32,percent of total billed charges,,,,,,,no IP contract,,50,,9.58,percent of total billed charges,,,,,,no IP contract,,,78,,14.94,percent of total billed charges,,,70,,13.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.38,3324,
magnesium hydroxide 8% Susp,63739-0196-10,NDC,,,,inpatient,1,EA,25.4,15.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.59,percent of total billed charges,,,85,,21.59,percent of total billed charges,,,49,,12.45,percent of total billed charges,,,90,,22.86,percent of total billed charges,,,,,,,no IP contract,,80,,20.32,percent of total billed charges,,,,,,,no IP contract,,50,,12.7,percent of total billed charges,,,,,,no IP contract,,,78,,19.81,percent of total billed charges,,,70,,17.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.45,3324,
63739-0200-10 - PHENobarbital 16.2 mg Tab,63739-0200-10,NDC,,,,inpatient,1,EA,6.1,3.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.19,percent of total billed charges,,,85,,5.19,percent of total billed charges,,,49,,2.99,percent of total billed charges,,,90,,5.49,percent of total billed charges,,,,,,,no IP contract,,80,,4.88,percent of total billed charges,,,,,,,no IP contract,,50,,3.05,percent of total billed charges,,,,,,no IP contract,,,78,,4.76,percent of total billed charges,,,70,,4.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.99,3324,
63739-0201-10 - PHENobarbital 32.4 mg Tab,63739-0201-10,NDC,,,,inpatient,1,EA,4.45,2.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.78,percent of total billed charges,,,85,,3.78,percent of total billed charges,,,49,,2.18,percent of total billed charges,,,90,,4.01,percent of total billed charges,,,,,,,no IP contract,,80,,3.56,percent of total billed charges,,,,,,,no IP contract,,50,,2.23,percent of total billed charges,,,,,,no IP contract,,,78,,3.47,percent of total billed charges,,,70,,3.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.18,3324,
63739-0208-10 - predniSONE 10 mg Tab,63739-0208-10,NDC,,,,inpatient,1,EA,7.25,4.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.16,percent of total billed charges,,,85,,6.16,percent of total billed charges,,,49,,3.55,percent of total billed charges,,,90,,6.53,percent of total billed charges,,,,,,,no IP contract,,80,,5.8,percent of total billed charges,,,,,,,no IP contract,,50,,3.63,percent of total billed charges,,,,,,no IP contract,,,78,,5.66,percent of total billed charges,,,70,,5.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.55,3324,
63739-0208-15 - predniSONE 10 mg Tab,63739-0208-15,NDC,,,,inpatient,1,EA,7.25,4.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.16,percent of total billed charges,,,85,,6.16,percent of total billed charges,,,49,,3.55,percent of total billed charges,,,90,,6.53,percent of total billed charges,,,,,,,no IP contract,,80,,5.8,percent of total billed charges,,,,,,,no IP contract,,50,,3.63,percent of total billed charges,,,,,,no IP contract,,,78,,5.66,percent of total billed charges,,,70,,5.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.55,3324,
63739-0212-02 - aspirin 81 mg EC Ta,63739-0212-02,NDC,,,,inpatient,1,EA,4.3,2.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.66,percent of total billed charges,,,85,,3.66,percent of total billed charges,,,49,,2.11,percent of total billed charges,,,90,,3.87,percent of total billed charges,,,,,,,no IP contract,,80,,3.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.15,percent of total billed charges,,,,,,no IP contract,,,78,,3.35,percent of total billed charges,,,70,,3.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.11,3324,
63739-0225-10 - simethicone 80 mg Chew,63739-0225-10,NDC,,,,inpatient,1,EA,4.6,2.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.91,percent of total billed charges,,,85,,3.91,percent of total billed charges,,,49,,2.25,percent of total billed charges,,,90,,4.14,percent of total billed charges,,,,,,,no IP contract,,80,,3.68,percent of total billed charges,,,,,,,no IP contract,,50,,2.3,percent of total billed charges,,,,,,no IP contract,,,78,,3.59,percent of total billed charges,,,70,,3.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.25,3324,
63739-0251-10 - valproic acid 250 mg Cap,63739-0251-10,NDC,,,,inpatient,1,EA,11.85,7.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.07,percent of total billed charges,,,85,,10.07,percent of total billed charges,,,49,,5.81,percent of total billed charges,,,90,,10.67,percent of total billed charges,,,,,,,no IP contract,,80,,9.48,percent of total billed charges,,,,,,,no IP contract,,50,,5.93,percent of total billed charges,,,,,,no IP contract,,,78,,9.24,percent of total billed charges,,,70,,8.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.81,3324,
63739-0263-10 - clonazepam 0.5 mg Tab,63739-0263-10,NDC,,,,inpatient,1,EA,12.1,7.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.29,percent of total billed charges,,,85,,10.29,percent of total billed charges,,,49,,5.93,percent of total billed charges,,,90,,10.89,percent of total billed charges,,,,,,,no IP contract,,80,,9.68,percent of total billed charges,,,,,,,no IP contract,,50,,6.05,percent of total billed charges,,,,,,no IP contract,,,78,,9.44,percent of total billed charges,,,70,,8.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.93,3324,
63739-0264-10 - clonazepam 1 mg Tab,63739-0264-10,NDC,,,,inpatient,1,EA,13,7.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.05,percent of total billed charges,,,85,,11.05,percent of total billed charges,,,49,,6.37,percent of total billed charges,,,90,,11.7,percent of total billed charges,,,,,,,no IP contract,,80,,10.4,percent of total billed charges,,,,,,,no IP contract,,50,,6.5,percent of total billed charges,,,,,,no IP contract,,,78,,10.14,percent of total billed charges,,,70,,9.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.37,3324,
63739-0265-10 - lithium 300 mg Cap,63739-0265-10,NDC,,,,inpatient,1,EA,5.4,3.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.59,percent of total billed charges,,,85,,4.59,percent of total billed charges,,,49,,2.65,percent of total billed charges,,,90,,4.86,percent of total billed charges,,,,,,,no IP contract,,80,,4.32,percent of total billed charges,,,,,,,no IP contract,,50,,2.7,percent of total billed charges,,,,,,no IP contract,,,78,,4.21,percent of total billed charges,,,70,,3.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.65,3324,
63739-0269-10 - tamoxifen 10 mg Tab,63739-0269-10,NDC,,,,inpatient,1,EA,22.65,13.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.25,percent of total billed charges,,,85,,19.25,percent of total billed charges,,,49,,11.1,percent of total billed charges,,,90,,20.39,percent of total billed charges,,,,,,,no IP contract,,80,,18.12,percent of total billed charges,,,,,,,no IP contract,,50,,11.33,percent of total billed charges,,,,,,no IP contract,,,78,,17.67,percent of total billed charges,,,70,,15.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.1,3324,
63739-0272-01 - aspirin 81 mg EC Ta,63739-0272-01,NDC,,,,inpatient,1,EA,4.6,2.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.91,percent of total billed charges,,,85,,3.91,percent of total billed charges,,,49,,2.25,percent of total billed charges,,,90,,4.14,percent of total billed charges,,,,,,,no IP contract,,80,,3.68,percent of total billed charges,,,,,,,no IP contract,,50,,2.3,percent of total billed charges,,,,,,no IP contract,,,78,,3.59,percent of total billed charges,,,70,,3.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.25,3324,
63739-0272-03 - aspirin 81 mg EC Ta,63739-0272-03,NDC,,,,inpatient,1,EA,4.6,2.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.91,percent of total billed charges,,,85,,3.91,percent of total billed charges,,,49,,2.25,percent of total billed charges,,,90,,4.14,percent of total billed charges,,,,,,,no IP contract,,80,,3.68,percent of total billed charges,,,,,,,no IP contract,,50,,2.3,percent of total billed charges,,,,,,no IP contract,,,78,,3.59,percent of total billed charges,,,70,,3.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.25,3324,
hydrALAZINE 25 mg Tab,63739-0327-10,NDC,,,,inpatient,1,EA,4.95,2.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.21,percent of total billed charges,,,85,,4.21,percent of total billed charges,,,49,,2.43,percent of total billed charges,,,90,,4.46,percent of total billed charges,,,,,,,no IP contract,,80,,3.96,percent of total billed charges,,,,,,,no IP contract,,50,,2.48,percent of total billed charges,,,,,,no IP contract,,,78,,3.86,percent of total billed charges,,,70,,3.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.43,3324,
hydrALAZINE 50 mg Tab,63739-0328-10,NDC,,,,inpatient,1,EA,5.1,3.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.34,percent of total billed charges,,,85,,4.34,percent of total billed charges,,,49,,2.5,percent of total billed charges,,,90,,4.59,percent of total billed charges,,,,,,,no IP contract,,80,,4.08,percent of total billed charges,,,,,,,no IP contract,,50,,2.55,percent of total billed charges,,,,,,no IP contract,,,78,,3.98,percent of total billed charges,,,70,,3.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.5,3324,
63739-0354-10 - magnesium oxide 400 mg Tab,63739-0354-10,NDC,,,,inpatient,1,EA,5.25,3.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.46,percent of total billed charges,,,85,,4.46,percent of total billed charges,,,49,,2.57,percent of total billed charges,,,90,,4.73,percent of total billed charges,,,,,,,no IP contract,,80,,4.2,percent of total billed charges,,,,,,,no IP contract,,50,,2.63,percent of total billed charges,,,,,,no IP contract,,,78,,4.1,percent of total billed charges,,,70,,3.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.57,3324,
63739-0367-10 - isosorbide dinitrate 20 mg Tab,63739-0367-10,NDC,,,,inpatient,1,EA,11.4,6.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.69,percent of total billed charges,,,85,,9.69,percent of total billed charges,,,49,,5.59,percent of total billed charges,,,90,,10.26,percent of total billed charges,,,,,,,no IP contract,,80,,9.12,percent of total billed charges,,,,,,,no IP contract,,50,,5.7,percent of total billed charges,,,,,,no IP contract,,,78,,8.89,percent of total billed charges,,,70,,7.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.59,3324,
63739-0410-10 - allopurinol 100 mg Tab,63739-0410-10,NDC,,,,inpatient,1,EA,6.2,3.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.27,percent of total billed charges,,,85,,5.27,percent of total billed charges,,,49,,3.04,percent of total billed charges,,,90,,5.58,percent of total billed charges,,,,,,,no IP contract,,80,,4.96,percent of total billed charges,,,,,,,no IP contract,,50,,3.1,percent of total billed charges,,,,,,no IP contract,,,78,,4.84,percent of total billed charges,,,70,,4.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.04,3324,
63739-0432-02 - docusate-senna 50 mg-8.6 mg Tab,63739-0432-02,NDC,,,,inpatient,1,EA,4.4,2.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.74,percent of total billed charges,,,85,,3.74,percent of total billed charges,,,49,,2.16,percent of total billed charges,,,90,,3.96,percent of total billed charges,,,,,,,no IP contract,,80,,3.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.2,percent of total billed charges,,,,,,no IP contract,,,78,,3.43,percent of total billed charges,,,70,,3.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.16,3324,
63739-0432-10 - docusate-senna 50 mg-8.6 mg Tab,63739-0432-10,NDC,,,,inpatient,1,EA,5.25,3.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.46,percent of total billed charges,,,85,,4.46,percent of total billed charges,,,49,,2.57,percent of total billed charges,,,90,,4.73,percent of total billed charges,,,,,,,no IP contract,,80,,4.2,percent of total billed charges,,,,,,,no IP contract,,50,,2.63,percent of total billed charges,,,,,,no IP contract,,,78,,4.1,percent of total billed charges,,,70,,3.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.57,3324,
63739-0434-01 - aspirin 81 mg Chew,63739-0434-01,NDC,,,,inpatient,1,EA,4.6,2.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.91,percent of total billed charges,,,85,,3.91,percent of total billed charges,,,49,,2.25,percent of total billed charges,,,90,,4.14,percent of total billed charges,,,,,,,no IP contract,,80,,3.68,percent of total billed charges,,,,,,,no IP contract,,50,,2.3,percent of total billed charges,,,,,,no IP contract,,,78,,3.59,percent of total billed charges,,,70,,3.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.25,3324,
63739-0434-02 - aspirin 81 mg Chew,63739-0434-02,NDC,,,,inpatient,1,EA,4.3,2.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.66,percent of total billed charges,,,85,,3.66,percent of total billed charges,,,49,,2.11,percent of total billed charges,,,90,,3.87,percent of total billed charges,,,,,,,no IP contract,,80,,3.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.15,percent of total billed charges,,,,,,no IP contract,,,78,,3.35,percent of total billed charges,,,70,,3.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.11,3324,
63739-0442-10 - ibuprofen 400 mg Tab,63739-0442-10,NDC,,,,inpatient,1,EA,5.5,3.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.68,percent of total billed charges,,,85,,4.68,percent of total billed charges,,,49,,2.7,percent of total billed charges,,,90,,4.95,percent of total billed charges,,,,,,,no IP contract,,80,,4.4,percent of total billed charges,,,,,,,no IP contract,,50,,2.75,percent of total billed charges,,,,,,no IP contract,,,78,,4.29,percent of total billed charges,,,70,,3.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.7,3324,
63739-0443-10 - ibuprofen 600 mg Tab,63739-0443-10,NDC,,,,inpatient,1,EA,6.2,3.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.27,percent of total billed charges,,,85,,5.27,percent of total billed charges,,,49,,3.04,percent of total billed charges,,,90,,5.58,percent of total billed charges,,,,,,,no IP contract,,80,,4.96,percent of total billed charges,,,,,,,no IP contract,,50,,3.1,percent of total billed charges,,,,,,no IP contract,,,78,,4.84,percent of total billed charges,,,70,,4.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.04,3324,
63739-0478-01 - docusate sodium 100 mg Cap,63739-0478-01,NDC,,,,inpatient,1,EA,4.15,2.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.53,percent of total billed charges,,,85,,3.53,percent of total billed charges,,,49,,2.03,percent of total billed charges,,,90,,3.74,percent of total billed charges,,,,,,,no IP contract,,80,,3.32,percent of total billed charges,,,,,,,no IP contract,,50,,2.08,percent of total billed charges,,,,,,no IP contract,,,78,,3.24,percent of total billed charges,,,70,,2.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.03,3324,
63739-0478-10 - docusate sodium 100 mg Cap,63739-0478-10,NDC,,,,inpatient,1,EA,4.15,2.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.53,percent of total billed charges,,,85,,3.53,percent of total billed charges,,,49,,2.03,percent of total billed charges,,,90,,3.74,percent of total billed charges,,,,,,,no IP contract,,80,,3.32,percent of total billed charges,,,,,,,no IP contract,,50,,2.08,percent of total billed charges,,,,,,no IP contract,,,78,,3.24,percent of total billed charges,,,70,,2.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.03,3324,
63739-0479-10 - baclofen 10 mg Tab,63739-0479-10,NDC,,,,inpatient,1,EA,9.95,5.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.46,percent of total billed charges,,,85,,8.46,percent of total billed charges,,,49,,4.88,percent of total billed charges,,,90,,8.96,percent of total billed charges,,,,,,,no IP contract,,80,,7.96,percent of total billed charges,,,,,,,no IP contract,,50,,4.98,percent of total billed charges,,,,,,no IP contract,,,78,,7.76,percent of total billed charges,,,70,,6.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.88,3324,
63739-0480-10 - baclofen 20 mg Tab,63739-0480-10,NDC,,,,inpatient,1,EA,13.85,8.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.77,percent of total billed charges,,,85,,11.77,percent of total billed charges,,,49,,6.79,percent of total billed charges,,,90,,12.47,percent of total billed charges,,,,,,,no IP contract,,80,,11.08,percent of total billed charges,,,,,,,no IP contract,,50,,6.93,percent of total billed charges,,,,,,no IP contract,,,78,,10.8,percent of total billed charges,,,70,,9.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.79,3324,
63739-0482-10 - metoclopramide 10 mg Tab,63739-0482-10,NDC,,,,inpatient,1,EA,6.15,3.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.23,percent of total billed charges,,,85,,5.23,percent of total billed charges,,,49,,3.01,percent of total billed charges,,,90,,5.54,percent of total billed charges,,,,,,,no IP contract,,80,,4.92,percent of total billed charges,,,,,,,no IP contract,,50,,3.08,percent of total billed charges,,,,,,no IP contract,,,78,,4.8,percent of total billed charges,,,70,,4.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.01,3324,
63739-0486-10 - hydrOXYzine hydrochloride 25 mg Tab,63739-0486-10,NDC,,,,inpatient,1,EA,6.35,3.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.4,percent of total billed charges,,,85,,5.4,percent of total billed charges,,,49,,3.11,percent of total billed charges,,,90,,5.72,percent of total billed charges,,,,,,,no IP contract,,80,,5.08,percent of total billed charges,,,,,,,no IP contract,,50,,3.18,percent of total billed charges,,,,,,no IP contract,,,78,,4.95,percent of total billed charges,,,70,,4.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.11,3324,
63739-0499-10 - lorazepam 0.5 mg Tab,63739-0499-10,NDC,,,,inpatient,1,EA,6.15,3.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.23,percent of total billed charges,,,85,,5.23,percent of total billed charges,,,49,,3.01,percent of total billed charges,,,90,,5.54,percent of total billed charges,,,,,,,no IP contract,,80,,4.92,percent of total billed charges,,,,,,,no IP contract,,50,,3.08,percent of total billed charges,,,,,,no IP contract,,,78,,4.8,percent of total billed charges,,,70,,4.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.01,3324,
63739-0516-10 - lamoTRIgine 100 mg Tab,63739-0516-10,NDC,,,,inpatient,1,EA,23.55,14.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.02,percent of total billed charges,,,85,,20.02,percent of total billed charges,,,49,,11.54,percent of total billed charges,,,90,,21.2,percent of total billed charges,,,,,,,no IP contract,,80,,18.84,percent of total billed charges,,,,,,,no IP contract,,50,,11.78,percent of total billed charges,,,,,,no IP contract,,,78,,18.37,percent of total billed charges,,,70,,16.49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.54,3324,
63739-0519-10 - predniSONE 10 mg Tab,63739-0519-10,NDC,,,,inpatient,1,EA,4.85,2.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.12,percent of total billed charges,,,85,,4.12,percent of total billed charges,,,49,,2.38,percent of total billed charges,,,90,,4.37,percent of total billed charges,,,,,,,no IP contract,,80,,3.88,percent of total billed charges,,,,,,,no IP contract,,50,,2.43,percent of total billed charges,,,,,,no IP contract,,,78,,3.78,percent of total billed charges,,,70,,3.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.38,3324,
63739-0522-10 - aspirin 81 mg EC Ta,63739-0522-10,NDC,,,,inpatient,1,EA,4.2,2.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.57,percent of total billed charges,,,85,,3.57,percent of total billed charges,,,49,,2.06,percent of total billed charges,,,90,,3.78,percent of total billed charges,,,,,,,no IP contract,,80,,3.36,percent of total billed charges,,,,,,,no IP contract,,50,,2.1,percent of total billed charges,,,,,,no IP contract,,,78,,3.28,percent of total billed charges,,,70,,2.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.06,3324,
63739-0523-01 - aspirin 325 mg EC Ta,63739-0523-01,NDC,,,,inpatient,1,EA,4.3,2.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.66,percent of total billed charges,,,85,,3.66,percent of total billed charges,,,49,,2.11,percent of total billed charges,,,90,,3.87,percent of total billed charges,,,,,,,no IP contract,,80,,3.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.15,percent of total billed charges,,,,,,no IP contract,,,78,,3.35,percent of total billed charges,,,70,,3.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.11,3324,
63739-0531-10 - cyclobenzaprine 10 mg Tab,63739-0531-10,NDC,,,,inpatient,1,EA,4.55,2.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.87,percent of total billed charges,,,85,,3.87,percent of total billed charges,,,49,,2.23,percent of total billed charges,,,90,,4.1,percent of total billed charges,,,,,,,no IP contract,,80,,3.64,percent of total billed charges,,,,,,,no IP contract,,50,,2.28,percent of total billed charges,,,,,,no IP contract,,,78,,3.55,percent of total billed charges,,,70,,3.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.23,3324,
63739-0544-10 - spironolactone 25 mg Tab,63739-0544-10,NDC,,,,inpatient,1,EA,7.25,4.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.16,percent of total billed charges,,,85,,6.16,percent of total billed charges,,,49,,3.55,percent of total billed charges,,,90,,6.53,percent of total billed charges,,,,,,,no IP contract,,80,,5.8,percent of total billed charges,,,,,,,no IP contract,,50,,3.63,percent of total billed charges,,,,,,no IP contract,,,78,,5.66,percent of total billed charges,,,70,,5.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.55,3324,
63739-0545-10 - spironolactone 50 mg Tab,63739-0545-10,NDC,,,,inpatient,1,EA,10.75,6.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.14,percent of total billed charges,,,85,,9.14,percent of total billed charges,,,49,,5.27,percent of total billed charges,,,90,,9.68,percent of total billed charges,,,,,,,no IP contract,,80,,8.6,percent of total billed charges,,,,,,,no IP contract,,50,,5.38,percent of total billed charges,,,,,,no IP contract,,,78,,8.39,percent of total billed charges,,,70,,7.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.27,3324,
63739-0560-10 - gabapentin 600 mg Tab,63739-0560-10,NDC,,,,inpatient,1,EA,10.1,6.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.59,percent of total billed charges,,,85,,8.59,percent of total billed charges,,,49,,4.95,percent of total billed charges,,,90,,9.09,percent of total billed charges,,,,,,,no IP contract,,80,,8.08,percent of total billed charges,,,,,,,no IP contract,,50,,5.05,percent of total billed charges,,,,,,no IP contract,,,78,,7.88,percent of total billed charges,,,70,,7.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.95,3324,
63739-0567-10 - tamsulosin 0.4 mg Cap,63739-0567-10,NDC,,,,inpatient,1,EA,7.55,4.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.42,percent of total billed charges,,,85,,6.42,percent of total billed charges,,,49,,3.7,percent of total billed charges,,,90,,6.8,percent of total billed charges,,,,,,,no IP contract,,80,,6.04,percent of total billed charges,,,,,,,no IP contract,,50,,3.78,percent of total billed charges,,,,,,no IP contract,,,78,,5.89,percent of total billed charges,,,70,,5.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.7,3324,
simvastatin 40 mg Tab,63739-0573-10,NDC,,,,inpatient,1,EA,5.5,3.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.68,percent of total billed charges,,,85,,4.68,percent of total billed charges,,,49,,2.7,percent of total billed charges,,,90,,4.95,percent of total billed charges,,,,,,,no IP contract,,80,,4.4,percent of total billed charges,,,,,,,no IP contract,,50,,2.75,percent of total billed charges,,,,,,no IP contract,,,78,,4.29,percent of total billed charges,,,70,,3.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.7,3324,
63739-0588-10 - predniSONE 20 mg Tab,63739-0588-10,NDC,,,,inpatient,1,EA,8.3,4.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.06,percent of total billed charges,,,85,,7.06,percent of total billed charges,,,49,,4.07,percent of total billed charges,,,90,,7.47,percent of total billed charges,,,,,,,no IP contract,,80,,6.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.15,percent of total billed charges,,,,,,no IP contract,,,78,,6.47,percent of total billed charges,,,70,,5.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.07,3324,
63739-0645-10 - famotidine 20 mg Tab,63739-0645-10,NDC,,,,inpatient,1,EA,4.6,2.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.91,percent of total billed charges,,,85,,3.91,percent of total billed charges,,,49,,2.25,percent of total billed charges,,,90,,4.14,percent of total billed charges,,,,,,,no IP contract,,80,,3.68,percent of total billed charges,,,,,,,no IP contract,,50,,2.3,percent of total billed charges,,,,,,no IP contract,,,78,,3.59,percent of total billed charges,,,70,,3.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.25,3324,
63739-0672-10 - ibuprofen 400 mg Tab,63739-0672-10,NDC,,,,inpatient,1,EA,4.4,2.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.74,percent of total billed charges,,,85,,3.74,percent of total billed charges,,,49,,2.16,percent of total billed charges,,,90,,3.96,percent of total billed charges,,,,,,,no IP contract,,80,,3.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.2,percent of total billed charges,,,,,,no IP contract,,,78,,3.43,percent of total billed charges,,,70,,3.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.16,3324,
losartan 25 mg Tab,63739-0673-10,NDC,,,,inpatient,1,EA,8.6,5.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.31,percent of total billed charges,,,85,,7.31,percent of total billed charges,,,49,,4.21,percent of total billed charges,,,90,,7.74,percent of total billed charges,,,,,,,no IP contract,,80,,6.88,percent of total billed charges,,,,,,,no IP contract,,50,,4.3,percent of total billed charges,,,,,,no IP contract,,,78,,6.71,percent of total billed charges,,,70,,6.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.21,3324,
63739-0684-10 - ibuprofen 600 mg Tab,63739-0684-10,NDC,,,,inpatient,1,EA,4.45,2.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.78,percent of total billed charges,,,85,,3.78,percent of total billed charges,,,49,,2.18,percent of total billed charges,,,90,,4.01,percent of total billed charges,,,,,,,no IP contract,,80,,3.56,percent of total billed charges,,,,,,,no IP contract,,50,,2.23,percent of total billed charges,,,,,,no IP contract,,,78,,3.47,percent of total billed charges,,,70,,3.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.18,3324,
63739-0701-10 - meloxicam 7.5 mg Tab,63739-0701-10,NDC,,,,inpatient,1,EA,5.2,3.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.42,percent of total billed charges,,,85,,4.42,percent of total billed charges,,,49,,2.55,percent of total billed charges,,,90,,4.68,percent of total billed charges,,,,,,,no IP contract,,80,,4.16,percent of total billed charges,,,,,,,no IP contract,,50,,2.6,percent of total billed charges,,,,,,no IP contract,,,78,,4.06,percent of total billed charges,,,70,,3.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.55,3324,
63739-0795-10 - levETIRAcetam 250 mg Tab,63739-0795-10,NDC,,,,inpatient,1,EA,5.65,3.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.8,percent of total billed charges,,,85,,4.8,percent of total billed charges,,,49,,2.77,percent of total billed charges,,,90,,5.09,percent of total billed charges,,,,,,,no IP contract,,80,,4.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.83,percent of total billed charges,,,,,,no IP contract,,,78,,4.41,percent of total billed charges,,,70,,3.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.77,3324,
63739-0797-33 - niMODipine 30 mg Cap,63739-0797-33,NDC,,,,inpatient,1,EA,31.25,18.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,25.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.56,percent of total billed charges,,,85,,26.56,percent of total billed charges,,,49,,15.31,percent of total billed charges,,,90,,28.13,percent of total billed charges,,,,,,,no IP contract,,80,,25,percent of total billed charges,,,,,,,no IP contract,,50,,15.63,percent of total billed charges,,,,,,no IP contract,,,78,,24.38,percent of total billed charges,,,70,,21.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.31,3324,
gabapentin 100 mg Cap,63739-0902-10,NDC,,,,inpatient,1,EA,4.7,2.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4,percent of total billed charges,,,85,,4,percent of total billed charges,,,49,,2.3,percent of total billed charges,,,90,,4.23,percent of total billed charges,,,,,,,no IP contract,,80,,3.76,percent of total billed charges,,,,,,,no IP contract,,50,,2.35,percent of total billed charges,,,,,,no IP contract,,,78,,3.67,percent of total billed charges,,,70,,3.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.3,3324,
gabapentin 300 mg Cap,63739-0903-10,NDC,,,,inpatient,1,EA,5.4,3.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.59,percent of total billed charges,,,85,,4.59,percent of total billed charges,,,49,,2.65,percent of total billed charges,,,90,,4.86,percent of total billed charges,,,,,,,no IP contract,,80,,4.32,percent of total billed charges,,,,,,,no IP contract,,50,,2.7,percent of total billed charges,,,,,,no IP contract,,,78,,4.21,percent of total billed charges,,,70,,3.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.65,3324,
63739-0931-28 - heparin 1000 units/mL Soln,63739-0931-28,NDC,,,,inpatient,10,ML,47.25,28.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,38.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,40.16,percent of total billed charges,,,85,,40.16,percent of total billed charges,,,49,,23.15,percent of total billed charges,,,90,,42.53,percent of total billed charges,,,,,,,no IP contract,,80,,37.8,percent of total billed charges,,,,,,,no IP contract,,50,,23.63,percent of total billed charges,,,,,,no IP contract,,,78,,36.86,percent of total billed charges,,,70,,33.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.15,3324,
63739-0984-10 - gabapentin 400 mg Cap,63739-0984-10,NDC,,,,inpatient,1,EA,5.55,3.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.72,percent of total billed charges,,,85,,4.72,percent of total billed charges,,,49,,2.72,percent of total billed charges,,,90,,5,percent of total billed charges,,,,,,,no IP contract,,80,,4.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.78,percent of total billed charges,,,,,,no IP contract,,,78,,4.33,percent of total billed charges,,,70,,3.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.72,3324,
ziprasidone 20 mg Cap,63739-0988-32,NDC,,,,inpatient,1,EA,30.4,18.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.84,percent of total billed charges,,,85,,25.84,percent of total billed charges,,,49,,14.9,percent of total billed charges,,,90,,27.36,percent of total billed charges,,,,,,,no IP contract,,80,,24.32,percent of total billed charges,,,,,,,no IP contract,,50,,15.2,percent of total billed charges,,,,,,no IP contract,,,78,,23.71,percent of total billed charges,,,70,,21.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.9,3324,
divalproex sodium 125 mg DRC,63739-0995-10,NDC,,,,inpatient,1,EA,11,6.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.35,percent of total billed charges,,,85,,9.35,percent of total billed charges,,,49,,5.39,percent of total billed charges,,,90,,9.9,percent of total billed charges,,,,,,,no IP contract,,80,,8.8,percent of total billed charges,,,,,,,no IP contract,,50,,5.5,percent of total billed charges,,,,,,no IP contract,,,78,,8.58,percent of total billed charges,,,70,,7.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.39,3324,
63807-0500-55 - heparin flush 10 units/mL Soln,63807-0500-55,NDC,,,,inpatient,5,ML,32.5,19.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,26.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,27.63,percent of total billed charges,,,85,,27.63,percent of total billed charges,,,49,,15.93,percent of total billed charges,,,90,,29.25,percent of total billed charges,,,,,,,no IP contract,,80,,26,percent of total billed charges,,,,,,,no IP contract,,50,,16.25,percent of total billed charges,,,,,,no IP contract,,,78,,25.35,percent of total billed charges,,,70,,22.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.93,3324,
63824-0008-13 - guafenesin 600 mg ER Tablet,63824-0008-13,NDC,,,,inpatient,1,EA,7.4,4.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.29,percent of total billed charges,,,85,,6.29,percent of total billed charges,,,49,,3.63,percent of total billed charges,,,90,,6.66,percent of total billed charges,,,,,,,no IP contract,,80,,5.92,percent of total billed charges,,,,,,,no IP contract,,50,,3.7,percent of total billed charges,,,,,,no IP contract,,,78,,5.77,percent of total billed charges,,,70,,5.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.63,3324,
63824-0008-15 - guaiFENesin 600 mg ER Ta,63824-0008-15,NDC,,,,inpatient,1,EA,7.5,4.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.38,percent of total billed charges,,,85,,6.38,percent of total billed charges,,,49,,3.68,percent of total billed charges,,,90,,6.75,percent of total billed charges,,,,,,,no IP contract,,80,,6,percent of total billed charges,,,,,,,no IP contract,,50,,3.75,percent of total billed charges,,,,,,no IP contract,,,78,,5.85,percent of total billed charges,,,70,,5.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.68,3324,
63824-0008-61 - guaiFENesin 600 mg ER Ta,63824-0008-61,NDC,,,,inpatient,1,EA,7.5,4.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.38,percent of total billed charges,,,85,,6.38,percent of total billed charges,,,49,,3.68,percent of total billed charges,,,90,,6.75,percent of total billed charges,,,,,,,no IP contract,,80,,6,percent of total billed charges,,,,,,,no IP contract,,50,,3.75,percent of total billed charges,,,,,,no IP contract,,,78,,5.85,percent of total billed charges,,,70,,5.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.68,3324,
63824-0056-01 - dextromethorphan-guaifenesin 30 mg-600 mg ER Ta,63824-0056-01,NDC,,,,inpatient,1,EA,8.9,5.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.57,percent of total billed charges,,,85,,7.57,percent of total billed charges,,,49,,4.36,percent of total billed charges,,,90,,8.01,percent of total billed charges,,,,,,,no IP contract,,80,,7.12,percent of total billed charges,,,,,,,no IP contract,,50,,4.45,percent of total billed charges,,,,,,no IP contract,,,78,,6.94,percent of total billed charges,,,70,,6.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.36,3324,
63824-0056-32 - dextromethorphan-guaifenesin 30 mg-600 mg ER Ta,63824-0056-32,NDC,,,,inpatient,1,EA,8.05,4.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.84,percent of total billed charges,,,85,,6.84,percent of total billed charges,,,49,,3.94,percent of total billed charges,,,90,,7.25,percent of total billed charges,,,,,,,no IP contract,,80,,6.44,percent of total billed charges,,,,,,,no IP contract,,50,,4.03,percent of total billed charges,,,,,,no IP contract,,,78,,6.28,percent of total billed charges,,,70,,5.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.94,3324,
64019-0553-67 - methadone 10 mg/mL Conc,64019-0553-67,NDC,,,,inpatient,1,ML,6.1,3.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.19,percent of total billed charges,,,85,,5.19,percent of total billed charges,,,49,,2.99,percent of total billed charges,,,90,,5.49,percent of total billed charges,,,,,,,no IP contract,,80,,4.88,percent of total billed charges,,,,,,,no IP contract,,50,,3.05,percent of total billed charges,,,,,,no IP contract,,,78,,4.76,percent of total billed charges,,,70,,4.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.99,3324,
64253-0222-35 - heparin flush 10 units/mL Soln,64253-0222-35,NDC,,,,inpatient,5,ML,39.65,23.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.7,percent of total billed charges,,,85,,33.7,percent of total billed charges,,,49,,19.43,percent of total billed charges,,,90,,35.69,percent of total billed charges,,,,,,,no IP contract,,80,,31.72,percent of total billed charges,,,,,,,no IP contract,,50,,19.83,percent of total billed charges,,,,,,no IP contract,,,78,,30.93,percent of total billed charges,,,70,,27.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.43,3324,
64253-0333-35 - heparin flush 100 units/mL Soln,64253-0333-35,NDC,,,,inpatient,5,ML,40.5,24.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34.43,percent of total billed charges,,,85,,34.43,percent of total billed charges,,,49,,19.85,percent of total billed charges,,,90,,36.45,percent of total billed charges,,,,,,,no IP contract,,80,,32.4,percent of total billed charges,,,,,,,no IP contract,,50,,20.25,percent of total billed charges,,,,,,no IP contract,,,78,,31.59,percent of total billed charges,,,70,,28.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.85,3324,
64380-0151-02 - testosterone 1% Gel,64380-0151-02,NDC,,,,inpatient,1,UN,102.55,61.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,83.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,87.17,percent of total billed charges,,,85,,87.17,percent of total billed charges,,,49,,50.25,percent of total billed charges,,,90,,92.3,percent of total billed charges,,,,,,,no IP contract,,80,,82.04,percent of total billed charges,,,,,,,no IP contract,,50,,51.28,percent of total billed charges,,,,,,no IP contract,,,78,,79.99,percent of total billed charges,,,70,,71.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,50.25,3324,
testosterone 50 mg/5 g (1%) Gel,64380-0152-02,NDC,,,,inpatient,1,EA,130.35,78.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,105.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,110.8,percent of total billed charges,,,85,,110.8,percent of total billed charges,,,49,,63.87,percent of total billed charges,,,90,,117.32,percent of total billed charges,,,,,,,no IP contract,,80,,104.28,percent of total billed charges,,,,,,,no IP contract,,50,,65.18,percent of total billed charges,,,,,,no IP contract,,,78,,101.67,percent of total billed charges,,,70,,91.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,63.87,3324,
64380-0172-02 - OLANZapine 5 mg DIS T,64380-0172-02,NDC,,,,inpatient,1,EA,117.25,70.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,94.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,99.66,percent of total billed charges,,,85,,99.66,percent of total billed charges,,,49,,57.45,percent of total billed charges,,,90,,105.53,percent of total billed charges,,,,,,,no IP contract,,80,,93.8,percent of total billed charges,,,,,,,no IP contract,,50,,58.63,percent of total billed charges,,,,,,no IP contract,,,78,,91.46,percent of total billed charges,,,70,,82.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,57.45,3324,
lamiVUDine 150 mg Tab,64380-0710-03,NDC,,,,inpatient,1,EA,60.65,36.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,49.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,51.55,percent of total billed charges,,,85,,51.55,percent of total billed charges,,,49,,29.72,percent of total billed charges,,,90,,54.59,percent of total billed charges,,,,,,,no IP contract,,80,,48.52,percent of total billed charges,,,,,,,no IP contract,,50,,30.33,percent of total billed charges,,,,,,no IP contract,,,78,,47.31,percent of total billed charges,,,70,,42.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,29.72,3324,
tacrolimus 5 mg Cap,64380-0722-06,NDC,,,,inpatient,1,EA,181.1,108.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,146.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,153.94,percent of total billed charges,,,85,,153.94,percent of total billed charges,,,49,,88.74,percent of total billed charges,,,90,,162.99,percent of total billed charges,,,,,,,no IP contract,,80,,144.88,percent of total billed charges,,,,,,,no IP contract,,50,,90.55,percent of total billed charges,,,,,,no IP contract,,,78,,141.26,percent of total billed charges,,,70,,126.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,88.74,3324,
64380-0723-06 - calcitriol 0.25 mcg Cap,64380-0723-06,NDC,,,,inpatient,1,EA,13.45,8.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.43,percent of total billed charges,,,85,,11.43,percent of total billed charges,,,49,,6.59,percent of total billed charges,,,90,,12.11,percent of total billed charges,,,,,,,no IP contract,,80,,10.76,percent of total billed charges,,,,,,,no IP contract,,50,,6.73,percent of total billed charges,,,,,,no IP contract,,,78,,10.49,percent of total billed charges,,,70,,9.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.59,3324,
64380-0724-06 - calcitriol 0.5 mcg Cap,64380-0724-06,NDC,,,,inpatient,1,EA,19.15,11.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.28,percent of total billed charges,,,85,,16.28,percent of total billed charges,,,49,,9.38,percent of total billed charges,,,90,,17.24,percent of total billed charges,,,,,,,no IP contract,,80,,15.32,percent of total billed charges,,,,,,,no IP contract,,50,,9.58,percent of total billed charges,,,,,,no IP contract,,,78,,14.94,percent of total billed charges,,,70,,13.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.38,3324,
64380-0725-06 - mycophenolate mofetil 500 mg Tab,64380-0725-06,NDC,,,,inpatient,1,EA,66.85,40.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,54.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.82,percent of total billed charges,,,85,,56.82,percent of total billed charges,,,49,,32.76,percent of total billed charges,,,90,,60.17,percent of total billed charges,,,,,,,no IP contract,,80,,53.48,percent of total billed charges,,,,,,,no IP contract,,50,,33.43,percent of total billed charges,,,,,,no IP contract,,,78,,52.14,percent of total billed charges,,,70,,46.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.76,3324,
64380-0742-06 - busPIRone 10 mg Tab,64380-0742-06,NDC,,,,inpatient,1,EA,14.5,8.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.33,percent of total billed charges,,,85,,12.33,percent of total billed charges,,,49,,7.11,percent of total billed charges,,,90,,13.05,percent of total billed charges,,,,,,,no IP contract,,80,,11.6,percent of total billed charges,,,,,,,no IP contract,,50,,7.25,percent of total billed charges,,,,,,no IP contract,,,78,,11.31,percent of total billed charges,,,70,,10.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.11,3324,
oseltamivir 30 mg Cap,64380-0797-01,NDC,,,,inpatient,1,EA,116.55,69.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,94.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,99.07,percent of total billed charges,,,85,,99.07,percent of total billed charges,,,49,,57.11,percent of total billed charges,,,90,,104.9,percent of total billed charges,,,,,,,no IP contract,,80,,93.24,percent of total billed charges,,,,,,,no IP contract,,50,,58.28,percent of total billed charges,,,,,,no IP contract,,,78,,90.91,percent of total billed charges,,,70,,81.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,57.11,3324,
64380-0799-01 - oseltamivir 75 mg Cap,64380-0799-01,NDC,,,,inpatient,1,EA,126.75,76.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,102.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,107.74,percent of total billed charges,,,85,,107.74,percent of total billed charges,,,49,,62.11,percent of total billed charges,,,90,,114.08,percent of total billed charges,,,,,,,no IP contract,,80,,101.4,percent of total billed charges,,,,,,,no IP contract,,50,,63.38,percent of total billed charges,,,,,,no IP contract,,,78,,98.87,percent of total billed charges,,,70,,88.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,62.11,3324,
64380-0808-06 - ibuprofen 600 mg Tab,64380-0808-06,NDC,,,,inpatient,1,EA,8.45,5.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.18,percent of total billed charges,,,85,,7.18,percent of total billed charges,,,49,,4.14,percent of total billed charges,,,90,,7.61,percent of total billed charges,,,,,,,no IP contract,,80,,6.76,percent of total billed charges,,,,,,,no IP contract,,50,,4.23,percent of total billed charges,,,,,,no IP contract,,,78,,6.59,percent of total billed charges,,,70,,5.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.14,3324,
64380-0844-06 - ursodiol 300 mg Cap,64380-0844-06,NDC,,,,inpatient,1,EA,62.25,37.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,50.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,52.91,percent of total billed charges,,,85,,52.91,percent of total billed charges,,,49,,30.5,percent of total billed charges,,,90,,56.03,percent of total billed charges,,,,,,,no IP contract,,80,,49.8,percent of total billed charges,,,,,,,no IP contract,,50,,31.13,percent of total billed charges,,,,,,no IP contract,,,78,,48.56,percent of total billed charges,,,70,,43.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,30.5,3324,
64380-0878-06 - ethosuximide 250 mg Cap,64380-0878-06,NDC,,,,inpatient,1,EA,25.95,15.57,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.06,percent of total billed charges,,,85,,22.06,percent of total billed charges,,,49,,12.72,percent of total billed charges,,,90,,23.36,percent of total billed charges,,,,,,,no IP contract,,80,,20.76,percent of total billed charges,,,,,,,no IP contract,,50,,12.98,percent of total billed charges,,,,,,no IP contract,,,78,,20.24,percent of total billed charges,,,70,,18.17,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.72,3324,
sevelamer carbonate 0.8 g REC P,64380-0880-80,NDC,,,,inpatient,1,EA,149.25,89.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,120.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,126.86,percent of total billed charges,,,85,,126.86,percent of total billed charges,,,49,,73.13,percent of total billed charges,,,90,,134.33,percent of total billed charges,,,,,,,no IP contract,,80,,119.4,percent of total billed charges,,,,,,,no IP contract,,50,,74.63,percent of total billed charges,,,,,,no IP contract,,,78,,116.42,percent of total billed charges,,,70,,104.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,73.13,3324,
sevelamer carbonate 2.4 g REC P,64380-0881-80,NDC,,,,inpatient,1,EA,149.25,89.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,120.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,126.86,percent of total billed charges,,,85,,126.86,percent of total billed charges,,,49,,73.13,percent of total billed charges,,,90,,134.33,percent of total billed charges,,,,,,,no IP contract,,80,,119.4,percent of total billed charges,,,,,,,no IP contract,,50,,74.63,percent of total billed charges,,,,,,no IP contract,,,78,,116.42,percent of total billed charges,,,70,,104.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,73.13,3324,
cinacalcet 30 mg Tab,64380-0883-04,NDC,,,,inpatient,1,EA,247.5,148.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,200.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,210.38,percent of total billed charges,,,85,,210.38,percent of total billed charges,,,49,,121.28,percent of total billed charges,,,90,,222.75,percent of total billed charges,,,,,,,no IP contract,,80,,198,percent of total billed charges,,,,,,,no IP contract,,50,,123.75,percent of total billed charges,,,,,,no IP contract,,,78,,193.05,percent of total billed charges,,,70,,173.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,121.28,3324,
64380-0970-23 - hydroCORTisone 5 mg Tab,64380-0970-23,NDC,,,,inpatient,1,EA,11.95,7.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.16,percent of total billed charges,,,85,,10.16,percent of total billed charges,,,49,,5.86,percent of total billed charges,,,90,,10.76,percent of total billed charges,,,,,,,no IP contract,,80,,9.56,percent of total billed charges,,,,,,,no IP contract,,50,,5.98,percent of total billed charges,,,,,,no IP contract,,,78,,9.32,percent of total billed charges,,,70,,8.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.86,3324,
64380-0971-06 - hydroCORTisone 10 mg Tab,64380-0971-06,NDC,,,,inpatient,1,EA,16.05,9.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.64,percent of total billed charges,,,85,,13.64,percent of total billed charges,,,49,,7.86,percent of total billed charges,,,90,,14.45,percent of total billed charges,,,,,,,no IP contract,,80,,12.84,percent of total billed charges,,,,,,,no IP contract,,50,,8.03,percent of total billed charges,,,,,,no IP contract,,,78,,12.52,percent of total billed charges,,,70,,11.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.86,3324,
64455-0064-01 - lorazepam 1 mg Tab,64455-0064-01,NDC,,,,inpatient,1,EA,18,10.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.3,percent of total billed charges,,,85,,15.3,percent of total billed charges,,,49,,8.82,percent of total billed charges,,,90,,16.2,percent of total billed charges,,,,,,,no IP contract,,80,,14.4,percent of total billed charges,,,,,,,no IP contract,,50,,9,percent of total billed charges,,,,,,no IP contract,,,78,,14.04,percent of total billed charges,,,70,,12.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.82,3324,
64455-0798-49 - diltiazem 300 mg/24 hours ER Cap,64455-0798-49,NDC,,,,inpatient,1,EA,32.35,19.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,26.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,27.5,percent of total billed charges,,,85,,27.5,percent of total billed charges,,,49,,15.85,percent of total billed charges,,,90,,29.12,percent of total billed charges,,,,,,,no IP contract,,80,,25.88,percent of total billed charges,,,,,,,no IP contract,,50,,16.18,percent of total billed charges,,,,,,no IP contract,,,78,,25.23,percent of total billed charges,,,70,,22.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.85,3324,
64597-0301-60 - Dextromethorphan / Quinidine 20mg / 10mg Cap,64597-0301-60,NDC,,,,inpatient,1,EA,108.6,65.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,87.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,92.31,percent of total billed charges,,,85,,92.31,percent of total billed charges,,,49,,53.21,percent of total billed charges,,,90,,97.74,percent of total billed charges,,,,,,,no IP contract,,80,,86.88,percent of total billed charges,,,,,,,no IP contract,,50,,54.3,percent of total billed charges,,,,,,no IP contract,,,78,,84.71,percent of total billed charges,,,70,,76.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,53.21,3324,
64679-0056-01 - piperacillin-tazobactam 3 g-0.375 g REC I,64679-0056-01,NDC,,,,inpatient,1,EA,192.75,115.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,156.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,163.84,percent of total billed charges,,,85,,163.84,percent of total billed charges,,,49,,94.45,percent of total billed charges,,,90,,173.48,percent of total billed charges,,,,,,,no IP contract,,80,,154.2,percent of total billed charges,,,,,,,no IP contract,,50,,96.38,percent of total billed charges,,,,,,no IP contract,,,78,,150.35,percent of total billed charges,,,70,,134.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,94.45,3324,
64679-0758-06 - ketorolac 30 mg/mL Soln,64679-0758-06,NDC,,,,inpatient,1,ML,17.75,10.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.09,percent of total billed charges,,,85,,15.09,percent of total billed charges,,,49,,8.7,percent of total billed charges,,,90,,15.98,percent of total billed charges,,,,,,,no IP contract,,80,,14.2,percent of total billed charges,,,,,,,no IP contract,,50,,8.88,percent of total billed charges,,,,,,no IP contract,,,78,,13.85,percent of total billed charges,,,70,,12.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.7,3324,
64679-0923-02 - enalapril 2.5 mg Tab,64679-0923-02,NDC,,,,inpatient,1,EA,10.2,6.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.67,percent of total billed charges,,,85,,8.67,percent of total billed charges,,,49,,5,percent of total billed charges,,,90,,9.18,percent of total billed charges,,,,,,,no IP contract,,80,,8.16,percent of total billed charges,,,,,,,no IP contract,,50,,5.1,percent of total billed charges,,,,,,no IP contract,,,78,,7.96,percent of total billed charges,,,70,,7.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5,3324,
64720-0130-10 - amphetamine-dextroamphetamine 5 mg Tab,64720-0130-10,NDC,,,,inpatient,1,EA,16.85,10.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.32,percent of total billed charges,,,85,,14.32,percent of total billed charges,,,49,,8.26,percent of total billed charges,,,90,,15.17,percent of total billed charges,,,,,,,no IP contract,,80,,13.48,percent of total billed charges,,,,,,,no IP contract,,50,,8.43,percent of total billed charges,,,,,,no IP contract,,,78,,13.14,percent of total billed charges,,,70,,11.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.26,3324,
64720-0139-10 - methenamine 1 gm Tab,64720-0139-10,NDC,,,,inpatient,1,EA,20.35,12.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.3,percent of total billed charges,,,85,,17.3,percent of total billed charges,,,49,,9.97,percent of total billed charges,,,90,,18.32,percent of total billed charges,,,,,,,no IP contract,,80,,16.28,percent of total billed charges,,,,,,,no IP contract,,50,,10.18,percent of total billed charges,,,,,,no IP contract,,,78,,15.87,percent of total billed charges,,,70,,14.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.97,3324,
64720-0322-10 - zaleplon 5 mg Cap,64720-0322-10,NDC,,,,inpatient,1,EA,3042.9,1825.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2464.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2586.47,percent of total billed charges,,,85,,2586.47,percent of total billed charges,,,49,,1491.02,percent of total billed charges,,,90,,2738.61,percent of total billed charges,,,,,,,no IP contract,,80,,2434.32,percent of total billed charges,,,,,,,no IP contract,,50,,1521.45,percent of total billed charges,,,,,,no IP contract,,,78,,2373.46,percent of total billed charges,,,70,,2130.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
64764-0171-30 - dexlansoprazole 30 mg CR Capsule,64764-0171-30,NDC,,,,inpatient,1,EA,44.95,26.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,38.21,percent of total billed charges,,,85,,38.21,percent of total billed charges,,,49,,22.03,percent of total billed charges,,,90,,40.46,percent of total billed charges,,,,,,,no IP contract,,80,,35.96,percent of total billed charges,,,,,,,no IP contract,,50,,22.48,percent of total billed charges,,,,,,no IP contract,,,78,,35.06,percent of total billed charges,,,70,,31.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.03,3324,
64764-0240-10 - lubiprostone 24 mcg Cap,64764-0240-10,NDC,,,,inpatient,1,EA,29.9,17.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.42,percent of total billed charges,,,85,,25.42,percent of total billed charges,,,49,,14.65,percent of total billed charges,,,90,,26.91,percent of total billed charges,,,,,,,no IP contract,,80,,23.92,percent of total billed charges,,,,,,,no IP contract,,50,,14.95,percent of total billed charges,,,,,,no IP contract,,,78,,23.32,percent of total billed charges,,,70,,20.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.65,3324,
64764-0240-60 - lubiprostone 24 mcg Cap,64764-0240-60,NDC,,,,inpatient,1,EA,35.3,21.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.01,percent of total billed charges,,,85,,30.01,percent of total billed charges,,,49,,17.3,percent of total billed charges,,,90,,31.77,percent of total billed charges,,,,,,,no IP contract,,80,,28.24,percent of total billed charges,,,,,,,no IP contract,,50,,17.65,percent of total billed charges,,,,,,no IP contract,,,78,,27.53,percent of total billed charges,,,70,,24.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.3,3324,
64764-0905-30 - dexlansoprazole 30 mg DRC,64764-0905-30,NDC,,,,inpatient,1,EA,40.1,24.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34.09,percent of total billed charges,,,85,,34.09,percent of total billed charges,,,49,,19.65,percent of total billed charges,,,90,,36.09,percent of total billed charges,,,,,,,no IP contract,,80,,32.08,percent of total billed charges,,,,,,,no IP contract,,50,,20.05,percent of total billed charges,,,,,,no IP contract,,,78,,31.28,percent of total billed charges,,,70,,28.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.65,3324,
64814-0695-60 - indomethacin 75 mg ER Ca,64814-0695-60,NDC,,,,inpatient,1,EA,24.5,14.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.83,percent of total billed charges,,,85,,20.83,percent of total billed charges,,,49,,12.01,percent of total billed charges,,,90,,22.05,percent of total billed charges,,,,,,,no IP contract,,80,,19.6,percent of total billed charges,,,,,,,no IP contract,,50,,12.25,percent of total billed charges,,,,,,no IP contract,,,78,,19.11,percent of total billed charges,,,70,,17.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.01,3324,
amphetamine-dextroamphetamine 5 mg Tab,64850-0500-01,NDC,,,,inpatient,1,EA,19.65,11.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.7,percent of total billed charges,,,85,,16.7,percent of total billed charges,,,49,,9.63,percent of total billed charges,,,90,,17.69,percent of total billed charges,,,,,,,no IP contract,,80,,15.72,percent of total billed charges,,,,,,,no IP contract,,50,,9.83,percent of total billed charges,,,,,,no IP contract,,,78,,15.33,percent of total billed charges,,,70,,13.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.63,3324,
64850-0511-01 - amphetamine-dextroamphetamine 10 mg ER Ca,64850-0511-01,NDC,,,,inpatient,1,EA,56.5,33.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,45.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,48.03,percent of total billed charges,,,85,,48.03,percent of total billed charges,,,49,,27.69,percent of total billed charges,,,90,,50.85,percent of total billed charges,,,,,,,no IP contract,,80,,45.2,percent of total billed charges,,,,,,,no IP contract,,50,,28.25,percent of total billed charges,,,,,,no IP contract,,,78,,44.07,percent of total billed charges,,,70,,39.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.69,3324,
64896-0661-01 - carbidopa-levodopa 23.75 mg-95 mg ER Ca,64896-0661-01,NDC,,,,inpatient,1,EA,29.1,17.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.74,percent of total billed charges,,,85,,24.74,percent of total billed charges,,,49,,14.26,percent of total billed charges,,,90,,26.19,percent of total billed charges,,,,,,,no IP contract,,80,,23.28,percent of total billed charges,,,,,,,no IP contract,,50,,14.55,percent of total billed charges,,,,,,no IP contract,,,78,,22.7,percent of total billed charges,,,70,,20.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.26,3324,
64896-0662-01 - carbidopa-levodopa 36.25 mg-145 mg ER Ca,64896-0662-01,NDC,,,,inpatient,1,EA,29.1,17.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.74,percent of total billed charges,,,85,,24.74,percent of total billed charges,,,49,,14.26,percent of total billed charges,,,90,,26.19,percent of total billed charges,,,,,,,no IP contract,,80,,23.28,percent of total billed charges,,,,,,,no IP contract,,50,,14.55,percent of total billed charges,,,,,,no IP contract,,,78,,22.7,percent of total billed charges,,,70,,20.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.26,3324,
64896-0663-01 - carbidopa-levodopa 48.75 mg-195 mg ER Ca,64896-0663-01,NDC,,,,inpatient,1,EA,29.1,17.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.74,percent of total billed charges,,,85,,24.74,percent of total billed charges,,,49,,14.26,percent of total billed charges,,,90,,26.19,percent of total billed charges,,,,,,,no IP contract,,80,,23.28,percent of total billed charges,,,,,,,no IP contract,,50,,14.55,percent of total billed charges,,,,,,no IP contract,,,78,,22.7,percent of total billed charges,,,70,,20.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.26,3324,
64896-0664-01 - carbidopa-levodopa 61.25 mg-245 mg ER Ca,64896-0664-01,NDC,,,,inpatient,1,EA,35.6,21.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.26,percent of total billed charges,,,85,,30.26,percent of total billed charges,,,49,,17.44,percent of total billed charges,,,90,,32.04,percent of total billed charges,,,,,,,no IP contract,,80,,28.48,percent of total billed charges,,,,,,,no IP contract,,50,,17.8,percent of total billed charges,,,,,,no IP contract,,,78,,27.77,percent of total billed charges,,,70,,24.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.44,3324,
64950-0354-50 - oxyCODONE 5 mg/5 mL Soln,64950-0354-50,NDC,,,,inpatient,1,ML,7.65,4.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.5,percent of total billed charges,,,85,,6.5,percent of total billed charges,,,49,,3.75,percent of total billed charges,,,90,,6.89,percent of total billed charges,,,,,,,no IP contract,,80,,6.12,percent of total billed charges,,,,,,,no IP contract,,50,,3.83,percent of total billed charges,,,,,,no IP contract,,,78,,5.97,percent of total billed charges,,,70,,5.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.75,3324,
64950-0354-55 - oxyCODONE 5 mg/5 mL Soln,64950-0354-55,NDC,,,,inpatient,5,ML,67.05,40.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,54.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.99,percent of total billed charges,,,85,,56.99,percent of total billed charges,,,49,,32.85,percent of total billed charges,,,90,,60.35,percent of total billed charges,,,,,,,no IP contract,,80,,53.64,percent of total billed charges,,,,,,,no IP contract,,50,,33.53,percent of total billed charges,,,,,,no IP contract,,,78,,52.3,percent of total billed charges,,,70,,46.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.85,3324,
64980-0104-01 - potassium phosphate-sodium phosphate 250 mg-45 mg-298 mg Tab,64980-0104-01,NDC,,,,inpatient,1,EA,5.1,3.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.34,percent of total billed charges,,,85,,4.34,percent of total billed charges,,,49,,2.5,percent of total billed charges,,,90,,4.59,percent of total billed charges,,,,,,,no IP contract,,80,,4.08,percent of total billed charges,,,,,,,no IP contract,,50,,2.55,percent of total billed charges,,,,,,no IP contract,,,78,,3.98,percent of total billed charges,,,70,,3.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.5,3324,
64980-0119-01 - methenamine hippurate 1 g Tab,64980-0119-01,NDC,,,,inpatient,1,EA,18.05,10.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.34,percent of total billed charges,,,85,,15.34,percent of total billed charges,,,49,,8.84,percent of total billed charges,,,90,,16.25,percent of total billed charges,,,,,,,no IP contract,,80,,14.44,percent of total billed charges,,,,,,,no IP contract,,50,,9.03,percent of total billed charges,,,,,,no IP contract,,,78,,14.08,percent of total billed charges,,,70,,12.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.84,3324,
levOCARNitine 330 mg Tab,64980-0130-09,NDC,,,,inpatient,1,EA,10.65,6.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.05,percent of total billed charges,,,85,,9.05,percent of total billed charges,,,49,,5.22,percent of total billed charges,,,90,,9.59,percent of total billed charges,,,,,,,no IP contract,,80,,8.52,percent of total billed charges,,,,,,,no IP contract,,50,,5.33,percent of total billed charges,,,,,,no IP contract,,,78,,8.31,percent of total billed charges,,,70,,7.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.22,3324,
64980-0133-01 - dipyridamole 25 mg Tab,64980-0133-01,NDC,,,,inpatient,1,EA,12.25,7.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.41,percent of total billed charges,,,85,,10.41,percent of total billed charges,,,49,,6,percent of total billed charges,,,90,,11.03,percent of total billed charges,,,,,,,no IP contract,,80,,9.8,percent of total billed charges,,,,,,,no IP contract,,50,,6.13,percent of total billed charges,,,,,,no IP contract,,,78,,9.56,percent of total billed charges,,,70,,8.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6,3324,
64980-0209-01 - oxyBUTYnin 5 mg/24 hours ER Ta,64980-0209-01,NDC,,,,inpatient,1,EA,18.55,11.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.77,percent of total billed charges,,,85,,15.77,percent of total billed charges,,,49,,9.09,percent of total billed charges,,,90,,16.7,percent of total billed charges,,,,,,,no IP contract,,80,,14.84,percent of total billed charges,,,,,,,no IP contract,,50,,9.28,percent of total billed charges,,,,,,no IP contract,,,78,,14.47,percent of total billed charges,,,70,,12.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.09,3324,
64980-0210-01 - oxybutynin 10 mg/24 hr ER Ta,64980-0210-01,NDC,,,,inpatient,1,EA,19.65,11.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.7,percent of total billed charges,,,85,,16.7,percent of total billed charges,,,49,,9.63,percent of total billed charges,,,90,,17.69,percent of total billed charges,,,,,,,no IP contract,,80,,15.72,percent of total billed charges,,,,,,,no IP contract,,50,,9.83,percent of total billed charges,,,,,,no IP contract,,,78,,15.33,percent of total billed charges,,,70,,13.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.63,3324,
64980-0220-03 - pyridostigmine 180 mg ER Ta,64980-0220-03,NDC,,,,inpatient,1,EA,201.05,120.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,162.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,170.89,percent of total billed charges,,,85,,170.89,percent of total billed charges,,,49,,98.51,percent of total billed charges,,,90,,180.95,percent of total billed charges,,,,,,,no IP contract,,80,,160.84,percent of total billed charges,,,,,,,no IP contract,,50,,100.53,percent of total billed charges,,,,,,no IP contract,,,78,,156.82,percent of total billed charges,,,70,,140.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,98.51,3324,
64980-0280-01 - glipiZIDE 5 mg ER Ta,64980-0280-01,NDC,,,,inpatient,1,EA,7.1,4.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.04,percent of total billed charges,,,85,,6.04,percent of total billed charges,,,49,,3.48,percent of total billed charges,,,90,,6.39,percent of total billed charges,,,,,,,no IP contract,,80,,5.68,percent of total billed charges,,,,,,,no IP contract,,50,,3.55,percent of total billed charges,,,,,,no IP contract,,,78,,5.54,percent of total billed charges,,,70,,4.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.48,3324,
glipiZIDE 10 mg ER Ta,64980-0281-01,NDC,,,,inpatient,1,EA,10.25,6.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.71,percent of total billed charges,,,85,,8.71,percent of total billed charges,,,49,,5.02,percent of total billed charges,,,90,,9.23,percent of total billed charges,,,,,,,no IP contract,,80,,8.2,percent of total billed charges,,,,,,,no IP contract,,50,,5.13,percent of total billed charges,,,,,,no IP contract,,,78,,8,percent of total billed charges,,,70,,7.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.02,3324,
64980-0320-05 - triamcinolone topical 0.1% Paste,64980-0320-05,NDC,,,,inpatient,1,UN,680.6,408.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,551.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,578.51,percent of total billed charges,,,85,,578.51,percent of total billed charges,,,49,,333.49,percent of total billed charges,,,90,,612.54,percent of total billed charges,,,,,,,no IP contract,,80,,544.48,percent of total billed charges,,,,,,,no IP contract,,50,,340.3,percent of total billed charges,,,,,,no IP contract,,,78,,530.87,percent of total billed charges,,,70,,476.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,333.49,3324,
hydrocortisone topical 2.5% Cream,64980-0324-30,NDC,,,,inpatient,1,EA,736.45,441.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,596.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,625.98,percent of total billed charges,,,85,,625.98,percent of total billed charges,,,49,,360.86,percent of total billed charges,,,90,,662.81,percent of total billed charges,,,,,,,no IP contract,,80,,589.16,percent of total billed charges,,,,,,,no IP contract,,50,,368.23,percent of total billed charges,,,,,,no IP contract,,,78,,574.43,percent of total billed charges,,,70,,515.52,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,360.86,3324,
64980-0339-01 - magnesium oxide 400 mg Tab,64980-0339-01,NDC,,,,inpatient,1,EA,5,3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.25,percent of total billed charges,,,85,,4.25,percent of total billed charges,,,49,,2.45,percent of total billed charges,,,90,,4.5,percent of total billed charges,,,,,,,no IP contract,,80,,4,percent of total billed charges,,,,,,,no IP contract,,50,,2.5,percent of total billed charges,,,,,,no IP contract,,,78,,3.9,percent of total billed charges,,,70,,3.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.45,3324,
64980-0342-14 - alendronate 70 mg Tab,64980-0342-14,NDC,,,,inpatient,1,EA,166.65,99.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,134.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,141.65,percent of total billed charges,,,85,,141.65,percent of total billed charges,,,49,,81.66,percent of total billed charges,,,90,,149.99,percent of total billed charges,,,,,,,no IP contract,,80,,133.32,percent of total billed charges,,,,,,,no IP contract,,50,,83.33,percent of total billed charges,,,,,,no IP contract,,,78,,129.99,percent of total billed charges,,,70,,116.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,81.66,3324,
64980-0373-03 - atomoxetine 10 mg Cap,64980-0373-03,NDC,,,,inpatient,1,EA,116.95,70.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,94.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,99.41,percent of total billed charges,,,85,,99.41,percent of total billed charges,,,49,,57.31,percent of total billed charges,,,90,,105.26,percent of total billed charges,,,,,,,no IP contract,,80,,93.56,percent of total billed charges,,,,,,,no IP contract,,50,,58.48,percent of total billed charges,,,,,,no IP contract,,,78,,91.22,percent of total billed charges,,,70,,81.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,57.31,3324,
64980-0374-03 - atomoxetine 18 mg Cap,64980-0374-03,NDC,,,,inpatient,1,EA,116.95,70.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,94.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,99.41,percent of total billed charges,,,85,,99.41,percent of total billed charges,,,49,,57.31,percent of total billed charges,,,90,,105.26,percent of total billed charges,,,,,,,no IP contract,,80,,93.56,percent of total billed charges,,,,,,,no IP contract,,50,,58.48,percent of total billed charges,,,,,,no IP contract,,,78,,91.22,percent of total billed charges,,,70,,81.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,57.31,3324,
64980-0375-03 - atomoxetine 25 mg Cap,64980-0375-03,NDC,,,,inpatient,1,EA,116.95,70.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,94.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,99.41,percent of total billed charges,,,85,,99.41,percent of total billed charges,,,49,,57.31,percent of total billed charges,,,90,,105.26,percent of total billed charges,,,,,,,no IP contract,,80,,93.56,percent of total billed charges,,,,,,,no IP contract,,50,,58.48,percent of total billed charges,,,,,,no IP contract,,,78,,91.22,percent of total billed charges,,,70,,81.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,57.31,3324,
64980-0409-06 - sertraline 20 mg/mL Conc 20 mg/mL Conc,64980-0409-06,NDC,,,,inpatient,1,ML,14.75,8.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.54,percent of total billed charges,,,85,,12.54,percent of total billed charges,,,49,,7.23,percent of total billed charges,,,90,,13.28,percent of total billed charges,,,,,,,no IP contract,,80,,11.8,percent of total billed charges,,,,,,,no IP contract,,50,,7.38,percent of total billed charges,,,,,,no IP contract,,,78,,11.51,percent of total billed charges,,,70,,10.33,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.23,3324,
calcitriol 1 mcg/mL LIQ,64980-0447-15,NDC,,,,inpatient,1,mL,269.75,161.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,218.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,229.29,percent of total billed charges,,,85,,229.29,percent of total billed charges,,,49,,132.18,percent of total billed charges,,,90,,242.78,percent of total billed charges,,,,,,,no IP contract,,80,,215.8,percent of total billed charges,,,,,,,no IP contract,,50,,134.88,percent of total billed charges,,,,,,no IP contract,,,78,,210.41,percent of total billed charges,,,70,,188.83,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,132.18,3324,
64980-0452-06 - fluocinonide topical 0.05% Soln,64980-0452-06,NDC,,,,inpatient,1,UN,898.85,539.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,728.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,764.02,percent of total billed charges,,,85,,764.02,percent of total billed charges,,,49,,440.44,percent of total billed charges,,,90,,808.97,percent of total billed charges,,,,,,,no IP contract,,80,,719.08,percent of total billed charges,,,,,,,no IP contract,,50,,449.43,percent of total billed charges,,,,,,no IP contract,,,78,,701.1,percent of total billed charges,,,70,,629.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,440.44,3324,
64980-0503-12 - levocarnitine 100 mg/mL Soln,64980-0503-12,NDC,,,,inpatient,1,ML,7.5,4.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.38,percent of total billed charges,,,85,,6.38,percent of total billed charges,,,49,,3.68,percent of total billed charges,,,90,,6.75,percent of total billed charges,,,,,,,no IP contract,,80,,6,percent of total billed charges,,,,,,,no IP contract,,50,,3.75,percent of total billed charges,,,,,,no IP contract,,,78,,5.85,percent of total billed charges,,,70,,5.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.68,3324,
64980-0504-48 - cyproheptadine 2 mg/5 mL Syrup,64980-0504-48,NDC,,,,inpatient,1,ML,6.35,3.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.4,percent of total billed charges,,,85,,5.4,percent of total billed charges,,,49,,3.11,percent of total billed charges,,,90,,5.72,percent of total billed charges,,,,,,,no IP contract,,80,,5.08,percent of total billed charges,,,,,,,no IP contract,,50,,3.18,percent of total billed charges,,,,,,no IP contract,,,78,,4.95,percent of total billed charges,,,70,,4.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.11,3324,
64980-0511-10 - clindamycin 75 mg/5 mL REC P,64980-0511-10,NDC,,,,inpatient,1,ML,10.6,6.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.01,percent of total billed charges,,,85,,9.01,percent of total billed charges,,,49,,5.19,percent of total billed charges,,,90,,9.54,percent of total billed charges,,,,,,,no IP contract,,80,,8.48,percent of total billed charges,,,,,,,no IP contract,,50,,5.3,percent of total billed charges,,,,,,no IP contract,,,78,,8.27,percent of total billed charges,,,70,,7.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.19,3324,
64980-0515-05 - ofloxacin ophthalmic 0.3% Soln,64980-0515-05,NDC,,,,inpatient,1,UN,595.25,357.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,482.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,505.96,percent of total billed charges,,,85,,505.96,percent of total billed charges,,,49,,291.67,percent of total billed charges,,,90,,535.73,percent of total billed charges,,,,,,,no IP contract,,80,,476.2,percent of total billed charges,,,,,,,no IP contract,,50,,297.63,percent of total billed charges,,,,,,no IP contract,,,78,,464.3,percent of total billed charges,,,70,,416.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,291.67,3324,
64980-0517-05 - olopatadine 0.1% Soln,64980-0517-05,NDC,,,,inpatient,1,UN,2145.85,1287.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1738.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1823.97,percent of total billed charges,,,85,,1823.97,percent of total billed charges,,,49,,1051.47,percent of total billed charges,,,90,,1931.27,percent of total billed charges,,,,,,,no IP contract,,80,,1716.68,percent of total billed charges,,,,,,,no IP contract,,50,,1072.93,percent of total billed charges,,,,,,no IP contract,,,78,,1673.76,percent of total billed charges,,,70,,1502.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
dapsone 25 mg Tab,64980-0567-03,NDC,,,,inpatient,1,EA,23.45,14.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.93,percent of total billed charges,,,85,,19.93,percent of total billed charges,,,49,,11.49,percent of total billed charges,,,90,,21.11,percent of total billed charges,,,,,,,no IP contract,,80,,18.76,percent of total billed charges,,,,,,,no IP contract,,50,,11.73,percent of total billed charges,,,,,,no IP contract,,,78,,18.29,percent of total billed charges,,,70,,16.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.49,3324,
oxyCODONE 5 mg Tab,65162-0047-10,NDC,,,,inpatient,1,EA,9.9,5.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.42,percent of total billed charges,,,85,,8.42,percent of total billed charges,,,49,,4.85,percent of total billed charges,,,90,,8.91,percent of total billed charges,,,,,,,no IP contract,,80,,7.92,percent of total billed charges,,,,,,,no IP contract,,50,,4.95,percent of total billed charges,,,,,,no IP contract,,,78,,7.72,percent of total billed charges,,,70,,6.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.85,3324,
65162-0058-27 - sevelamer carbonate 800 mg Tab,65162-0058-27,NDC,,,,inpatient,1,EA,52.3,31.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,42.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,44.46,percent of total billed charges,,,85,,44.46,percent of total billed charges,,,49,,25.63,percent of total billed charges,,,90,,47.07,percent of total billed charges,,,,,,,no IP contract,,80,,41.84,percent of total billed charges,,,,,,,no IP contract,,50,,26.15,percent of total billed charges,,,,,,no IP contract,,,78,,40.79,percent of total billed charges,,,70,,36.61,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.63,3324,
65162-0101-10 - gabapentin 100 mg Cap,65162-0101-10,NDC,,,,inpatient,1,EA,8.1,4.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.89,percent of total billed charges,,,85,,6.89,percent of total billed charges,,,49,,3.97,percent of total billed charges,,,90,,7.29,percent of total billed charges,,,,,,,no IP contract,,80,,6.48,percent of total billed charges,,,,,,,no IP contract,,50,,4.05,percent of total billed charges,,,,,,no IP contract,,,78,,6.32,percent of total billed charges,,,70,,5.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.97,3324,
65162-0103-10 - gabapentin 400 mg Cap,65162-0103-10,NDC,,,,inpatient,1,EA,16.55,9.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.07,percent of total billed charges,,,85,,14.07,percent of total billed charges,,,49,,8.11,percent of total billed charges,,,90,,14.9,percent of total billed charges,,,,,,,no IP contract,,80,,13.24,percent of total billed charges,,,,,,,no IP contract,,50,,8.28,percent of total billed charges,,,,,,no IP contract,,,78,,12.91,percent of total billed charges,,,70,,11.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.11,3324,
65162-0323-09 - niacin 1000 mg ER Ta,65162-0323-09,NDC,,,,inpatient,1,EA,77.1,46.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,62.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,65.54,percent of total billed charges,,,85,,65.54,percent of total billed charges,,,49,,37.78,percent of total billed charges,,,90,,69.39,percent of total billed charges,,,,,,,no IP contract,,80,,61.68,percent of total billed charges,,,,,,,no IP contract,,50,,38.55,percent of total billed charges,,,,,,no IP contract,,,78,,60.14,percent of total billed charges,,,70,,53.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,37.78,3324,
65162-0351-09 - sildenafil 20 mg Tab,65162-0351-09,NDC,,,,inpatient,1,EA,162.8,97.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,131.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,138.38,percent of total billed charges,,,85,,138.38,percent of total billed charges,,,49,,79.77,percent of total billed charges,,,90,,146.52,percent of total billed charges,,,,,,,no IP contract,,80,,130.24,percent of total billed charges,,,,,,,no IP contract,,50,,81.4,percent of total billed charges,,,,,,no IP contract,,,78,,126.98,percent of total billed charges,,,70,,113.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,79.77,3324,
65162-0371-10 - oxyBUTYnin 5 mg/24 hours ER Ta,65162-0371-10,NDC,,,,inpatient,1,EA,53.45,32.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,43.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,45.43,percent of total billed charges,,,85,,45.43,percent of total billed charges,,,49,,26.19,percent of total billed charges,,,90,,48.11,percent of total billed charges,,,,,,,no IP contract,,80,,42.76,percent of total billed charges,,,,,,,no IP contract,,50,,26.73,percent of total billed charges,,,,,,no IP contract,,,78,,41.69,percent of total billed charges,,,70,,37.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.19,3324,
65162-0554-10 - demeclocycline 150 mg Tab,65162-0554-10,NDC,,,,inpatient,1,EA,78.55,47.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,63.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,66.77,percent of total billed charges,,,85,,66.77,percent of total billed charges,,,49,,38.49,percent of total billed charges,,,90,,70.7,percent of total billed charges,,,,,,,no IP contract,,80,,62.84,percent of total billed charges,,,,,,,no IP contract,,50,,39.28,percent of total billed charges,,,,,,no IP contract,,,78,,61.27,percent of total billed charges,,,70,,54.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,38.49,3324,
65162-0573-10 - bethanechol 25 mg Tab,65162-0573-10,NDC,,,,inpatient,1,EA,20.85,12.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.72,percent of total billed charges,,,85,,17.72,percent of total billed charges,,,49,,10.22,percent of total billed charges,,,90,,18.77,percent of total billed charges,,,,,,,no IP contract,,80,,16.68,percent of total billed charges,,,,,,,no IP contract,,50,,10.43,percent of total billed charges,,,,,,no IP contract,,,78,,16.26,percent of total billed charges,,,70,,14.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.22,3324,
65162-0596-06 - aspirin-dipyridamole 25 mg-200 mg ER Ca,65162-0596-06,NDC,,,,inpatient,1,EA,70.3,42.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,56.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,59.76,percent of total billed charges,,,85,,59.76,percent of total billed charges,,,49,,34.45,percent of total billed charges,,,90,,63.27,percent of total billed charges,,,,,,,no IP contract,,80,,56.24,percent of total billed charges,,,,,,,no IP contract,,50,,35.15,percent of total billed charges,,,,,,no IP contract,,,78,,54.83,percent of total billed charges,,,70,,49.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,34.45,3324,
65162-0649-78 - OXcarbazepine 300 mg/5 mL Susp,65162-0649-78,NDC,,,,inpatient,1,ML,12.35,7.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.5,percent of total billed charges,,,85,,10.5,percent of total billed charges,,,49,,6.05,percent of total billed charges,,,90,,11.12,percent of total billed charges,,,,,,,no IP contract,,80,,9.88,percent of total billed charges,,,,,,,no IP contract,,50,,6.18,percent of total billed charges,,,,,,no IP contract,,,78,,9.63,percent of total billed charges,,,70,,8.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.05,3324,
65162-0676-84 - azelastine nasal 137 mcg/inh Spray,65162-0676-84,NDC,,,,inpatient,1,UN,1221.25,732.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,989.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1038.06,percent of total billed charges,,,85,,1038.06,percent of total billed charges,,,49,,598.41,percent of total billed charges,,,90,,1099.13,percent of total billed charges,,,,,,,no IP contract,,80,,977,percent of total billed charges,,,,,,,no IP contract,,50,,610.63,percent of total billed charges,,,,,,no IP contract,,,78,,952.58,percent of total billed charges,,,70,,854.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,598.41,3324,
65162-0681-10 - phenazopyridine 100 mg Tab,65162-0681-10,NDC,,,,inpatient,1,EA,25.3,15.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.51,percent of total billed charges,,,85,,21.51,percent of total billed charges,,,49,,12.4,percent of total billed charges,,,90,,22.77,percent of total billed charges,,,,,,,no IP contract,,80,,20.24,percent of total billed charges,,,,,,,no IP contract,,50,,12.65,percent of total billed charges,,,,,,no IP contract,,,78,,19.73,percent of total billed charges,,,70,,17.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.4,3324,
65162-0686-88 - felbamate 600 mg/5 mL Susp,65162-0686-88,NDC,,,,inpatient,1,ML,27.65,16.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.5,percent of total billed charges,,,85,,23.5,percent of total billed charges,,,49,,13.55,percent of total billed charges,,,90,,24.89,percent of total billed charges,,,,,,,no IP contract,,80,,22.12,percent of total billed charges,,,,,,,no IP contract,,50,,13.83,percent of total billed charges,,,,,,no IP contract,,,78,,21.57,percent of total billed charges,,,70,,19.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.55,3324,
LORazepam 2 mg/mL Conc,65162-0687-84,NDC,,,,inpatient,1,mL,18.75,11.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.94,percent of total billed charges,,,85,,15.94,percent of total billed charges,,,49,,9.19,percent of total billed charges,,,90,,16.88,percent of total billed charges,,,,,,,no IP contract,,80,,15,percent of total billed charges,,,,,,,no IP contract,,50,,9.38,percent of total billed charges,,,,,,no IP contract,,,78,,14.63,percent of total billed charges,,,70,,13.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.19,3324,
65162-0689-88 - nitrofurantoin 25 mg / 5 mL Susp,65162-0689-88,NDC,,,,inpatient,1,ML,27.5,16.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.38,percent of total billed charges,,,85,,23.38,percent of total billed charges,,,49,,13.48,percent of total billed charges,,,90,,24.75,percent of total billed charges,,,,,,,no IP contract,,80,,22,percent of total billed charges,,,,,,,no IP contract,,50,,13.75,percent of total billed charges,,,,,,no IP contract,,,78,,21.45,percent of total billed charges,,,70,,19.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.48,3324,
65162-0698-90 - gabapentin 250 mg/5 mL Soln,65162-0698-90,NDC,,,,inpatient,1,ML,8,4.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.8,percent of total billed charges,,,85,,6.8,percent of total billed charges,,,49,,3.92,percent of total billed charges,,,90,,7.2,percent of total billed charges,,,,,,,no IP contract,,80,,6.4,percent of total billed charges,,,,,,,no IP contract,,50,,4,percent of total billed charges,,,,,,no IP contract,,,78,,6.24,percent of total billed charges,,,70,,5.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.92,3324,
65162-0704-86 - fluocinolone topical 0.01% Oil,65162-0704-86,NDC,,,,inpatient,1,UN,310.15,186.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,251.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,263.63,percent of total billed charges,,,85,,263.63,percent of total billed charges,,,49,,151.97,percent of total billed charges,,,90,,279.14,percent of total billed charges,,,,,,,no IP contract,,80,,248.12,percent of total billed charges,,,,,,,no IP contract,,50,,155.08,percent of total billed charges,,,,,,no IP contract,,,78,,241.92,percent of total billed charges,,,70,,217.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,151.97,3324,
65162-0713-10 - guanFACINE 2 mg Tab,65162-0713-10,NDC,,,,inpatient,1,EA,14.5,8.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.33,percent of total billed charges,,,85,,12.33,percent of total billed charges,,,49,,7.11,percent of total billed charges,,,90,,13.05,percent of total billed charges,,,,,,,no IP contract,,80,,11.6,percent of total billed charges,,,,,,,no IP contract,,50,,7.25,percent of total billed charges,,,,,,no IP contract,,,78,,11.31,percent of total billed charges,,,70,,10.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.11,3324,
65162-0735-03 - felbamate 600 mg Tab,65162-0735-03,NDC,,,,inpatient,1,EA,51.35,30.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,41.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,43.65,percent of total billed charges,,,85,,43.65,percent of total billed charges,,,49,,25.16,percent of total billed charges,,,90,,46.22,percent of total billed charges,,,,,,,no IP contract,,80,,41.08,percent of total billed charges,,,,,,,no IP contract,,50,,25.68,percent of total billed charges,,,,,,no IP contract,,,78,,40.05,percent of total billed charges,,,70,,35.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.16,3324,
65162-0751-10 - benazepril 5 mg Tab,65162-0751-10,NDC,,,,inpatient,1,EA,12.15,7.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.33,percent of total billed charges,,,85,,10.33,percent of total billed charges,,,49,,5.95,percent of total billed charges,,,90,,10.94,percent of total billed charges,,,,,,,no IP contract,,80,,9.72,percent of total billed charges,,,,,,,no IP contract,,50,,6.08,percent of total billed charges,,,,,,no IP contract,,,78,,9.48,percent of total billed charges,,,70,,8.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.95,3324,
65162-0753-10 - benazepril 20 mg Tab,65162-0753-10,NDC,,,,inpatient,1,EA,12.15,7.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.33,percent of total billed charges,,,85,,10.33,percent of total billed charges,,,49,,5.95,percent of total billed charges,,,90,,10.94,percent of total billed charges,,,,,,,no IP contract,,80,,9.72,percent of total billed charges,,,,,,,no IP contract,,50,,6.08,percent of total billed charges,,,,,,no IP contract,,,78,,9.48,percent of total billed charges,,,70,,8.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.95,3324,
65162-0755-10 - divalproex sodium 250 mg ER Ta,65162-0755-10,NDC,,,,inpatient,1,EA,23.3,13.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.81,percent of total billed charges,,,85,,19.81,percent of total billed charges,,,49,,11.42,percent of total billed charges,,,90,,20.97,percent of total billed charges,,,,,,,no IP contract,,80,,18.64,percent of total billed charges,,,,,,,no IP contract,,50,,11.65,percent of total billed charges,,,,,,no IP contract,,,78,,18.17,percent of total billed charges,,,70,,16.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.42,3324,
65162-0768-10 - warfarin 7.5 mg Tab,65162-0768-10,NDC,,,,inpatient,1,EA,11.45,6.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.73,percent of total billed charges,,,85,,9.73,percent of total billed charges,,,49,,5.61,percent of total billed charges,,,90,,10.31,percent of total billed charges,,,,,,,no IP contract,,80,,9.16,percent of total billed charges,,,,,,,no IP contract,,50,,5.73,percent of total billed charges,,,,,,no IP contract,,,78,,8.93,percent of total billed charges,,,70,,8.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.61,3324,
65162-0769-10 - warfarin 10 mg Tab,65162-0769-10,NDC,,,,inpatient,1,EA,11.75,7.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.99,percent of total billed charges,,,85,,9.99,percent of total billed charges,,,49,,5.76,percent of total billed charges,,,90,,10.58,percent of total billed charges,,,,,,,no IP contract,,80,,9.4,percent of total billed charges,,,,,,,no IP contract,,50,,5.88,percent of total billed charges,,,,,,no IP contract,,,78,,9.17,percent of total billed charges,,,70,,8.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.76,3324,
65162-0914-46 - tobramycin inhalation soln 300 mg / 5 mL Soln,65162-0914-46,NDC,,,,inpatient,5,ML,1186.65,711.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,961.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1008.65,percent of total billed charges,,,85,,1008.65,percent of total billed charges,,,49,,581.46,percent of total billed charges,,,90,,1067.99,percent of total billed charges,,,,,,,no IP contract,,80,,949.32,percent of total billed charges,,,,,,,no IP contract,,50,,593.33,percent of total billed charges,,,,,,no IP contract,,,78,,925.59,percent of total billed charges,,,70,,830.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,581.46,3324,
65197-0002-01 - triamterene 50 mg Cap,65197-0002-01,NDC,,,,inpatient,1,EA,13.15,7.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.18,percent of total billed charges,,,85,,11.18,percent of total billed charges,,,49,,6.44,percent of total billed charges,,,90,,11.84,percent of total billed charges,,,,,,,no IP contract,,80,,10.52,percent of total billed charges,,,,,,,no IP contract,,50,,6.58,percent of total billed charges,,,,,,no IP contract,,,78,,10.26,percent of total billed charges,,,70,,9.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.44,3324,
65219-0052-29 - potassium phosphate 3 mmol/mL (with potassium 4.4 mEq/mL) Soln,65219-0052-29,NDC,,,,inpatient,1,ML,57.9,34.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,46.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,49.22,percent of total billed charges,,,85,,49.22,percent of total billed charges,,,49,,28.37,percent of total billed charges,,,90,,52.11,percent of total billed charges,,,,,,,no IP contract,,80,,46.32,percent of total billed charges,,,,,,,no IP contract,,50,,28.95,percent of total billed charges,,,,,,no IP contract,,,78,,45.16,percent of total billed charges,,,70,,40.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,28.37,3324,
65219-0259-45 - piperacillin-tazobactam 4 g-0.5 g REC I,65219-0259-45,NDC,,,,inpatient,1,EA,180.9,108.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,146.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,153.77,percent of total billed charges,,,85,,153.77,percent of total billed charges,,,49,,88.64,percent of total billed charges,,,90,,162.81,percent of total billed charges,,,,,,,no IP contract,,80,,144.72,percent of total billed charges,,,,,,,no IP contract,,50,,90.45,percent of total billed charges,,,,,,no IP contract,,,78,,141.1,percent of total billed charges,,,70,,126.63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,88.64,3324,
65473-0703-01 - bethanechol 10 mg Tab,65473-0703-01,NDC,,,,inpatient,1,EA,15.75,9.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.39,percent of total billed charges,,,85,,13.39,percent of total billed charges,,,49,,7.72,percent of total billed charges,,,90,,14.18,percent of total billed charges,,,,,,,no IP contract,,80,,12.6,percent of total billed charges,,,,,,,no IP contract,,50,,7.88,percent of total billed charges,,,,,,no IP contract,,,78,,12.29,percent of total billed charges,,,70,,11.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.72,3324,
65473-0980-04 - trospium 20 mg Tab,65473-0980-04,NDC,,,,inpatient,1,EA,16.85,10.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.32,percent of total billed charges,,,85,,14.32,percent of total billed charges,,,49,,8.26,percent of total billed charges,,,90,,15.17,percent of total billed charges,,,,,,,no IP contract,,80,,13.48,percent of total billed charges,,,,,,,no IP contract,,50,,8.43,percent of total billed charges,,,,,,no IP contract,,,78,,13.14,percent of total billed charges,,,70,,11.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.26,3324,
65483-0392-22 - labetalol 200 mg Tab,65483-0392-22,NDC,,,,inpatient,1,EA,11.75,7.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.99,percent of total billed charges,,,85,,9.99,percent of total billed charges,,,49,,5.76,percent of total billed charges,,,90,,10.58,percent of total billed charges,,,,,,,no IP contract,,80,,9.4,percent of total billed charges,,,,,,,no IP contract,,50,,5.88,percent of total billed charges,,,,,,no IP contract,,,78,,9.17,percent of total billed charges,,,70,,8.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.76,3324,
65483-0590-10 - azathioprine 50 mg Tab,65483-0590-10,NDC,,,,inpatient,1,EA,28.05,16.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.84,percent of total billed charges,,,85,,23.84,percent of total billed charges,,,49,,13.74,percent of total billed charges,,,90,,25.25,percent of total billed charges,,,,,,,no IP contract,,80,,22.44,percent of total billed charges,,,,,,,no IP contract,,50,,14.03,percent of total billed charges,,,,,,no IP contract,,,78,,21.88,percent of total billed charges,,,70,,19.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.74,3324,
65483-0991-10 - allopurinol 100 mg Tab,65483-0991-10,NDC,,,,inpatient,1,EA,7.3,4.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.21,percent of total billed charges,,,85,,6.21,percent of total billed charges,,,49,,3.58,percent of total billed charges,,,90,,6.57,percent of total billed charges,,,,,,,no IP contract,,80,,5.84,percent of total billed charges,,,,,,,no IP contract,,50,,3.65,percent of total billed charges,,,,,,no IP contract,,,78,,5.69,percent of total billed charges,,,70,,5.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.58,3324,
65597-0101-30 - olmesartan 5 mg Tab,65597-0101-30,NDC,,,,inpatient,1,EA,26.25,15.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.31,percent of total billed charges,,,85,,22.31,percent of total billed charges,,,49,,12.86,percent of total billed charges,,,90,,23.63,percent of total billed charges,,,,,,,no IP contract,,80,,21,percent of total billed charges,,,,,,,no IP contract,,50,,13.13,percent of total billed charges,,,,,,no IP contract,,,78,,20.48,percent of total billed charges,,,70,,18.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.86,3324,
65597-0103-30 - olmesartan 20 mg Tab,65597-0103-30,NDC,,,,inpatient,1,EA,17.75,10.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.09,percent of total billed charges,,,85,,15.09,percent of total billed charges,,,49,,8.7,percent of total billed charges,,,90,,15.98,percent of total billed charges,,,,,,,no IP contract,,80,,14.2,percent of total billed charges,,,,,,,no IP contract,,50,,8.88,percent of total billed charges,,,,,,no IP contract,,,78,,13.85,percent of total billed charges,,,70,,12.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.7,3324,
65597-0104-30 - olmesartan 40 mg Tab,65597-0104-30,NDC,,,,inpatient,1,EA,19.9,11.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.92,percent of total billed charges,,,85,,16.92,percent of total billed charges,,,49,,9.75,percent of total billed charges,,,90,,17.91,percent of total billed charges,,,,,,,no IP contract,,80,,15.92,percent of total billed charges,,,,,,,no IP contract,,50,,9.95,percent of total billed charges,,,,,,no IP contract,,,78,,15.52,percent of total billed charges,,,70,,13.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.75,3324,
65628-0208-10 - vancomycin 50 mg/mL REC P,65628-0208-10,NDC,,,,inpatient,1,ML,12.1,7.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.29,percent of total billed charges,,,85,,10.29,percent of total billed charges,,,49,,5.93,percent of total billed charges,,,90,,10.89,percent of total billed charges,,,,,,,no IP contract,,80,,9.68,percent of total billed charges,,,,,,,no IP contract,,50,,6.05,percent of total billed charges,,,,,,no IP contract,,,78,,9.44,percent of total billed charges,,,70,,8.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.93,3324,
65649-0103-02 - mesalamine 0.375 g ER Ca,65649-0103-02,NDC,,,,inpatient,1,EA,21.95,13.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.66,percent of total billed charges,,,85,,18.66,percent of total billed charges,,,49,,10.76,percent of total billed charges,,,90,,19.76,percent of total billed charges,,,,,,,no IP contract,,80,,17.56,percent of total billed charges,,,,,,,no IP contract,,50,,10.98,percent of total billed charges,,,,,,no IP contract,,,78,,17.12,percent of total billed charges,,,70,,15.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.76,3324,
65649-0301-03 - rifaximin 200 mg Tab,65649-0301-03,NDC,,,,inpatient,1,EA,99.6,59.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,80.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,84.66,percent of total billed charges,,,85,,84.66,percent of total billed charges,,,49,,48.8,percent of total billed charges,,,90,,89.64,percent of total billed charges,,,,,,,no IP contract,,80,,79.68,percent of total billed charges,,,,,,,no IP contract,,50,,49.8,percent of total billed charges,,,,,,no IP contract,,,78,,77.69,percent of total billed charges,,,70,,69.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,48.8,3324,
65649-0303-02 - Rifaximin 550 mg Tab,65649-0303-02,NDC,,,,inpatient,1,EA,228.65,137.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,185.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,194.35,percent of total billed charges,,,85,,194.35,percent of total billed charges,,,49,,112.04,percent of total billed charges,,,90,,205.79,percent of total billed charges,,,,,,,no IP contract,,80,,182.92,percent of total billed charges,,,,,,,no IP contract,,50,,114.33,percent of total billed charges,,,,,,no IP contract,,,78,,178.35,percent of total billed charges,,,70,,160.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,112.04,3324,
65649-0303-03 - rifaximin 550 mg Tab,65649-0303-03,NDC,,,,inpatient,1,EA,228.65,137.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,185.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,194.35,percent of total billed charges,,,85,,194.35,percent of total billed charges,,,49,,112.04,percent of total billed charges,,,90,,205.79,percent of total billed charges,,,,,,,no IP contract,,80,,182.92,percent of total billed charges,,,,,,,no IP contract,,50,,114.33,percent of total billed charges,,,,,,no IP contract,,,78,,178.35,percent of total billed charges,,,70,,160.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,112.04,3324,
65649-0311-12 - chlorothiazide 250 mg/5 mL Susp,65649-0311-12,NDC,,,,inpatient,1,ML,7.6,4.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.46,percent of total billed charges,,,85,,6.46,percent of total billed charges,,,49,,3.72,percent of total billed charges,,,90,,6.84,percent of total billed charges,,,,,,,no IP contract,,80,,6.08,percent of total billed charges,,,,,,,no IP contract,,50,,3.8,percent of total billed charges,,,,,,no IP contract,,,78,,5.93,percent of total billed charges,,,70,,5.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.72,3324,
65862-0012-01 - sertraline 50 mg Tab,65862-0012-01,NDC,,,,inpatient,1,EA,26.5,15.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.53,percent of total billed charges,,,85,,22.53,percent of total billed charges,,,49,,12.99,percent of total billed charges,,,90,,23.85,percent of total billed charges,,,,,,,no IP contract,,80,,21.2,percent of total billed charges,,,,,,,no IP contract,,50,,13.25,percent of total billed charges,,,,,,no IP contract,,,78,,20.67,percent of total billed charges,,,70,,18.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.99,3324,
65862-0012-30 - sertraline 50 mg Tab,65862-0012-30,NDC,,,,inpatient,1,EA,26.5,15.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.53,percent of total billed charges,,,85,,22.53,percent of total billed charges,,,49,,12.99,percent of total billed charges,,,90,,23.85,percent of total billed charges,,,,,,,no IP contract,,80,,21.2,percent of total billed charges,,,,,,,no IP contract,,50,,13.25,percent of total billed charges,,,,,,no IP contract,,,78,,20.67,percent of total billed charges,,,70,,18.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.99,3324,
65862-0013-01 - sertraline 100 mg Tab,65862-0013-01,NDC,,,,inpatient,1,EA,26.5,15.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.53,percent of total billed charges,,,85,,22.53,percent of total billed charges,,,49,,12.99,percent of total billed charges,,,90,,23.85,percent of total billed charges,,,,,,,no IP contract,,80,,21.2,percent of total billed charges,,,,,,,no IP contract,,50,,13.25,percent of total billed charges,,,,,,no IP contract,,,78,,20.67,percent of total billed charges,,,70,,18.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.99,3324,
65862-0018-01 - cephalexin 250 mg Cap,65862-0018-01,NDC,,,,inpatient,1,EA,9.4,5.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.99,percent of total billed charges,,,85,,7.99,percent of total billed charges,,,49,,4.61,percent of total billed charges,,,90,,8.46,percent of total billed charges,,,,,,,no IP contract,,80,,7.52,percent of total billed charges,,,,,,,no IP contract,,50,,4.7,percent of total billed charges,,,,,,no IP contract,,,78,,7.33,percent of total billed charges,,,70,,6.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.61,3324,
65862-0021-06 - mirtazapine 15 mg DIS T,65862-0021-06,NDC,,,,inpatient,1,EA,22.5,13.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.13,percent of total billed charges,,,85,,19.13,percent of total billed charges,,,49,,11.03,percent of total billed charges,,,90,,20.25,percent of total billed charges,,,,,,,no IP contract,,80,,18,percent of total billed charges,,,,,,,no IP contract,,50,,11.25,percent of total billed charges,,,,,,no IP contract,,,78,,17.55,percent of total billed charges,,,70,,15.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.03,3324,
65862-0022-06 - mirtazapine 30 mg DIS T,65862-0022-06,NDC,,,,inpatient,1,EA,23.15,13.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.68,percent of total billed charges,,,85,,19.68,percent of total billed charges,,,49,,11.34,percent of total billed charges,,,90,,20.84,percent of total billed charges,,,,,,,no IP contract,,80,,18.52,percent of total billed charges,,,,,,,no IP contract,,50,,11.58,percent of total billed charges,,,,,,no IP contract,,,78,,18.06,percent of total billed charges,,,70,,16.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.34,3324,
65862-0078-50 - ciprofloxacin 750 mg Tab,65862-0078-50,NDC,,,,inpatient,1,EA,48.5,29.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,39.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,41.23,percent of total billed charges,,,85,,41.23,percent of total billed charges,,,49,,23.77,percent of total billed charges,,,90,,43.65,percent of total billed charges,,,,,,,no IP contract,,80,,38.8,percent of total billed charges,,,,,,,no IP contract,,50,,24.25,percent of total billed charges,,,,,,no IP contract,,,78,,37.83,percent of total billed charges,,,70,,33.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.77,3324,
65862-0079-30 - terbinafine 250 mg Tab,65862-0079-30,NDC,,,,inpatient,1,EA,105.45,63.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,85.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,89.63,percent of total billed charges,,,85,,89.63,percent of total billed charges,,,49,,51.67,percent of total billed charges,,,90,,94.91,percent of total billed charges,,,,,,,no IP contract,,80,,84.36,percent of total billed charges,,,,,,,no IP contract,,50,,52.73,percent of total billed charges,,,,,,no IP contract,,,78,,82.25,percent of total billed charges,,,70,,73.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,51.67,3324,
65862-0096-20 - cefpodoxime 200 mg Tab,65862-0096-20,NDC,,,,inpatient,1,EA,54.8,32.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,44.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,46.58,percent of total billed charges,,,85,,46.58,percent of total billed charges,,,49,,26.85,percent of total billed charges,,,90,,49.32,percent of total billed charges,,,,,,,no IP contract,,80,,43.84,percent of total billed charges,,,,,,,no IP contract,,50,,27.4,percent of total billed charges,,,,,,no IP contract,,,78,,42.74,percent of total billed charges,,,70,,38.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.85,3324,
65862-0107-01 - zidovudine 100 mg Cap,65862-0107-01,NDC,,,,inpatient,1,EA,19.9,11.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.92,percent of total billed charges,,,85,,16.92,percent of total billed charges,,,49,,9.75,percent of total billed charges,,,90,,17.91,percent of total billed charges,,,,,,,no IP contract,,80,,15.92,percent of total billed charges,,,,,,,no IP contract,,50,,9.95,percent of total billed charges,,,,,,no IP contract,,,78,,15.52,percent of total billed charges,,,70,,13.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.75,3324,
carvedilol 12.5 mg Tab,65862-0144-01,NDC,,,,inpatient,1,EA,19.35,11.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.45,percent of total billed charges,,,85,,16.45,percent of total billed charges,,,49,,9.48,percent of total billed charges,,,90,,17.42,percent of total billed charges,,,,,,,no IP contract,,80,,15.48,percent of total billed charges,,,,,,,no IP contract,,50,,9.68,percent of total billed charges,,,,,,no IP contract,,,78,,15.09,percent of total billed charges,,,70,,13.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.48,3324,
carvedilol 25 mg Tab,65862-0145-01,NDC,,,,inpatient,1,EA,19.35,11.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.45,percent of total billed charges,,,85,,16.45,percent of total billed charges,,,49,,9.48,percent of total billed charges,,,90,,17.42,percent of total billed charges,,,,,,,no IP contract,,80,,15.48,percent of total billed charges,,,,,,,no IP contract,,50,,9.68,percent of total billed charges,,,,,,no IP contract,,,78,,15.09,percent of total billed charges,,,70,,13.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.48,3324,
65862-0146-36 - SUMAtriptan 25 mg Tab,65862-0146-36,NDC,,,,inpatient,1,EA,218.85,131.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,177.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,186.02,percent of total billed charges,,,85,,186.02,percent of total billed charges,,,49,,107.24,percent of total billed charges,,,90,,196.97,percent of total billed charges,,,,,,,no IP contract,,80,,175.08,percent of total billed charges,,,,,,,no IP contract,,50,,109.43,percent of total billed charges,,,,,,no IP contract,,,78,,170.7,percent of total billed charges,,,70,,153.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,107.24,3324,
finasteride 5 mg Tab,65862-0149-30,NDC,,,,inpatient,1,EA,28.7,17.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.4,percent of total billed charges,,,85,,24.4,percent of total billed charges,,,49,,14.06,percent of total billed charges,,,90,,25.83,percent of total billed charges,,,,,,,no IP contract,,80,,22.96,percent of total billed charges,,,,,,,no IP contract,,50,,14.35,percent of total billed charges,,,,,,no IP contract,,,78,,22.39,percent of total billed charges,,,70,,20.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.06,3324,
65862-0177-60 - cefdinir 300 mg Cap,65862-0177-60,NDC,,,,inpatient,1,EA,44.45,26.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,37.78,percent of total billed charges,,,85,,37.78,percent of total billed charges,,,49,,21.78,percent of total billed charges,,,90,,40.01,percent of total billed charges,,,,,,,no IP contract,,80,,35.56,percent of total billed charges,,,,,,,no IP contract,,50,,22.23,percent of total billed charges,,,,,,no IP contract,,,78,,34.67,percent of total billed charges,,,70,,31.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.78,3324,
FLUoxetine 10 mg Cap,65862-0192-01,NDC,,,,inpatient,1,EA,24.5,14.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.83,percent of total billed charges,,,85,,20.83,percent of total billed charges,,,49,,12.01,percent of total billed charges,,,90,,22.05,percent of total billed charges,,,,,,,no IP contract,,80,,19.6,percent of total billed charges,,,,,,,no IP contract,,50,,12.25,percent of total billed charges,,,,,,no IP contract,,,78,,19.11,percent of total billed charges,,,70,,17.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.01,3324,
65862-0193-01 - FLUoxetine 20 mg Cap,65862-0193-01,NDC,,,,inpatient,1,EA,25.05,15.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.29,percent of total billed charges,,,85,,21.29,percent of total billed charges,,,49,,12.27,percent of total billed charges,,,90,,22.55,percent of total billed charges,,,,,,,no IP contract,,80,,20.04,percent of total billed charges,,,,,,,no IP contract,,50,,12.53,percent of total billed charges,,,,,,no IP contract,,,78,,19.54,percent of total billed charges,,,70,,17.54,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.27,3324,
65862-0198-01 - gabapentin 100 mg Cap,65862-0198-01,NDC,,,,inpatient,1,EA,8.05,4.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.84,percent of total billed charges,,,85,,6.84,percent of total billed charges,,,49,,3.94,percent of total billed charges,,,90,,7.25,percent of total billed charges,,,,,,,no IP contract,,80,,6.44,percent of total billed charges,,,,,,,no IP contract,,50,,4.03,percent of total billed charges,,,,,,no IP contract,,,78,,6.28,percent of total billed charges,,,70,,5.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.94,3324,
65862-0201-90 - losartan 25 mg Tab,65862-0201-90,NDC,,,,inpatient,1,EA,17.2,10.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.62,percent of total billed charges,,,85,,14.62,percent of total billed charges,,,49,,8.43,percent of total billed charges,,,90,,15.48,percent of total billed charges,,,,,,,no IP contract,,80,,13.76,percent of total billed charges,,,,,,,no IP contract,,50,,8.6,percent of total billed charges,,,,,,no IP contract,,,78,,13.42,percent of total billed charges,,,70,,12.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.43,3324,
65862-0202-30 - losartan 50 mg Tab,65862-0202-30,NDC,,,,inpatient,1,EA,21.8,13.08,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.53,percent of total billed charges,,,85,,18.53,percent of total billed charges,,,49,,10.68,percent of total billed charges,,,90,,19.62,percent of total billed charges,,,,,,,no IP contract,,80,,17.44,percent of total billed charges,,,,,,,no IP contract,,50,,10.9,percent of total billed charges,,,,,,no IP contract,,,78,,17,percent of total billed charges,,,70,,15.26,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.68,3324,
65862-0202-90 - losartan 50 mg Tab,65862-0202-90,NDC,,,,inpatient,1,EA,21.8,13.08,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.53,percent of total billed charges,,,85,,18.53,percent of total billed charges,,,49,,10.68,percent of total billed charges,,,90,,19.62,percent of total billed charges,,,,,,,no IP contract,,80,,17.44,percent of total billed charges,,,,,,,no IP contract,,50,,10.9,percent of total billed charges,,,,,,no IP contract,,,78,,17,percent of total billed charges,,,70,,15.26,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.68,3324,
65862-0202-99 - losartan 50 mg Tab,65862-0202-99,NDC,,,,inpatient,1,EA,21.8,13.08,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.53,percent of total billed charges,,,85,,18.53,percent of total billed charges,,,49,,10.68,percent of total billed charges,,,90,,19.62,percent of total billed charges,,,,,,,no IP contract,,80,,17.44,percent of total billed charges,,,,,,,no IP contract,,50,,10.9,percent of total billed charges,,,,,,no IP contract,,,78,,17,percent of total billed charges,,,70,,15.26,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.68,3324,
65862-0211-50 - minocycline 100 mg Cap,65862-0211-50,NDC,,,,inpatient,1,EA,30.85,18.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.22,percent of total billed charges,,,85,,26.22,percent of total billed charges,,,49,,15.12,percent of total billed charges,,,90,,27.77,percent of total billed charges,,,,,,,no IP contract,,80,,24.68,percent of total billed charges,,,,,,,no IP contract,,50,,15.43,percent of total billed charges,,,,,,no IP contract,,,78,,24.06,percent of total billed charges,,,70,,21.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.12,3324,
65862-0218-60 - cefdinir 125 mg/5 mL REC P,65862-0218-60,NDC,,,,inpatient,1,ML,12.5,7.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.63,percent of total billed charges,,,85,,10.63,percent of total billed charges,,,49,,6.13,percent of total billed charges,,,90,,11.25,percent of total billed charges,,,,,,,no IP contract,,80,,10,percent of total billed charges,,,,,,,no IP contract,,50,,6.25,percent of total billed charges,,,,,,no IP contract,,,78,,9.75,percent of total billed charges,,,70,,8.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.13,3324,
65862-0225-60 - clarithromycin 250 mg Tab,65862-0225-60,NDC,,,,inpatient,1,EA,12.75,7.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.84,percent of total billed charges,,,85,,10.84,percent of total billed charges,,,49,,6.25,percent of total billed charges,,,90,,11.48,percent of total billed charges,,,,,,,no IP contract,,80,,10.2,percent of total billed charges,,,,,,,no IP contract,,50,,6.38,percent of total billed charges,,,,,,no IP contract,,,78,,9.95,percent of total billed charges,,,70,,8.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.25,3324,
FLUoxetine 20 mg/5 mL Soln,65862-0306-12,NDC,,,,inpatient,1,mL,13.6,8.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.56,percent of total billed charges,,,85,,11.56,percent of total billed charges,,,49,,6.66,percent of total billed charges,,,90,,12.24,percent of total billed charges,,,,,,,no IP contract,,80,,10.88,percent of total billed charges,,,,,,,no IP contract,,50,,6.8,percent of total billed charges,,,,,,no IP contract,,,78,,10.61,percent of total billed charges,,,70,,9.52,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.66,3324,
65862-0329-04 - alendronate 70 mg Tab,65862-0329-04,NDC,,,,inpatient,1,EA,166.7,100.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,135.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,141.7,percent of total billed charges,,,85,,141.7,percent of total billed charges,,,49,,81.68,percent of total billed charges,,,90,,150.03,percent of total billed charges,,,,,,,no IP contract,,80,,133.36,percent of total billed charges,,,,,,,no IP contract,,50,,83.35,percent of total billed charges,,,,,,no IP contract,,,78,,130.03,percent of total billed charges,,,70,,116.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,81.68,3324,
65862-0390-10 - ondansetron 4 mg DIS T,65862-0390-10,NDC,,,,inpatient,1,EA,181.05,108.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,146.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,153.89,percent of total billed charges,,,85,,153.89,percent of total billed charges,,,49,,88.71,percent of total billed charges,,,90,,162.95,percent of total billed charges,,,,,,,no IP contract,,80,,144.84,percent of total billed charges,,,,,,,no IP contract,,50,,90.53,percent of total billed charges,,,,,,no IP contract,,,78,,141.22,percent of total billed charges,,,70,,126.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,88.71,3324,
65862-0391-10 - ondansetron 8 mg DIS T,65862-0391-10,NDC,,,,inpatient,1,EA,299,179.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,242.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,254.15,percent of total billed charges,,,85,,254.15,percent of total billed charges,,,49,,146.51,percent of total billed charges,,,90,,269.1,percent of total billed charges,,,,,,,no IP contract,,80,,239.2,percent of total billed charges,,,,,,,no IP contract,,50,,149.5,percent of total billed charges,,,,,,no IP contract,,,78,,233.22,percent of total billed charges,,,70,,209.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,146.51,3324,
65862-0419-01 - sulfamethoxazole-trimethoprim 400 mg-80 mg Tab,65862-0419-01,NDC,,,,inpatient,1,EA,9.05,5.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.69,percent of total billed charges,,,85,,7.69,percent of total billed charges,,,49,,4.43,percent of total billed charges,,,90,,8.15,percent of total billed charges,,,,,,,no IP contract,,80,,7.24,percent of total billed charges,,,,,,,no IP contract,,50,,4.53,percent of total billed charges,,,,,,no IP contract,,,78,,7.06,percent of total billed charges,,,70,,6.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.43,3324,
65862-0421-30 - tenofovir 300 mg Tab,65862-0421-30,NDC,,,,inpatient,1,EA,22.9,13.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.47,percent of total billed charges,,,85,,19.47,percent of total billed charges,,,49,,11.22,percent of total billed charges,,,90,,20.61,percent of total billed charges,,,,,,,no IP contract,,80,,18.32,percent of total billed charges,,,,,,,no IP contract,,50,,11.45,percent of total billed charges,,,,,,no IP contract,,,78,,17.86,percent of total billed charges,,,70,,16.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.22,3324,
65862-0449-90 - valACYclovir 1 g Tab,65862-0449-90,NDC,,,,inpatient,1,EA,102.25,61.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,82.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,86.91,percent of total billed charges,,,85,,86.91,percent of total billed charges,,,49,,50.1,percent of total billed charges,,,90,,92.03,percent of total billed charges,,,,,,,no IP contract,,80,,81.8,percent of total billed charges,,,,,,,no IP contract,,50,,51.13,percent of total billed charges,,,,,,no IP contract,,,78,,79.76,percent of total billed charges,,,70,,71.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,50.1,3324,
65862-0458-60 - galantamine 4 mg Tab,65862-0458-60,NDC,,,,inpatient,1,EA,29.1,17.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.74,percent of total billed charges,,,85,,24.74,percent of total billed charges,,,49,,14.26,percent of total billed charges,,,90,,26.19,percent of total billed charges,,,,,,,no IP contract,,80,,23.28,percent of total billed charges,,,,,,,no IP contract,,50,,14.55,percent of total billed charges,,,,,,no IP contract,,,78,,22.7,percent of total billed charges,,,70,,20.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.26,3324,
65862-0459-60 - galantamine 8 mg Tab,65862-0459-60,NDC,,,,inpatient,1,EA,29.1,17.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.74,percent of total billed charges,,,85,,24.74,percent of total billed charges,,,49,,14.26,percent of total billed charges,,,90,,26.19,percent of total billed charges,,,,,,,no IP contract,,80,,23.28,percent of total billed charges,,,,,,,no IP contract,,50,,14.55,percent of total billed charges,,,,,,no IP contract,,,78,,22.7,percent of total billed charges,,,70,,20.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.26,3324,
65862-0502-20 - amoxicillin-clavulanate 500 mg-125 mg Tab,65862-0502-20,NDC,,,,inpatient,1,EA,33.9,20.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.82,percent of total billed charges,,,85,,28.82,percent of total billed charges,,,49,,16.61,percent of total billed charges,,,90,,30.51,percent of total billed charges,,,,,,,no IP contract,,80,,27.12,percent of total billed charges,,,,,,,no IP contract,,50,,16.95,percent of total billed charges,,,,,,no IP contract,,,78,,26.44,percent of total billed charges,,,70,,23.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.61,3324,
65862-0503-01 - amoxicillin-clavulanate 875 mg-125 mg Tab,65862-0503-01,NDC,,,,inpatient,1,EA,43.2,25.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36.72,percent of total billed charges,,,85,,36.72,percent of total billed charges,,,49,,21.17,percent of total billed charges,,,90,,38.88,percent of total billed charges,,,,,,,no IP contract,,80,,34.56,percent of total billed charges,,,,,,,no IP contract,,50,,21.6,percent of total billed charges,,,,,,no IP contract,,,78,,33.7,percent of total billed charges,,,70,,30.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.17,3324,
65862-0503-20 - amoxicillin-clavulanate 875 mg-125 mg Tab,65862-0503-20,NDC,,,,inpatient,1,EA,43.95,26.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,35.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,37.36,percent of total billed charges,,,85,,37.36,percent of total billed charges,,,49,,21.54,percent of total billed charges,,,90,,39.56,percent of total billed charges,,,,,,,no IP contract,,80,,35.16,percent of total billed charges,,,,,,,no IP contract,,50,,21.98,percent of total billed charges,,,,,,no IP contract,,,78,,34.28,percent of total billed charges,,,70,,30.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.54,3324,
65862-0528-90 - venlafaxine 75 mg ER Ca,65862-0528-90,NDC,,,,inpatient,1,EA,40.95,24.57,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34.81,percent of total billed charges,,,85,,34.81,percent of total billed charges,,,49,,20.07,percent of total billed charges,,,90,,36.86,percent of total billed charges,,,,,,,no IP contract,,80,,32.76,percent of total billed charges,,,,,,,no IP contract,,50,,20.48,percent of total billed charges,,,,,,no IP contract,,,78,,31.94,percent of total billed charges,,,70,,28.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.07,3324,
65862-0534-01 - amoxicillin-clavulanate 400 mg-57 mg/5 mL REC P,65862-0534-01,NDC,,,,inpatient,1,ML,11.15,6.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.48,percent of total billed charges,,,85,,9.48,percent of total billed charges,,,49,,5.46,percent of total billed charges,,,90,,10.04,percent of total billed charges,,,,,,,no IP contract,,80,,8.92,percent of total billed charges,,,,,,,no IP contract,,50,,5.58,percent of total billed charges,,,,,,no IP contract,,,78,,8.7,percent of total billed charges,,,70,,7.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.46,3324,
65862-0537-50 - levoFLOXacin 500 mg Tab,65862-0537-50,NDC,,,,inpatient,1,EA,157,94.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,127.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,133.45,percent of total billed charges,,,85,,133.45,percent of total billed charges,,,49,,76.93,percent of total billed charges,,,90,,141.3,percent of total billed charges,,,,,,,no IP contract,,80,,125.6,percent of total billed charges,,,,,,,no IP contract,,50,,78.5,percent of total billed charges,,,,,,no IP contract,,,78,,122.46,percent of total billed charges,,,70,,109.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,76.93,3324,
65862-0596-02 - clindamycin 75 mg/5 mL REC P,65862-0596-02,NDC,,,,inpatient,1,ML,10.6,6.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.01,percent of total billed charges,,,85,,9.01,percent of total billed charges,,,49,,5.19,percent of total billed charges,,,90,,9.54,percent of total billed charges,,,,,,,no IP contract,,80,,8.48,percent of total billed charges,,,,,,,no IP contract,,50,,5.3,percent of total billed charges,,,,,,no IP contract,,,78,,8.27,percent of total billed charges,,,70,,7.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.19,3324,
65862-0601-30 - modafinil 100 mg Tab,65862-0601-30,NDC,,,,inpatient,1,EA,225.35,135.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,182.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,191.55,percent of total billed charges,,,85,,191.55,percent of total billed charges,,,49,,110.42,percent of total billed charges,,,90,,202.82,percent of total billed charges,,,,,,,no IP contract,,80,,180.28,percent of total billed charges,,,,,,,no IP contract,,50,,112.68,percent of total billed charges,,,,,,no IP contract,,,78,,175.77,percent of total billed charges,,,70,,157.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,110.42,3324,
65862-0654-01 - entacapone 200 mg Tab,65862-0654-01,NDC,,,,inpatient,1,EA,39.9,23.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.92,percent of total billed charges,,,85,,33.92,percent of total billed charges,,,49,,19.55,percent of total billed charges,,,90,,35.91,percent of total billed charges,,,,,,,no IP contract,,80,,31.92,percent of total billed charges,,,,,,,no IP contract,,50,,19.95,percent of total billed charges,,,,,,no IP contract,,,78,,31.12,percent of total billed charges,,,70,,27.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.55,3324,
65862-0661-30 - ARIPiprazole 2 mg Tab,65862-0661-30,NDC,,,,inpatient,1,EA,259.1,155.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,209.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,220.24,percent of total billed charges,,,85,,220.24,percent of total billed charges,,,49,,126.96,percent of total billed charges,,,90,,233.19,percent of total billed charges,,,,,,,no IP contract,,80,,207.28,percent of total billed charges,,,,,,,no IP contract,,50,,129.55,percent of total billed charges,,,,,,no IP contract,,,78,,202.1,percent of total billed charges,,,70,,181.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,126.96,3324,
65862-0676-01 - ALPRAZolam 0.25 mg Tab,65862-0676-01,NDC,,,,inpatient,1,EA,11.25,6.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.56,percent of total billed charges,,,85,,9.56,percent of total billed charges,,,49,,5.51,percent of total billed charges,,,90,,10.13,percent of total billed charges,,,,,,,no IP contract,,80,,9,percent of total billed charges,,,,,,,no IP contract,,50,,5.63,percent of total billed charges,,,,,,no IP contract,,,78,,8.78,percent of total billed charges,,,70,,7.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.51,3324,
ALPRAZolam 0.5 mg Tab,65862-0677-01,NDC,,,,inpatient,1,EA,13.15,7.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.18,percent of total billed charges,,,85,,11.18,percent of total billed charges,,,49,,6.44,percent of total billed charges,,,90,,11.84,percent of total billed charges,,,,,,,no IP contract,,80,,10.52,percent of total billed charges,,,,,,,no IP contract,,50,,6.58,percent of total billed charges,,,,,,no IP contract,,,78,,10.26,percent of total billed charges,,,70,,9.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.44,3324,
65862-0687-30 - ritonavir 100 mg Tab,65862-0687-30,NDC,,,,inpatient,1,EA,77.45,46.47,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,62.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,65.83,percent of total billed charges,,,85,,65.83,percent of total billed charges,,,49,,37.95,percent of total billed charges,,,90,,69.71,percent of total billed charges,,,,,,,no IP contract,,80,,61.96,percent of total billed charges,,,,,,,no IP contract,,50,,38.73,percent of total billed charges,,,,,,no IP contract,,,78,,60.41,percent of total billed charges,,,70,,54.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,37.95,3324,
65862-0697-90 - venlafaxine 150 mg ER Ca,65862-0697-90,NDC,,,,inpatient,1,EA,44.2,26.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,35.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,37.57,percent of total billed charges,,,85,,37.57,percent of total billed charges,,,49,,21.66,percent of total billed charges,,,90,,39.78,percent of total billed charges,,,,,,,no IP contract,,80,,35.36,percent of total billed charges,,,,,,,no IP contract,,50,,22.1,percent of total billed charges,,,,,,no IP contract,,,78,,34.48,percent of total billed charges,,,70,,30.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.66,3324,
65862-0699-60 - cefuroxime 250 mg Tab,65862-0699-60,NDC,,,,inpatient,1,EA,38.8,23.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.98,percent of total billed charges,,,85,,32.98,percent of total billed charges,,,49,,19.01,percent of total billed charges,,,90,,34.92,percent of total billed charges,,,,,,,no IP contract,,80,,31.04,percent of total billed charges,,,,,,,no IP contract,,50,,19.4,percent of total billed charges,,,,,,no IP contract,,,78,,30.26,percent of total billed charges,,,70,,27.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.01,3324,
65862-0707-55 - amoxicillin 250 mg/5 mL REC P,65862-0707-55,NDC,,,,inpatient,1,ML,5.85,3.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.97,percent of total billed charges,,,85,,4.97,percent of total billed charges,,,49,,2.87,percent of total billed charges,,,90,,5.27,percent of total billed charges,,,,,,,no IP contract,,80,,4.68,percent of total billed charges,,,,,,,no IP contract,,50,,2.93,percent of total billed charges,,,,,,no IP contract,,,78,,4.56,percent of total billed charges,,,70,,4.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.87,3324,
65862-0732-60 - amiodarone 200 mg Tab,65862-0732-60,NDC,,,,inpatient,1,EA,30.7,18.42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.1,percent of total billed charges,,,85,,26.1,percent of total billed charges,,,49,,15.04,percent of total billed charges,,,90,,27.63,percent of total billed charges,,,,,,,no IP contract,,80,,24.56,percent of total billed charges,,,,,,,no IP contract,,50,,15.35,percent of total billed charges,,,,,,no IP contract,,,78,,23.95,percent of total billed charges,,,70,,21.49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.04,3324,
65862-0743-30 - olmesartan 40 mg Tab,65862-0743-30,NDC,,,,inpatient,1,EA,80.2,48.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,64.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,68.17,percent of total billed charges,,,85,,68.17,percent of total billed charges,,,49,,39.3,percent of total billed charges,,,90,,72.18,percent of total billed charges,,,,,,,no IP contract,,80,,64.16,percent of total billed charges,,,,,,,no IP contract,,50,,40.1,percent of total billed charges,,,,,,no IP contract,,,78,,62.56,percent of total billed charges,,,70,,56.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,39.3,3324,
65862-0746-30 - galantamine 24 mg ER Ca,65862-0746-30,NDC,,,,inpatient,1,EA,18.15,10.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.43,percent of total billed charges,,,85,,15.43,percent of total billed charges,,,49,,8.89,percent of total billed charges,,,90,,16.34,percent of total billed charges,,,,,,,no IP contract,,80,,14.52,percent of total billed charges,,,,,,,no IP contract,,50,,9.08,percent of total billed charges,,,,,,no IP contract,,,78,,14.16,percent of total billed charges,,,70,,12.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.89,3324,
65862-0752-50 - cefixime 200 mg/5 mL REC P,65862-0752-50,NDC,,,,inpatient,1,ML,79.65,47.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,64.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,67.7,percent of total billed charges,,,85,,67.7,percent of total billed charges,,,49,,39.03,percent of total billed charges,,,90,,71.69,percent of total billed charges,,,,,,,no IP contract,,80,,63.72,percent of total billed charges,,,,,,,no IP contract,,50,,39.83,percent of total billed charges,,,,,,no IP contract,,,78,,62.13,percent of total billed charges,,,70,,55.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,39.03,3324,
65862-0782-01 - methenamine hippurate 1 g Tab,65862-0782-01,NDC,,,,inpatient,1,EA,20.45,12.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.38,percent of total billed charges,,,85,,17.38,percent of total billed charges,,,49,,10.02,percent of total billed charges,,,90,,18.41,percent of total billed charges,,,,,,,no IP contract,,80,,16.36,percent of total billed charges,,,,,,,no IP contract,,50,,10.23,percent of total billed charges,,,,,,no IP contract,,,78,,15.95,percent of total billed charges,,,70,,14.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.02,3324,
65862-0805-30 - armodafinil 50 mg Tab,65862-0805-30,NDC,,,,inpatient,1,EA,65.9,39.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,53.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.02,percent of total billed charges,,,85,,56.02,percent of total billed charges,,,49,,32.29,percent of total billed charges,,,90,,59.31,percent of total billed charges,,,,,,,no IP contract,,80,,52.72,percent of total billed charges,,,,,,,no IP contract,,50,,32.95,percent of total billed charges,,,,,,no IP contract,,,78,,51.4,percent of total billed charges,,,70,,46.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.29,3324,
65862-0892-30 - voriconazole 200 mg Tab,65862-0892-30,NDC,,,,inpatient,1,EA,403.3,241.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,326.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,342.81,percent of total billed charges,,,85,,342.81,percent of total billed charges,,,49,,197.62,percent of total billed charges,,,90,,362.97,percent of total billed charges,,,,,,,no IP contract,,80,,322.64,percent of total billed charges,,,,,,,no IP contract,,50,,201.65,percent of total billed charges,,,,,,no IP contract,,,78,,314.57,percent of total billed charges,,,70,,282.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,197.62,3324,
finasteride 1 mg Tab,65862-0927-30,NDC,,,,inpatient,1,EA,25.35,15.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.55,percent of total billed charges,,,85,,21.55,percent of total billed charges,,,49,,12.42,percent of total billed charges,,,90,,22.82,percent of total billed charges,,,,,,,no IP contract,,80,,20.28,percent of total billed charges,,,,,,,no IP contract,,50,,12.68,percent of total billed charges,,,,,,no IP contract,,,78,,19.77,percent of total billed charges,,,70,,17.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.42,3324,
65862-0930-90 - sevelamer carbonate 0.8 g REC P,65862-0930-90,NDC,,,,inpatient,30,ML,149.25,89.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,120.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,126.86,percent of total billed charges,,,85,,126.86,percent of total billed charges,,,49,,73.13,percent of total billed charges,,,90,,134.33,percent of total billed charges,,,,,,,no IP contract,,80,,119.4,percent of total billed charges,,,,,,,no IP contract,,50,,74.63,percent of total billed charges,,,,,,no IP contract,,,78,,116.42,percent of total billed charges,,,70,,104.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,73.13,3324,
65862-0931-90 - sevelamer carbonate 2.4 g REC P,65862-0931-90,NDC,,,,inpatient,60,ML,149.25,89.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,120.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,126.86,percent of total billed charges,,,85,,126.86,percent of total billed charges,,,49,,73.13,percent of total billed charges,,,90,,134.33,percent of total billed charges,,,,,,,no IP contract,,80,,119.4,percent of total billed charges,,,,,,,no IP contract,,50,,74.63,percent of total billed charges,,,,,,no IP contract,,,78,,116.42,percent of total billed charges,,,70,,104.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,73.13,3324,
65862-0946-01 - dorzolamide-timolol ophthalmic 2%-0.5% Soln,65862-0946-01,NDC,,,,inpatient,1,UN,1025.5,615.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,830.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,871.68,percent of total billed charges,,,85,,871.68,percent of total billed charges,,,49,,502.5,percent of total billed charges,,,90,,922.95,percent of total billed charges,,,,,,,no IP contract,,80,,820.4,percent of total billed charges,,,,,,,no IP contract,,50,,512.75,percent of total billed charges,,,,,,no IP contract,,,78,,799.89,percent of total billed charges,,,70,,717.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,502.5,3324,
eszopiclone 1 mg Tab,65862-0967-01,NDC,,,,inpatient,1,EA,102.65,61.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,83.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,87.25,percent of total billed charges,,,85,,87.25,percent of total billed charges,,,49,,50.3,percent of total billed charges,,,90,,92.39,percent of total billed charges,,,,,,,no IP contract,,80,,82.12,percent of total billed charges,,,,,,,no IP contract,,50,,51.33,percent of total billed charges,,,,,,no IP contract,,,78,,80.07,percent of total billed charges,,,70,,71.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,50.3,3324,
66304-0836-01 -,66304-0836-01,NDC,,,,inpatient,1,EA,13.2,7.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.22,percent of total billed charges,,,85,,11.22,percent of total billed charges,,,49,,6.47,percent of total billed charges,,,90,,11.88,percent of total billed charges,,,,,,,no IP contract,,80,,10.56,percent of total billed charges,,,,,,,no IP contract,,50,,6.6,percent of total billed charges,,,,,,no IP contract,,,78,,10.3,percent of total billed charges,,,70,,9.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.47,3324,
66479-0022-82 - aminocaproic acid 1000 mg Tab,66479-0022-82,NDC,,,,inpatient,1,EA,63.7,38.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,51.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,54.15,percent of total billed charges,,,85,,54.15,percent of total billed charges,,,49,,31.21,percent of total billed charges,,,90,,57.33,percent of total billed charges,,,,,,,no IP contract,,80,,50.96,percent of total billed charges,,,,,,,no IP contract,,50,,31.85,percent of total billed charges,,,,,,no IP contract,,,78,,49.69,percent of total billed charges,,,70,,44.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.21,3324,
66479-0560-12 - morphine 20 mg/mL Conc,66479-0560-12,NDC,,,,inpatient,0.1,ML,10.25,6.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.71,percent of total billed charges,,,85,,8.71,percent of total billed charges,,,49,,5.02,percent of total billed charges,,,90,,9.23,percent of total billed charges,,,,,,,no IP contract,,80,,8.2,percent of total billed charges,,,,,,,no IP contract,,50,,5.13,percent of total billed charges,,,,,,no IP contract,,,78,,8,percent of total billed charges,,,70,,7.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.02,3324,
66490-0650-20 - diazepam 2.5 mg Kit,66490-0650-20,NDC,,,,inpatient,1,EA,2374.75,1424.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1923.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2018.54,percent of total billed charges,,,85,,2018.54,percent of total billed charges,,,49,,1163.63,percent of total billed charges,,,90,,2137.28,percent of total billed charges,,,,,,,no IP contract,,80,,1899.8,percent of total billed charges,,,,,,,no IP contract,,50,,1187.38,percent of total billed charges,,,,,,no IP contract,,,78,,1852.31,percent of total billed charges,,,70,,1662.33,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
diazepam 5 mg gel syringe,66490-0651-20,NDC,,,,inpatient,1,ME,1024.4,614.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,829.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,870.74,percent of total billed charges,,,85,,870.74,percent of total billed charges,,,49,,501.96,percent of total billed charges,,,90,,921.96,percent of total billed charges,,,,,,,no IP contract,,80,,819.52,percent of total billed charges,,,,,,,no IP contract,,50,,512.2,percent of total billed charges,,,,,,no IP contract,,,78,,799.03,percent of total billed charges,,,70,,717.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,501.96,3324,
66553-0001-01 - aspirin 325 mg Tab,66553-0001-01,NDC,,,,inpatient,1,EA,4.3,2.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.66,percent of total billed charges,,,85,,3.66,percent of total billed charges,,,49,,2.11,percent of total billed charges,,,90,,3.87,percent of total billed charges,,,,,,,no IP contract,,80,,3.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.15,percent of total billed charges,,,,,,no IP contract,,,78,,3.35,percent of total billed charges,,,70,,3.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.11,3324,
66553-0001-01 - aspirin 325 mg Tab,66553-0001-01,NDC,,,,inpatient,1,EA,4.3,2.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.66,percent of total billed charges,,,85,,3.66,percent of total billed charges,,,49,,2.11,percent of total billed charges,,,90,,3.87,percent of total billed charges,,,,,,,no IP contract,,80,,3.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.15,percent of total billed charges,,,,,,no IP contract,,,78,,3.35,percent of total billed charges,,,70,,3.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.11,3324,
66553-0002-01 - aspirin 81 mg Chew tab,66553-0002-01,NDC,,,,inpatient,1,EA,275,165,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,222.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,233.75,percent of total billed charges,,,85,,233.75,percent of total billed charges,,,49,,134.75,percent of total billed charges,,,90,,247.5,percent of total billed charges,,,,,,,no IP contract,,80,,220,percent of total billed charges,,,,,,,no IP contract,,50,,137.5,percent of total billed charges,,,,,,no IP contract,,,78,,214.5,percent of total billed charges,,,70,,192.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,134.75,3324,
66553-0004-01 - calcium carbonate 500 mg Chew,66553-0004-01,NDC,,,,inpatient,1,EA,4.4,2.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.74,percent of total billed charges,,,85,,3.74,percent of total billed charges,,,49,,2.16,percent of total billed charges,,,90,,3.96,percent of total billed charges,,,,,,,no IP contract,,80,,3.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.2,percent of total billed charges,,,,,,no IP contract,,,78,,3.43,percent of total billed charges,,,70,,3.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.16,3324,
66553-0005-01 - polycarbophil 625 mg Tab,66553-0005-01,NDC,,,,inpatient,1,EA,4.6,2.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.91,percent of total billed charges,,,85,,3.91,percent of total billed charges,,,49,,2.25,percent of total billed charges,,,90,,4.14,percent of total billed charges,,,,,,,no IP contract,,80,,3.68,percent of total billed charges,,,,,,,no IP contract,,50,,2.3,percent of total billed charges,,,,,,no IP contract,,,78,,3.59,percent of total billed charges,,,70,,3.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.25,3324,
66553-0008-01 - sodium bicarbonate 650 mg Tab,66553-0008-01,NDC,,,,inpatient,1,EA,4.4,2.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.74,percent of total billed charges,,,85,,3.74,percent of total billed charges,,,49,,2.16,percent of total billed charges,,,90,,3.96,percent of total billed charges,,,,,,,no IP contract,,80,,3.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.2,percent of total billed charges,,,,,,no IP contract,,,78,,3.43,percent of total billed charges,,,70,,3.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.16,3324,
66593-3126-02 - vancomycin 250 mg Cap,66593-3126-02,NDC,,,,inpatient,1,EA,262.9,157.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,212.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,223.47,percent of total billed charges,,,85,,223.47,percent of total billed charges,,,49,,128.82,percent of total billed charges,,,90,,236.61,percent of total billed charges,,,,,,,no IP contract,,80,,210.32,percent of total billed charges,,,,,,,no IP contract,,50,,131.45,percent of total billed charges,,,,,,no IP contract,,,78,,205.06,percent of total billed charges,,,70,,184.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,128.82,3324,
66685-1001-01 - amoxicillin-clavulanate 875 mg-125 mg Tab,66685-1001-01,NDC,,,,inpatient,1,EA,42.8,25.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36.38,percent of total billed charges,,,85,,36.38,percent of total billed charges,,,49,,20.97,percent of total billed charges,,,90,,38.52,percent of total billed charges,,,,,,,no IP contract,,80,,34.24,percent of total billed charges,,,,,,,no IP contract,,50,,21.4,percent of total billed charges,,,,,,no IP contract,,,78,,33.38,percent of total billed charges,,,70,,29.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.97,3324,
66685-1002-02 - amoxicillin-clavulanate 500 mg-125 mg Tab,66685-1002-02,NDC,,,,inpatient,1,EA,33,19.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,26.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.05,percent of total billed charges,,,85,,28.05,percent of total billed charges,,,49,,16.17,percent of total billed charges,,,90,,29.7,percent of total billed charges,,,,,,,no IP contract,,80,,26.4,percent of total billed charges,,,,,,,no IP contract,,50,,16.5,percent of total billed charges,,,,,,no IP contract,,,78,,25.74,percent of total billed charges,,,70,,23.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.17,3324,
66689-0020-50 - megestrol 40 mg/mL Susp,66689-0020-50,NDC,,,,inpatient,10,ML,41.25,24.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,35.06,percent of total billed charges,,,85,,35.06,percent of total billed charges,,,49,,20.21,percent of total billed charges,,,90,,37.13,percent of total billed charges,,,,,,,no IP contract,,80,,33,percent of total billed charges,,,,,,,no IP contract,,50,,20.63,percent of total billed charges,,,,,,no IP contract,,,78,,32.18,percent of total billed charges,,,70,,28.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.21,3324,
66689-0025-30 - oxyCODONE 20 mg/mL Conc,66689-0025-30,NDC,,,,inpatient,0.1,ML,52.4,31.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,42.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,44.54,percent of total billed charges,,,85,,44.54,percent of total billed charges,,,49,,25.68,percent of total billed charges,,,90,,47.16,percent of total billed charges,,,,,,,no IP contract,,80,,41.92,percent of total billed charges,,,,,,,no IP contract,,50,,26.2,percent of total billed charges,,,,,,no IP contract,,,78,,40.87,percent of total billed charges,,,70,,36.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.68,3324,
66689-0031-50 - metoclopramide 5 mg/5 mL Syrup,66689-0031-50,NDC,,,,inpatient,10,ML,11.25,6.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.56,percent of total billed charges,,,85,,9.56,percent of total billed charges,,,49,,5.51,percent of total billed charges,,,90,,10.13,percent of total billed charges,,,,,,,no IP contract,,80,,9,percent of total billed charges,,,,,,,no IP contract,,50,,5.63,percent of total billed charges,,,,,,no IP contract,,,78,,8.78,percent of total billed charges,,,70,,7.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.51,3324,
66689-0032-50 - morphine 10 mg/5 mL Soln,66689-0032-50,NDC,,,,inpatient,5,ML,11.25,6.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.56,percent of total billed charges,,,85,,9.56,percent of total billed charges,,,49,,5.51,percent of total billed charges,,,90,,10.13,percent of total billed charges,,,,,,,no IP contract,,80,,9,percent of total billed charges,,,,,,,no IP contract,,50,,5.63,percent of total billed charges,,,,,,no IP contract,,,78,,8.78,percent of total billed charges,,,70,,7.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.51,3324,
66689-0037-50 - nystatin 100000 units/mL Susp,66689-0037-50,NDC,,,,inpatient,5,ML,18.35,11.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.6,percent of total billed charges,,,85,,15.6,percent of total billed charges,,,49,,8.99,percent of total billed charges,,,90,,16.52,percent of total billed charges,,,,,,,no IP contract,,80,,14.68,percent of total billed charges,,,,,,,no IP contract,,50,,9.18,percent of total billed charges,,,,,,no IP contract,,,78,,14.31,percent of total billed charges,,,70,,12.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.99,3324,
66689-0038-50 - lactulose 10 g/15 mL Syrup,66689-0038-50,NDC,,,,inpatient,30,ML,15.4,9.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.09,percent of total billed charges,,,85,,13.09,percent of total billed charges,,,49,,7.55,percent of total billed charges,,,90,,13.86,percent of total billed charges,,,,,,,no IP contract,,80,,12.32,percent of total billed charges,,,,,,,no IP contract,,50,,7.7,percent of total billed charges,,,,,,no IP contract,,,78,,12.01,percent of total billed charges,,,70,,10.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.55,3324,
66689-0053-99 - magnesium hydroxide 8% Susp,66689-0053-99,NDC,,,,inpatient,30,ML,27.9,16.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.72,percent of total billed charges,,,85,,23.72,percent of total billed charges,,,49,,13.67,percent of total billed charges,,,90,,25.11,percent of total billed charges,,,,,,,no IP contract,,80,,22.32,percent of total billed charges,,,,,,,no IP contract,,50,,13.95,percent of total billed charges,,,,,,no IP contract,,,78,,21.76,percent of total billed charges,,,70,,19.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.67,3324,
66689-0056-99 - acetaminophen soln [UD] 160 mg / 5 mL Soln,66689-0056-99,NDC,,,,inpatient,20.3,ML,28.75,17.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.44,percent of total billed charges,,,85,,24.44,percent of total billed charges,,,49,,14.09,percent of total billed charges,,,90,,25.88,percent of total billed charges,,,,,,,no IP contract,,80,,23,percent of total billed charges,,,,,,,no IP contract,,50,,14.38,percent of total billed charges,,,,,,no IP contract,,,78,,22.43,percent of total billed charges,,,70,,20.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.09,3324,
66689-0305-16 - sucralfate 1 g/10 mL Susp,66689-0305-16,NDC,,,,inpatient,1,ML,10.15,6.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.63,percent of total billed charges,,,85,,8.63,percent of total billed charges,,,49,,4.97,percent of total billed charges,,,90,,9.14,percent of total billed charges,,,,,,,no IP contract,,80,,8.12,percent of total billed charges,,,,,,,no IP contract,,50,,5.08,percent of total billed charges,,,,,,no IP contract,,,78,,7.92,percent of total billed charges,,,70,,7.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.97,3324,
66689-0327-02 - digoxin 50 mcg/mL (0.05 mg/mL) Elixi,66689-0327-02,NDC,,,,inpatient,1,ML,26.1,15.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.19,percent of total billed charges,,,85,,22.19,percent of total billed charges,,,49,,12.79,percent of total billed charges,,,90,,23.49,percent of total billed charges,,,,,,,no IP contract,,80,,20.88,percent of total billed charges,,,,,,,no IP contract,,50,,13.05,percent of total billed charges,,,,,,no IP contract,,,78,,20.36,percent of total billed charges,,,70,,18.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.79,3324,
66689-0347-02 - sirolimus 1 mg/mL Soln,66689-0347-02,NDC,,,,inpatient,1,ML,296.95,178.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,240.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,252.41,percent of total billed charges,,,85,,252.41,percent of total billed charges,,,49,,145.51,percent of total billed charges,,,90,,267.26,percent of total billed charges,,,,,,,no IP contract,,80,,237.56,percent of total billed charges,,,,,,,no IP contract,,50,,148.48,percent of total billed charges,,,,,,no IP contract,,,78,,231.62,percent of total billed charges,,,70,,207.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,145.51,3324,
66689-0401-50 - oxyCODONE 5 mg/5 mL Soln,66689-0401-50,NDC,,,,inpatient,5,ML,42.9,25.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36.47,percent of total billed charges,,,85,,36.47,percent of total billed charges,,,49,,21.02,percent of total billed charges,,,90,,38.61,percent of total billed charges,,,,,,,no IP contract,,80,,34.32,percent of total billed charges,,,,,,,no IP contract,,50,,21.45,percent of total billed charges,,,,,,no IP contract,,,78,,33.46,percent of total billed charges,,,70,,30.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.02,3324,
66689-0403-16 - oxycodone 5 mg/5 mL Soln,66689-0403-16,NDC,,,,inpatient,1,ML,7,4.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.95,percent of total billed charges,,,85,,5.95,percent of total billed charges,,,49,,3.43,percent of total billed charges,,,90,,6.3,percent of total billed charges,,,,,,,no IP contract,,80,,5.6,percent of total billed charges,,,,,,,no IP contract,,50,,3.5,percent of total billed charges,,,,,,no IP contract,,,78,,5.46,percent of total billed charges,,,70,,4.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.43,3324,
66689-0694-30 - methadone 10 mg/mL Conc,66689-0694-30,NDC,,,,inpatient,1,ML,33.15,19.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,26.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.18,percent of total billed charges,,,85,,28.18,percent of total billed charges,,,49,,16.24,percent of total billed charges,,,90,,29.84,percent of total billed charges,,,,,,,no IP contract,,80,,26.52,percent of total billed charges,,,,,,,no IP contract,,50,,16.58,percent of total billed charges,,,,,,no IP contract,,,78,,25.86,percent of total billed charges,,,70,,23.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.24,3324,
66689-0711-16 - methadone 5 mg/5 mL Soln,66689-0711-16,NDC,,,,inpatient,1,ML,6.15,3.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.23,percent of total billed charges,,,85,,5.23,percent of total billed charges,,,49,,3.01,percent of total billed charges,,,90,,5.54,percent of total billed charges,,,,,,,no IP contract,,80,,4.92,percent of total billed charges,,,,,,,no IP contract,,50,,3.08,percent of total billed charges,,,,,,no IP contract,,,78,,4.8,percent of total billed charges,,,70,,4.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.01,3324,
66689-0735-05 - ARIPiprazole 1 mg/mL Soln,66689-0735-05,NDC,,,,inpatient,1,ML,22.75,13.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.34,percent of total billed charges,,,85,,19.34,percent of total billed charges,,,49,,11.15,percent of total billed charges,,,90,,20.48,percent of total billed charges,,,,,,,no IP contract,,80,,18.2,percent of total billed charges,,,,,,,no IP contract,,50,,11.38,percent of total billed charges,,,,,,no IP contract,,,78,,17.75,percent of total billed charges,,,70,,15.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.15,3324,
66758-0004-02 - cysteine 50 mg/mL Soln,66758-0004-02,NDC,,,,inpatient,1,ML,22.05,13.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.74,percent of total billed charges,,,85,,18.74,percent of total billed charges,,,49,,10.8,percent of total billed charges,,,90,,19.85,percent of total billed charges,,,,,,,no IP contract,,80,,17.64,percent of total billed charges,,,,,,,no IP contract,,50,,11.03,percent of total billed charges,,,,,,no IP contract,,,78,,17.2,percent of total billed charges,,,70,,15.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.8,3324,
66758-0160-13 - potassium chloride 10 mEq ER Tablet,66758-0160-13,NDC,,,,inpatient,1,EA,9,5.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.65,percent of total billed charges,,,85,,7.65,percent of total billed charges,,,49,,4.41,percent of total billed charges,,,90,,8.1,percent of total billed charges,,,,,,,no IP contract,,80,,7.2,percent of total billed charges,,,,,,,no IP contract,,50,,4.5,percent of total billed charges,,,,,,no IP contract,,,78,,7.02,percent of total billed charges,,,70,,6.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.41,3324,
66780-0210-07 - exenatide 250 mcg/mL Soln,66780-0210-07,NDC,,,,inpatient,0.02,ML,628.15,376.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,508.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,533.93,percent of total billed charges,,,85,,533.93,percent of total billed charges,,,49,,307.79,percent of total billed charges,,,90,,565.34,percent of total billed charges,,,,,,,no IP contract,,80,,502.52,percent of total billed charges,,,,,,,no IP contract,,50,,314.08,percent of total billed charges,,,,,,no IP contract,,,78,,489.96,percent of total billed charges,,,70,,439.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,307.79,3324,
baclofen 0.5 mg/mL Soln,66794-0155-02,NDC,,,,inpatient,1,EA,734.55,440.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,594.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,624.37,percent of total billed charges,,,85,,624.37,percent of total billed charges,,,49,,359.93,percent of total billed charges,,,90,,661.1,percent of total billed charges,,,,,,,no IP contract,,80,,587.64,percent of total billed charges,,,,,,,no IP contract,,50,,367.28,percent of total billed charges,,,,,,no IP contract,,,78,,572.95,percent of total billed charges,,,70,,514.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,359.93,3324,
baclofen 1 mg/mL Soln,66794-0156-02,NDC,,,,inpatient,1,EA,1468.55,881.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1189.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1248.27,percent of total billed charges,,,85,,1248.27,percent of total billed charges,,,49,,719.59,percent of total billed charges,,,90,,1321.7,percent of total billed charges,,,,,,,no IP contract,,80,,1174.84,percent of total billed charges,,,,,,,no IP contract,,50,,734.28,percent of total billed charges,,,,,,no IP contract,,,78,,1145.47,percent of total billed charges,,,70,,1027.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,719.59,3324,
baclofen 2 mg/mL Soln,66794-0157-02,NDC,,,,inpatient,1,EA,2937.6,1762.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2379.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2496.96,percent of total billed charges,,,85,,2496.96,percent of total billed charges,,,49,,1439.42,percent of total billed charges,,,90,,2643.84,percent of total billed charges,,,,,,,no IP contract,,80,,2350.08,percent of total billed charges,,,,,,,no IP contract,,50,,1468.8,percent of total billed charges,,,,,,no IP contract,,,78,,2291.33,percent of total billed charges,,,70,,2056.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
66794-0206-41 - ampicillin-sulbactam 1 g-0.5 g REC I,66794-0206-41,NDC,,,,inpatient,1,EA,127.6,76.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,103.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,108.46,percent of total billed charges,,,85,,108.46,percent of total billed charges,,,49,,62.52,percent of total billed charges,,,90,,114.84,percent of total billed charges,,,,,,,no IP contract,,80,,102.08,percent of total billed charges,,,,,,,no IP contract,,50,,63.8,percent of total billed charges,,,,,,no IP contract,,,78,,99.53,percent of total billed charges,,,70,,89.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,62.52,3324,
66794-0207-41 - ampicillin-SULbactam [Unasyn] 3 gm REC Injection,66794-0207-41,NDC,,,,inpatient,8,ML,95.3,57.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,77.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,81.01,percent of total billed charges,,,85,,81.01,percent of total billed charges,,,49,,46.7,percent of total billed charges,,,90,,85.77,percent of total billed charges,,,,,,,no IP contract,,80,,76.24,percent of total billed charges,,,,,,,no IP contract,,50,,47.65,percent of total billed charges,,,,,,no IP contract,,,78,,74.33,percent of total billed charges,,,70,,66.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,46.7,3324,
66794-0219-43 - linezolid 2 mg/mL-D5% Soln,66794-0219-43,NDC,,,,inpatient,300,ML,211.65,126.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,171.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,179.9,percent of total billed charges,,,85,,179.9,percent of total billed charges,,,49,,103.71,percent of total billed charges,,,90,,190.49,percent of total billed charges,,,,,,,no IP contract,,80,,169.32,percent of total billed charges,,,,,,,no IP contract,,50,,105.83,percent of total billed charges,,,,,,no IP contract,,,78,,165.09,percent of total billed charges,,,70,,148.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,103.71,3324,
66825-0002-01 - saccharomyces boulardii lyo 250 mg Cap,66825-0002-01,NDC,,,,inpatient,1,EA,10.8,6.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.18,percent of total billed charges,,,85,,9.18,percent of total billed charges,,,49,,5.29,percent of total billed charges,,,90,,9.72,percent of total billed charges,,,,,,,no IP contract,,80,,8.64,percent of total billed charges,,,,,,,no IP contract,,50,,5.4,percent of total billed charges,,,,,,no IP contract,,,78,,8.42,percent of total billed charges,,,70,,7.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.29,3324,
66993-0019-68 - albuterol 90 mcg/inh Aeros,66993-0019-68,NDC,,,,inpatient,1,UN,254.9,152.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,206.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,216.67,percent of total billed charges,,,85,,216.67,percent of total billed charges,,,49,,124.9,percent of total billed charges,,,90,,229.41,percent of total billed charges,,,,,,,no IP contract,,80,,203.92,percent of total billed charges,,,,,,,no IP contract,,50,,127.45,percent of total billed charges,,,,,,no IP contract,,,78,,198.82,percent of total billed charges,,,70,,178.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,124.9,3324,
66993-0022-27 - levalbuterol 0.63 mg/3 mL Soln,66993-0022-27,NDC,,,,inpatient,3,ML,64.95,38.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,52.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,55.21,percent of total billed charges,,,85,,55.21,percent of total billed charges,,,49,,31.83,percent of total billed charges,,,90,,58.46,percent of total billed charges,,,,,,,no IP contract,,80,,51.96,percent of total billed charges,,,,,,,no IP contract,,50,,32.48,percent of total billed charges,,,,,,no IP contract,,,78,,50.66,percent of total billed charges,,,70,,45.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.83,3324,
66993-0023-27 - levalbuterol 1.25 mg/3 mL Soln,66993-0023-27,NDC,,,,inpatient,3,ML,64.95,38.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,52.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,55.21,percent of total billed charges,,,85,,55.21,percent of total billed charges,,,49,,31.83,percent of total billed charges,,,90,,58.46,percent of total billed charges,,,,,,,no IP contract,,80,,51.96,percent of total billed charges,,,,,,,no IP contract,,50,,32.48,percent of total billed charges,,,,,,no IP contract,,,78,,50.66,percent of total billed charges,,,70,,45.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.83,3324,
66993-0025-01 - desmopressin 10 mcg/inh Spray,66993-0025-01,NDC,,,,inpatient,1,UN,2066.3,1239.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1673.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1756.36,percent of total billed charges,,,85,,1756.36,percent of total billed charges,,,49,,1012.49,percent of total billed charges,,,90,,1859.67,percent of total billed charges,,,,,,,no IP contract,,80,,1653.04,percent of total billed charges,,,,,,,no IP contract,,50,,1033.15,percent of total billed charges,,,,,,no IP contract,,,78,,1611.71,percent of total billed charges,,,70,,1446.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
66993-0041-30 - atomoxetine 18 mg Cap,66993-0041-30,NDC,,,,inpatient,1,EA,116.85,70.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,94.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,99.32,percent of total billed charges,,,85,,99.32,percent of total billed charges,,,49,,57.26,percent of total billed charges,,,90,,105.17,percent of total billed charges,,,,,,,no IP contract,,80,,93.48,percent of total billed charges,,,,,,,no IP contract,,50,,58.43,percent of total billed charges,,,,,,no IP contract,,,78,,91.14,percent of total billed charges,,,70,,81.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,57.26,3324,
66993-0062-72 - atovaquone 750 mg/5 mL Susp,66993-0062-72,NDC,,,,inpatient,1,ML,60.05,36.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,48.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,51.04,percent of total billed charges,,,85,,51.04,percent of total billed charges,,,49,,29.42,percent of total billed charges,,,90,,54.05,percent of total billed charges,,,,,,,no IP contract,,80,,48.04,percent of total billed charges,,,,,,,no IP contract,,50,,30.03,percent of total billed charges,,,,,,no IP contract,,,78,,46.84,percent of total billed charges,,,70,,42.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,29.42,3324,
66993-0078-96 - fluticasone 44 mcg / 1 INH Inhaler,66993-0078-96,NDC,,,,inpatient,1,UN,1951.8,1171.08,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1580.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1659.03,percent of total billed charges,,,85,,1659.03,percent of total billed charges,,,49,,956.38,percent of total billed charges,,,90,,1756.62,percent of total billed charges,,,,,,,no IP contract,,80,,1561.44,percent of total billed charges,,,,,,,no IP contract,,50,,975.9,percent of total billed charges,,,,,,no IP contract,,,78,,1522.4,percent of total billed charges,,,70,,1366.26,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,956.38,3324,
66993-0079-96 - fluticasone CFC free 110 mcg/inh Aeros,66993-0079-96,NDC,,,,inpatient,1,UN,2609.2,1565.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2113.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2217.82,percent of total billed charges,,,85,,2217.82,percent of total billed charges,,,49,,1278.51,percent of total billed charges,,,90,,2348.28,percent of total billed charges,,,,,,,no IP contract,,80,,2087.36,percent of total billed charges,,,,,,,no IP contract,,50,,1304.6,percent of total billed charges,,,,,,no IP contract,,,78,,2035.18,percent of total billed charges,,,70,,1826.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
66993-0080-96 - fluticasone CFC free 220 mcg/inh Aeros,66993-0080-96,NDC,,,,inpatient,1,UN,4048.6,2429.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3279.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3441.31,percent of total billed charges,,,85,,3441.31,percent of total billed charges,,,49,,1983.81,percent of total billed charges,,,90,,3643.74,percent of total billed charges,,,,,,,no IP contract,,80,,3238.88,percent of total billed charges,,,,,,,no IP contract,,50,,2024.3,percent of total billed charges,,,,,,no IP contract,,,78,,3157.91,percent of total billed charges,,,70,,2834.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3643.74,
66993-0165-02 - colchicine 0.6 mg Tab,66993-0165-02,NDC,,,,inpatient,1,EA,57.4,34.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,46.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,48.79,percent of total billed charges,,,85,,48.79,percent of total billed charges,,,49,,28.13,percent of total billed charges,,,90,,51.66,percent of total billed charges,,,,,,,no IP contract,,80,,45.92,percent of total billed charges,,,,,,,no IP contract,,50,,28.7,percent of total billed charges,,,,,,no IP contract,,,78,,44.77,percent of total billed charges,,,70,,40.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,28.13,3324,
phenytoin 50 mg Chew,66993-0372-02,NDC,,,,inpatient,1,EA,8.05,4.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.84,percent of total billed charges,,,85,,6.84,percent of total billed charges,,,49,,3.94,percent of total billed charges,,,90,,7.25,percent of total billed charges,,,,,,,no IP contract,,80,,6.44,percent of total billed charges,,,,,,,no IP contract,,50,,4.03,percent of total billed charges,,,,,,no IP contract,,,78,,6.28,percent of total billed charges,,,70,,5.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.94,3324,
66993-0407-32 - carBAMazepine 100 mg ER Ca,66993-0407-32,NDC,,,,inpatient,1,EA,18.05,10.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.34,percent of total billed charges,,,85,,15.34,percent of total billed charges,,,49,,8.84,percent of total billed charges,,,90,,16.25,percent of total billed charges,,,,,,,no IP contract,,80,,14.44,percent of total billed charges,,,,,,,no IP contract,,50,,9.03,percent of total billed charges,,,,,,no IP contract,,,78,,14.08,percent of total billed charges,,,70,,12.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.84,3324,
66993-0687-38 - olanzapine DIS Tab 10 mg Tab,66993-0687-38,NDC,,,,inpatient,1,EA,170.4,102.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,138.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,144.84,percent of total billed charges,,,85,,144.84,percent of total billed charges,,,49,,83.5,percent of total billed charges,,,90,,153.36,percent of total billed charges,,,,,,,no IP contract,,80,,136.32,percent of total billed charges,,,,,,,no IP contract,,50,,85.2,percent of total billed charges,,,,,,no IP contract,,,78,,132.91,percent of total billed charges,,,70,,119.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,83.5,3324,
66993-0877-61 - calcipotriene topical 0.005% Cream,66993-0877-61,NDC,,,,inpatient,1,UN,3537.8,2122.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2865.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3007.13,percent of total billed charges,,,85,,3007.13,percent of total billed charges,,,49,,1733.52,percent of total billed charges,,,90,,3184.02,percent of total billed charges,,,,,,,no IP contract,,80,,2830.24,percent of total billed charges,,,,,,,no IP contract,,50,,1768.9,percent of total billed charges,,,,,,no IP contract,,,78,,2759.48,percent of total billed charges,,,70,,2476.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
67112-0905-50 - multivitamin Vitamin D and K Cap,67112-0905-50,NDC,,,,inpatient,1,EA,13.85,8.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.77,percent of total billed charges,,,85,,11.77,percent of total billed charges,,,49,,6.79,percent of total billed charges,,,90,,12.47,percent of total billed charges,,,,,,,no IP contract,,80,,11.08,percent of total billed charges,,,,,,,no IP contract,,50,,6.93,percent of total billed charges,,,,,,no IP contract,,,78,,10.8,percent of total billed charges,,,70,,9.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.79,3324,
67159-0112-03 - ranolazine 500 mg ER Ta,67159-0112-03,NDC,,,,inpatient,1,EA,34.85,20.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.62,percent of total billed charges,,,85,,29.62,percent of total billed charges,,,49,,17.08,percent of total billed charges,,,90,,31.37,percent of total billed charges,,,,,,,no IP contract,,80,,27.88,percent of total billed charges,,,,,,,no IP contract,,50,,17.43,percent of total billed charges,,,,,,no IP contract,,,78,,27.18,percent of total billed charges,,,70,,24.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.08,3324,
67253-0141-10 - amoxicillin 500 mg Cap,67253-0141-10,NDC,,,,inpatient,1,EA,8.5,5.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.23,percent of total billed charges,,,85,,7.23,percent of total billed charges,,,49,,4.17,percent of total billed charges,,,90,,7.65,percent of total billed charges,,,,,,,no IP contract,,80,,6.8,percent of total billed charges,,,,,,,no IP contract,,50,,4.25,percent of total billed charges,,,,,,no IP contract,,,78,,6.63,percent of total billed charges,,,70,,5.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.17,3324,
67253-0180-10 - ampicillin 250 mg Cap,67253-0180-10,NDC,,,,inpatient,1,EA,5.55,3.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.72,percent of total billed charges,,,85,,4.72,percent of total billed charges,,,49,,2.72,percent of total billed charges,,,90,,5,percent of total billed charges,,,,,,,no IP contract,,80,,4.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.78,percent of total billed charges,,,,,,no IP contract,,,78,,4.33,percent of total billed charges,,,70,,3.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.72,3324,
67253-0181-10 - ampicillin 500 mg Cap,67253-0181-10,NDC,,,,inpatient,1,EA,6.85,4.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.82,percent of total billed charges,,,85,,5.82,percent of total billed charges,,,49,,3.36,percent of total billed charges,,,90,,6.17,percent of total billed charges,,,,,,,no IP contract,,80,,5.48,percent of total billed charges,,,,,,,no IP contract,,50,,3.43,percent of total billed charges,,,,,,no IP contract,,,78,,5.34,percent of total billed charges,,,70,,4.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.36,3324,
67253-0700-06 - selegiline 5 mg Cap,67253-0700-06,NDC,,,,inpatient,1,EA,22.1,13.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.79,percent of total billed charges,,,85,,18.79,percent of total billed charges,,,49,,10.83,percent of total billed charges,,,90,,19.89,percent of total billed charges,,,,,,,no IP contract,,80,,17.68,percent of total billed charges,,,,,,,no IP contract,,50,,11.05,percent of total billed charges,,,,,,no IP contract,,,78,,17.24,percent of total billed charges,,,70,,15.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.83,3324,
67253-0900-10 - ALPRAZolam 0.25 mg Tab,67253-0900-10,NDC,,,,inpatient,1,EA,11.25,6.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.56,percent of total billed charges,,,85,,9.56,percent of total billed charges,,,49,,5.51,percent of total billed charges,,,90,,10.13,percent of total billed charges,,,,,,,no IP contract,,80,,9,percent of total billed charges,,,,,,,no IP contract,,50,,5.63,percent of total billed charges,,,,,,no IP contract,,,78,,8.78,percent of total billed charges,,,70,,7.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.51,3324,
67286-0771-01 - isosorbide mononitrate 20 mg Tab,67286-0771-01,NDC,,,,inpatient,1,EA,19.1,11.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.24,percent of total billed charges,,,85,,16.24,percent of total billed charges,,,49,,9.36,percent of total billed charges,,,90,,17.19,percent of total billed charges,,,,,,,no IP contract,,80,,15.28,percent of total billed charges,,,,,,,no IP contract,,50,,9.55,percent of total billed charges,,,,,,no IP contract,,,78,,14.9,percent of total billed charges,,,70,,13.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.36,3324,
67386-0311-01 - clobazam 10 mg Tab,67386-0311-01,NDC,,,,inpatient,1,EA,66.7,40.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,54.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.7,percent of total billed charges,,,85,,56.7,percent of total billed charges,,,49,,32.68,percent of total billed charges,,,90,,60.03,percent of total billed charges,,,,,,,no IP contract,,80,,53.36,percent of total billed charges,,,,,,,no IP contract,,50,,33.35,percent of total billed charges,,,,,,no IP contract,,,78,,52.03,percent of total billed charges,,,70,,46.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.68,3324,
67386-0313-21 - clobazam 2.5 mg/mL Susp,67386-0313-21,NDC,,,,inpatient,1,ML,56.05,33.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,45.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,47.64,percent of total billed charges,,,85,,47.64,percent of total billed charges,,,49,,27.46,percent of total billed charges,,,90,,50.45,percent of total billed charges,,,,,,,no IP contract,,80,,44.84,percent of total billed charges,,,,,,,no IP contract,,50,,28.03,percent of total billed charges,,,,,,no IP contract,,,78,,43.72,percent of total billed charges,,,70,,39.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.46,3324,
67386-0314-01 - clobazam 10 mg Tab,67386-0314-01,NDC,,,,inpatient,1,EA,66.7,40.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,54.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.7,percent of total billed charges,,,85,,56.7,percent of total billed charges,,,49,,32.68,percent of total billed charges,,,90,,60.03,percent of total billed charges,,,,,,,no IP contract,,80,,53.36,percent of total billed charges,,,,,,,no IP contract,,50,,33.35,percent of total billed charges,,,,,,no IP contract,,,78,,52.03,percent of total billed charges,,,70,,46.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.68,3324,
67457-0118-50 - ascorbic acid 500 mg/mL Soln,67457-0118-50,NDC,,,,inpatient,1,ML,12.6,7.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.71,percent of total billed charges,,,85,,10.71,percent of total billed charges,,,49,,6.17,percent of total billed charges,,,90,,11.34,percent of total billed charges,,,,,,,no IP contract,,80,,10.08,percent of total billed charges,,,,,,,no IP contract,,50,,6.3,percent of total billed charges,,,,,,no IP contract,,,78,,9.83,percent of total billed charges,,,70,,8.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.17,3324,
67457-0196-02 - thiamine 100 mg/mL Soln,67457-0196-02,NDC,,,,inpatient,2,ML,100.55,60.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,81.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,85.47,percent of total billed charges,,,85,,85.47,percent of total billed charges,,,49,,49.27,percent of total billed charges,,,90,,90.5,percent of total billed charges,,,,,,,no IP contract,,80,,80.44,percent of total billed charges,,,,,,,no IP contract,,50,,50.28,percent of total billed charges,,,,,,no IP contract,,,78,,78.43,percent of total billed charges,,,70,,70.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,49.27,3324,
67457-0239-01 - octreotide 50 mcg/mL Soln,67457-0239-01,NDC,,,,inpatient,1,ML,49.8,29.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,40.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,42.33,percent of total billed charges,,,85,,42.33,percent of total billed charges,,,49,,24.4,percent of total billed charges,,,90,,44.82,percent of total billed charges,,,,,,,no IP contract,,80,,39.84,percent of total billed charges,,,,,,,no IP contract,,50,,24.9,percent of total billed charges,,,,,,no IP contract,,,78,,38.84,percent of total billed charges,,,70,,34.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.4,3324,
67457-0292-02 - naloxone 0.4 mg/mL Soln,67457-0292-02,NDC,,,,inpatient,1,ML,212.15,127.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,171.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,180.33,percent of total billed charges,,,85,,180.33,percent of total billed charges,,,49,,103.95,percent of total billed charges,,,90,,190.94,percent of total billed charges,,,,,,,no IP contract,,80,,169.72,percent of total billed charges,,,,,,,no IP contract,,50,,106.08,percent of total billed charges,,,,,,no IP contract,,,78,,165.48,percent of total billed charges,,,70,,148.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,103.95,3324,
67457-0352-10 - ampicillin 2 g REC I,67457-0352-10,NDC,,,,inpatient,1,EA,207.75,124.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,168.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,176.59,percent of total billed charges,,,85,,176.59,percent of total billed charges,,,49,,101.8,percent of total billed charges,,,90,,186.98,percent of total billed charges,,,,,,,no IP contract,,80,,166.2,percent of total billed charges,,,,,,,no IP contract,,50,,103.88,percent of total billed charges,,,,,,no IP contract,,,78,,162.05,percent of total billed charges,,,70,,145.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,101.8,3324,
67457-0385-99 - heparin 1000 units/mL Soln,67457-0385-99,NDC,,,,inpatient,10,ML,45.55,27.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,38.72,percent of total billed charges,,,85,,38.72,percent of total billed charges,,,49,,22.32,percent of total billed charges,,,90,,41,percent of total billed charges,,,,,,,no IP contract,,80,,36.44,percent of total billed charges,,,,,,,no IP contract,,50,,22.78,percent of total billed charges,,,,,,no IP contract,,,78,,35.53,percent of total billed charges,,,70,,31.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.32,3324,
67457-0421-30 - dexamethasone 4 mg/mL Soln,67457-0421-30,NDC,,,,inpatient,1,ML,115.55,69.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,93.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,98.22,percent of total billed charges,,,85,,98.22,percent of total billed charges,,,49,,56.62,percent of total billed charges,,,90,,104,percent of total billed charges,,,,,,,no IP contract,,80,,92.44,percent of total billed charges,,,,,,,no IP contract,,50,,57.78,percent of total billed charges,,,,,,no IP contract,,,78,,90.13,percent of total billed charges,,,70,,80.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,56.62,3324,
67457-0445-60 - rifampin 600 mg REC I,67457-0445-60,NDC,,,,inpatient,10,ML,1633.2,979.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1322.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1388.22,percent of total billed charges,,,85,,1388.22,percent of total billed charges,,,49,,800.27,percent of total billed charges,,,90,,1469.88,percent of total billed charges,,,,,,,no IP contract,,80,,1306.56,percent of total billed charges,,,,,,,no IP contract,,50,,816.6,percent of total billed charges,,,,,,no IP contract,,,78,,1273.9,percent of total billed charges,,,70,,1143.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,800.27,3324,
67457-0455-52 - cytarabine 20 mg/mL Soln,67457-0455-52,NDC,,,,inpatient,1,ML,44.9,26.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,38.17,percent of total billed charges,,,85,,38.17,percent of total billed charges,,,49,,22,percent of total billed charges,,,90,,40.41,percent of total billed charges,,,,,,,no IP contract,,80,,35.92,percent of total billed charges,,,,,,,no IP contract,,50,,22.45,percent of total billed charges,,,,,,no IP contract,,,78,,35.02,percent of total billed charges,,,70,,31.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22,3324,
67457-0523-45 - piperacillin-tazobactam 4 g-0.5 g REC I,67457-0523-45,NDC,,,,inpatient,1,EA,304.6,182.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,246.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,258.91,percent of total billed charges,,,85,,258.91,percent of total billed charges,,,49,,149.25,percent of total billed charges,,,90,,274.14,percent of total billed charges,,,,,,,no IP contract,,80,,243.68,percent of total billed charges,,,,,,,no IP contract,,50,,152.3,percent of total billed charges,,,,,,no IP contract,,,78,,237.59,percent of total billed charges,,,70,,213.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,149.25,3324,
67457-0582-10 - fondaparinux 2.5 mg Injection,67457-0582-10,NDC,,,,inpatient,0.5,ML,930.7,558.42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,753.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,791.1,percent of total billed charges,,,85,,791.1,percent of total billed charges,,,49,,456.04,percent of total billed charges,,,90,,837.63,percent of total billed charges,,,,,,,no IP contract,,80,,744.56,percent of total billed charges,,,,,,,no IP contract,,50,,465.35,percent of total billed charges,,,,,,no IP contract,,,78,,725.95,percent of total billed charges,,,70,,651.49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,456.04,3324,
67457-0585-08 - fondaparinux 10 mg/0.8 mL Soln,67457-0585-08,NDC,,,,inpatient,0.8,ML,1364.55,818.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1105.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1159.87,percent of total billed charges,,,85,,1159.87,percent of total billed charges,,,49,,668.63,percent of total billed charges,,,90,,1228.1,percent of total billed charges,,,,,,,no IP contract,,80,,1091.64,percent of total billed charges,,,,,,,no IP contract,,50,,682.28,percent of total billed charges,,,,,,no IP contract,,,78,,1064.35,percent of total billed charges,,,70,,955.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,668.63,3324,
67457-0675-02 - calcitonin INJection 200 unit(s) / 1 mL Injection,67457-0675-02,NDC,,,,inpatient,1,ML,10421.2,6252.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8441.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8858.02,percent of total billed charges,,,85,,8858.02,percent of total billed charges,,,49,,5106.39,percent of total billed charges,,,90,,9379.08,percent of total billed charges,,,,,,,no IP contract,,80,,8336.96,percent of total billed charges,,,,,,,no IP contract,,50,,5210.6,percent of total billed charges,,,,,,no IP contract,,,78,,8128.54,percent of total billed charges,,,70,,7294.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,9379.08,
67618-0300-10 - senna 8.6 mg Tab,67618-0300-10,NDC,,,,inpatient,1,EA,5.35,3.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.55,percent of total billed charges,,,85,,4.55,percent of total billed charges,,,49,,2.62,percent of total billed charges,,,90,,4.82,percent of total billed charges,,,,,,,no IP contract,,80,,4.28,percent of total billed charges,,,,,,,no IP contract,,50,,2.68,percent of total billed charges,,,,,,no IP contract,,,78,,4.17,percent of total billed charges,,,70,,3.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.62,3324,
67618-0300-50 - senna 8.6 mg Tab,67618-0300-50,NDC,,,,inpatient,1,EA,5.5,3.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.68,percent of total billed charges,,,85,,4.68,percent of total billed charges,,,49,,2.7,percent of total billed charges,,,90,,4.95,percent of total billed charges,,,,,,,no IP contract,,80,,4.4,percent of total billed charges,,,,,,,no IP contract,,50,,2.75,percent of total billed charges,,,,,,no IP contract,,,78,,4.29,percent of total billed charges,,,70,,3.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.7,3324,
67850-0022-10 - ampicillin 2 g REC I,67850-0022-10,NDC,,,,inpatient,1,EA,206.75,124.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,167.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,175.74,percent of total billed charges,,,85,,175.74,percent of total billed charges,,,49,,101.31,percent of total billed charges,,,90,,186.08,percent of total billed charges,,,,,,,no IP contract,,80,,165.4,percent of total billed charges,,,,,,,no IP contract,,50,,103.38,percent of total billed charges,,,,,,no IP contract,,,78,,161.27,percent of total billed charges,,,70,,144.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,101.31,3324,
67857-0702-01 - isosorbide mononitrate 20 mg Tab,67857-0702-01,NDC,,,,inpatient,1,EA,19.1,11.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.24,percent of total billed charges,,,85,,16.24,percent of total billed charges,,,49,,9.36,percent of total billed charges,,,90,,17.19,percent of total billed charges,,,,,,,no IP contract,,80,,15.28,percent of total billed charges,,,,,,,no IP contract,,50,,9.55,percent of total billed charges,,,,,,no IP contract,,,78,,14.9,percent of total billed charges,,,70,,13.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.36,3324,
67877-0124-05 - silver sulfADIAZINE topical 1% Cream,67877-0124-05,NDC,,,,inpatient,1,UN,134.15,80.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,108.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,114.03,percent of total billed charges,,,85,,114.03,percent of total billed charges,,,49,,65.73,percent of total billed charges,,,90,,120.74,percent of total billed charges,,,,,,,no IP contract,,80,,107.32,percent of total billed charges,,,,,,,no IP contract,,50,,67.08,percent of total billed charges,,,,,,no IP contract,,,78,,104.64,percent of total billed charges,,,70,,93.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,65.73,3324,
67877-0124-40 - silver sulfADIAZINE topical 1% Cream,67877-0124-40,NDC,,,,inpatient,1,UN,542.35,325.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,439.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,461,percent of total billed charges,,,85,,461,percent of total billed charges,,,49,,265.75,percent of total billed charges,,,90,,488.12,percent of total billed charges,,,,,,,no IP contract,,80,,433.88,percent of total billed charges,,,,,,,no IP contract,,50,,271.18,percent of total billed charges,,,,,,no IP contract,,,78,,423.03,percent of total billed charges,,,70,,379.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,265.75,3324,
67877-0146-01 - temazepam 15 mg Cap,67877-0146-01,NDC,,,,inpatient,1,EA,12.15,7.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.33,percent of total billed charges,,,85,,10.33,percent of total billed charges,,,49,,5.95,percent of total billed charges,,,90,,10.94,percent of total billed charges,,,,,,,no IP contract,,80,,9.72,percent of total billed charges,,,,,,,no IP contract,,50,,6.08,percent of total billed charges,,,,,,no IP contract,,,78,,9.48,percent of total billed charges,,,70,,8.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.95,3324,
67877-0197-90 - amLODIPine 2.5 mg Tab,67877-0197-90,NDC,,,,inpatient,1,EA,17.65,10.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15,percent of total billed charges,,,85,,15,percent of total billed charges,,,49,,8.65,percent of total billed charges,,,90,,15.89,percent of total billed charges,,,,,,,no IP contract,,80,,14.12,percent of total billed charges,,,,,,,no IP contract,,50,,8.83,percent of total billed charges,,,,,,no IP contract,,,78,,13.77,percent of total billed charges,,,70,,12.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.65,3324,
67877-0215-60 - cefuroxime 250 mg Tab,67877-0215-60,NDC,,,,inpatient,1,EA,49.05,29.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,39.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,41.69,percent of total billed charges,,,85,,41.69,percent of total billed charges,,,49,,24.03,percent of total billed charges,,,90,,44.15,percent of total billed charges,,,,,,,no IP contract,,80,,39.24,percent of total billed charges,,,,,,,no IP contract,,50,,24.53,percent of total billed charges,,,,,,no IP contract,,,78,,38.26,percent of total billed charges,,,70,,34.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.03,3324,
67877-0223-01 - gabapentin 300 mg Cap,67877-0223-01,NDC,,,,inpatient,1,EA,14.5,8.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.33,percent of total billed charges,,,85,,12.33,percent of total billed charges,,,49,,7.11,percent of total billed charges,,,90,,13.05,percent of total billed charges,,,,,,,no IP contract,,80,,11.6,percent of total billed charges,,,,,,,no IP contract,,50,,7.25,percent of total billed charges,,,,,,no IP contract,,,78,,11.31,percent of total billed charges,,,70,,10.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.11,3324,
67877-0225-01 - mycophenolate mofetil 500 mg Tab,67877-0225-01,NDC,,,,inpatient,1,EA,67.05,40.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,54.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.99,percent of total billed charges,,,85,,56.99,percent of total billed charges,,,49,,32.85,percent of total billed charges,,,90,,60.35,percent of total billed charges,,,,,,,no IP contract,,80,,53.64,percent of total billed charges,,,,,,,no IP contract,,50,,33.53,percent of total billed charges,,,,,,no IP contract,,,78,,52.3,percent of total billed charges,,,70,,46.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.85,3324,
67877-0230-22 - mycophenolate mofetil 200 mg/mL REC P,67877-0230-22,NDC,,,,inpatient,1,ML,74.55,44.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63.37,percent of total billed charges,,,85,,63.37,percent of total billed charges,,,49,,36.53,percent of total billed charges,,,90,,67.1,percent of total billed charges,,,,,,,no IP contract,,80,,59.64,percent of total billed charges,,,,,,,no IP contract,,50,,37.28,percent of total billed charges,,,,,,no IP contract,,,78,,58.15,percent of total billed charges,,,70,,52.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.53,3324,
67877-0242-01 - QUEtiapine 25 mg Tab,67877-0242-01,NDC,,,,inpatient,1,EA,35.6,21.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.26,percent of total billed charges,,,85,,30.26,percent of total billed charges,,,49,,17.44,percent of total billed charges,,,90,,32.04,percent of total billed charges,,,,,,,no IP contract,,80,,28.48,percent of total billed charges,,,,,,,no IP contract,,50,,17.8,percent of total billed charges,,,,,,no IP contract,,,78,,27.77,percent of total billed charges,,,70,,24.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.44,3324,
67877-0249-01 - QUEtiapine 50 mg Tab,67877-0249-01,NDC,,,,inpatient,1,EA,56.05,33.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,45.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,47.64,percent of total billed charges,,,85,,47.64,percent of total billed charges,,,49,,27.46,percent of total billed charges,,,90,,50.45,percent of total billed charges,,,,,,,no IP contract,,80,,44.84,percent of total billed charges,,,,,,,no IP contract,,50,,28.03,percent of total billed charges,,,,,,no IP contract,,,78,,43.72,percent of total billed charges,,,70,,39.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.46,3324,
67877-0250-01 - QUEtiapine 100 mg Tab,67877-0250-01,NDC,,,,inpatient,1,EA,58.35,35.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,47.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,49.6,percent of total billed charges,,,85,,49.6,percent of total billed charges,,,49,,28.59,percent of total billed charges,,,90,,52.52,percent of total billed charges,,,,,,,no IP contract,,80,,46.68,percent of total billed charges,,,,,,,no IP contract,,50,,29.18,percent of total billed charges,,,,,,no IP contract,,,78,,45.51,percent of total billed charges,,,70,,40.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,28.59,3324,
67877-0266-01 - mycophenolate mofetil 250 mg Cap,67877-0266-01,NDC,,,,inpatient,1,EA,35.55,21.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.22,percent of total billed charges,,,85,,30.22,percent of total billed charges,,,49,,17.42,percent of total billed charges,,,90,,32,percent of total billed charges,,,,,,,no IP contract,,80,,28.44,percent of total billed charges,,,,,,,no IP contract,,50,,17.78,percent of total billed charges,,,,,,no IP contract,,,78,,27.73,percent of total billed charges,,,70,,24.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.42,3324,
67877-0286-60 - riluzole 50 mg Tab,67877-0286-60,NDC,,,,inpatient,1,EA,297.5,178.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,240.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,252.88,percent of total billed charges,,,85,,252.88,percent of total billed charges,,,49,,145.78,percent of total billed charges,,,90,,267.75,percent of total billed charges,,,,,,,no IP contract,,80,,238,percent of total billed charges,,,,,,,no IP contract,,50,,148.75,percent of total billed charges,,,,,,no IP contract,,,78,,232.05,percent of total billed charges,,,70,,208.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,145.78,3324,
ibuprofen 400 mg Tab,67877-0319-01,NDC,,,,inpatient,1,EA,6.75,4.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.74,percent of total billed charges,,,85,,5.74,percent of total billed charges,,,49,,3.31,percent of total billed charges,,,90,,6.08,percent of total billed charges,,,,,,,no IP contract,,80,,5.4,percent of total billed charges,,,,,,,no IP contract,,50,,3.38,percent of total billed charges,,,,,,no IP contract,,,78,,5.27,percent of total billed charges,,,70,,4.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.31,3324,
67877-0417-90 - valsartan 160 mg Tab,67877-0417-90,NDC,,,,inpatient,1,EA,41.45,24.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,35.23,percent of total billed charges,,,85,,35.23,percent of total billed charges,,,49,,20.31,percent of total billed charges,,,90,,37.31,percent of total billed charges,,,,,,,no IP contract,,80,,33.16,percent of total billed charges,,,,,,,no IP contract,,50,,20.73,percent of total billed charges,,,,,,no IP contract,,,78,,32.33,percent of total billed charges,,,70,,29.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.31,3324,
67877-0419-20 - linezolid 600 mg Tab,67877-0419-20,NDC,,,,inpatient,1,EA,1463.9,878.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1185.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1244.32,percent of total billed charges,,,85,,1244.32,percent of total billed charges,,,49,,717.31,percent of total billed charges,,,90,,1317.51,percent of total billed charges,,,,,,,no IP contract,,80,,1171.12,percent of total billed charges,,,,,,,no IP contract,,50,,731.95,percent of total billed charges,,,,,,no IP contract,,,78,,1141.84,percent of total billed charges,,,70,,1024.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,717.31,3324,
67877-0419-84 - linezolid 600 mg Tab,67877-0419-84,NDC,,,,inpatient,1,EA,1463.9,878.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1185.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1244.32,percent of total billed charges,,,85,,1244.32,percent of total billed charges,,,49,,717.31,percent of total billed charges,,,90,,1317.51,percent of total billed charges,,,,,,,no IP contract,,80,,1171.12,percent of total billed charges,,,,,,,no IP contract,,50,,731.95,percent of total billed charges,,,,,,no IP contract,,,78,,1141.84,percent of total billed charges,,,70,,1024.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,717.31,3324,
67877-0426-12 - mycophenolic acid 180 mg EC Ta,67877-0426-12,NDC,,,,inpatient,1,EA,40.15,24.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34.13,percent of total billed charges,,,85,,34.13,percent of total billed charges,,,49,,19.67,percent of total billed charges,,,90,,36.14,percent of total billed charges,,,,,,,no IP contract,,80,,32.12,percent of total billed charges,,,,,,,no IP contract,,50,,20.08,percent of total billed charges,,,,,,no IP contract,,,78,,31.32,percent of total billed charges,,,70,,28.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.67,3324,
67877-0427-12 - mycophenolic acid 360 mg EC Ta,67877-0427-12,NDC,,,,inpatient,1,EA,76.4,45.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,61.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,64.94,percent of total billed charges,,,85,,64.94,percent of total billed charges,,,49,,37.44,percent of total billed charges,,,90,,68.76,percent of total billed charges,,,,,,,no IP contract,,80,,61.12,percent of total billed charges,,,,,,,no IP contract,,50,,38.2,percent of total billed charges,,,,,,no IP contract,,,78,,59.59,percent of total billed charges,,,70,,53.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,37.44,3324,
67877-0454-30 - itraconazole 100 mg Cap,67877-0454-30,NDC,,,,inpatient,1,EA,195.75,117.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,158.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,166.39,percent of total billed charges,,,85,,166.39,percent of total billed charges,,,49,,95.92,percent of total billed charges,,,90,,176.18,percent of total billed charges,,,,,,,no IP contract,,80,,156.6,percent of total billed charges,,,,,,,no IP contract,,50,,97.88,percent of total billed charges,,,,,,no IP contract,,,78,,152.69,percent of total billed charges,,,70,,137.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,95.92,3324,
67877-0490-90 - ezetimibe 10 mg Tab,67877-0490-90,NDC,,,,inpatient,1,EA,85.55,51.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,69.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,72.72,percent of total billed charges,,,85,,72.72,percent of total billed charges,,,49,,41.92,percent of total billed charges,,,90,,77,percent of total billed charges,,,,,,,no IP contract,,80,,68.44,percent of total billed charges,,,,,,,no IP contract,,50,,42.78,percent of total billed charges,,,,,,no IP contract,,,78,,66.73,percent of total billed charges,,,70,,59.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,41.92,3324,
67877-0538-14 - temozolomide 20 mg Cap,67877-0538-14,NDC,,,,inpatient,1,EA,455.55,273.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,369,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,387.22,percent of total billed charges,,,85,,387.22,percent of total billed charges,,,49,,223.22,percent of total billed charges,,,90,,410,percent of total billed charges,,,,,,,no IP contract,,80,,364.44,percent of total billed charges,,,,,,,no IP contract,,50,,227.78,percent of total billed charges,,,,,,no IP contract,,,78,,355.33,percent of total billed charges,,,70,,318.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,223.22,3324,
67877-0562-01 - metFORMIN 850 mg Tab,67877-0562-01,NDC,,,,inpatient,1,EA,13.45,8.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.43,percent of total billed charges,,,85,,11.43,percent of total billed charges,,,49,,6.59,percent of total billed charges,,,90,,12.11,percent of total billed charges,,,,,,,no IP contract,,80,,10.76,percent of total billed charges,,,,,,,no IP contract,,50,,6.73,percent of total billed charges,,,,,,no IP contract,,,78,,10.49,percent of total billed charges,,,70,,9.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.59,3324,
67877-0605-30 - prasugrel 10 mg Tab,67877-0605-30,NDC,,,,inpatient,1,EA,135,81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,109.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,114.75,percent of total billed charges,,,85,,114.75,percent of total billed charges,,,49,,66.15,percent of total billed charges,,,90,,121.5,percent of total billed charges,,,,,,,no IP contract,,80,,108,percent of total billed charges,,,,,,,no IP contract,,50,,67.5,percent of total billed charges,,,,,,no IP contract,,,78,,105.3,percent of total billed charges,,,70,,94.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,66.15,3324,
67877-0673-62 - rufinamide 40 mg/mL Susp,67877-0673-62,NDC,,,,inpatient,1,ML,39.75,23.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.79,percent of total billed charges,,,85,,33.79,percent of total billed charges,,,49,,19.48,percent of total billed charges,,,90,,35.78,percent of total billed charges,,,,,,,no IP contract,,80,,31.8,percent of total billed charges,,,,,,,no IP contract,,50,,19.88,percent of total billed charges,,,,,,no IP contract,,,78,,31.01,percent of total billed charges,,,70,,27.83,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.48,3324,
67877-0678-70 - tobramycin 60 mg/mL Soln,67877-0678-70,NDC,,,,inpatient,5,ML,1186.65,711.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,961.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1008.65,percent of total billed charges,,,85,,1008.65,percent of total billed charges,,,49,,581.46,percent of total billed charges,,,90,,1067.99,percent of total billed charges,,,,,,,no IP contract,,80,,949.32,percent of total billed charges,,,,,,,no IP contract,,50,,593.33,percent of total billed charges,,,,,,no IP contract,,,78,,925.59,percent of total billed charges,,,70,,830.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,581.46,3324,
67877-0697-01 - chlorthalidone 50 mg Tab,67877-0697-01,NDC,,,,inpatient,1,EA,15.6,9.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.26,percent of total billed charges,,,85,,13.26,percent of total billed charges,,,49,,7.64,percent of total billed charges,,,90,,14.04,percent of total billed charges,,,,,,,no IP contract,,80,,12.48,percent of total billed charges,,,,,,,no IP contract,,50,,7.8,percent of total billed charges,,,,,,no IP contract,,,78,,12.17,percent of total billed charges,,,70,,10.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.64,3324,
67877-0734-60 - lacosamide 100 mg Tab,67877-0734-60,NDC,,,,inpatient,1,EA,153.45,92.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,124.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,130.43,percent of total billed charges,,,85,,130.43,percent of total billed charges,,,49,,75.19,percent of total billed charges,,,90,,138.11,percent of total billed charges,,,,,,,no IP contract,,80,,122.76,percent of total billed charges,,,,,,,no IP contract,,50,,76.73,percent of total billed charges,,,,,,no IP contract,,,78,,119.69,percent of total billed charges,,,70,,107.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,75.19,3324,
67877-0753-60 - dronabinol 2.5 mg Cap,67877-0753-60,NDC,,,,inpatient,1,EA,54.5,32.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,44.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,46.33,percent of total billed charges,,,85,,46.33,percent of total billed charges,,,49,,26.71,percent of total billed charges,,,90,,49.05,percent of total billed charges,,,,,,,no IP contract,,80,,43.6,percent of total billed charges,,,,,,,no IP contract,,50,,27.25,percent of total billed charges,,,,,,no IP contract,,,78,,42.51,percent of total billed charges,,,70,,38.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.71,3324,
67877-0754-60 - droNABinol 5 mg Cap,67877-0754-60,NDC,,,,inpatient,1,EA,107.55,64.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,87.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,91.42,percent of total billed charges,,,85,,91.42,percent of total billed charges,,,49,,52.7,percent of total billed charges,,,90,,96.8,percent of total billed charges,,,,,,,no IP contract,,80,,86.04,percent of total billed charges,,,,,,,no IP contract,,50,,53.78,percent of total billed charges,,,,,,no IP contract,,,78,,83.89,percent of total billed charges,,,70,,75.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,52.7,3324,
cefpodoxime 200 mg Tab,67877-0879-20,NDC,,,,inpatient,1,EA,70.85,42.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,57.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,60.22,percent of total billed charges,,,85,,60.22,percent of total billed charges,,,49,,34.72,percent of total billed charges,,,90,,63.77,percent of total billed charges,,,,,,,no IP contract,,80,,56.68,percent of total billed charges,,,,,,,no IP contract,,50,,35.43,percent of total billed charges,,,,,,no IP contract,,,78,,55.26,percent of total billed charges,,,70,,49.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,34.72,3324,
67919-0011-01 - daptomycin 500 mg REC Inj,67919-0011-01,NDC,,,,inpatient,10,ML,3385.95,2031.57,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2742.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2878.06,percent of total billed charges,,,85,,2878.06,percent of total billed charges,,,49,,1659.12,percent of total billed charges,,,90,,3047.36,percent of total billed charges,,,,,,,no IP contract,,80,,2708.76,percent of total billed charges,,,,,,,no IP contract,,50,,1692.98,percent of total billed charges,,,,,,no IP contract,,,78,,2641.04,percent of total billed charges,,,70,,2370.17,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
67919-0030-01 - ceftolozane-tazobactam 1 g-0.5 g REC I,67919-0030-01,NDC,,,,inpatient,11.4,ML,888.1,532.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,719.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,754.89,percent of total billed charges,,,85,,754.89,percent of total billed charges,,,49,,435.17,percent of total billed charges,,,90,,799.29,percent of total billed charges,,,,,,,no IP contract,,80,,710.48,percent of total billed charges,,,,,,,no IP contract,,50,,444.05,percent of total billed charges,,,,,,no IP contract,,,78,,692.72,percent of total billed charges,,,70,,621.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,435.17,3324,
68001-0007-00 - gabapentin 800 mg Tab,68001-0007-00,NDC,,,,inpatient,1,EA,27.9,16.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.72,percent of total billed charges,,,85,,23.72,percent of total billed charges,,,49,,13.67,percent of total billed charges,,,90,,25.11,percent of total billed charges,,,,,,,no IP contract,,80,,22.32,percent of total billed charges,,,,,,,no IP contract,,50,,13.95,percent of total billed charges,,,,,,no IP contract,,,78,,21.76,percent of total billed charges,,,70,,19.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.67,3324,
68001-0106-00 - divalproex sodium 500 mg ER Ta,68001-0106-00,NDC,,,,inpatient,1,EA,36.2,21.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.77,percent of total billed charges,,,85,,30.77,percent of total billed charges,,,49,,17.74,percent of total billed charges,,,90,,32.58,percent of total billed charges,,,,,,,no IP contract,,80,,28.96,percent of total billed charges,,,,,,,no IP contract,,50,,18.1,percent of total billed charges,,,,,,no IP contract,,,78,,28.24,percent of total billed charges,,,70,,25.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.74,3324,
68001-0141-00 - ramipril 10 mg Cap,68001-0141-00,NDC,,,,inpatient,1,EA,20.5,12.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.43,percent of total billed charges,,,85,,17.43,percent of total billed charges,,,49,,10.05,percent of total billed charges,,,90,,18.45,percent of total billed charges,,,,,,,no IP contract,,80,,16.4,percent of total billed charges,,,,,,,no IP contract,,50,,10.25,percent of total billed charges,,,,,,no IP contract,,,78,,15.99,percent of total billed charges,,,70,,14.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.05,3324,
68001-0143-00 - ramipril 5 mg Cap,68001-0143-00,NDC,,,,inpatient,1,EA,18.15,10.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.43,percent of total billed charges,,,85,,15.43,percent of total billed charges,,,49,,8.89,percent of total billed charges,,,90,,16.34,percent of total billed charges,,,,,,,no IP contract,,80,,14.52,percent of total billed charges,,,,,,,no IP contract,,50,,9.08,percent of total billed charges,,,,,,no IP contract,,,78,,14.16,percent of total billed charges,,,70,,12.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.89,3324,
68001-0151-00 - carvedilol 12.5 mg Tab,68001-0151-00,NDC,,,,inpatient,1,EA,20.85,12.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.72,percent of total billed charges,,,85,,17.72,percent of total billed charges,,,49,,10.22,percent of total billed charges,,,90,,18.77,percent of total billed charges,,,,,,,no IP contract,,80,,16.68,percent of total billed charges,,,,,,,no IP contract,,50,,10.43,percent of total billed charges,,,,,,no IP contract,,,78,,16.26,percent of total billed charges,,,70,,14.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.22,3324,
68001-0153-00 - carvedilol 3.125 mg Tab,68001-0153-00,NDC,,,,inpatient,1,EA,20.85,12.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.72,percent of total billed charges,,,85,,17.72,percent of total billed charges,,,49,,10.22,percent of total billed charges,,,90,,18.77,percent of total billed charges,,,,,,,no IP contract,,80,,16.68,percent of total billed charges,,,,,,,no IP contract,,50,,10.43,percent of total billed charges,,,,,,no IP contract,,,78,,16.26,percent of total billed charges,,,70,,14.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.22,3324,
68001-0158-00 - venlafaxine 37.5 mg Tab,68001-0158-00,NDC,,,,inpatient,1,EA,19.7,11.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.75,percent of total billed charges,,,85,,16.75,percent of total billed charges,,,49,,9.65,percent of total billed charges,,,90,,17.73,percent of total billed charges,,,,,,,no IP contract,,80,,15.76,percent of total billed charges,,,,,,,no IP contract,,50,,9.85,percent of total billed charges,,,,,,no IP contract,,,78,,15.37,percent of total billed charges,,,70,,13.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.65,3324,
68001-0162-00 - promethazine 25 mg Tab,68001-0162-00,NDC,,,,inpatient,1,EA,7.9,4.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.72,percent of total billed charges,,,85,,6.72,percent of total billed charges,,,49,,3.87,percent of total billed charges,,,90,,7.11,percent of total billed charges,,,,,,,no IP contract,,80,,6.32,percent of total billed charges,,,,,,,no IP contract,,50,,3.95,percent of total billed charges,,,,,,no IP contract,,,78,,6.16,percent of total billed charges,,,70,,5.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.87,3324,
68001-0177-00 - glimepiride 1 mg Tab,68001-0177-00,NDC,,,,inpatient,1,EA,7,4.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.95,percent of total billed charges,,,85,,5.95,percent of total billed charges,,,49,,3.43,percent of total billed charges,,,90,,6.3,percent of total billed charges,,,,,,,no IP contract,,80,,5.6,percent of total billed charges,,,,,,,no IP contract,,50,,3.5,percent of total billed charges,,,,,,no IP contract,,,78,,5.46,percent of total billed charges,,,70,,4.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.43,3324,
68001-0196-00 - escitalopram 10 mg Tab,68001-0196-00,NDC,,,,inpatient,1,EA,38.25,22.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.51,percent of total billed charges,,,85,,32.51,percent of total billed charges,,,49,,18.74,percent of total billed charges,,,90,,34.43,percent of total billed charges,,,,,,,no IP contract,,80,,30.6,percent of total billed charges,,,,,,,no IP contract,,50,,19.13,percent of total billed charges,,,,,,no IP contract,,,78,,29.84,percent of total billed charges,,,70,,26.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.74,3324,
68001-0237-00 - cloNIDine 0.1 mg Tab,68001-0237-00,NDC,,,,inpatient,1,EA,5.75,3.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.89,percent of total billed charges,,,85,,4.89,percent of total billed charges,,,49,,2.82,percent of total billed charges,,,90,,5.18,percent of total billed charges,,,,,,,no IP contract,,80,,4.6,percent of total billed charges,,,,,,,no IP contract,,50,,2.88,percent of total billed charges,,,,,,no IP contract,,,78,,4.49,percent of total billed charges,,,70,,4.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.82,3324,
68001-0237-03 - cloNIDine 0.1 mg Tab,68001-0237-03,NDC,,,,inpatient,1,EA,13.9,8.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.82,percent of total billed charges,,,85,,11.82,percent of total billed charges,,,49,,6.81,percent of total billed charges,,,90,,12.51,percent of total billed charges,,,,,,,no IP contract,,80,,11.12,percent of total billed charges,,,,,,,no IP contract,,50,,6.95,percent of total billed charges,,,,,,no IP contract,,,78,,10.84,percent of total billed charges,,,70,,9.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.81,3324,
68001-0238-00 - cloNIDine 0.2 mg Tab,68001-0238-00,NDC,,,,inpatient,1,EA,6.85,4.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.82,percent of total billed charges,,,85,,5.82,percent of total billed charges,,,49,,3.36,percent of total billed charges,,,90,,6.17,percent of total billed charges,,,,,,,no IP contract,,80,,5.48,percent of total billed charges,,,,,,,no IP contract,,50,,3.43,percent of total billed charges,,,,,,no IP contract,,,78,,5.34,percent of total billed charges,,,70,,4.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.36,3324,
68001-0239-00 - cloNIDine 0.3 mg Tab,68001-0239-00,NDC,,,,inpatient,1,EA,7.95,4.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.76,percent of total billed charges,,,85,,6.76,percent of total billed charges,,,49,,3.9,percent of total billed charges,,,90,,7.16,percent of total billed charges,,,,,,,no IP contract,,80,,6.36,percent of total billed charges,,,,,,,no IP contract,,50,,3.98,percent of total billed charges,,,,,,no IP contract,,,78,,6.2,percent of total billed charges,,,70,,5.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.9,3324,
68001-0243-00 - zonisamide 50 mg Cap,68001-0243-00,NDC,,,,inpatient,1,EA,12.55,7.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.67,percent of total billed charges,,,85,,10.67,percent of total billed charges,,,49,,6.15,percent of total billed charges,,,90,,11.3,percent of total billed charges,,,,,,,no IP contract,,80,,10.04,percent of total billed charges,,,,,,,no IP contract,,50,,6.28,percent of total billed charges,,,,,,no IP contract,,,78,,9.79,percent of total billed charges,,,70,,8.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.15,3324,
68001-0246-04 - ondansetron 4 mg DIS T,68001-0246-04,NDC,,,,inpatient,1,EA,181.05,108.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,146.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,153.89,percent of total billed charges,,,85,,153.89,percent of total billed charges,,,49,,88.71,percent of total billed charges,,,90,,162.95,percent of total billed charges,,,,,,,no IP contract,,80,,144.84,percent of total billed charges,,,,,,,no IP contract,,50,,90.53,percent of total billed charges,,,,,,no IP contract,,,78,,141.22,percent of total billed charges,,,70,,126.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,88.71,3324,
68001-0246-17 - ondansetron 4 mg DIS T,68001-0246-17,NDC,,,,inpatient,1,EA,187.55,112.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,151.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,159.42,percent of total billed charges,,,85,,159.42,percent of total billed charges,,,49,,91.9,percent of total billed charges,,,90,,168.8,percent of total billed charges,,,,,,,no IP contract,,80,,150.04,percent of total billed charges,,,,,,,no IP contract,,50,,93.78,percent of total billed charges,,,,,,no IP contract,,,78,,146.29,percent of total billed charges,,,70,,131.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,91.9,3324,
68001-0247-17 - ondansetron 8 mg DIS T,68001-0247-17,NDC,,,,inpatient,1,EA,309.9,185.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,251.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,263.42,percent of total billed charges,,,85,,263.42,percent of total billed charges,,,49,,151.85,percent of total billed charges,,,90,,278.91,percent of total billed charges,,,,,,,no IP contract,,80,,247.92,percent of total billed charges,,,,,,,no IP contract,,50,,154.95,percent of total billed charges,,,,,,no IP contract,,,78,,241.72,percent of total billed charges,,,70,,216.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,151.85,3324,
68001-0253-17 - fluconazole 150 mg Tab,68001-0253-17,NDC,,,,inpatient,1,EA,115.2,69.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,93.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,97.92,percent of total billed charges,,,85,,97.92,percent of total billed charges,,,49,,56.45,percent of total billed charges,,,90,,103.68,percent of total billed charges,,,,,,,no IP contract,,80,,92.16,percent of total billed charges,,,,,,,no IP contract,,50,,57.6,percent of total billed charges,,,,,,no IP contract,,,78,,89.86,percent of total billed charges,,,70,,80.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,56.45,3324,
68001-0280-00 - diclofenac sodium 50 mg EC Ta,68001-0280-00,NDC,,,,inpatient,1,EA,15.5,9.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.18,percent of total billed charges,,,85,,13.18,percent of total billed charges,,,49,,7.6,percent of total billed charges,,,90,,13.95,percent of total billed charges,,,,,,,no IP contract,,80,,12.4,percent of total billed charges,,,,,,,no IP contract,,50,,7.75,percent of total billed charges,,,,,,no IP contract,,,78,,12.09,percent of total billed charges,,,70,,10.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.6,3324,
68001-0315-00 - lovastatin 20 mg Tab,68001-0315-00,NDC,,,,inpatient,1,EA,22.65,13.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.25,percent of total billed charges,,,85,,19.25,percent of total billed charges,,,49,,11.1,percent of total billed charges,,,90,,20.39,percent of total billed charges,,,,,,,no IP contract,,80,,18.12,percent of total billed charges,,,,,,,no IP contract,,50,,11.33,percent of total billed charges,,,,,,no IP contract,,,78,,17.67,percent of total billed charges,,,70,,15.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.1,3324,
68001-0317-00 - nadolol 20 mg Tab,68001-0317-00,NDC,,,,inpatient,1,EA,30.8,18.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.18,percent of total billed charges,,,85,,26.18,percent of total billed charges,,,49,,15.09,percent of total billed charges,,,90,,27.72,percent of total billed charges,,,,,,,no IP contract,,80,,24.64,percent of total billed charges,,,,,,,no IP contract,,50,,15.4,percent of total billed charges,,,,,,no IP contract,,,78,,24.02,percent of total billed charges,,,70,,21.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.09,3324,
68001-0318-00 - nadolol 40 mg Tab,68001-0318-00,NDC,,,,inpatient,1,EA,35.7,21.42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.35,percent of total billed charges,,,85,,30.35,percent of total billed charges,,,49,,17.49,percent of total billed charges,,,90,,32.13,percent of total billed charges,,,,,,,no IP contract,,80,,28.56,percent of total billed charges,,,,,,,no IP contract,,50,,17.85,percent of total billed charges,,,,,,no IP contract,,,78,,27.85,percent of total billed charges,,,70,,24.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.49,3324,
68001-0321-04 - buPROPion 300 mg/24 hours ER Ta,68001-0321-04,NDC,,,,inpatient,1,EA,53.9,32.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,43.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,45.82,percent of total billed charges,,,85,,45.82,percent of total billed charges,,,49,,26.41,percent of total billed charges,,,90,,48.51,percent of total billed charges,,,,,,,no IP contract,,80,,43.12,percent of total billed charges,,,,,,,no IP contract,,50,,26.95,percent of total billed charges,,,,,,no IP contract,,,78,,42.04,percent of total billed charges,,,70,,37.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,26.41,3324,
68001-0325-00 - desmopressin 0.1 mg Tab,68001-0325-00,NDC,,,,inpatient,1,EA,45.9,27.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,37.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,39.02,percent of total billed charges,,,85,,39.02,percent of total billed charges,,,49,,22.49,percent of total billed charges,,,90,,41.31,percent of total billed charges,,,,,,,no IP contract,,80,,36.72,percent of total billed charges,,,,,,,no IP contract,,50,,22.95,percent of total billed charges,,,,,,no IP contract,,,78,,35.8,percent of total billed charges,,,70,,32.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.49,3324,
68001-0326-00 - desmopressin 0.2 mg Tab,68001-0326-00,NDC,,,,inpatient,1,EA,64.4,38.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,52.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,54.74,percent of total billed charges,,,85,,54.74,percent of total billed charges,,,49,,31.56,percent of total billed charges,,,90,,57.96,percent of total billed charges,,,,,,,no IP contract,,80,,51.52,percent of total billed charges,,,,,,,no IP contract,,50,,32.2,percent of total billed charges,,,,,,no IP contract,,,78,,50.23,percent of total billed charges,,,70,,45.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.56,3324,
68001-0333-00 - lisinopril 5 mg Tab,68001-0333-00,NDC,,,,inpatient,1,EA,11.55,6.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.82,percent of total billed charges,,,85,,9.82,percent of total billed charges,,,49,,5.66,percent of total billed charges,,,90,,10.4,percent of total billed charges,,,,,,,no IP contract,,80,,9.24,percent of total billed charges,,,,,,,no IP contract,,50,,5.78,percent of total billed charges,,,,,,no IP contract,,,78,,9.01,percent of total billed charges,,,70,,8.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.66,3324,
68001-0333-08 - lisinopril 5 mg Tab,68001-0333-08,NDC,,,,inpatient,1,EA,11.55,6.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.82,percent of total billed charges,,,85,,9.82,percent of total billed charges,,,49,,5.66,percent of total billed charges,,,90,,10.4,percent of total billed charges,,,,,,,no IP contract,,80,,9.24,percent of total billed charges,,,,,,,no IP contract,,50,,5.78,percent of total billed charges,,,,,,no IP contract,,,78,,9.01,percent of total billed charges,,,70,,8.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.66,3324,
68001-0335-00 - lisinopril 20 mg Tab,68001-0335-00,NDC,,,,inpatient,1,EA,12.25,7.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.41,percent of total billed charges,,,85,,10.41,percent of total billed charges,,,49,,6,percent of total billed charges,,,90,,11.03,percent of total billed charges,,,,,,,no IP contract,,80,,9.8,percent of total billed charges,,,,,,,no IP contract,,50,,6.13,percent of total billed charges,,,,,,no IP contract,,,78,,9.56,percent of total billed charges,,,70,,8.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6,3324,
68001-0362-06 - cefdinir 300 mg Cap,68001-0362-06,NDC,,,,inpatient,1,EA,44.45,26.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,37.78,percent of total billed charges,,,85,,37.78,percent of total billed charges,,,49,,21.78,percent of total billed charges,,,90,,40.01,percent of total billed charges,,,,,,,no IP contract,,80,,35.56,percent of total billed charges,,,,,,,no IP contract,,50,,22.23,percent of total billed charges,,,,,,no IP contract,,,78,,34.67,percent of total billed charges,,,70,,31.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.78,3324,
68001-0365-00 - metroNIDAZOLE 500 mg Tab,68001-0365-00,NDC,,,,inpatient,1,EA,9.65,5.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.2,percent of total billed charges,,,85,,8.2,percent of total billed charges,,,49,,4.73,percent of total billed charges,,,90,,8.69,percent of total billed charges,,,,,,,no IP contract,,80,,7.72,percent of total billed charges,,,,,,,no IP contract,,50,,4.83,percent of total billed charges,,,,,,no IP contract,,,78,,7.53,percent of total billed charges,,,70,,6.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.73,3324,
68001-0381-00 - labetalol 100 mg Tab,68001-0381-00,NDC,,,,inpatient,1,EA,7.9,4.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.72,percent of total billed charges,,,85,,6.72,percent of total billed charges,,,49,,3.87,percent of total billed charges,,,90,,7.11,percent of total billed charges,,,,,,,no IP contract,,80,,6.32,percent of total billed charges,,,,,,,no IP contract,,50,,3.95,percent of total billed charges,,,,,,no IP contract,,,78,,6.16,percent of total billed charges,,,70,,5.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.87,3324,
68001-0382-00 - labetalol 200 mg Tab,68001-0382-00,NDC,,,,inpatient,1,EA,9.65,5.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.2,percent of total billed charges,,,85,,8.2,percent of total billed charges,,,49,,4.73,percent of total billed charges,,,90,,8.69,percent of total billed charges,,,,,,,no IP contract,,80,,7.72,percent of total billed charges,,,,,,,no IP contract,,50,,4.83,percent of total billed charges,,,,,,no IP contract,,,78,,7.53,percent of total billed charges,,,70,,6.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.73,3324,
68001-0385-00 - nitrofurantoin macrocrystals 50 mg Cap,68001-0385-00,NDC,,,,inpatient,1,EA,20.75,12.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.64,percent of total billed charges,,,85,,17.64,percent of total billed charges,,,49,,10.17,percent of total billed charges,,,90,,18.68,percent of total billed charges,,,,,,,no IP contract,,80,,16.6,percent of total billed charges,,,,,,,no IP contract,,50,,10.38,percent of total billed charges,,,,,,no IP contract,,,78,,16.19,percent of total billed charges,,,70,,14.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.17,3324,
68001-0397-00 - famotidine 20 mg Tab,68001-0397-00,NDC,,,,inpatient,1,EA,23.05,13.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.59,percent of total billed charges,,,85,,19.59,percent of total billed charges,,,49,,11.29,percent of total billed charges,,,90,,20.75,percent of total billed charges,,,,,,,no IP contract,,80,,18.44,percent of total billed charges,,,,,,,no IP contract,,50,,11.53,percent of total billed charges,,,,,,no IP contract,,,78,,17.98,percent of total billed charges,,,70,,16.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.29,3324,
68001-0403-03 - levETIRAcetam 500 mg Tab,68001-0403-03,NDC,,,,inpatient,1,EA,31.75,19.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,25.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.99,percent of total billed charges,,,85,,26.99,percent of total billed charges,,,49,,15.56,percent of total billed charges,,,90,,28.58,percent of total billed charges,,,,,,,no IP contract,,80,,25.4,percent of total billed charges,,,,,,,no IP contract,,50,,15.88,percent of total billed charges,,,,,,no IP contract,,,78,,24.77,percent of total billed charges,,,70,,22.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.56,3324,
68001-0403-07 - levETIRAcetam 500 mg Tab,68001-0403-07,NDC,,,,inpatient,1,EA,31.75,19.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,25.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.99,percent of total billed charges,,,85,,26.99,percent of total billed charges,,,49,,15.56,percent of total billed charges,,,90,,28.58,percent of total billed charges,,,,,,,no IP contract,,80,,25.4,percent of total billed charges,,,,,,,no IP contract,,50,,15.88,percent of total billed charges,,,,,,no IP contract,,,78,,24.77,percent of total billed charges,,,70,,22.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.56,3324,
68001-0413-06 - DULoxetine 20 mg DR Ca,68001-0413-06,NDC,,,,inpatient,1,EA,59.4,35.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,48.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,50.49,percent of total billed charges,,,85,,50.49,percent of total billed charges,,,49,,29.11,percent of total billed charges,,,90,,53.46,percent of total billed charges,,,,,,,no IP contract,,80,,47.52,percent of total billed charges,,,,,,,no IP contract,,50,,29.7,percent of total billed charges,,,,,,no IP contract,,,78,,46.33,percent of total billed charges,,,70,,41.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,29.11,3324,
68001-0414-05 - DULoxetine 30 mg DR Ca,68001-0414-05,NDC,,,,inpatient,1,EA,66.15,39.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,53.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.23,percent of total billed charges,,,85,,56.23,percent of total billed charges,,,49,,32.41,percent of total billed charges,,,90,,59.54,percent of total billed charges,,,,,,,no IP contract,,80,,52.92,percent of total billed charges,,,,,,,no IP contract,,50,,33.08,percent of total billed charges,,,,,,no IP contract,,,78,,51.6,percent of total billed charges,,,70,,46.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.41,3324,
68001-0423-00 - nitrofurantoin macrocrystals-monohydrate 100 mg Cap,68001-0423-00,NDC,,,,inpatient,1,EA,33.8,20.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.73,percent of total billed charges,,,85,,28.73,percent of total billed charges,,,49,,16.56,percent of total billed charges,,,90,,30.42,percent of total billed charges,,,,,,,no IP contract,,80,,27.04,percent of total billed charges,,,,,,,no IP contract,,50,,16.9,percent of total billed charges,,,,,,no IP contract,,,78,,26.36,percent of total billed charges,,,70,,23.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.56,3324,
68001-0430-00 - ramipril 5 mg Cap,68001-0430-00,NDC,,,,inpatient,1,EA,18.15,10.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.43,percent of total billed charges,,,85,,15.43,percent of total billed charges,,,49,,8.89,percent of total billed charges,,,90,,16.34,percent of total billed charges,,,,,,,no IP contract,,80,,14.52,percent of total billed charges,,,,,,,no IP contract,,50,,9.08,percent of total billed charges,,,,,,no IP contract,,,78,,14.16,percent of total billed charges,,,70,,12.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.89,3324,
68001-0431-00 - ramipril 10 mg Cap,68001-0431-00,NDC,,,,inpatient,1,EA,20.5,12.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.43,percent of total billed charges,,,85,,17.43,percent of total billed charges,,,49,,10.05,percent of total billed charges,,,90,,18.45,percent of total billed charges,,,,,,,no IP contract,,80,,16.4,percent of total billed charges,,,,,,,no IP contract,,50,,10.25,percent of total billed charges,,,,,,no IP contract,,,78,,15.99,percent of total billed charges,,,70,,14.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.05,3324,
68001-0435-94 - ibuprofen 100 mg/5 mL Susp,68001-0435-94,NDC,,,,inpatient,1,ML,35.4,21.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.09,percent of total billed charges,,,85,,30.09,percent of total billed charges,,,49,,17.35,percent of total billed charges,,,90,,31.86,percent of total billed charges,,,,,,,no IP contract,,80,,28.32,percent of total billed charges,,,,,,,no IP contract,,50,,17.7,percent of total billed charges,,,,,,no IP contract,,,78,,27.61,percent of total billed charges,,,70,,24.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.35,3324,
68001-0439-00 - fexofenadine 60 mg Tab,68001-0439-00,NDC,,,,inpatient,1,EA,9.95,5.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.46,percent of total billed charges,,,85,,8.46,percent of total billed charges,,,49,,4.88,percent of total billed charges,,,90,,8.96,percent of total billed charges,,,,,,,no IP contract,,80,,7.96,percent of total billed charges,,,,,,,no IP contract,,50,,4.98,percent of total billed charges,,,,,,no IP contract,,,78,,7.76,percent of total billed charges,,,70,,6.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.88,3324,
68001-0450-06 - ziprasidone 20 mg Cap,68001-0450-06,NDC,,,,inpatient,1,EA,75.05,45.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63.79,percent of total billed charges,,,85,,63.79,percent of total billed charges,,,49,,36.77,percent of total billed charges,,,90,,67.55,percent of total billed charges,,,,,,,no IP contract,,80,,60.04,percent of total billed charges,,,,,,,no IP contract,,50,,37.53,percent of total billed charges,,,,,,no IP contract,,,78,,58.54,percent of total billed charges,,,70,,52.54,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.77,3324,
68001-0458-42 - enoxaparin 40 mg/0.4 mL Soln,68001-0458-42,NDC,,,,inpatient,0.4,ML,167.4,100.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,135.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,142.29,percent of total billed charges,,,85,,142.29,percent of total billed charges,,,49,,82.03,percent of total billed charges,,,90,,150.66,percent of total billed charges,,,,,,,no IP contract,,80,,133.92,percent of total billed charges,,,,,,,no IP contract,,50,,83.7,percent of total billed charges,,,,,,no IP contract,,,78,,130.57,percent of total billed charges,,,70,,117.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,82.03,3324,
68001-0472-00 - divalproex sodium 125 mg EC Ta,68001-0472-00,NDC,,,,inpatient,1,EA,11,6.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.35,percent of total billed charges,,,85,,9.35,percent of total billed charges,,,49,,5.39,percent of total billed charges,,,90,,9.9,percent of total billed charges,,,,,,,no IP contract,,80,,8.8,percent of total billed charges,,,,,,,no IP contract,,50,,5.5,percent of total billed charges,,,,,,no IP contract,,,78,,8.58,percent of total billed charges,,,70,,7.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.39,3324,
68001-0475-47 - clotrimazole topical 1% Cream,68001-0475-47,NDC,,,,inpatient,1,UN,86.7,52.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,70.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,73.7,percent of total billed charges,,,85,,73.7,percent of total billed charges,,,49,,42.48,percent of total billed charges,,,90,,78.03,percent of total billed charges,,,,,,,no IP contract,,80,,69.36,percent of total billed charges,,,,,,,no IP contract,,50,,43.35,percent of total billed charges,,,,,,no IP contract,,,78,,67.63,percent of total billed charges,,,70,,60.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,42.48,3324,
68001-0476-46 - hydrocortisone topical 1% Cream,68001-0476-46,NDC,,,,inpatient,1,UN,41.7,25.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,35.45,percent of total billed charges,,,85,,35.45,percent of total billed charges,,,49,,20.43,percent of total billed charges,,,90,,37.53,percent of total billed charges,,,,,,,no IP contract,,80,,33.36,percent of total billed charges,,,,,,,no IP contract,,50,,20.85,percent of total billed charges,,,,,,no IP contract,,,78,,32.53,percent of total billed charges,,,70,,29.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.43,3324,
68001-0519-05 - buPROPion 150 mg/24 hours ER Ta,68001-0519-05,NDC,,,,inpatient,1,EA,45.3,27.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,38.51,percent of total billed charges,,,85,,38.51,percent of total billed charges,,,49,,22.2,percent of total billed charges,,,90,,40.77,percent of total billed charges,,,,,,,no IP contract,,80,,36.24,percent of total billed charges,,,,,,,no IP contract,,50,,22.65,percent of total billed charges,,,,,,no IP contract,,,78,,35.33,percent of total billed charges,,,70,,31.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.2,3324,
68084-0021-21 - abacavir 300 mg Tab,68084-0021-21,NDC,,,,inpatient,1,EA,83.65,50.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,67.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,71.1,percent of total billed charges,,,85,,71.1,percent of total billed charges,,,49,,40.99,percent of total billed charges,,,90,,75.29,percent of total billed charges,,,,,,,no IP contract,,80,,66.92,percent of total billed charges,,,,,,,no IP contract,,50,,41.83,percent of total billed charges,,,,,,no IP contract,,,78,,65.25,percent of total billed charges,,,70,,58.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,40.99,3324,
68084-0027-01 - warfarin 2.5 mg Tab,68084-0027-01,NDC,,,,inpatient,1,EA,8.85,5.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.52,percent of total billed charges,,,85,,7.52,percent of total billed charges,,,49,,4.34,percent of total billed charges,,,90,,7.97,percent of total billed charges,,,,,,,no IP contract,,80,,7.08,percent of total billed charges,,,,,,,no IP contract,,50,,4.43,percent of total billed charges,,,,,,no IP contract,,,78,,6.9,percent of total billed charges,,,70,,6.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.34,3324,
68084-0029-01 - busPIRone 10 mg Tab,68084-0029-01,NDC,,,,inpatient,1,EA,14,8.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.9,percent of total billed charges,,,85,,11.9,percent of total billed charges,,,49,,6.86,percent of total billed charges,,,90,,12.6,percent of total billed charges,,,,,,,no IP contract,,80,,11.2,percent of total billed charges,,,,,,,no IP contract,,50,,7,percent of total billed charges,,,,,,no IP contract,,,78,,10.92,percent of total billed charges,,,70,,9.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.86,3324,
68084-0031-01 - nortriptyline 10 mg Cap,68084-0031-01,NDC,,,,inpatient,1,EA,7.3,4.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.21,percent of total billed charges,,,85,,6.21,percent of total billed charges,,,49,,3.58,percent of total billed charges,,,90,,6.57,percent of total billed charges,,,,,,,no IP contract,,80,,5.84,percent of total billed charges,,,,,,,no IP contract,,50,,3.65,percent of total billed charges,,,,,,no IP contract,,,78,,5.69,percent of total billed charges,,,70,,5.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.58,3324,
68084-0040-01 - misoprostol 100 mcg Tab,68084-0040-01,NDC,,,,inpatient,1,EA,11.7,7.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.95,percent of total billed charges,,,85,,9.95,percent of total billed charges,,,49,,5.73,percent of total billed charges,,,90,,10.53,percent of total billed charges,,,,,,,no IP contract,,80,,9.36,percent of total billed charges,,,,,,,no IP contract,,50,,5.85,percent of total billed charges,,,,,,no IP contract,,,78,,9.13,percent of total billed charges,,,70,,8.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.73,3324,
PARoxetine 10 mg Tab,68084-0044-11,NDC,,,,inpatient,1,EA,25.05,15.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.29,percent of total billed charges,,,85,,21.29,percent of total billed charges,,,49,,12.27,percent of total billed charges,,,90,,22.55,percent of total billed charges,,,,,,,no IP contract,,80,,20.04,percent of total billed charges,,,,,,,no IP contract,,50,,12.53,percent of total billed charges,,,,,,no IP contract,,,78,,19.54,percent of total billed charges,,,70,,17.54,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.27,3324,
68084-0045-01 - paroxetine 20 mg Tab,68084-0045-01,NDC,,,,inpatient,1,EA,26,15.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.1,percent of total billed charges,,,85,,22.1,percent of total billed charges,,,49,,12.74,percent of total billed charges,,,90,,23.4,percent of total billed charges,,,,,,,no IP contract,,80,,20.8,percent of total billed charges,,,,,,,no IP contract,,50,,13,percent of total billed charges,,,,,,no IP contract,,,78,,20.28,percent of total billed charges,,,70,,18.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.74,3324,
68084-0056-01 - methocarbamol 500 mg Tab,68084-0056-01,NDC,,,,inpatient,1,EA,7.15,4.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.08,percent of total billed charges,,,85,,6.08,percent of total billed charges,,,49,,3.5,percent of total billed charges,,,90,,6.44,percent of total billed charges,,,,,,,no IP contract,,80,,5.72,percent of total billed charges,,,,,,,no IP contract,,50,,3.58,percent of total billed charges,,,,,,no IP contract,,,78,,5.58,percent of total billed charges,,,70,,5.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.5,3324,
68084-0069-01 - ciprofloxacin 250 mg Tab,68084-0069-01,NDC,,,,inpatient,1,EA,47.25,28.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,38.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,40.16,percent of total billed charges,,,85,,40.16,percent of total billed charges,,,49,,23.15,percent of total billed charges,,,90,,42.53,percent of total billed charges,,,,,,,no IP contract,,80,,37.8,percent of total billed charges,,,,,,,no IP contract,,50,,23.63,percent of total billed charges,,,,,,no IP contract,,,78,,36.86,percent of total billed charges,,,70,,33.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.15,3324,
68084-0069-11 - ciprofloxacin 250 mg Tab,68084-0069-11,NDC,,,,inpatient,1,EA,47.25,28.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,38.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,40.16,percent of total billed charges,,,85,,40.16,percent of total billed charges,,,49,,23.15,percent of total billed charges,,,90,,42.53,percent of total billed charges,,,,,,,no IP contract,,80,,37.8,percent of total billed charges,,,,,,,no IP contract,,50,,23.63,percent of total billed charges,,,,,,no IP contract,,,78,,36.86,percent of total billed charges,,,70,,33.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.15,3324,
ciprofloxacin 500 mg Tab,68084-0070-01,NDC,,,,inpatient,1,EA,29.1,17.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.74,percent of total billed charges,,,85,,24.74,percent of total billed charges,,,49,,14.26,percent of total billed charges,,,90,,26.19,percent of total billed charges,,,,,,,no IP contract,,80,,23.28,percent of total billed charges,,,,,,,no IP contract,,50,,14.55,percent of total billed charges,,,,,,no IP contract,,,78,,22.7,percent of total billed charges,,,70,,20.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.26,3324,
68084-0071-01 - ciprofloxacin 750 mg Tab,68084-0071-01,NDC,,,,inpatient,1,EA,64.7,38.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,52.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,55,percent of total billed charges,,,85,,55,percent of total billed charges,,,49,,31.7,percent of total billed charges,,,90,,58.23,percent of total billed charges,,,,,,,no IP contract,,80,,51.76,percent of total billed charges,,,,,,,no IP contract,,50,,32.35,percent of total billed charges,,,,,,no IP contract,,,78,,50.47,percent of total billed charges,,,70,,45.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.7,3324,
68084-0077-01 - nitrofurantoin macrocrystals 50 mg Cap,68084-0077-01,NDC,,,,inpatient,1,EA,38.95,23.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.11,percent of total billed charges,,,85,,33.11,percent of total billed charges,,,49,,19.09,percent of total billed charges,,,90,,35.06,percent of total billed charges,,,,,,,no IP contract,,80,,31.16,percent of total billed charges,,,,,,,no IP contract,,50,,19.48,percent of total billed charges,,,,,,no IP contract,,,78,,30.38,percent of total billed charges,,,70,,27.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.09,3324,
68084-0083-01 - isosorbide dinitrate 20 mg Tab,68084-0083-01,NDC,,,,inpatient,1,EA,14.55,8.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.37,percent of total billed charges,,,85,,12.37,percent of total billed charges,,,49,,7.13,percent of total billed charges,,,90,,13.1,percent of total billed charges,,,,,,,no IP contract,,80,,11.64,percent of total billed charges,,,,,,,no IP contract,,50,,7.28,percent of total billed charges,,,,,,no IP contract,,,78,,11.35,percent of total billed charges,,,70,,10.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.13,3324,
68084-0093-01 - carbidopa-levodopa 25 mg-100 mg Tab,68084-0093-01,NDC,,,,inpatient,1,EA,10.35,6.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.8,percent of total billed charges,,,85,,8.8,percent of total billed charges,,,49,,5.07,percent of total billed charges,,,90,,9.32,percent of total billed charges,,,,,,,no IP contract,,80,,8.28,percent of total billed charges,,,,,,,no IP contract,,50,,5.18,percent of total billed charges,,,,,,no IP contract,,,78,,8.07,percent of total billed charges,,,70,,7.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.07,3324,
68084-0094-01 - carbidopa-levodopa 25 mg-250 mg Tab,68084-0094-01,NDC,,,,inpatient,1,EA,11.4,6.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.69,percent of total billed charges,,,85,,9.69,percent of total billed charges,,,49,,5.59,percent of total billed charges,,,90,,10.26,percent of total billed charges,,,,,,,no IP contract,,80,,9.12,percent of total billed charges,,,,,,,no IP contract,,50,,5.7,percent of total billed charges,,,,,,no IP contract,,,78,,8.89,percent of total billed charges,,,70,,7.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.59,3324,
68084-0097-01 - atorvastatin 10 mg tab,68084-0097-01,NDC,,,,inpatient,1,EA,8.85,5.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.52,percent of total billed charges,,,85,,7.52,percent of total billed charges,,,49,,4.34,percent of total billed charges,,,90,,7.97,percent of total billed charges,,,,,,,no IP contract,,80,,7.08,percent of total billed charges,,,,,,,no IP contract,,50,,4.43,percent of total billed charges,,,,,,no IP contract,,,78,,6.9,percent of total billed charges,,,70,,6.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.34,3324,
68084-0098-01 - atorvastatin 20 mg Tab,68084-0098-01,NDC,,,,inpatient,1,EA,10.65,6.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.05,percent of total billed charges,,,85,,9.05,percent of total billed charges,,,49,,5.22,percent of total billed charges,,,90,,9.59,percent of total billed charges,,,,,,,no IP contract,,80,,8.52,percent of total billed charges,,,,,,,no IP contract,,50,,5.33,percent of total billed charges,,,,,,no IP contract,,,78,,8.31,percent of total billed charges,,,70,,7.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.22,3324,
68084-0099-01 - atorvastatin  40 mg Tab,68084-0099-01,NDC,,,,inpatient,1,EA,10.65,6.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.05,percent of total billed charges,,,85,,9.05,percent of total billed charges,,,49,,5.22,percent of total billed charges,,,90,,9.59,percent of total billed charges,,,,,,,no IP contract,,80,,8.52,percent of total billed charges,,,,,,,no IP contract,,50,,5.33,percent of total billed charges,,,,,,no IP contract,,,78,,8.31,percent of total billed charges,,,70,,7.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.22,3324,
68084-0107-01 - acyclovir 200 mg Cap,68084-0107-01,NDC,,,,inpatient,1,EA,14.25,8.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.11,percent of total billed charges,,,85,,12.11,percent of total billed charges,,,49,,6.98,percent of total billed charges,,,90,,12.83,percent of total billed charges,,,,,,,no IP contract,,80,,11.4,percent of total billed charges,,,,,,,no IP contract,,50,,7.13,percent of total billed charges,,,,,,no IP contract,,,78,,11.12,percent of total billed charges,,,70,,9.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.98,3324,
68084-0108-01 - acyclovir 400 mg Tab,68084-0108-01,NDC,,,,inpatient,1,EA,19.55,11.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.62,percent of total billed charges,,,85,,16.62,percent of total billed charges,,,49,,9.58,percent of total billed charges,,,90,,17.6,percent of total billed charges,,,,,,,no IP contract,,80,,15.64,percent of total billed charges,,,,,,,no IP contract,,50,,9.78,percent of total billed charges,,,,,,no IP contract,,,78,,15.25,percent of total billed charges,,,70,,13.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.58,3324,
68084-0109-01 - acyclovir 800 mg Tab,68084-0109-01,NDC,,,,inpatient,1,EA,40,24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34,percent of total billed charges,,,85,,34,percent of total billed charges,,,49,,19.6,percent of total billed charges,,,90,,36,percent of total billed charges,,,,,,,no IP contract,,80,,32,percent of total billed charges,,,,,,,no IP contract,,50,,20,percent of total billed charges,,,,,,no IP contract,,,78,,31.2,percent of total billed charges,,,70,,28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.6,3324,
68084-0111-01 - glipiZIDE 5 mg ER Ta,68084-0111-01,NDC,,,,inpatient,1,EA,7.65,4.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.5,percent of total billed charges,,,85,,6.5,percent of total billed charges,,,49,,3.75,percent of total billed charges,,,90,,6.89,percent of total billed charges,,,,,,,no IP contract,,80,,6.12,percent of total billed charges,,,,,,,no IP contract,,50,,3.83,percent of total billed charges,,,,,,no IP contract,,,78,,5.97,percent of total billed charges,,,70,,5.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.75,3324,
68084-0111-11 - glipiZIDE 5 mg ER Ta,68084-0111-11,NDC,,,,inpatient,1,EA,8.1,4.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.89,percent of total billed charges,,,85,,6.89,percent of total billed charges,,,49,,3.97,percent of total billed charges,,,90,,7.29,percent of total billed charges,,,,,,,no IP contract,,80,,6.48,percent of total billed charges,,,,,,,no IP contract,,50,,4.05,percent of total billed charges,,,,,,no IP contract,,,78,,6.32,percent of total billed charges,,,70,,5.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.97,3324,
68084-0112-01 - glipiZIDE 10 mg ER Ta,68084-0112-01,NDC,,,,inpatient,1,EA,9.4,5.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.99,percent of total billed charges,,,85,,7.99,percent of total billed charges,,,49,,4.61,percent of total billed charges,,,90,,8.46,percent of total billed charges,,,,,,,no IP contract,,80,,7.52,percent of total billed charges,,,,,,,no IP contract,,50,,4.7,percent of total billed charges,,,,,,no IP contract,,,78,,7.33,percent of total billed charges,,,70,,6.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.61,3324,
68084-0119-01 - mirtazapine 15 mg Tab,68084-0119-01,NDC,,,,inpatient,1,EA,25.35,15.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.55,percent of total billed charges,,,85,,21.55,percent of total billed charges,,,49,,12.42,percent of total billed charges,,,90,,22.82,percent of total billed charges,,,,,,,no IP contract,,80,,20.28,percent of total billed charges,,,,,,,no IP contract,,50,,12.68,percent of total billed charges,,,,,,no IP contract,,,78,,19.77,percent of total billed charges,,,70,,17.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.42,3324,
68084-0120-01 - mirtazapine 30 mg Tab,68084-0120-01,NDC,,,,inpatient,1,EA,3.8,2.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.23,percent of total billed charges,,,85,,3.23,percent of total billed charges,,,49,,1.86,percent of total billed charges,,,90,,3.42,percent of total billed charges,,,,,,,no IP contract,,80,,3.04,percent of total billed charges,,,,,,,no IP contract,,50,,1.9,percent of total billed charges,,,,,,no IP contract,,,78,,2.96,percent of total billed charges,,,70,,2.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.86,3324,
68084-0128-01 - omeprazole 20 mg DRC,68084-0128-01,NDC,,,,inpatient,1,EA,12.65,7.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.75,percent of total billed charges,,,85,,10.75,percent of total billed charges,,,49,,6.2,percent of total billed charges,,,90,,11.39,percent of total billed charges,,,,,,,no IP contract,,80,,10.12,percent of total billed charges,,,,,,,no IP contract,,50,,6.33,percent of total billed charges,,,,,,no IP contract,,,78,,9.87,percent of total billed charges,,,70,,8.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.2,3324,
68084-0149-01 - methylPREDNISolone 4 mg Tab,68084-0149-01,NDC,,,,inpatient,1,EA,20.9,12.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.77,percent of total billed charges,,,85,,17.77,percent of total billed charges,,,49,,10.24,percent of total billed charges,,,90,,18.81,percent of total billed charges,,,,,,,no IP contract,,80,,16.72,percent of total billed charges,,,,,,,no IP contract,,50,,10.45,percent of total billed charges,,,,,,no IP contract,,,78,,16.3,percent of total billed charges,,,70,,14.63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.24,3324,
68084-0154-01 - promethazine 12.5 mg Tab,68084-0154-01,NDC,,,,inpatient,1,EA,8.3,4.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.06,percent of total billed charges,,,85,,7.06,percent of total billed charges,,,49,,4.07,percent of total billed charges,,,90,,7.47,percent of total billed charges,,,,,,,no IP contract,,80,,6.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.15,percent of total billed charges,,,,,,no IP contract,,,78,,6.47,percent of total billed charges,,,70,,5.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.07,3324,
68084-0155-01 - promethazine 25 mg Tab,68084-0155-01,NDC,,,,inpatient,1,EA,8.1,4.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.89,percent of total billed charges,,,85,,6.89,percent of total billed charges,,,49,,3.97,percent of total billed charges,,,90,,7.29,percent of total billed charges,,,,,,,no IP contract,,80,,6.48,percent of total billed charges,,,,,,,no IP contract,,50,,4.05,percent of total billed charges,,,,,,no IP contract,,,78,,6.32,percent of total billed charges,,,70,,5.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.97,3324,
68084-0158-01 - morphine 30 mg/8 to 12 hr ER Ta,68084-0158-01,NDC,,,,inpatient,1,EA,17.75,10.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.09,percent of total billed charges,,,85,,15.09,percent of total billed charges,,,49,,8.7,percent of total billed charges,,,90,,15.98,percent of total billed charges,,,,,,,no IP contract,,80,,14.2,percent of total billed charges,,,,,,,no IP contract,,50,,8.88,percent of total billed charges,,,,,,no IP contract,,,78,,13.85,percent of total billed charges,,,70,,12.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.7,3324,
68084-0166-01 - bethanechol 10 mg Tab,68084-0166-01,NDC,,,,inpatient,1,EA,15.65,9.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.3,percent of total billed charges,,,85,,13.3,percent of total billed charges,,,49,,7.67,percent of total billed charges,,,90,,14.09,percent of total billed charges,,,,,,,no IP contract,,80,,12.52,percent of total billed charges,,,,,,,no IP contract,,50,,7.83,percent of total billed charges,,,,,,no IP contract,,,78,,12.21,percent of total billed charges,,,70,,10.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.67,3324,
68084-0166-11 - bethanechol 10 mg Tab,68084-0166-11,NDC,,,,inpatient,1,EA,1191.4,714.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,965.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1012.69,percent of total billed charges,,,85,,1012.69,percent of total billed charges,,,49,,583.79,percent of total billed charges,,,90,,1072.26,percent of total billed charges,,,,,,,no IP contract,,80,,953.12,percent of total billed charges,,,,,,,no IP contract,,50,,595.7,percent of total billed charges,,,,,,no IP contract,,,78,,929.29,percent of total billed charges,,,70,,833.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,583.79,3324,
68084-0174-01 - dronabinol 2.5 mg Cap,68084-0174-01,NDC,,,,inpatient,1,EA,52.75,31.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,42.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,44.84,percent of total billed charges,,,85,,44.84,percent of total billed charges,,,49,,25.85,percent of total billed charges,,,90,,47.48,percent of total billed charges,,,,,,,no IP contract,,80,,42.2,percent of total billed charges,,,,,,,no IP contract,,50,,26.38,percent of total billed charges,,,,,,no IP contract,,,78,,41.15,percent of total billed charges,,,70,,36.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.85,3324,
68084-0175-11 - dronabinol 5 mg Capsule,68084-0175-11,NDC,,,,inpatient,1,EA,107.55,64.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,87.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,91.42,percent of total billed charges,,,85,,91.42,percent of total billed charges,,,49,,52.7,percent of total billed charges,,,90,,96.8,percent of total billed charges,,,,,,,no IP contract,,80,,86.04,percent of total billed charges,,,,,,,no IP contract,,50,,53.78,percent of total billed charges,,,,,,no IP contract,,,78,,83.89,percent of total billed charges,,,70,,75.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,52.7,3324,
68084-0175-21 - dronabinol 5 mg Cap,68084-0175-21,NDC,,,,inpatient,1,EA,107.55,64.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,87.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,91.42,percent of total billed charges,,,85,,91.42,percent of total billed charges,,,49,,52.7,percent of total billed charges,,,90,,96.8,percent of total billed charges,,,,,,,no IP contract,,80,,86.04,percent of total billed charges,,,,,,,no IP contract,,50,,53.78,percent of total billed charges,,,,,,no IP contract,,,78,,83.89,percent of total billed charges,,,70,,75.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,52.7,3324,
68084-0180-01 - sertraline 25 mg Tab,68084-0180-01,NDC,,,,inpatient,1,EA,7,4.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.95,percent of total billed charges,,,85,,5.95,percent of total billed charges,,,49,,3.43,percent of total billed charges,,,90,,6.3,percent of total billed charges,,,,,,,no IP contract,,80,,5.6,percent of total billed charges,,,,,,,no IP contract,,50,,3.5,percent of total billed charges,,,,,,no IP contract,,,78,,5.46,percent of total billed charges,,,70,,4.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.43,3324,
68084-0182-01 - sertraline 100 mg Tab,68084-0182-01,NDC,,,,inpatient,1,EA,7,4.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.95,percent of total billed charges,,,85,,5.95,percent of total billed charges,,,49,,3.43,percent of total billed charges,,,90,,6.3,percent of total billed charges,,,,,,,no IP contract,,80,,5.6,percent of total billed charges,,,,,,,no IP contract,,50,,3.5,percent of total billed charges,,,,,,no IP contract,,,78,,5.46,percent of total billed charges,,,70,,4.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.43,3324,
68084-0184-01 - oxyCODONE 15 mg Tab,68084-0184-01,NDC,,,,inpatient,1,EA,9.5,5.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.08,percent of total billed charges,,,85,,8.08,percent of total billed charges,,,49,,4.66,percent of total billed charges,,,90,,8.55,percent of total billed charges,,,,,,,no IP contract,,80,,7.6,percent of total billed charges,,,,,,,no IP contract,,50,,4.75,percent of total billed charges,,,,,,no IP contract,,,78,,7.41,percent of total billed charges,,,70,,6.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.66,3324,
68084-0189-01 - zolpidem 5 mg Tab,68084-0189-01,NDC,,,,inpatient,1,EA,20.1,12.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.09,percent of total billed charges,,,85,,17.09,percent of total billed charges,,,49,,9.85,percent of total billed charges,,,90,,18.09,percent of total billed charges,,,,,,,no IP contract,,80,,16.08,percent of total billed charges,,,,,,,no IP contract,,50,,10.05,percent of total billed charges,,,,,,no IP contract,,,78,,15.68,percent of total billed charges,,,70,,14.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.85,3324,
68084-0196-01 - lisinopril 5 mg Tab,68084-0196-01,NDC,,,,inpatient,1,EA,10.75,6.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.14,percent of total billed charges,,,85,,9.14,percent of total billed charges,,,49,,5.27,percent of total billed charges,,,90,,9.68,percent of total billed charges,,,,,,,no IP contract,,80,,8.6,percent of total billed charges,,,,,,,no IP contract,,50,,5.38,percent of total billed charges,,,,,,no IP contract,,,78,,8.39,percent of total billed charges,,,70,,7.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.27,3324,
68084-0198-01 - lisinopril 20 mg Tab,68084-0198-01,NDC,,,,inpatient,1,EA,7,4.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.95,percent of total billed charges,,,85,,5.95,percent of total billed charges,,,49,,3.43,percent of total billed charges,,,90,,6.3,percent of total billed charges,,,,,,,no IP contract,,80,,5.6,percent of total billed charges,,,,,,,no IP contract,,50,,3.5,percent of total billed charges,,,,,,no IP contract,,,78,,5.46,percent of total billed charges,,,70,,4.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.43,3324,
68084-0199-01 - lisinopril 40 mg Tab,68084-0199-01,NDC,,,,inpatient,1,EA,8.65,5.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.35,percent of total billed charges,,,85,,7.35,percent of total billed charges,,,49,,4.24,percent of total billed charges,,,90,,7.79,percent of total billed charges,,,,,,,no IP contract,,80,,6.92,percent of total billed charges,,,,,,,no IP contract,,50,,4.33,percent of total billed charges,,,,,,no IP contract,,,78,,6.75,percent of total billed charges,,,70,,6.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.24,3324,
68084-0202-01 - primidone 50 mg Tab,68084-0202-01,NDC,,,,inpatient,1,EA,10.1,6.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.59,percent of total billed charges,,,85,,8.59,percent of total billed charges,,,49,,4.95,percent of total billed charges,,,90,,9.09,percent of total billed charges,,,,,,,no IP contract,,80,,8.08,percent of total billed charges,,,,,,,no IP contract,,50,,5.05,percent of total billed charges,,,,,,no IP contract,,,78,,7.88,percent of total billed charges,,,70,,7.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.95,3324,
68084-0203-01 - primidone 250 mg Tab,68084-0203-01,NDC,,,,inpatient,1,EA,11.4,6.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.69,percent of total billed charges,,,85,,9.69,percent of total billed charges,,,49,,5.59,percent of total billed charges,,,90,,10.26,percent of total billed charges,,,,,,,no IP contract,,80,,9.12,percent of total billed charges,,,,,,,no IP contract,,50,,5.7,percent of total billed charges,,,,,,no IP contract,,,78,,8.89,percent of total billed charges,,,70,,7.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.59,3324,
68084-0204-01 - minoxidil 2.5 mg Tab,68084-0204-01,NDC,,,,inpatient,1,EA,17.35,10.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.75,percent of total billed charges,,,85,,14.75,percent of total billed charges,,,49,,8.5,percent of total billed charges,,,90,,15.62,percent of total billed charges,,,,,,,no IP contract,,80,,13.88,percent of total billed charges,,,,,,,no IP contract,,50,,8.68,percent of total billed charges,,,,,,no IP contract,,,78,,13.53,percent of total billed charges,,,70,,12.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.5,3324,
68084-0204-11 - minoxidil 2.5 mg Tab,68084-0204-11,NDC,,,,inpatient,1,EA,17.35,10.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.75,percent of total billed charges,,,85,,14.75,percent of total billed charges,,,49,,8.5,percent of total billed charges,,,90,,15.62,percent of total billed charges,,,,,,,no IP contract,,80,,13.88,percent of total billed charges,,,,,,,no IP contract,,50,,8.68,percent of total billed charges,,,,,,no IP contract,,,78,,13.53,percent of total billed charges,,,70,,12.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.5,3324,
68084-0205-01 - minoxidil 10 mg Tab,68084-0205-01,NDC,,,,inpatient,1,EA,20.7,12.42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.6,percent of total billed charges,,,85,,17.6,percent of total billed charges,,,49,,10.14,percent of total billed charges,,,90,,18.63,percent of total billed charges,,,,,,,no IP contract,,80,,16.56,percent of total billed charges,,,,,,,no IP contract,,50,,10.35,percent of total billed charges,,,,,,no IP contract,,,78,,16.15,percent of total billed charges,,,70,,14.49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.14,3324,
68084-0214-01 - benzonatate 100 mg Cap,68084-0214-01,NDC,,,,inpatient,1,EA,9.65,5.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.2,percent of total billed charges,,,85,,8.2,percent of total billed charges,,,49,,4.73,percent of total billed charges,,,90,,8.69,percent of total billed charges,,,,,,,no IP contract,,80,,7.72,percent of total billed charges,,,,,,,no IP contract,,50,,4.83,percent of total billed charges,,,,,,no IP contract,,,78,,7.53,percent of total billed charges,,,70,,6.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.73,3324,
68084-0214-11 - benzonatate 100 mg Cap,68084-0214-11,NDC,,,,inpatient,1,EA,10.1,6.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.59,percent of total billed charges,,,85,,8.59,percent of total billed charges,,,49,,4.95,percent of total billed charges,,,90,,9.09,percent of total billed charges,,,,,,,no IP contract,,80,,8.08,percent of total billed charges,,,,,,,no IP contract,,50,,5.05,percent of total billed charges,,,,,,no IP contract,,,78,,7.88,percent of total billed charges,,,70,,7.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.95,3324,
68084-0217-21 - irbesartan 150 mg Tab,68084-0217-21,NDC,,,,inpatient,1,EA,28.7,17.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.4,percent of total billed charges,,,85,,24.4,percent of total billed charges,,,49,,14.06,percent of total billed charges,,,90,,25.83,percent of total billed charges,,,,,,,no IP contract,,80,,22.96,percent of total billed charges,,,,,,,no IP contract,,50,,14.35,percent of total billed charges,,,,,,no IP contract,,,78,,22.39,percent of total billed charges,,,70,,20.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.06,3324,
68084-0220-01 - ondansetron 4 mg Tab,68084-0220-01,NDC,,,,inpatient,1,EA,194.15,116.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,157.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,165.03,percent of total billed charges,,,85,,165.03,percent of total billed charges,,,49,,95.13,percent of total billed charges,,,90,,174.74,percent of total billed charges,,,,,,,no IP contract,,80,,155.32,percent of total billed charges,,,,,,,no IP contract,,50,,97.08,percent of total billed charges,,,,,,no IP contract,,,78,,151.44,percent of total billed charges,,,70,,135.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,95.13,3324,
68084-0221-01 - ondansetron 8 mg Tab,68084-0221-01,NDC,,,,inpatient,1,EA,321.45,192.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,260.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,273.23,percent of total billed charges,,,85,,273.23,percent of total billed charges,,,49,,157.51,percent of total billed charges,,,90,,289.31,percent of total billed charges,,,,,,,no IP contract,,80,,257.16,percent of total billed charges,,,,,,,no IP contract,,50,,160.73,percent of total billed charges,,,,,,no IP contract,,,78,,250.73,percent of total billed charges,,,70,,225.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,157.51,3324,
68084-0229-01 - azathioprine 50 mg Tab,68084-0229-01,NDC,,,,inpatient,1,EA,10.6,6.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.01,percent of total billed charges,,,85,,9.01,percent of total billed charges,,,49,,5.19,percent of total billed charges,,,90,,9.54,percent of total billed charges,,,,,,,no IP contract,,80,,8.48,percent of total billed charges,,,,,,,no IP contract,,50,,5.3,percent of total billed charges,,,,,,no IP contract,,,78,,8.27,percent of total billed charges,,,70,,7.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.19,3324,
68084-0229-11 - azathioprine 50 mg Tab,68084-0229-11,NDC,,,,inpatient,1,EA,10.6,6.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.01,percent of total billed charges,,,85,,9.01,percent of total billed charges,,,49,,5.19,percent of total billed charges,,,90,,9.54,percent of total billed charges,,,,,,,no IP contract,,80,,8.48,percent of total billed charges,,,,,,,no IP contract,,50,,5.3,percent of total billed charges,,,,,,no IP contract,,,78,,8.27,percent of total billed charges,,,70,,7.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.19,3324,
68084-0230-01 - sulfamethoxazole-trimethoprim 800 mg-160 mg Tab,68084-0230-01,NDC,,,,inpatient,1,EA,6.15,3.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.23,percent of total billed charges,,,85,,5.23,percent of total billed charges,,,49,,3.01,percent of total billed charges,,,90,,5.54,percent of total billed charges,,,,,,,no IP contract,,80,,4.92,percent of total billed charges,,,,,,,no IP contract,,50,,3.08,percent of total billed charges,,,,,,no IP contract,,,78,,4.8,percent of total billed charges,,,70,,4.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.01,3324,
68084-0241-01 - midodrine 5 mg Tab,68084-0241-01,NDC,,,,inpatient,1,EA,20.1,12.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.09,percent of total billed charges,,,85,,17.09,percent of total billed charges,,,49,,9.85,percent of total billed charges,,,90,,18.09,percent of total billed charges,,,,,,,no IP contract,,80,,16.08,percent of total billed charges,,,,,,,no IP contract,,50,,10.05,percent of total billed charges,,,,,,no IP contract,,,78,,15.68,percent of total billed charges,,,70,,14.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.85,3324,
68084-0243-01 - clindamycin 150 mg Cap,68084-0243-01,NDC,,,,inpatient,1,EA,8.85,5.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.52,percent of total billed charges,,,85,,7.52,percent of total billed charges,,,49,,4.34,percent of total billed charges,,,90,,7.97,percent of total billed charges,,,,,,,no IP contract,,80,,7.08,percent of total billed charges,,,,,,,no IP contract,,50,,4.43,percent of total billed charges,,,,,,no IP contract,,,78,,6.9,percent of total billed charges,,,70,,6.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.34,3324,
68084-0244-01 - clindamycin 300 mg Cap,68084-0244-01,NDC,,,,inpatient,1,EA,14.15,8.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.03,percent of total billed charges,,,85,,12.03,percent of total billed charges,,,49,,6.93,percent of total billed charges,,,90,,12.74,percent of total billed charges,,,,,,,no IP contract,,80,,11.32,percent of total billed charges,,,,,,,no IP contract,,50,,7.08,percent of total billed charges,,,,,,no IP contract,,,78,,11.04,percent of total billed charges,,,70,,9.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.93,3324,
68084-0248-01 - loratadine 10 mg Tab,68084-0248-01,NDC,,,,inpatient,1,EA,9.4,5.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.99,percent of total billed charges,,,85,,7.99,percent of total billed charges,,,49,,4.61,percent of total billed charges,,,90,,8.46,percent of total billed charges,,,,,,,no IP contract,,80,,7.52,percent of total billed charges,,,,,,,no IP contract,,50,,4.7,percent of total billed charges,,,,,,no IP contract,,,78,,7.33,percent of total billed charges,,,70,,6.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.61,3324,
68084-0248-11 - loratadine 10 mg Tab,68084-0248-11,NDC,,,,inpatient,1,EA,9.4,5.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.99,percent of total billed charges,,,85,,7.99,percent of total billed charges,,,49,,4.61,percent of total billed charges,,,90,,8.46,percent of total billed charges,,,,,,,no IP contract,,80,,7.52,percent of total billed charges,,,,,,,no IP contract,,50,,4.7,percent of total billed charges,,,,,,no IP contract,,,78,,7.33,percent of total billed charges,,,70,,6.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.61,3324,
68084-0252-21 - buPROPion 300 mg ER Tablet,68084-0252-21,NDC,,,,inpatient,1,EA,41.75,25.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,35.49,percent of total billed charges,,,85,,35.49,percent of total billed charges,,,49,,20.46,percent of total billed charges,,,90,,37.58,percent of total billed charges,,,,,,,no IP contract,,80,,33.4,percent of total billed charges,,,,,,,no IP contract,,50,,20.88,percent of total billed charges,,,,,,no IP contract,,,78,,32.57,percent of total billed charges,,,70,,29.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.46,3324,
68084-0253-01 - hydrOXYzine hydrochloride 10 mg Tab,68084-0253-01,NDC,,,,inpatient,1,EA,6.05,3.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.14,percent of total billed charges,,,85,,5.14,percent of total billed charges,,,49,,2.96,percent of total billed charges,,,90,,5.45,percent of total billed charges,,,,,,,no IP contract,,80,,4.84,percent of total billed charges,,,,,,,no IP contract,,50,,3.03,percent of total billed charges,,,,,,no IP contract,,,78,,4.72,percent of total billed charges,,,70,,4.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.96,3324,
68084-0254-01 - hydrOXYzine hydrochloride 25 mg Tab,68084-0254-01,NDC,,,,inpatient,1,EA,6.95,4.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.91,percent of total billed charges,,,85,,5.91,percent of total billed charges,,,49,,3.41,percent of total billed charges,,,90,,6.26,percent of total billed charges,,,,,,,no IP contract,,80,,5.56,percent of total billed charges,,,,,,,no IP contract,,50,,3.48,percent of total billed charges,,,,,,no IP contract,,,78,,5.42,percent of total billed charges,,,70,,4.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.41,3324,
68084-0257-21 - terbutaline 5 mg Tab,68084-0257-21,NDC,,,,inpatient,1,EA,10.9,6.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.27,percent of total billed charges,,,85,,9.27,percent of total billed charges,,,49,,5.34,percent of total billed charges,,,90,,9.81,percent of total billed charges,,,,,,,no IP contract,,80,,8.72,percent of total billed charges,,,,,,,no IP contract,,50,,5.45,percent of total billed charges,,,,,,no IP contract,,,78,,8.5,percent of total billed charges,,,70,,7.63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.34,3324,
68084-0266-01 - ramipril 2.5 mg Cap,68084-0266-01,NDC,,,,inpatient,1,EA,19.25,11.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.36,percent of total billed charges,,,85,,16.36,percent of total billed charges,,,49,,9.43,percent of total billed charges,,,90,,17.33,percent of total billed charges,,,,,,,no IP contract,,80,,15.4,percent of total billed charges,,,,,,,no IP contract,,50,,9.63,percent of total billed charges,,,,,,no IP contract,,,78,,15.02,percent of total billed charges,,,70,,13.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.43,3324,
68084-0266-11 - ramipril 2.5 mg Cap,68084-0266-11,NDC,,,,inpatient,1,EA,19.25,11.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.36,percent of total billed charges,,,85,,16.36,percent of total billed charges,,,49,,9.43,percent of total billed charges,,,90,,17.33,percent of total billed charges,,,,,,,no IP contract,,80,,15.4,percent of total billed charges,,,,,,,no IP contract,,50,,9.63,percent of total billed charges,,,,,,no IP contract,,,78,,15.02,percent of total billed charges,,,70,,13.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.43,3324,
68084-0267-01 - ramipril 5 mg Cap,68084-0267-01,NDC,,,,inpatient,1,EA,20.05,12.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.04,percent of total billed charges,,,85,,17.04,percent of total billed charges,,,49,,9.82,percent of total billed charges,,,90,,18.05,percent of total billed charges,,,,,,,no IP contract,,80,,16.04,percent of total billed charges,,,,,,,no IP contract,,50,,10.03,percent of total billed charges,,,,,,no IP contract,,,78,,15.64,percent of total billed charges,,,70,,14.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.82,3324,
68084-0268-01 - ramipril 10 mg Cap,68084-0268-01,NDC,,,,inpatient,1,EA,22.65,13.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.25,percent of total billed charges,,,85,,19.25,percent of total billed charges,,,49,,11.1,percent of total billed charges,,,90,,20.39,percent of total billed charges,,,,,,,no IP contract,,80,,18.12,percent of total billed charges,,,,,,,no IP contract,,50,,11.33,percent of total billed charges,,,,,,no IP contract,,,78,,17.67,percent of total billed charges,,,70,,15.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.1,3324,
68084-0269-01 - hydroxychloroquine 200 mg Tab,68084-0269-01,NDC,,,,inpatient,1,EA,8.5,5.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.23,percent of total billed charges,,,85,,7.23,percent of total billed charges,,,49,,4.17,percent of total billed charges,,,90,,7.65,percent of total billed charges,,,,,,,no IP contract,,80,,6.8,percent of total billed charges,,,,,,,no IP contract,,50,,4.25,percent of total billed charges,,,,,,no IP contract,,,78,,6.63,percent of total billed charges,,,70,,5.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.17,3324,
68084-0270-01 - risperiDONE 0.25 mg Tab,68084-0270-01,NDC,,,,inpatient,1,EA,34.75,20.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.54,percent of total billed charges,,,85,,29.54,percent of total billed charges,,,49,,17.03,percent of total billed charges,,,90,,31.28,percent of total billed charges,,,,,,,no IP contract,,80,,27.8,percent of total billed charges,,,,,,,no IP contract,,50,,17.38,percent of total billed charges,,,,,,no IP contract,,,78,,27.11,percent of total billed charges,,,70,,24.33,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.03,3324,
68084-0271-01 - risperiDONE 0.5 mg Tab,68084-0271-01,NDC,,,,inpatient,1,EA,37.75,22.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.09,percent of total billed charges,,,85,,32.09,percent of total billed charges,,,49,,18.5,percent of total billed charges,,,90,,33.98,percent of total billed charges,,,,,,,no IP contract,,80,,30.2,percent of total billed charges,,,,,,,no IP contract,,50,,18.88,percent of total billed charges,,,,,,no IP contract,,,78,,29.45,percent of total billed charges,,,70,,26.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.5,3324,
68084-0272-01 - risperiDONE 1 mg Tab,68084-0272-01,NDC,,,,inpatient,1,EA,39.9,23.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.92,percent of total billed charges,,,85,,33.92,percent of total billed charges,,,49,,19.55,percent of total billed charges,,,90,,35.91,percent of total billed charges,,,,,,,no IP contract,,80,,31.92,percent of total billed charges,,,,,,,no IP contract,,50,,19.95,percent of total billed charges,,,,,,no IP contract,,,78,,31.12,percent of total billed charges,,,70,,27.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.55,3324,
68084-0273-01 - risperiDONE 2 mg Tab,68084-0273-01,NDC,,,,inpatient,1,EA,64.15,38.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,51.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,54.53,percent of total billed charges,,,85,,54.53,percent of total billed charges,,,49,,31.43,percent of total billed charges,,,90,,57.74,percent of total billed charges,,,,,,,no IP contract,,80,,51.32,percent of total billed charges,,,,,,,no IP contract,,50,,32.08,percent of total billed charges,,,,,,no IP contract,,,78,,50.04,percent of total billed charges,,,70,,44.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.43,3324,
68084-0276-01 - methimazole 10 mg Tab,68084-0276-01,NDC,,,,inpatient,1,EA,9.95,5.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.46,percent of total billed charges,,,85,,8.46,percent of total billed charges,,,49,,4.88,percent of total billed charges,,,90,,8.96,percent of total billed charges,,,,,,,no IP contract,,80,,7.96,percent of total billed charges,,,,,,,no IP contract,,50,,4.98,percent of total billed charges,,,,,,no IP contract,,,78,,7.76,percent of total billed charges,,,70,,6.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.88,3324,
68084-0280-01 - ethambutol 400 mg Tab,68084-0280-01,NDC,,,,inpatient,1,EA,16.7,10.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.2,percent of total billed charges,,,85,,14.2,percent of total billed charges,,,49,,8.18,percent of total billed charges,,,90,,15.03,percent of total billed charges,,,,,,,no IP contract,,80,,13.36,percent of total billed charges,,,,,,,no IP contract,,50,,8.35,percent of total billed charges,,,,,,no IP contract,,,78,,13.03,percent of total billed charges,,,70,,11.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.18,3324,
68084-0281-01 - carbidopa-levodopa 25 mg-100 mg ER Ta,68084-0281-01,NDC,,,,inpatient,1,EA,10.5,6.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.93,percent of total billed charges,,,85,,8.93,percent of total billed charges,,,49,,5.15,percent of total billed charges,,,90,,9.45,percent of total billed charges,,,,,,,no IP contract,,80,,8.4,percent of total billed charges,,,,,,,no IP contract,,50,,5.25,percent of total billed charges,,,,,,no IP contract,,,78,,8.19,percent of total billed charges,,,70,,7.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.15,3324,
68084-0282-01 - carbidopa-levodopa 50 mg-200 mg ER Ta,68084-0282-01,NDC,,,,inpatient,1,EA,16.4,9.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.94,percent of total billed charges,,,85,,13.94,percent of total billed charges,,,49,,8.04,percent of total billed charges,,,90,,14.76,percent of total billed charges,,,,,,,no IP contract,,80,,13.12,percent of total billed charges,,,,,,,no IP contract,,50,,8.2,percent of total billed charges,,,,,,no IP contract,,,78,,12.79,percent of total billed charges,,,70,,11.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.04,3324,
68084-0284-01 - hydroxyurea 500 mg Cap,68084-0284-01,NDC,,,,inpatient,1,EA,10.8,6.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.18,percent of total billed charges,,,85,,9.18,percent of total billed charges,,,49,,5.29,percent of total billed charges,,,90,,9.72,percent of total billed charges,,,,,,,no IP contract,,80,,8.64,percent of total billed charges,,,,,,,no IP contract,,50,,5.4,percent of total billed charges,,,,,,no IP contract,,,78,,8.42,percent of total billed charges,,,70,,7.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.29,3324,
68084-0288-01 - fludrocortisone 0.1 mg Tab,68084-0288-01,NDC,,,,inpatient,1,EA,10.2,6.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.67,percent of total billed charges,,,85,,8.67,percent of total billed charges,,,49,,5,percent of total billed charges,,,90,,9.18,percent of total billed charges,,,,,,,no IP contract,,80,,8.16,percent of total billed charges,,,,,,,no IP contract,,50,,5.1,percent of total billed charges,,,,,,no IP contract,,,78,,7.96,percent of total billed charges,,,70,,7.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5,3324,
68084-0295-11 - glipiZIDE 2.5 mg ER Ta,68084-0295-11,NDC,,,,inpatient,1,EA,9.15,5.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.78,percent of total billed charges,,,85,,7.78,percent of total billed charges,,,49,,4.48,percent of total billed charges,,,90,,8.24,percent of total billed charges,,,,,,,no IP contract,,80,,7.32,percent of total billed charges,,,,,,,no IP contract,,50,,4.58,percent of total billed charges,,,,,,no IP contract,,,78,,7.14,percent of total billed charges,,,70,,6.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.48,3324,
68084-0295-21 - glipiZIDE 2.5 mg ER Ta,68084-0295-21,NDC,,,,inpatient,1,EA,9.15,5.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.78,percent of total billed charges,,,85,,7.78,percent of total billed charges,,,49,,4.48,percent of total billed charges,,,90,,8.24,percent of total billed charges,,,,,,,no IP contract,,80,,7.32,percent of total billed charges,,,,,,,no IP contract,,50,,4.58,percent of total billed charges,,,,,,no IP contract,,,78,,7.14,percent of total billed charges,,,70,,6.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.48,3324,
68084-0299-01 - tamsulosin 0.4 mg Cap,68084-0299-01,NDC,,,,inpatient,1,EA,37.3,22.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.71,percent of total billed charges,,,85,,31.71,percent of total billed charges,,,49,,18.28,percent of total billed charges,,,90,,33.57,percent of total billed charges,,,,,,,no IP contract,,80,,29.84,percent of total billed charges,,,,,,,no IP contract,,50,,18.65,percent of total billed charges,,,,,,no IP contract,,,78,,29.09,percent of total billed charges,,,70,,26.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.28,3324,
68084-0300-21 - dantrolene 25 mg Cap,68084-0300-21,NDC,,,,inpatient,1,EA,13.2,7.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.22,percent of total billed charges,,,85,,11.22,percent of total billed charges,,,49,,6.47,percent of total billed charges,,,90,,11.88,percent of total billed charges,,,,,,,no IP contract,,80,,10.56,percent of total billed charges,,,,,,,no IP contract,,50,,6.6,percent of total billed charges,,,,,,no IP contract,,,78,,10.3,percent of total billed charges,,,70,,9.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.47,3324,
68084-0309-21 - valACYclovir 1 g Tab,68084-0309-21,NDC,,,,inpatient,1,EA,53.05,31.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,42.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,45.09,percent of total billed charges,,,85,,45.09,percent of total billed charges,,,49,,25.99,percent of total billed charges,,,90,,47.75,percent of total billed charges,,,,,,,no IP contract,,80,,42.44,percent of total billed charges,,,,,,,no IP contract,,50,,26.53,percent of total billed charges,,,,,,no IP contract,,,78,,41.38,percent of total billed charges,,,70,,37.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.99,3324,
68084-0310-01 - divalproex sodium 250 mg ER Ta,68084-0310-01,NDC,,,,inpatient,1,EA,23.3,13.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.81,percent of total billed charges,,,85,,19.81,percent of total billed charges,,,49,,11.42,percent of total billed charges,,,90,,20.97,percent of total billed charges,,,,,,,no IP contract,,80,,18.64,percent of total billed charges,,,,,,,no IP contract,,50,,11.65,percent of total billed charges,,,,,,no IP contract,,,78,,18.17,percent of total billed charges,,,70,,16.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.42,3324,
68084-0313-01 - divalproex sodium 125 mg DRC,68084-0313-01,NDC,,,,inpatient,1,EA,10.1,6.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.59,percent of total billed charges,,,85,,8.59,percent of total billed charges,,,49,,4.95,percent of total billed charges,,,90,,9.09,percent of total billed charges,,,,,,,no IP contract,,80,,8.08,percent of total billed charges,,,,,,,no IP contract,,50,,5.05,percent of total billed charges,,,,,,no IP contract,,,78,,7.88,percent of total billed charges,,,70,,7.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.95,3324,
68084-0313-11 - divalproex sodium 125 mg Cap,68084-0313-11,NDC,,,,inpatient,1,EA,10.1,6.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.59,percent of total billed charges,,,85,,8.59,percent of total billed charges,,,49,,4.95,percent of total billed charges,,,90,,9.09,percent of total billed charges,,,,,,,no IP contract,,80,,8.08,percent of total billed charges,,,,,,,no IP contract,,50,,5.05,percent of total billed charges,,,,,,no IP contract,,,78,,7.88,percent of total billed charges,,,70,,7.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.95,3324,
68084-0318-01 - lamoTRIgine 25 mg Tab,68084-0318-01,NDC,,,,inpatient,1,EA,5,3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.25,percent of total billed charges,,,85,,4.25,percent of total billed charges,,,49,,2.45,percent of total billed charges,,,90,,4.5,percent of total billed charges,,,,,,,no IP contract,,80,,4,percent of total billed charges,,,,,,,no IP contract,,50,,2.5,percent of total billed charges,,,,,,no IP contract,,,78,,3.9,percent of total billed charges,,,70,,3.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.45,3324,
68084-0319-01 - lamoTRIgine 100 mg Tab,68084-0319-01,NDC,,,,inpatient,1,EA,5.4,3.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.59,percent of total billed charges,,,85,,4.59,percent of total billed charges,,,49,,2.65,percent of total billed charges,,,90,,4.86,percent of total billed charges,,,,,,,no IP contract,,80,,4.32,percent of total billed charges,,,,,,,no IP contract,,50,,2.7,percent of total billed charges,,,,,,no IP contract,,,78,,4.21,percent of total billed charges,,,70,,3.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.65,3324,
68084-0326-01 - glimepiride 2 mg Tab,68084-0326-01,NDC,,,,inpatient,1,EA,10.8,6.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.18,percent of total billed charges,,,85,,9.18,percent of total billed charges,,,49,,5.29,percent of total billed charges,,,90,,9.72,percent of total billed charges,,,,,,,no IP contract,,80,,8.64,percent of total billed charges,,,,,,,no IP contract,,50,,5.4,percent of total billed charges,,,,,,no IP contract,,,78,,8.42,percent of total billed charges,,,70,,7.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.29,3324,
68084-0327-01 - glimepiride 4 mg Tab,68084-0327-01,NDC,,,,inpatient,1,EA,13.5,8.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.48,percent of total billed charges,,,85,,11.48,percent of total billed charges,,,49,,6.62,percent of total billed charges,,,90,,12.15,percent of total billed charges,,,,,,,no IP contract,,80,,10.8,percent of total billed charges,,,,,,,no IP contract,,50,,6.75,percent of total billed charges,,,,,,no IP contract,,,78,,10.53,percent of total billed charges,,,70,,9.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.62,3324,
68084-0339-97 - sumatriptan 25 mg Tab,68084-0339-97,NDC,,,,inpatient,1,EA,64.55,38.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,52.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,54.87,percent of total billed charges,,,85,,54.87,percent of total billed charges,,,49,,31.63,percent of total billed charges,,,90,,58.1,percent of total billed charges,,,,,,,no IP contract,,80,,51.64,percent of total billed charges,,,,,,,no IP contract,,50,,32.28,percent of total billed charges,,,,,,no IP contract,,,78,,50.35,percent of total billed charges,,,70,,45.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.63,3324,
68084-0342-01 - topiramate 25 mg Tab,68084-0342-01,NDC,,,,inpatient,1,EA,20.5,12.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.43,percent of total billed charges,,,85,,17.43,percent of total billed charges,,,49,,10.05,percent of total billed charges,,,90,,18.45,percent of total billed charges,,,,,,,no IP contract,,80,,16.4,percent of total billed charges,,,,,,,no IP contract,,50,,10.25,percent of total billed charges,,,,,,no IP contract,,,78,,15.99,percent of total billed charges,,,70,,14.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.05,3324,
68084-0343-21 - topiramate 50 mg Tab,68084-0343-21,NDC,,,,inpatient,1,EA,39.35,23.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.45,percent of total billed charges,,,85,,33.45,percent of total billed charges,,,49,,19.28,percent of total billed charges,,,90,,35.42,percent of total billed charges,,,,,,,no IP contract,,80,,31.48,percent of total billed charges,,,,,,,no IP contract,,50,,19.68,percent of total billed charges,,,,,,no IP contract,,,78,,30.69,percent of total billed charges,,,70,,27.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.28,3324,
68084-0345-21 - topiramate 200 mg Tab,68084-0345-21,NDC,,,,inpatient,1,EA,61.6,36.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,49.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,52.36,percent of total billed charges,,,85,,52.36,percent of total billed charges,,,49,,30.18,percent of total billed charges,,,90,,55.44,percent of total billed charges,,,,,,,no IP contract,,80,,49.28,percent of total billed charges,,,,,,,no IP contract,,50,,30.8,percent of total billed charges,,,,,,no IP contract,,,78,,48.05,percent of total billed charges,,,70,,43.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,30.18,3324,
68084-0346-01 - losartan 25 mg Tab,68084-0346-01,NDC,,,,inpatient,1,EA,17.2,10.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.62,percent of total billed charges,,,85,,14.62,percent of total billed charges,,,49,,8.43,percent of total billed charges,,,90,,15.48,percent of total billed charges,,,,,,,no IP contract,,80,,13.76,percent of total billed charges,,,,,,,no IP contract,,50,,8.6,percent of total billed charges,,,,,,no IP contract,,,78,,13.42,percent of total billed charges,,,70,,12.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.43,3324,
68084-0347-01 - losartan 50 mg Tab,68084-0347-01,NDC,,,,inpatient,1,EA,21.7,13.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.45,percent of total billed charges,,,85,,18.45,percent of total billed charges,,,49,,10.63,percent of total billed charges,,,90,,19.53,percent of total billed charges,,,,,,,no IP contract,,80,,17.36,percent of total billed charges,,,,,,,no IP contract,,50,,10.85,percent of total billed charges,,,,,,no IP contract,,,78,,16.93,percent of total billed charges,,,70,,15.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.63,3324,
68084-0354-01 - oxyCODONE 5 mg Tab,68084-0354-01,NDC,,,,inpatient,1,EA,8.6,5.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.31,percent of total billed charges,,,85,,7.31,percent of total billed charges,,,49,,4.21,percent of total billed charges,,,90,,7.74,percent of total billed charges,,,,,,,no IP contract,,80,,6.88,percent of total billed charges,,,,,,,no IP contract,,50,,4.3,percent of total billed charges,,,,,,no IP contract,,,78,,6.71,percent of total billed charges,,,70,,6.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.21,3324,
68084-0355-01 - acetaminophen-oxyCODONE 325 mg-5 mg Tab,68084-0355-01,NDC,,,,inpatient,1,EA,7.75,4.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.59,percent of total billed charges,,,85,,6.59,percent of total billed charges,,,49,,3.8,percent of total billed charges,,,90,,6.98,percent of total billed charges,,,,,,,no IP contract,,80,,6.2,percent of total billed charges,,,,,,,no IP contract,,50,,3.88,percent of total billed charges,,,,,,no IP contract,,,78,,6.05,percent of total billed charges,,,70,,5.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.8,3324,
68084-0357-21 - rifampin 150 mg Cap,68084-0357-21,NDC,,,,inpatient,1,EA,15.45,9.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.13,percent of total billed charges,,,85,,13.13,percent of total billed charges,,,49,,7.57,percent of total billed charges,,,90,,13.91,percent of total billed charges,,,,,,,no IP contract,,80,,12.36,percent of total billed charges,,,,,,,no IP contract,,50,,7.73,percent of total billed charges,,,,,,no IP contract,,,78,,12.05,percent of total billed charges,,,70,,10.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.57,3324,
68084-0358-01 - rifampin 300 mg Cap,68084-0358-01,NDC,,,,inpatient,1,EA,14.65,8.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.45,percent of total billed charges,,,85,,12.45,percent of total billed charges,,,49,,7.18,percent of total billed charges,,,90,,13.19,percent of total billed charges,,,,,,,no IP contract,,80,,11.72,percent of total billed charges,,,,,,,no IP contract,,50,,7.33,percent of total billed charges,,,,,,no IP contract,,,78,,11.43,percent of total billed charges,,,70,,10.26,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.18,3324,
68084-0361-01 - propafenone 150 mg Tab,68084-0361-01,NDC,,,,inpatient,1,EA,11.3,6.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.61,percent of total billed charges,,,85,,9.61,percent of total billed charges,,,49,,5.54,percent of total billed charges,,,90,,10.17,percent of total billed charges,,,,,,,no IP contract,,80,,9.04,percent of total billed charges,,,,,,,no IP contract,,50,,5.65,percent of total billed charges,,,,,,no IP contract,,,78,,8.81,percent of total billed charges,,,70,,7.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.54,3324,
68084-0365-01 - bethanechol 10 mg Tab,68084-0365-01,NDC,,,,inpatient,1,EA,4.85,2.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.12,percent of total billed charges,,,85,,4.12,percent of total billed charges,,,49,,2.38,percent of total billed charges,,,90,,4.37,percent of total billed charges,,,,,,,no IP contract,,80,,3.88,percent of total billed charges,,,,,,,no IP contract,,50,,2.43,percent of total billed charges,,,,,,no IP contract,,,78,,3.78,percent of total billed charges,,,70,,3.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.38,3324,
68084-0366-01 - digoxin 125 mcg (0.125 mg) Tab,68084-0366-01,NDC,,,,inpatient,1,EA,24.2,14.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.57,percent of total billed charges,,,85,,20.57,percent of total billed charges,,,49,,11.86,percent of total billed charges,,,90,,21.78,percent of total billed charges,,,,,,,no IP contract,,80,,19.36,percent of total billed charges,,,,,,,no IP contract,,50,,12.1,percent of total billed charges,,,,,,no IP contract,,,78,,18.88,percent of total billed charges,,,70,,16.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.86,3324,
68084-0371-01 - amiodarone 200 mg Tab,68084-0371-01,NDC,,,,inpatient,1,EA,30,18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.5,percent of total billed charges,,,85,,25.5,percent of total billed charges,,,49,,14.7,percent of total billed charges,,,90,,27,percent of total billed charges,,,,,,,no IP contract,,80,,24,percent of total billed charges,,,,,,,no IP contract,,50,,15,percent of total billed charges,,,,,,no IP contract,,,78,,23.4,percent of total billed charges,,,70,,21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.7,3324,
68084-0372-01 - acetaminophen-codeine 300 mg-30 mg Tab,68084-0372-01,NDC,,,,inpatient,1,EA,10.5,6.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.93,percent of total billed charges,,,85,,8.93,percent of total billed charges,,,49,,5.15,percent of total billed charges,,,90,,9.45,percent of total billed charges,,,,,,,no IP contract,,80,,8.4,percent of total billed charges,,,,,,,no IP contract,,50,,5.25,percent of total billed charges,,,,,,no IP contract,,,78,,8.19,percent of total billed charges,,,70,,7.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.15,3324,
68084-0376-01 - phenytoin 100 mg ER Capsule,68084-0376-01,NDC,,,,inpatient,1,EA,6.95,4.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.91,percent of total billed charges,,,85,,5.91,percent of total billed charges,,,49,,3.41,percent of total billed charges,,,90,,6.26,percent of total billed charges,,,,,,,no IP contract,,80,,5.56,percent of total billed charges,,,,,,,no IP contract,,50,,3.48,percent of total billed charges,,,,,,no IP contract,,,78,,5.42,percent of total billed charges,,,70,,4.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.41,3324,
68084-0380-01 - carisoprodol 350 mg Tab,68084-0380-01,NDC,,,,inpatient,1,EA,5.35,3.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.55,percent of total billed charges,,,85,,4.55,percent of total billed charges,,,49,,2.62,percent of total billed charges,,,90,,4.82,percent of total billed charges,,,,,,,no IP contract,,80,,4.28,percent of total billed charges,,,,,,,no IP contract,,50,,2.68,percent of total billed charges,,,,,,no IP contract,,,78,,4.17,percent of total billed charges,,,70,,3.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.62,3324,
68084-0388-01 - benztropine 1 mg Tab,68084-0388-01,NDC,,,,inpatient,1,EA,5,3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.25,percent of total billed charges,,,85,,4.25,percent of total billed charges,,,49,,2.45,percent of total billed charges,,,90,,4.5,percent of total billed charges,,,,,,,no IP contract,,80,,4,percent of total billed charges,,,,,,,no IP contract,,50,,2.5,percent of total billed charges,,,,,,no IP contract,,,78,,3.9,percent of total billed charges,,,70,,3.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.45,3324,
68084-0388-11 - benztropine 1 mg Tab,68084-0388-11,NDC,,,,inpatient,1,EA,5,3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.25,percent of total billed charges,,,85,,4.25,percent of total billed charges,,,49,,2.45,percent of total billed charges,,,90,,4.5,percent of total billed charges,,,,,,,no IP contract,,80,,4,percent of total billed charges,,,,,,,no IP contract,,50,,2.5,percent of total billed charges,,,,,,no IP contract,,,78,,3.9,percent of total billed charges,,,70,,3.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.45,3324,
68084-0389-01 - benztropine 2 mg Tab,68084-0389-01,NDC,,,,inpatient,1,EA,5.25,3.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.46,percent of total billed charges,,,85,,4.46,percent of total billed charges,,,49,,2.57,percent of total billed charges,,,90,,4.73,percent of total billed charges,,,,,,,no IP contract,,80,,4.2,percent of total billed charges,,,,,,,no IP contract,,50,,2.63,percent of total billed charges,,,,,,no IP contract,,,78,,4.1,percent of total billed charges,,,70,,3.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.57,3324,
68084-0390-01 - enalapril 5 mg Tab,68084-0390-01,NDC,,,,inpatient,1,EA,4.45,2.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.78,percent of total billed charges,,,85,,3.78,percent of total billed charges,,,49,,2.18,percent of total billed charges,,,90,,4.01,percent of total billed charges,,,,,,,no IP contract,,80,,3.56,percent of total billed charges,,,,,,,no IP contract,,50,,2.23,percent of total billed charges,,,,,,no IP contract,,,78,,3.47,percent of total billed charges,,,70,,3.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.18,3324,
68084-0390-11 - enalapril 5 mg Tab,68084-0390-11,NDC,,,,inpatient,1,EA,4.45,2.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.78,percent of total billed charges,,,85,,3.78,percent of total billed charges,,,49,,2.18,percent of total billed charges,,,90,,4.01,percent of total billed charges,,,,,,,no IP contract,,80,,3.56,percent of total billed charges,,,,,,,no IP contract,,50,,2.23,percent of total billed charges,,,,,,no IP contract,,,78,,3.47,percent of total billed charges,,,70,,3.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.18,3324,
68084-0392-01 - enalapril 20 mg Tab,68084-0392-01,NDC,,,,inpatient,1,EA,4.85,2.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.12,percent of total billed charges,,,85,,4.12,percent of total billed charges,,,49,,2.38,percent of total billed charges,,,90,,4.37,percent of total billed charges,,,,,,,no IP contract,,80,,3.88,percent of total billed charges,,,,,,,no IP contract,,50,,2.43,percent of total billed charges,,,,,,no IP contract,,,78,,3.78,percent of total billed charges,,,70,,3.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.38,3324,
68084-0396-65 - acetaminophen/butalbital/caffeine 325 mg-50 mg-40 mg Tab,68084-0396-65,NDC,,,,inpatient,1,EA,17.25,10.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.66,percent of total billed charges,,,85,,14.66,percent of total billed charges,,,49,,8.45,percent of total billed charges,,,90,,15.53,percent of total billed charges,,,,,,,no IP contract,,80,,13.8,percent of total billed charges,,,,,,,no IP contract,,50,,8.63,percent of total billed charges,,,,,,no IP contract,,,78,,13.46,percent of total billed charges,,,70,,12.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.45,3324,
68084-0399-01 - finasteride 5 mg Tab,68084-0399-01,NDC,,,,inpatient,1,EA,18.35,11.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.6,percent of total billed charges,,,85,,15.6,percent of total billed charges,,,49,,8.99,percent of total billed charges,,,90,,16.52,percent of total billed charges,,,,,,,no IP contract,,80,,14.68,percent of total billed charges,,,,,,,no IP contract,,50,,9.18,percent of total billed charges,,,,,,no IP contract,,,78,,14.31,percent of total billed charges,,,70,,12.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.99,3324,
68084-0400-01 - oxybutynin 5 mg Tab,68084-0400-01,NDC,,,,inpatient,1,EA,4.6,2.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.91,percent of total billed charges,,,85,,3.91,percent of total billed charges,,,49,,2.25,percent of total billed charges,,,90,,4.14,percent of total billed charges,,,,,,,no IP contract,,80,,3.68,percent of total billed charges,,,,,,,no IP contract,,50,,2.3,percent of total billed charges,,,,,,no IP contract,,,78,,3.59,percent of total billed charges,,,70,,3.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.25,3324,
68084-0401-21 - acetaZOLAMIDE 500 mg ER Ca,68084-0401-21,NDC,,,,inpatient,1,EA,42.7,25.62,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36.3,percent of total billed charges,,,85,,36.3,percent of total billed charges,,,49,,20.92,percent of total billed charges,,,90,,38.43,percent of total billed charges,,,,,,,no IP contract,,80,,34.16,percent of total billed charges,,,,,,,no IP contract,,50,,21.35,percent of total billed charges,,,,,,no IP contract,,,78,,33.31,percent of total billed charges,,,70,,29.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.92,3324,
68084-0404-01 - morphine 30 mg/12 hr ER Ta,68084-0404-01,NDC,,,,inpatient,1,EA,20.15,12.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.13,percent of total billed charges,,,85,,17.13,percent of total billed charges,,,49,,9.87,percent of total billed charges,,,90,,18.14,percent of total billed charges,,,,,,,no IP contract,,80,,16.12,percent of total billed charges,,,,,,,no IP contract,,50,,10.08,percent of total billed charges,,,,,,no IP contract,,,78,,15.72,percent of total billed charges,,,70,,14.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.87,3324,
68084-0411-11 - indomethacin 75 mg ER Capsule,68084-0411-11,NDC,,,,inpatient,1,EA,28.3,16.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.06,percent of total billed charges,,,85,,24.06,percent of total billed charges,,,49,,13.87,percent of total billed charges,,,90,,25.47,percent of total billed charges,,,,,,,no IP contract,,80,,22.64,percent of total billed charges,,,,,,,no IP contract,,50,,14.15,percent of total billed charges,,,,,,no IP contract,,,78,,22.07,percent of total billed charges,,,70,,19.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.87,3324,
68084-0411-21 - indomethacin 75 mg ER Ca,68084-0411-21,NDC,,,,inpatient,1,EA,28.3,16.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.06,percent of total billed charges,,,85,,24.06,percent of total billed charges,,,49,,13.87,percent of total billed charges,,,90,,25.47,percent of total billed charges,,,,,,,no IP contract,,80,,22.64,percent of total billed charges,,,,,,,no IP contract,,50,,14.15,percent of total billed charges,,,,,,no IP contract,,,78,,22.07,percent of total billed charges,,,70,,19.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.87,3324,
68084-0415-01 - divalproex sodium 500 mg ER Ta,68084-0415-01,NDC,,,,inpatient,1,EA,34.85,20.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.62,percent of total billed charges,,,85,,29.62,percent of total billed charges,,,49,,17.08,percent of total billed charges,,,90,,31.37,percent of total billed charges,,,,,,,no IP contract,,80,,27.88,percent of total billed charges,,,,,,,no IP contract,,50,,17.43,percent of total billed charges,,,,,,no IP contract,,,78,,27.18,percent of total billed charges,,,70,,24.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.08,3324,
68084-0423-01 - HYDROmorphone 2 mg Tab,68084-0423-01,NDC,,,,inpatient,1,EA,7.1,4.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.04,percent of total billed charges,,,85,,6.04,percent of total billed charges,,,49,,3.48,percent of total billed charges,,,90,,6.39,percent of total billed charges,,,,,,,no IP contract,,80,,5.68,percent of total billed charges,,,,,,,no IP contract,,50,,3.55,percent of total billed charges,,,,,,no IP contract,,,78,,5.54,percent of total billed charges,,,70,,4.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.48,3324,
68084-0440-01 - pramipexole 0.25 mg Tab,68084-0440-01,NDC,,,,inpatient,1,EA,27.05,16.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.99,percent of total billed charges,,,85,,22.99,percent of total billed charges,,,49,,13.25,percent of total billed charges,,,90,,24.35,percent of total billed charges,,,,,,,no IP contract,,80,,21.64,percent of total billed charges,,,,,,,no IP contract,,50,,13.53,percent of total billed charges,,,,,,no IP contract,,,78,,21.1,percent of total billed charges,,,70,,18.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.25,3324,
68084-0444-01 - carbamazepine 200 mg Tab,68084-0444-01,NDC,,,,inpatient,1,EA,16.85,10.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.32,percent of total billed charges,,,85,,14.32,percent of total billed charges,,,49,,8.26,percent of total billed charges,,,90,,15.17,percent of total billed charges,,,,,,,no IP contract,,80,,13.48,percent of total billed charges,,,,,,,no IP contract,,50,,8.43,percent of total billed charges,,,,,,no IP contract,,,78,,13.14,percent of total billed charges,,,70,,11.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.26,3324,
68084-0446-01 - nitrofurantoin macrocrystals-monohydrate 100 mg Cap,68084-0446-01,NDC,,,,inpatient,1,EA,24.35,14.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.7,percent of total billed charges,,,85,,20.7,percent of total billed charges,,,49,,11.93,percent of total billed charges,,,90,,21.92,percent of total billed charges,,,,,,,no IP contract,,80,,19.48,percent of total billed charges,,,,,,,no IP contract,,50,,12.18,percent of total billed charges,,,,,,no IP contract,,,78,,18.99,percent of total billed charges,,,70,,17.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.93,3324,
68084-0447-01 - hydrALAZINE 10 mg Tab,68084-0447-01,NDC,,,,inpatient,1,EA,8.05,4.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.84,percent of total billed charges,,,85,,6.84,percent of total billed charges,,,49,,3.94,percent of total billed charges,,,90,,7.25,percent of total billed charges,,,,,,,no IP contract,,80,,6.44,percent of total billed charges,,,,,,,no IP contract,,50,,4.03,percent of total billed charges,,,,,,no IP contract,,,78,,6.28,percent of total billed charges,,,70,,5.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.94,3324,
68084-0449-01 - tacrolimus 0.5 mg Cap,68084-0449-01,NDC,,,,inpatient,1,EA,21.55,12.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.32,percent of total billed charges,,,85,,18.32,percent of total billed charges,,,49,,10.56,percent of total billed charges,,,90,,19.4,percent of total billed charges,,,,,,,no IP contract,,80,,17.24,percent of total billed charges,,,,,,,no IP contract,,50,,10.78,percent of total billed charges,,,,,,no IP contract,,,78,,16.81,percent of total billed charges,,,70,,15.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.56,3324,
68084-0449-11 - tacrolimus 0.5 mg Cap,68084-0449-11,NDC,,,,inpatient,1,EA,21.55,12.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.32,percent of total billed charges,,,85,,18.32,percent of total billed charges,,,49,,10.56,percent of total billed charges,,,90,,19.4,percent of total billed charges,,,,,,,no IP contract,,80,,17.24,percent of total billed charges,,,,,,,no IP contract,,50,,10.78,percent of total billed charges,,,,,,no IP contract,,,78,,16.81,percent of total billed charges,,,70,,15.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.56,3324,
68084-0450-01 - tacrolimus 1 mg Cap,68084-0450-01,NDC,,,,inpatient,1,EA,39.3,23.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.41,percent of total billed charges,,,85,,33.41,percent of total billed charges,,,49,,19.26,percent of total billed charges,,,90,,35.37,percent of total billed charges,,,,,,,no IP contract,,80,,31.44,percent of total billed charges,,,,,,,no IP contract,,50,,19.65,percent of total billed charges,,,,,,no IP contract,,,78,,30.65,percent of total billed charges,,,70,,27.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.26,3324,
68084-0457-01 - labetalol 300 mg Tab,68084-0457-01,NDC,,,,inpatient,1,EA,12.15,7.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.33,percent of total billed charges,,,85,,10.33,percent of total billed charges,,,49,,5.95,percent of total billed charges,,,90,,10.94,percent of total billed charges,,,,,,,no IP contract,,80,,9.72,percent of total billed charges,,,,,,,no IP contract,,50,,6.08,percent of total billed charges,,,,,,no IP contract,,,78,,9.48,percent of total billed charges,,,70,,8.51,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.95,3324,
68084-0461-21 - zidovudine 100 mg Cap,68084-0461-21,NDC,,,,inpatient,1,EA,21.1,12.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.94,percent of total billed charges,,,85,,17.94,percent of total billed charges,,,49,,10.34,percent of total billed charges,,,90,,18.99,percent of total billed charges,,,,,,,no IP contract,,80,,16.88,percent of total billed charges,,,,,,,no IP contract,,50,,10.55,percent of total billed charges,,,,,,no IP contract,,,78,,16.46,percent of total billed charges,,,70,,14.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.34,3324,
68084-0462-21 - zidovudine 300 mg Tab,68084-0462-21,NDC,,,,inpatient,1,EA,15.85,9.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.47,percent of total billed charges,,,85,,13.47,percent of total billed charges,,,49,,7.77,percent of total billed charges,,,90,,14.27,percent of total billed charges,,,,,,,no IP contract,,80,,12.68,percent of total billed charges,,,,,,,no IP contract,,50,,7.93,percent of total billed charges,,,,,,no IP contract,,,78,,12.36,percent of total billed charges,,,70,,11.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.77,3324,
"68084-0463-01 - ergocalciferol 50,000 intl units Cap",68084-0463-01,NDC,,,,inpatient,1,EA,16,9.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.6,percent of total billed charges,,,85,,13.6,percent of total billed charges,,,49,,7.84,percent of total billed charges,,,90,,14.4,percent of total billed charges,,,,,,,no IP contract,,80,,12.8,percent of total billed charges,,,,,,,no IP contract,,50,,8,percent of total billed charges,,,,,,no IP contract,,,78,,12.48,percent of total billed charges,,,70,,11.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.84,3324,
68084-0469-01 - hydrocortisone 10 mg Tab,68084-0469-01,NDC,,,,inpatient,1,EA,8.35,5.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.1,percent of total billed charges,,,85,,7.1,percent of total billed charges,,,49,,4.09,percent of total billed charges,,,90,,7.52,percent of total billed charges,,,,,,,no IP contract,,80,,6.68,percent of total billed charges,,,,,,,no IP contract,,50,,4.18,percent of total billed charges,,,,,,no IP contract,,,78,,6.51,percent of total billed charges,,,70,,5.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.09,3324,
68084-0472-01 - hydromorphone 4 mg Tab,68084-0472-01,NDC,,,,inpatient,1,EA,7.6,4.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.46,percent of total billed charges,,,85,,6.46,percent of total billed charges,,,49,,3.72,percent of total billed charges,,,90,,6.84,percent of total billed charges,,,,,,,no IP contract,,80,,6.08,percent of total billed charges,,,,,,,no IP contract,,50,,3.8,percent of total billed charges,,,,,,no IP contract,,,78,,5.93,percent of total billed charges,,,70,,5.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.72,3324,
68084-0479-01 - calcium acetate 667 mg Cap,68084-0479-01,NDC,,,,inpatient,1,EA,15.35,9.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.05,percent of total billed charges,,,85,,13.05,percent of total billed charges,,,49,,7.52,percent of total billed charges,,,90,,13.82,percent of total billed charges,,,,,,,no IP contract,,80,,12.28,percent of total billed charges,,,,,,,no IP contract,,50,,7.68,percent of total billed charges,,,,,,no IP contract,,,78,,11.97,percent of total billed charges,,,70,,10.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.52,3324,
68084-0480-01 - oxybutynin 5 mg/24 hours ER Ta,68084-0480-01,NDC,,,,inpatient,1,EA,27.75,16.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.59,percent of total billed charges,,,85,,23.59,percent of total billed charges,,,49,,13.6,percent of total billed charges,,,90,,24.98,percent of total billed charges,,,,,,,no IP contract,,80,,22.2,percent of total billed charges,,,,,,,no IP contract,,50,,13.88,percent of total billed charges,,,,,,no IP contract,,,78,,21.65,percent of total billed charges,,,70,,19.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.6,3324,
68084-0481-01 - levofloxacin 250 mg Tab,68084-0481-01,NDC,,,,inpatient,1,EA,134.9,80.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,109.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,114.67,percent of total billed charges,,,85,,114.67,percent of total billed charges,,,49,,66.1,percent of total billed charges,,,90,,121.41,percent of total billed charges,,,,,,,no IP contract,,80,,107.92,percent of total billed charges,,,,,,,no IP contract,,50,,67.45,percent of total billed charges,,,,,,no IP contract,,,78,,105.22,percent of total billed charges,,,70,,94.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,66.1,3324,
68084-0482-01 - levofloxacin 500 mg Tab,68084-0482-01,NDC,,,,inpatient,1,EA,154.1,92.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,124.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,130.99,percent of total billed charges,,,85,,130.99,percent of total billed charges,,,49,,75.51,percent of total billed charges,,,90,,138.69,percent of total billed charges,,,,,,,no IP contract,,80,,123.28,percent of total billed charges,,,,,,,no IP contract,,50,,77.05,percent of total billed charges,,,,,,no IP contract,,,78,,120.2,percent of total billed charges,,,70,,107.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,75.51,3324,
68084-0484-01 - venlafaxine 37.5 mg ER Capsule,68084-0484-01,NDC,,,,inpatient,1,EA,33.55,20.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.52,percent of total billed charges,,,85,,28.52,percent of total billed charges,,,49,,16.44,percent of total billed charges,,,90,,30.2,percent of total billed charges,,,,,,,no IP contract,,80,,26.84,percent of total billed charges,,,,,,,no IP contract,,50,,16.78,percent of total billed charges,,,,,,no IP contract,,,78,,26.17,percent of total billed charges,,,70,,23.49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.44,3324,
68084-0484-11 - venlafaxine 37.5 mg Tab,68084-0484-11,NDC,,,,inpatient,1,EA,33.55,20.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.52,percent of total billed charges,,,85,,28.52,percent of total billed charges,,,49,,16.44,percent of total billed charges,,,90,,30.2,percent of total billed charges,,,,,,,no IP contract,,80,,26.84,percent of total billed charges,,,,,,,no IP contract,,50,,16.78,percent of total billed charges,,,,,,no IP contract,,,78,,26.17,percent of total billed charges,,,70,,23.49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.44,3324,
68084-0490-01 - meclizine 12.5 mg Tab,68084-0490-01,NDC,,,,inpatient,1,EA,9.45,5.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.03,percent of total billed charges,,,85,,8.03,percent of total billed charges,,,49,,4.63,percent of total billed charges,,,90,,8.51,percent of total billed charges,,,,,,,no IP contract,,80,,7.56,percent of total billed charges,,,,,,,no IP contract,,50,,4.73,percent of total billed charges,,,,,,no IP contract,,,78,,7.37,percent of total billed charges,,,70,,6.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.63,3324,
68084-0491-01 - meclizine 25 mg Tab,68084-0491-01,NDC,,,,inpatient,1,EA,10.65,6.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.05,percent of total billed charges,,,85,,9.05,percent of total billed charges,,,49,,5.22,percent of total billed charges,,,90,,9.59,percent of total billed charges,,,,,,,no IP contract,,80,,8.52,percent of total billed charges,,,,,,,no IP contract,,50,,5.33,percent of total billed charges,,,,,,no IP contract,,,78,,8.31,percent of total billed charges,,,70,,7.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.22,3324,
68084-0494-01 - pyridostigmine 60 mg Tab,68084-0494-01,NDC,,,,inpatient,1,EA,8.6,5.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.31,percent of total billed charges,,,85,,7.31,percent of total billed charges,,,49,,4.21,percent of total billed charges,,,90,,7.74,percent of total billed charges,,,,,,,no IP contract,,80,,6.88,percent of total billed charges,,,,,,,no IP contract,,50,,4.3,percent of total billed charges,,,,,,no IP contract,,,78,,6.71,percent of total billed charges,,,70,,6.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.21,3324,
68084-0511-01 - simvastatin 10 mg Tab,68084-0511-01,NDC,,,,inpatient,1,EA,26,15.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.1,percent of total billed charges,,,85,,22.1,percent of total billed charges,,,49,,12.74,percent of total billed charges,,,90,,23.4,percent of total billed charges,,,,,,,no IP contract,,80,,20.8,percent of total billed charges,,,,,,,no IP contract,,50,,13,percent of total billed charges,,,,,,no IP contract,,,78,,20.28,percent of total billed charges,,,70,,18.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.74,3324,
68084-0512-01 - simvastatin 20 mg Tab,68084-0512-01,NDC,,,,inpatient,1,EA,11.85,7.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.07,percent of total billed charges,,,85,,10.07,percent of total billed charges,,,49,,5.81,percent of total billed charges,,,90,,10.67,percent of total billed charges,,,,,,,no IP contract,,80,,9.48,percent of total billed charges,,,,,,,no IP contract,,50,,5.93,percent of total billed charges,,,,,,no IP contract,,,78,,9.24,percent of total billed charges,,,70,,8.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.81,3324,
68084-0513-01 - simvastatin 40 mg Tab,68084-0513-01,NDC,,,,inpatient,1,EA,42.95,25.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36.51,percent of total billed charges,,,85,,36.51,percent of total billed charges,,,49,,21.05,percent of total billed charges,,,90,,38.66,percent of total billed charges,,,,,,,no IP contract,,80,,34.36,percent of total billed charges,,,,,,,no IP contract,,50,,21.48,percent of total billed charges,,,,,,no IP contract,,,78,,33.5,percent of total billed charges,,,70,,30.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.05,3324,
68084-0524-01 - potassium chloride 10 mEq ER Ta,68084-0524-01,NDC,,,,inpatient,1,EA,8.65,5.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.35,percent of total billed charges,,,85,,7.35,percent of total billed charges,,,49,,4.24,percent of total billed charges,,,90,,7.79,percent of total billed charges,,,,,,,no IP contract,,80,,6.92,percent of total billed charges,,,,,,,no IP contract,,50,,4.33,percent of total billed charges,,,,,,no IP contract,,,78,,6.75,percent of total billed charges,,,70,,6.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.24,3324,
68084-0528-01 - OLANZapine 15 mg Tab,68084-0528-01,NDC,,,,inpatient,1,EA,246.05,147.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,199.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,209.14,percent of total billed charges,,,85,,209.14,percent of total billed charges,,,49,,120.56,percent of total billed charges,,,90,,221.45,percent of total billed charges,,,,,,,no IP contract,,80,,196.84,percent of total billed charges,,,,,,,no IP contract,,50,,123.03,percent of total billed charges,,,,,,no IP contract,,,78,,191.92,percent of total billed charges,,,70,,172.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,120.56,3324,
68084-0532-01 - QUEtiapine 100 mg Tab,68084-0532-01,NDC,,,,inpatient,1,EA,55.35,33.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,44.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,47.05,percent of total billed charges,,,85,,47.05,percent of total billed charges,,,49,,27.12,percent of total billed charges,,,90,,49.82,percent of total billed charges,,,,,,,no IP contract,,80,,44.28,percent of total billed charges,,,,,,,no IP contract,,50,,27.68,percent of total billed charges,,,,,,no IP contract,,,78,,43.17,percent of total billed charges,,,70,,38.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.12,3324,
68084-0536-01 - clopidogrel 75 mg Tab,68084-0536-01,NDC,,,,inpatient,1,EA,57.95,34.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,46.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,49.26,percent of total billed charges,,,85,,49.26,percent of total billed charges,,,49,,28.4,percent of total billed charges,,,90,,52.16,percent of total billed charges,,,,,,,no IP contract,,80,,46.36,percent of total billed charges,,,,,,,no IP contract,,50,,28.98,percent of total billed charges,,,,,,no IP contract,,,78,,45.2,percent of total billed charges,,,70,,40.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,28.4,3324,
68084-0538-25 - voriconazole 200 mg Tab,68084-0538-25,NDC,,,,inpatient,1,EA,376.75,226.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,305.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,320.24,percent of total billed charges,,,85,,320.24,percent of total billed charges,,,49,,184.61,percent of total billed charges,,,90,,339.08,percent of total billed charges,,,,,,,no IP contract,,80,,301.4,percent of total billed charges,,,,,,,no IP contract,,50,,188.38,percent of total billed charges,,,,,,no IP contract,,,78,,293.87,percent of total billed charges,,,70,,263.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,184.61,3324,
68084-0539-01 - torsemide 20 mg Tab,68084-0539-01,NDC,,,,inpatient,1,EA,10.5,6.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.93,percent of total billed charges,,,85,,8.93,percent of total billed charges,,,49,,5.15,percent of total billed charges,,,90,,9.45,percent of total billed charges,,,,,,,no IP contract,,80,,8.4,percent of total billed charges,,,,,,,no IP contract,,50,,5.25,percent of total billed charges,,,,,,no IP contract,,,78,,8.19,percent of total billed charges,,,70,,7.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.15,3324,
68084-0539-11 - torsemide 20 mg Tab,68084-0539-11,NDC,,,,inpatient,1,EA,10.5,6.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.93,percent of total billed charges,,,85,,8.93,percent of total billed charges,,,49,,5.15,percent of total billed charges,,,90,,9.45,percent of total billed charges,,,,,,,no IP contract,,80,,8.4,percent of total billed charges,,,,,,,no IP contract,,50,,5.25,percent of total billed charges,,,,,,no IP contract,,,78,,8.19,percent of total billed charges,,,70,,7.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.15,3324,
68084-0540-25 - flecainide 100 mg Tab,68084-0540-25,NDC,,,,inpatient,1,EA,35.7,21.42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.35,percent of total billed charges,,,85,,30.35,percent of total billed charges,,,49,,17.49,percent of total billed charges,,,90,,32.13,percent of total billed charges,,,,,,,no IP contract,,80,,28.56,percent of total billed charges,,,,,,,no IP contract,,50,,17.85,percent of total billed charges,,,,,,no IP contract,,,78,,27.85,percent of total billed charges,,,70,,24.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.49,3324,
68084-0549-21 - temazepam 7.5 mg Cap,68084-0549-21,NDC,,,,inpatient,1,EA,75,45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63.75,percent of total billed charges,,,85,,63.75,percent of total billed charges,,,49,,36.75,percent of total billed charges,,,90,,67.5,percent of total billed charges,,,,,,,no IP contract,,80,,60,percent of total billed charges,,,,,,,no IP contract,,50,,37.5,percent of total billed charges,,,,,,no IP contract,,,78,,58.5,percent of total billed charges,,,70,,52.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.75,3324,
68084-0550-01 - rivastigmine 1.5 mg Cap,68084-0550-01,NDC,,,,inpatient,1,EA,36.9,22.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,29.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.37,percent of total billed charges,,,85,,31.37,percent of total billed charges,,,49,,18.08,percent of total billed charges,,,90,,33.21,percent of total billed charges,,,,,,,no IP contract,,80,,29.52,percent of total billed charges,,,,,,,no IP contract,,50,,18.45,percent of total billed charges,,,,,,no IP contract,,,78,,28.78,percent of total billed charges,,,70,,25.83,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.08,3324,
68084-0559-01 - lovastatin 20 mg Tab,68084-0559-01,NDC,,,,inpatient,1,EA,13.85,8.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.77,percent of total billed charges,,,85,,11.77,percent of total billed charges,,,49,,6.79,percent of total billed charges,,,90,,12.47,percent of total billed charges,,,,,,,no IP contract,,80,,11.08,percent of total billed charges,,,,,,,no IP contract,,50,,6.93,percent of total billed charges,,,,,,no IP contract,,,78,,10.8,percent of total billed charges,,,70,,9.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.79,3324,
68084-0561-21 - carBAMazepine 200 mg ER Ta,68084-0561-21,NDC,,,,inpatient,1,EA,21.3,12.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.11,percent of total billed charges,,,85,,18.11,percent of total billed charges,,,49,,10.44,percent of total billed charges,,,90,,19.17,percent of total billed charges,,,,,,,no IP contract,,80,,17.04,percent of total billed charges,,,,,,,no IP contract,,50,,10.65,percent of total billed charges,,,,,,no IP contract,,,78,,16.61,percent of total billed charges,,,70,,14.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.44,3324,
68084-0572-01 - guaifenesin ER Tab 600 mg ER Tablet,68084-0572-01,NDC,,,,inpatient,1,EA,11.75,7.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.99,percent of total billed charges,,,85,,9.99,percent of total billed charges,,,49,,5.76,percent of total billed charges,,,90,,10.58,percent of total billed charges,,,,,,,no IP contract,,80,,9.4,percent of total billed charges,,,,,,,no IP contract,,50,,5.88,percent of total billed charges,,,,,,no IP contract,,,78,,9.17,percent of total billed charges,,,70,,8.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.76,3324,
68084-0578-21 - lamiVUDine 150 mg Tab,68084-0578-21,NDC,,,,inpatient,1,EA,68.8,41.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,55.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,58.48,percent of total billed charges,,,85,,58.48,percent of total billed charges,,,49,,33.71,percent of total billed charges,,,90,,61.92,percent of total billed charges,,,,,,,no IP contract,,80,,55.04,percent of total billed charges,,,,,,,no IP contract,,50,,34.4,percent of total billed charges,,,,,,no IP contract,,,78,,53.66,percent of total billed charges,,,70,,48.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,33.71,3324,
68084-0590-25 - atorvastatin 80 mg Tab,68084-0590-25,NDC,,,,inpatient,1,EA,19.4,11.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.49,percent of total billed charges,,,85,,16.49,percent of total billed charges,,,49,,9.51,percent of total billed charges,,,90,,17.46,percent of total billed charges,,,,,,,no IP contract,,80,,15.52,percent of total billed charges,,,,,,,no IP contract,,50,,9.7,percent of total billed charges,,,,,,no IP contract,,,78,,15.13,percent of total billed charges,,,70,,13.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.51,3324,
68084-0591-01 - isosorbide mononitrate 30 mg ER Ta,68084-0591-01,NDC,,,,inpatient,1,EA,17.2,10.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.62,percent of total billed charges,,,85,,14.62,percent of total billed charges,,,49,,8.43,percent of total billed charges,,,90,,15.48,percent of total billed charges,,,,,,,no IP contract,,80,,13.76,percent of total billed charges,,,,,,,no IP contract,,50,,8.6,percent of total billed charges,,,,,,no IP contract,,,78,,13.42,percent of total billed charges,,,70,,12.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.43,3324,
68084-0597-01 - NIFEdipine 30 mg ER Ta,68084-0597-01,NDC,,,,inpatient,1,EA,14.55,8.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.37,percent of total billed charges,,,85,,12.37,percent of total billed charges,,,49,,7.13,percent of total billed charges,,,90,,13.1,percent of total billed charges,,,,,,,no IP contract,,80,,11.64,percent of total billed charges,,,,,,,no IP contract,,50,,7.28,percent of total billed charges,,,,,,no IP contract,,,78,,11.35,percent of total billed charges,,,70,,10.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.13,3324,
68084-0598-01 - NIFEdipine 60 mg ER Ta,68084-0598-01,NDC,,,,inpatient,1,EA,22.65,13.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.25,percent of total billed charges,,,85,,19.25,percent of total billed charges,,,49,,11.1,percent of total billed charges,,,90,,20.39,percent of total billed charges,,,,,,,no IP contract,,80,,18.12,percent of total billed charges,,,,,,,no IP contract,,50,,11.33,percent of total billed charges,,,,,,no IP contract,,,78,,17.67,percent of total billed charges,,,70,,15.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.1,3324,
68084-0603-21 - NIFEdipine 90 mg ER Ta,68084-0603-21,NDC,,,,inpatient,1,EA,24.55,14.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.87,percent of total billed charges,,,85,,20.87,percent of total billed charges,,,49,,12.03,percent of total billed charges,,,90,,22.1,percent of total billed charges,,,,,,,no IP contract,,80,,19.64,percent of total billed charges,,,,,,,no IP contract,,50,,12.28,percent of total billed charges,,,,,,no IP contract,,,78,,19.15,percent of total billed charges,,,70,,17.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.03,3324,
68084-0605-01 - FLUoxetine 20 mg Cap,68084-0605-01,NDC,,,,inpatient,1,EA,23.85,14.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.27,percent of total billed charges,,,85,,20.27,percent of total billed charges,,,49,,11.69,percent of total billed charges,,,90,,21.47,percent of total billed charges,,,,,,,no IP contract,,80,,19.08,percent of total billed charges,,,,,,,no IP contract,,50,,11.93,percent of total billed charges,,,,,,no IP contract,,,78,,18.6,percent of total billed charges,,,70,,16.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.69,3324,
68084-0606-21 - desmopressin 0.1 mg Tab,68084-0606-21,NDC,,,,inpatient,1,EA,27.85,16.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.67,percent of total billed charges,,,85,,23.67,percent of total billed charges,,,49,,13.65,percent of total billed charges,,,90,,25.07,percent of total billed charges,,,,,,,no IP contract,,80,,22.28,percent of total billed charges,,,,,,,no IP contract,,50,,13.93,percent of total billed charges,,,,,,no IP contract,,,78,,21.72,percent of total billed charges,,,70,,19.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.65,3324,
68084-0610-21 - oxybutynin 10 mg/24 hr ER Ta,68084-0610-21,NDC,,,,inpatient,1,EA,30,18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.5,percent of total billed charges,,,85,,25.5,percent of total billed charges,,,49,,14.7,percent of total billed charges,,,90,,27,percent of total billed charges,,,,,,,no IP contract,,80,,24,percent of total billed charges,,,,,,,no IP contract,,50,,15,percent of total billed charges,,,,,,no IP contract,,,78,,23.4,percent of total billed charges,,,70,,21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.7,3324,
68084-0617-01 - escitalopram 10 mg Tab,68084-0617-01,NDC,,,,inpatient,1,EA,38.15,22.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.43,percent of total billed charges,,,85,,32.43,percent of total billed charges,,,49,,18.69,percent of total billed charges,,,90,,34.34,percent of total billed charges,,,,,,,no IP contract,,80,,30.52,percent of total billed charges,,,,,,,no IP contract,,50,,19.08,percent of total billed charges,,,,,,no IP contract,,,78,,29.76,percent of total billed charges,,,70,,26.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.69,3324,
68084-0618-01 - escitalopram 20 mg Tab,68084-0618-01,NDC,,,,inpatient,1,EA,39.7,23.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.75,percent of total billed charges,,,85,,33.75,percent of total billed charges,,,49,,19.45,percent of total billed charges,,,90,,35.73,percent of total billed charges,,,,,,,no IP contract,,80,,31.76,percent of total billed charges,,,,,,,no IP contract,,50,,19.85,percent of total billed charges,,,,,,no IP contract,,,78,,30.97,percent of total billed charges,,,70,,27.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.45,3324,
68084-0621-21 - modafinil 100 mg Tab,68084-0621-21,NDC,,,,inpatient,1,EA,225.15,135.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,182.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,191.38,percent of total billed charges,,,85,,191.38,percent of total billed charges,,,49,,110.32,percent of total billed charges,,,90,,202.64,percent of total billed charges,,,,,,,no IP contract,,80,,180.12,percent of total billed charges,,,,,,,no IP contract,,50,,112.58,percent of total billed charges,,,,,,no IP contract,,,78,,175.62,percent of total billed charges,,,70,,157.61,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,110.32,3324,
68084-0635-21 - fenofibrate 48 mg Tab,68084-0635-21,NDC,,,,inpatient,1,EA,19,11.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.15,percent of total billed charges,,,85,,16.15,percent of total billed charges,,,49,,9.31,percent of total billed charges,,,90,,17.1,percent of total billed charges,,,,,,,no IP contract,,80,,15.2,percent of total billed charges,,,,,,,no IP contract,,50,,9.5,percent of total billed charges,,,,,,no IP contract,,,78,,14.82,percent of total billed charges,,,70,,13.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.31,3324,
68084-0636-25 - fenofibrate 145 mg Tab,68084-0636-25,NDC,,,,inpatient,1,EA,44.75,26.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,38.04,percent of total billed charges,,,85,,38.04,percent of total billed charges,,,49,,21.93,percent of total billed charges,,,90,,40.28,percent of total billed charges,,,,,,,no IP contract,,80,,35.8,percent of total billed charges,,,,,,,no IP contract,,50,,22.38,percent of total billed charges,,,,,,no IP contract,,,78,,34.91,percent of total billed charges,,,70,,31.33,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.93,3324,
68084-0640-01 - lithium 300 mg ER Ta,68084-0640-01,NDC,,,,inpatient,1,EA,7.65,4.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.5,percent of total billed charges,,,85,,6.5,percent of total billed charges,,,49,,3.75,percent of total billed charges,,,90,,6.89,percent of total billed charges,,,,,,,no IP contract,,80,,6.12,percent of total billed charges,,,,,,,no IP contract,,50,,3.83,percent of total billed charges,,,,,,no IP contract,,,78,,5.97,percent of total billed charges,,,70,,5.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.75,3324,
68084-0643-01 - pantoprazole 20 mg EC Ta,68084-0643-01,NDC,,,,inpatient,1,EA,34.05,20.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.94,percent of total billed charges,,,85,,28.94,percent of total billed charges,,,49,,16.68,percent of total billed charges,,,90,,30.65,percent of total billed charges,,,,,,,no IP contract,,80,,27.24,percent of total billed charges,,,,,,,no IP contract,,50,,17.03,percent of total billed charges,,,,,,no IP contract,,,78,,26.56,percent of total billed charges,,,70,,23.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.68,3324,
68084-0645-01 - tiZANidine 4 mg Tab,68084-0645-01,NDC,,,,inpatient,1,EA,15.85,9.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.47,percent of total billed charges,,,85,,13.47,percent of total billed charges,,,49,,7.77,percent of total billed charges,,,90,,14.27,percent of total billed charges,,,,,,,no IP contract,,80,,12.68,percent of total billed charges,,,,,,,no IP contract,,50,,7.93,percent of total billed charges,,,,,,no IP contract,,,78,,12.36,percent of total billed charges,,,70,,11.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.77,3324,
68084-0647-01 - ALPRAZolam 0.25 mg Tab,68084-0647-01,NDC,,,,inpatient,1,EA,10.85,6.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.22,percent of total billed charges,,,85,,9.22,percent of total billed charges,,,49,,5.32,percent of total billed charges,,,90,,9.77,percent of total billed charges,,,,,,,no IP contract,,80,,8.68,percent of total billed charges,,,,,,,no IP contract,,50,,5.43,percent of total billed charges,,,,,,no IP contract,,,78,,8.46,percent of total billed charges,,,70,,7.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.32,3324,
68084-0654-01 - sotalol 80 mg Tab,68084-0654-01,NDC,,,,inpatient,1,EA,7.25,4.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.16,percent of total billed charges,,,85,,6.16,percent of total billed charges,,,49,,3.55,percent of total billed charges,,,90,,6.53,percent of total billed charges,,,,,,,no IP contract,,80,,5.8,percent of total billed charges,,,,,,,no IP contract,,50,,3.63,percent of total billed charges,,,,,,no IP contract,,,78,,5.66,percent of total billed charges,,,70,,5.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.55,3324,
68084-0655-01 - lithium 450 mg ER Ta,68084-0655-01,NDC,,,,inpatient,1,EA,9.85,5.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.37,percent of total billed charges,,,85,,8.37,percent of total billed charges,,,49,,4.83,percent of total billed charges,,,90,,8.87,percent of total billed charges,,,,,,,no IP contract,,80,,7.88,percent of total billed charges,,,,,,,no IP contract,,50,,4.93,percent of total billed charges,,,,,,no IP contract,,,78,,7.68,percent of total billed charges,,,70,,6.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.83,3324,
68084-0658-01 - ibuprofen 400 mg Tab,68084-0658-01,NDC,,,,inpatient,1,EA,5.9,3.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.02,percent of total billed charges,,,85,,5.02,percent of total billed charges,,,49,,2.89,percent of total billed charges,,,90,,5.31,percent of total billed charges,,,,,,,no IP contract,,80,,4.72,percent of total billed charges,,,,,,,no IP contract,,50,,2.95,percent of total billed charges,,,,,,no IP contract,,,78,,4.6,percent of total billed charges,,,70,,4.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.89,3324,
68084-0659-01 - metoprolol 25 mg ER Ta,68084-0659-01,NDC,,,,inpatient,1,EA,12.65,7.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.75,percent of total billed charges,,,85,,10.75,percent of total billed charges,,,49,,6.2,percent of total billed charges,,,90,,11.39,percent of total billed charges,,,,,,,no IP contract,,80,,10.12,percent of total billed charges,,,,,,,no IP contract,,50,,6.33,percent of total billed charges,,,,,,no IP contract,,,78,,9.87,percent of total billed charges,,,70,,8.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.2,3324,
68084-0673-01 - metoprolol 100 mg ER Tablet,68084-0673-01,NDC,,,,inpatient,1,EA,17.75,10.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.09,percent of total billed charges,,,85,,15.09,percent of total billed charges,,,49,,8.7,percent of total billed charges,,,90,,15.98,percent of total billed charges,,,,,,,no IP contract,,80,,14.2,percent of total billed charges,,,,,,,no IP contract,,50,,8.88,percent of total billed charges,,,,,,no IP contract,,,78,,13.85,percent of total billed charges,,,70,,12.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.7,3324,
68084-0675-21 - DULoxetine 20 mg DR Ca,68084-0675-21,NDC,,,,inpatient,1,EA,68.7,41.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,55.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,58.4,percent of total billed charges,,,85,,58.4,percent of total billed charges,,,49,,33.66,percent of total billed charges,,,90,,61.83,percent of total billed charges,,,,,,,no IP contract,,80,,54.96,percent of total billed charges,,,,,,,no IP contract,,50,,34.35,percent of total billed charges,,,,,,no IP contract,,,78,,53.59,percent of total billed charges,,,70,,48.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,33.66,3324,
68084-0676-01 - metoclopramide 10 mg Tab,68084-0676-01,NDC,,,,inpatient,1,EA,6.15,3.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.23,percent of total billed charges,,,85,,5.23,percent of total billed charges,,,49,,3.01,percent of total billed charges,,,90,,5.54,percent of total billed charges,,,,,,,no IP contract,,80,,4.92,percent of total billed charges,,,,,,,no IP contract,,50,,3.08,percent of total billed charges,,,,,,no IP contract,,,78,,4.8,percent of total billed charges,,,70,,4.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.01,3324,
68084-0680-01 - digoxin 250 mcg (0.25 mg) Tab,68084-0680-01,NDC,,,,inpatient,1,EA,24.2,14.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.57,percent of total billed charges,,,85,,20.57,percent of total billed charges,,,49,,11.86,percent of total billed charges,,,90,,21.78,percent of total billed charges,,,,,,,no IP contract,,80,,19.36,percent of total billed charges,,,,,,,no IP contract,,50,,12.1,percent of total billed charges,,,,,,no IP contract,,,78,,18.88,percent of total billed charges,,,70,,16.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.86,3324,
68084-0683-01 - DULoxetine 30 mg DRC,68084-0683-01,NDC,,,,inpatient,1,EA,65.05,39.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,52.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,55.29,percent of total billed charges,,,85,,55.29,percent of total billed charges,,,49,,31.87,percent of total billed charges,,,90,,58.55,percent of total billed charges,,,,,,,no IP contract,,80,,52.04,percent of total billed charges,,,,,,,no IP contract,,50,,32.53,percent of total billed charges,,,,,,no IP contract,,,78,,50.74,percent of total billed charges,,,70,,45.54,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.87,3324,
68084-0692-01 - duloxetine 60 mg EC Capsule,68084-0692-01,NDC,,,,inpatient,1,EA,65.05,39.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,52.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,55.29,percent of total billed charges,,,85,,55.29,percent of total billed charges,,,49,,31.87,percent of total billed charges,,,90,,58.55,percent of total billed charges,,,,,,,no IP contract,,80,,52.04,percent of total billed charges,,,,,,,no IP contract,,50,,32.53,percent of total billed charges,,,,,,no IP contract,,,78,,50.74,percent of total billed charges,,,70,,45.54,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.87,3324,
68084-0697-01 - buPROPion 100 mg/12 hours ER Ta,68084-0697-01,NDC,,,,inpatient,1,EA,17,10.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.45,percent of total billed charges,,,85,,14.45,percent of total billed charges,,,49,,8.33,percent of total billed charges,,,90,,15.3,percent of total billed charges,,,,,,,no IP contract,,80,,13.6,percent of total billed charges,,,,,,,no IP contract,,50,,8.5,percent of total billed charges,,,,,,no IP contract,,,78,,13.26,percent of total billed charges,,,70,,11.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.33,3324,
68084-0698-01 - venlafaxine 37.5 mg ER Ca,68084-0698-01,NDC,,,,inpatient,1,EA,33.55,20.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.52,percent of total billed charges,,,85,,28.52,percent of total billed charges,,,49,,16.44,percent of total billed charges,,,90,,30.2,percent of total billed charges,,,,,,,no IP contract,,80,,26.84,percent of total billed charges,,,,,,,no IP contract,,50,,16.78,percent of total billed charges,,,,,,no IP contract,,,78,,26.17,percent of total billed charges,,,70,,23.49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.44,3324,
68084-0703-01 - ibuprofen 600 mg Tab,68084-0703-01,NDC,,,,inpatient,1,EA,6.2,3.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.27,percent of total billed charges,,,85,,5.27,percent of total billed charges,,,49,,3.04,percent of total billed charges,,,90,,5.58,percent of total billed charges,,,,,,,no IP contract,,80,,4.96,percent of total billed charges,,,,,,,no IP contract,,50,,3.1,percent of total billed charges,,,,,,no IP contract,,,78,,4.84,percent of total billed charges,,,70,,4.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.04,3324,
68084-0704-01 - bethanechol 25 mg Tab,68084-0704-01,NDC,,,,inpatient,1,EA,5.25,3.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.46,percent of total billed charges,,,85,,4.46,percent of total billed charges,,,49,,2.57,percent of total billed charges,,,90,,4.73,percent of total billed charges,,,,,,,no IP contract,,80,,4.2,percent of total billed charges,,,,,,,no IP contract,,50,,2.63,percent of total billed charges,,,,,,no IP contract,,,78,,4.1,percent of total billed charges,,,70,,3.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.57,3324,
68084-0709-01 - venlafaxine 75 mg ER Ca,68084-0709-01,NDC,,,,inpatient,1,EA,37.2,22.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.62,percent of total billed charges,,,85,,31.62,percent of total billed charges,,,49,,18.23,percent of total billed charges,,,90,,33.48,percent of total billed charges,,,,,,,no IP contract,,80,,29.76,percent of total billed charges,,,,,,,no IP contract,,50,,18.6,percent of total billed charges,,,,,,no IP contract,,,78,,29.02,percent of total billed charges,,,70,,26.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.23,3324,
68084-0713-01 - venlafaxine 150 mg ER Capsule,68084-0713-01,NDC,,,,inpatient,1,EA,40.15,24.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34.13,percent of total billed charges,,,85,,34.13,percent of total billed charges,,,49,,19.67,percent of total billed charges,,,90,,36.14,percent of total billed charges,,,,,,,no IP contract,,80,,32.12,percent of total billed charges,,,,,,,no IP contract,,50,,20.08,percent of total billed charges,,,,,,no IP contract,,,78,,31.32,percent of total billed charges,,,70,,28.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.67,3324,
68084-0723-01 - OLANZapine 5 mg Tab,68084-0723-01,NDC,,,,inpatient,1,EA,90.4,54.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,73.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,76.84,percent of total billed charges,,,85,,76.84,percent of total billed charges,,,49,,44.3,percent of total billed charges,,,90,,81.36,percent of total billed charges,,,,,,,no IP contract,,80,,72.32,percent of total billed charges,,,,,,,no IP contract,,50,,45.2,percent of total billed charges,,,,,,no IP contract,,,78,,70.51,percent of total billed charges,,,70,,63.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,44.3,3324,
68084-0728-01 - fluconazole 100 mg Tab,68084-0728-01,NDC,,,,inpatient,1,EA,24.8,14.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.08,percent of total billed charges,,,85,,21.08,percent of total billed charges,,,49,,12.15,percent of total billed charges,,,90,,22.32,percent of total billed charges,,,,,,,no IP contract,,80,,19.84,percent of total billed charges,,,,,,,no IP contract,,50,,12.4,percent of total billed charges,,,,,,no IP contract,,,78,,19.34,percent of total billed charges,,,70,,17.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.15,3324,
68084-0729-21 - galantamine 4 mg Tab,68084-0729-21,NDC,,,,inpatient,1,EA,25.45,15.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.63,percent of total billed charges,,,85,,21.63,percent of total billed charges,,,49,,12.47,percent of total billed charges,,,90,,22.91,percent of total billed charges,,,,,,,no IP contract,,80,,20.36,percent of total billed charges,,,,,,,no IP contract,,50,,12.73,percent of total billed charges,,,,,,no IP contract,,,78,,19.85,percent of total billed charges,,,70,,17.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.47,3324,
68084-0734-01 - donepezil 10 mg Tab,68084-0734-01,NDC,,,,inpatient,1,EA,10.05,6.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.54,percent of total billed charges,,,85,,8.54,percent of total billed charges,,,49,,4.92,percent of total billed charges,,,90,,9.05,percent of total billed charges,,,,,,,no IP contract,,80,,8.04,percent of total billed charges,,,,,,,no IP contract,,50,,5.03,percent of total billed charges,,,,,,no IP contract,,,78,,7.84,percent of total billed charges,,,70,,7.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.92,3324,
68084-0736-01 - LORazepam 0.5 mg Tab,68084-0736-01,NDC,,,,inpatient,1,EA,8.6,5.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.31,percent of total billed charges,,,85,,7.31,percent of total billed charges,,,49,,4.21,percent of total billed charges,,,90,,7.74,percent of total billed charges,,,,,,,no IP contract,,80,,6.88,percent of total billed charges,,,,,,,no IP contract,,50,,4.3,percent of total billed charges,,,,,,no IP contract,,,78,,6.71,percent of total billed charges,,,70,,6.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.21,3324,
68084-0738-01 - methadone 10 mg Tab,68084-0738-01,NDC,,,,inpatient,1,EA,9.1,5.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.74,percent of total billed charges,,,85,,7.74,percent of total billed charges,,,49,,4.46,percent of total billed charges,,,90,,8.19,percent of total billed charges,,,,,,,no IP contract,,80,,7.28,percent of total billed charges,,,,,,,no IP contract,,50,,4.55,percent of total billed charges,,,,,,no IP contract,,,78,,7.1,percent of total billed charges,,,70,,6.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.46,3324,
68084-0740-01 - OLANZapine 10 mg Tab,68084-0740-01,NDC,,,,inpatient,1,EA,165.35,99.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,133.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,140.55,percent of total billed charges,,,85,,140.55,percent of total billed charges,,,49,,81.02,percent of total billed charges,,,90,,148.82,percent of total billed charges,,,,,,,no IP contract,,80,,132.28,percent of total billed charges,,,,,,,no IP contract,,50,,82.68,percent of total billed charges,,,,,,no IP contract,,,78,,128.97,percent of total billed charges,,,70,,115.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,81.02,3324,
68084-0744-01 - citalopram 20 mg Tab,68084-0744-01,NDC,,,,inpatient,1,EA,24.1,14.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.49,percent of total billed charges,,,85,,20.49,percent of total billed charges,,,49,,11.81,percent of total billed charges,,,90,,21.69,percent of total billed charges,,,,,,,no IP contract,,80,,19.28,percent of total billed charges,,,,,,,no IP contract,,50,,12.05,percent of total billed charges,,,,,,no IP contract,,,78,,18.8,percent of total billed charges,,,70,,16.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.81,3324,
68084-0750-25 - hydrochlorothiazide-triamterene 25 mg-37.5 mg Tab,68084-0750-25,NDC,,,,inpatient,1,EA,10.9,6.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.27,percent of total billed charges,,,85,,9.27,percent of total billed charges,,,49,,5.34,percent of total billed charges,,,90,,9.81,percent of total billed charges,,,,,,,no IP contract,,80,,8.72,percent of total billed charges,,,,,,,no IP contract,,50,,5.45,percent of total billed charges,,,,,,no IP contract,,,78,,8.5,percent of total billed charges,,,70,,7.63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.34,3324,
68084-0756-35 - niacin 500 mg ER Ta,68084-0756-35,NDC,,,,inpatient,1,EA,49.45,29.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,40.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,42.03,percent of total billed charges,,,85,,42.03,percent of total billed charges,,,49,,24.23,percent of total billed charges,,,90,,44.51,percent of total billed charges,,,,,,,no IP contract,,80,,39.56,percent of total billed charges,,,,,,,no IP contract,,50,,24.73,percent of total billed charges,,,,,,no IP contract,,,78,,38.57,percent of total billed charges,,,70,,34.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,24.23,3324,
68084-0762-01 - gabapentin 300 mg Cap,68084-0762-01,NDC,,,,inpatient,1,EA,14.8,8.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.58,percent of total billed charges,,,85,,12.58,percent of total billed charges,,,49,,7.25,percent of total billed charges,,,90,,13.32,percent of total billed charges,,,,,,,no IP contract,,80,,11.84,percent of total billed charges,,,,,,,no IP contract,,50,,7.4,percent of total billed charges,,,,,,no IP contract,,,78,,11.54,percent of total billed charges,,,70,,10.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.25,3324,
68084-0774-01 - gabapentin 400 mg Cap,68084-0774-01,NDC,,,,inpatient,1,EA,13.5,8.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.48,percent of total billed charges,,,85,,11.48,percent of total billed charges,,,49,,6.62,percent of total billed charges,,,90,,12.15,percent of total billed charges,,,,,,,no IP contract,,80,,10.8,percent of total billed charges,,,,,,,no IP contract,,50,,6.75,percent of total billed charges,,,,,,no IP contract,,,78,,10.53,percent of total billed charges,,,70,,9.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.62,3324,
68084-0775-21 - tizanidine 2 mg Tab,68084-0775-21,NDC,,,,inpatient,1,EA,17.75,10.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.09,percent of total billed charges,,,85,,15.09,percent of total billed charges,,,49,,8.7,percent of total billed charges,,,90,,15.98,percent of total billed charges,,,,,,,no IP contract,,80,,14.2,percent of total billed charges,,,,,,,no IP contract,,50,,8.88,percent of total billed charges,,,,,,no IP contract,,,78,,13.85,percent of total billed charges,,,70,,12.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.7,3324,
68084-0776-01 - divalproex sodium 250 mg EC Tablet,68084-0776-01,NDC,,,,inpatient,1,EA,7.5,4.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.38,percent of total billed charges,,,85,,6.38,percent of total billed charges,,,49,,3.68,percent of total billed charges,,,90,,6.75,percent of total billed charges,,,,,,,no IP contract,,80,,6,percent of total billed charges,,,,,,,no IP contract,,50,,3.75,percent of total billed charges,,,,,,no IP contract,,,78,,5.85,percent of total billed charges,,,70,,5.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.68,3324,
68084-0776-35 - divalproex sodium 250 mg EC Tablet,68084-0776-35,NDC,,,,inpatient,1,EA,7.5,4.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.38,percent of total billed charges,,,85,,6.38,percent of total billed charges,,,49,,3.68,percent of total billed charges,,,90,,6.75,percent of total billed charges,,,,,,,no IP contract,,80,,6,percent of total billed charges,,,,,,,no IP contract,,50,,3.75,percent of total billed charges,,,,,,no IP contract,,,78,,5.85,percent of total billed charges,,,70,,5.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.68,3324,
68084-0782-01 - divalproex EC (delayed release) 500 mg Tab,68084-0782-01,NDC,,,,inpatient,1,EA,29.5,17.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.08,percent of total billed charges,,,85,,25.08,percent of total billed charges,,,49,,14.46,percent of total billed charges,,,90,,26.55,percent of total billed charges,,,,,,,no IP contract,,80,,23.6,percent of total billed charges,,,,,,,no IP contract,,50,,14.75,percent of total billed charges,,,,,,no IP contract,,,78,,23.01,percent of total billed charges,,,70,,20.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.46,3324,
68084-0782-61 - divalproex EC (delayed release) 500 mg Tab,68084-0782-61,NDC,,,,inpatient,1,EA,6.6,3.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.61,percent of total billed charges,,,85,,5.61,percent of total billed charges,,,49,,3.23,percent of total billed charges,,,90,,5.94,percent of total billed charges,,,,,,,no IP contract,,80,,5.28,percent of total billed charges,,,,,,,no IP contract,,50,,3.3,percent of total billed charges,,,,,,no IP contract,,,78,,5.15,percent of total billed charges,,,70,,4.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.23,3324,
68084-0783-01 - gabapentin 100 mg Cap,68084-0783-01,NDC,,,,inpatient,1,EA,8.45,5.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.18,percent of total billed charges,,,85,,7.18,percent of total billed charges,,,49,,4.14,percent of total billed charges,,,90,,7.61,percent of total billed charges,,,,,,,no IP contract,,80,,6.76,percent of total billed charges,,,,,,,no IP contract,,50,,4.23,percent of total billed charges,,,,,,no IP contract,,,78,,6.59,percent of total billed charges,,,70,,5.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.14,3324,
68084-0788-25 - glimepiride 1 mg Tab,68084-0788-25,NDC,,,,inpatient,1,EA,11.85,7.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.07,percent of total billed charges,,,85,,10.07,percent of total billed charges,,,49,,5.81,percent of total billed charges,,,90,,10.67,percent of total billed charges,,,,,,,no IP contract,,80,,9.48,percent of total billed charges,,,,,,,no IP contract,,50,,5.93,percent of total billed charges,,,,,,no IP contract,,,78,,9.24,percent of total billed charges,,,70,,8.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.81,3324,
68084-0789-25 - hydrocortisone 5 mg Tab,68084-0789-25,NDC,,,,inpatient,1,EA,12.1,7.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.29,percent of total billed charges,,,85,,10.29,percent of total billed charges,,,49,,5.93,percent of total billed charges,,,90,,10.89,percent of total billed charges,,,,,,,no IP contract,,80,,9.68,percent of total billed charges,,,,,,,no IP contract,,50,,6.05,percent of total billed charges,,,,,,no IP contract,,,78,,9.44,percent of total billed charges,,,70,,8.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.93,3324,
68084-0797-01 - gabapentin 600 mg Tab,68084-0797-01,NDC,,,,inpatient,1,EA,23.05,13.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.59,percent of total billed charges,,,85,,19.59,percent of total billed charges,,,49,,11.29,percent of total billed charges,,,90,,20.75,percent of total billed charges,,,,,,,no IP contract,,80,,18.44,percent of total billed charges,,,,,,,no IP contract,,50,,11.53,percent of total billed charges,,,,,,no IP contract,,,78,,17.98,percent of total billed charges,,,70,,16.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.29,3324,
68084-0801-01 - mycophenolate mofetil 500 mg Tab,68084-0801-01,NDC,,,,inpatient,1,EA,16.25,9.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.81,percent of total billed charges,,,85,,13.81,percent of total billed charges,,,49,,7.96,percent of total billed charges,,,90,,14.63,percent of total billed charges,,,,,,,no IP contract,,80,,13,percent of total billed charges,,,,,,,no IP contract,,50,,8.13,percent of total billed charges,,,,,,no IP contract,,,78,,12.68,percent of total billed charges,,,70,,11.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.96,3324,
68084-0802-01 - gabapentin 800 mg Tab,68084-0802-01,NDC,,,,inpatient,1,EA,26.95,16.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.91,percent of total billed charges,,,85,,22.91,percent of total billed charges,,,49,,13.21,percent of total billed charges,,,90,,24.26,percent of total billed charges,,,,,,,no IP contract,,80,,21.56,percent of total billed charges,,,,,,,no IP contract,,50,,13.48,percent of total billed charges,,,,,,no IP contract,,,78,,21.02,percent of total billed charges,,,70,,18.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.21,3324,
68084-0805-21 - methylphenidate 5 mg Tab,68084-0805-21,NDC,,,,inpatient,1,EA,17.25,10.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.66,percent of total billed charges,,,85,,14.66,percent of total billed charges,,,49,,8.45,percent of total billed charges,,,90,,15.53,percent of total billed charges,,,,,,,no IP contract,,80,,13.8,percent of total billed charges,,,,,,,no IP contract,,50,,8.63,percent of total billed charges,,,,,,no IP contract,,,78,,13.46,percent of total billed charges,,,70,,12.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.45,3324,
68084-0808-01 - traMADol 50 mg Tab,68084-0808-01,NDC,,,,inpatient,1,EA,10.35,6.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.8,percent of total billed charges,,,85,,8.8,percent of total billed charges,,,49,,5.07,percent of total billed charges,,,90,,9.32,percent of total billed charges,,,,,,,no IP contract,,80,,8.28,percent of total billed charges,,,,,,,no IP contract,,50,,5.18,percent of total billed charges,,,,,,no IP contract,,,78,,8.07,percent of total billed charges,,,70,,7.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.07,3324,
68084-0813-09 - pantoprazole 40 mg EC Ta,68084-0813-09,NDC,,,,inpatient,1,EA,7.5,4.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.38,percent of total billed charges,,,85,,6.38,percent of total billed charges,,,49,,3.68,percent of total billed charges,,,90,,6.75,percent of total billed charges,,,,,,,no IP contract,,80,,6,percent of total billed charges,,,,,,,no IP contract,,50,,3.75,percent of total billed charges,,,,,,no IP contract,,,78,,5.85,percent of total billed charges,,,70,,5.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.68,3324,
68084-0823-21 - methylphenidate 10 mg Tab,68084-0823-21,NDC,,,,inpatient,1,EA,7.35,4.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.25,percent of total billed charges,,,85,,6.25,percent of total billed charges,,,49,,3.6,percent of total billed charges,,,90,,6.62,percent of total billed charges,,,,,,,no IP contract,,80,,5.88,percent of total billed charges,,,,,,,no IP contract,,50,,3.68,percent of total billed charges,,,,,,no IP contract,,,78,,5.73,percent of total billed charges,,,70,,5.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.6,3324,
68084-0825-01 - acetaminophen-traMADol 325 mg-37.5 mg Tab,68084-0825-01,NDC,,,,inpatient,1,EA,11.45,6.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.73,percent of total billed charges,,,85,,9.73,percent of total billed charges,,,49,,5.61,percent of total billed charges,,,90,,10.31,percent of total billed charges,,,,,,,no IP contract,,80,,9.16,percent of total billed charges,,,,,,,no IP contract,,50,,5.73,percent of total billed charges,,,,,,no IP contract,,,78,,8.93,percent of total billed charges,,,70,,8.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.61,3324,
68084-0836-01 - doxazosin 1 mg Tab,68084-0836-01,NDC,,,,inpatient,1,EA,12.5,7.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.63,percent of total billed charges,,,85,,10.63,percent of total billed charges,,,49,,6.13,percent of total billed charges,,,90,,11.25,percent of total billed charges,,,,,,,no IP contract,,80,,10,percent of total billed charges,,,,,,,no IP contract,,50,,6.25,percent of total billed charges,,,,,,no IP contract,,,78,,9.75,percent of total billed charges,,,70,,8.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.13,3324,
68084-0836-25 - doxazosin 1 mg Tab,68084-0836-25,NDC,,,,inpatient,1,EA,11.95,7.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.16,percent of total billed charges,,,85,,10.16,percent of total billed charges,,,49,,5.86,percent of total billed charges,,,90,,10.76,percent of total billed charges,,,,,,,no IP contract,,80,,9.56,percent of total billed charges,,,,,,,no IP contract,,50,,5.98,percent of total billed charges,,,,,,no IP contract,,,78,,9.32,percent of total billed charges,,,70,,8.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.86,3324,
68084-0844-01 - venlafaxine 37.5 mg Tab,68084-0844-01,NDC,,,,inpatient,1,EA,19.7,11.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.75,percent of total billed charges,,,85,,16.75,percent of total billed charges,,,49,,9.65,percent of total billed charges,,,90,,17.73,percent of total billed charges,,,,,,,no IP contract,,80,,15.76,percent of total billed charges,,,,,,,no IP contract,,50,,9.85,percent of total billed charges,,,,,,no IP contract,,,78,,15.37,percent of total billed charges,,,70,,13.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.65,3324,
68084-0845-01 - OXcarbazepine 150 mg Tab,68084-0845-01,NDC,,,,inpatient,1,EA,15.85,9.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.47,percent of total billed charges,,,85,,13.47,percent of total billed charges,,,49,,7.77,percent of total billed charges,,,90,,14.27,percent of total billed charges,,,,,,,no IP contract,,80,,12.68,percent of total billed charges,,,,,,,no IP contract,,50,,7.93,percent of total billed charges,,,,,,no IP contract,,,78,,12.36,percent of total billed charges,,,70,,11.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.77,3324,
68084-0847-01 - hydrOXYzine pamoate 25 mg Cap,68084-0847-01,NDC,,,,inpatient,1,EA,6.2,3.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.27,percent of total billed charges,,,85,,5.27,percent of total billed charges,,,49,,3.04,percent of total billed charges,,,90,,5.58,percent of total billed charges,,,,,,,no IP contract,,80,,4.96,percent of total billed charges,,,,,,,no IP contract,,50,,3.1,percent of total billed charges,,,,,,no IP contract,,,78,,4.84,percent of total billed charges,,,70,,4.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.04,3324,
68084-0853-01 - OXcarbazepine 300 mg Tab,68084-0853-01,NDC,,,,inpatient,1,EA,9.15,5.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.78,percent of total billed charges,,,85,,7.78,percent of total billed charges,,,49,,4.48,percent of total billed charges,,,90,,8.24,percent of total billed charges,,,,,,,no IP contract,,80,,7.32,percent of total billed charges,,,,,,,no IP contract,,50,,4.58,percent of total billed charges,,,,,,no IP contract,,,78,,7.14,percent of total billed charges,,,70,,6.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.48,3324,
68084-0854-01 - carvedilol 6.25 mg Tab,68084-0854-01,NDC,,,,inpatient,1,EA,4.4,2.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.74,percent of total billed charges,,,85,,3.74,percent of total billed charges,,,49,,2.16,percent of total billed charges,,,90,,3.96,percent of total billed charges,,,,,,,no IP contract,,80,,3.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.2,percent of total billed charges,,,,,,no IP contract,,,78,,3.43,percent of total billed charges,,,70,,3.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.16,3324,
68084-0855-01 - baclofen 10 mg Tab,68084-0855-01,NDC,,,,inpatient,1,EA,7.8,4.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.63,percent of total billed charges,,,85,,6.63,percent of total billed charges,,,49,,3.82,percent of total billed charges,,,90,,7.02,percent of total billed charges,,,,,,,no IP contract,,80,,6.24,percent of total billed charges,,,,,,,no IP contract,,50,,3.9,percent of total billed charges,,,,,,no IP contract,,,78,,6.08,percent of total billed charges,,,70,,5.46,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.82,3324,
68084-0856-01 - venlafaxine 75 mg Tab,68084-0856-01,NDC,,,,inpatient,1,EA,21.15,12.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.98,percent of total billed charges,,,85,,17.98,percent of total billed charges,,,49,,10.36,percent of total billed charges,,,90,,19.04,percent of total billed charges,,,,,,,no IP contract,,80,,16.92,percent of total billed charges,,,,,,,no IP contract,,50,,10.58,percent of total billed charges,,,,,,no IP contract,,,78,,16.5,percent of total billed charges,,,70,,14.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.36,3324,
68084-0859-01 - levetiracetam 250 mg Tab,68084-0859-01,NDC,,,,inpatient,1,EA,8.6,5.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.31,percent of total billed charges,,,85,,7.31,percent of total billed charges,,,49,,4.21,percent of total billed charges,,,90,,7.74,percent of total billed charges,,,,,,,no IP contract,,80,,6.88,percent of total billed charges,,,,,,,no IP contract,,50,,4.3,percent of total billed charges,,,,,,no IP contract,,,78,,6.71,percent of total billed charges,,,70,,6.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.21,3324,
68084-0867-01 - OXcarbazepine 600 mg Tab,68084-0867-01,NDC,,,,inpatient,1,EA,44.05,26.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,35.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,37.44,percent of total billed charges,,,85,,37.44,percent of total billed charges,,,49,,21.58,percent of total billed charges,,,90,,39.65,percent of total billed charges,,,,,,,no IP contract,,80,,35.24,percent of total billed charges,,,,,,,no IP contract,,50,,22.03,percent of total billed charges,,,,,,no IP contract,,,78,,34.36,percent of total billed charges,,,70,,30.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.58,3324,
68084-0868-01 - baclofen 20 mg Tab,68084-0868-01,NDC,,,,inpatient,1,EA,10.35,6.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.8,percent of total billed charges,,,85,,8.8,percent of total billed charges,,,49,,5.07,percent of total billed charges,,,90,,9.32,percent of total billed charges,,,,,,,no IP contract,,80,,8.28,percent of total billed charges,,,,,,,no IP contract,,50,,5.18,percent of total billed charges,,,,,,no IP contract,,,78,,8.07,percent of total billed charges,,,70,,7.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.07,3324,
68084-0869-21 - sildenafil 20 mg Tab,68084-0869-21,NDC,,,,inpatient,1,EA,13.7,8.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.65,percent of total billed charges,,,85,,11.65,percent of total billed charges,,,49,,6.71,percent of total billed charges,,,90,,12.33,percent of total billed charges,,,,,,,no IP contract,,80,,10.96,percent of total billed charges,,,,,,,no IP contract,,50,,6.85,percent of total billed charges,,,,,,no IP contract,,,78,,10.69,percent of total billed charges,,,70,,9.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.71,3324,
68084-0870-01 - levetiracetam 500 mg Tab,68084-0870-01,NDC,,,,inpatient,1,EA,9.55,5.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.12,percent of total billed charges,,,85,,8.12,percent of total billed charges,,,49,,4.68,percent of total billed charges,,,90,,8.6,percent of total billed charges,,,,,,,no IP contract,,80,,7.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.78,percent of total billed charges,,,,,,no IP contract,,,78,,7.45,percent of total billed charges,,,70,,6.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.68,3324,
68084-0875-01 - montelukast 10 mg Tab,68084-0875-01,NDC,,,,inpatient,1,EA,47.65,28.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,38.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,40.5,percent of total billed charges,,,85,,40.5,percent of total billed charges,,,49,,23.35,percent of total billed charges,,,90,,42.89,percent of total billed charges,,,,,,,no IP contract,,80,,38.12,percent of total billed charges,,,,,,,no IP contract,,50,,23.83,percent of total billed charges,,,,,,no IP contract,,,78,,37.17,percent of total billed charges,,,70,,33.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.35,3324,
68084-0876-01 - carvedilol 25 mg Tab,68084-0876-01,NDC,,,,inpatient,1,EA,19.35,11.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.45,percent of total billed charges,,,85,,16.45,percent of total billed charges,,,49,,9.48,percent of total billed charges,,,90,,17.42,percent of total billed charges,,,,,,,no IP contract,,80,,15.48,percent of total billed charges,,,,,,,no IP contract,,50,,9.68,percent of total billed charges,,,,,,no IP contract,,,78,,15.09,percent of total billed charges,,,70,,13.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.48,3324,
68084-0878-01 - pioglitazone 15 mg Tab,68084-0878-01,NDC,,,,inpatient,1,EA,12.65,7.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.75,percent of total billed charges,,,85,,10.75,percent of total billed charges,,,49,,6.2,percent of total billed charges,,,90,,11.39,percent of total billed charges,,,,,,,no IP contract,,80,,10.12,percent of total billed charges,,,,,,,no IP contract,,50,,6.33,percent of total billed charges,,,,,,no IP contract,,,78,,9.87,percent of total billed charges,,,70,,8.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.2,3324,
68084-0882-01 - levetiracetam 750 mg Tab,68084-0882-01,NDC,,,,inpatient,1,EA,10.5,6.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.93,percent of total billed charges,,,85,,8.93,percent of total billed charges,,,49,,5.15,percent of total billed charges,,,90,,9.45,percent of total billed charges,,,,,,,no IP contract,,80,,8.4,percent of total billed charges,,,,,,,no IP contract,,50,,5.25,percent of total billed charges,,,,,,no IP contract,,,78,,8.19,percent of total billed charges,,,70,,7.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.15,3324,
68084-0895-01 - acetaminophen-HYDROcodone [Norco] 325 mg-5 mg Tab,68084-0895-01,NDC,,,,inpatient,1,EA,10.6,6.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.01,percent of total billed charges,,,85,,9.01,percent of total billed charges,,,49,,5.19,percent of total billed charges,,,90,,9.54,percent of total billed charges,,,,,,,no IP contract,,80,,8.48,percent of total billed charges,,,,,,,no IP contract,,50,,5.3,percent of total billed charges,,,,,,no IP contract,,,78,,8.27,percent of total billed charges,,,70,,7.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.19,3324,
68084-0895-09 - APAP-HYDROcodone 5 mg-325 mg Tab,68084-0895-09,NDC,,,,inpatient,1,EA,11.15,6.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.48,percent of total billed charges,,,85,,9.48,percent of total billed charges,,,49,,5.46,percent of total billed charges,,,90,,10.04,percent of total billed charges,,,,,,,no IP contract,,80,,8.92,percent of total billed charges,,,,,,,no IP contract,,50,,5.58,percent of total billed charges,,,,,,no IP contract,,,78,,8.7,percent of total billed charges,,,70,,7.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.46,3324,
68084-0896-25 - venlafaxine 25 mg Tab,68084-0896-25,NDC,,,,inpatient,1,EA,20.3,12.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.26,percent of total billed charges,,,85,,17.26,percent of total billed charges,,,49,,9.95,percent of total billed charges,,,90,,18.27,percent of total billed charges,,,,,,,no IP contract,,80,,16.24,percent of total billed charges,,,,,,,no IP contract,,50,,10.15,percent of total billed charges,,,,,,no IP contract,,,78,,15.83,percent of total billed charges,,,70,,14.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.95,3324,
68084-0907-21 - mycophenolic acid 180 mg EC Ta,68084-0907-21,NDC,,,,inpatient,1,EA,43.55,26.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,35.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,37.02,percent of total billed charges,,,85,,37.02,percent of total billed charges,,,49,,21.34,percent of total billed charges,,,90,,39.2,percent of total billed charges,,,,,,,no IP contract,,80,,34.84,percent of total billed charges,,,,,,,no IP contract,,50,,21.78,percent of total billed charges,,,,,,no IP contract,,,78,,33.97,percent of total billed charges,,,70,,30.49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.34,3324,
68084-0915-25 - sirolimus 1 mg Tab,68084-0915-25,NDC,,,,inpatient,1,EA,139.35,83.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,112.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,118.45,percent of total billed charges,,,85,,118.45,percent of total billed charges,,,49,,68.28,percent of total billed charges,,,90,,125.42,percent of total billed charges,,,,,,,no IP contract,,80,,111.48,percent of total billed charges,,,,,,,no IP contract,,50,,69.68,percent of total billed charges,,,,,,no IP contract,,,78,,108.69,percent of total billed charges,,,70,,97.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,68.28,3324,
68084-0918-25 - mycophenolic acid 360 mg EC Tablet,68084-0918-25,NDC,,,,inpatient,1,EA,83.3,49.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,67.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,70.81,percent of total billed charges,,,85,,70.81,percent of total billed charges,,,49,,40.82,percent of total billed charges,,,90,,74.97,percent of total billed charges,,,,,,,no IP contract,,80,,66.64,percent of total billed charges,,,,,,,no IP contract,,50,,41.65,percent of total billed charges,,,,,,no IP contract,,,78,,64.97,percent of total billed charges,,,70,,58.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,40.82,3324,
68084-0928-25 - pilocarpine 5 mg Tab,68084-0928-25,NDC,,,,inpatient,1,EA,27.65,16.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.5,percent of total billed charges,,,85,,23.5,percent of total billed charges,,,49,,13.55,percent of total billed charges,,,90,,24.89,percent of total billed charges,,,,,,,no IP contract,,80,,22.12,percent of total billed charges,,,,,,,no IP contract,,50,,13.83,percent of total billed charges,,,,,,no IP contract,,,78,,21.57,percent of total billed charges,,,70,,19.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.55,3324,
68084-0948-25 - eplerenone 25 mg Tab,68084-0948-25,NDC,,,,inpatient,1,EA,32.9,19.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,26.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,27.97,percent of total billed charges,,,85,,27.97,percent of total billed charges,,,49,,16.12,percent of total billed charges,,,90,,29.61,percent of total billed charges,,,,,,,no IP contract,,80,,26.32,percent of total billed charges,,,,,,,no IP contract,,50,,16.45,percent of total billed charges,,,,,,no IP contract,,,78,,25.66,percent of total billed charges,,,70,,23.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.12,3324,
68084-0964-25 - propylthiouracil 50 mg Tab,68084-0964-25,NDC,,,,inpatient,1,EA,17.65,10.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15,percent of total billed charges,,,85,,15,percent of total billed charges,,,49,,8.65,percent of total billed charges,,,90,,15.89,percent of total billed charges,,,,,,,no IP contract,,80,,14.12,percent of total billed charges,,,,,,,no IP contract,,50,,8.83,percent of total billed charges,,,,,,no IP contract,,,78,,13.77,percent of total billed charges,,,70,,12.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.65,3324,
68084-0965-25 - valganciclovir 450 mg Tab,68084-0965-25,NDC,,,,inpatient,1,EA,1220.15,732.09,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,988.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1037.13,percent of total billed charges,,,85,,1037.13,percent of total billed charges,,,49,,597.87,percent of total billed charges,,,90,,1098.14,percent of total billed charges,,,,,,,no IP contract,,80,,976.12,percent of total billed charges,,,,,,,no IP contract,,50,,610.08,percent of total billed charges,,,,,,no IP contract,,,78,,951.72,percent of total billed charges,,,70,,854.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,597.87,3324,
68084-0966-01 - metronidazole 500 mg Tab,68084-0966-01,NDC,,,,inpatient,1,EA,11.15,6.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.48,percent of total billed charges,,,85,,9.48,percent of total billed charges,,,49,,5.46,percent of total billed charges,,,90,,10.04,percent of total billed charges,,,,,,,no IP contract,,80,,8.92,percent of total billed charges,,,,,,,no IP contract,,50,,5.58,percent of total billed charges,,,,,,no IP contract,,,78,,8.7,percent of total billed charges,,,70,,7.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.46,3324,
68084-0969-01 - celecoxib 100 mg Cap,68084-0969-01,NDC,,,,inpatient,1,EA,40.55,24.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34.47,percent of total billed charges,,,85,,34.47,percent of total billed charges,,,49,,19.87,percent of total billed charges,,,90,,36.5,percent of total billed charges,,,,,,,no IP contract,,80,,32.44,percent of total billed charges,,,,,,,no IP contract,,50,,20.28,percent of total billed charges,,,,,,no IP contract,,,78,,31.63,percent of total billed charges,,,70,,28.39,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.87,3324,
68084-0975-01 - oxyCODONE 15 mg Tab,68084-0975-01,NDC,,,,inpatient,1,EA,21,12.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.85,percent of total billed charges,,,85,,17.85,percent of total billed charges,,,49,,10.29,percent of total billed charges,,,90,,18.9,percent of total billed charges,,,,,,,no IP contract,,80,,16.8,percent of total billed charges,,,,,,,no IP contract,,50,,10.5,percent of total billed charges,,,,,,no IP contract,,,78,,16.38,percent of total billed charges,,,70,,14.7,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.29,3324,
68084-0976-01 - celecoxib 200 mg Cap,68084-0976-01,NDC,,,,inpatient,1,EA,23.15,13.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.68,percent of total billed charges,,,85,,19.68,percent of total billed charges,,,49,,11.34,percent of total billed charges,,,90,,20.84,percent of total billed charges,,,,,,,no IP contract,,80,,18.52,percent of total billed charges,,,,,,,no IP contract,,50,,11.58,percent of total billed charges,,,,,,no IP contract,,,78,,18.06,percent of total billed charges,,,70,,16.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.34,3324,
68084-0996-01 - prazosin 1 mg Cap,68084-0996-01,NDC,,,,inpatient,1,EA,18.05,10.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.34,percent of total billed charges,,,85,,15.34,percent of total billed charges,,,49,,8.84,percent of total billed charges,,,90,,16.25,percent of total billed charges,,,,,,,no IP contract,,80,,14.44,percent of total billed charges,,,,,,,no IP contract,,50,,9.03,percent of total billed charges,,,,,,no IP contract,,,78,,14.08,percent of total billed charges,,,70,,12.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.84,3324,
68094-0001-62 - morphine 10 mg/5 mL Soln,68094-0001-62,NDC,,,,inpatient,5,ML,19.6,11.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.66,percent of total billed charges,,,85,,16.66,percent of total billed charges,,,49,,9.6,percent of total billed charges,,,90,,17.64,percent of total billed charges,,,,,,,no IP contract,,80,,15.68,percent of total billed charges,,,,,,,no IP contract,,50,,9.8,percent of total billed charges,,,,,,no IP contract,,,78,,15.29,percent of total billed charges,,,70,,13.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.6,3324,
68094-0063-62 - megestrol 40 mg/mL Susp,68094-0063-62,NDC,,,,inpatient,10,ML,52.9,31.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,42.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,44.97,percent of total billed charges,,,85,,44.97,percent of total billed charges,,,49,,25.92,percent of total billed charges,,,90,,47.61,percent of total billed charges,,,,,,,no IP contract,,80,,42.32,percent of total billed charges,,,,,,,no IP contract,,50,,26.45,percent of total billed charges,,,,,,no IP contract,,,78,,41.26,percent of total billed charges,,,70,,37.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.92,3324,
68094-0193-61 - valproic acid 250 mg/5 mL Syrup,68094-0193-61,NDC,,,,inpatient,5,ML,10.85,6.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.22,percent of total billed charges,,,85,,9.22,percent of total billed charges,,,49,,5.32,percent of total billed charges,,,90,,9.77,percent of total billed charges,,,,,,,no IP contract,,80,,8.68,percent of total billed charges,,,,,,,no IP contract,,50,,5.43,percent of total billed charges,,,,,,no IP contract,,,78,,8.46,percent of total billed charges,,,70,,7.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.32,3324,
68094-0204-62 - ranitidine 15 mg/mL Syrup,68094-0204-62,NDC,,,,inpatient,10,ML,72.9,43.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,59.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,61.97,percent of total billed charges,,,85,,61.97,percent of total billed charges,,,49,,35.72,percent of total billed charges,,,90,,65.61,percent of total billed charges,,,,,,,no IP contract,,80,,58.32,percent of total billed charges,,,,,,,no IP contract,,50,,36.45,percent of total billed charges,,,,,,no IP contract,,,78,,56.86,percent of total billed charges,,,70,,51.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,35.72,3324,
68094-0204-62 - ranitidine 15 mg/mL Syrup,68094-0204-62,NDC,,,,inpatient,10,ML,72.9,43.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,59.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,61.97,percent of total billed charges,,,85,,61.97,percent of total billed charges,,,49,,35.72,percent of total billed charges,,,90,,65.61,percent of total billed charges,,,,,,,no IP contract,,80,,58.32,percent of total billed charges,,,,,,,no IP contract,,50,,36.45,percent of total billed charges,,,,,,no IP contract,,,78,,56.86,percent of total billed charges,,,70,,51.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,35.72,3324,
68094-0250-62 - megestrol 40 mg/mL Susp,68094-0250-62,NDC,,,,inpatient,10,ML,40.4,24.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34.34,percent of total billed charges,,,85,,34.34,percent of total billed charges,,,49,,19.8,percent of total billed charges,,,90,,36.36,percent of total billed charges,,,,,,,no IP contract,,80,,32.32,percent of total billed charges,,,,,,,no IP contract,,50,,20.2,percent of total billed charges,,,,,,no IP contract,,,78,,31.51,percent of total billed charges,,,70,,28.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.8,3324,
68094-0599-58 - nystatin 100000 units/mL Susp,68094-0599-58,NDC,,,,inpatient,5,ML,25.4,15.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.59,percent of total billed charges,,,85,,21.59,percent of total billed charges,,,49,,12.45,percent of total billed charges,,,90,,22.86,percent of total billed charges,,,,,,,no IP contract,,80,,20.32,percent of total billed charges,,,,,,,no IP contract,,50,,12.7,percent of total billed charges,,,,,,no IP contract,,,78,,19.81,percent of total billed charges,,,70,,17.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.45,3324,
68094-0676-59 - metoclopramide 10 mg Soln,68094-0676-59,NDC,,,,inpatient,10,ML,912.55,547.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,739.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,775.67,percent of total billed charges,,,85,,775.67,percent of total billed charges,,,49,,447.15,percent of total billed charges,,,90,,821.3,percent of total billed charges,,,,,,,no IP contract,,80,,730.04,percent of total billed charges,,,,,,,no IP contract,,50,,456.28,percent of total billed charges,,,,,,no IP contract,,,78,,711.79,percent of total billed charges,,,70,,638.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,447.15,3324,
68094-0701-59 - valproic acid 5 mL Syrup,68094-0701-59,NDC,,,,inpatient,10,ML,104.55,62.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,84.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,88.87,percent of total billed charges,,,85,,88.87,percent of total billed charges,,,49,,51.23,percent of total billed charges,,,90,,94.1,percent of total billed charges,,,,,,,no IP contract,,80,,83.64,percent of total billed charges,,,,,,,no IP contract,,50,,52.28,percent of total billed charges,,,,,,no IP contract,,,78,,81.55,percent of total billed charges,,,70,,73.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,51.23,3324,
68094-0701-62 - valproic acid 250 mg/5 mL Syrup,68094-0701-62,NDC,,,,inpatient,10,ML,21.25,12.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.06,percent of total billed charges,,,85,,18.06,percent of total billed charges,,,49,,10.41,percent of total billed charges,,,90,,19.13,percent of total billed charges,,,,,,,no IP contract,,80,,17,percent of total billed charges,,,,,,,no IP contract,,50,,10.63,percent of total billed charges,,,,,,no IP contract,,,78,,16.58,percent of total billed charges,,,70,,14.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.41,3324,
68094-0701-62 - valproic acid 250 mg/5 mL Syrup,68094-0701-62,NDC,,,,inpatient,10,ML,21.25,12.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.06,percent of total billed charges,,,85,,18.06,percent of total billed charges,,,49,,10.41,percent of total billed charges,,,90,,19.13,percent of total billed charges,,,,,,,no IP contract,,80,,17,percent of total billed charges,,,,,,,no IP contract,,50,,10.63,percent of total billed charges,,,,,,no IP contract,,,78,,16.58,percent of total billed charges,,,70,,14.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.41,3324,
68094-0852-61 - HYDROmorphone 8 mg Tab,68094-0852-61,NDC,,,,inpatient,1,EA,12.35,7.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.5,percent of total billed charges,,,85,,10.5,percent of total billed charges,,,49,,6.05,percent of total billed charges,,,90,,11.12,percent of total billed charges,,,,,,,no IP contract,,80,,9.88,percent of total billed charges,,,,,,,no IP contract,,50,,6.18,percent of total billed charges,,,,,,no IP contract,,,78,,9.63,percent of total billed charges,,,70,,8.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.05,3324,
68180-0113-16 - levETIRAcetam 500 mg Tab,68180-0113-16,NDC,,,,inpatient,1,EA,31.75,19.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,25.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.99,percent of total billed charges,,,85,,26.99,percent of total billed charges,,,49,,15.56,percent of total billed charges,,,90,,28.58,percent of total billed charges,,,,,,,no IP contract,,80,,25.4,percent of total billed charges,,,,,,,no IP contract,,50,,15.88,percent of total billed charges,,,,,,no IP contract,,,78,,24.77,percent of total billed charges,,,70,,22.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.56,3324,
68180-0150-01 - famotidine 40 mg/5 mL REC P,68180-0150-01,NDC,,,,inpatient,1,ML,34.9,20.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.67,percent of total billed charges,,,85,,29.67,percent of total billed charges,,,49,,17.1,percent of total billed charges,,,90,,31.41,percent of total billed charges,,,,,,,no IP contract,,80,,27.92,percent of total billed charges,,,,,,,no IP contract,,50,,17.45,percent of total billed charges,,,,,,no IP contract,,,78,,27.22,percent of total billed charges,,,70,,24.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.1,3324,
68180-0180-01 - cefadroxil 500 mg Cap,68180-0180-01,NDC,,,,inpatient,1,EA,32.45,19.47,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,26.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,27.58,percent of total billed charges,,,85,,27.58,percent of total billed charges,,,49,,15.9,percent of total billed charges,,,90,,29.21,percent of total billed charges,,,,,,,no IP contract,,80,,25.96,percent of total billed charges,,,,,,,no IP contract,,50,,16.23,percent of total billed charges,,,,,,no IP contract,,,78,,25.31,percent of total billed charges,,,70,,22.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.9,3324,
68180-0180-08 - cefadroxil 500 mg Cap,68180-0180-08,NDC,,,,inpatient,1,EA,33.4,20.04,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.39,percent of total billed charges,,,85,,28.39,percent of total billed charges,,,49,,16.37,percent of total billed charges,,,90,,30.06,percent of total billed charges,,,,,,,no IP contract,,80,,26.72,percent of total billed charges,,,,,,,no IP contract,,50,,16.7,percent of total billed charges,,,,,,no IP contract,,,78,,26.05,percent of total billed charges,,,70,,23.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.37,3324,
68180-0181-02 - cefadroxil 250 mg/5 mL REC P,68180-0181-02,NDC,,,,inpatient,1,ML,10.5,6.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.93,percent of total billed charges,,,85,,8.93,percent of total billed charges,,,49,,5.15,percent of total billed charges,,,90,,9.45,percent of total billed charges,,,,,,,no IP contract,,80,,8.4,percent of total billed charges,,,,,,,no IP contract,,50,,5.25,percent of total billed charges,,,,,,no IP contract,,,78,,8.19,percent of total billed charges,,,70,,7.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.15,3324,
68180-0280-01 - ethambutol 100 mg Tab,68180-0280-01,NDC,,,,inpatient,1,EA,8.5,5.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.23,percent of total billed charges,,,85,,7.23,percent of total billed charges,,,49,,4.17,percent of total billed charges,,,90,,7.65,percent of total billed charges,,,,,,,no IP contract,,80,,6.8,percent of total billed charges,,,,,,,no IP contract,,50,,4.25,percent of total billed charges,,,,,,no IP contract,,,78,,6.63,percent of total billed charges,,,70,,5.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.17,3324,
68180-0319-09 - buPROPion 150 mg/24 hours ER Ta,68180-0319-09,NDC,,,,inpatient,1,EA,41.75,25.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,35.49,percent of total billed charges,,,85,,35.49,percent of total billed charges,,,49,,20.46,percent of total billed charges,,,90,,37.58,percent of total billed charges,,,,,,,no IP contract,,80,,33.4,percent of total billed charges,,,,,,,no IP contract,,50,,20.88,percent of total billed charges,,,,,,no IP contract,,,78,,32.57,percent of total billed charges,,,70,,29.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.46,3324,
68180-0320-06 - buPROPion 300 mg/24 hours ER Ta,68180-0320-06,NDC,,,,inpatient,1,EA,41.75,25.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,35.49,percent of total billed charges,,,85,,35.49,percent of total billed charges,,,49,,20.46,percent of total billed charges,,,90,,37.58,percent of total billed charges,,,,,,,no IP contract,,80,,33.4,percent of total billed charges,,,,,,,no IP contract,,50,,20.88,percent of total billed charges,,,,,,no IP contract,,,78,,32.57,percent of total billed charges,,,70,,29.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.46,3324,
68180-0320-09 - buPROPion 300 mg/24 hours ER Ta,68180-0320-09,NDC,,,,inpatient,1,EA,41.75,25.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,35.49,percent of total billed charges,,,85,,35.49,percent of total billed charges,,,49,,20.46,percent of total billed charges,,,90,,37.58,percent of total billed charges,,,,,,,no IP contract,,80,,33.4,percent of total billed charges,,,,,,,no IP contract,,50,,20.88,percent of total billed charges,,,,,,no IP contract,,,78,,32.57,percent of total billed charges,,,70,,29.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.46,3324,
68180-0322-01 - eszopiclone 1 mg Tab,68180-0322-01,NDC,,,,inpatient,1,EA,102.65,61.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,83.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,87.25,percent of total billed charges,,,85,,87.25,percent of total billed charges,,,49,,50.3,percent of total billed charges,,,90,,92.39,percent of total billed charges,,,,,,,no IP contract,,80,,82.12,percent of total billed charges,,,,,,,no IP contract,,50,,51.33,percent of total billed charges,,,,,,no IP contract,,,78,,80.07,percent of total billed charges,,,70,,71.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,50.3,3324,
68180-0392-01 - ciprofloxacin 250 mg/5 mL REC P,68180-0392-01,NDC,,,,inpatient,1,ML,15.6,9.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.26,percent of total billed charges,,,85,,13.26,percent of total billed charges,,,49,,7.64,percent of total billed charges,,,90,,14.04,percent of total billed charges,,,,,,,no IP contract,,80,,12.48,percent of total billed charges,,,,,,,no IP contract,,50,,7.8,percent of total billed charges,,,,,,no IP contract,,,78,,12.17,percent of total billed charges,,,70,,10.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.64,3324,
celecoxib 200 mg Cap,68180-0399-01,NDC,,,,inpatient,1,EA,64.1,38.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,51.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,54.49,percent of total billed charges,,,85,,54.49,percent of total billed charges,,,49,,31.41,percent of total billed charges,,,90,,57.69,percent of total billed charges,,,,,,,no IP contract,,80,,51.28,percent of total billed charges,,,,,,,no IP contract,,50,,32.05,percent of total billed charges,,,,,,no IP contract,,,78,,50,percent of total billed charges,,,70,,44.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.41,3324,
68180-0407-03 - cefixime 200 mg / 5 mL REC Powder,68180-0407-03,NDC,,,,inpatient,1,ML,79.65,47.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,64.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,67.7,percent of total billed charges,,,85,,67.7,percent of total billed charges,,,49,,39.03,percent of total billed charges,,,90,,71.69,percent of total billed charges,,,,,,,no IP contract,,80,,63.72,percent of total billed charges,,,,,,,no IP contract,,50,,39.83,percent of total billed charges,,,,,,no IP contract,,,78,,62.13,percent of total billed charges,,,70,,55.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,39.03,3324,
68180-0411-06 - irbesartan 150 mg Tab,68180-0411-06,NDC,,,,inpatient,1,EA,28.25,16.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.01,percent of total billed charges,,,85,,24.01,percent of total billed charges,,,49,,13.84,percent of total billed charges,,,90,,25.43,percent of total billed charges,,,,,,,no IP contract,,80,,22.6,percent of total billed charges,,,,,,,no IP contract,,50,,14.13,percent of total billed charges,,,,,,no IP contract,,,78,,22.04,percent of total billed charges,,,70,,19.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.84,3324,
68180-0422-01 - moxifloxacin ophthalmic 0.5% Soln,68180-0422-01,NDC,,,,inpatient,1,UN,1403.15,841.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1136.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1192.68,percent of total billed charges,,,85,,1192.68,percent of total billed charges,,,49,,687.54,percent of total billed charges,,,90,,1262.84,percent of total billed charges,,,,,,,no IP contract,,80,,1122.52,percent of total billed charges,,,,,,,no IP contract,,50,,701.58,percent of total billed charges,,,,,,no IP contract,,,78,,1094.46,percent of total billed charges,,,70,,982.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,687.54,3324,
68180-0441-01 - cephalexin 250 mg/5 mL REC P,68180-0441-01,NDC,,,,inpatient,1,ML,7.85,4.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.67,percent of total billed charges,,,85,,6.67,percent of total billed charges,,,49,,3.85,percent of total billed charges,,,90,,7.07,percent of total billed charges,,,,,,,no IP contract,,80,,6.28,percent of total billed charges,,,,,,,no IP contract,,50,,3.93,percent of total billed charges,,,,,,no IP contract,,,78,,6.12,percent of total billed charges,,,70,,5.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.85,3324,
68180-0479-02 - simvastatin 20 mg Tab,68180-0479-02,NDC,,,,inpatient,1,EA,42.95,25.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36.51,percent of total billed charges,,,85,,36.51,percent of total billed charges,,,49,,21.05,percent of total billed charges,,,90,,38.66,percent of total billed charges,,,,,,,no IP contract,,80,,34.36,percent of total billed charges,,,,,,,no IP contract,,50,,21.48,percent of total billed charges,,,,,,no IP contract,,,78,,33.5,percent of total billed charges,,,70,,30.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.05,3324,
68180-0545-02 - nystatin-triamcinolone topical 100000 units/g-0.1% Cream,68180-0545-02,NDC,,,,inpatient,1,UN,1338.7,803.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1084.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1137.9,percent of total billed charges,,,85,,1137.9,percent of total billed charges,,,49,,655.96,percent of total billed charges,,,90,,1204.83,percent of total billed charges,,,,,,,no IP contract,,80,,1070.96,percent of total billed charges,,,,,,,no IP contract,,50,,669.35,percent of total billed charges,,,,,,no IP contract,,,78,,1044.19,percent of total billed charges,,,70,,937.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,655.96,3324,
68180-0590-01 - ramipril 5 mg Cap,68180-0590-01,NDC,,,,inpatient,1,EA,18.85,11.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.02,percent of total billed charges,,,85,,16.02,percent of total billed charges,,,49,,9.24,percent of total billed charges,,,90,,16.97,percent of total billed charges,,,,,,,no IP contract,,80,,15.08,percent of total billed charges,,,,,,,no IP contract,,50,,9.43,percent of total billed charges,,,,,,no IP contract,,,78,,14.7,percent of total billed charges,,,70,,13.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.24,3324,
68180-0675-11 - oseltamivir 30 mg Cap,68180-0675-11,NDC,,,,inpatient,1,EA,116.55,69.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,94.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,99.07,percent of total billed charges,,,85,,99.07,percent of total billed charges,,,49,,57.11,percent of total billed charges,,,90,,104.9,percent of total billed charges,,,,,,,no IP contract,,80,,93.24,percent of total billed charges,,,,,,,no IP contract,,50,,58.28,percent of total billed charges,,,,,,no IP contract,,,78,,90.91,percent of total billed charges,,,70,,81.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,57.11,3324,
68180-0677-11 - oseltamivir 75 mg Cap,68180-0677-11,NDC,,,,inpatient,1,EA,126.75,76.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,102.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,107.74,percent of total billed charges,,,85,,107.74,percent of total billed charges,,,49,,62.11,percent of total billed charges,,,90,,114.08,percent of total billed charges,,,,,,,no IP contract,,80,,101.4,percent of total billed charges,,,,,,,no IP contract,,50,,63.38,percent of total billed charges,,,,,,no IP contract,,,78,,98.87,percent of total billed charges,,,70,,88.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,62.11,3324,
68180-0697-06 - traMADol 100 mg/24 hours ER Ta,68180-0697-06,NDC,,,,inpatient,1,EA,35.75,21.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.39,percent of total billed charges,,,85,,30.39,percent of total billed charges,,,49,,17.52,percent of total billed charges,,,90,,32.18,percent of total billed charges,,,,,,,no IP contract,,80,,28.6,percent of total billed charges,,,,,,,no IP contract,,50,,17.88,percent of total billed charges,,,,,,no IP contract,,,78,,27.89,percent of total billed charges,,,70,,25.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.52,3324,
68180-0711-60 - cefdinir 300 mg Cap,68180-0711-60,NDC,,,,inpatient,1,EA,44.45,26.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,37.78,percent of total billed charges,,,85,,37.78,percent of total billed charges,,,49,,21.78,percent of total billed charges,,,90,,40.01,percent of total billed charges,,,,,,,no IP contract,,80,,35.56,percent of total billed charges,,,,,,,no IP contract,,50,,22.23,percent of total billed charges,,,,,,no IP contract,,,78,,34.67,percent of total billed charges,,,70,,31.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.78,3324,
68180-0722-04 - cefdinir 125 mg/5 mL REC P,68180-0722-04,NDC,,,,inpatient,1,ML,12.5,7.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.63,percent of total billed charges,,,85,,10.63,percent of total billed charges,,,49,,6.13,percent of total billed charges,,,90,,11.25,percent of total billed charges,,,,,,,no IP contract,,80,,10,percent of total billed charges,,,,,,,no IP contract,,50,,6.25,percent of total billed charges,,,,,,no IP contract,,,78,,9.75,percent of total billed charges,,,70,,8.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.13,3324,
68180-0722-20 - cefdinir 125 mg/5 mL REC P,68180-0722-20,NDC,,,,inpatient,1,ML,12.5,7.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.63,percent of total billed charges,,,85,,10.63,percent of total billed charges,,,49,,6.13,percent of total billed charges,,,90,,11.25,percent of total billed charges,,,,,,,no IP contract,,80,,10,percent of total billed charges,,,,,,,no IP contract,,50,,6.25,percent of total billed charges,,,,,,no IP contract,,,78,,9.75,percent of total billed charges,,,70,,8.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.13,3324,
68180-0779-01 - zolpidem 6.25 mg ER Ta,68180-0779-01,NDC,,,,inpatient,1,EA,56.3,33.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,45.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,47.86,percent of total billed charges,,,85,,47.86,percent of total billed charges,,,49,,27.59,percent of total billed charges,,,90,,50.67,percent of total billed charges,,,,,,,no IP contract,,80,,45.04,percent of total billed charges,,,,,,,no IP contract,,50,,28.15,percent of total billed charges,,,,,,no IP contract,,,78,,43.91,percent of total billed charges,,,70,,39.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.59,3324,
68220-0112-10 - hyoscyamine 0.125 mg Tab,68220-0112-10,NDC,,,,inpatient,1,EA,12.8,7.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.88,percent of total billed charges,,,85,,10.88,percent of total billed charges,,,49,,6.27,percent of total billed charges,,,90,,11.52,percent of total billed charges,,,,,,,no IP contract,,80,,10.24,percent of total billed charges,,,,,,,no IP contract,,50,,6.4,percent of total billed charges,,,,,,no IP contract,,,78,,9.98,percent of total billed charges,,,70,,8.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.27,3324,
68220-0142-10 - hydrocortisone-pramoxine topical 1%-1% Foam,68220-0142-10,NDC,,,,inpatient,1,UN,542.05,325.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,439.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,460.74,percent of total billed charges,,,85,,460.74,percent of total billed charges,,,49,,265.6,percent of total billed charges,,,90,,487.85,percent of total billed charges,,,,,,,no IP contract,,80,,433.64,percent of total billed charges,,,,,,,no IP contract,,50,,271.03,percent of total billed charges,,,,,,no IP contract,,,78,,422.8,percent of total billed charges,,,70,,379.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,265.6,3324,
68308-0152-15 - nystatin topical 100000 units/g Powde,68308-0152-15,NDC,,,,inpatient,1,UN,234.15,140.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,189.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,199.03,percent of total billed charges,,,85,,199.03,percent of total billed charges,,,49,,114.73,percent of total billed charges,,,90,,210.74,percent of total billed charges,,,,,,,no IP contract,,80,,187.32,percent of total billed charges,,,,,,,no IP contract,,50,,117.08,percent of total billed charges,,,,,,no IP contract,,,78,,182.64,percent of total billed charges,,,70,,163.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,114.73,3324,
68308-0405-47 - acetaminophen-oxyCODONE 325 mg-5 mg Tab,68308-0405-47,NDC,,,,inpatient,1,EA,16.25,9.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.81,percent of total billed charges,,,85,,13.81,percent of total billed charges,,,49,,7.96,percent of total billed charges,,,90,,14.63,percent of total billed charges,,,,,,,no IP contract,,80,,13,percent of total billed charges,,,,,,,no IP contract,,50,,8.13,percent of total billed charges,,,,,,no IP contract,,,78,,12.68,percent of total billed charges,,,70,,11.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.96,3324,
68382-0005-14 - topiramate 25 mg Cap,68382-0005-14,NDC,,,,inpatient,1,EA,27.05,16.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.99,percent of total billed charges,,,85,,22.99,percent of total billed charges,,,49,,13.25,percent of total billed charges,,,90,,24.35,percent of total billed charges,,,,,,,no IP contract,,80,,21.64,percent of total billed charges,,,,,,,no IP contract,,50,,13.53,percent of total billed charges,,,,,,no IP contract,,,78,,21.1,percent of total billed charges,,,70,,18.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.25,3324,
68382-0035-16 - venlafaxine 75 mg ER Ca,68382-0035-16,NDC,,,,inpatient,1,EA,40.95,24.57,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34.81,percent of total billed charges,,,85,,34.81,percent of total billed charges,,,49,,20.07,percent of total billed charges,,,90,,36.86,percent of total billed charges,,,,,,,no IP contract,,80,,32.76,percent of total billed charges,,,,,,,no IP contract,,50,,20.48,percent of total billed charges,,,,,,no IP contract,,,78,,31.94,percent of total billed charges,,,70,,28.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.07,3324,
68382-0036-16 - venlafaxine 150 mg ER Ca,68382-0036-16,NDC,,,,inpatient,1,EA,44.2,26.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,35.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,37.57,percent of total billed charges,,,85,,37.57,percent of total billed charges,,,49,,21.66,percent of total billed charges,,,90,,39.78,percent of total billed charges,,,,,,,no IP contract,,80,,35.36,percent of total billed charges,,,,,,,no IP contract,,50,,22.1,percent of total billed charges,,,,,,no IP contract,,,78,,34.48,percent of total billed charges,,,70,,30.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.66,3324,
68382-0051-01 - meloxicam 15 mg Tab,68382-0051-01,NDC,,,,inpatient,1,EA,42.3,25.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,35.96,percent of total billed charges,,,85,,35.96,percent of total billed charges,,,49,,20.73,percent of total billed charges,,,90,,38.07,percent of total billed charges,,,,,,,no IP contract,,80,,33.84,percent of total billed charges,,,,,,,no IP contract,,50,,21.15,percent of total billed charges,,,,,,no IP contract,,,78,,32.99,percent of total billed charges,,,70,,29.61,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.73,3324,
68382-0096-01 - hydroxychloroquine 200 mg Tab,68382-0096-01,NDC,,,,inpatient,1,EA,13.6,8.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.56,percent of total billed charges,,,85,,11.56,percent of total billed charges,,,49,,6.66,percent of total billed charges,,,90,,12.24,percent of total billed charges,,,,,,,no IP contract,,80,,10.88,percent of total billed charges,,,,,,,no IP contract,,50,,6.8,percent of total billed charges,,,,,,no IP contract,,,78,,10.61,percent of total billed charges,,,70,,9.52,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.66,3324,
bromocriptine 5 mg Cap,68382-0110-06,NDC,,,,inpatient,1,EA,77.85,46.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,63.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,66.17,percent of total billed charges,,,85,,66.17,percent of total billed charges,,,49,,38.15,percent of total billed charges,,,90,,70.07,percent of total billed charges,,,,,,,no IP contract,,80,,62.28,percent of total billed charges,,,,,,,no IP contract,,50,,38.93,percent of total billed charges,,,,,,no IP contract,,,78,,60.72,percent of total billed charges,,,70,,54.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,38.15,3324,
68382-0121-16 - amLODIPine 2.5 mg Tab,68382-0121-16,NDC,,,,inpatient,1,EA,17.6,10.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.96,percent of total billed charges,,,85,,14.96,percent of total billed charges,,,49,,8.62,percent of total billed charges,,,90,,15.84,percent of total billed charges,,,,,,,no IP contract,,80,,14.08,percent of total billed charges,,,,,,,no IP contract,,50,,8.8,percent of total billed charges,,,,,,no IP contract,,,78,,13.73,percent of total billed charges,,,70,,12.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.62,3324,
68382-0132-01 - tamsulosin 0.4 mg Cap,68382-0132-01,NDC,,,,inpatient,1,EA,37.45,22.47,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.83,percent of total billed charges,,,85,,31.83,percent of total billed charges,,,49,,18.35,percent of total billed charges,,,90,,33.71,percent of total billed charges,,,,,,,no IP contract,,80,,29.96,percent of total billed charges,,,,,,,no IP contract,,50,,18.73,percent of total billed charges,,,,,,no IP contract,,,78,,29.21,percent of total billed charges,,,70,,26.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.35,3324,
68382-0135-16 - losartan 25 mg Tab,68382-0135-16,NDC,,,,inpatient,1,EA,17.2,10.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.62,percent of total billed charges,,,85,,14.62,percent of total billed charges,,,49,,8.43,percent of total billed charges,,,90,,15.48,percent of total billed charges,,,,,,,no IP contract,,80,,13.76,percent of total billed charges,,,,,,,no IP contract,,50,,8.6,percent of total billed charges,,,,,,no IP contract,,,78,,13.42,percent of total billed charges,,,70,,12.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.43,3324,
68382-0136-16 - losartan 50 mg Tab,68382-0136-16,NDC,,,,inpatient,1,EA,21.8,13.08,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.53,percent of total billed charges,,,85,,18.53,percent of total billed charges,,,49,,10.68,percent of total billed charges,,,90,,19.62,percent of total billed charges,,,,,,,no IP contract,,80,,17.44,percent of total billed charges,,,,,,,no IP contract,,50,,10.9,percent of total billed charges,,,,,,no IP contract,,,78,,17,percent of total billed charges,,,70,,15.26,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.68,3324,
68382-0139-14 - topiramate 50 mg Tab,68382-0139-14,NDC,,,,inpatient,1,EA,44.35,26.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,35.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,37.7,percent of total billed charges,,,85,,37.7,percent of total billed charges,,,49,,21.73,percent of total billed charges,,,90,,39.92,percent of total billed charges,,,,,,,no IP contract,,80,,35.48,percent of total billed charges,,,,,,,no IP contract,,50,,22.18,percent of total billed charges,,,,,,no IP contract,,,78,,34.59,percent of total billed charges,,,70,,31.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.73,3324,
68382-0140-14 - topiramate 100 mg Tab,68382-0140-14,NDC,,,,inpatient,1,EA,59.15,35.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,47.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,50.28,percent of total billed charges,,,85,,50.28,percent of total billed charges,,,49,,28.98,percent of total billed charges,,,90,,53.24,percent of total billed charges,,,,,,,no IP contract,,80,,47.32,percent of total billed charges,,,,,,,no IP contract,,50,,29.58,percent of total billed charges,,,,,,no IP contract,,,78,,46.14,percent of total billed charges,,,70,,41.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,28.98,3324,
68382-0141-14 - topiramate 200 mg Tab,68382-0141-14,NDC,,,,inpatient,1,EA,68.6,41.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,55.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,58.31,percent of total billed charges,,,85,,58.31,percent of total billed charges,,,49,,33.61,percent of total billed charges,,,90,,61.74,percent of total billed charges,,,,,,,no IP contract,,80,,54.88,percent of total billed charges,,,,,,,no IP contract,,50,,34.3,percent of total billed charges,,,,,,no IP contract,,,78,,53.51,percent of total billed charges,,,70,,48.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,33.61,3324,
ramipril 5 mg Cap,68382-0146-01,NDC,,,,inpatient,1,EA,18.85,11.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.02,percent of total billed charges,,,85,,16.02,percent of total billed charges,,,49,,9.24,percent of total billed charges,,,90,,16.97,percent of total billed charges,,,,,,,no IP contract,,80,,15.08,percent of total billed charges,,,,,,,no IP contract,,50,,9.43,percent of total billed charges,,,,,,no IP contract,,,78,,14.7,percent of total billed charges,,,70,,13.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.24,3324,
68382-0309-30 - nitroglycerin 0.2 mg/hr ER Fi,68382-0309-30,NDC,,,,inpatient,1,EA,25.05,15.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.29,percent of total billed charges,,,85,,21.29,percent of total billed charges,,,49,,12.27,percent of total billed charges,,,90,,22.55,percent of total billed charges,,,,,,,no IP contract,,80,,20.04,percent of total billed charges,,,,,,,no IP contract,,50,,12.53,percent of total billed charges,,,,,,no IP contract,,,78,,19.54,percent of total billed charges,,,70,,17.54,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.27,3324,
68382-0310-30 - nitroglycerin 0.4 mg/hr ER Fi,68382-0310-30,NDC,,,,inpatient,1,UN,27.3,16.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.21,percent of total billed charges,,,85,,23.21,percent of total billed charges,,,49,,13.38,percent of total billed charges,,,90,,24.57,percent of total billed charges,,,,,,,no IP contract,,80,,21.84,percent of total billed charges,,,,,,,no IP contract,,50,,13.65,percent of total billed charges,,,,,,no IP contract,,,78,,21.29,percent of total billed charges,,,70,,19.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.38,3324,
68382-0370-01 - nystatin topical 100000 units/g Powde,68382-0370-01,NDC,,,,inpatient,1,UN,242.9,145.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,196.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,206.47,percent of total billed charges,,,85,,206.47,percent of total billed charges,,,49,,119.02,percent of total billed charges,,,90,,218.61,percent of total billed charges,,,,,,,no IP contract,,80,,194.32,percent of total billed charges,,,,,,,no IP contract,,50,,121.45,percent of total billed charges,,,,,,no IP contract,,,78,,189.46,percent of total billed charges,,,70,,170.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,119.02,3324,
68382-0411-01 - omeprazole 10 mg DR Ca,68382-0411-01,NDC,,,,inpatient,1,EA,33.25,19.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,26.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,28.26,percent of total billed charges,,,85,,28.26,percent of total billed charges,,,49,,16.29,percent of total billed charges,,,90,,29.93,percent of total billed charges,,,,,,,no IP contract,,80,,26.6,percent of total billed charges,,,,,,,no IP contract,,50,,16.63,percent of total billed charges,,,,,,no IP contract,,,78,,25.94,percent of total billed charges,,,70,,23.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.29,3324,
68382-0444-05 - famotidine  20 mg Susp,68382-0444-05,NDC,,,,inpatient,1,ML,34.9,20.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.67,percent of total billed charges,,,85,,29.67,percent of total billed charges,,,49,,17.1,percent of total billed charges,,,90,,31.41,percent of total billed charges,,,,,,,no IP contract,,80,,27.92,percent of total billed charges,,,,,,,no IP contract,,50,,17.45,percent of total billed charges,,,,,,no IP contract,,,78,,27.22,percent of total billed charges,,,70,,24.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.1,3324,
68382-0512-01 - amantadine 100 mg Cap,68382-0512-01,NDC,,,,inpatient,1,EA,19.9,11.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.92,percent of total billed charges,,,85,,16.92,percent of total billed charges,,,49,,9.75,percent of total billed charges,,,90,,17.91,percent of total billed charges,,,,,,,no IP contract,,80,,15.92,percent of total billed charges,,,,,,,no IP contract,,50,,9.95,percent of total billed charges,,,,,,no IP contract,,,78,,15.52,percent of total billed charges,,,70,,13.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.75,3324,
68382-0520-01 - sirolimus 0.5 mg Tab,68382-0520-01,NDC,,,,inpatient,1,EA,72.6,43.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,58.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,61.71,percent of total billed charges,,,85,,61.71,percent of total billed charges,,,49,,35.57,percent of total billed charges,,,90,,65.34,percent of total billed charges,,,,,,,no IP contract,,80,,58.08,percent of total billed charges,,,,,,,no IP contract,,50,,36.3,percent of total billed charges,,,,,,no IP contract,,,78,,56.63,percent of total billed charges,,,70,,50.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,35.57,3324,
68382-0528-60 - cholestyramine 4 g/9 g REC P,68382-0528-60,NDC,,,,inpatient,1,UN,30.6,18.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.01,percent of total billed charges,,,85,,26.01,percent of total billed charges,,,49,,14.99,percent of total billed charges,,,90,,27.54,percent of total billed charges,,,,,,,no IP contract,,80,,24.48,percent of total billed charges,,,,,,,no IP contract,,50,,15.3,percent of total billed charges,,,,,,no IP contract,,,78,,23.87,percent of total billed charges,,,70,,21.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.99,3324,
dilTIAZem 300 mg/24 hours ER Ca,68382-0598-16,NDC,,,,inpatient,1,EA,24.95,14.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.21,percent of total billed charges,,,85,,21.21,percent of total billed charges,,,49,,12.23,percent of total billed charges,,,90,,22.46,percent of total billed charges,,,,,,,no IP contract,,80,,19.96,percent of total billed charges,,,,,,,no IP contract,,50,,12.48,percent of total billed charges,,,,,,no IP contract,,,78,,19.46,percent of total billed charges,,,70,,17.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.23,3324,
68382-0659-06 - pyridostigmine 60 mg Tab,68382-0659-06,NDC,,,,inpatient,1,EA,14,8.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.9,percent of total billed charges,,,85,,11.9,percent of total billed charges,,,49,,6.86,percent of total billed charges,,,90,,12.6,percent of total billed charges,,,,,,,no IP contract,,80,,11.2,percent of total billed charges,,,,,,,no IP contract,,50,,7,percent of total billed charges,,,,,,no IP contract,,,78,,10.92,percent of total billed charges,,,70,,9.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.86,3324,
68382-0711-19 - mesalamine 1.2 g EC Ta,68382-0711-19,NDC,,,,inpatient,1,EA,84.2,50.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,68.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,71.57,percent of total billed charges,,,85,,71.57,percent of total billed charges,,,49,,41.26,percent of total billed charges,,,90,,75.78,percent of total billed charges,,,,,,,no IP contract,,80,,67.36,percent of total billed charges,,,,,,,no IP contract,,50,,42.1,percent of total billed charges,,,,,,no IP contract,,,78,,65.68,percent of total billed charges,,,70,,58.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,41.26,3324,
68382-0720-01 - budesonide 3 mg DR Ca,68382-0720-01,NDC,,,,inpatient,1,EA,201.45,120.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,163.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,171.23,percent of total billed charges,,,85,,171.23,percent of total billed charges,,,49,,98.71,percent of total billed charges,,,90,,181.31,percent of total billed charges,,,,,,,no IP contract,,80,,161.16,percent of total billed charges,,,,,,,no IP contract,,50,,100.73,percent of total billed charges,,,,,,no IP contract,,,78,,157.13,percent of total billed charges,,,70,,141.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,98.71,3324,
68382-0739-01 - midodrine 10 mg Tab,68382-0739-01,NDC,,,,inpatient,1,EA,42.3,25.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,35.96,percent of total billed charges,,,85,,35.96,percent of total billed charges,,,49,,20.73,percent of total billed charges,,,90,,38.07,percent of total billed charges,,,,,,,no IP contract,,80,,33.84,percent of total billed charges,,,,,,,no IP contract,,50,,21.15,percent of total billed charges,,,,,,no IP contract,,,78,,32.99,percent of total billed charges,,,70,,29.61,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.73,3324,
ezetimibe 10 mg Tab,68382-0773-16,NDC,,,,inpatient,1,EA,93.65,56.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,75.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,79.6,percent of total billed charges,,,85,,79.6,percent of total billed charges,,,49,,45.89,percent of total billed charges,,,90,,84.29,percent of total billed charges,,,,,,,no IP contract,,80,,74.92,percent of total billed charges,,,,,,,no IP contract,,50,,46.83,percent of total billed charges,,,,,,no IP contract,,,78,,73.05,percent of total billed charges,,,70,,65.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,45.89,3324,
doxazosin 4 mg Tab,68382-0785-01,NDC,,,,inpatient,1,EA,15.1,9.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.84,percent of total billed charges,,,85,,12.84,percent of total billed charges,,,49,,7.4,percent of total billed charges,,,90,,13.59,percent of total billed charges,,,,,,,no IP contract,,80,,12.08,percent of total billed charges,,,,,,,no IP contract,,50,,7.55,percent of total billed charges,,,,,,no IP contract,,,78,,11.78,percent of total billed charges,,,70,,10.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.4,3324,
68382-0792-01 - acyclovir 800 mg Tab,68382-0792-01,NDC,,,,inpatient,1,EA,32.9,19.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,26.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,27.97,percent of total billed charges,,,85,,27.97,percent of total billed charges,,,49,,16.12,percent of total billed charges,,,90,,29.61,percent of total billed charges,,,,,,,no IP contract,,80,,26.32,percent of total billed charges,,,,,,,no IP contract,,50,,16.45,percent of total billed charges,,,,,,no IP contract,,,78,,25.66,percent of total billed charges,,,70,,23.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.12,3324,
68382-0799-01 - labetalol 200 mg Tab,68382-0799-01,NDC,,,,inpatient,1,EA,12.9,7.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.97,percent of total billed charges,,,85,,10.97,percent of total billed charges,,,49,,6.32,percent of total billed charges,,,90,,11.61,percent of total billed charges,,,,,,,no IP contract,,80,,10.32,percent of total billed charges,,,,,,,no IP contract,,50,,6.45,percent of total billed charges,,,,,,no IP contract,,,78,,10.06,percent of total billed charges,,,70,,9.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.32,3324,
68382-0800-01 - labetalol 300 mg Tab,68382-0800-01,NDC,,,,inpatient,1,EA,12.95,7.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.01,percent of total billed charges,,,85,,11.01,percent of total billed charges,,,49,,6.35,percent of total billed charges,,,90,,11.66,percent of total billed charges,,,,,,,no IP contract,,80,,10.36,percent of total billed charges,,,,,,,no IP contract,,50,,6.48,percent of total billed charges,,,,,,no IP contract,,,78,,10.1,percent of total billed charges,,,70,,9.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.35,3324,
68382-0916-01 - methylPREDNISolone 4 mg Tab,68382-0916-01,NDC,,,,inpatient,1,EA,16.95,10.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.41,percent of total billed charges,,,85,,14.41,percent of total billed charges,,,49,,8.31,percent of total billed charges,,,90,,15.26,percent of total billed charges,,,,,,,no IP contract,,80,,13.56,percent of total billed charges,,,,,,,no IP contract,,50,,8.48,percent of total billed charges,,,,,,no IP contract,,,78,,13.22,percent of total billed charges,,,70,,11.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.31,3324,
68382-0918-18 - methylPREDNISolone 16 mg Tab,68382-0918-18,NDC,,,,inpatient,1,EA,31.95,19.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,25.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,27.16,percent of total billed charges,,,85,,27.16,percent of total billed charges,,,49,,15.66,percent of total billed charges,,,90,,28.76,percent of total billed charges,,,,,,,no IP contract,,80,,25.56,percent of total billed charges,,,,,,,no IP contract,,50,,15.98,percent of total billed charges,,,,,,no IP contract,,,78,,24.92,percent of total billed charges,,,70,,22.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.66,3324,
68382-0982-06 - lamoTRIgine 200 mg ER Ta,68382-0982-06,NDC,,,,inpatient,1,EA,122.75,73.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,99.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,104.34,percent of total billed charges,,,85,,104.34,percent of total billed charges,,,49,,60.15,percent of total billed charges,,,90,,110.48,percent of total billed charges,,,,,,,no IP contract,,80,,98.2,percent of total billed charges,,,,,,,no IP contract,,50,,61.38,percent of total billed charges,,,,,,no IP contract,,,78,,95.75,percent of total billed charges,,,70,,85.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,60.15,3324,
68462-0102-30 - fluconazole 100 mg Tab,68462-0102-30,NDC,,,,inpatient,1,EA,73.8,44.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,59.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,62.73,percent of total billed charges,,,85,,62.73,percent of total billed charges,,,49,,36.16,percent of total billed charges,,,90,,66.42,percent of total billed charges,,,,,,,no IP contract,,80,,59.04,percent of total billed charges,,,,,,,no IP contract,,50,,36.9,percent of total billed charges,,,,,,no IP contract,,,78,,57.56,percent of total billed charges,,,70,,51.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.16,3324,
68462-0105-30 - ondansetron 4 mg Tab,68462-0105-30,NDC,,,,inpatient,1,EA,198.6,119.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,160.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,168.81,percent of total billed charges,,,85,,168.81,percent of total billed charges,,,49,,97.31,percent of total billed charges,,,90,,178.74,percent of total billed charges,,,,,,,no IP contract,,80,,158.88,percent of total billed charges,,,,,,,no IP contract,,50,,99.3,percent of total billed charges,,,,,,no IP contract,,,78,,154.91,percent of total billed charges,,,70,,139.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,97.31,3324,
68462-0127-01 - gabapentin 800 mg Tab,68462-0127-01,NDC,,,,inpatient,1,EA,27.9,16.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.72,percent of total billed charges,,,85,,23.72,percent of total billed charges,,,49,,13.67,percent of total billed charges,,,90,,25.11,percent of total billed charges,,,,,,,no IP contract,,80,,22.32,percent of total billed charges,,,,,,,no IP contract,,50,,13.95,percent of total billed charges,,,,,,no IP contract,,,78,,21.76,percent of total billed charges,,,70,,19.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.67,3324,
68462-0128-01 - zonisamide 25 mg Cap,68462-0128-01,NDC,,,,inpatient,1,EA,8.2,4.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.97,percent of total billed charges,,,85,,6.97,percent of total billed charges,,,49,,4.02,percent of total billed charges,,,90,,7.38,percent of total billed charges,,,,,,,no IP contract,,80,,6.56,percent of total billed charges,,,,,,,no IP contract,,50,,4.1,percent of total billed charges,,,,,,no IP contract,,,78,,6.4,percent of total billed charges,,,70,,5.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.02,3324,
68462-0129-01 - zonisamide 50 mg Cap,68462-0129-01,NDC,,,,inpatient,1,EA,12.55,7.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.67,percent of total billed charges,,,85,,10.67,percent of total billed charges,,,49,,6.15,percent of total billed charges,,,90,,11.3,percent of total billed charges,,,,,,,no IP contract,,80,,10.04,percent of total billed charges,,,,,,,no IP contract,,50,,6.28,percent of total billed charges,,,,,,no IP contract,,,78,,9.79,percent of total billed charges,,,70,,8.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.15,3324,
68462-0142-01 - clindamycin 75 mg Cap,68462-0142-01,NDC,,,,inpatient,1,EA,9.55,5.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.12,percent of total billed charges,,,85,,8.12,percent of total billed charges,,,49,,4.68,percent of total billed charges,,,90,,8.6,percent of total billed charges,,,,,,,no IP contract,,80,,7.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.78,percent of total billed charges,,,,,,no IP contract,,,78,,7.45,percent of total billed charges,,,70,,6.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.68,3324,
68462-0153-60 - topiramate 50 mg Tab,68462-0153-60,NDC,,,,inpatient,1,EA,38.95,23.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.11,percent of total billed charges,,,85,,33.11,percent of total billed charges,,,49,,19.09,percent of total billed charges,,,90,,35.06,percent of total billed charges,,,,,,,no IP contract,,80,,31.16,percent of total billed charges,,,,,,,no IP contract,,50,,19.48,percent of total billed charges,,,,,,no IP contract,,,78,,30.38,percent of total billed charges,,,70,,27.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.09,3324,
68462-0157-13 - ondansetron 4 mg DIS T,68462-0157-13,NDC,,,,inpatient,1,EA,187.55,112.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,151.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,159.42,percent of total billed charges,,,85,,159.42,percent of total billed charges,,,49,,91.9,percent of total billed charges,,,90,,168.8,percent of total billed charges,,,,,,,no IP contract,,80,,150.04,percent of total billed charges,,,,,,,no IP contract,,50,,93.78,percent of total billed charges,,,,,,no IP contract,,,78,,146.29,percent of total billed charges,,,70,,131.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,91.9,3324,
68462-0180-22 - mupirocin topical 2% Ointm,68462-0180-22,NDC,,,,inpatient,1,UN,364.75,218.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,295.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,310.04,percent of total billed charges,,,85,,310.04,percent of total billed charges,,,49,,178.73,percent of total billed charges,,,90,,328.28,percent of total billed charges,,,,,,,no IP contract,,80,,291.8,percent of total billed charges,,,,,,,no IP contract,,50,,182.38,percent of total billed charges,,,,,,no IP contract,,,78,,284.51,percent of total billed charges,,,70,,255.33,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,178.73,3324,
68462-0188-01 - naproxen 250 mg Tab,68462-0188-01,NDC,,,,inpatient,1,EA,10.05,6.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.54,percent of total billed charges,,,85,,8.54,percent of total billed charges,,,49,,4.92,percent of total billed charges,,,90,,9.05,percent of total billed charges,,,,,,,no IP contract,,80,,8.04,percent of total billed charges,,,,,,,no IP contract,,50,,5.03,percent of total billed charges,,,,,,no IP contract,,,78,,7.84,percent of total billed charges,,,70,,7.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.92,3324,
68462-0190-01 - naproxen 500 mg Tab,68462-0190-01,NDC,,,,inpatient,1,EA,14.15,8.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.03,percent of total billed charges,,,85,,12.03,percent of total billed charges,,,49,,6.93,percent of total billed charges,,,90,,12.74,percent of total billed charges,,,,,,,no IP contract,,80,,11.32,percent of total billed charges,,,,,,,no IP contract,,50,,7.08,percent of total billed charges,,,,,,no IP contract,,,78,,11.04,percent of total billed charges,,,70,,9.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.93,3324,
68462-0197-90 - pravastatin 40 mg Tab,68462-0197-90,NDC,,,,inpatient,1,EA,41.9,25.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,35.62,percent of total billed charges,,,85,,35.62,percent of total billed charges,,,49,,20.53,percent of total billed charges,,,90,,37.71,percent of total billed charges,,,,,,,no IP contract,,80,,33.52,percent of total billed charges,,,,,,,no IP contract,,50,,20.95,percent of total billed charges,,,,,,no IP contract,,,78,,32.68,percent of total billed charges,,,70,,29.33,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.53,3324,
68462-0253-01 - rOPINIRole 0.25 mg Tab,68462-0253-01,NDC,,,,inpatient,1,EA,23.8,14.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.23,percent of total billed charges,,,85,,20.23,percent of total billed charges,,,49,,11.66,percent of total billed charges,,,90,,21.42,percent of total billed charges,,,,,,,no IP contract,,80,,19.04,percent of total billed charges,,,,,,,no IP contract,,50,,11.9,percent of total billed charges,,,,,,no IP contract,,,78,,18.56,percent of total billed charges,,,70,,16.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.66,3324,
68462-0255-01 - rOPINIRole 1 mg Tab,68462-0255-01,NDC,,,,inpatient,1,EA,23.8,14.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.23,percent of total billed charges,,,85,,20.23,percent of total billed charges,,,49,,11.66,percent of total billed charges,,,90,,21.42,percent of total billed charges,,,,,,,no IP contract,,80,,19.04,percent of total billed charges,,,,,,,no IP contract,,50,,11.9,percent of total billed charges,,,,,,no IP contract,,,78,,18.56,percent of total billed charges,,,70,,16.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.66,3324,
68462-0258-01 - rOPINIRole 4 mg Tab,68462-0258-01,NDC,,,,inpatient,1,EA,24.5,14.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.83,percent of total billed charges,,,85,,20.83,percent of total billed charges,,,49,,12.01,percent of total billed charges,,,90,,22.05,percent of total billed charges,,,,,,,no IP contract,,80,,19.6,percent of total billed charges,,,,,,,no IP contract,,50,,12.25,percent of total billed charges,,,,,,no IP contract,,,78,,19.11,percent of total billed charges,,,70,,17.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.01,3324,
68462-0260-01 - verapamil 240 mg/12 hours ER Ta,68462-0260-01,NDC,,,,inpatient,1,EA,16.85,10.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.32,percent of total billed charges,,,85,,14.32,percent of total billed charges,,,49,,8.26,percent of total billed charges,,,90,,15.17,percent of total billed charges,,,,,,,no IP contract,,80,,13.48,percent of total billed charges,,,,,,,no IP contract,,50,,8.43,percent of total billed charges,,,,,,no IP contract,,,78,,13.14,percent of total billed charges,,,70,,11.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.26,3324,
68462-0263-90 - rosuvastatin 20 mg Tab,68462-0263-90,NDC,,,,inpatient,1,EA,74.9,44.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63.67,percent of total billed charges,,,85,,63.67,percent of total billed charges,,,49,,36.7,percent of total billed charges,,,90,,67.41,percent of total billed charges,,,,,,,no IP contract,,80,,59.92,percent of total billed charges,,,,,,,no IP contract,,50,,37.45,percent of total billed charges,,,,,,no IP contract,,,78,,58.42,percent of total billed charges,,,70,,52.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.7,3324,
68462-0292-01 - verapamil 120 mg/12 hours ER Ta,68462-0292-01,NDC,,,,inpatient,1,EA,12.35,7.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.5,percent of total billed charges,,,85,,10.5,percent of total billed charges,,,49,,6.05,percent of total billed charges,,,90,,11.12,percent of total billed charges,,,,,,,no IP contract,,80,,9.88,percent of total billed charges,,,,,,,no IP contract,,50,,6.18,percent of total billed charges,,,,,,no IP contract,,,78,,9.63,percent of total billed charges,,,70,,8.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.05,3324,
68462-0293-01 - verapamil 180 mg/12 hours ER Ta,68462-0293-01,NDC,,,,inpatient,1,EA,15.25,9.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.96,percent of total billed charges,,,85,,12.96,percent of total billed charges,,,49,,7.47,percent of total billed charges,,,90,,13.73,percent of total billed charges,,,,,,,no IP contract,,80,,12.2,percent of total billed charges,,,,,,,no IP contract,,50,,7.63,percent of total billed charges,,,,,,no IP contract,,,78,,11.9,percent of total billed charges,,,70,,10.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.47,3324,
68462-0298-55 - betamethasone-clotrimazole topical 0.05%-1% Cream,68462-0298-55,NDC,,,,inpatient,1,UN,1017.55,610.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,824.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,864.92,percent of total billed charges,,,85,,864.92,percent of total billed charges,,,49,,498.6,percent of total billed charges,,,90,,915.8,percent of total billed charges,,,,,,,no IP contract,,80,,814.04,percent of total billed charges,,,,,,,no IP contract,,50,,508.78,percent of total billed charges,,,,,,no IP contract,,,78,,793.69,percent of total billed charges,,,70,,712.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,498.6,3324,
68462-0299-17 - alclometasone topical 0.05% Ointm,68462-0299-17,NDC,,,,inpatient,1,UN,1693.55,1016.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1371.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1439.52,percent of total billed charges,,,85,,1439.52,percent of total billed charges,,,49,,829.84,percent of total billed charges,,,90,,1524.2,percent of total billed charges,,,,,,,no IP contract,,80,,1354.84,percent of total billed charges,,,,,,,no IP contract,,50,,846.78,percent of total billed charges,,,,,,no IP contract,,,78,,1320.97,percent of total billed charges,,,70,,1185.49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,829.84,3324,
68462-0314-35 - nystatin-triamcinolone topical 100000 units/g-0.1% Cream,68462-0314-35,NDC,,,,inpatient,1,UN,1338.7,803.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1084.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1137.9,percent of total billed charges,,,85,,1137.9,percent of total billed charges,,,49,,655.96,percent of total billed charges,,,90,,1204.83,percent of total billed charges,,,,,,,no IP contract,,80,,1070.96,percent of total billed charges,,,,,,,no IP contract,,50,,669.35,percent of total billed charges,,,,,,no IP contract,,,78,,1044.19,percent of total billed charges,,,70,,937.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,655.96,3324,
68462-0325-60 - indomethacin 75 mg ER Ca,68462-0325-60,NDC,,,,inpatient,1,EA,28,16.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.8,percent of total billed charges,,,85,,23.8,percent of total billed charges,,,49,,13.72,percent of total billed charges,,,90,,25.2,percent of total billed charges,,,,,,,no IP contract,,80,,22.4,percent of total billed charges,,,,,,,no IP contract,,50,,14,percent of total billed charges,,,,,,no IP contract,,,78,,21.84,percent of total billed charges,,,70,,19.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.72,3324,
indomethacin 75 mg ER Ca,68462-0325-90,NDC,,,,inpatient,1,EA,28,16.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.8,percent of total billed charges,,,85,,23.8,percent of total billed charges,,,49,,13.72,percent of total billed charges,,,90,,25.2,percent of total billed charges,,,,,,,no IP contract,,80,,22.4,percent of total billed charges,,,,,,,no IP contract,,50,,14,percent of total billed charges,,,,,,no IP contract,,,78,,21.84,percent of total billed charges,,,70,,19.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.72,3324,
68462-0381-60 - riluzole 50 mg Tab,68462-0381-60,NDC,,,,inpatient,1,EA,263.8,158.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,213.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,224.23,percent of total billed charges,,,85,,224.23,percent of total billed charges,,,49,,129.26,percent of total billed charges,,,90,,237.42,percent of total billed charges,,,,,,,no IP contract,,80,,211.04,percent of total billed charges,,,,,,,no IP contract,,50,,131.9,percent of total billed charges,,,,,,no IP contract,,,78,,205.76,percent of total billed charges,,,70,,184.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,129.26,3324,
68462-0382-01 - eszopiclone 1 mg Tab,68462-0382-01,NDC,,,,inpatient,1,EA,106.65,63.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,86.39,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,90.65,percent of total billed charges,,,85,,90.65,percent of total billed charges,,,49,,52.26,percent of total billed charges,,,90,,95.99,percent of total billed charges,,,,,,,no IP contract,,80,,85.32,percent of total billed charges,,,,,,,no IP contract,,50,,53.33,percent of total billed charges,,,,,,no IP contract,,,78,,83.19,percent of total billed charges,,,70,,74.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,52.26,3324,
68462-0437-30 - olmesartan 20 mg Tab,68462-0437-30,NDC,,,,inpatient,1,EA,58.75,35.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,47.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,49.94,percent of total billed charges,,,85,,49.94,percent of total billed charges,,,49,,28.79,percent of total billed charges,,,90,,52.88,percent of total billed charges,,,,,,,no IP contract,,80,,47,percent of total billed charges,,,,,,,no IP contract,,50,,29.38,percent of total billed charges,,,,,,no IP contract,,,78,,45.83,percent of total billed charges,,,70,,41.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,28.79,3324,
68462-0438-90 - olmesartan 40 mg Tab,68462-0438-90,NDC,,,,inpatient,1,EA,80.2,48.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,64.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,68.17,percent of total billed charges,,,85,,68.17,percent of total billed charges,,,49,,39.3,percent of total billed charges,,,90,,72.18,percent of total billed charges,,,,,,,no IP contract,,80,,64.16,percent of total billed charges,,,,,,,no IP contract,,50,,40.1,percent of total billed charges,,,,,,no IP contract,,,78,,62.56,percent of total billed charges,,,70,,56.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,39.3,3324,
68462-0447-18 - sevelamer  800 mg Tab,68462-0447-18,NDC,,,,inpatient,1,EA,67.75,40.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,54.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,57.59,percent of total billed charges,,,85,,57.59,percent of total billed charges,,,49,,33.2,percent of total billed charges,,,90,,60.98,percent of total billed charges,,,,,,,no IP contract,,80,,54.2,percent of total billed charges,,,,,,,no IP contract,,50,,33.88,percent of total billed charges,,,,,,no IP contract,,,78,,52.85,percent of total billed charges,,,70,,47.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,33.2,3324,
68462-0461-60 - trospium 20 mg Tab,68462-0461-60,NDC,,,,inpatient,1,EA,26.4,15.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.44,percent of total billed charges,,,85,,22.44,percent of total billed charges,,,49,,12.94,percent of total billed charges,,,90,,23.76,percent of total billed charges,,,,,,,no IP contract,,80,,21.12,percent of total billed charges,,,,,,,no IP contract,,50,,13.2,percent of total billed charges,,,,,,no IP contract,,,78,,20.59,percent of total billed charges,,,70,,18.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.94,3324,
68462-0501-65 - calcipotriene topical 0.005% Cream 60 gm 1 gm Cream,68462-0501-65,NDC,,,,inpatient,1,UN,5087.2,3052.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4120.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4324.12,percent of total billed charges,,,85,,4324.12,percent of total billed charges,,,49,,2492.73,percent of total billed charges,,,90,,4578.48,percent of total billed charges,,,,,,,no IP contract,,80,,4069.76,percent of total billed charges,,,,,,,no IP contract,,50,,2543.6,percent of total billed charges,,,,,,no IP contract,,,78,,3968.02,percent of total billed charges,,,70,,3561.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4578.48,
68462-0534-35 - tacrolimus topical 0.1% Ointm,68462-0534-35,NDC,,,,inpatient,1,UN,2178.35,1307.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1764.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1851.6,percent of total billed charges,,,85,,1851.6,percent of total billed charges,,,49,,1067.39,percent of total billed charges,,,90,,1960.52,percent of total billed charges,,,,,,,no IP contract,,80,,1742.68,percent of total billed charges,,,,,,,no IP contract,,50,,1089.18,percent of total billed charges,,,,,,no IP contract,,,78,,1699.11,percent of total billed charges,,,70,,1524.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
68462-0534-65 - tacrolimus topical 0.1% Ointm,68462-0534-65,NDC,,,,inpatient,1,UN,2178.35,1307.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1764.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1851.6,percent of total billed charges,,,85,,1851.6,percent of total billed charges,,,49,,1067.39,percent of total billed charges,,,90,,1960.52,percent of total billed charges,,,,,,,no IP contract,,80,,1742.68,percent of total billed charges,,,,,,,no IP contract,,50,,1089.18,percent of total billed charges,,,,,,no IP contract,,,78,,1699.11,percent of total billed charges,,,70,,1524.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
68462-0572-30 - voriconazole 50 mg Tab,68462-0572-30,NDC,,,,inpatient,1,EA,161.85,97.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,131.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,137.57,percent of total billed charges,,,85,,137.57,percent of total billed charges,,,49,,79.31,percent of total billed charges,,,90,,145.67,percent of total billed charges,,,,,,,no IP contract,,80,,129.48,percent of total billed charges,,,,,,,no IP contract,,50,,80.93,percent of total billed charges,,,,,,no IP contract,,,78,,126.24,percent of total billed charges,,,70,,113.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,79.31,3324,
68462-0573-30 - voriconazole 200 mg Tab,68462-0573-30,NDC,,,,inpatient,1,EA,636,381.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,515.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,540.6,percent of total billed charges,,,85,,540.6,percent of total billed charges,,,49,,311.64,percent of total billed charges,,,90,,572.4,percent of total billed charges,,,,,,,no IP contract,,80,,508.8,percent of total billed charges,,,,,,,no IP contract,,50,,318,percent of total billed charges,,,,,,no IP contract,,,78,,496.08,percent of total billed charges,,,70,,445.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,311.64,3324,
68462-0639-45 - nitroglycerin 0.4 mg Tab,68462-0639-45,NDC,,,,inpatient,1,EA,208.55,125.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,168.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,177.27,percent of total billed charges,,,85,,177.27,percent of total billed charges,,,49,,102.19,percent of total billed charges,,,90,,187.7,percent of total billed charges,,,,,,,no IP contract,,80,,166.84,percent of total billed charges,,,,,,,no IP contract,,50,,104.28,percent of total billed charges,,,,,,no IP contract,,,78,,162.67,percent of total billed charges,,,70,,145.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,102.19,3324,
68462-0682-01 - sirolimus 0.5 mg Tab,68462-0682-01,NDC,,,,inpatient,1,EA,71.15,42.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,57.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,60.48,percent of total billed charges,,,85,,60.48,percent of total billed charges,,,49,,34.86,percent of total billed charges,,,90,,64.04,percent of total billed charges,,,,,,,no IP contract,,80,,56.92,percent of total billed charges,,,,,,,no IP contract,,50,,35.58,percent of total billed charges,,,,,,no IP contract,,,78,,55.5,percent of total billed charges,,,70,,49.81,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,34.86,3324,
68462-0714-08 - rufinamide 400 mg Tab,68462-0714-08,NDC,,,,inpatient,1,EA,230.5,138.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,186.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,195.93,percent of total billed charges,,,85,,195.93,percent of total billed charges,,,49,,112.95,percent of total billed charges,,,90,,207.45,percent of total billed charges,,,,,,,no IP contract,,80,,184.4,percent of total billed charges,,,,,,,no IP contract,,50,,115.25,percent of total billed charges,,,,,,no IP contract,,,78,,179.79,percent of total billed charges,,,70,,161.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,112.95,3324,
68462-0721-01 - theophylline 300 mg ER Ta,68462-0721-01,NDC,,,,inpatient,1,EA,38,22.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.3,percent of total billed charges,,,85,,32.3,percent of total billed charges,,,49,,18.62,percent of total billed charges,,,90,,34.2,percent of total billed charges,,,,,,,no IP contract,,80,,30.4,percent of total billed charges,,,,,,,no IP contract,,50,,19,percent of total billed charges,,,,,,no IP contract,,,78,,29.64,percent of total billed charges,,,70,,26.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.62,3324,
68462-0799-35 - nystatin-triamcinolone topical 100000 units/g-0.1% Ointm,68462-0799-35,NDC,,,,inpatient,1,UN,1338.7,803.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1084.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1137.9,percent of total billed charges,,,85,,1137.9,percent of total billed charges,,,49,,655.96,percent of total billed charges,,,90,,1204.83,percent of total billed charges,,,,,,,no IP contract,,80,,1070.96,percent of total billed charges,,,,,,,no IP contract,,50,,669.35,percent of total billed charges,,,,,,no IP contract,,,78,,1044.19,percent of total billed charges,,,70,,937.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,655.96,3324,
68462-0861-01 - chlorproMAZINE 10 mg Tab,68462-0861-01,NDC,,,,inpatient,1,EA,38,22.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.3,percent of total billed charges,,,85,,32.3,percent of total billed charges,,,49,,18.62,percent of total billed charges,,,90,,34.2,percent of total billed charges,,,,,,,no IP contract,,80,,30.4,percent of total billed charges,,,,,,,no IP contract,,50,,19,percent of total billed charges,,,,,,no IP contract,,,78,,29.64,percent of total billed charges,,,70,,26.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.62,3324,
68462-0862-01 - chlorproMAZINE 25 mg Tab,68462-0862-01,NDC,,,,inpatient,1,EA,64.55,38.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,52.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,54.87,percent of total billed charges,,,85,,54.87,percent of total billed charges,,,49,,31.63,percent of total billed charges,,,90,,58.1,percent of total billed charges,,,,,,,no IP contract,,80,,51.64,percent of total billed charges,,,,,,,no IP contract,,50,,32.28,percent of total billed charges,,,,,,no IP contract,,,78,,50.35,percent of total billed charges,,,70,,45.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.63,3324,
68546-0229-56 - rasagiline 1 mg Tab,68546-0229-56,NDC,,,,inpatient,1,EA,94.85,56.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,76.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,80.62,percent of total billed charges,,,85,,80.62,percent of total billed charges,,,49,,46.48,percent of total billed charges,,,90,,85.37,percent of total billed charges,,,,,,,no IP contract,,80,,75.88,percent of total billed charges,,,,,,,no IP contract,,50,,47.43,percent of total billed charges,,,,,,no IP contract,,,78,,73.98,percent of total billed charges,,,70,,66.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,46.48,3324,
68585-0005-75 - magnesium chloride 64 mg ER Ta,68585-0005-75,NDC,,,,inpatient,1,EA,4.8,2.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.08,percent of total billed charges,,,85,,4.08,percent of total billed charges,,,49,,2.35,percent of total billed charges,,,90,,4.32,percent of total billed charges,,,,,,,no IP contract,,80,,3.84,percent of total billed charges,,,,,,,no IP contract,,50,,2.4,percent of total billed charges,,,,,,no IP contract,,,78,,3.74,percent of total billed charges,,,70,,3.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.35,3324,
68669-0135-05 - levofloxacin ophthalmic 0.5% Soln,68669-0135-05,NDC,,,,inpatient,1,UN,453,271.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,366.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,385.05,percent of total billed charges,,,85,,385.05,percent of total billed charges,,,49,,221.97,percent of total billed charges,,,90,,407.7,percent of total billed charges,,,,,,,no IP contract,,80,,362.4,percent of total billed charges,,,,,,,no IP contract,,50,,226.5,percent of total billed charges,,,,,,no IP contract,,,78,,353.34,percent of total billed charges,,,70,,317.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,221.97,3324,
68682-0006-10 - dilTIAZem 30 mg Tab,68682-0006-10,NDC,,,,inpatient,1,EA,11.75,7.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.99,percent of total billed charges,,,85,,9.99,percent of total billed charges,,,49,,5.76,percent of total billed charges,,,90,,10.58,percent of total billed charges,,,,,,,no IP contract,,80,,9.4,percent of total billed charges,,,,,,,no IP contract,,50,,5.88,percent of total billed charges,,,,,,no IP contract,,,78,,9.17,percent of total billed charges,,,70,,8.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.76,3324,
68682-0007-10 - dilTIAZem 60 mg Tab,68682-0007-10,NDC,,,,inpatient,1,EA,16.3,9.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.86,percent of total billed charges,,,85,,13.86,percent of total billed charges,,,49,,7.99,percent of total billed charges,,,90,,14.67,percent of total billed charges,,,,,,,no IP contract,,80,,13.04,percent of total billed charges,,,,,,,no IP contract,,50,,8.15,percent of total billed charges,,,,,,no IP contract,,,78,,12.71,percent of total billed charges,,,70,,11.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.99,3324,
68682-0008-10 - dilTIAZem 90 mg Tab,68682-0008-10,NDC,,,,inpatient,1,EA,23.25,13.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.76,percent of total billed charges,,,85,,19.76,percent of total billed charges,,,49,,11.39,percent of total billed charges,,,90,,20.93,percent of total billed charges,,,,,,,no IP contract,,80,,18.6,percent of total billed charges,,,,,,,no IP contract,,50,,11.63,percent of total billed charges,,,,,,no IP contract,,,78,,18.14,percent of total billed charges,,,70,,16.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.39,3324,
68682-0101-10 - pentoxifylline 400 mg ER Ta,68682-0101-10,NDC,,,,inpatient,1,EA,7.25,4.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.16,percent of total billed charges,,,85,,6.16,percent of total billed charges,,,49,,3.55,percent of total billed charges,,,90,,6.53,percent of total billed charges,,,,,,,no IP contract,,80,,5.8,percent of total billed charges,,,,,,,no IP contract,,50,,3.63,percent of total billed charges,,,,,,no IP contract,,,78,,5.66,percent of total billed charges,,,70,,5.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.55,3324,
68682-0200-25 - carbidopa 25 mg Tab,68682-0200-25,NDC,,,,inpatient,1,EA,17.75,10.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.09,percent of total billed charges,,,85,,15.09,percent of total billed charges,,,49,,8.7,percent of total billed charges,,,90,,15.98,percent of total billed charges,,,,,,,no IP contract,,80,,14.2,percent of total billed charges,,,,,,,no IP contract,,50,,8.88,percent of total billed charges,,,,,,no IP contract,,,78,,13.85,percent of total billed charges,,,70,,12.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.7,3324,
68682-0299-10 - loteprednol ophthalmic 0.5% Susp,68682-0299-10,NDC,,,,inpatient,1,UN,4281.7,2569.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3468.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3639.45,percent of total billed charges,,,85,,3639.45,percent of total billed charges,,,49,,2098.03,percent of total billed charges,,,90,,3853.53,percent of total billed charges,,,,,,,no IP contract,,80,,3425.36,percent of total billed charges,,,,,,,no IP contract,,50,,2140.85,percent of total billed charges,,,,,,no IP contract,,,78,,3339.73,percent of total billed charges,,,70,,2997.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3853.53,
68682-0301-30 - pyridostigmine 180 mg ER Ta,68682-0301-30,NDC,,,,inpatient,1,EA,201.2,120.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,162.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,171.02,percent of total billed charges,,,85,,171.02,percent of total billed charges,,,49,,98.59,percent of total billed charges,,,90,,181.08,percent of total billed charges,,,,,,,no IP contract,,80,,160.96,percent of total billed charges,,,,,,,no IP contract,,50,,100.6,percent of total billed charges,,,,,,no IP contract,,,78,,156.94,percent of total billed charges,,,70,,140.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,98.59,3324,
68682-0464-10 - brinzolamide ophthalmic 1% Susp,68682-0464-10,NDC,,,,inpatient,1,UN,3093.8,1856.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2505.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2629.73,percent of total billed charges,,,85,,2629.73,percent of total billed charges,,,49,,1515.96,percent of total billed charges,,,90,,2784.42,percent of total billed charges,,,,,,,no IP contract,,80,,2475.04,percent of total billed charges,,,,,,,no IP contract,,50,,1546.9,percent of total billed charges,,,,,,no IP contract,,,78,,2413.16,percent of total billed charges,,,70,,2165.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
68682-0650-20 - diazePAM 2.5 mg Kit,68682-0650-20,NDC,,,,inpatient,1,EA,2561.9,1537.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2075.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2177.62,percent of total billed charges,,,85,,2177.62,percent of total billed charges,,,49,,1255.33,percent of total billed charges,,,90,,2305.71,percent of total billed charges,,,,,,,no IP contract,,80,,2049.52,percent of total billed charges,,,,,,,no IP contract,,50,,1280.95,percent of total billed charges,,,,,,no IP contract,,,78,,1998.28,percent of total billed charges,,,70,,1793.33,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
68682-0652-20 - diazePAM 10 mg Kit,68682-0652-20,NDC,,,,inpatient,1,EA,3038.05,1822.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2460.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2582.34,percent of total billed charges,,,85,,2582.34,percent of total billed charges,,,49,,1488.64,percent of total billed charges,,,90,,2734.25,percent of total billed charges,,,,,,,no IP contract,,80,,2430.44,percent of total billed charges,,,,,,,no IP contract,,50,,1519.03,percent of total billed charges,,,,,,no IP contract,,,78,,2369.68,percent of total billed charges,,,70,,2126.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
68682-0655-20 - diazePAM 20 mg Kit,68682-0655-20,NDC,,,,inpatient,1,EA,3038.05,1822.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2460.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2582.34,percent of total billed charges,,,85,,2582.34,percent of total billed charges,,,49,,1488.64,percent of total billed charges,,,90,,2734.25,percent of total billed charges,,,,,,,no IP contract,,80,,2430.44,percent of total billed charges,,,,,,,no IP contract,,50,,1519.03,percent of total billed charges,,,,,,no IP contract,,,78,,2369.68,percent of total billed charges,,,70,,2126.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
68682-0711-01 - enalapril 5 mg Tab,68682-0711-01,NDC,,,,inpatient,1,EA,9.15,5.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.78,percent of total billed charges,,,85,,7.78,percent of total billed charges,,,49,,4.48,percent of total billed charges,,,90,,8.24,percent of total billed charges,,,,,,,no IP contract,,80,,7.32,percent of total billed charges,,,,,,,no IP contract,,50,,4.58,percent of total billed charges,,,,,,no IP contract,,,78,,7.14,percent of total billed charges,,,70,,6.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.48,3324,
68682-0712-01 - enalapril 10 mg Tab,68682-0712-01,NDC,,,,inpatient,1,EA,9.4,5.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.99,percent of total billed charges,,,85,,7.99,percent of total billed charges,,,49,,4.61,percent of total billed charges,,,90,,8.46,percent of total billed charges,,,,,,,no IP contract,,80,,7.52,percent of total billed charges,,,,,,,no IP contract,,50,,4.7,percent of total billed charges,,,,,,no IP contract,,,78,,7.33,percent of total billed charges,,,70,,6.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.61,3324,
68682-0813-05 - timolol ophthalmic maleate 0.5% Soln,68682-0813-05,NDC,,,,inpatient,1,UN,119.2,71.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,96.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,101.32,percent of total billed charges,,,85,,101.32,percent of total billed charges,,,49,,58.41,percent of total billed charges,,,90,,107.28,percent of total billed charges,,,,,,,no IP contract,,80,,95.36,percent of total billed charges,,,,,,,no IP contract,,50,,59.6,percent of total billed charges,,,,,,no IP contract,,,78,,92.98,percent of total billed charges,,,70,,83.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.41,3324,
68774-0303-35 - clarithromycin 250 mg/5 mL REC P,68774-0303-35,NDC,,,,inpatient,1,ML,12.35,7.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.5,percent of total billed charges,,,85,,10.5,percent of total billed charges,,,49,,6.05,percent of total billed charges,,,90,,11.12,percent of total billed charges,,,,,,,no IP contract,,80,,9.88,percent of total billed charges,,,,,,,no IP contract,,50,,6.18,percent of total billed charges,,,,,,no IP contract,,,78,,9.63,percent of total billed charges,,,70,,8.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.05,3324,
68850-0012-01 - ethambutol 400 mg Tab,68850-0012-01,NDC,,,,inpatient,1,EA,18.15,10.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.43,percent of total billed charges,,,85,,15.43,percent of total billed charges,,,49,,8.89,percent of total billed charges,,,90,,16.34,percent of total billed charges,,,,,,,no IP contract,,80,,14.52,percent of total billed charges,,,,,,,no IP contract,,50,,9.08,percent of total billed charges,,,,,,no IP contract,,,78,,14.16,percent of total billed charges,,,70,,12.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.89,3324,
68982-0643-02 - albumin human 25% Soln,68982-0643-02,NDC,,,,inpatient,100,ML,1016.35,609.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,823.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,863.9,percent of total billed charges,,,85,,863.9,percent of total billed charges,,,49,,498.01,percent of total billed charges,,,90,,914.72,percent of total billed charges,,,,,,,no IP contract,,80,,813.08,percent of total billed charges,,,,,,,no IP contract,,50,,508.18,percent of total billed charges,,,,,,no IP contract,,,78,,792.75,percent of total billed charges,,,70,,711.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,498.01,3324,
immune globulin intravenous 10% Soln,68982-0850-02,NDC,,,,inpatient,1,EA,4040.2,2424.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3272.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3434.17,percent of total billed charges,,,85,,3434.17,percent of total billed charges,,,49,,1979.7,percent of total billed charges,,,90,,3636.18,percent of total billed charges,,,,,,,no IP contract,,80,,3232.16,percent of total billed charges,,,,,,,no IP contract,,50,,2020.1,percent of total billed charges,,,,,,no IP contract,,,78,,3151.36,percent of total billed charges,,,70,,2828.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3636.18,
immune globulin intravenous 10% Soln,68982-0850-03,NDC,,,,inpatient,1,EA,8005.3,4803.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6484.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6804.51,percent of total billed charges,,,85,,6804.51,percent of total billed charges,,,49,,3922.6,percent of total billed charges,,,90,,7204.77,percent of total billed charges,,,,,,,no IP contract,,80,,6404.24,percent of total billed charges,,,,,,,no IP contract,,50,,4002.65,percent of total billed charges,,,,,,no IP contract,,,78,,6244.13,percent of total billed charges,,,70,,5603.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,7204.77,
immune globulin intravenous 10% Soln,68982-0850-04,NDC,,,,inpatient,1,EA,15935.45,9561.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12907.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13545.13,percent of total billed charges,,,85,,13545.13,percent of total billed charges,,,49,,7808.37,percent of total billed charges,,,90,,14341.91,percent of total billed charges,,,,,,,no IP contract,,80,,12748.36,percent of total billed charges,,,,,,,no IP contract,,50,,7967.73,percent of total billed charges,,,,,,no IP contract,,,78,,12429.65,percent of total billed charges,,,70,,11154.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,14341.91,
immune globulin intravenous 10% Soln,68982-0850-05,NDC,,,,inpatient,1,EA,23865.6,14319.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19331.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20285.76,percent of total billed charges,,,85,,20285.76,percent of total billed charges,,,49,,11694.14,percent of total billed charges,,,90,,21479.04,percent of total billed charges,,,,,,,no IP contract,,80,,19092.48,percent of total billed charges,,,,,,,no IP contract,,50,,11932.8,percent of total billed charges,,,,,,no IP contract,,,78,,18615.17,percent of total billed charges,,,70,,16705.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,21479.04,
68992-3010-03 - tacrolimus 1 mg ER Ta,68992-3010-03,NDC,,,,inpatient,1,EA,40.95,24.57,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,34.81,percent of total billed charges,,,85,,34.81,percent of total billed charges,,,49,,20.07,percent of total billed charges,,,90,,36.86,percent of total billed charges,,,,,,,no IP contract,,80,,32.76,percent of total billed charges,,,,,,,no IP contract,,50,,20.48,percent of total billed charges,,,,,,no IP contract,,,78,,31.94,percent of total billed charges,,,70,,28.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.07,3324,
68992-3040-03 - tacrolimus 4 mg ER Ta,68992-3040-03,NDC,,,,inpatient,1,EA,152.25,91.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,123.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,129.41,percent of total billed charges,,,85,,129.41,percent of total billed charges,,,49,,74.6,percent of total billed charges,,,90,,137.03,percent of total billed charges,,,,,,,no IP contract,,80,,121.8,percent of total billed charges,,,,,,,no IP contract,,50,,76.13,percent of total billed charges,,,,,,no IP contract,,,78,,118.76,percent of total billed charges,,,70,,106.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,74.6,3324,
68992-3075-03 - tacrolimus 0.75 mg ER Ta,68992-3075-03,NDC,,,,inpatient,1,EA,31.65,18.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,25.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.9,percent of total billed charges,,,85,,26.9,percent of total billed charges,,,49,,15.51,percent of total billed charges,,,90,,28.49,percent of total billed charges,,,,,,,no IP contract,,80,,25.32,percent of total billed charges,,,,,,,no IP contract,,50,,15.83,percent of total billed charges,,,,,,no IP contract,,,78,,24.69,percent of total billed charges,,,70,,22.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.51,3324,
69076-0105-03 - tenofovir 300 mg Tab,69076-0105-03,NDC,,,,inpatient,1,EA,309.05,185.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,250.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,262.69,percent of total billed charges,,,85,,262.69,percent of total billed charges,,,49,,151.43,percent of total billed charges,,,90,,278.15,percent of total billed charges,,,,,,,no IP contract,,80,,247.24,percent of total billed charges,,,,,,,no IP contract,,50,,154.53,percent of total billed charges,,,,,,no IP contract,,,78,,241.06,percent of total billed charges,,,70,,216.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,151.43,3324,
69076-0913-02 - mercaptopurine 50 mg Tab,69076-0913-02,NDC,,,,inpatient,1,EA,52.95,31.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,42.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,45.01,percent of total billed charges,,,85,,45.01,percent of total billed charges,,,49,,25.95,percent of total billed charges,,,90,,47.66,percent of total billed charges,,,,,,,no IP contract,,80,,42.36,percent of total billed charges,,,,,,,no IP contract,,50,,26.48,percent of total billed charges,,,,,,no IP contract,,,78,,41.3,percent of total billed charges,,,70,,37.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.95,3324,
69097-0126-15 - amLODIPine 2.5 mg Tab,69097-0126-15,NDC,,,,inpatient,1,EA,17.6,10.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.96,percent of total billed charges,,,85,,14.96,percent of total billed charges,,,49,,8.62,percent of total billed charges,,,90,,15.84,percent of total billed charges,,,,,,,no IP contract,,80,,14.08,percent of total billed charges,,,,,,,no IP contract,,50,,8.8,percent of total billed charges,,,,,,no IP contract,,,78,,13.73,percent of total billed charges,,,70,,12.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.62,3324,
69097-0152-03 - lamoTRIgine 200 mg Tab,69097-0152-03,NDC,,,,inpatient,1,EA,48.9,29.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,39.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,41.57,percent of total billed charges,,,85,,41.57,percent of total billed charges,,,49,,23.96,percent of total billed charges,,,90,,44.01,percent of total billed charges,,,,,,,no IP contract,,80,,39.12,percent of total billed charges,,,,,,,no IP contract,,50,,24.45,percent of total billed charges,,,,,,no IP contract,,,78,,38.14,percent of total billed charges,,,70,,34.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.96,3324,
arformoterol 15 mcg/2 mL Soln,69097-0168-64,NDC,,,,inpatient,1,EA,178,106.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,144.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,151.3,percent of total billed charges,,,85,,151.3,percent of total billed charges,,,49,,87.22,percent of total billed charges,,,90,,160.2,percent of total billed charges,,,,,,,no IP contract,,80,,142.4,percent of total billed charges,,,,,,,no IP contract,,50,,89,percent of total billed charges,,,,,,no IP contract,,,78,,138.84,percent of total billed charges,,,70,,124.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,87.22,3324,
69097-0210-02 - efavirenz/emtricitabine/tenofovir 600 mg-200 mg-300 mg Tab,69097-0210-02,NDC,,,,inpatient,1,EA,908.55,545.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,735.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,772.27,percent of total billed charges,,,85,,772.27,percent of total billed charges,,,49,,445.19,percent of total billed charges,,,90,,817.7,percent of total billed charges,,,,,,,no IP contract,,80,,726.84,percent of total billed charges,,,,,,,no IP contract,,50,,454.28,percent of total billed charges,,,,,,no IP contract,,,78,,708.67,percent of total billed charges,,,70,,635.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,445.19,3324,
69097-0316-02 - exemestane 25 mg Tab,69097-0316-02,NDC,,,,inpatient,1,EA,107.5,64.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,87.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,91.38,percent of total billed charges,,,85,,91.38,percent of total billed charges,,,49,,52.68,percent of total billed charges,,,90,,96.75,percent of total billed charges,,,,,,,no IP contract,,80,,86,percent of total billed charges,,,,,,,no IP contract,,50,,53.75,percent of total billed charges,,,,,,no IP contract,,,78,,83.85,percent of total billed charges,,,70,,75.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,52.68,3324,
69097-0318-53 - budesonide 0.25 mg/2 mL Susp,69097-0318-53,NDC,,,,inpatient,2,ML,88.2,52.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,71.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,74.97,percent of total billed charges,,,85,,74.97,percent of total billed charges,,,49,,43.22,percent of total billed charges,,,90,,79.38,percent of total billed charges,,,,,,,no IP contract,,80,,70.56,percent of total billed charges,,,,,,,no IP contract,,50,,44.1,percent of total billed charges,,,,,,no IP contract,,,78,,68.8,percent of total billed charges,,,70,,61.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,43.22,3324,
69097-0318-87 - budesonide  0.25 mg / 2 mL Soln,69097-0318-87,NDC,,,,inpatient,2,ML,56.7,34.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,45.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,48.2,percent of total billed charges,,,85,,48.2,percent of total billed charges,,,49,,27.78,percent of total billed charges,,,90,,51.03,percent of total billed charges,,,,,,,no IP contract,,80,,45.36,percent of total billed charges,,,,,,,no IP contract,,50,,28.35,percent of total billed charges,,,,,,no IP contract,,,78,,44.23,percent of total billed charges,,,70,,39.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.78,3324,
69097-0410-02 - cinacalcet 30 mg Tab,69097-0410-02,NDC,,,,inpatient,1,EA,139.95,83.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,113.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,118.96,percent of total billed charges,,,85,,118.96,percent of total billed charges,,,49,,68.58,percent of total billed charges,,,90,,125.96,percent of total billed charges,,,,,,,no IP contract,,80,,111.96,percent of total billed charges,,,,,,,no IP contract,,50,,69.98,percent of total billed charges,,,,,,no IP contract,,,78,,109.16,percent of total billed charges,,,70,,97.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,68.58,3324,
69097-0533-02 - tenofovir 300 mg Tab,69097-0533-02,NDC,,,,inpatient,1,EA,48.1,28.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,38.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,40.89,percent of total billed charges,,,85,,40.89,percent of total billed charges,,,49,,23.57,percent of total billed charges,,,90,,43.29,percent of total billed charges,,,,,,,no IP contract,,80,,38.48,percent of total billed charges,,,,,,,no IP contract,,50,,24.05,percent of total billed charges,,,,,,no IP contract,,,78,,37.52,percent of total billed charges,,,70,,33.67,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.57,3324,
69097-0679-05 - pregabalin 75 mg Cap,69097-0679-05,NDC,,,,inpatient,1,EA,61.6,36.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,49.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,52.36,percent of total billed charges,,,85,,52.36,percent of total billed charges,,,49,,30.18,percent of total billed charges,,,90,,55.44,percent of total billed charges,,,,,,,no IP contract,,80,,49.28,percent of total billed charges,,,,,,,no IP contract,,50,,30.8,percent of total billed charges,,,,,,no IP contract,,,78,,48.05,percent of total billed charges,,,70,,43.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,30.18,3324,
69097-0681-05 - pregabalin 100 mg Cap,69097-0681-05,NDC,,,,inpatient,1,EA,66,39.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,53.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.1,percent of total billed charges,,,85,,56.1,percent of total billed charges,,,49,,32.34,percent of total billed charges,,,90,,59.4,percent of total billed charges,,,,,,,no IP contract,,80,,52.8,percent of total billed charges,,,,,,,no IP contract,,50,,33,percent of total billed charges,,,,,,no IP contract,,,78,,51.48,percent of total billed charges,,,70,,46.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.34,3324,
69097-0683-05 - pregabalin 200 mg Cap,69097-0683-05,NDC,,,,inpatient,1,EA,66.15,39.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,53.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.23,percent of total billed charges,,,85,,56.23,percent of total billed charges,,,49,,32.41,percent of total billed charges,,,90,,59.54,percent of total billed charges,,,,,,,no IP contract,,80,,52.92,percent of total billed charges,,,,,,,no IP contract,,50,,33.08,percent of total billed charges,,,,,,no IP contract,,,78,,51.6,percent of total billed charges,,,70,,46.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.41,3324,
69097-0685-05 - pregabalin 300 mg Cap,69097-0685-05,NDC,,,,inpatient,1,EA,66.15,39.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,53.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.23,percent of total billed charges,,,85,,56.23,percent of total billed charges,,,49,,32.41,percent of total billed charges,,,90,,59.54,percent of total billed charges,,,,,,,no IP contract,,80,,52.92,percent of total billed charges,,,,,,,no IP contract,,50,,33.08,percent of total billed charges,,,,,,no IP contract,,,78,,51.6,percent of total billed charges,,,70,,46.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.41,3324,
69097-0846-07 - cyclobenzaprine 10 mg Tab,69097-0846-07,NDC,,,,inpatient,1,EA,13.05,7.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.09,percent of total billed charges,,,85,,11.09,percent of total billed charges,,,49,,6.39,percent of total billed charges,,,90,,11.75,percent of total billed charges,,,,,,,no IP contract,,80,,10.44,percent of total billed charges,,,,,,,no IP contract,,50,,6.53,percent of total billed charges,,,,,,no IP contract,,,78,,10.18,percent of total billed charges,,,70,,9.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.39,3324,
69097-0848-05 - escitalopram 10 mg Tab,69097-0848-05,NDC,,,,inpatient,1,EA,45.5,27.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,38.68,percent of total billed charges,,,85,,38.68,percent of total billed charges,,,49,,22.3,percent of total billed charges,,,90,,40.95,percent of total billed charges,,,,,,,no IP contract,,80,,36.4,percent of total billed charges,,,,,,,no IP contract,,50,,22.75,percent of total billed charges,,,,,,no IP contract,,,78,,35.49,percent of total billed charges,,,70,,31.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.3,3324,
69097-0854-12 - naproxen 375 mg Tab,69097-0854-12,NDC,,,,inpatient,1,EA,11.6,6.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.86,percent of total billed charges,,,85,,9.86,percent of total billed charges,,,49,,5.68,percent of total billed charges,,,90,,10.44,percent of total billed charges,,,,,,,no IP contract,,80,,9.28,percent of total billed charges,,,,,,,no IP contract,,50,,5.8,percent of total billed charges,,,,,,no IP contract,,,78,,9.05,percent of total billed charges,,,70,,8.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.68,3324,
69097-0862-83 - calcium acetate 667 mg Cap,69097-0862-83,NDC,,,,inpatient,1,EA,9.55,5.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.12,percent of total billed charges,,,85,,8.12,percent of total billed charges,,,49,,4.68,percent of total billed charges,,,90,,8.6,percent of total billed charges,,,,,,,no IP contract,,80,,7.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.78,percent of total billed charges,,,,,,no IP contract,,,78,,7.45,percent of total billed charges,,,70,,6.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.68,3324,
69097-0868-07 - nadolol 40 mg Tab,69097-0868-07,NDC,,,,inpatient,1,EA,35.3,21.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,30.01,percent of total billed charges,,,85,,30.01,percent of total billed charges,,,49,,17.3,percent of total billed charges,,,90,,31.77,percent of total billed charges,,,,,,,no IP contract,,80,,28.24,percent of total billed charges,,,,,,,no IP contract,,50,,17.65,percent of total billed charges,,,,,,no IP contract,,,78,,27.53,percent of total billed charges,,,70,,24.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.3,3324,
69097-0956-05 - pregabalin 75 mg Cap,69097-0956-05,NDC,,,,inpatient,1,EA,61.6,36.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,49.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,52.36,percent of total billed charges,,,85,,52.36,percent of total billed charges,,,49,,30.18,percent of total billed charges,,,90,,55.44,percent of total billed charges,,,,,,,no IP contract,,80,,49.28,percent of total billed charges,,,,,,,no IP contract,,50,,30.8,percent of total billed charges,,,,,,no IP contract,,,78,,48.05,percent of total billed charges,,,70,,43.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,30.18,3324,
vilazodone 20 mg Tab,69097-0981-02,NDC,,,,inpatient,1,EA,99.05,59.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,80.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,84.19,percent of total billed charges,,,85,,84.19,percent of total billed charges,,,49,,48.53,percent of total billed charges,,,90,,89.15,percent of total billed charges,,,,,,,no IP contract,,80,,79.24,percent of total billed charges,,,,,,,no IP contract,,50,,49.53,percent of total billed charges,,,,,,no IP contract,,,78,,77.26,percent of total billed charges,,,70,,69.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,48.53,3324,
69238-1054-01 - chlorproMAZINE 10 mg Tab,69238-1054-01,NDC,,,,inpatient,1,EA,38,22.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.3,percent of total billed charges,,,85,,32.3,percent of total billed charges,,,49,,18.62,percent of total billed charges,,,90,,34.2,percent of total billed charges,,,,,,,no IP contract,,80,,30.4,percent of total billed charges,,,,,,,no IP contract,,50,,19,percent of total billed charges,,,,,,no IP contract,,,78,,29.64,percent of total billed charges,,,70,,26.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.62,3324,
69238-1056-01 - chlorproMAZINE 25 mg Tab,69238-1056-01,NDC,,,,inpatient,1,EA,64.55,38.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,52.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,54.87,percent of total billed charges,,,85,,54.87,percent of total billed charges,,,49,,31.63,percent of total billed charges,,,90,,58.1,percent of total billed charges,,,,,,,no IP contract,,80,,51.64,percent of total billed charges,,,,,,,no IP contract,,50,,32.28,percent of total billed charges,,,,,,no IP contract,,,78,,50.35,percent of total billed charges,,,70,,45.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.63,3324,
69238-1266-01 - oseltamivir 75 mg Cap,69238-1266-01,NDC,,,,inpatient,1,EA,126.75,76.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,102.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,107.74,percent of total billed charges,,,85,,107.74,percent of total billed charges,,,49,,62.11,percent of total billed charges,,,90,,114.08,percent of total billed charges,,,,,,,no IP contract,,80,,101.4,percent of total billed charges,,,,,,,no IP contract,,50,,63.38,percent of total billed charges,,,,,,no IP contract,,,78,,98.87,percent of total billed charges,,,70,,88.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,62.11,3324,
69238-1305-01 - cloBAZam 10 mg Tab,69238-1305-01,NDC,,,,inpatient,1,EA,169.75,101.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,137.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,144.29,percent of total billed charges,,,85,,144.29,percent of total billed charges,,,49,,83.18,percent of total billed charges,,,90,,152.78,percent of total billed charges,,,,,,,no IP contract,,80,,135.8,percent of total billed charges,,,,,,,no IP contract,,50,,84.88,percent of total billed charges,,,,,,no IP contract,,,78,,132.41,percent of total billed charges,,,70,,118.83,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,83.18,3324,
bumetanide 1 mg Tab,69238-1490-01,NDC,,,,inpatient,1,EA,25.3,15.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.51,percent of total billed charges,,,85,,21.51,percent of total billed charges,,,49,,12.4,percent of total billed charges,,,90,,22.77,percent of total billed charges,,,,,,,no IP contract,,80,,20.24,percent of total billed charges,,,,,,,no IP contract,,50,,12.65,percent of total billed charges,,,,,,no IP contract,,,78,,19.73,percent of total billed charges,,,70,,17.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.4,3324,
69238-1540-01 - ursodiol 300 mg Cap,69238-1540-01,NDC,,,,inpatient,1,EA,62.25,37.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,50.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,52.91,percent of total billed charges,,,85,,52.91,percent of total billed charges,,,49,,30.5,percent of total billed charges,,,90,,56.03,percent of total billed charges,,,,,,,no IP contract,,80,,49.8,percent of total billed charges,,,,,,,no IP contract,,50,,31.13,percent of total billed charges,,,,,,no IP contract,,,78,,48.56,percent of total billed charges,,,70,,43.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,30.5,3324,
69238-1544-01 - hydroxychloroquine 200 mg Tab,69238-1544-01,NDC,,,,inpatient,1,EA,38.5,23.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.73,percent of total billed charges,,,85,,32.73,percent of total billed charges,,,49,,18.87,percent of total billed charges,,,90,,34.65,percent of total billed charges,,,,,,,no IP contract,,80,,30.8,percent of total billed charges,,,,,,,no IP contract,,50,,19.25,percent of total billed charges,,,,,,no IP contract,,,78,,30.03,percent of total billed charges,,,70,,26.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.87,3324,
69238-1595-02 - mycophenolate mofetil 200 mg/mL REC P,69238-1595-02,NDC,,,,inpatient,1,ML,80.9,48.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,65.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,68.77,percent of total billed charges,,,85,,68.77,percent of total billed charges,,,49,,39.64,percent of total billed charges,,,90,,72.81,percent of total billed charges,,,,,,,no IP contract,,80,,64.72,percent of total billed charges,,,,,,,no IP contract,,50,,40.45,percent of total billed charges,,,,,,no IP contract,,,78,,63.1,percent of total billed charges,,,70,,56.63,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,39.64,3324,
69238-1615-03 - ofloxacin otic 0.3% Soln,69238-1615-03,NDC,,,,inpatient,1,UN,1319.95,791.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1069.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1121.96,percent of total billed charges,,,85,,1121.96,percent of total billed charges,,,49,,646.78,percent of total billed charges,,,90,,1187.96,percent of total billed charges,,,,,,,no IP contract,,80,,1055.96,percent of total billed charges,,,,,,,no IP contract,,50,,659.98,percent of total billed charges,,,,,,no IP contract,,,78,,1029.56,percent of total billed charges,,,70,,923.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,646.78,3324,
69238-1617-03 - potassium chloride 20 mEq REC P,69238-1617-03,NDC,,,,inpatient,1,UN,89.2,53.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,72.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,75.82,percent of total billed charges,,,85,,75.82,percent of total billed charges,,,49,,43.71,percent of total billed charges,,,90,,80.28,percent of total billed charges,,,,,,,no IP contract,,80,,71.36,percent of total billed charges,,,,,,,no IP contract,,50,,44.6,percent of total billed charges,,,,,,no IP contract,,,78,,69.58,percent of total billed charges,,,70,,62.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,43.71,3324,
69238-1830-01 - levothyroxine 25 mcg (0.025 mg) Tab,69238-1830-01,NDC,,,,inpatient,1,EA,7.3,4.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.21,percent of total billed charges,,,85,,6.21,percent of total billed charges,,,49,,3.58,percent of total billed charges,,,90,,6.57,percent of total billed charges,,,,,,,no IP contract,,80,,5.84,percent of total billed charges,,,,,,,no IP contract,,50,,3.65,percent of total billed charges,,,,,,no IP contract,,,78,,5.69,percent of total billed charges,,,70,,5.11,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.58,3324,
69238-1836-01 - levothyroxine 125 mcg (0.125 mg) Tab,69238-1836-01,NDC,,,,inpatient,1,EA,9.05,5.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.69,percent of total billed charges,,,85,,7.69,percent of total billed charges,,,49,,4.43,percent of total billed charges,,,90,,8.15,percent of total billed charges,,,,,,,no IP contract,,80,,7.24,percent of total billed charges,,,,,,,no IP contract,,50,,4.53,percent of total billed charges,,,,,,no IP contract,,,78,,7.06,percent of total billed charges,,,70,,6.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.43,3324,
69238-1837-01 - levothyroxine 137 mcg Tab,69238-1837-01,NDC,,,,inpatient,1,EA,9.15,5.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.78,percent of total billed charges,,,85,,7.78,percent of total billed charges,,,49,,4.48,percent of total billed charges,,,90,,8.24,percent of total billed charges,,,,,,,no IP contract,,80,,7.32,percent of total billed charges,,,,,,,no IP contract,,50,,4.58,percent of total billed charges,,,,,,no IP contract,,,78,,7.14,percent of total billed charges,,,70,,6.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.48,3324,
69238-1840-01 - levothyroxine 200 mcg (0.2 mg) Tab,69238-1840-01,NDC,,,,inpatient,1,EA,10.25,6.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.71,percent of total billed charges,,,85,,8.71,percent of total billed charges,,,49,,5.02,percent of total billed charges,,,90,,9.23,percent of total billed charges,,,,,,,no IP contract,,80,,8.2,percent of total billed charges,,,,,,,no IP contract,,50,,5.13,percent of total billed charges,,,,,,no IP contract,,,78,,8,percent of total billed charges,,,70,,7.18,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.02,3324,
69238-1841-01 - levothyroxine 300 mcg (0.3 mg) Tab,69238-1841-01,NDC,,,,inpatient,1,EA,12.5,7.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.63,percent of total billed charges,,,85,,10.63,percent of total billed charges,,,49,,6.13,percent of total billed charges,,,90,,11.25,percent of total billed charges,,,,,,,no IP contract,,80,,10,percent of total billed charges,,,,,,,no IP contract,,50,,6.25,percent of total billed charges,,,,,,no IP contract,,,78,,9.75,percent of total billed charges,,,70,,8.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.13,3324,
mupirocin topical 2% Cream,69238-2029-03,NDC,,,,inpatient,1,EA,3470.35,2082.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2810.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2949.8,percent of total billed charges,,,85,,2949.8,percent of total billed charges,,,49,,1700.47,percent of total billed charges,,,90,,3123.32,percent of total billed charges,,,,,,,no IP contract,,80,,2776.28,percent of total billed charges,,,,,,,no IP contract,,50,,1735.18,percent of total billed charges,,,,,,no IP contract,,,78,,2706.87,percent of total billed charges,,,70,,2429.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
propranolol 10 mg Tab,69238-2077-01,NDC,,,,inpatient,1,EA,7.1,4.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.04,percent of total billed charges,,,85,,6.04,percent of total billed charges,,,49,,3.48,percent of total billed charges,,,90,,6.39,percent of total billed charges,,,,,,,no IP contract,,80,,5.68,percent of total billed charges,,,,,,,no IP contract,,50,,3.55,percent of total billed charges,,,,,,no IP contract,,,78,,5.54,percent of total billed charges,,,70,,4.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.48,3324,
propranolol 20 mg Tab,69238-2078-01,NDC,,,,inpatient,1,EA,7.9,4.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.72,percent of total billed charges,,,85,,6.72,percent of total billed charges,,,49,,3.87,percent of total billed charges,,,90,,7.11,percent of total billed charges,,,,,,,no IP contract,,80,,6.32,percent of total billed charges,,,,,,,no IP contract,,50,,3.95,percent of total billed charges,,,,,,no IP contract,,,78,,6.16,percent of total billed charges,,,70,,5.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.87,3324,
propranolol 40 mg Tab,69238-2079-01,NDC,,,,inpatient,1,EA,9.55,5.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.12,percent of total billed charges,,,85,,8.12,percent of total billed charges,,,49,,4.68,percent of total billed charges,,,90,,8.6,percent of total billed charges,,,,,,,no IP contract,,80,,7.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.78,percent of total billed charges,,,,,,no IP contract,,,78,,7.45,percent of total billed charges,,,70,,6.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.68,3324,
69238-2296-01 - oxyCODONE 20 mg ER Ta,69238-2296-01,NDC,,,,inpatient,1,EA,83.5,50.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,67.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,70.98,percent of total billed charges,,,85,,70.98,percent of total billed charges,,,49,,40.92,percent of total billed charges,,,90,,75.15,percent of total billed charges,,,,,,,no IP contract,,80,,66.8,percent of total billed charges,,,,,,,no IP contract,,50,,41.75,percent of total billed charges,,,,,,no IP contract,,,78,,65.13,percent of total billed charges,,,70,,58.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,40.92,3324,
69292-0522-01 - captopril 12.5 mg Tab,69292-0522-01,NDC,,,,inpatient,1,EA,13.35,8.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.35,percent of total billed charges,,,85,,11.35,percent of total billed charges,,,49,,6.54,percent of total billed charges,,,90,,12.02,percent of total billed charges,,,,,,,no IP contract,,80,,10.68,percent of total billed charges,,,,,,,no IP contract,,50,,6.68,percent of total billed charges,,,,,,no IP contract,,,78,,10.41,percent of total billed charges,,,70,,9.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.54,3324,
69292-0562-01 - metOLazone 2.5 mg Tab,69292-0562-01,NDC,,,,inpatient,1,EA,24.35,14.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.7,percent of total billed charges,,,85,,20.7,percent of total billed charges,,,49,,11.93,percent of total billed charges,,,90,,21.92,percent of total billed charges,,,,,,,no IP contract,,80,,19.48,percent of total billed charges,,,,,,,no IP contract,,50,,12.18,percent of total billed charges,,,,,,no IP contract,,,78,,18.99,percent of total billed charges,,,70,,17.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.93,3324,
digoxin 50 mcg/mL (0.05 mg/mL) Elixi,69292-0605-60,NDC,,,,inpatient,1,mL,29.1,17.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.74,percent of total billed charges,,,85,,24.74,percent of total billed charges,,,49,,14.26,percent of total billed charges,,,90,,26.19,percent of total billed charges,,,,,,,no IP contract,,80,,23.28,percent of total billed charges,,,,,,,no IP contract,,50,,14.55,percent of total billed charges,,,,,,no IP contract,,,78,,22.7,percent of total billed charges,,,70,,20.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.26,3324,
69315-0117-01 - furosemide 40 mg Tab,69315-0117-01,NDC,,,,inpatient,1,EA,5.1,3.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.34,percent of total billed charges,,,85,,4.34,percent of total billed charges,,,49,,2.5,percent of total billed charges,,,90,,4.59,percent of total billed charges,,,,,,,no IP contract,,80,,4.08,percent of total billed charges,,,,,,,no IP contract,,50,,2.55,percent of total billed charges,,,,,,no IP contract,,,78,,3.98,percent of total billed charges,,,70,,3.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.5,3324,
69315-0127-01 - folic acid 1 mg Tab,69315-0127-01,NDC,,,,inpatient,1,EA,6.7,4.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.7,percent of total billed charges,,,85,,5.7,percent of total billed charges,,,49,,3.28,percent of total billed charges,,,90,,6.03,percent of total billed charges,,,,,,,no IP contract,,80,,5.36,percent of total billed charges,,,,,,,no IP contract,,50,,3.35,percent of total billed charges,,,,,,no IP contract,,,78,,5.23,percent of total billed charges,,,70,,4.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.28,3324,
69315-0304-10 - dorzolamide ophthalmic 2% Soln,69315-0304-10,NDC,,,,inpatient,1,UN,349.1,209.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,282.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,296.74,percent of total billed charges,,,85,,296.74,percent of total billed charges,,,49,,171.06,percent of total billed charges,,,90,,314.19,percent of total billed charges,,,,,,,no IP contract,,80,,279.28,percent of total billed charges,,,,,,,no IP contract,,50,,174.55,percent of total billed charges,,,,,,no IP contract,,,78,,272.3,percent of total billed charges,,,70,,244.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,171.06,3324,
69315-0306-15 - nystatin topical 100000 units/g Powde,69315-0306-15,NDC,,,,inpatient,1,UN,202.9,121.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,164.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,172.47,percent of total billed charges,,,85,,172.47,percent of total billed charges,,,49,,99.42,percent of total billed charges,,,90,,182.61,percent of total billed charges,,,,,,,no IP contract,,80,,162.32,percent of total billed charges,,,,,,,no IP contract,,50,,101.45,percent of total billed charges,,,,,,no IP contract,,,78,,158.26,percent of total billed charges,,,70,,142.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,99.42,3324,
69315-0306-30 - nystatin topical 100000 units/g Powde,69315-0306-30,NDC,,,,inpatient,1,UN,202.9,121.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,164.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,172.47,percent of total billed charges,,,85,,172.47,percent of total billed charges,,,49,,99.42,percent of total billed charges,,,90,,182.61,percent of total billed charges,,,,,,,no IP contract,,80,,162.32,percent of total billed charges,,,,,,,no IP contract,,50,,101.45,percent of total billed charges,,,,,,no IP contract,,,78,,158.26,percent of total billed charges,,,70,,142.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,99.42,3324,
69315-0306-60 - nystatin topical 100000 units/g Powde,69315-0306-60,NDC,,,,inpatient,1,UN,182.9,109.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,148.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,155.47,percent of total billed charges,,,85,,155.47,percent of total billed charges,,,49,,89.62,percent of total billed charges,,,90,,164.61,percent of total billed charges,,,,,,,no IP contract,,80,,146.32,percent of total billed charges,,,,,,,no IP contract,,50,,91.45,percent of total billed charges,,,,,,no IP contract,,,78,,142.66,percent of total billed charges,,,70,,128.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,89.62,3324,
69315-0308-02 - ciprofloxacin ophthalmic 0.3% Soln,69315-0308-02,NDC,,,,inpatient,1,UN,219.15,131.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,177.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,186.28,percent of total billed charges,,,85,,186.28,percent of total billed charges,,,49,,107.38,percent of total billed charges,,,90,,197.24,percent of total billed charges,,,,,,,no IP contract,,80,,175.32,percent of total billed charges,,,,,,,no IP contract,,50,,109.58,percent of total billed charges,,,,,,no IP contract,,,78,,170.94,percent of total billed charges,,,70,,153.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,107.38,3324,
69315-0308-10 - ciprofloxacin ophthalmic 0.3% Soln,69315-0308-10,NDC,,,,inpatient,1,UN,119.2,71.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,96.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,101.32,percent of total billed charges,,,85,,101.32,percent of total billed charges,,,49,,58.41,percent of total billed charges,,,90,,107.28,percent of total billed charges,,,,,,,no IP contract,,80,,95.36,percent of total billed charges,,,,,,,no IP contract,,50,,59.6,percent of total billed charges,,,,,,no IP contract,,,78,,92.98,percent of total billed charges,,,70,,83.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,58.41,3324,
69315-0312-28 - hydrocortisone topical 2.5% Cream,69315-0312-28,NDC,,,,inpatient,1,UN,758.9,455.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,614.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,645.07,percent of total billed charges,,,85,,645.07,percent of total billed charges,,,49,,371.86,percent of total billed charges,,,90,,683.01,percent of total billed charges,,,,,,,no IP contract,,80,,607.12,percent of total billed charges,,,,,,,no IP contract,,50,,379.45,percent of total billed charges,,,,,,no IP contract,,,78,,591.94,percent of total billed charges,,,70,,531.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,371.86,3324,
69315-0904-01 - LORazepam 0.5 mg Tab,69315-0904-01,NDC,,,,inpatient,1,EA,10.75,6.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.14,percent of total billed charges,,,85,,9.14,percent of total billed charges,,,49,,5.27,percent of total billed charges,,,90,,9.68,percent of total billed charges,,,,,,,no IP contract,,80,,8.6,percent of total billed charges,,,,,,,no IP contract,,50,,5.38,percent of total billed charges,,,,,,no IP contract,,,78,,8.39,percent of total billed charges,,,70,,7.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.27,3324,
69315-0905-01 - LORazepam 1 mg Tab,69315-0905-01,NDC,,,,inpatient,1,EA,12.4,7.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.54,percent of total billed charges,,,85,,10.54,percent of total billed charges,,,49,,6.08,percent of total billed charges,,,90,,11.16,percent of total billed charges,,,,,,,no IP contract,,80,,9.92,percent of total billed charges,,,,,,,no IP contract,,50,,6.2,percent of total billed charges,,,,,,no IP contract,,,78,,9.67,percent of total billed charges,,,70,,8.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.08,3324,
69339-0149-19 - dextromethorphan-guaifenesin 10 mg-100 mg/5 mL LIQ,69339-0149-19,NDC,,,,inpatient,5,ML,23.7,14.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.15,percent of total billed charges,,,85,,20.15,percent of total billed charges,,,49,,11.61,percent of total billed charges,,,90,,21.33,percent of total billed charges,,,,,,,no IP contract,,80,,18.96,percent of total billed charges,,,,,,,no IP contract,,50,,11.85,percent of total billed charges,,,,,,no IP contract,,,78,,18.49,percent of total billed charges,,,70,,16.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.61,3324,
nitroglycerin 0.4 mg Tab,69339-0174-41,NDC,,,,inpatient,1,EA,208.55,125.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,168.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,177.27,percent of total billed charges,,,85,,177.27,percent of total billed charges,,,49,,102.19,percent of total billed charges,,,90,,187.7,percent of total billed charges,,,,,,,no IP contract,,80,,166.84,percent of total billed charges,,,,,,,no IP contract,,50,,104.28,percent of total billed charges,,,,,,no IP contract,,,78,,162.67,percent of total billed charges,,,70,,145.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,102.19,3324,
69367-0162-04 - phenazopyridine 100 mg Tab,69367-0162-04,NDC,,,,inpatient,1,EA,25.3,15.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.51,percent of total billed charges,,,85,,21.51,percent of total billed charges,,,49,,12.4,percent of total billed charges,,,90,,22.77,percent of total billed charges,,,,,,,no IP contract,,80,,20.24,percent of total billed charges,,,,,,,no IP contract,,50,,12.65,percent of total billed charges,,,,,,no IP contract,,,78,,19.73,percent of total billed charges,,,70,,17.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.4,3324,
69367-0165-04 - ferrous gluconate 324 mg Tab,69367-0165-04,NDC,,,,inpatient,1,EA,4.3,2.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.66,percent of total billed charges,,,85,,3.66,percent of total billed charges,,,49,,2.11,percent of total billed charges,,,90,,3.87,percent of total billed charges,,,,,,,no IP contract,,80,,3.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.15,percent of total billed charges,,,,,,no IP contract,,,78,,3.35,percent of total billed charges,,,70,,3.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.11,3324,
69367-0220-01 - sodium chloride 1 g Tab,69367-0220-01,NDC,,,,inpatient,1,EA,5.2,3.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.42,percent of total billed charges,,,85,,4.42,percent of total billed charges,,,49,,2.55,percent of total billed charges,,,90,,4.68,percent of total billed charges,,,,,,,no IP contract,,80,,4.16,percent of total billed charges,,,,,,,no IP contract,,50,,2.6,percent of total billed charges,,,,,,no IP contract,,,78,,4.06,percent of total billed charges,,,70,,3.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.55,3324,
69367-0262-09 - valACYclovir 500 mg Tab,69367-0262-09,NDC,,,,inpatient,1,EA,61.2,36.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,49.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,52.02,percent of total billed charges,,,85,,52.02,percent of total billed charges,,,49,,29.99,percent of total billed charges,,,90,,55.08,percent of total billed charges,,,,,,,no IP contract,,80,,48.96,percent of total billed charges,,,,,,,no IP contract,,50,,30.6,percent of total billed charges,,,,,,no IP contract,,,78,,47.74,percent of total billed charges,,,70,,42.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,29.99,3324,
69367-0263-09 - valACYclovir 1 g Tab,69367-0263-09,NDC,,,,inpatient,1,EA,104.3,62.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,84.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,88.66,percent of total billed charges,,,85,,88.66,percent of total billed charges,,,49,,51.11,percent of total billed charges,,,90,,93.87,percent of total billed charges,,,,,,,no IP contract,,80,,83.44,percent of total billed charges,,,,,,,no IP contract,,50,,52.15,percent of total billed charges,,,,,,no IP contract,,,78,,81.35,percent of total billed charges,,,70,,73.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,51.11,3324,
69367-0283-02 - ergocalciferol 200 mcg/mL Soln,69367-0283-02,NDC,,,,inpatient,1,ML,19.35,11.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.45,percent of total billed charges,,,85,,16.45,percent of total billed charges,,,49,,9.48,percent of total billed charges,,,90,,17.42,percent of total billed charges,,,,,,,no IP contract,,80,,15.48,percent of total billed charges,,,,,,,no IP contract,,50,,9.68,percent of total billed charges,,,,,,no IP contract,,,78,,15.09,percent of total billed charges,,,70,,13.55,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.48,3324,
69452-0126-19 - sevelamer carbonate 0.8 g REC P,69452-0126-19,NDC,,,,inpatient,30,ML,156.85,94.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,127.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,133.32,percent of total billed charges,,,85,,133.32,percent of total billed charges,,,49,,76.86,percent of total billed charges,,,90,,141.17,percent of total billed charges,,,,,,,no IP contract,,80,,125.48,percent of total billed charges,,,,,,,no IP contract,,50,,78.43,percent of total billed charges,,,,,,no IP contract,,,78,,122.34,percent of total billed charges,,,70,,109.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,76.86,3324,
69452-0143-20 - benzonatate 100 mg Cap,69452-0143-20,NDC,,,,inpatient,1,EA,23.7,14.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.15,percent of total billed charges,,,85,,20.15,percent of total billed charges,,,49,,11.61,percent of total billed charges,,,90,,21.33,percent of total billed charges,,,,,,,no IP contract,,80,,18.96,percent of total billed charges,,,,,,,no IP contract,,50,,11.85,percent of total billed charges,,,,,,no IP contract,,,78,,18.49,percent of total billed charges,,,70,,16.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.61,3324,
69452-0150-20 - valproic acid 250 mg Cap,69452-0150-20,NDC,,,,inpatient,1,EA,10.5,6.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.93,percent of total billed charges,,,85,,8.93,percent of total billed charges,,,49,,5.15,percent of total billed charges,,,90,,9.45,percent of total billed charges,,,,,,,no IP contract,,80,,8.4,percent of total billed charges,,,,,,,no IP contract,,50,,5.25,percent of total billed charges,,,,,,no IP contract,,,78,,8.19,percent of total billed charges,,,70,,7.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.15,3324,
"69452-0151-20 - ergocalciferol 50,000 intl units Cap",69452-0151-20,NDC,,,,inpatient,1,EA,9.55,5.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.12,percent of total billed charges,,,85,,8.12,percent of total billed charges,,,49,,4.68,percent of total billed charges,,,90,,8.6,percent of total billed charges,,,,,,,no IP contract,,80,,7.64,percent of total billed charges,,,,,,,no IP contract,,50,,4.78,percent of total billed charges,,,,,,no IP contract,,,78,,7.45,percent of total billed charges,,,70,,6.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.68,3324,
69452-0171-73 - azithromycin 250 mg Tab,69452-0171-73,NDC,,,,inpatient,1,EA,65.7,39.42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,53.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,55.85,percent of total billed charges,,,85,,55.85,percent of total billed charges,,,49,,32.19,percent of total billed charges,,,90,,59.13,percent of total billed charges,,,,,,,no IP contract,,80,,52.56,percent of total billed charges,,,,,,,no IP contract,,50,,32.85,percent of total billed charges,,,,,,no IP contract,,,78,,51.25,percent of total billed charges,,,70,,45.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.19,3324,
69452-0208-20 - calcitriol 0.5 mcg Cap,69452-0208-20,NDC,,,,inpatient,1,EA,19.15,11.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.28,percent of total billed charges,,,85,,16.28,percent of total billed charges,,,49,,9.38,percent of total billed charges,,,90,,17.24,percent of total billed charges,,,,,,,no IP contract,,80,,15.32,percent of total billed charges,,,,,,,no IP contract,,50,,9.58,percent of total billed charges,,,,,,no IP contract,,,78,,14.94,percent of total billed charges,,,70,,13.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.38,3324,
69452-0209-20 - niMODipine 30 mg Cap,69452-0209-20,NDC,,,,inpatient,1,EA,150.2,90.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,121.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,127.67,percent of total billed charges,,,85,,127.67,percent of total billed charges,,,49,,73.6,percent of total billed charges,,,90,,135.18,percent of total billed charges,,,,,,,no IP contract,,80,,120.16,percent of total billed charges,,,,,,,no IP contract,,50,,75.1,percent of total billed charges,,,,,,no IP contract,,,78,,117.16,percent of total billed charges,,,70,,105.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,73.6,3324,
69452-0237-46 - enalapril 1 mg/mL LIQ,69452-0237-46,NDC,,,,inpatient,1,ML,39.4,23.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.49,percent of total billed charges,,,85,,33.49,percent of total billed charges,,,49,,19.31,percent of total billed charges,,,90,,35.46,percent of total billed charges,,,,,,,no IP contract,,80,,31.52,percent of total billed charges,,,,,,,no IP contract,,50,,19.7,percent of total billed charges,,,,,,no IP contract,,,78,,30.73,percent of total billed charges,,,70,,27.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.31,3324,
69452-0241-20 - trihexyphenidyl 2 mg Tab,69452-0241-20,NDC,,,,inpatient,1,EA,8.2,4.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.97,percent of total billed charges,,,85,,6.97,percent of total billed charges,,,49,,4.02,percent of total billed charges,,,90,,7.38,percent of total billed charges,,,,,,,no IP contract,,80,,6.56,percent of total billed charges,,,,,,,no IP contract,,50,,4.1,percent of total billed charges,,,,,,no IP contract,,,78,,6.4,percent of total billed charges,,,70,,5.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.02,3324,
69452-0342-13 - modafinil 100 mg Tab,69452-0342-13,NDC,,,,inpatient,1,EA,189.25,113.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,153.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,160.86,percent of total billed charges,,,85,,160.86,percent of total billed charges,,,49,,92.73,percent of total billed charges,,,90,,170.33,percent of total billed charges,,,,,,,no IP contract,,80,,151.4,percent of total billed charges,,,,,,,no IP contract,,50,,94.63,percent of total billed charges,,,,,,no IP contract,,,78,,147.62,percent of total billed charges,,,70,,132.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,92.73,3324,
69452-0389-98 - magnesium citrate 1.745 g/30 mL LIQ,69452-0389-98,NDC,,,,inpatient,296,ML,30.1,18.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.59,percent of total billed charges,,,85,,25.59,percent of total billed charges,,,49,,14.75,percent of total billed charges,,,90,,27.09,percent of total billed charges,,,,,,,no IP contract,,80,,24.08,percent of total billed charges,,,,,,,no IP contract,,50,,15.05,percent of total billed charges,,,,,,no IP contract,,,78,,23.48,percent of total billed charges,,,70,,21.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.75,3324,
69543-0131-20 - alendronate 70 mg Tab,69543-0131-20,NDC,,,,inpatient,1,EA,166.7,100.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,135.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,141.7,percent of total billed charges,,,85,,141.7,percent of total billed charges,,,49,,81.68,percent of total billed charges,,,90,,150.03,percent of total billed charges,,,,,,,no IP contract,,80,,133.36,percent of total billed charges,,,,,,,no IP contract,,50,,83.35,percent of total billed charges,,,,,,no IP contract,,,78,,130.03,percent of total billed charges,,,70,,116.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,81.68,3324,
69543-0150-30 - dapsone 25 mg Tab,69543-0150-30,NDC,,,,inpatient,1,EA,23.45,14.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.93,percent of total billed charges,,,85,,19.93,percent of total billed charges,,,49,,11.49,percent of total billed charges,,,90,,21.11,percent of total billed charges,,,,,,,no IP contract,,80,,18.76,percent of total billed charges,,,,,,,no IP contract,,50,,11.73,percent of total billed charges,,,,,,no IP contract,,,78,,18.29,percent of total billed charges,,,70,,16.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.49,3324,
69543-0379-30 - potassium chloride 20 mEq REC Powder,69543-0379-30,NDC,,,,inpatient,1,UN,89.2,53.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,72.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,75.82,percent of total billed charges,,,85,,75.82,percent of total billed charges,,,49,,43.71,percent of total billed charges,,,90,,80.28,percent of total billed charges,,,,,,,no IP contract,,80,,71.36,percent of total billed charges,,,,,,,no IP contract,,50,,44.6,percent of total billed charges,,,,,,no IP contract,,,78,,69.58,percent of total billed charges,,,70,,62.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,43.71,3324,
69547-0353-02 - naloxone 4 mg/0.1 mL Spray,69547-0353-02,NDC,,,,inpatient,0.1,ML,633.95,380.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,513.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,538.86,percent of total billed charges,,,85,,538.86,percent of total billed charges,,,49,,310.64,percent of total billed charges,,,90,,570.56,percent of total billed charges,,,,,,,no IP contract,,80,,507.16,percent of total billed charges,,,,,,,no IP contract,,50,,316.98,percent of total billed charges,,,,,,no IP contract,,,78,,494.48,percent of total billed charges,,,70,,443.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,310.64,3324,
69547-0627-02 - naloxone 4 mg/0.1 mL Spray,69547-0627-02,NDC,,,,inpatient,0.1,ML,234.15,140.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,189.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,199.03,percent of total billed charges,,,85,,199.03,percent of total billed charges,,,49,,114.73,percent of total billed charges,,,90,,210.74,percent of total billed charges,,,,,,,no IP contract,,80,,187.32,percent of total billed charges,,,,,,,no IP contract,,50,,117.08,percent of total billed charges,,,,,,no IP contract,,,78,,182.64,percent of total billed charges,,,70,,163.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,114.73,3324,
69584-0111-10 - carisoprodol 350 mg Tab,69584-0111-10,NDC,,,,inpatient,1,EA,8.6,5.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.31,percent of total billed charges,,,85,,7.31,percent of total billed charges,,,49,,4.21,percent of total billed charges,,,90,,7.74,percent of total billed charges,,,,,,,no IP contract,,80,,6.88,percent of total billed charges,,,,,,,no IP contract,,50,,4.3,percent of total billed charges,,,,,,no IP contract,,,78,,6.71,percent of total billed charges,,,70,,6.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.21,3324,
aspirin 325 mg EC Ta,69618-0015-01,NDC,,,,inpatient,1,EA,4,2.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.4,percent of total billed charges,,,85,,3.4,percent of total billed charges,,,49,,1.96,percent of total billed charges,,,90,,3.6,percent of total billed charges,,,,,,,no IP contract,,80,,3.2,percent of total billed charges,,,,,,,no IP contract,,50,,2,percent of total billed charges,,,,,,no IP contract,,,78,,3.12,percent of total billed charges,,,70,,2.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.96,3324,
69618-0020-15 - calcium carbonate 500 mg Chew,69618-0020-15,NDC,,,,inpatient,1,EA,4,2.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.4,percent of total billed charges,,,85,,3.4,percent of total billed charges,,,49,,1.96,percent of total billed charges,,,90,,3.6,percent of total billed charges,,,,,,,no IP contract,,80,,3.2,percent of total billed charges,,,,,,,no IP contract,,50,,2,percent of total billed charges,,,,,,no IP contract,,,78,,3.12,percent of total billed charges,,,70,,2.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.96,3324,
69618-0027-01 - meclizine 12.5 mg Tab,69618-0027-01,NDC,,,,inpatient,1,EA,4,2.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.4,percent of total billed charges,,,85,,3.4,percent of total billed charges,,,49,,1.96,percent of total billed charges,,,90,,3.6,percent of total billed charges,,,,,,,no IP contract,,80,,3.2,percent of total billed charges,,,,,,,no IP contract,,50,,2,percent of total billed charges,,,,,,no IP contract,,,78,,3.12,percent of total billed charges,,,70,,2.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.96,3324,
69618-0064-01 - senna 8.6 mg Tab,69618-0064-01,NDC,,,,inpatient,1,EA,4,2.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.4,percent of total billed charges,,,85,,3.4,percent of total billed charges,,,49,,1.96,percent of total billed charges,,,90,,3.6,percent of total billed charges,,,,,,,no IP contract,,80,,3.2,percent of total billed charges,,,,,,,no IP contract,,50,,2,percent of total billed charges,,,,,,no IP contract,,,78,,3.12,percent of total billed charges,,,70,,2.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.96,3324,
miconazole topical 2% Cream,69740-0329-00,NDC,,,,inpatient,1,EA,198.5,119.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,160.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,168.73,percent of total billed charges,,,85,,168.73,percent of total billed charges,,,49,,97.27,percent of total billed charges,,,90,,178.65,percent of total billed charges,,,,,,,no IP contract,,80,,158.8,percent of total billed charges,,,,,,,no IP contract,,50,,99.25,percent of total billed charges,,,,,,no IP contract,,,78,,154.83,percent of total billed charges,,,70,,138.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,97.27,3324,
69918-0501-05 - desmopressin 10 mcg/inh Spray,69918-0501-05,NDC,,,,inpatient,1,UN,1978.45,1187.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1602.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1681.68,percent of total billed charges,,,85,,1681.68,percent of total billed charges,,,49,,969.44,percent of total billed charges,,,90,,1780.61,percent of total billed charges,,,,,,,no IP contract,,80,,1582.76,percent of total billed charges,,,,,,,no IP contract,,50,,989.23,percent of total billed charges,,,,,,no IP contract,,,78,,1543.19,percent of total billed charges,,,70,,1384.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,969.44,3324,
69918-0899-10 - desmopressin 4 mcg/mL Soln,69918-0899-10,NDC,,,,inpatient,1,ML,604.05,362.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,489.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,513.44,percent of total billed charges,,,85,,513.44,percent of total billed charges,,,49,,295.98,percent of total billed charges,,,90,,543.65,percent of total billed charges,,,,,,,no IP contract,,80,,483.24,percent of total billed charges,,,,,,,no IP contract,,50,,302.03,percent of total billed charges,,,,,,no IP contract,,,78,,471.16,percent of total billed charges,,,70,,422.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,295.98,3324,
70010-0012-01 - methylphenidate (50/50 release) 10 mg/24 hr ER Ca,70010-0012-01,NDC,,,,inpatient,1,EA,108.15,64.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,87.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,91.93,percent of total billed charges,,,85,,91.93,percent of total billed charges,,,49,,52.99,percent of total billed charges,,,90,,97.34,percent of total billed charges,,,,,,,no IP contract,,80,,86.52,percent of total billed charges,,,,,,,no IP contract,,50,,54.08,percent of total billed charges,,,,,,no IP contract,,,78,,84.36,percent of total billed charges,,,70,,75.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,52.99,3324,
70010-0013-01 - methylphenidate ER/24hr 20 mg/24 hr ER Capsule,70010-0013-01,NDC,,,,inpatient,1,EA,113.55,68.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,91.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,96.52,percent of total billed charges,,,85,,96.52,percent of total billed charges,,,49,,55.64,percent of total billed charges,,,90,,102.2,percent of total billed charges,,,,,,,no IP contract,,80,,90.84,percent of total billed charges,,,,,,,no IP contract,,50,,56.78,percent of total billed charges,,,,,,no IP contract,,,78,,88.57,percent of total billed charges,,,70,,79.49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,55.64,3324,
amphetamine-dextroamphetamine 10 mg ER Ca,70010-0030-01,NDC,,,,inpatient,1,EA,65.4,39.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,52.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,55.59,percent of total billed charges,,,85,,55.59,percent of total billed charges,,,49,,32.05,percent of total billed charges,,,90,,58.86,percent of total billed charges,,,,,,,no IP contract,,80,,52.32,percent of total billed charges,,,,,,,no IP contract,,50,,32.7,percent of total billed charges,,,,,,no IP contract,,,78,,51.01,percent of total billed charges,,,70,,45.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.05,3324,
70010-0063-01 - metFORMIN 500 mg Tab,70010-0063-01,NDC,,,,inpatient,1,EA,9.4,5.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.99,percent of total billed charges,,,85,,7.99,percent of total billed charges,,,49,,4.61,percent of total billed charges,,,90,,8.46,percent of total billed charges,,,,,,,no IP contract,,80,,7.52,percent of total billed charges,,,,,,,no IP contract,,50,,4.7,percent of total billed charges,,,,,,no IP contract,,,78,,7.33,percent of total billed charges,,,70,,6.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.61,3324,
70010-0084-01 - prazosin 1 mg Cap,70010-0084-01,NDC,,,,inpatient,1,EA,11.4,6.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.69,percent of total billed charges,,,85,,9.69,percent of total billed charges,,,49,,5.59,percent of total billed charges,,,90,,10.26,percent of total billed charges,,,,,,,no IP contract,,80,,9.12,percent of total billed charges,,,,,,,no IP contract,,50,,5.7,percent of total billed charges,,,,,,no IP contract,,,78,,8.89,percent of total billed charges,,,70,,7.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.59,3324,
70010-0149-01 - acetaminophen/butalbital/caffeine 325 mg-50 mg-40 mg Tab,70010-0149-01,NDC,,,,inpatient,1,EA,17.25,10.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.66,percent of total billed charges,,,85,,14.66,percent of total billed charges,,,49,,8.45,percent of total billed charges,,,90,,15.53,percent of total billed charges,,,,,,,no IP contract,,80,,13.8,percent of total billed charges,,,,,,,no IP contract,,50,,8.63,percent of total billed charges,,,,,,no IP contract,,,78,,13.46,percent of total billed charges,,,70,,12.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.45,3324,
metFORMIN 500 mg ER Ta,70010-0491-01,NDC,,,,inpatient,1,EA,10.6,6.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.01,percent of total billed charges,,,85,,9.01,percent of total billed charges,,,49,,5.19,percent of total billed charges,,,90,,9.54,percent of total billed charges,,,,,,,no IP contract,,80,,8.48,percent of total billed charges,,,,,,,no IP contract,,50,,5.3,percent of total billed charges,,,,,,no IP contract,,,78,,8.27,percent of total billed charges,,,70,,7.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.19,3324,
70010-0754-01 - methocarbamol 500 mg Tab,70010-0754-01,NDC,,,,inpatient,1,EA,7.9,4.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.72,percent of total billed charges,,,85,,6.72,percent of total billed charges,,,49,,3.87,percent of total billed charges,,,90,,7.11,percent of total billed charges,,,,,,,no IP contract,,80,,6.32,percent of total billed charges,,,,,,,no IP contract,,50,,3.95,percent of total billed charges,,,,,,no IP contract,,,78,,6.16,percent of total billed charges,,,70,,5.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.87,3324,
70010-0770-01 - methocarbamol 750 mg Tab,70010-0770-01,NDC,,,,inpatient,1,EA,9.65,5.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.2,percent of total billed charges,,,85,,8.2,percent of total billed charges,,,49,,4.73,percent of total billed charges,,,90,,8.69,percent of total billed charges,,,,,,,no IP contract,,80,,7.72,percent of total billed charges,,,,,,,no IP contract,,50,,4.83,percent of total billed charges,,,,,,no IP contract,,,78,,7.53,percent of total billed charges,,,70,,6.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.73,3324,
cyanocobalamin 1000 mcg/mL Soln,70069-0005-10,NDC,,,,inpatient,1,EA,46.85,28.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,37.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,39.82,percent of total billed charges,,,85,,39.82,percent of total billed charges,,,49,,22.96,percent of total billed charges,,,90,,42.17,percent of total billed charges,,,,,,,no IP contract,,80,,37.48,percent of total billed charges,,,,,,,no IP contract,,50,,23.43,percent of total billed charges,,,,,,no IP contract,,,78,,36.54,percent of total billed charges,,,70,,32.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.96,3324,
70069-0007-01 - olopatadine ophthalmic 0.1% Soln,70069-0007-01,NDC,,,,inpatient,1,UN,411.55,246.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,333.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,349.82,percent of total billed charges,,,85,,349.82,percent of total billed charges,,,49,,201.66,percent of total billed charges,,,90,,370.4,percent of total billed charges,,,,,,,no IP contract,,80,,329.24,percent of total billed charges,,,,,,,no IP contract,,50,,205.78,percent of total billed charges,,,,,,no IP contract,,,78,,321.01,percent of total billed charges,,,70,,288.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,201.66,3324,
70069-0051-01 - dorzolamide-timolol  2%-0.5% Soln,70069-0051-01,NDC,,,,inpatient,1,UN,1030.5,618.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,834.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,875.93,percent of total billed charges,,,85,,875.93,percent of total billed charges,,,49,,504.95,percent of total billed charges,,,90,,927.45,percent of total billed charges,,,,,,,no IP contract,,80,,824.4,percent of total billed charges,,,,,,,no IP contract,,50,,515.25,percent of total billed charges,,,,,,no IP contract,,,78,,803.79,percent of total billed charges,,,70,,721.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,504.95,3324,
ROPivacaine 0.2% Soln,70069-0061-10,NDC,,,,inpatient,1,EA,60.75,36.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,49.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,51.64,percent of total billed charges,,,85,,51.64,percent of total billed charges,,,49,,29.77,percent of total billed charges,,,90,,54.68,percent of total billed charges,,,,,,,no IP contract,,80,,48.6,percent of total billed charges,,,,,,,no IP contract,,50,,30.38,percent of total billed charges,,,,,,no IP contract,,,78,,47.39,percent of total billed charges,,,70,,42.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,29.77,3324,
70069-0064-01 - ropivacaine 0.5% Soln,70069-0064-01,NDC,,,,inpatient,30,ML,72.55,43.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,58.77,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,61.67,percent of total billed charges,,,85,,61.67,percent of total billed charges,,,49,,35.55,percent of total billed charges,,,90,,65.3,percent of total billed charges,,,,,,,no IP contract,,80,,58.04,percent of total billed charges,,,,,,,no IP contract,,50,,36.28,percent of total billed charges,,,,,,no IP contract,,,78,,56.59,percent of total billed charges,,,70,,50.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,35.55,3324,
70069-0131-01 - tobramycin ophthalmic 0.3% Soln,70069-0131-01,NDC,,,,inpatient,1,UN,124.6,74.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,100.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,105.91,percent of total billed charges,,,85,,105.91,percent of total billed charges,,,49,,61.05,percent of total billed charges,,,90,,112.14,percent of total billed charges,,,,,,,no IP contract,,80,,99.68,percent of total billed charges,,,,,,,no IP contract,,50,,62.3,percent of total billed charges,,,,,,no IP contract,,,78,,97.19,percent of total billed charges,,,70,,87.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,61.05,3324,
70121-1552-01 - methylPREDNISolone 80 mg/mL Susp,70121-1552-01,NDC,,,,inpatient,1,ML,174.4,104.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,141.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,148.24,percent of total billed charges,,,85,,148.24,percent of total billed charges,,,49,,85.46,percent of total billed charges,,,90,,156.96,percent of total billed charges,,,,,,,no IP contract,,80,,139.52,percent of total billed charges,,,,,,,no IP contract,,50,,87.2,percent of total billed charges,,,,,,no IP contract,,,78,,136.03,percent of total billed charges,,,70,,122.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,85.46,3324,
triamcinolone acetonide 40 mg/mL Susp,70121-1651-01,NDC,,,,inpatient,1,EA,95.3,57.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,77.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,81.01,percent of total billed charges,,,85,,81.01,percent of total billed charges,,,49,,46.7,percent of total billed charges,,,90,,85.77,percent of total billed charges,,,,,,,no IP contract,,80,,76.24,percent of total billed charges,,,,,,,no IP contract,,50,,47.65,percent of total billed charges,,,,,,no IP contract,,,78,,74.33,percent of total billed charges,,,70,,66.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,46.7,3324,
70121-1653-01 - triamcinolone acetonide 40 mg/mL Susp,70121-1653-01,NDC,,,,inpatient,10,ML,664.35,398.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,538.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,564.7,percent of total billed charges,,,85,,564.7,percent of total billed charges,,,49,,325.53,percent of total billed charges,,,90,,597.92,percent of total billed charges,,,,,,,no IP contract,,80,,531.48,percent of total billed charges,,,,,,,no IP contract,,50,,332.18,percent of total billed charges,,,,,,no IP contract,,,78,,518.19,percent of total billed charges,,,70,,465.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,325.53,3324,
70127-0100-10 - cannabidiol 100 mg/mL LIQ,70127-0100-10,NDC,,,,inpatient,0.01,ML,128.9,77.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,104.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,109.57,percent of total billed charges,,,85,,109.57,percent of total billed charges,,,49,,63.16,percent of total billed charges,,,90,,116.01,percent of total billed charges,,,,,,,no IP contract,,80,,103.12,percent of total billed charges,,,,,,,no IP contract,,50,,64.45,percent of total billed charges,,,,,,no IP contract,,,78,,100.54,percent of total billed charges,,,70,,90.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,63.16,3324,
baclofen 0.5 mg/mL Soln,70257-0560-01,NDC,,,,inpatient,1,EA,734.55,440.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,594.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,624.37,percent of total billed charges,,,85,,624.37,percent of total billed charges,,,49,,359.93,percent of total billed charges,,,90,,661.1,percent of total billed charges,,,,,,,no IP contract,,80,,587.64,percent of total billed charges,,,,,,,no IP contract,,50,,367.28,percent of total billed charges,,,,,,no IP contract,,,78,,572.95,percent of total billed charges,,,70,,514.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,359.93,3324,
baclofen 0.5 mg/mL Soln,70257-0560-02,NDC,,,,inpatient,2,EA,734.55,440.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,594.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,624.37,percent of total billed charges,,,85,,624.37,percent of total billed charges,,,49,,359.93,percent of total billed charges,,,90,,661.1,percent of total billed charges,,,,,,,no IP contract,,80,,587.64,percent of total billed charges,,,,,,,no IP contract,,50,,367.28,percent of total billed charges,,,,,,no IP contract,,,78,,572.95,percent of total billed charges,,,70,,514.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,359.93,3324,
baclofen 2 mg/mL Soln,70257-0561-02,NDC,,,,inpatient,1,EA,1468.8,881.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1189.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1248.48,percent of total billed charges,,,85,,1248.48,percent of total billed charges,,,49,,719.71,percent of total billed charges,,,90,,1321.92,percent of total billed charges,,,,,,,no IP contract,,80,,1175.04,percent of total billed charges,,,,,,,no IP contract,,50,,734.4,percent of total billed charges,,,,,,no IP contract,,,78,,1145.66,percent of total billed charges,,,70,,1028.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,719.71,3324,
baclofen 2 mg/mL Soln,70257-0563-01,NDC,,,,inpatient,1,EA,2937.6,1762.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2379.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2496.96,percent of total billed charges,,,85,,2496.96,percent of total billed charges,,,49,,1439.42,percent of total billed charges,,,90,,2643.84,percent of total billed charges,,,,,,,no IP contract,,80,,2350.08,percent of total billed charges,,,,,,,no IP contract,,50,,1468.8,percent of total billed charges,,,,,,no IP contract,,,78,,2291.33,percent of total billed charges,,,70,,2056.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
baclofen 2 mg/mL Soln,70257-0563-01,NDC,,,,inpatient,1,EA,2937.6,1762.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2379.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2496.96,percent of total billed charges,,,85,,2496.96,percent of total billed charges,,,49,,1439.42,percent of total billed charges,,,90,,2643.84,percent of total billed charges,,,,,,,no IP contract,,80,,2350.08,percent of total billed charges,,,,,,,no IP contract,,50,,1468.8,percent of total billed charges,,,,,,no IP contract,,,78,,2291.33,percent of total billed charges,,,70,,2056.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
baclofen 2 mg/mL Soln,70257-0563-02,NDC,,,,inpatient,2,EA,2937.6,1762.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2379.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2496.96,percent of total billed charges,,,85,,2496.96,percent of total billed charges,,,49,,1439.42,percent of total billed charges,,,90,,2643.84,percent of total billed charges,,,,,,,no IP contract,,80,,2350.08,percent of total billed charges,,,,,,,no IP contract,,50,,1468.8,percent of total billed charges,,,,,,no IP contract,,,78,,2291.33,percent of total billed charges,,,70,,2056.32,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
70377-0006-12 - rosuvastatin 5 mg Tab,70377-0006-12,NDC,,,,inpatient,1,EA,74.9,44.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63.67,percent of total billed charges,,,85,,63.67,percent of total billed charges,,,49,,36.7,percent of total billed charges,,,90,,67.41,percent of total billed charges,,,,,,,no IP contract,,80,,59.92,percent of total billed charges,,,,,,,no IP contract,,50,,37.45,percent of total billed charges,,,,,,no IP contract,,,78,,58.42,percent of total billed charges,,,70,,52.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.7,3324,
70377-0008-12 - rosuvastatin 20 mg Tab,70377-0008-12,NDC,,,,inpatient,1,EA,74.8,44.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63.58,percent of total billed charges,,,85,,63.58,percent of total billed charges,,,49,,36.65,percent of total billed charges,,,90,,67.32,percent of total billed charges,,,,,,,no IP contract,,80,,59.84,percent of total billed charges,,,,,,,no IP contract,,50,,37.4,percent of total billed charges,,,,,,no IP contract,,,78,,58.34,percent of total billed charges,,,70,,52.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.65,3324,
70377-0046-12 - pravastatin 20 mg Tab,70377-0046-12,NDC,,,,inpatient,1,EA,29.8,17.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.33,percent of total billed charges,,,85,,25.33,percent of total billed charges,,,49,,14.6,percent of total billed charges,,,90,,26.82,percent of total billed charges,,,,,,,no IP contract,,80,,23.84,percent of total billed charges,,,,,,,no IP contract,,50,,14.9,percent of total billed charges,,,,,,no IP contract,,,78,,23.24,percent of total billed charges,,,70,,20.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.6,3324,
70436-0012-04 - desvenlafaxine 50 mg ER Ta,70436-0012-04,NDC,,,,inpatient,1,EA,91.35,54.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,73.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,77.65,percent of total billed charges,,,85,,77.65,percent of total billed charges,,,49,,44.76,percent of total billed charges,,,90,,82.22,percent of total billed charges,,,,,,,no IP contract,,80,,73.08,percent of total billed charges,,,,,,,no IP contract,,50,,45.68,percent of total billed charges,,,,,,no IP contract,,,78,,71.25,percent of total billed charges,,,70,,63.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,44.76,3324,
70436-0058-01 - buPROPion ER/12hr [Wellbutrin SR] 100 mg/12 hr Tab,70436-0058-01,NDC,,,,inpatient,1,EA,17.25,10.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.66,percent of total billed charges,,,85,,14.66,percent of total billed charges,,,49,,8.45,percent of total billed charges,,,90,,15.53,percent of total billed charges,,,,,,,no IP contract,,80,,13.8,percent of total billed charges,,,,,,,no IP contract,,50,,8.63,percent of total billed charges,,,,,,no IP contract,,,78,,13.46,percent of total billed charges,,,70,,12.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.45,3324,
70594-0023-01 - colistimethate 150 mg (colistin base) REC I,70594-0023-01,NDC,,,,inpatient,2,ML,292.55,175.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,236.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,248.67,percent of total billed charges,,,85,,248.67,percent of total billed charges,,,49,,143.35,percent of total billed charges,,,90,,263.3,percent of total billed charges,,,,,,,no IP contract,,80,,234.04,percent of total billed charges,,,,,,,no IP contract,,50,,146.28,percent of total billed charges,,,,,,no IP contract,,,78,,228.19,percent of total billed charges,,,70,,204.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,143.35,3324,
70594-0258-10 - sulfamethoxazole-trimethoprim 200 mg-40 mg/5 mL Susp,70594-0258-10,NDC,,,,inpatient,1,ML,9.25,5.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.86,percent of total billed charges,,,85,,7.86,percent of total billed charges,,,49,,4.53,percent of total billed charges,,,90,,8.33,percent of total billed charges,,,,,,,no IP contract,,80,,7.4,percent of total billed charges,,,,,,,no IP contract,,50,,4.63,percent of total billed charges,,,,,,no IP contract,,,78,,7.22,percent of total billed charges,,,70,,6.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.53,3324,
oxymetazoline nasal 0.05% Spray,70677-1037-01,NDC,,,,inpatient,1,EA,26.7,16.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.7,percent of total billed charges,,,85,,22.7,percent of total billed charges,,,49,,13.08,percent of total billed charges,,,90,,24.03,percent of total billed charges,,,,,,,no IP contract,,80,,21.36,percent of total billed charges,,,,,,,no IP contract,,50,,13.35,percent of total billed charges,,,,,,no IP contract,,,78,,20.83,percent of total billed charges,,,70,,18.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.08,3324,
calcium carbonate 500 mg Chew,70677-1081-01,NDC,,,,inpatient,1,EA,4,2.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.4,percent of total billed charges,,,85,,3.4,percent of total billed charges,,,49,,1.96,percent of total billed charges,,,90,,3.6,percent of total billed charges,,,,,,,no IP contract,,80,,3.2,percent of total billed charges,,,,,,,no IP contract,,50,,2,percent of total billed charges,,,,,,no IP contract,,,78,,3.12,percent of total billed charges,,,70,,2.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.96,3324,
diclofenac topical 1% Gel,70677-1125-01,NDC,,,,inpatient,1,EA,125.85,75.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,101.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,106.97,percent of total billed charges,,,85,,106.97,percent of total billed charges,,,49,,61.67,percent of total billed charges,,,90,,113.27,percent of total billed charges,,,,,,,no IP contract,,80,,100.68,percent of total billed charges,,,,,,,no IP contract,,50,,62.93,percent of total billed charges,,,,,,no IP contract,,,78,,98.16,percent of total billed charges,,,70,,88.1,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,61.67,3324,
70700-0268-94 - fosfomycin 3 g REC G,70700-0268-94,NDC,,,,inpatient,1,UN,802,481.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,649.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,681.7,percent of total billed charges,,,85,,681.7,percent of total billed charges,,,49,,392.98,percent of total billed charges,,,90,,721.8,percent of total billed charges,,,,,,,no IP contract,,80,,641.6,percent of total billed charges,,,,,,,no IP contract,,50,,401,percent of total billed charges,,,,,,no IP contract,,,78,,625.56,percent of total billed charges,,,70,,561.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,392.98,3324,
70710-1157-03 - leflunomide 10 mg Tab,70710-1157-03,NDC,,,,inpatient,1,EA,134.3,80.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,108.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,114.16,percent of total billed charges,,,85,,114.16,percent of total billed charges,,,49,,65.81,percent of total billed charges,,,90,,120.87,percent of total billed charges,,,,,,,no IP contract,,80,,107.44,percent of total billed charges,,,,,,,no IP contract,,50,,67.15,percent of total billed charges,,,,,,no IP contract,,,78,,104.75,percent of total billed charges,,,70,,94.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,65.81,3324,
meclizine 12.5 mg Tab,70710-1161-01,NDC,,,,inpatient,1,EA,6.45,3.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.48,percent of total billed charges,,,85,,5.48,percent of total billed charges,,,49,,3.16,percent of total billed charges,,,90,,5.81,percent of total billed charges,,,,,,,no IP contract,,80,,5.16,percent of total billed charges,,,,,,,no IP contract,,50,,3.23,percent of total billed charges,,,,,,no IP contract,,,78,,5.03,percent of total billed charges,,,70,,4.52,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.16,3324,
70710-1165-06 - oseltamivir 6 mg/mL REC P,70710-1165-06,NDC,,,,inpatient,1,ML,28.15,16.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.93,percent of total billed charges,,,85,,23.93,percent of total billed charges,,,49,,13.79,percent of total billed charges,,,90,,25.34,percent of total billed charges,,,,,,,no IP contract,,80,,22.52,percent of total billed charges,,,,,,,no IP contract,,50,,14.08,percent of total billed charges,,,,,,no IP contract,,,78,,21.96,percent of total billed charges,,,70,,19.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.79,3324,
70710-1285-01 - baclofen 10 mg Tab,70710-1285-01,NDC,,,,inpatient,1,EA,23.45,14.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19.93,percent of total billed charges,,,85,,19.93,percent of total billed charges,,,49,,11.49,percent of total billed charges,,,90,,21.11,percent of total billed charges,,,,,,,no IP contract,,80,,18.76,percent of total billed charges,,,,,,,no IP contract,,50,,11.73,percent of total billed charges,,,,,,no IP contract,,,78,,18.29,percent of total billed charges,,,70,,16.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.49,3324,
70710-1286-01 - baclofen 20 mg Tab,70710-1286-01,NDC,,,,inpatient,1,EA,44.6,26.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,37.91,percent of total billed charges,,,85,,37.91,percent of total billed charges,,,49,,21.85,percent of total billed charges,,,90,,40.14,percent of total billed charges,,,,,,,no IP contract,,80,,35.68,percent of total billed charges,,,,,,,no IP contract,,50,,22.3,percent of total billed charges,,,,,,no IP contract,,,78,,34.79,percent of total billed charges,,,70,,31.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.85,3324,
70710-1302-07 - mesalamine 1000 mg Supp,70710-1302-07,NDC,,,,inpatient,1,UN,307.5,184.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,249.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,261.38,percent of total billed charges,,,85,,261.38,percent of total billed charges,,,49,,150.68,percent of total billed charges,,,90,,276.75,percent of total billed charges,,,,,,,no IP contract,,80,,246,percent of total billed charges,,,,,,,no IP contract,,50,,153.75,percent of total billed charges,,,,,,no IP contract,,,78,,239.85,percent of total billed charges,,,70,,215.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,150.68,3324,
70710-1483-01 - ursodiol 300 mg Cap,70710-1483-01,NDC,,,,inpatient,1,EA,62.25,37.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,50.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,52.91,percent of total billed charges,,,85,,52.91,percent of total billed charges,,,49,,30.5,percent of total billed charges,,,90,,56.03,percent of total billed charges,,,,,,,no IP contract,,80,,49.8,percent of total billed charges,,,,,,,no IP contract,,50,,31.13,percent of total billed charges,,,,,,no IP contract,,,78,,48.56,percent of total billed charges,,,70,,43.58,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,30.5,3324,
70710-1515-06 - fondaparinux 5 mg/0.4 mL Soln,70710-1515-06,NDC,,,,inpatient,0.4,ML,2719.8,1631.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2203.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2311.83,percent of total billed charges,,,85,,2311.83,percent of total billed charges,,,49,,1332.7,percent of total billed charges,,,90,,2447.82,percent of total billed charges,,,,,,,no IP contract,,80,,2175.84,percent of total billed charges,,,,,,,no IP contract,,50,,1359.9,percent of total billed charges,,,,,,no IP contract,,,78,,2121.44,percent of total billed charges,,,70,,1903.86,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
70710-1516-06 - fondaparinux 7.5 mg/0.6 mL Soln,70710-1516-06,NDC,,,,inpatient,0.6,ML,1816.3,1089.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1471.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1543.86,percent of total billed charges,,,85,,1543.86,percent of total billed charges,,,49,,889.99,percent of total billed charges,,,90,,1634.67,percent of total billed charges,,,,,,,no IP contract,,80,,1453.04,percent of total billed charges,,,,,,,no IP contract,,50,,908.15,percent of total billed charges,,,,,,no IP contract,,,78,,1416.71,percent of total billed charges,,,70,,1271.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,889.99,3324,
70710-1517-06 - fondaparinux 10 mg/0.8 mL Soln,70710-1517-06,NDC,,,,inpatient,0.8,ML,1364.55,818.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1105.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1159.87,percent of total billed charges,,,85,,1159.87,percent of total billed charges,,,49,,668.63,percent of total billed charges,,,90,,1228.1,percent of total billed charges,,,,,,,no IP contract,,80,,1091.64,percent of total billed charges,,,,,,,no IP contract,,50,,682.28,percent of total billed charges,,,,,,no IP contract,,,78,,1064.35,percent of total billed charges,,,70,,955.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,668.63,3324,
70748-0129-06 - leflunomide 10 mg Tab,70748-0129-06,NDC,,,,inpatient,1,EA,134.35,80.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,108.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,114.2,percent of total billed charges,,,85,,114.2,percent of total billed charges,,,49,,65.83,percent of total billed charges,,,90,,120.92,percent of total billed charges,,,,,,,no IP contract,,80,,107.48,percent of total billed charges,,,,,,,no IP contract,,50,,67.18,percent of total billed charges,,,,,,no IP contract,,,78,,104.79,percent of total billed charges,,,70,,94.05,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,65.83,3324,
70748-0186-01 - mycophenolate mofetil  250 mg Cap,70748-0186-01,NDC,,,,inpatient,1,EA,35,21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.75,percent of total billed charges,,,85,,29.75,percent of total billed charges,,,49,,17.15,percent of total billed charges,,,90,,31.5,percent of total billed charges,,,,,,,no IP contract,,80,,28,percent of total billed charges,,,,,,,no IP contract,,50,,17.5,percent of total billed charges,,,,,,no IP contract,,,78,,27.3,percent of total billed charges,,,70,,24.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.15,3324,
70748-0221-01 - tacrolimus 5 mg Cap,70748-0221-01,NDC,,,,inpatient,1,EA,181.1,108.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,146.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,153.94,percent of total billed charges,,,85,,153.94,percent of total billed charges,,,49,,88.74,percent of total billed charges,,,90,,162.99,percent of total billed charges,,,,,,,no IP contract,,80,,144.88,percent of total billed charges,,,,,,,no IP contract,,50,,90.55,percent of total billed charges,,,,,,no IP contract,,,78,,141.26,percent of total billed charges,,,70,,126.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,88.74,3324,
70748-0299-01 - atovaquone 750 mg/5 mL Susp,70748-0299-01,NDC,,,,inpatient,1,ML,60.05,36.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,48.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,51.04,percent of total billed charges,,,85,,51.04,percent of total billed charges,,,49,,29.42,percent of total billed charges,,,90,,54.05,percent of total billed charges,,,,,,,no IP contract,,80,,48.04,percent of total billed charges,,,,,,,no IP contract,,50,,30.03,percent of total billed charges,,,,,,no IP contract,,,78,,46.84,percent of total billed charges,,,70,,42.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,29.42,3324,
amitriptyline 25 mg Tab,70756-0202-11,NDC,,,,inpatient,1,EA,8.9,5.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.57,percent of total billed charges,,,85,,7.57,percent of total billed charges,,,49,,4.36,percent of total billed charges,,,90,,8.01,percent of total billed charges,,,,,,,no IP contract,,80,,7.12,percent of total billed charges,,,,,,,no IP contract,,50,,4.45,percent of total billed charges,,,,,,no IP contract,,,78,,6.94,percent of total billed charges,,,70,,6.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.36,3324,
tobramycin 60 mg/mL Soln,70756-0604-56,NDC,,,,inpatient,1,EA,1081.7,649.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,876.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,919.45,percent of total billed charges,,,85,,919.45,percent of total billed charges,,,49,,530.03,percent of total billed charges,,,90,,973.53,percent of total billed charges,,,,,,,no IP contract,,80,,865.36,percent of total billed charges,,,,,,,no IP contract,,50,,540.85,percent of total billed charges,,,,,,no IP contract,,,78,,843.73,percent of total billed charges,,,70,,757.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,530.03,3324,
ofloxacin otic 0.3% Soln,70756-0609-15,NDC,,,,inpatient,1,EA,1319.95,791.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1069.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1121.96,percent of total billed charges,,,85,,1121.96,percent of total billed charges,,,49,,646.78,percent of total billed charges,,,90,,1187.96,percent of total billed charges,,,,,,,no IP contract,,80,,1055.96,percent of total billed charges,,,,,,,no IP contract,,50,,659.98,percent of total billed charges,,,,,,no IP contract,,,78,,1029.56,percent of total billed charges,,,70,,923.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,646.78,3324,
70756-0721-11 - acetaZOLAMIDE 250 mg Tab,70756-0721-11,NDC,,,,inpatient,1,EA,25.75,15.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.89,percent of total billed charges,,,85,,21.89,percent of total billed charges,,,49,,12.62,percent of total billed charges,,,90,,23.18,percent of total billed charges,,,,,,,no IP contract,,80,,20.6,percent of total billed charges,,,,,,,no IP contract,,50,,12.88,percent of total billed charges,,,,,,no IP contract,,,78,,20.09,percent of total billed charges,,,70,,18.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.62,3324,
70860-0103-10 - polymyxin B sulfate 500000 units REC I,70860-0103-10,NDC,,,,inpatient,1,EA,165.1,99.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,133.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,140.34,percent of total billed charges,,,85,,140.34,percent of total billed charges,,,49,,80.9,percent of total billed charges,,,90,,148.59,percent of total billed charges,,,,,,,no IP contract,,80,,132.08,percent of total billed charges,,,,,,,no IP contract,,50,,82.55,percent of total billed charges,,,,,,no IP contract,,,78,,128.78,percent of total billed charges,,,70,,115.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,80.9,3324,
70860-0114-15 - ampicillin 1 g REC I,70860-0114-15,NDC,,,,inpatient,1,EA,150.1,90.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,121.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,127.59,percent of total billed charges,,,85,,127.59,percent of total billed charges,,,49,,73.55,percent of total billed charges,,,90,,135.09,percent of total billed charges,,,,,,,no IP contract,,80,,120.08,percent of total billed charges,,,,,,,no IP contract,,50,,75.05,percent of total billed charges,,,,,,no IP contract,,,78,,117.08,percent of total billed charges,,,70,,105.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,73.55,3324,
70954-0041-10 - rifabutin 150 mg Cap,70954-0041-10,NDC,,,,inpatient,1,EA,142.85,85.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,115.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,121.42,percent of total billed charges,,,85,,121.42,percent of total billed charges,,,49,,70,percent of total billed charges,,,90,,128.57,percent of total billed charges,,,,,,,no IP contract,,80,,114.28,percent of total billed charges,,,,,,,no IP contract,,50,,71.43,percent of total billed charges,,,,,,no IP contract,,,78,,111.42,percent of total billed charges,,,70,,100,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,70,3324,
70954-0136-10 - dapsone 100 mg Tab,70954-0136-10,NDC,,,,inpatient,1,EA,27.85,16.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.67,percent of total billed charges,,,85,,23.67,percent of total billed charges,,,49,,13.65,percent of total billed charges,,,90,,25.07,percent of total billed charges,,,,,,,no IP contract,,80,,22.28,percent of total billed charges,,,,,,,no IP contract,,50,,13.93,percent of total billed charges,,,,,,no IP contract,,,78,,21.72,percent of total billed charges,,,70,,19.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.65,3324,
dapsone 100 mg Tab,70954-0136-20,NDC,,,,inpatient,1,EA,25.3,15.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,20.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,21.51,percent of total billed charges,,,85,,21.51,percent of total billed charges,,,49,,12.4,percent of total billed charges,,,90,,22.77,percent of total billed charges,,,,,,,no IP contract,,80,,20.24,percent of total billed charges,,,,,,,no IP contract,,50,,12.65,percent of total billed charges,,,,,,no IP contract,,,78,,19.73,percent of total billed charges,,,70,,17.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.4,3324,
70954-0140-10 - levOCARNitine 100 mg/mL Soln,70954-0140-10,NDC,,,,inpatient,1,ML,8.65,5.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.01,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.35,percent of total billed charges,,,85,,7.35,percent of total billed charges,,,49,,4.24,percent of total billed charges,,,90,,7.79,percent of total billed charges,,,,,,,no IP contract,,80,,6.92,percent of total billed charges,,,,,,,no IP contract,,50,,4.33,percent of total billed charges,,,,,,no IP contract,,,78,,6.75,percent of total billed charges,,,70,,6.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.24,3324,
70954-0188-10 - acyclovir 200 mg/5 mL Susp,70954-0188-10,NDC,,,,inpatient,1,ML,13.25,7.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.26,percent of total billed charges,,,85,,11.26,percent of total billed charges,,,49,,6.49,percent of total billed charges,,,90,,11.93,percent of total billed charges,,,,,,,no IP contract,,80,,10.6,percent of total billed charges,,,,,,,no IP contract,,50,,6.63,percent of total billed charges,,,,,,no IP contract,,,78,,10.34,percent of total billed charges,,,70,,9.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.49,3324,
70954-0212-10 - trihexyphenidyl 2 mg Tab,70954-0212-10,NDC,,,,inpatient,1,EA,6.75,4.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.74,percent of total billed charges,,,85,,5.74,percent of total billed charges,,,49,,3.31,percent of total billed charges,,,90,,6.08,percent of total billed charges,,,,,,,no IP contract,,80,,5.4,percent of total billed charges,,,,,,,no IP contract,,50,,3.38,percent of total billed charges,,,,,,no IP contract,,,78,,5.27,percent of total billed charges,,,70,,4.73,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.31,3324,
70954-0319-10 - PARoxetine 10 mg/5 mL Susp,70954-0319-10,NDC,,,,inpatient,1,ML,18.6,11.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.81,percent of total billed charges,,,85,,15.81,percent of total billed charges,,,49,,9.11,percent of total billed charges,,,90,,16.74,percent of total billed charges,,,,,,,no IP contract,,80,,14.88,percent of total billed charges,,,,,,,no IP contract,,50,,9.3,percent of total billed charges,,,,,,no IP contract,,,78,,14.51,percent of total billed charges,,,70,,13.02,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.11,3324,
70954-0492-10 - levOCARNitine 330 mg Tab,70954-0492-10,NDC,,,,inpatient,1,EA,12.55,7.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.67,percent of total billed charges,,,85,,10.67,percent of total billed charges,,,49,,6.15,percent of total billed charges,,,90,,11.3,percent of total billed charges,,,,,,,no IP contract,,80,,10.04,percent of total billed charges,,,,,,,no IP contract,,50,,6.28,percent of total billed charges,,,,,,no IP contract,,,78,,9.79,percent of total billed charges,,,70,,8.79,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.15,3324,
70954-0541-10 - trimethoprim 100 mg Tab,70954-0541-10,NDC,,,,inpatient,1,EA,22.35,13.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19,percent of total billed charges,,,85,,19,percent of total billed charges,,,49,,10.95,percent of total billed charges,,,90,,20.12,percent of total billed charges,,,,,,,no IP contract,,80,,17.88,percent of total billed charges,,,,,,,no IP contract,,50,,11.18,percent of total billed charges,,,,,,no IP contract,,,78,,17.43,percent of total billed charges,,,70,,15.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.95,3324,
70954-0560-10 - l-methylfolate 15 mg Tab,70954-0560-10,NDC,,,,inpatient,1,EA,27.35,16.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.25,percent of total billed charges,,,85,,23.25,percent of total billed charges,,,49,,13.4,percent of total billed charges,,,90,,24.62,percent of total billed charges,,,,,,,no IP contract,,80,,21.88,percent of total billed charges,,,,,,,no IP contract,,50,,13.68,percent of total billed charges,,,,,,no IP contract,,,78,,21.33,percent of total billed charges,,,70,,19.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.4,3324,
71288-0005-20 - ampicillin-sulbactam 1 g-0.5 g REC I,71288-0005-20,NDC,,,,inpatient,1,EA,114.7,68.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,92.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,97.5,percent of total billed charges,,,85,,97.5,percent of total billed charges,,,49,,56.2,percent of total billed charges,,,90,,103.23,percent of total billed charges,,,,,,,no IP contract,,80,,91.76,percent of total billed charges,,,,,,,no IP contract,,50,,57.35,percent of total billed charges,,,,,,no IP contract,,,78,,89.47,percent of total billed charges,,,70,,80.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,56.2,3324,
71288-0403-02 - heparin 5000 units/mL Soln,71288-0403-02,NDC,,,,inpatient,1,ML,28.55,17.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.27,percent of total billed charges,,,85,,24.27,percent of total billed charges,,,49,,13.99,percent of total billed charges,,,90,,25.7,percent of total billed charges,,,,,,,no IP contract,,80,,22.84,percent of total billed charges,,,,,,,no IP contract,,50,,14.28,percent of total billed charges,,,,,,no IP contract,,,78,,22.27,percent of total billed charges,,,70,,19.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.99,3324,
71288-0410-83 - enoxaparin 40 mg/0.4 mL Soln,71288-0410-83,NDC,,,,inpatient,0.4,ML,161.05,96.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,130.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,136.89,percent of total billed charges,,,85,,136.89,percent of total billed charges,,,49,,78.91,percent of total billed charges,,,90,,144.95,percent of total billed charges,,,,,,,no IP contract,,80,,128.84,percent of total billed charges,,,,,,,no IP contract,,50,,80.53,percent of total billed charges,,,,,,no IP contract,,,78,,125.62,percent of total billed charges,,,70,,112.74,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,78.91,3324,
71288-0435-92 - enoxaparin 80 mg/0.8 mL Soln,71288-0435-92,NDC,,,,inpatient,0.8,ML,64.65,38.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,52.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,54.95,percent of total billed charges,,,85,,54.95,percent of total billed charges,,,49,,31.68,percent of total billed charges,,,90,,58.19,percent of total billed charges,,,,,,,no IP contract,,80,,51.72,percent of total billed charges,,,,,,,no IP contract,,50,,32.33,percent of total billed charges,,,,,,no IP contract,,,78,,50.43,percent of total billed charges,,,70,,45.26,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,31.68,3324,
71288-0802-04 - doxercalciferol 2 mcg/mL Soln,71288-0802-04,NDC,,,,inpatient,2,ML,39.65,23.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,32.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.7,percent of total billed charges,,,85,,33.7,percent of total billed charges,,,49,,19.43,percent of total billed charges,,,90,,35.69,percent of total billed charges,,,,,,,no IP contract,,80,,31.72,percent of total billed charges,,,,,,,no IP contract,,50,,19.83,percent of total billed charges,,,,,,no IP contract,,,78,,30.93,percent of total billed charges,,,70,,27.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.43,3324,
71351-0010-01 - potassium phosphate-sodium phosphate 250 mg-280 mg-160 mg REC P,71351-0010-01,NDC,,,,inpatient,1,UN,7.5,4.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.38,percent of total billed charges,,,85,,6.38,percent of total billed charges,,,49,,3.68,percent of total billed charges,,,90,,6.75,percent of total billed charges,,,,,,,no IP contract,,80,,6,percent of total billed charges,,,,,,,no IP contract,,50,,3.75,percent of total billed charges,,,,,,no IP contract,,,78,,5.85,percent of total billed charges,,,70,,5.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.68,3324,
71399-8022-01 - acetaminophen 500 mg Tab,71399-8022-01,NDC,,,,inpatient,1,EA,4.05,2.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.44,percent of total billed charges,,,85,,3.44,percent of total billed charges,,,49,,1.98,percent of total billed charges,,,90,,3.65,percent of total billed charges,,,,,,,no IP contract,,80,,3.24,percent of total billed charges,,,,,,,no IP contract,,50,,2.03,percent of total billed charges,,,,,,no IP contract,,,78,,3.16,percent of total billed charges,,,70,,2.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.98,3324,
71399-8237-08 - senna 8.8 mg/5 mL Syrup,71399-8237-08,NDC,,,,inpatient,1,ML,6,3.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.1,percent of total billed charges,,,85,,5.1,percent of total billed charges,,,49,,2.94,percent of total billed charges,,,90,,5.4,percent of total billed charges,,,,,,,no IP contract,,80,,4.8,percent of total billed charges,,,,,,,no IP contract,,50,,3,percent of total billed charges,,,,,,no IP contract,,,78,,4.68,percent of total billed charges,,,70,,4.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.94,3324,
71399-8434-03 - Urea 20% Cream,71399-8434-03,NDC,,,,inpatient,1,UN,136.65,81.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,110.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,116.15,percent of total billed charges,,,85,,116.15,percent of total billed charges,,,49,,66.96,percent of total billed charges,,,90,,122.99,percent of total billed charges,,,,,,,no IP contract,,80,,109.32,percent of total billed charges,,,,,,,no IP contract,,50,,68.33,percent of total billed charges,,,,,,no IP contract,,,78,,106.59,percent of total billed charges,,,70,,95.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,66.96,3324,
71428-0003-60 - clindamycin topical 1% Soln,71428-0003-60,NDC,,,,inpatient,1,UN,688.95,413.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,558.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,585.61,percent of total billed charges,,,85,,585.61,percent of total billed charges,,,49,,337.59,percent of total billed charges,,,90,,620.06,percent of total billed charges,,,,,,,no IP contract,,80,,551.16,percent of total billed charges,,,,,,,no IP contract,,50,,344.48,percent of total billed charges,,,,,,no IP contract,,,78,,537.38,percent of total billed charges,,,70,,482.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,337.59,3324,
cenobamate 50 mg Tab,71699-0050-30,NDC,,,,inpatient,1,EA,376.35,225.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,304.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,319.9,percent of total billed charges,,,85,,319.9,percent of total billed charges,,,49,,184.41,percent of total billed charges,,,90,,338.72,percent of total billed charges,,,,,,,no IP contract,,80,,301.08,percent of total billed charges,,,,,,,no IP contract,,50,,188.18,percent of total billed charges,,,,,,no IP contract,,,78,,293.55,percent of total billed charges,,,70,,263.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,184.41,3324,
71699-0100-30 - cenobamate 100 mg Tab,71699-0100-30,NDC,,,,inpatient,1,EA,376.35,225.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,304.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,319.9,percent of total billed charges,,,85,,319.9,percent of total billed charges,,,49,,184.41,percent of total billed charges,,,90,,338.72,percent of total billed charges,,,,,,,no IP contract,,80,,301.08,percent of total billed charges,,,,,,,no IP contract,,50,,188.18,percent of total billed charges,,,,,,no IP contract,,,78,,293.55,percent of total billed charges,,,70,,263.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,184.41,3324,
71699-0200-30 - cenobamate 200 mg Tab,71699-0200-30,NDC,,,,inpatient,1,EA,376.35,225.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,304.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,319.9,percent of total billed charges,,,85,,319.9,percent of total billed charges,,,49,,184.41,percent of total billed charges,,,90,,338.72,percent of total billed charges,,,,,,,no IP contract,,80,,301.08,percent of total billed charges,,,,,,,no IP contract,,50,,188.18,percent of total billed charges,,,,,,no IP contract,,,78,,293.55,percent of total billed charges,,,70,,263.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,184.41,3324,
71715-0001-02 - omadacycline 100 mg REC I,71715-0001-02,NDC,,,,inpatient,5,ML,3507.05,2104.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2840.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2980.99,percent of total billed charges,,,85,,2980.99,percent of total billed charges,,,49,,1718.45,percent of total billed charges,,,90,,3156.35,percent of total billed charges,,,,,,,no IP contract,,80,,2805.64,percent of total billed charges,,,,,,,no IP contract,,50,,1753.53,percent of total billed charges,,,,,,no IP contract,,,78,,2735.5,percent of total billed charges,,,70,,2454.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
71715-0002-21 - omadacycline 150 mg Tab,71715-0002-21,NDC,,,,inpatient,1,EA,1887.95,1132.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1529.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1604.76,percent of total billed charges,,,85,,1604.76,percent of total billed charges,,,49,,925.1,percent of total billed charges,,,90,,1699.16,percent of total billed charges,,,,,,,no IP contract,,80,,1510.36,percent of total billed charges,,,,,,,no IP contract,,50,,943.98,percent of total billed charges,,,,,,no IP contract,,,78,,1472.6,percent of total billed charges,,,70,,1321.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,925.1,3324,
71839-0116-10 - enoxaparin 150 mg/mL Soln,71839-0116-10,NDC,,,,inpatient,1,ML,357.05,214.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,289.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,303.49,percent of total billed charges,,,85,,303.49,percent of total billed charges,,,49,,174.95,percent of total billed charges,,,90,,321.35,percent of total billed charges,,,,,,,no IP contract,,80,,285.64,percent of total billed charges,,,,,,,no IP contract,,50,,178.53,percent of total billed charges,,,,,,no IP contract,,,78,,278.5,percent of total billed charges,,,70,,249.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,174.95,3324,
71858-0405-05 - diclofenac topical 1.3% ER Fi,71858-0405-05,NDC,,,,inpatient,1,UN,117.2,70.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,94.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,99.62,percent of total billed charges,,,85,,99.62,percent of total billed charges,,,49,,57.43,percent of total billed charges,,,90,,105.48,percent of total billed charges,,,,,,,no IP contract,,80,,93.76,percent of total billed charges,,,,,,,no IP contract,,50,,58.6,percent of total billed charges,,,,,,no IP contract,,,78,,91.42,percent of total billed charges,,,70,,82.04,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,57.43,3324,
71930-0028-90 - pyridostigmine 60 mg Tab,71930-0028-90,NDC,,,,inpatient,1,EA,13.5,8.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.48,percent of total billed charges,,,85,,11.48,percent of total billed charges,,,49,,6.62,percent of total billed charges,,,90,,12.15,percent of total billed charges,,,,,,,no IP contract,,80,,10.8,percent of total billed charges,,,,,,,no IP contract,,50,,6.75,percent of total billed charges,,,,,,no IP contract,,,78,,10.53,percent of total billed charges,,,70,,9.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.62,3324,
72000-0310-06 - tedizolid 200 mg Tab,72000-0310-06,NDC,,,,inpatient,1,EA,4028.5,2417.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3263.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3424.23,percent of total billed charges,,,85,,3424.23,percent of total billed charges,,,49,,1973.97,percent of total billed charges,,,90,,3625.65,percent of total billed charges,,,,,,,no IP contract,,80,,3222.8,percent of total billed charges,,,,,,,no IP contract,,50,,2014.25,percent of total billed charges,,,,,,no IP contract,,,78,,3142.23,percent of total billed charges,,,70,,2819.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3625.65,
72000-0310-30 - tedizolid 200 mg Tab,72000-0310-30,NDC,,,,inpatient,1,EA,4028.5,2417.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3263.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3424.23,percent of total billed charges,,,85,,3424.23,percent of total billed charges,,,49,,1973.97,percent of total billed charges,,,90,,3625.65,percent of total billed charges,,,,,,,no IP contract,,80,,3222.8,percent of total billed charges,,,,,,,no IP contract,,50,,2014.25,percent of total billed charges,,,,,,no IP contract,,,78,,3142.23,percent of total billed charges,,,70,,2819.95,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3625.65,
72162-1176-01 - propranolol 20 mg Tab,72162-1176-01,NDC,,,,inpatient,1,EA,7.9,4.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.72,percent of total billed charges,,,85,,6.72,percent of total billed charges,,,49,,3.87,percent of total billed charges,,,90,,7.11,percent of total billed charges,,,,,,,no IP contract,,80,,6.32,percent of total billed charges,,,,,,,no IP contract,,50,,3.95,percent of total billed charges,,,,,,no IP contract,,,78,,6.16,percent of total billed charges,,,70,,5.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.87,3324,
pregabalin 100 mg Cap,72205-0014-90,NDC,,,,inpatient,1,EA,75.65,45.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,61.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,64.3,percent of total billed charges,,,85,,64.3,percent of total billed charges,,,49,,37.07,percent of total billed charges,,,90,,68.09,percent of total billed charges,,,,,,,no IP contract,,80,,60.52,percent of total billed charges,,,,,,,no IP contract,,50,,37.83,percent of total billed charges,,,,,,no IP contract,,,78,,59.01,percent of total billed charges,,,70,,52.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,37.07,3324,
72205-0023-90 - atorvastatin 20 mg Tab,72205-0023-90,NDC,,,,inpatient,1,EA,47.45,28.47,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,38.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,40.33,percent of total billed charges,,,85,,40.33,percent of total billed charges,,,49,,23.25,percent of total billed charges,,,90,,42.71,percent of total billed charges,,,,,,,no IP contract,,80,,37.96,percent of total billed charges,,,,,,,no IP contract,,50,,23.73,percent of total billed charges,,,,,,no IP contract,,,78,,37.01,percent of total billed charges,,,70,,33.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.25,3324,
vilazodone 20 mg Tab,72205-0261-30,NDC,,,,inpatient,1,EA,85.7,51.42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,69.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,72.85,percent of total billed charges,,,85,,72.85,percent of total billed charges,,,49,,41.99,percent of total billed charges,,,90,,77.13,percent of total billed charges,,,,,,,no IP contract,,80,,68.56,percent of total billed charges,,,,,,,no IP contract,,50,,42.85,percent of total billed charges,,,,,,no IP contract,,,78,,66.85,percent of total billed charges,,,70,,59.99,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,41.99,3324,
72241-0011-03 - rivastigmine 1.5 mg Cap,72241-0011-03,NDC,,,,inpatient,1,EA,5.4,3.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.59,percent of total billed charges,,,85,,4.59,percent of total billed charges,,,49,,2.65,percent of total billed charges,,,90,,4.86,percent of total billed charges,,,,,,,no IP contract,,80,,4.32,percent of total billed charges,,,,,,,no IP contract,,50,,2.7,percent of total billed charges,,,,,,no IP contract,,,78,,4.21,percent of total billed charges,,,70,,3.78,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.65,3324,
72241-0039-05 - glyBURIDE 2.5 mg Tab,72241-0039-05,NDC,,,,inpatient,1,EA,7.5,4.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.38,percent of total billed charges,,,85,,6.38,percent of total billed charges,,,49,,3.68,percent of total billed charges,,,90,,6.75,percent of total billed charges,,,,,,,no IP contract,,80,,6,percent of total billed charges,,,,,,,no IP contract,,50,,3.75,percent of total billed charges,,,,,,no IP contract,,,78,,5.85,percent of total billed charges,,,70,,5.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.68,3324,
diazePAM 5 mg/dose Spray,72252-0505-02,NDC,,,,inpatient,1,EA,3489.1,2093.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2826.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2965.74,percent of total billed charges,,,85,,2965.74,percent of total billed charges,,,49,,1709.66,percent of total billed charges,,,90,,3140.19,percent of total billed charges,,,,,,,no IP contract,,80,,2791.28,percent of total billed charges,,,,,,,no IP contract,,50,,1744.55,percent of total billed charges,,,,,,no IP contract,,,78,,2721.5,percent of total billed charges,,,70,,2442.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
diazePAM 10 mg/dose Spray,72252-0510-02,NDC,,,,inpatient,1,EA,3489.1,2093.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2826.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2965.74,percent of total billed charges,,,85,,2965.74,percent of total billed charges,,,49,,1709.66,percent of total billed charges,,,90,,3140.19,percent of total billed charges,,,,,,,no IP contract,,80,,2791.28,percent of total billed charges,,,,,,,no IP contract,,50,,1744.55,percent of total billed charges,,,,,,no IP contract,,,78,,2721.5,percent of total billed charges,,,70,,2442.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
diazePAM 15 mg/dose Spray,72252-0515-04,NDC,,,,inpatient,1,EA,3489.1,2093.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2826.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2965.74,percent of total billed charges,,,85,,2965.74,percent of total billed charges,,,49,,1709.66,percent of total billed charges,,,90,,3140.19,percent of total billed charges,,,,,,,no IP contract,,80,,2791.28,percent of total billed charges,,,,,,,no IP contract,,50,,1744.55,percent of total billed charges,,,,,,no IP contract,,,78,,2721.5,percent of total billed charges,,,70,,2442.37,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
72266-0158-01 - moxifloxacin ophthalmic 0.5% Soln,72266-0158-01,NDC,,,,inpatient,1,UN,125.2,75.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,101.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,106.42,percent of total billed charges,,,85,,106.42,percent of total billed charges,,,49,,61.35,percent of total billed charges,,,90,,112.68,percent of total billed charges,,,,,,,no IP contract,,80,,100.16,percent of total billed charges,,,,,,,no IP contract,,50,,62.6,percent of total billed charges,,,,,,no IP contract,,,78,,97.66,percent of total billed charges,,,70,,87.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,61.35,3324,
72485-0101-25 - diphenhydrAMINE 50 mg/mL Soln,72485-0101-25,NDC,,,,inpatient,1,ML,59.9,35.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,48.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,50.92,percent of total billed charges,,,85,,50.92,percent of total billed charges,,,49,,29.35,percent of total billed charges,,,90,,53.91,percent of total billed charges,,,,,,,no IP contract,,80,,47.92,percent of total billed charges,,,,,,,no IP contract,,50,,29.95,percent of total billed charges,,,,,,no IP contract,,,78,,46.72,percent of total billed charges,,,70,,41.93,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,29.35,3324,
72485-0110-10 - caffeine citrate 20 mg/mL LIQ,72485-0110-10,NDC,,,,inpatient,1,ML,71.75,43.05,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,58.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,60.99,percent of total billed charges,,,85,,60.99,percent of total billed charges,,,49,,35.16,percent of total billed charges,,,90,,64.58,percent of total billed charges,,,,,,,no IP contract,,80,,57.4,percent of total billed charges,,,,,,,no IP contract,,50,,35.88,percent of total billed charges,,,,,,no IP contract,,,78,,55.97,percent of total billed charges,,,70,,50.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,35.16,3324,
72485-0403-10 - piperacillin-tazobactam 3 g-0.375 g REC I,72485-0403-10,NDC,,,,inpatient,1,EA,153.8,92.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,124.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,130.73,percent of total billed charges,,,85,,130.73,percent of total billed charges,,,49,,75.36,percent of total billed charges,,,90,,138.42,percent of total billed charges,,,,,,,no IP contract,,80,,123.04,percent of total billed charges,,,,,,,no IP contract,,50,,76.9,percent of total billed charges,,,,,,no IP contract,,,78,,119.96,percent of total billed charges,,,70,,107.66,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,75.36,3324,
72485-0409-10 - oxacillin 2 g REC I,72485-0409-10,NDC,,,,inpatient,1,EA,100.35,60.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,81.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,85.3,percent of total billed charges,,,85,,85.3,percent of total billed charges,,,49,,49.17,percent of total billed charges,,,90,,90.32,percent of total billed charges,,,,,,,no IP contract,,80,,80.28,percent of total billed charges,,,,,,,no IP contract,,50,,50.18,percent of total billed charges,,,,,,no IP contract,,,78,,78.27,percent of total billed charges,,,70,,70.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,49.17,3324,
72485-0417-10 - ampicillin-sulbactam 2 g-1 g REC I,72485-0417-10,NDC,,,,inpatient,8,ML,62.95,37.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,50.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,53.51,percent of total billed charges,,,85,,53.51,percent of total billed charges,,,49,,30.85,percent of total billed charges,,,90,,56.66,percent of total billed charges,,,,,,,no IP contract,,80,,50.36,percent of total billed charges,,,,,,,no IP contract,,50,,31.48,percent of total billed charges,,,,,,no IP contract,,,78,,49.1,percent of total billed charges,,,70,,44.07,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,30.85,3324,
72485-0422-10 - ampicillin 2 g REC I,72485-0422-10,NDC,,,,inpatient,1,EA,146.1,87.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,118.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,124.19,percent of total billed charges,,,85,,124.19,percent of total billed charges,,,49,,71.59,percent of total billed charges,,,90,,131.49,percent of total billed charges,,,,,,,no IP contract,,80,,116.88,percent of total billed charges,,,,,,,no IP contract,,50,,73.05,percent of total billed charges,,,,,,no IP contract,,,78,,113.96,percent of total billed charges,,,70,,102.27,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,71.59,3324,
72578-0057-01 - felbamate 600 mg Tab,72578-0057-01,NDC,,,,inpatient,1,EA,32.6,19.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,26.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,27.71,percent of total billed charges,,,85,,27.71,percent of total billed charges,,,49,,15.97,percent of total billed charges,,,90,,29.34,percent of total billed charges,,,,,,,no IP contract,,80,,26.08,percent of total billed charges,,,,,,,no IP contract,,50,,16.3,percent of total billed charges,,,,,,no IP contract,,,78,,25.43,percent of total billed charges,,,70,,22.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.97,3324,
felbamate 600 mg Tab,72578-0057-16,NDC,,,,inpatient,1,EA,34.25,20.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,27.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.11,percent of total billed charges,,,85,,29.11,percent of total billed charges,,,49,,16.78,percent of total billed charges,,,90,,30.83,percent of total billed charges,,,,,,,no IP contract,,80,,27.4,percent of total billed charges,,,,,,,no IP contract,,50,,17.13,percent of total billed charges,,,,,,no IP contract,,,78,,26.72,percent of total billed charges,,,70,,23.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,16.78,3324,
72578-0062-06 - voriconazole 50 mg Tab,72578-0062-06,NDC,,,,inpatient,1,EA,161.85,97.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,131.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,137.57,percent of total billed charges,,,85,,137.57,percent of total billed charges,,,49,,79.31,percent of total billed charges,,,90,,145.67,percent of total billed charges,,,,,,,no IP contract,,80,,129.48,percent of total billed charges,,,,,,,no IP contract,,50,,80.93,percent of total billed charges,,,,,,no IP contract,,,78,,126.24,percent of total billed charges,,,70,,113.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,79.31,3324,
72578-0063-06 - voriconazole 200 mg Tab,72578-0063-06,NDC,,,,inpatient,1,EA,636,381.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,515.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,540.6,percent of total billed charges,,,85,,540.6,percent of total billed charges,,,49,,311.64,percent of total billed charges,,,90,,572.4,percent of total billed charges,,,,,,,no IP contract,,80,,508.8,percent of total billed charges,,,,,,,no IP contract,,50,,318,percent of total billed charges,,,,,,no IP contract,,,78,,496.08,percent of total billed charges,,,70,,445.2,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,311.64,3324,
72578-0084-03 - clindamycin topical 1% Soln,72578-0084-03,NDC,,,,inpatient,1,UN,633.95,380.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,513.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,538.86,percent of total billed charges,,,85,,538.86,percent of total billed charges,,,49,,310.64,percent of total billed charges,,,90,,570.56,percent of total billed charges,,,,,,,no IP contract,,80,,507.16,percent of total billed charges,,,,,,,no IP contract,,50,,316.98,percent of total billed charges,,,,,,no IP contract,,,78,,494.48,percent of total billed charges,,,70,,443.77,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,310.64,3324,
desonide topical 0.05% Cream,72578-0086-02,NDC,,,,inpatient,1,EA,2683.15,1609.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,2173.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,2280.68,percent of total billed charges,,,85,,2280.68,percent of total billed charges,,,49,,1314.74,percent of total billed charges,,,90,,2414.84,percent of total billed charges,,,,,,,no IP contract,,80,,2146.52,percent of total billed charges,,,,,,,no IP contract,,50,,1341.58,percent of total billed charges,,,,,,no IP contract,,,78,,2092.86,percent of total billed charges,,,70,,1878.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3324,
enoxaparin 40 mg/0.4 mL Soln,72603-0175-10,NDC,,,,inpatient,1,EA,207.45,124.47,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,168.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,176.33,percent of total billed charges,,,85,,176.33,percent of total billed charges,,,49,,101.65,percent of total billed charges,,,90,,186.71,percent of total billed charges,,,,,,,no IP contract,,80,,165.96,percent of total billed charges,,,,,,,no IP contract,,50,,103.73,percent of total billed charges,,,,,,no IP contract,,,78,,161.81,percent of total billed charges,,,70,,145.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,101.65,3324,
atovaquone 750 mg / 5 mL Susp,72603-0248-01,NDC,,,,inpatient,1,mL,61.3,36.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,49.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,52.11,percent of total billed charges,,,85,,52.11,percent of total billed charges,,,49,,30.04,percent of total billed charges,,,90,,55.17,percent of total billed charges,,,,,,,no IP contract,,80,,49.04,percent of total billed charges,,,,,,,no IP contract,,50,,30.65,percent of total billed charges,,,,,,no IP contract,,,78,,47.81,percent of total billed charges,,,70,,42.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,30.04,3324,
72611-0740-10 - metoprolol 1 mg/mL Soln,72611-0740-10,NDC,,,,inpatient,5,ML,19.45,11.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.53,percent of total billed charges,,,85,,16.53,percent of total billed charges,,,49,,9.53,percent of total billed charges,,,90,,17.51,percent of total billed charges,,,,,,,no IP contract,,80,,15.56,percent of total billed charges,,,,,,,no IP contract,,50,,9.73,percent of total billed charges,,,,,,no IP contract,,,78,,15.17,percent of total billed charges,,,70,,13.62,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.53,3324,
72611-0761-10 - vancomycin 500 mg REC I,72611-0761-10,NDC,,,,inpatient,5,ML,105.1,63.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,85.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,89.34,percent of total billed charges,,,85,,89.34,percent of total billed charges,,,49,,51.5,percent of total billed charges,,,90,,94.59,percent of total billed charges,,,,,,,no IP contract,,80,,84.08,percent of total billed charges,,,,,,,no IP contract,,50,,52.55,percent of total billed charges,,,,,,no IP contract,,,78,,81.98,percent of total billed charges,,,70,,73.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,51.5,3324,
potassium chloride 20 mEq REC P,72888-0024-07,NDC,,,,inpatient,1,EA,89.2,53.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,72.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,75.82,percent of total billed charges,,,85,,75.82,percent of total billed charges,,,49,,43.71,percent of total billed charges,,,90,,80.28,percent of total billed charges,,,,,,,no IP contract,,80,,71.36,percent of total billed charges,,,,,,,no IP contract,,50,,44.6,percent of total billed charges,,,,,,no IP contract,,,78,,69.58,percent of total billed charges,,,70,,62.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,43.71,3324,
72888-0030-01 - oxybutynin 5 mg/24 hours ER Ta,72888-0030-01,NDC,,,,inpatient,1,EA,30,18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.5,percent of total billed charges,,,85,,25.5,percent of total billed charges,,,49,,14.7,percent of total billed charges,,,90,,27,percent of total billed charges,,,,,,,no IP contract,,80,,24,percent of total billed charges,,,,,,,no IP contract,,50,,15,percent of total billed charges,,,,,,no IP contract,,,78,,23.4,percent of total billed charges,,,70,,21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.7,3324,
72888-0031-01 - oxybutynin 10 mg/24 hr ER Ta,72888-0031-01,NDC,,,,inpatient,1,EA,30,18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.5,percent of total billed charges,,,85,,25.5,percent of total billed charges,,,49,,14.7,percent of total billed charges,,,90,,27,percent of total billed charges,,,,,,,no IP contract,,80,,24,percent of total billed charges,,,,,,,no IP contract,,50,,15,percent of total billed charges,,,,,,no IP contract,,,78,,23.4,percent of total billed charges,,,70,,21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.7,3324,
72888-0035-01 - carvedilol 6.25 mg Tab,72888-0035-01,NDC,,,,inpatient,1,EA,18.45,11.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.68,percent of total billed charges,,,85,,15.68,percent of total billed charges,,,49,,9.04,percent of total billed charges,,,90,,16.61,percent of total billed charges,,,,,,,no IP contract,,80,,14.76,percent of total billed charges,,,,,,,no IP contract,,50,,9.23,percent of total billed charges,,,,,,no IP contract,,,78,,14.39,percent of total billed charges,,,70,,12.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.04,3324,
carvedilol 12.5 mg Tab,72888-0036-01,NDC,,,,inpatient,1,EA,19.65,11.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.92,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.7,percent of total billed charges,,,85,,16.7,percent of total billed charges,,,49,,9.63,percent of total billed charges,,,90,,17.69,percent of total billed charges,,,,,,,no IP contract,,80,,15.72,percent of total billed charges,,,,,,,no IP contract,,50,,9.83,percent of total billed charges,,,,,,no IP contract,,,78,,15.33,percent of total billed charges,,,70,,13.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.63,3324,
carvedilol 25 mg Tab,72888-0037-01,NDC,,,,inpatient,1,EA,20.85,12.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.72,percent of total billed charges,,,85,,17.72,percent of total billed charges,,,49,,10.22,percent of total billed charges,,,90,,18.77,percent of total billed charges,,,,,,,no IP contract,,80,,16.68,percent of total billed charges,,,,,,,no IP contract,,50,,10.43,percent of total billed charges,,,,,,no IP contract,,,78,,16.26,percent of total billed charges,,,70,,14.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.22,3324,
72888-0052-01 - metOLazone 2.5 mg Tab,72888-0052-01,NDC,,,,inpatient,1,EA,20.3,12.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.26,percent of total billed charges,,,85,,17.26,percent of total billed charges,,,49,,9.95,percent of total billed charges,,,90,,18.27,percent of total billed charges,,,,,,,no IP contract,,80,,16.24,percent of total billed charges,,,,,,,no IP contract,,50,,10.15,percent of total billed charges,,,,,,no IP contract,,,78,,15.83,percent of total billed charges,,,70,,14.21,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.95,3324,
cevimeline 30 mg Cap,72888-0118-30,NDC,,,,inpatient,1,EA,32.35,19.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,26.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,27.5,percent of total billed charges,,,85,,27.5,percent of total billed charges,,,49,,15.85,percent of total billed charges,,,90,,29.12,percent of total billed charges,,,,,,,no IP contract,,80,,25.88,percent of total billed charges,,,,,,,no IP contract,,50,,16.18,percent of total billed charges,,,,,,no IP contract,,,78,,25.23,percent of total billed charges,,,70,,22.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,15.85,3324,
73336-0075-30 - vibegron 75 mg Tab,73336-0075-30,NDC,,,,inpatient,1,EA,149.65,89.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,121.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,127.2,percent of total billed charges,,,85,,127.2,percent of total billed charges,,,49,,73.33,percent of total billed charges,,,90,,134.69,percent of total billed charges,,,,,,,no IP contract,,80,,119.72,percent of total billed charges,,,,,,,no IP contract,,50,,74.83,percent of total billed charges,,,,,,no IP contract,,,78,,116.73,percent of total billed charges,,,70,,104.76,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,73.33,3324,
74300-0003-93 - hydrocortisone topical 1% Ointm,74300-0003-93,NDC,,,,inpatient,1,UN,41.9,25.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,33.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,35.62,percent of total billed charges,,,85,,35.62,percent of total billed charges,,,49,,20.53,percent of total billed charges,,,90,,37.71,percent of total billed charges,,,,,,,no IP contract,,80,,33.52,percent of total billed charges,,,,,,,no IP contract,,50,,20.95,percent of total billed charges,,,,,,no IP contract,,,78,,32.68,percent of total billed charges,,,70,,29.33,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,20.53,3324,
74312-0006-40 - riboflavin 100 mg Tab,74312-0006-40,NDC,,,,inpatient,1,EA,4.3,2.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.66,percent of total billed charges,,,85,,3.66,percent of total billed charges,,,49,,2.11,percent of total billed charges,,,90,,3.87,percent of total billed charges,,,,,,,no IP contract,,80,,3.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.15,percent of total billed charges,,,,,,no IP contract,,,78,,3.35,percent of total billed charges,,,70,,3.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.11,3324,
ascorbic acid 500 mg Chew,74312-0038-80,NDC,,,,inpatient,1,EA,4.6,2.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.91,percent of total billed charges,,,85,,3.91,percent of total billed charges,,,49,,2.25,percent of total billed charges,,,90,,4.14,percent of total billed charges,,,,,,,no IP contract,,80,,3.68,percent of total billed charges,,,,,,,no IP contract,,50,,2.3,percent of total billed charges,,,,,,no IP contract,,,78,,3.59,percent of total billed charges,,,70,,3.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.25,3324,
75826-0140-10 - PHENobarbital 60 mg Tab,75826-0140-10,NDC,,,,inpatient,1,EA,9.85,5.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.37,percent of total billed charges,,,85,,8.37,percent of total billed charges,,,49,,4.83,percent of total billed charges,,,90,,8.87,percent of total billed charges,,,,,,,no IP contract,,80,,7.88,percent of total billed charges,,,,,,,no IP contract,,50,,4.93,percent of total billed charges,,,,,,no IP contract,,,78,,7.68,percent of total billed charges,,,70,,6.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.83,3324,
75834-0010-60 - ergocalciferol 200 mcg/mL Soln,75834-0010-60,NDC,,,,inpatient,1,ML,10.35,6.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,8.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.8,percent of total billed charges,,,85,,8.8,percent of total billed charges,,,49,,5.07,percent of total billed charges,,,90,,9.32,percent of total billed charges,,,,,,,no IP contract,,80,,8.28,percent of total billed charges,,,,,,,no IP contract,,50,,5.18,percent of total billed charges,,,,,,no IP contract,,,78,,8.07,percent of total billed charges,,,70,,7.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.07,3324,
75834-0159-01 - verapamil 240 mg/12 hours ER Ta,75834-0159-01,NDC,,,,inpatient,1,EA,16.85,10.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.32,percent of total billed charges,,,85,,14.32,percent of total billed charges,,,49,,8.26,percent of total billed charges,,,90,,15.17,percent of total billed charges,,,,,,,no IP contract,,80,,13.48,percent of total billed charges,,,,,,,no IP contract,,50,,8.43,percent of total billed charges,,,,,,no IP contract,,,78,,13.14,percent of total billed charges,,,70,,11.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.26,3324,
erythromycin 250 mg Tab,75834-0242-30,NDC,,,,inpatient,1,EA,109,65.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,88.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,92.65,percent of total billed charges,,,85,,92.65,percent of total billed charges,,,49,,53.41,percent of total billed charges,,,90,,98.1,percent of total billed charges,,,,,,,no IP contract,,80,,87.2,percent of total billed charges,,,,,,,no IP contract,,50,,54.5,percent of total billed charges,,,,,,no IP contract,,,78,,85.02,percent of total billed charges,,,70,,76.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,53.41,3324,
erythromycin ethylsuccinate 200 mg/5 mL REC G,75834-0295-01,NDC,,,,inpatient,1,mL,39.15,23.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,33.28,percent of total billed charges,,,85,,33.28,percent of total billed charges,,,49,,19.18,percent of total billed charges,,,90,,35.24,percent of total billed charges,,,,,,,no IP contract,,80,,31.32,percent of total billed charges,,,,,,,no IP contract,,50,,19.58,percent of total billed charges,,,,,,no IP contract,,,78,,30.54,percent of total billed charges,,,70,,27.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,19.18,3324,
cloNIDine 0.1 mg/24 hr ER Fi,75907-0023-48,NDC,,,,inpatient,1,EA,285.45,171.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,231.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,242.63,percent of total billed charges,,,85,,242.63,percent of total billed charges,,,49,,139.87,percent of total billed charges,,,90,,256.91,percent of total billed charges,,,,,,,no IP contract,,80,,228.36,percent of total billed charges,,,,,,,no IP contract,,50,,142.73,percent of total billed charges,,,,,,no IP contract,,,78,,222.65,percent of total billed charges,,,70,,199.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,139.87,3324,
cloNIDine 0.2 mg/24 hr Patch,75907-0024-48,NDC,,,,inpatient,1,EA,474.3,284.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,384.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,403.16,percent of total billed charges,,,85,,403.16,percent of total billed charges,,,49,,232.41,percent of total billed charges,,,90,,426.87,percent of total billed charges,,,,,,,no IP contract,,80,,379.44,percent of total billed charges,,,,,,,no IP contract,,50,,237.15,percent of total billed charges,,,,,,no IP contract,,,78,,369.95,percent of total billed charges,,,70,,332.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,232.41,3324,
cloNIDine 0.3 mg/24 hr ER Fi,75907-0025-48,NDC,,,,inpatient,1,EA,654.4,392.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,530.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,556.24,percent of total billed charges,,,85,,556.24,percent of total billed charges,,,49,,320.66,percent of total billed charges,,,90,,588.96,percent of total billed charges,,,,,,,no IP contract,,80,,523.52,percent of total billed charges,,,,,,,no IP contract,,50,,327.2,percent of total billed charges,,,,,,no IP contract,,,78,,510.43,percent of total billed charges,,,70,,458.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,320.66,3324,
trimethoprim 100 mg Tab,75907-0043-01,NDC,,,,inpatient,1,EA,22.35,13.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,18.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,19,percent of total billed charges,,,85,,19,percent of total billed charges,,,49,,10.95,percent of total billed charges,,,90,,20.12,percent of total billed charges,,,,,,,no IP contract,,80,,17.88,percent of total billed charges,,,,,,,no IP contract,,50,,11.18,percent of total billed charges,,,,,,no IP contract,,,78,,17.43,percent of total billed charges,,,70,,15.65,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.95,3324,
dexamethasone 10 mg/mL preservative-free Soln,76045-0109-10,NDC,,,,inpatient,1,EA,67.85,40.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,54.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,57.67,percent of total billed charges,,,85,,57.67,percent of total billed charges,,,49,,33.25,percent of total billed charges,,,90,,61.07,percent of total billed charges,,,,,,,no IP contract,,80,,54.28,percent of total billed charges,,,,,,,no IP contract,,50,,33.93,percent of total billed charges,,,,,,no IP contract,,,78,,52.92,percent of total billed charges,,,70,,47.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,33.25,3324,
76170-0400-01 -,76170-0400-01,NDC,,,,inpatient,1,UN,229.15,137.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,185.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,194.78,percent of total billed charges,,,85,,194.78,percent of total billed charges,,,49,,112.28,percent of total billed charges,,,90,,206.24,percent of total billed charges,,,,,,,no IP contract,,80,,183.32,percent of total billed charges,,,,,,,no IP contract,,50,,114.58,percent of total billed charges,,,,,,no IP contract,,,78,,178.74,percent of total billed charges,,,70,,160.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,112.28,3324,
ipratropium 500 mcg/2.5 mL Soln,76204-0100-01,NDC,,,,inpatient,1,EA,24.65,14.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.95,percent of total billed charges,,,85,,20.95,percent of total billed charges,,,49,,12.08,percent of total billed charges,,,90,,22.19,percent of total billed charges,,,,,,,no IP contract,,80,,19.72,percent of total billed charges,,,,,,,no IP contract,,50,,12.33,percent of total billed charges,,,,,,no IP contract,,,78,,19.23,percent of total billed charges,,,70,,17.26,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.08,3324,
76204-0200-25 - albuterol 2.5 mg/3 mL (0.083%) Soln,76204-0200-25,NDC,,,,inpatient,3,ML,20.2,12.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,16.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,17.17,percent of total billed charges,,,85,,17.17,percent of total billed charges,,,49,,9.9,percent of total billed charges,,,90,,18.18,percent of total billed charges,,,,,,,no IP contract,,80,,16.16,percent of total billed charges,,,,,,,no IP contract,,50,,10.1,percent of total billed charges,,,,,,no IP contract,,,78,,15.76,percent of total billed charges,,,70,,14.14,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.9,3324,
76204-0600-01 - albuterol-ipratropium 2.5 mg-0.5 mg/3 mL Soln,76204-0600-01,NDC,,,,inpatient,3,ML,28.45,17.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,23.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,24.18,percent of total billed charges,,,85,,24.18,percent of total billed charges,,,49,,13.94,percent of total billed charges,,,90,,25.61,percent of total billed charges,,,,,,,no IP contract,,80,,22.76,percent of total billed charges,,,,,,,no IP contract,,50,,14.23,percent of total billed charges,,,,,,no IP contract,,,78,,22.19,percent of total billed charges,,,70,,19.92,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.94,3324,
76204-0600-60 - albuterol-ipratropium 2.5 mg-0.5 mg/3 mL Soln,76204-0600-60,NDC,,,,inpatient,3,ML,27.45,16.47,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.33,percent of total billed charges,,,85,,23.33,percent of total billed charges,,,49,,13.45,percent of total billed charges,,,90,,24.71,percent of total billed charges,,,,,,,no IP contract,,80,,21.96,percent of total billed charges,,,,,,,no IP contract,,50,,13.73,percent of total billed charges,,,,,,no IP contract,,,78,,21.41,percent of total billed charges,,,70,,19.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.45,3324,
76204-0800-01 - levalbuterol 0.63 mg/3 mL Soln,76204-0800-01,NDC,,,,inpatient,3,ML,25.95,15.57,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.06,percent of total billed charges,,,85,,22.06,percent of total billed charges,,,49,,12.72,percent of total billed charges,,,90,,23.36,percent of total billed charges,,,,,,,no IP contract,,80,,20.76,percent of total billed charges,,,,,,,no IP contract,,50,,12.98,percent of total billed charges,,,,,,no IP contract,,,78,,20.24,percent of total billed charges,,,70,,18.17,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.72,3324,
76204-0800-25 - levalbuterol 0.63 mg/3 mL Soln,76204-0800-25,NDC,,,,inpatient,3,ML,25.95,15.57,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.06,percent of total billed charges,,,85,,22.06,percent of total billed charges,,,49,,12.72,percent of total billed charges,,,90,,23.36,percent of total billed charges,,,,,,,no IP contract,,80,,20.76,percent of total billed charges,,,,,,,no IP contract,,50,,12.98,percent of total billed charges,,,,,,no IP contract,,,78,,20.24,percent of total billed charges,,,70,,18.17,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.72,3324,
76204-0900-01 - levalbuterol 1.25 mg/3 mL Soln,76204-0900-01,NDC,,,,inpatient,3,ML,25.95,15.57,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.06,percent of total billed charges,,,85,,22.06,percent of total billed charges,,,49,,12.72,percent of total billed charges,,,90,,23.36,percent of total billed charges,,,,,,,no IP contract,,80,,20.76,percent of total billed charges,,,,,,,no IP contract,,50,,12.98,percent of total billed charges,,,,,,no IP contract,,,78,,20.24,percent of total billed charges,,,70,,18.17,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.72,3324,
76204-0900-25 - levalbuterol 1.25 mg/3 mL Soln,76204-0900-25,NDC,,,,inpatient,3,ML,25.95,15.57,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.06,percent of total billed charges,,,85,,22.06,percent of total billed charges,,,49,,12.72,percent of total billed charges,,,90,,23.36,percent of total billed charges,,,,,,,no IP contract,,80,,20.76,percent of total billed charges,,,,,,,no IP contract,,50,,12.98,percent of total billed charges,,,,,,no IP contract,,,78,,20.24,percent of total billed charges,,,70,,18.17,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.72,3324,
vilazodone 20 mg Tab,76282-0545-30,NDC,,,,inpatient,1,EA,30.6,18.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,26.01,percent of total billed charges,,,85,,26.01,percent of total billed charges,,,49,,14.99,percent of total billed charges,,,90,,27.54,percent of total billed charges,,,,,,,no IP contract,,80,,24.48,percent of total billed charges,,,,,,,no IP contract,,50,,15.3,percent of total billed charges,,,,,,no IP contract,,,78,,23.87,percent of total billed charges,,,70,,21.42,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.99,3324,
76310-0024-25 - foscarnet 24 mg/mL Soln,76310-0024-25,NDC,,,,inpatient,1,ML,67.85,40.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,54.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,57.67,percent of total billed charges,,,85,,57.67,percent of total billed charges,,,49,,33.25,percent of total billed charges,,,90,,61.07,percent of total billed charges,,,,,,,no IP contract,,80,,54.28,percent of total billed charges,,,,,,,no IP contract,,50,,33.93,percent of total billed charges,,,,,,no IP contract,,,78,,52.92,percent of total billed charges,,,70,,47.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,33.25,3324,
76329-3012-05 - lidocaine topical 2% Gel,76329-3012-05,NDC,,,,inpatient,5,ML,66.7,40.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,54.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56.7,percent of total billed charges,,,85,,56.7,percent of total billed charges,,,49,,32.68,percent of total billed charges,,,90,,60.03,percent of total billed charges,,,,,,,no IP contract,,80,,53.36,percent of total billed charges,,,,,,,no IP contract,,50,,33.35,percent of total billed charges,,,,,,no IP contract,,,78,,52.03,percent of total billed charges,,,70,,46.69,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,32.68,3324,
76329-3301-01 - glucose 50% Soln,76329-3301-01,NDC,,,,inpatient,50,ML,68.35,41.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,55.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,58.1,percent of total billed charges,,,85,,58.1,percent of total billed charges,,,49,,33.49,percent of total billed charges,,,90,,61.52,percent of total billed charges,,,,,,,no IP contract,,80,,54.68,percent of total billed charges,,,,,,,no IP contract,,50,,34.18,percent of total billed charges,,,,,,no IP contract,,,78,,53.31,percent of total billed charges,,,70,,47.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,33.49,3324,
76329-3316-01 - EPINEPHrine 0.1 mg/mL Soln,76329-3316-01,NDC,,,,inpatient,1,ML,97.85,58.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,79.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,83.17,percent of total billed charges,,,85,,83.17,percent of total billed charges,,,49,,47.95,percent of total billed charges,,,90,,88.07,percent of total billed charges,,,,,,,no IP contract,,80,,78.28,percent of total billed charges,,,,,,,no IP contract,,50,,48.93,percent of total billed charges,,,,,,no IP contract,,,78,,76.32,percent of total billed charges,,,70,,68.5,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,47.95,3324,
76329-3339-01 - atropine 0.1 mg/mL Soln,76329-3339-01,NDC,,,,inpatient,10,ML,100.35,60.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,81.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,85.3,percent of total billed charges,,,85,,85.3,percent of total billed charges,,,49,,49.17,percent of total billed charges,,,90,,90.32,percent of total billed charges,,,,,,,no IP contract,,80,,80.28,percent of total billed charges,,,,,,,no IP contract,,50,,50.18,percent of total billed charges,,,,,,no IP contract,,,78,,78.27,percent of total billed charges,,,70,,70.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,49.17,3324,
atropine 0.1 mg/mL Soln,76329-3340-01,NDC,,,,inpatient,1,EA,124.8,74.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,101.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,106.08,percent of total billed charges,,,85,,106.08,percent of total billed charges,,,49,,61.15,percent of total billed charges,,,90,,112.32,percent of total billed charges,,,,,,,no IP contract,,80,,99.84,percent of total billed charges,,,,,,,no IP contract,,50,,62.4,percent of total billed charges,,,,,,no IP contract,,,78,,97.34,percent of total billed charges,,,70,,87.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,61.15,3324,
76385-0114-01 - sotalol 80 mg Tab,76385-0114-01,NDC,,,,inpatient,1,EA,24.2,14.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,19.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,20.57,percent of total billed charges,,,85,,20.57,percent of total billed charges,,,49,,11.86,percent of total billed charges,,,90,,21.78,percent of total billed charges,,,,,,,no IP contract,,80,,19.36,percent of total billed charges,,,,,,,no IP contract,,50,,12.1,percent of total billed charges,,,,,,no IP contract,,,78,,18.88,percent of total billed charges,,,70,,16.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,11.86,3324,
76385-0129-01 - metFORMIN 750 mg ER Ta,76385-0129-01,NDC,,,,inpatient,1,EA,13.35,8.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,11.35,percent of total billed charges,,,85,,11.35,percent of total billed charges,,,49,,6.54,percent of total billed charges,,,90,,12.02,percent of total billed charges,,,,,,,no IP contract,,80,,10.68,percent of total billed charges,,,,,,,no IP contract,,50,,6.68,percent of total billed charges,,,,,,no IP contract,,,78,,10.41,percent of total billed charges,,,70,,9.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.54,3324,
76385-0136-01 - metOLazone 2.5 mg Tab,76385-0136-01,NDC,,,,inpatient,1,EA,21.85,13.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,17.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,18.57,percent of total billed charges,,,85,,18.57,percent of total billed charges,,,49,,10.71,percent of total billed charges,,,90,,19.67,percent of total billed charges,,,,,,,no IP contract,,80,,17.48,percent of total billed charges,,,,,,,no IP contract,,50,,10.93,percent of total billed charges,,,,,,no IP contract,,,78,,17.04,percent of total billed charges,,,70,,15.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,10.71,3324,
76439-0343-10 - potassium chloride 20 mEq REC P,76439-0343-10,NDC,,,,inpatient,1,UN,51.85,31.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,44.07,percent of total billed charges,,,85,,44.07,percent of total billed charges,,,49,,25.41,percent of total billed charges,,,90,,46.67,percent of total billed charges,,,,,,,no IP contract,,80,,41.48,percent of total billed charges,,,,,,,no IP contract,,50,,25.93,percent of total billed charges,,,,,,no IP contract,,,78,,40.44,percent of total billed charges,,,70,,36.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.41,3324,
76439-0343-30 - potassium chloride 20 mEq REC P,76439-0343-30,NDC,,,,inpatient,1,UN,51.85,31.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,44.07,percent of total billed charges,,,85,,44.07,percent of total billed charges,,,49,,25.41,percent of total billed charges,,,90,,46.67,percent of total billed charges,,,,,,,no IP contract,,80,,41.48,percent of total billed charges,,,,,,,no IP contract,,50,,25.93,percent of total billed charges,,,,,,no IP contract,,,78,,40.44,percent of total billed charges,,,70,,36.3,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.41,3324,
76439-0358-90 - l-methylfolate 15 mg Tab,76439-0358-90,NDC,,,,inpatient,1,EA,27.35,16.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,22.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,23.25,percent of total billed charges,,,85,,23.25,percent of total billed charges,,,49,,13.4,percent of total billed charges,,,90,,24.62,percent of total billed charges,,,,,,,no IP contract,,80,,21.88,percent of total billed charges,,,,,,,no IP contract,,50,,13.68,percent of total billed charges,,,,,,no IP contract,,,78,,21.33,percent of total billed charges,,,70,,19.15,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,13.4,3324,
77333-0800-50 - saccharomyces boulardii lyo 250 mg Cap,77333-0800-50,NDC,,,,inpatient,1,EA,11.3,6.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.15,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.61,percent of total billed charges,,,85,,9.61,percent of total billed charges,,,49,,5.54,percent of total billed charges,,,90,,10.17,percent of total billed charges,,,,,,,no IP contract,,80,,9.04,percent of total billed charges,,,,,,,no IP contract,,50,,5.65,percent of total billed charges,,,,,,no IP contract,,,78,,8.81,percent of total billed charges,,,70,,7.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.54,3324,
77333-0812-10 - simethicone 80 mg Chew tab,77333-0812-10,NDC,,,,inpatient,1,EA,5.75,3.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.89,percent of total billed charges,,,85,,4.89,percent of total billed charges,,,49,,2.82,percent of total billed charges,,,90,,5.18,percent of total billed charges,,,,,,,no IP contract,,80,,4.6,percent of total billed charges,,,,,,,no IP contract,,50,,2.88,percent of total billed charges,,,,,,no IP contract,,,78,,4.49,percent of total billed charges,,,70,,4.03,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.82,3324,
77333-0827-10 - sodium bicarbonate 650 mg Tab,77333-0827-10,NDC,,,,inpatient,1,EA,6.15,3.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.23,percent of total billed charges,,,85,,5.23,percent of total billed charges,,,49,,3.01,percent of total billed charges,,,90,,5.54,percent of total billed charges,,,,,,,no IP contract,,80,,4.92,percent of total billed charges,,,,,,,no IP contract,,50,,3.08,percent of total billed charges,,,,,,no IP contract,,,78,,4.8,percent of total billed charges,,,70,,4.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.01,3324,
77333-0835-10 - sodium chloride 1 g Tab,77333-0835-10,NDC,,,,inpatient,1,EA,6.15,3.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.23,percent of total billed charges,,,85,,5.23,percent of total billed charges,,,49,,3.01,percent of total billed charges,,,90,,5.54,percent of total billed charges,,,,,,,no IP contract,,80,,4.92,percent of total billed charges,,,,,,,no IP contract,,50,,3.08,percent of total billed charges,,,,,,no IP contract,,,78,,4.8,percent of total billed charges,,,70,,4.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.01,3324,
77333-0844-10 - sodium chloride 1 g Tab,77333-0844-10,NDC,,,,inpatient,1,EA,7.1,4.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.04,percent of total billed charges,,,85,,6.04,percent of total billed charges,,,49,,3.48,percent of total billed charges,,,90,,6.39,percent of total billed charges,,,,,,,no IP contract,,80,,5.68,percent of total billed charges,,,,,,,no IP contract,,50,,3.55,percent of total billed charges,,,,,,no IP contract,,,78,,5.54,percent of total billed charges,,,70,,4.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.48,3324,
77333-0934-10 - thiamine 100 mg Tab,77333-0934-10,NDC,,,,inpatient,1,EA,4.2,2.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.57,percent of total billed charges,,,85,,3.57,percent of total billed charges,,,49,,2.06,percent of total billed charges,,,90,,3.78,percent of total billed charges,,,,,,,no IP contract,,80,,3.36,percent of total billed charges,,,,,,,no IP contract,,50,,2.1,percent of total billed charges,,,,,,no IP contract,,,78,,3.28,percent of total billed charges,,,70,,2.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.06,3324,
77333-0937-10 - cyanocobalamin 500 mcg Tab,77333-0937-10,NDC,,,,inpatient,1,EA,5.35,3.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.55,percent of total billed charges,,,85,,4.55,percent of total billed charges,,,49,,2.62,percent of total billed charges,,,90,,4.82,percent of total billed charges,,,,,,,no IP contract,,80,,4.28,percent of total billed charges,,,,,,,no IP contract,,50,,2.68,percent of total billed charges,,,,,,no IP contract,,,78,,4.17,percent of total billed charges,,,70,,3.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.62,3324,
77333-0938-10 - cyanocobalamin 1000 mcg Tab,77333-0938-10,NDC,,,,inpatient,1,EA,5.5,3.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.68,percent of total billed charges,,,85,,4.68,percent of total billed charges,,,49,,2.7,percent of total billed charges,,,90,,4.95,percent of total billed charges,,,,,,,no IP contract,,80,,4.4,percent of total billed charges,,,,,,,no IP contract,,50,,2.75,percent of total billed charges,,,,,,no IP contract,,,78,,4.29,percent of total billed charges,,,70,,3.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.7,3324,
77333-0940-10 - pyridoxine 50 mg Tab,77333-0940-10,NDC,,,,inpatient,1,EA,5.2,3.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.42,percent of total billed charges,,,85,,4.42,percent of total billed charges,,,49,,2.55,percent of total billed charges,,,90,,4.68,percent of total billed charges,,,,,,,no IP contract,,80,,4.16,percent of total billed charges,,,,,,,no IP contract,,50,,2.6,percent of total billed charges,,,,,,no IP contract,,,78,,4.06,percent of total billed charges,,,70,,3.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.55,3324,
77333-0948-10 - cholecalciferol 400 intl units Tab,77333-0948-10,NDC,,,,inpatient,1,EA,6.35,3.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.4,percent of total billed charges,,,85,,5.4,percent of total billed charges,,,49,,3.11,percent of total billed charges,,,90,,5.72,percent of total billed charges,,,,,,,no IP contract,,80,,5.08,percent of total billed charges,,,,,,,no IP contract,,50,,3.18,percent of total billed charges,,,,,,no IP contract,,,78,,4.95,percent of total billed charges,,,70,,4.45,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.11,3324,
77333-0951-10 - vitamin E 180 mg Cap,77333-0951-10,NDC,,,,inpatient,1,EA,5.9,3.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.02,percent of total billed charges,,,85,,5.02,percent of total billed charges,,,49,,2.89,percent of total billed charges,,,90,,5.31,percent of total billed charges,,,,,,,no IP contract,,80,,4.72,percent of total billed charges,,,,,,,no IP contract,,50,,2.95,percent of total billed charges,,,,,,no IP contract,,,78,,4.6,percent of total billed charges,,,70,,4.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.89,3324,
77333-0983-10 - zinc sulfate 220 mg Cap,77333-0983-10,NDC,,,,inpatient,1,EA,5.65,3.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,4.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4.8,percent of total billed charges,,,85,,4.8,percent of total billed charges,,,49,,2.77,percent of total billed charges,,,90,,5.09,percent of total billed charges,,,,,,,no IP contract,,80,,4.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.83,percent of total billed charges,,,,,,no IP contract,,,78,,4.41,percent of total billed charges,,,70,,3.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.77,3324,
78112-0011-03 - phenol topical 1.4% Spray,78112-0011-03,NDC,,,,inpatient,1,UN,38.7,23.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,31.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,32.9,percent of total billed charges,,,85,,32.9,percent of total billed charges,,,49,,18.96,percent of total billed charges,,,90,,34.83,percent of total billed charges,,,,,,,no IP contract,,80,,30.96,percent of total billed charges,,,,,,,no IP contract,,50,,19.35,percent of total billed charges,,,,,,no IP contract,,,78,,30.19,percent of total billed charges,,,70,,27.09,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.96,3324,
79854-0200-10 - thiamine 100 mg Tab,79854-0200-10,NDC,,,,inpatient,1,EA,4.05,2.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.44,percent of total billed charges,,,85,,3.44,percent of total billed charges,,,49,,1.98,percent of total billed charges,,,90,,3.65,percent of total billed charges,,,,,,,no IP contract,,80,,3.24,percent of total billed charges,,,,,,,no IP contract,,50,,2.03,percent of total billed charges,,,,,,no IP contract,,,78,,3.16,percent of total billed charges,,,70,,2.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.98,3324,
80208-0000-04 -,80208-0000-04,NDC,,,,inpatient,1,UN,99.2,59.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,80.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,84.32,percent of total billed charges,,,85,,84.32,percent of total billed charges,,,49,,48.61,percent of total billed charges,,,90,,89.28,percent of total billed charges,,,,,,,no IP contract,,80,,79.36,percent of total billed charges,,,,,,,no IP contract,,50,,49.6,percent of total billed charges,,,,,,no IP contract,,,78,,77.38,percent of total billed charges,,,70,,69.44,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,48.61,3324,
80681-0049-00 - multivitamin Multiple Vitamins Chew,80681-0049-00,NDC,,,,inpatient,1,EA,4.05,2.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.44,percent of total billed charges,,,85,,3.44,percent of total billed charges,,,49,,1.98,percent of total billed charges,,,90,,3.65,percent of total billed charges,,,,,,,no IP contract,,80,,3.24,percent of total billed charges,,,,,,,no IP contract,,50,,2.03,percent of total billed charges,,,,,,no IP contract,,,78,,3.16,percent of total billed charges,,,70,,2.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.98,3324,
multivitamin with minerals Antioxidant Multiple Vitamins and Minerals Tab,80681-0052-00,NDC,,,,inpatient,1,EA,4.45,2.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.78,percent of total billed charges,,,85,,3.78,percent of total billed charges,,,49,,2.18,percent of total billed charges,,,90,,4.01,percent of total billed charges,,,,,,,no IP contract,,80,,3.56,percent of total billed charges,,,,,,,no IP contract,,50,,2.23,percent of total billed charges,,,,,,no IP contract,,,78,,3.47,percent of total billed charges,,,70,,3.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.18,3324,
80681-0057-00 - niacin 100 mg Tab,80681-0057-00,NDC,,,,inpatient,1,EA,18,10.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.3,percent of total billed charges,,,85,,15.3,percent of total billed charges,,,49,,8.82,percent of total billed charges,,,90,,16.2,percent of total billed charges,,,,,,,no IP contract,,80,,14.4,percent of total billed charges,,,,,,,no IP contract,,50,,9,percent of total billed charges,,,,,,no IP contract,,,78,,14.04,percent of total billed charges,,,70,,12.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.82,3324,
80681-0071-00 - cyanocobalamin 100 mcg Tab,80681-0071-00,NDC,,,,inpatient,1,EA,4.05,2.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.44,percent of total billed charges,,,85,,3.44,percent of total billed charges,,,49,,1.98,percent of total billed charges,,,90,,3.65,percent of total billed charges,,,,,,,no IP contract,,80,,3.24,percent of total billed charges,,,,,,,no IP contract,,50,,2.03,percent of total billed charges,,,,,,no IP contract,,,78,,3.16,percent of total billed charges,,,70,,2.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.98,3324,
melatonin 3 mg Tab,80681-0085-00,NDC,,,,inpatient,1,EA,4.4,2.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.74,percent of total billed charges,,,85,,3.74,percent of total billed charges,,,49,,2.16,percent of total billed charges,,,90,,3.96,percent of total billed charges,,,,,,,no IP contract,,80,,3.52,percent of total billed charges,,,,,,,no IP contract,,50,,2.2,percent of total billed charges,,,,,,no IP contract,,,78,,3.43,percent of total billed charges,,,70,,3.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.16,3324,
80681-0099-00 - folic acid 0.4 mg Tab,80681-0099-00,NDC,,,,inpatient,1,EA,4,2.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.4,percent of total billed charges,,,85,,3.4,percent of total billed charges,,,49,,1.96,percent of total billed charges,,,90,,3.6,percent of total billed charges,,,,,,,no IP contract,,80,,3.2,percent of total billed charges,,,,,,,no IP contract,,50,,2,percent of total billed charges,,,,,,no IP contract,,,78,,3.12,percent of total billed charges,,,70,,2.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.96,3324,
80681-0140-00 - calcium citrate 950 mg (200 mg elemental calcium) Tab,80681-0140-00,NDC,,,,inpatient,1,EA,4.05,2.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.44,percent of total billed charges,,,85,,3.44,percent of total billed charges,,,49,,1.98,percent of total billed charges,,,90,,3.65,percent of total billed charges,,,,,,,no IP contract,,80,,3.24,percent of total billed charges,,,,,,,no IP contract,,50,,2.03,percent of total billed charges,,,,,,no IP contract,,,78,,3.16,percent of total billed charges,,,70,,2.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.98,3324,
80681-0159-00 - vitamin E 90 mg Cap,80681-0159-00,NDC,,,,inpatient,1,EA,4.2,2.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.57,percent of total billed charges,,,85,,3.57,percent of total billed charges,,,49,,2.06,percent of total billed charges,,,90,,3.78,percent of total billed charges,,,,,,,no IP contract,,80,,3.36,percent of total billed charges,,,,,,,no IP contract,,50,,2.1,percent of total billed charges,,,,,,no IP contract,,,78,,3.28,percent of total billed charges,,,70,,2.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.06,3324,
80681-0160-00 - multivitamin with minerals Therapeutic Multiple Vitamins with Minerals Tab,80681-0160-00,NDC,,,,inpatient,1,EA,4.05,2.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.44,percent of total billed charges,,,85,,3.44,percent of total billed charges,,,49,,1.98,percent of total billed charges,,,90,,3.65,percent of total billed charges,,,,,,,no IP contract,,80,,3.24,percent of total billed charges,,,,,,,no IP contract,,50,,2.03,percent of total billed charges,,,,,,no IP contract,,,78,,3.16,percent of total billed charges,,,70,,2.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.98,3324,
80681-0165-00 - cyanocobalamin 250 mcg Tab,80681-0165-00,NDC,,,,inpatient,1,EA,4,2.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.4,percent of total billed charges,,,85,,3.4,percent of total billed charges,,,49,,1.96,percent of total billed charges,,,90,,3.6,percent of total billed charges,,,,,,,no IP contract,,80,,3.2,percent of total billed charges,,,,,,,no IP contract,,50,,2,percent of total billed charges,,,,,,no IP contract,,,78,,3.12,percent of total billed charges,,,70,,2.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.96,3324,
80681-0169-00 - cholecalciferol 1000 intl units Tab,80681-0169-00,NDC,,,,inpatient,1,EA,4,2.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.4,percent of total billed charges,,,85,,3.4,percent of total billed charges,,,49,,1.96,percent of total billed charges,,,90,,3.6,percent of total billed charges,,,,,,,no IP contract,,80,,3.2,percent of total billed charges,,,,,,,no IP contract,,50,,2,percent of total billed charges,,,,,,no IP contract,,,78,,3.12,percent of total billed charges,,,70,,2.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.96,3324,
81033-0002-30 - acetaminophen 650 mg/20.3 mL LIQ,81033-0002-30,NDC,,,,inpatient,20.3,ML,30.4,18.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.84,percent of total billed charges,,,85,,25.84,percent of total billed charges,,,49,,14.9,percent of total billed charges,,,90,,27.36,percent of total billed charges,,,,,,,no IP contract,,80,,24.32,percent of total billed charges,,,,,,,no IP contract,,50,,15.2,percent of total billed charges,,,,,,no IP contract,,,78,,23.71,percent of total billed charges,,,70,,21.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.9,3324,
81952-0128-28 - enoxaparin 80 mg/0.8 mL Soln,81952-0128-28,NDC,,,,inpatient,0.8,ML,224.1,134.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,181.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,190.49,percent of total billed charges,,,85,,190.49,percent of total billed charges,,,49,,109.81,percent of total billed charges,,,90,,201.69,percent of total billed charges,,,,,,,no IP contract,,80,,179.28,percent of total billed charges,,,,,,,no IP contract,,50,,112.05,percent of total billed charges,,,,,,no IP contract,,,78,,174.8,percent of total billed charges,,,70,,156.87,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,109.81,3324,
brimonidine ophthalmic 0.15% Soln,82182-0773-10,NDC,,,,inpatient,1,EA,1605.65,963.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1300.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1364.8,percent of total billed charges,,,85,,1364.8,percent of total billed charges,,,49,,786.77,percent of total billed charges,,,90,,1445.09,percent of total billed charges,,,,,,,no IP contract,,80,,1284.52,percent of total billed charges,,,,,,,no IP contract,,50,,802.83,percent of total billed charges,,,,,,no IP contract,,,78,,1252.41,percent of total billed charges,,,70,,1123.96,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,786.77,3324,
82347-0405-05 - diclofenac topical 1.3% ER Fi,82347-0405-05,NDC,,,,inpatient,1,UN,115.5,69.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,93.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,98.18,percent of total billed charges,,,85,,98.18,percent of total billed charges,,,49,,56.6,percent of total billed charges,,,90,,103.95,percent of total billed charges,,,,,,,no IP contract,,80,,92.4,percent of total billed charges,,,,,,,no IP contract,,50,,57.75,percent of total billed charges,,,,,,no IP contract,,,78,,90.09,percent of total billed charges,,,70,,80.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,56.6,3324,
naloxegol 12.5 mg Tab,82625-8801-01,NDC,,,,inpatient,1,EA,135.95,81.57,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,110.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,115.56,percent of total billed charges,,,85,,115.56,percent of total billed charges,,,49,,66.62,percent of total billed charges,,,90,,122.36,percent of total billed charges,,,,,,,no IP contract,,80,,108.76,percent of total billed charges,,,,,,,no IP contract,,50,,67.98,percent of total billed charges,,,,,,no IP contract,,,78,,106.04,percent of total billed charges,,,70,,95.17,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,66.62,3324,
82903-0065-00 - sodium chloride 5 mL Soln,82903-0065-00,NDC,,,,inpatient,10,ML,12.3,7.38,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.46,percent of total billed charges,,,85,,10.46,percent of total billed charges,,,49,,6.03,percent of total billed charges,,,90,,11.07,percent of total billed charges,,,,,,,no IP contract,,80,,9.84,percent of total billed charges,,,,,,,no IP contract,,50,,6.15,percent of total billed charges,,,,,,no IP contract,,,78,,9.59,percent of total billed charges,,,70,,8.61,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.03,3324,
82903-0065-10 - heparin 10 units/mL 5 mL Syringe,82903-0065-10,NDC,,,,inpatient,5,ML,37.55,22.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31.92,percent of total billed charges,,,85,,31.92,percent of total billed charges,,,49,,18.4,percent of total billed charges,,,90,,33.8,percent of total billed charges,,,,,,,no IP contract,,80,,30.04,percent of total billed charges,,,,,,,no IP contract,,50,,18.78,percent of total billed charges,,,,,,no IP contract,,,78,,29.29,percent of total billed charges,,,70,,26.29,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,18.4,3324,
83490-0107-60 - sodium chloride 7% Soln,83490-0107-60,NDC,,,,inpatient,4,ML,16.55,9.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,13.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.07,percent of total billed charges,,,85,,14.07,percent of total billed charges,,,49,,8.11,percent of total billed charges,,,90,,14.9,percent of total billed charges,,,,,,,no IP contract,,80,,13.24,percent of total billed charges,,,,,,,no IP contract,,50,,8.28,percent of total billed charges,,,,,,no IP contract,,,78,,12.91,percent of total billed charges,,,70,,11.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.11,3324,
desmopressin 4 mcg/mL Soln,83634-0451-01,NDC,,,,inpatient,1,mL,408.9,245.34,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,331.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,347.57,percent of total billed charges,,,85,,347.57,percent of total billed charges,,,49,,200.36,percent of total billed charges,,,90,,368.01,percent of total billed charges,,,,,,,no IP contract,,80,,327.12,percent of total billed charges,,,,,,,no IP contract,,50,,204.45,percent of total billed charges,,,,,,no IP contract,,,78,,318.94,percent of total billed charges,,,70,,286.23,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,200.36,3324,
87651-0760-26 - d-mannose 500 mg Cap,87651-0760-26,NDC,,,,inpatient,1,EA,6.55,3.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.57,percent of total billed charges,,,85,,5.57,percent of total billed charges,,,49,,3.21,percent of total billed charges,,,90,,5.9,percent of total billed charges,,,,,,,no IP contract,,80,,5.24,percent of total billed charges,,,,,,,no IP contract,,50,,3.28,percent of total billed charges,,,,,,no IP contract,,,78,,5.11,percent of total billed charges,,,70,,4.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.21,3324,
87701-0407-43 - ascorbic acid 500 mg Chew,87701-0407-43,NDC,,,,inpatient,1,EA,4.3,2.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.66,percent of total billed charges,,,85,,3.66,percent of total billed charges,,,49,,2.11,percent of total billed charges,,,90,,3.87,percent of total billed charges,,,,,,,no IP contract,,80,,3.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.15,percent of total billed charges,,,,,,no IP contract,,,78,,3.35,percent of total billed charges,,,70,,3.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.11,3324,
calcium-vitamin D 600 mg-20 mcg Tab,87701-0407-69,NDC,,,,inpatient,1,EA,4.45,2.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.78,percent of total billed charges,,,85,,3.78,percent of total billed charges,,,49,,2.18,percent of total billed charges,,,90,,4.01,percent of total billed charges,,,,,,,no IP contract,,80,,3.56,percent of total billed charges,,,,,,,no IP contract,,50,,2.23,percent of total billed charges,,,,,,no IP contract,,,78,,3.47,percent of total billed charges,,,70,,3.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.18,3324,
87701-0426-01 - glucose 4 g Chew tab,87701-0426-01,NDC,,,,inpatient,1,EA,18.05,10.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.34,percent of total billed charges,,,85,,15.34,percent of total billed charges,,,49,,8.84,percent of total billed charges,,,90,,16.25,percent of total billed charges,,,,,,,no IP contract,,80,,14.44,percent of total billed charges,,,,,,,no IP contract,,50,,9.03,percent of total billed charges,,,,,,no IP contract,,,78,,14.08,percent of total billed charges,,,70,,12.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.84,3324,
88395-0015-40 - omega-3 polyunsaturated fatty acids 1600 mg/5 mL LIQ,88395-0015-40,NDC,,,,inpatient,1,ML,6.4,3.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.44,percent of total billed charges,,,85,,5.44,percent of total billed charges,,,49,,3.14,percent of total billed charges,,,90,,5.76,percent of total billed charges,,,,,,,no IP contract,,80,,5.12,percent of total billed charges,,,,,,,no IP contract,,50,,3.2,percent of total billed charges,,,,,,no IP contract,,,78,,4.99,percent of total billed charges,,,70,,4.48,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.14,3324,
sodium hyaluronate 10 mg/mL Soln,89122-0724-20,NDC,,,,inpatient,1,EA,763.7,458.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,618.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,649.15,percent of total billed charges,,,85,,649.15,percent of total billed charges,,,49,,374.21,percent of total billed charges,,,90,,687.33,percent of total billed charges,,,,,,,no IP contract,,80,,610.96,percent of total billed charges,,,,,,,no IP contract,,50,,381.85,percent of total billed charges,,,,,,no IP contract,,,78,,595.69,percent of total billed charges,,,70,,534.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,374.21,3324,
sodium hyaluronate 20 mg/mL Soln,89130-2020-01,NDC,,,,inpatient,1,EA,3997.9,2398.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3238.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3398.22,percent of total billed charges,,,85,,3398.22,percent of total billed charges,,,49,,1958.97,percent of total billed charges,,,90,,3598.11,percent of total billed charges,,,,,,,no IP contract,,80,,3198.32,percent of total billed charges,,,,,,,no IP contract,,50,,1998.95,percent of total billed charges,,,,,,no IP contract,,,78,,3118.36,percent of total billed charges,,,70,,2798.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,3598.11,
sodium hyaluronate 8.4 mg/mL Soln,89130-3111-01,NDC,,,,inpatient,1,EA,1420.5,852.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,1150.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,1207.43,percent of total billed charges,,,85,,1207.43,percent of total billed charges,,,49,,696.05,percent of total billed charges,,,90,,1278.45,percent of total billed charges,,,,,,,no IP contract,,80,,1136.4,percent of total billed charges,,,,,,,no IP contract,,50,,710.25,percent of total billed charges,,,,,,no IP contract,,,78,,1107.99,percent of total billed charges,,,70,,994.35,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,696.05,3324,
sodium hyaluronate soln (Supartz) 10 mg/mL Soln,89130-4444-01,NDC,,,,inpatient,1,EA,951.2,570.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,770.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,808.52,percent of total billed charges,,,85,,808.52,percent of total billed charges,,,49,,466.09,percent of total billed charges,,,90,,856.08,percent of total billed charges,,,,,,,no IP contract,,80,,760.96,percent of total billed charges,,,,,,,no IP contract,,50,,475.6,percent of total billed charges,,,,,,no IP contract,,,78,,741.94,percent of total billed charges,,,70,,665.84,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,466.09,3324,
99207-0010-10 - ciclopirox Topical 1% Shamp,99207-0010-10,NDC,,,,inpatient,1,UN,4907.25,2944.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3974.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,4171.16,percent of total billed charges,,,85,,4171.16,percent of total billed charges,,,49,,2404.55,percent of total billed charges,,,90,,4416.53,percent of total billed charges,,,,,,,no IP contract,,80,,3925.8,percent of total billed charges,,,,,,,no IP contract,,50,,2453.63,percent of total billed charges,,,,,,no IP contract,,,78,,3827.66,percent of total billed charges,,,70,,3435.08,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,4416.53,
99345-0001-01 - Salt and Soda Mouthwash 1 mL Soln,99345-0001-01,NDC,,,,inpatient,1,ML,55.35,33.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,44.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,47.05,percent of total billed charges,,,85,,47.05,percent of total billed charges,,,49,,27.12,percent of total billed charges,,,90,,49.82,percent of total billed charges,,,,,,,no IP contract,,80,,44.28,percent of total billed charges,,,,,,,no IP contract,,50,,27.68,percent of total billed charges,,,,,,no IP contract,,,78,,43.17,percent of total billed charges,,,70,,38.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.12,3324,
99345-0001-04 - Benadryl-Maalox-Xylocaine 1 mL Susp,99345-0001-04,NDC,,,,inpatient,30,ML,113.7,68.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,92.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,96.65,percent of total billed charges,,,85,,96.65,percent of total billed charges,,,49,,55.71,percent of total billed charges,,,90,,102.33,percent of total billed charges,,,,,,,no IP contract,,80,,90.96,percent of total billed charges,,,,,,,no IP contract,,50,,56.85,percent of total billed charges,,,,,,no IP contract,,,78,,88.69,percent of total billed charges,,,70,,79.59,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,55.71,3324,
99345-0001-05 - clonidine oral suspension 20 mcg/mL Susp,99345-0001-05,NDC,,,,inpatient,1,ML,14.55,8.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.37,percent of total billed charges,,,85,,12.37,percent of total billed charges,,,49,,7.13,percent of total billed charges,,,90,,13.1,percent of total billed charges,,,,,,,no IP contract,,80,,11.64,percent of total billed charges,,,,,,,no IP contract,,50,,7.28,percent of total billed charges,,,,,,no IP contract,,,78,,11.35,percent of total billed charges,,,70,,10.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.13,3324,
99345-0001-06 - dantrolene oral suspension 5 mg/1 mL Susp,99345-0001-06,NDC,,,,inpatient,1,ML,7.1,4.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.04,percent of total billed charges,,,85,,6.04,percent of total billed charges,,,49,,3.48,percent of total billed charges,,,90,,6.39,percent of total billed charges,,,,,,,no IP contract,,80,,5.68,percent of total billed charges,,,,,,,no IP contract,,50,,3.55,percent of total billed charges,,,,,,no IP contract,,,78,,5.54,percent of total billed charges,,,70,,4.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.48,3324,
99345-0001-07 - omeprazole  20 mg Susp,99345-0001-07,NDC,,,,inpatient,10,ML,405.25,243.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,328.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,344.46,percent of total billed charges,,,85,,344.46,percent of total billed charges,,,49,,198.57,percent of total billed charges,,,90,,364.73,percent of total billed charges,,,,,,,no IP contract,,80,,324.2,percent of total billed charges,,,,,,,no IP contract,,50,,202.63,percent of total billed charges,,,,,,no IP contract,,,78,,316.1,percent of total billed charges,,,70,,283.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,198.57,3324,
99345-0001-13 - Miscellaneous OTC Item 1 Tab,99345-0001-13,NDC,,,,inpatient,1,EA,43.55,26.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,35.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,37.02,percent of total billed charges,,,85,,37.02,percent of total billed charges,,,49,,21.34,percent of total billed charges,,,90,,39.2,percent of total billed charges,,,,,,,no IP contract,,80,,34.84,percent of total billed charges,,,,,,,no IP contract,,50,,21.78,percent of total billed charges,,,,,,no IP contract,,,78,,33.97,percent of total billed charges,,,70,,30.49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,21.34,3324,
99345-0001-41 - warfarin sodium 0.5 mg Tab,99345-0001-41,NDC,,,,inpatient,0.5,EA,4.6,2.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.91,percent of total billed charges,,,85,,3.91,percent of total billed charges,,,49,,2.25,percent of total billed charges,,,90,,4.14,percent of total billed charges,,,,,,,no IP contract,,80,,3.68,percent of total billed charges,,,,,,,no IP contract,,50,,2.3,percent of total billed charges,,,,,,no IP contract,,,78,,3.59,percent of total billed charges,,,70,,3.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.25,3324,
99345-0001-45 - morphine 10 mg Soln,99345-0001-45,NDC,,,,inpatient,2.5,ML,17.9,10.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.22,percent of total billed charges,,,85,,15.22,percent of total billed charges,,,49,,8.77,percent of total billed charges,,,90,,16.11,percent of total billed charges,,,,,,,no IP contract,,80,,14.32,percent of total billed charges,,,,,,,no IP contract,,50,,8.95,percent of total billed charges,,,,,,no IP contract,,,78,,13.96,percent of total billed charges,,,70,,12.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.77,3324,
99345-0001-47 - diazepam 0.5 mg Soln,99345-0001-47,NDC,,,,inpatient,0.5,ML,7.1,4.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.04,percent of total billed charges,,,85,,6.04,percent of total billed charges,,,49,,3.48,percent of total billed charges,,,90,,6.39,percent of total billed charges,,,,,,,no IP contract,,80,,5.68,percent of total billed charges,,,,,,,no IP contract,,50,,3.55,percent of total billed charges,,,,,,no IP contract,,,78,,5.54,percent of total billed charges,,,70,,4.97,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.48,3324,
99345-0001-48 - diazepam 1 mg Soln,99345-0001-48,NDC,,,,inpatient,1,ML,8.75,5.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.44,percent of total billed charges,,,85,,7.44,percent of total billed charges,,,49,,4.29,percent of total billed charges,,,90,,7.88,percent of total billed charges,,,,,,,no IP contract,,80,,7,percent of total billed charges,,,,,,,no IP contract,,50,,4.38,percent of total billed charges,,,,,,no IP contract,,,78,,6.83,percent of total billed charges,,,70,,6.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.29,3324,
99345-0001-51 - lorazepam 0.25 mg Conc,99345-0001-51,NDC,,,,inpatient,0.25,ML,7.9,4.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.72,percent of total billed charges,,,85,,6.72,percent of total billed charges,,,49,,3.87,percent of total billed charges,,,90,,7.11,percent of total billed charges,,,,,,,no IP contract,,80,,6.32,percent of total billed charges,,,,,,,no IP contract,,50,,3.95,percent of total billed charges,,,,,,no IP contract,,,78,,6.16,percent of total billed charges,,,70,,5.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.87,3324,
99345-0001-52 - lorazepam 1 mg Conc,99345-0001-52,NDC,,,,inpatient,0.5,ML,12.1,7.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.29,percent of total billed charges,,,85,,10.29,percent of total billed charges,,,49,,5.93,percent of total billed charges,,,90,,10.89,percent of total billed charges,,,,,,,no IP contract,,80,,9.68,percent of total billed charges,,,,,,,no IP contract,,50,,6.05,percent of total billed charges,,,,,,no IP contract,,,78,,9.44,percent of total billed charges,,,70,,8.47,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.93,3324,
99345-0001-53 - lorazepam 2 mg Conc,99345-0001-53,NDC,,,,inpatient,5,ML,47.05,28.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,38.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,39.99,percent of total billed charges,,,85,,39.99,percent of total billed charges,,,49,,23.05,percent of total billed charges,,,90,,42.35,percent of total billed charges,,,,,,,no IP contract,,80,,37.64,percent of total billed charges,,,,,,,no IP contract,,50,,23.53,percent of total billed charges,,,,,,no IP contract,,,78,,36.7,percent of total billed charges,,,70,,32.94,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,23.05,3324,
99345-0001-54 - methadone 5 mg Soln,99345-0001-54,NDC,,,,inpatient,1,ML,18.75,11.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.94,percent of total billed charges,,,85,,15.94,percent of total billed charges,,,49,,9.19,percent of total billed charges,,,90,,16.88,percent of total billed charges,,,,,,,no IP contract,,80,,15,percent of total billed charges,,,,,,,no IP contract,,50,,9.38,percent of total billed charges,,,,,,no IP contract,,,78,,14.63,percent of total billed charges,,,70,,13.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.19,3324,
99345-0001-55 - morphine 5 mg Soln,99345-0001-55,NDC,,,,inpatient,5,ML,26.25,15.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.31,percent of total billed charges,,,85,,22.31,percent of total billed charges,,,49,,12.86,percent of total billed charges,,,90,,23.63,percent of total billed charges,,,,,,,no IP contract,,80,,21,percent of total billed charges,,,,,,,no IP contract,,50,,13.13,percent of total billed charges,,,,,,no IP contract,,,78,,20.48,percent of total billed charges,,,70,,18.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.86,3324,
99345-0001-58 - methadone 10 mg Soln,99345-0001-58,NDC,,,,inpatient,2.5,ML,8.75,5.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.44,percent of total billed charges,,,85,,7.44,percent of total billed charges,,,49,,4.29,percent of total billed charges,,,90,,7.88,percent of total billed charges,,,,,,,no IP contract,,80,,7,percent of total billed charges,,,,,,,no IP contract,,50,,4.38,percent of total billed charges,,,,,,no IP contract,,,78,,6.83,percent of total billed charges,,,70,,6.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.29,3324,
99345-0001-58 - methadone 2.5 mg Soln,99345-0001-58,NDC,,,,inpatient,2.5,ML,8.75,5.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,7.44,percent of total billed charges,,,85,,7.44,percent of total billed charges,,,49,,4.29,percent of total billed charges,,,90,,7.88,percent of total billed charges,,,,,,,no IP contract,,80,,7,percent of total billed charges,,,,,,,no IP contract,,50,,4.38,percent of total billed charges,,,,,,no IP contract,,,78,,6.83,percent of total billed charges,,,70,,6.13,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.29,3324,
99345-0001-59 - oxycodone 2.5 mg Soln,99345-0001-59,NDC,,,,inpatient,5,ML,26.25,15.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.26,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.31,percent of total billed charges,,,85,,22.31,percent of total billed charges,,,49,,12.86,percent of total billed charges,,,90,,23.63,percent of total billed charges,,,,,,,no IP contract,,80,,21,percent of total billed charges,,,,,,,no IP contract,,50,,13.13,percent of total billed charges,,,,,,no IP contract,,,78,,20.48,percent of total billed charges,,,70,,18.38,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.86,3324,
99345-0001-60 - oxycodone 2.5 mg Soln,99345-0001-60,NDC,,,,inpatient,2.5,ML,7.5,4.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.38,percent of total billed charges,,,85,,6.38,percent of total billed charges,,,49,,3.68,percent of total billed charges,,,90,,6.75,percent of total billed charges,,,,,,,no IP contract,,80,,6,percent of total billed charges,,,,,,,no IP contract,,50,,3.75,percent of total billed charges,,,,,,no IP contract,,,78,,5.85,percent of total billed charges,,,70,,5.25,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.68,3324,
99345-0001-63 - baclofen 5 mg Susp,99345-0001-63,NDC,,,,inpatient,1,ML,9.6,5.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.16,percent of total billed charges,,,85,,8.16,percent of total billed charges,,,49,,4.7,percent of total billed charges,,,90,,8.64,percent of total billed charges,,,,,,,no IP contract,,80,,7.68,percent of total billed charges,,,,,,,no IP contract,,50,,4.8,percent of total billed charges,,,,,,no IP contract,,,78,,7.49,percent of total billed charges,,,70,,6.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.7,3324,
99345-0001-63 - baclofen oral susp 5 mg/ml 5 mg Susp,99345-0001-63,NDC,,,,inpatient,1,ML,9.6,5.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.16,percent of total billed charges,,,85,,8.16,percent of total billed charges,,,49,,4.7,percent of total billed charges,,,90,,8.64,percent of total billed charges,,,,,,,no IP contract,,80,,7.68,percent of total billed charges,,,,,,,no IP contract,,50,,4.8,percent of total billed charges,,,,,,no IP contract,,,78,,7.49,percent of total billed charges,,,70,,6.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.7,3324,
99345-0001-65 - diazepam oral solution 2 mg Syringe,99345-0001-65,NDC,,,,inpatient,2,ML,12.6,7.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.71,percent of total billed charges,,,85,,10.71,percent of total billed charges,,,49,,6.17,percent of total billed charges,,,90,,11.34,percent of total billed charges,,,,,,,no IP contract,,80,,10.08,percent of total billed charges,,,,,,,no IP contract,,50,,6.3,percent of total billed charges,,,,,,no IP contract,,,78,,9.83,percent of total billed charges,,,70,,8.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.17,3324,
99345-0001-68 - ondansetron 2 mg Soln,99345-0001-68,NDC,,,,inpatient,2.5,ML,105.3,63.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,85.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,89.51,percent of total billed charges,,,85,,89.51,percent of total billed charges,,,49,,51.6,percent of total billed charges,,,90,,94.77,percent of total billed charges,,,,,,,no IP contract,,80,,84.24,percent of total billed charges,,,,,,,no IP contract,,50,,52.65,percent of total billed charges,,,,,,no IP contract,,,78,,82.13,percent of total billed charges,,,70,,73.71,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,51.6,3324,
99345-0001-69 - Tacrolimus oral susp 0.5 mg/mL Susp,99345-0001-69,NDC,,,,inpatient,1,ML,55.35,33.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,44.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,47.05,percent of total billed charges,,,85,,47.05,percent of total billed charges,,,49,,27.12,percent of total billed charges,,,90,,49.82,percent of total billed charges,,,,,,,no IP contract,,80,,44.28,percent of total billed charges,,,,,,,no IP contract,,50,,27.68,percent of total billed charges,,,,,,no IP contract,,,78,,43.17,percent of total billed charges,,,70,,38.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.12,3324,
99345-0001-70 - clonazepam 0.5 mg / 5 mL Susp,99345-0001-70,NDC,,,,inpatient,1,ML,11.65,6.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.44,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.9,percent of total billed charges,,,85,,9.9,percent of total billed charges,,,49,,5.71,percent of total billed charges,,,90,,10.49,percent of total billed charges,,,,,,,no IP contract,,80,,9.32,percent of total billed charges,,,,,,,no IP contract,,50,,5.83,percent of total billed charges,,,,,,no IP contract,,,78,,9.09,percent of total billed charges,,,70,,8.16,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.71,3324,
99345-0001-84 - PHENobarbital oral Elixir 20 mg / 5 mL Elixir,99345-0001-84,NDC,,,,inpatient,5,ML,11.25,6.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,9.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,9.56,percent of total billed charges,,,85,,9.56,percent of total billed charges,,,49,,5.51,percent of total billed charges,,,90,,10.13,percent of total billed charges,,,,,,,no IP contract,,80,,9,percent of total billed charges,,,,,,,no IP contract,,50,,5.63,percent of total billed charges,,,,,,no IP contract,,,78,,8.78,percent of total billed charges,,,70,,7.88,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,5.51,3324,
99345-0001-96 - sodium chloride 0.9% IV Flush Syringe Pump 0.9% Syringe,99345-0001-96,NDC,,,,inpatient,10,ML,17.75,10.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.09,percent of total billed charges,,,85,,15.09,percent of total billed charges,,,49,,8.7,percent of total billed charges,,,90,,15.98,percent of total billed charges,,,,,,,no IP contract,,80,,14.2,percent of total billed charges,,,,,,,no IP contract,,50,,8.88,percent of total billed charges,,,,,,no IP contract,,,78,,13.85,percent of total billed charges,,,70,,12.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.7,3324,
99345-0001-97 - dextrose 5% in water Syringe Pump Prime & Flush 10 mL soln 5% Syringe,99345-0001-97,NDC,,,,inpatient,10,ML,17.75,10.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.09,percent of total billed charges,,,85,,15.09,percent of total billed charges,,,49,,8.7,percent of total billed charges,,,90,,15.98,percent of total billed charges,,,,,,,no IP contract,,80,,14.2,percent of total billed charges,,,,,,,no IP contract,,50,,8.88,percent of total billed charges,,,,,,no IP contract,,,78,,13.85,percent of total billed charges,,,70,,12.43,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.7,3324,
99345-0001-98 - temozolomide 10 mg/mL Susp,99345-0001-98,NDC,,,,inpatient,1,ML,224.15,134.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,181.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,190.53,percent of total billed charges,,,85,,190.53,percent of total billed charges,,,49,,109.83,percent of total billed charges,,,90,,201.74,percent of total billed charges,,,,,,,no IP contract,,80,,179.32,percent of total billed charges,,,,,,,no IP contract,,50,,112.08,percent of total billed charges,,,,,,no IP contract,,,78,,174.84,percent of total billed charges,,,70,,156.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,109.83,3324,
99345-0001-99 - famotidine oral pre-filled syringe* 20 mg / 2.5 mL Susp,99345-0001-99,NDC,,,,inpatient,2.5,ML,79.05,47.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,64.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,67.19,percent of total billed charges,,,85,,67.19,percent of total billed charges,,,49,,38.73,percent of total billed charges,,,90,,71.15,percent of total billed charges,,,,,,,no IP contract,,80,,63.24,percent of total billed charges,,,,,,,no IP contract,,50,,39.53,percent of total billed charges,,,,,,no IP contract,,,78,,61.66,percent of total billed charges,,,70,,55.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,38.73,3324,
99345-0002-01 - enoxaparin (compound) 20 mg/mL Soln,99345-0002-01,NDC,,,,inpatient,1,ML,162.5,97.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,131.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,138.13,percent of total billed charges,,,85,,138.13,percent of total billed charges,,,49,,79.63,percent of total billed charges,,,90,,146.25,percent of total billed charges,,,,,,,no IP contract,,80,,130,percent of total billed charges,,,,,,,no IP contract,,50,,81.25,percent of total billed charges,,,,,,no IP contract,,,78,,126.75,percent of total billed charges,,,70,,113.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,79.63,3324,
99345-0002-02 - ondansetron oral soln 4 mg / 5 mL Soln,99345-0002-02,NDC,,,,inpatient,5,ML,205.2,123.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,166.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,174.42,percent of total billed charges,,,85,,174.42,percent of total billed charges,,,49,,100.55,percent of total billed charges,,,90,,184.68,percent of total billed charges,,,,,,,no IP contract,,80,,164.16,percent of total billed charges,,,,,,,no IP contract,,50,,102.6,percent of total billed charges,,,,,,no IP contract,,,78,,160.06,percent of total billed charges,,,70,,143.64,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,100.55,3324,
99345-0002-03 - lacosamide pre-filled syringe 100 mg / 10 mL Soln,99345-0002-03,NDC,,,,inpatient,10,ML,19.6,11.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,16.66,percent of total billed charges,,,85,,16.66,percent of total billed charges,,,49,,9.6,percent of total billed charges,,,90,,17.64,percent of total billed charges,,,,,,,no IP contract,,80,,15.68,percent of total billed charges,,,,,,,no IP contract,,50,,9.8,percent of total billed charges,,,,,,no IP contract,,,78,,15.29,percent of total billed charges,,,70,,13.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.6,3324,
99345-0002-04 - clobazam oral susp PFS 2.5 mg/mL Soln,99345-0002-04,NDC,,,,inpatient,4,ML,208,124.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,168.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,176.8,percent of total billed charges,,,85,,176.8,percent of total billed charges,,,49,,101.92,percent of total billed charges,,,90,,187.2,percent of total billed charges,,,,,,,no IP contract,,80,,166.4,percent of total billed charges,,,,,,,no IP contract,,50,,104,percent of total billed charges,,,,,,no IP contract,,,78,,162.24,percent of total billed charges,,,70,,145.6,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,101.92,3324,
99345-0002-05 - clobazam oral susp PFS 2.5 mg/mL Soln,99345-0002-05,NDC,,,,inpatient,1,ML,56.05,33.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,45.4,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,47.64,percent of total billed charges,,,85,,47.64,percent of total billed charges,,,49,,27.46,percent of total billed charges,,,90,,50.45,percent of total billed charges,,,,,,,no IP contract,,80,,44.84,percent of total billed charges,,,,,,,no IP contract,,50,,28.03,percent of total billed charges,,,,,,no IP contract,,,78,,43.72,percent of total billed charges,,,70,,39.24,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,27.46,3324,
99345-0002-06 - morphine oral conc PFS 20 mg/mL Conc,99345-0002-06,NDC,,,,inpatient,1,ML,12.4,7.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,10.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,10.54,percent of total billed charges,,,85,,10.54,percent of total billed charges,,,49,,6.08,percent of total billed charges,,,90,,11.16,percent of total billed charges,,,,,,,no IP contract,,80,,9.92,percent of total billed charges,,,,,,,no IP contract,,50,,6.2,percent of total billed charges,,,,,,no IP contract,,,78,,9.67,percent of total billed charges,,,70,,8.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.08,3324,
99345-0002-07 - zinc sulfate [compound] 10 mg/mL Soln,99345-0002-07,NDC,,,,inpatient,1,ML,17.9,10.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.22,percent of total billed charges,,,85,,15.22,percent of total billed charges,,,49,,8.77,percent of total billed charges,,,90,,16.11,percent of total billed charges,,,,,,,no IP contract,,80,,14.32,percent of total billed charges,,,,,,,no IP contract,,50,,8.95,percent of total billed charges,,,,,,no IP contract,,,78,,13.96,percent of total billed charges,,,70,,12.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.77,3324,
99345-0002-08 - AMIkacin NEB [compound] 250 mg/mL Soln,99345-0002-08,NDC,,,,inpatient,1.6,ML,79.05,47.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,64.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,67.19,percent of total billed charges,,,85,,67.19,percent of total billed charges,,,49,,38.73,percent of total billed charges,,,90,,71.15,percent of total billed charges,,,,,,,no IP contract,,80,,63.24,percent of total billed charges,,,,,,,no IP contract,,50,,39.53,percent of total billed charges,,,,,,no IP contract,,,78,,61.66,percent of total billed charges,,,70,,55.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,38.73,3324,
99345-0002-10 - amphotericin B [Conventional] NEB 5 mg/mL Soln,99345-0002-10,NDC,,,,inpatient,1,ML,51.7,31.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,41.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,43.95,percent of total billed charges,,,85,,43.95,percent of total billed charges,,,49,,25.33,percent of total billed charges,,,90,,46.53,percent of total billed charges,,,,,,,no IP contract,,80,,41.36,percent of total billed charges,,,,,,,no IP contract,,50,,25.85,percent of total billed charges,,,,,,no IP contract,,,78,,40.33,percent of total billed charges,,,70,,36.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,25.33,3324,
99345-0002-15 - colistimethate (Colistin base) NEB 75 mg/mL Soln,99345-0002-15,NDC,,,,inpatient,1,ML,153.65,92.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,124.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,130.6,percent of total billed charges,,,85,,130.6,percent of total billed charges,,,49,,75.29,percent of total billed charges,,,90,,138.29,percent of total billed charges,,,,,,,no IP contract,,80,,122.92,percent of total billed charges,,,,,,,no IP contract,,50,,76.83,percent of total billed charges,,,,,,no IP contract,,,78,,119.85,percent of total billed charges,,,70,,107.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,75.29,3324,
99345-0002-30 - amphotericin B [conventional] Nasal Spray 5 mg/mL Spray,99345-0002-30,NDC,,,,inpatient,1,UN,393.55,236.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,318.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,334.52,percent of total billed charges,,,85,,334.52,percent of total billed charges,,,49,,192.84,percent of total billed charges,,,90,,354.2,percent of total billed charges,,,,,,,no IP contract,,80,,314.84,percent of total billed charges,,,,,,,no IP contract,,50,,196.78,percent of total billed charges,,,,,,no IP contract,,,78,,306.97,percent of total billed charges,,,70,,275.49,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,192.84,3324,
99345-0002-40 - pantoprazole (compound) 2 mg/mL Susp,99345-0002-40,NDC,,,,inpatient,1,ML,14.15,8.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.03,percent of total billed charges,,,85,,12.03,percent of total billed charges,,,49,,6.93,percent of total billed charges,,,90,,12.74,percent of total billed charges,,,,,,,no IP contract,,80,,11.32,percent of total billed charges,,,,,,,no IP contract,,50,,7.08,percent of total billed charges,,,,,,no IP contract,,,78,,11.04,percent of total billed charges,,,70,,9.91,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,6.93,3324,
99345-0002-45 - methadone Oral prefilled syringe 1 mg / 1 mL Soln,99345-0002-45,NDC,,,,inpatient,1,ML,17.9,10.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.22,percent of total billed charges,,,85,,15.22,percent of total billed charges,,,49,,8.77,percent of total billed charges,,,90,,16.11,percent of total billed charges,,,,,,,no IP contract,,80,,14.32,percent of total billed charges,,,,,,,no IP contract,,50,,8.95,percent of total billed charges,,,,,,no IP contract,,,78,,13.96,percent of total billed charges,,,70,,12.53,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.77,3324,
99345-0002-60 - hydroCORTisone Oral suspension 2 mg/mL Susp,99345-0002-60,NDC,,,,inpatient,1,ML,15.55,9.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.22,percent of total billed charges,,,85,,13.22,percent of total billed charges,,,49,,7.62,percent of total billed charges,,,90,,14,percent of total billed charges,,,,,,,no IP contract,,80,,12.44,percent of total billed charges,,,,,,,no IP contract,,50,,7.78,percent of total billed charges,,,,,,no IP contract,,,78,,12.13,percent of total billed charges,,,70,,10.89,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.62,3324,
99345-0002-65 - metroNIDAZOLE Oral suspension 50 mg/mL Susp,99345-0002-65,NDC,,,,inpatient,1,ML,15.45,9.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.13,percent of total billed charges,,,85,,13.13,percent of total billed charges,,,49,,7.57,percent of total billed charges,,,90,,13.91,percent of total billed charges,,,,,,,no IP contract,,80,,12.36,percent of total billed charges,,,,,,,no IP contract,,50,,7.73,percent of total billed charges,,,,,,no IP contract,,,78,,12.05,percent of total billed charges,,,70,,10.82,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.57,3324,
99345-0002-85 - buffered lidocaine 1% [J-Tip] 1% buffered Injection,99345-0002-85,NDC,,,,inpatient,0.2,ML,18.65,11.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,15.11,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.85,percent of total billed charges,,,85,,15.85,percent of total billed charges,,,49,,9.14,percent of total billed charges,,,90,,16.79,percent of total billed charges,,,,,,,no IP contract,,80,,14.92,percent of total billed charges,,,,,,,no IP contract,,50,,9.33,percent of total billed charges,,,,,,no IP contract,,,78,,14.55,percent of total billed charges,,,70,,13.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,9.14,3324,
99345-0003-05 - traMADol 25 mg Tab,99345-0003-05,NDC,,,,inpatient,0.5,EA,7,4.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,5.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,5.95,percent of total billed charges,,,85,,5.95,percent of total billed charges,,,49,,3.43,percent of total billed charges,,,90,,6.3,percent of total billed charges,,,,,,,no IP contract,,80,,5.6,percent of total billed charges,,,,,,,no IP contract,,50,,3.5,percent of total billed charges,,,,,,no IP contract,,,78,,5.46,percent of total billed charges,,,70,,4.9,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.43,3324,
99345-0003-15 - cloBAZam 5 mg Tab,99345-0003-15,NDC,,,,inpatient,0.5,EA,35.25,21.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,28.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,29.96,percent of total billed charges,,,85,,29.96,percent of total billed charges,,,49,,17.27,percent of total billed charges,,,90,,31.73,percent of total billed charges,,,,,,,no IP contract,,80,,28.2,percent of total billed charges,,,,,,,no IP contract,,50,,17.63,percent of total billed charges,,,,,,no IP contract,,,78,,27.5,percent of total billed charges,,,70,,24.68,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,17.27,3324,
99345-0003-65 - ursodiol 60 mg/mL Susp,99345-0003-65,NDC,,,,inpatient,1,ML,15.8,9.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.43,percent of total billed charges,,,85,,13.43,percent of total billed charges,,,49,,7.74,percent of total billed charges,,,90,,14.22,percent of total billed charges,,,,,,,no IP contract,,80,,12.64,percent of total billed charges,,,,,,,no IP contract,,50,,7.9,percent of total billed charges,,,,,,no IP contract,,,78,,12.32,percent of total billed charges,,,70,,11.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.74,3324,
99345-0003-70 - valacyclovir 50 mg/mL Susp,99345-0003-70,NDC,,,,inpatient,1,ML,15.8,9.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.43,percent of total billed charges,,,85,,13.43,percent of total billed charges,,,49,,7.74,percent of total billed charges,,,90,,14.22,percent of total billed charges,,,,,,,no IP contract,,80,,12.64,percent of total billed charges,,,,,,,no IP contract,,50,,7.9,percent of total billed charges,,,,,,no IP contract,,,78,,12.32,percent of total billed charges,,,70,,11.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.74,3324,
99345-0003-95 - rifAMPin 25 mg/mL Susp,99345-0003-95,NDC,,,,inpatient,1,ML,15.8,9.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,12.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,13.43,percent of total billed charges,,,85,,13.43,percent of total billed charges,,,49,,7.74,percent of total billed charges,,,90,,14.22,percent of total billed charges,,,,,,,no IP contract,,80,,12.64,percent of total billed charges,,,,,,,no IP contract,,50,,7.9,percent of total billed charges,,,,,,no IP contract,,,78,,12.32,percent of total billed charges,,,70,,11.06,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.74,3324,
99345-0004-50 - Phenol 6% (compound) 6% Soln,99345-0004-50,NDC,,,,inpatient,5,ML,81.6,48.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,66.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,69.36,percent of total billed charges,,,85,,69.36,percent of total billed charges,,,49,,39.98,percent of total billed charges,,,90,,73.44,percent of total billed charges,,,,,,,no IP contract,,80,,65.28,percent of total billed charges,,,,,,,no IP contract,,50,,40.8,percent of total billed charges,,,,,,no IP contract,,,78,,63.65,percent of total billed charges,,,70,,57.12,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,39.98,3324,
99345-0004-65 - oxymetazoline-lidocaine 0.05%-4% soln 0.05%-4% Soln,99345-0004-65,NDC,,,,inpatient,5,UN,176.15,105.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,142.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,149.73,percent of total billed charges,,,85,,149.73,percent of total billed charges,,,49,,86.31,percent of total billed charges,,,90,,158.54,percent of total billed charges,,,,,,,no IP contract,,80,,140.92,percent of total billed charges,,,,,,,no IP contract,,50,,88.08,percent of total billed charges,,,,,,no IP contract,,,78,,137.4,percent of total billed charges,,,70,,123.31,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,86.31,3324,
99345-0004-85 - spironolactone 12.5 mg/0.5 tab Tab,99345-0004-85,NDC,,,,inpatient,0.5,EA,4,2.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.4,percent of total billed charges,,,85,,3.4,percent of total billed charges,,,49,,1.96,percent of total billed charges,,,90,,3.6,percent of total billed charges,,,,,,,no IP contract,,80,,3.2,percent of total billed charges,,,,,,,no IP contract,,50,,2,percent of total billed charges,,,,,,no IP contract,,,78,,3.12,percent of total billed charges,,,70,,2.8,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1.96,3324,
99345-0004-90 - finasteride CRUSHED 5 mg Tab,99345-0004-90,NDC,,,,inpatient,1,EA,18.35,11.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,15.6,percent of total billed charges,,,85,,15.6,percent of total billed charges,,,49,,8.99,percent of total billed charges,,,90,,16.52,percent of total billed charges,,,,,,,no IP contract,,80,,14.68,percent of total billed charges,,,,,,,no IP contract,,50,,9.18,percent of total billed charges,,,,,,no IP contract,,,78,,14.31,percent of total billed charges,,,70,,12.85,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.99,3324,
99345-0005-10 - salicylic acid 3%- sulfur 1%- hydrocortisone 1% topical ointment 3%-1%-1% Ointment,99345-0005-10,NDC,,,,inpatient,1,UN,46.2,27.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,37.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,39.27,percent of total billed charges,,,85,,39.27,percent of total billed charges,,,49,,22.64,percent of total billed charges,,,90,,41.58,percent of total billed charges,,,,,,,no IP contract,,80,,36.96,percent of total billed charges,,,,,,,no IP contract,,50,,23.1,percent of total billed charges,,,,,,no IP contract,,,78,,36.04,percent of total billed charges,,,70,,32.34,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,22.64,3324,
"99345-0005-15 - heparin PFS 7,500 units/ 1.5 mL Soln",99345-0005-15,NDC,,,,inpatient,1.5,ML,75.1,45.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63.84,percent of total billed charges,,,85,,63.84,percent of total billed charges,,,49,,36.8,percent of total billed charges,,,90,,67.59,percent of total billed charges,,,,,,,no IP contract,,80,,60.08,percent of total billed charges,,,,,,,no IP contract,,50,,37.55,percent of total billed charges,,,,,,no IP contract,,,78,,58.58,percent of total billed charges,,,70,,52.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.8,3324,
99345-0005-20 - cloNIDine (Quarter tab) 0.025 mg/ 0.25 tab Tab,99345-0005-20,NDC,,,,inpatient,0.25,EA,4.3,2.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,3.48,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,3.66,percent of total billed charges,,,85,,3.66,percent of total billed charges,,,49,,2.11,percent of total billed charges,,,90,,3.87,percent of total billed charges,,,,,,,no IP contract,,80,,3.44,percent of total billed charges,,,,,,,no IP contract,,50,,2.15,percent of total billed charges,,,,,,no IP contract,,,78,,3.35,percent of total billed charges,,,70,,3.01,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,2.11,3324,
99345-0005-25 - oxyCODONE 2.5 mg (Half tab) Tab,99345-0005-25,NDC,,,,inpatient,0.5,EA,7.65,4.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,6.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,6.5,percent of total billed charges,,,85,,6.5,percent of total billed charges,,,49,,3.75,percent of total billed charges,,,90,,6.89,percent of total billed charges,,,,,,,no IP contract,,80,,6.12,percent of total billed charges,,,,,,,no IP contract,,50,,3.83,percent of total billed charges,,,,,,no IP contract,,,78,,5.97,percent of total billed charges,,,70,,5.36,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,3.75,3324,
99345-0005-30 - Gentamicin 0.48 mg/mL Soln,99345-0005-30,NDC,,,,inpatient,1,ML,14.55,8.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.37,percent of total billed charges,,,85,,12.37,percent of total billed charges,,,49,,7.13,percent of total billed charges,,,90,,13.1,percent of total billed charges,,,,,,,no IP contract,,80,,11.64,percent of total billed charges,,,,,,,no IP contract,,50,,7.28,percent of total billed charges,,,,,,no IP contract,,,78,,11.35,percent of total billed charges,,,70,,10.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.13,3324,
99345-0005-35 - AMIkacin bladder irrigation 0.5 mg/mL Soln,99345-0005-35,NDC,,,,inpatient,1,ML,14.55,8.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,11.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,12.37,percent of total billed charges,,,85,,12.37,percent of total billed charges,,,49,,7.13,percent of total billed charges,,,90,,13.1,percent of total billed charges,,,,,,,no IP contract,,80,,11.64,percent of total billed charges,,,,,,,no IP contract,,50,,7.28,percent of total billed charges,,,,,,no IP contract,,,78,,11.35,percent of total billed charges,,,70,,10.19,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,7.13,3324,
99345-0005-50 - oxymetazoline 0.05% Soln,99345-0005-50,NDC,,,,inpatient,1,UN,26.3,15.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,21.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,22.36,percent of total billed charges,,,85,,22.36,percent of total billed charges,,,49,,12.89,percent of total billed charges,,,90,,23.67,percent of total billed charges,,,,,,,no IP contract,,80,,21.04,percent of total billed charges,,,,,,,no IP contract,,50,,13.15,percent of total billed charges,,,,,,no IP contract,,,78,,20.51,percent of total billed charges,,,70,,18.41,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,12.89,3324,
99345-0005-95 - ciprofloxacin-dexamethasone otic 0.3%-0.1% Soln,99345-0005-95,NDC,,,,inpatient,2,ML,312.5,187.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,253.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,265.63,percent of total billed charges,,,85,,265.63,percent of total billed charges,,,49,,153.13,percent of total billed charges,,,90,,281.25,percent of total billed charges,,,,,,,no IP contract,,80,,250,percent of total billed charges,,,,,,,no IP contract,,50,,156.25,percent of total billed charges,,,,,,no IP contract,,,78,,243.75,percent of total billed charges,,,70,,218.75,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,153.13,3324,
99345-0005-99 - amphotericin B liposomal 4 mg/mL Soln,99345-0005-99,NDC,,,,inpatient,1,ML,253.65,152.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,205.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,215.6,percent of total billed charges,,,85,,215.6,percent of total billed charges,,,49,,124.29,percent of total billed charges,,,90,,228.29,percent of total billed charges,,,,,,,no IP contract,,80,,202.92,percent of total billed charges,,,,,,,no IP contract,,50,,126.83,percent of total billed charges,,,,,,no IP contract,,,78,,197.85,percent of total billed charges,,,70,,177.56,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,124.29,3324,
"99345-0006-05 - heparin  2,500 unit(s) / 0.5 mL Syringe",99345-0006-05,NDC,,,,inpatient,0.5,ML,30.4,18.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,24.62,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,25.84,percent of total billed charges,,,85,,25.84,percent of total billed charges,,,49,,14.9,percent of total billed charges,,,90,,27.36,percent of total billed charges,,,,,,,no IP contract,,80,,24.32,percent of total billed charges,,,,,,,no IP contract,,50,,15.2,percent of total billed charges,,,,,,no IP contract,,,78,,23.71,percent of total billed charges,,,70,,21.28,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,14.9,3324,
99345-0006-10 - hydrOXYurea 100 mg/mL Susp,99345-0006-10,NDC,,,,inpatient,1,ML,17.45,10.47,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,14.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,14.83,percent of total billed charges,,,85,,14.83,percent of total billed charges,,,49,,8.55,percent of total billed charges,,,90,,15.71,percent of total billed charges,,,,,,,no IP contract,,80,,13.96,percent of total billed charges,,,,,,,no IP contract,,50,,8.73,percent of total billed charges,,,,,,no IP contract,,,78,,13.61,percent of total billed charges,,,70,,12.22,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,8.55,3324,
HYDROmorphone 1 mg/ 0.5 tab Tab,99345-0006-20,NDC,,,,inpatient,1,EA,9.6,5.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,7.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,8.16,percent of total billed charges,,,85,,8.16,percent of total billed charges,,,49,,4.7,percent of total billed charges,,,90,,8.64,percent of total billed charges,,,,,,,no IP contract,,80,,7.68,percent of total billed charges,,,,,,,no IP contract,,50,,4.8,percent of total billed charges,,,,,,no IP contract,,,78,,7.49,percent of total billed charges,,,70,,6.72,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,4.7,3324,
99999-9999-02 - TNF INT 1 EA Injection,99999-9999-02,NDC,,,,inpatient,1,ML,75.1,45.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63.84,percent of total billed charges,,,85,,63.84,percent of total billed charges,,,49,,36.8,percent of total billed charges,,,90,,67.59,percent of total billed charges,,,,,,,no IP contract,,80,,60.08,percent of total billed charges,,,,,,,no IP contract,,50,,37.55,percent of total billed charges,,,,,,no IP contract,,,78,,58.58,percent of total billed charges,,,70,,52.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.8,3324,
99999-9999-03 - TNF CONT 1 mL Soln,99999-9999-03,NDC,,,,inpatient,1,ML,75.1,45.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63.84,percent of total billed charges,,,85,,63.84,percent of total billed charges,,,49,,36.8,percent of total billed charges,,,90,,67.59,percent of total billed charges,,,,,,,no IP contract,,80,,60.08,percent of total billed charges,,,,,,,no IP contract,,50,,37.55,percent of total billed charges,,,,,,no IP contract,,,78,,58.58,percent of total billed charges,,,70,,52.57,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,36.8,3324,
Stroke A0101,A0101,LOCAL,,,,inpatient,,,50574.35,30344.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,40965.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,42988.2,percent of total billed charges,,,85,,42988.2,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,45516.92,percent of total billed charges,,,,,,,no IP contract,,80,,40459.48,percent of total billed charges,,,,,,,no IP contract,,50,,25287.18,percent of total billed charges,,,,,,no IP contract,,,78,,39447.99,percent of total billed charges,,,70,,35402.05,percent of total billed charges,,,,,,,,,,,11170.53,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Stroke A0102,A0102,LOCAL,,,,inpatient,,,65418.26,39250.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,52988.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,55605.52,percent of total billed charges,,,85,,55605.52,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,58876.43,percent of total billed charges,,,,,,,no IP contract,,80,,52334.61,percent of total billed charges,,,,,,,no IP contract,,50,,32709.13,percent of total billed charges,,,,,,no IP contract,,,78,,51026.24,percent of total billed charges,,,70,,45792.78,percent of total billed charges,,,,,,,,,,,16427.8,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Stroke A0103,A0103,LOCAL,,,,inpatient,,,92891.24,55734.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,75241.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,78957.56,percent of total billed charges,,,85,,78957.56,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,83602.12,percent of total billed charges,,,,,,,no IP contract,,80,,74312.99,percent of total billed charges,,,,,,,no IP contract,,50,,46445.62,percent of total billed charges,,,,,,no IP contract,,,78,,72455.17,percent of total billed charges,,,70,,65023.87,percent of total billed charges,,,,,,,,,,,28639,100% of Medicare,,,,,28527.98,100% of Medicare,,,,,28527.98,100% of Medicare,,,,,28527.98,100% of Medicare,,,,,28527.98,100% of Medicare,,,,,28527.98,100% of Medicare,,,,,28527.98,100% of Medicare,,,,,28527.98,100% of Medicare,,,,,28527.98,100% of Medicare,,,,,28527.98,100% of Medicare,,,,,28527.98,100% of Medicare,,,,,28527.98,100% of Medicare,,,,,,28527.98,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,83602.12,
Stroke A0104,A0104,LOCAL,,,,inpatient,,,118164.22,70898.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,95713.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,100439.59,percent of total billed charges,,,85,,100439.59,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,106347.8,percent of total billed charges,,,,,,,no IP contract,,80,,94531.37,percent of total billed charges,,,,,,,no IP contract,,50,,59082.11,percent of total billed charges,,,,,,no IP contract,,,78,,92168.09,percent of total billed charges,,,70,,82714.95,percent of total billed charges,,,,,,,,,,,34125.05,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Stroke A0105,A0105,LOCAL,,,,inpatient,,,122363.61,73418.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,99114.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,104009.07,percent of total billed charges,,,85,,104009.07,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,110127.25,percent of total billed charges,,,,,,,no IP contract,,80,,97890.89,percent of total billed charges,,,,,,,no IP contract,,50,,61181.81,percent of total billed charges,,,,,,no IP contract,,,78,,95443.62,percent of total billed charges,,,70,,85654.53,percent of total billed charges,,,,,,,,,,,47099.62,100% of Medicare,,,,,44097.64,100% of Medicare,,,,,44097.64,100% of Medicare,,,,,44097.64,100% of Medicare,,,,,44097.64,100% of Medicare,,,,,44097.64,100% of Medicare,,,,,44097.64,100% of Medicare,,,,,44097.64,100% of Medicare,,,,,44097.64,100% of Medicare,,,,,44097.64,100% of Medicare,,,,,44097.64,100% of Medicare,,,,,44097.64,100% of Medicare,,,,,,44097.64,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,110127.25,
Stroke A0106,A0106,LOCAL,,,,inpatient,,,158529.6,95117.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,128408.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,134750.16,percent of total billed charges,,,85,,134750.16,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,142676.64,percent of total billed charges,,,,,,,no IP contract,,80,,126823.68,percent of total billed charges,,,,,,,no IP contract,,50,,79264.8,percent of total billed charges,,,,,,no IP contract,,,78,,123653.09,percent of total billed charges,,,70,,110970.72,percent of total billed charges,,,,,,,,,,,43636.99,100% of Medicare,,,,,52413.81,100% of Medicare,,,,,52413.81,100% of Medicare,,,,,52413.81,100% of Medicare,,,,,52413.81,100% of Medicare,,,,,52413.81,100% of Medicare,,,,,52413.81,100% of Medicare,,,,,52413.81,100% of Medicare,,,,,52413.81,100% of Medicare,,,,,52413.81,100% of Medicare,,,,,52413.81,100% of Medicare,,,,,52413.81,100% of Medicare,,,,,,52413.81,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,142676.64,
Traumatic Brain Injury A0201,A0201,LOCAL,,,,inpatient,,,37168.84,22301.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,30106.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,31593.52,percent of total billed charges,,,85,,31593.52,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,33451.96,percent of total billed charges,,,,,,,no IP contract,,80,,29735.07,percent of total billed charges,,,,,,,no IP contract,,50,,18584.42,percent of total billed charges,,,,,,no IP contract,,,78,,28991.7,percent of total billed charges,,,70,,26018.19,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,26609.71,100% of Medicare,,,,,26609.71,100% of Medicare,,,,,26609.71,100% of Medicare,,,,,26609.71,100% of Medicare,,,,,26609.71,100% of Medicare,,,,,26609.71,100% of Medicare,,,,,26609.71,100% of Medicare,,,,,26609.71,100% of Medicare,,,,,26609.71,100% of Medicare,,,,,26609.71,100% of Medicare,,,,,26609.71,100% of Medicare,,,,,,26609.71,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Traumatic Brain Injury A0202,A0202,LOCAL,,,,inpatient,,,84193.67,50516.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,68196.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,71564.62,percent of total billed charges,,,85,,71564.62,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,75774.3,percent of total billed charges,,,,,,,no IP contract,,80,,67354.94,percent of total billed charges,,,,,,,no IP contract,,50,,42096.84,percent of total billed charges,,,,,,no IP contract,,,78,,65671.06,percent of total billed charges,,,70,,58935.57,percent of total billed charges,,,,,,,,,,,31960.45,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Traumatic Brain Injury A0203,A0203,LOCAL,,,,inpatient,,,108826.4,65295.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,88149.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,92502.44,percent of total billed charges,,,85,,92502.44,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,97943.76,percent of total billed charges,,,,,,,no IP contract,,80,,87061.12,percent of total billed charges,,,,,,,no IP contract,,50,,54413.2,percent of total billed charges,,,,,,no IP contract,,,78,,84884.59,percent of total billed charges,,,70,,76178.48,percent of total billed charges,,,,,,,,,,,25250.81,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Traumatic Brain Injury A0204,A0204,LOCAL,,,,inpatient,,,93675.3,56205.18,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,75876.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,79624.01,percent of total billed charges,,,85,,79624.01,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,84307.77,percent of total billed charges,,,,,,,no IP contract,,80,,74940.24,percent of total billed charges,,,,,,,no IP contract,,50,,46837.65,percent of total billed charges,,,,,,no IP contract,,,78,,73066.73,percent of total billed charges,,,70,,65572.71,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,28628.61,100% of Medicare,,,,,28628.61,100% of Medicare,,,,,28628.61,100% of Medicare,,,,,28628.61,100% of Medicare,,,,,28628.61,100% of Medicare,,,,,28628.61,100% of Medicare,,,,,28628.61,100% of Medicare,,,,,28628.61,100% of Medicare,,,,,28628.61,100% of Medicare,,,,,28628.61,100% of Medicare,,,,,28628.61,100% of Medicare,,,,,,28628.61,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Traumatic Brain Injury A0205,A0205,LOCAL,,,,inpatient,,,145989.95,87593.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,118251.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,124091.46,percent of total billed charges,,,85,,124091.46,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,131390.96,percent of total billed charges,,,,,,,no IP contract,,80,,116791.96,percent of total billed charges,,,,,,,no IP contract,,50,,72994.98,percent of total billed charges,,,,,,no IP contract,,,78,,113872.16,percent of total billed charges,,,70,,102192.97,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Non-traumatic Brain Injury A0301,A0301,LOCAL,,,,inpatient,,,72492.72,43495.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,58719.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,61618.81,percent of total billed charges,,,85,,61618.81,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,65243.45,percent of total billed charges,,,,,,,no IP contract,,80,,57994.17,percent of total billed charges,,,,,,,no IP contract,,50,,36246.36,percent of total billed charges,,,,,,no IP contract,,,78,,56544.32,percent of total billed charges,,,70,,50744.9,percent of total billed charges,,,,,,,,,,,18477.46,100% of Medicare,,,,,24060.33,100% of Medicare,,,,,24060.33,100% of Medicare,,,,,24060.33,100% of Medicare,,,,,24060.33,100% of Medicare,,,,,24060.33,100% of Medicare,,,,,24060.33,100% of Medicare,,,,,24060.33,100% of Medicare,,,,,24060.33,100% of Medicare,,,,,24060.33,100% of Medicare,,,,,24060.33,100% of Medicare,,,,,24060.33,100% of Medicare,,,,,,24060.33,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,65243.45,
Non-traumatic Brain Injury A0302,A0302,LOCAL,,,,inpatient,,,94846.9,56908.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,76825.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,80619.87,percent of total billed charges,,,85,,80619.87,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,85362.21,percent of total billed charges,,,,,,,no IP contract,,80,,75877.52,percent of total billed charges,,,,,,,no IP contract,,50,,47423.45,percent of total billed charges,,,,,,no IP contract,,,78,,73980.58,percent of total billed charges,,,70,,66392.83,percent of total billed charges,,,,,,,,,,,23774.35,100% of Medicare,,,,,28881.99,100% of Medicare,,,,,28881.99,100% of Medicare,,,,,28881.99,100% of Medicare,,,,,28881.99,100% of Medicare,,,,,28881.99,100% of Medicare,,,,,28881.99,100% of Medicare,,,,,28881.99,100% of Medicare,,,,,28881.99,100% of Medicare,,,,,28881.99,100% of Medicare,,,,,28881.99,100% of Medicare,,,,,28881.99,100% of Medicare,,,,,,28881.99,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,85362.21,
Non-traumatic Brain Injury A0303,A0303,LOCAL,,,,inpatient,,,95529,57317.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,77378.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,81199.65,percent of total billed charges,,,85,,81199.65,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,85976.1,percent of total billed charges,,,,,,,no IP contract,,80,,76423.2,percent of total billed charges,,,,,,,no IP contract,,50,,47764.5,percent of total billed charges,,,,,,no IP contract,,,78,,74512.62,percent of total billed charges,,,70,,66870.3,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Non-traumatic Brain Injury A0304,A0304,LOCAL,,,,inpatient,,,137277.27,82366.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,111194.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,116685.68,percent of total billed charges,,,85,,116685.68,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,123549.54,percent of total billed charges,,,,,,,no IP contract,,80,,109821.81,percent of total billed charges,,,,,,,no IP contract,,50,,68638.63,percent of total billed charges,,,,,,no IP contract,,,78,,107076.27,percent of total billed charges,,,70,,96094.09,percent of total billed charges,,,,,,,,,,,35329.05,100% of Medicare,,,,,39792.83,100% of Medicare,,,,,39792.83,100% of Medicare,,,,,39792.83,100% of Medicare,,,,,39792.83,100% of Medicare,,,,,39792.83,100% of Medicare,,,,,39792.83,100% of Medicare,,,,,39792.83,100% of Medicare,,,,,39792.83,100% of Medicare,,,,,39792.83,100% of Medicare,,,,,39792.83,100% of Medicare,,,,,39792.83,100% of Medicare,,,,,,39792.83,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,123549.54,
Non-traumatic Brain Injury A0305,A0305,LOCAL,,,,inpatient,,,154643.16,92785.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,125260.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,131446.68,percent of total billed charges,,,85,,131446.68,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,139178.84,percent of total billed charges,,,,,,,no IP contract,,80,,123714.53,percent of total billed charges,,,,,,,no IP contract,,50,,77321.58,percent of total billed charges,,,,,,no IP contract,,,78,,120621.66,percent of total billed charges,,,70,,108250.21,percent of total billed charges,,,,,,,,,,,36867.38,100% of Medicare,,,,,58143.02,100% of Medicare,,,,,58143.02,100% of Medicare,,,,,58143.02,100% of Medicare,,,,,58143.02,100% of Medicare,,,,,58143.02,100% of Medicare,,,,,58143.02,100% of Medicare,,,,,58143.02,100% of Medicare,,,,,58143.02,100% of Medicare,,,,,58143.02,100% of Medicare,,,,,58143.02,100% of Medicare,,,,,58143.02,100% of Medicare,,,,,,58143.02,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,139178.84,
Traumatic Spinal Cord A0401,A0401,LOCAL,,,,inpatient,,,75613.26,45367.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,61246.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,64271.27,percent of total billed charges,,,85,,64271.27,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,68051.94,percent of total billed charges,,,,,,,no IP contract,,80,,60490.61,percent of total billed charges,,,,,,,no IP contract,,50,,37806.63,percent of total billed charges,,,,,,no IP contract,,,78,,58978.34,percent of total billed charges,,,70,,52929.28,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,32439.6,100% of Medicare,,,,,32439.6,100% of Medicare,,,,,32439.6,100% of Medicare,,,,,32439.6,100% of Medicare,,,,,32439.6,100% of Medicare,,,,,32439.6,100% of Medicare,,,,,32439.6,100% of Medicare,,,,,32439.6,100% of Medicare,,,,,32439.6,100% of Medicare,,,,,32439.6,100% of Medicare,,,,,32439.6,100% of Medicare,,,,,,32439.6,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Traumatic Spinal Cord A0402,A0402,LOCAL,,,,inpatient,,,120334.69,72200.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,97471.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,102284.49,percent of total billed charges,,,85,,102284.49,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,108301.22,percent of total billed charges,,,,,,,no IP contract,,80,,96267.75,percent of total billed charges,,,,,,,no IP contract,,50,,60167.35,percent of total billed charges,,,,,,no IP contract,,,78,,93861.06,percent of total billed charges,,,70,,84234.28,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,34613.61,100% of Medicare,,,,,34613.61,100% of Medicare,,,,,34613.61,100% of Medicare,,,,,34613.61,100% of Medicare,,,,,34613.61,100% of Medicare,,,,,34613.61,100% of Medicare,,,,,34613.61,100% of Medicare,,,,,34613.61,100% of Medicare,,,,,34613.61,100% of Medicare,,,,,34613.61,100% of Medicare,,,,,34613.61,100% of Medicare,,,,,,34613.61,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Traumatic Spinal Cord A0403,A0403,LOCAL,,,,inpatient,,,141732.73,85039.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,114803.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,120472.82,percent of total billed charges,,,85,,120472.82,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,127559.46,percent of total billed charges,,,,,,,no IP contract,,80,,113386.19,percent of total billed charges,,,,,,,no IP contract,,50,,70866.37,percent of total billed charges,,,,,,no IP contract,,,78,,110551.53,percent of total billed charges,,,70,,99212.91,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Traumatic Spinal Cord A0404,A0404,LOCAL,,,,inpatient,,,252286.41,151371.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,204351.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,214443.44,percent of total billed charges,,,85,,214443.44,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,227057.77,percent of total billed charges,,,,,,,no IP contract,,80,,201829.12,percent of total billed charges,,,,,,,no IP contract,,50,,126143.2,percent of total billed charges,,,,,,no IP contract,,,78,,196783.4,percent of total billed charges,,,70,,176600.48,percent of total billed charges,,,,,,,,,,,52179.86,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Traumatic Spinal Cord A0405,A0405,LOCAL,,,,inpatient,,,180377.94,108226.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,146106.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,153321.25,percent of total billed charges,,,85,,153321.25,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,162340.15,percent of total billed charges,,,,,,,no IP contract,,80,,144302.36,percent of total billed charges,,,,,,,no IP contract,,50,,90188.97,percent of total billed charges,,,,,,no IP contract,,,78,,140694.8,percent of total billed charges,,,70,,126264.56,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,51690.41,100% of Medicare,,,,,51690.41,100% of Medicare,,,,,51690.41,100% of Medicare,,,,,51690.41,100% of Medicare,,,,,51690.41,100% of Medicare,,,,,51690.41,100% of Medicare,,,,,51690.41,100% of Medicare,,,,,51690.41,100% of Medicare,,,,,51690.41,100% of Medicare,,,,,51690.41,100% of Medicare,,,,,51690.41,100% of Medicare,,,,,,51690.41,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Traumatic Spinal Cord A0406,A0406,LOCAL,,,,inpatient,,,187882.53,112729.52,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,152184.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,159700.15,percent of total billed charges,,,85,,159700.15,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,169094.28,percent of total billed charges,,,,,,,no IP contract,,80,,150306.02,percent of total billed charges,,,,,,,no IP contract,,50,,93941.27,percent of total billed charges,,,,,,no IP contract,,,78,,146548.37,percent of total billed charges,,,70,,131517.77,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,57869.24,100% of Medicare,,,,,57869.24,100% of Medicare,,,,,57869.24,100% of Medicare,,,,,57869.24,100% of Medicare,,,,,57869.24,100% of Medicare,,,,,57869.24,100% of Medicare,,,,,57869.24,100% of Medicare,,,,,57869.24,100% of Medicare,,,,,57869.24,100% of Medicare,,,,,57869.24,100% of Medicare,,,,,57869.24,100% of Medicare,,,,,,57869.24,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Traumatic Spinal Cord A0407,A0407,LOCAL,,,,inpatient,,,273399.86,164039.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,221453.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,232389.88,percent of total billed charges,,,85,,232389.88,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,246059.87,percent of total billed charges,,,,,,,no IP contract,,80,,218719.88,percent of total billed charges,,,,,,,no IP contract,,50,,136699.93,percent of total billed charges,,,,,,no IP contract,,,78,,213251.89,percent of total billed charges,,,70,,191379.9,percent of total billed charges,,,,,,,,,,,51690.41,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Non-traumatic Spinal Cord A0501,A0501,LOCAL,,,,inpatient,,,66682,40009.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,54012.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56679.7,percent of total billed charges,,,85,,56679.7,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,60013.8,percent of total billed charges,,,,,,,no IP contract,,80,,53345.6,percent of total billed charges,,,,,,,no IP contract,,50,,33341,percent of total billed charges,,,,,,no IP contract,,,78,,52011.96,percent of total billed charges,,,70,,46677.4,percent of total billed charges,,,,,,,,,,,19895.42,100% of Medicare,,,,,27240.16,100% of Medicare,,,,,27240.16,100% of Medicare,,,,,27240.16,100% of Medicare,,,,,27240.16,100% of Medicare,,,,,27240.16,100% of Medicare,,,,,27240.16,100% of Medicare,,,,,27240.16,100% of Medicare,,,,,27240.16,100% of Medicare,,,,,27240.16,100% of Medicare,,,,,27240.16,100% of Medicare,,,,,27240.16,100% of Medicare,,,,,,27240.16,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,60013.8,
Non-traumatic Spinal Cord A0502,A0502,LOCAL,,,,inpatient,,,83610.4,50166.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,67724.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,71068.84,percent of total billed charges,,,85,,71068.84,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,75249.36,percent of total billed charges,,,,,,,no IP contract,,80,,66888.32,percent of total billed charges,,,,,,,no IP contract,,50,,41805.2,percent of total billed charges,,,,,,no IP contract,,,78,,65216.11,percent of total billed charges,,,70,,58527.28,percent of total billed charges,,,,,,,,,,,27039.92,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Non-traumatic Spinal Cord A0503,A0503,LOCAL,,,,inpatient,,,93252.22,55951.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,75534.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,79264.39,percent of total billed charges,,,85,,79264.39,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,83927,percent of total billed charges,,,,,,,no IP contract,,80,,74601.78,percent of total billed charges,,,,,,,no IP contract,,50,,46626.11,percent of total billed charges,,,,,,no IP contract,,,78,,72736.73,percent of total billed charges,,,70,,65276.56,percent of total billed charges,,,,,,,,,,,15870.17,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Non-traumatic Spinal Cord A0504,A0504,LOCAL,,,,inpatient,,,122702.25,73621.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,99388.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,104296.92,percent of total billed charges,,,85,,104296.92,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,110432.03,percent of total billed charges,,,,,,,no IP contract,,80,,98161.8,percent of total billed charges,,,,,,,no IP contract,,50,,61351.13,percent of total billed charges,,,,,,no IP contract,,,78,,95707.76,percent of total billed charges,,,70,,85891.58,percent of total billed charges,,,,,,,,,,,36275.51,100% of Medicare,,,,,33006.42,100% of Medicare,,,,,33006.42,100% of Medicare,,,,,33006.42,100% of Medicare,,,,,33006.42,100% of Medicare,,,,,33006.42,100% of Medicare,,,,,33006.42,100% of Medicare,,,,,33006.42,100% of Medicare,,,,,33006.42,100% of Medicare,,,,,33006.42,100% of Medicare,,,,,33006.42,100% of Medicare,,,,,33006.42,100% of Medicare,,,,,,33006.42,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,110432.03,
Non-traumatic Spinal Cord A0505,A0505,LOCAL,,,,inpatient,,,160087.44,96052.46,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,129670.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,136074.32,percent of total billed charges,,,85,,136074.32,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,144078.69,percent of total billed charges,,,,,,,no IP contract,,80,,128069.95,percent of total billed charges,,,,,,,no IP contract,,50,,80043.72,percent of total billed charges,,,,,,no IP contract,,,78,,124868.2,percent of total billed charges,,,70,,112061.21,percent of total billed charges,,,,,,,,,,,53937.55,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Neurological Conditions A0601,A0601,LOCAL,,,,inpatient,,,103167.98,61900.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,83566.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,87692.79,percent of total billed charges,,,85,,87692.79,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,92851.19,percent of total billed charges,,,,,,,no IP contract,,80,,82534.39,percent of total billed charges,,,,,,,no IP contract,,50,,51583.99,percent of total billed charges,,,,,,no IP contract,,,78,,80471.03,percent of total billed charges,,,70,,72217.59,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Neurological Conditions A0602,A0602,LOCAL,,,,inpatient,,,95169.11,57101.47,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,77086.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,80893.74,percent of total billed charges,,,85,,80893.74,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,85652.2,percent of total billed charges,,,,,,,no IP contract,,80,,76135.29,percent of total billed charges,,,,,,,no IP contract,,50,,47584.55,percent of total billed charges,,,,,,no IP contract,,,78,,74231.91,percent of total billed charges,,,70,,66618.38,percent of total billed charges,,,,,,,,,,,24500.64,100% of Medicare,,,,,27814.53,100% of Medicare,,,,,27814.53,100% of Medicare,,,,,27814.53,100% of Medicare,,,,,27814.53,100% of Medicare,,,,,27814.53,100% of Medicare,,,,,27814.53,100% of Medicare,,,,,27814.53,100% of Medicare,,,,,27814.53,100% of Medicare,,,,,27814.53,100% of Medicare,,,,,27814.53,100% of Medicare,,,,,27814.53,100% of Medicare,,,,,,27814.53,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,85652.2,
Neurological Conditions A0603,A0603,LOCAL,,,,inpatient,,,109850.73,65910.44,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,88979.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,93373.12,percent of total billed charges,,,85,,93373.12,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,98865.65,percent of total billed charges,,,,,,,no IP contract,,80,,87880.58,percent of total billed charges,,,,,,,no IP contract,,50,,54925.36,percent of total billed charges,,,,,,no IP contract,,,78,,85683.57,percent of total billed charges,,,70,,76895.51,percent of total billed charges,,,,,,,,,,,29170.22,100% of Medicare,,,,,50352.16,100% of Medicare,,,,,50352.16,100% of Medicare,,,,,50352.16,100% of Medicare,,,,,50352.16,100% of Medicare,,,,,50352.16,100% of Medicare,,,,,50352.16,100% of Medicare,,,,,50352.16,100% of Medicare,,,,,50352.16,100% of Medicare,,,,,50352.16,100% of Medicare,,,,,50352.16,100% of Medicare,,,,,50352.16,100% of Medicare,,,,,,50352.16,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,98865.65,
Neurological Conditions A0604,A0604,LOCAL,,,,inpatient,,,146616.18,87969.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,118759.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,124623.75,percent of total billed charges,,,85,,124623.75,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,131954.56,percent of total billed charges,,,,,,,no IP contract,,80,,117292.94,percent of total billed charges,,,,,,,no IP contract,,50,,73308.09,percent of total billed charges,,,,,,no IP contract,,,78,,114360.62,percent of total billed charges,,,70,,102631.32,percent of total billed charges,,,,,,,,,,,48351.3,100% of Medicare,,,,,54470.75,100% of Medicare,,,,,54470.75,100% of Medicare,,,,,54470.75,100% of Medicare,,,,,54470.75,100% of Medicare,,,,,54470.75,100% of Medicare,,,,,54470.75,100% of Medicare,,,,,54470.75,100% of Medicare,,,,,54470.75,100% of Medicare,,,,,54470.75,100% of Medicare,,,,,54470.75,100% of Medicare,,,,,54470.75,100% of Medicare,,,,,,54470.75,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,131954.56,
Fracture of Lower Extremity A0701,A0701,LOCAL,,,,inpatient,,,85613.03,51367.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,69346.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,72771.07,percent of total billed charges,,,85,,72771.07,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,77051.72,percent of total billed charges,,,,,,,no IP contract,,80,,68490.42,percent of total billed charges,,,,,,,no IP contract,,50,,42806.51,percent of total billed charges,,,,,,no IP contract,,,78,,66778.16,percent of total billed charges,,,70,,59929.12,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,21987.49,100% of Medicare,,,,,21987.49,100% of Medicare,,,,,21987.49,100% of Medicare,,,,,21987.49,100% of Medicare,,,,,21987.49,100% of Medicare,,,,,21987.49,100% of Medicare,,,,,21987.49,100% of Medicare,,,,,21987.49,100% of Medicare,,,,,21987.49,100% of Medicare,,,,,21987.49,100% of Medicare,,,,,21987.49,100% of Medicare,,,,,,21987.49,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Fracture of Lower Extremity A0702,A0702,LOCAL,,,,inpatient,,,74981.31,44988.79,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60734.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63734.11,percent of total billed charges,,,85,,63734.11,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,67483.18,percent of total billed charges,,,,,,,no IP contract,,80,,59985.05,percent of total billed charges,,,,,,,no IP contract,,50,,37490.65,percent of total billed charges,,,,,,no IP contract,,,78,,58485.42,percent of total billed charges,,,70,,52486.92,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,23693.87,100% of Medicare,,,,,23693.87,100% of Medicare,,,,,23693.87,100% of Medicare,,,,,23693.87,100% of Medicare,,,,,23693.87,100% of Medicare,,,,,23693.87,100% of Medicare,,,,,23693.87,100% of Medicare,,,,,23693.87,100% of Medicare,,,,,23693.87,100% of Medicare,,,,,23693.87,100% of Medicare,,,,,23693.87,100% of Medicare,,,,,,23693.87,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Fracture of Lower Extremity A0703,A0703,LOCAL,,,,inpatient,,,93387.45,56032.47,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,75643.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,79379.33,percent of total billed charges,,,85,,79379.33,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,84048.71,percent of total billed charges,,,,,,,no IP contract,,80,,74709.96,percent of total billed charges,,,,,,,no IP contract,,50,,46693.73,percent of total billed charges,,,,,,no IP contract,,,78,,72842.21,percent of total billed charges,,,70,,65371.22,percent of total billed charges,,,,,,,,,,,29175.68,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Fracture of Lower Extremity A0704,A0704,LOCAL,,,,inpatient,,,109985.55,65991.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,89088.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,93487.72,percent of total billed charges,,,85,,93487.72,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,98987,percent of total billed charges,,,,,,,no IP contract,,80,,87988.44,percent of total billed charges,,,,,,,no IP contract,,50,,54992.78,percent of total billed charges,,,,,,no IP contract,,,78,,85788.73,percent of total billed charges,,,70,,76989.89,percent of total billed charges,,,,,,,,,,,40177.4,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Replacement of Lower Extremity A0802,A0802,LOCAL,,,,inpatient,,,85750.65,51450.39,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,69458.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,72888.05,percent of total billed charges,,,85,,72888.05,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,77175.59,percent of total billed charges,,,,,,,no IP contract,,80,,68600.52,percent of total billed charges,,,,,,,no IP contract,,50,,42875.33,percent of total billed charges,,,,,,no IP contract,,,78,,66885.51,percent of total billed charges,,,70,,60025.46,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,29823.57,100% of Medicare,,,,,29823.57,100% of Medicare,,,,,29823.57,100% of Medicare,,,,,29823.57,100% of Medicare,,,,,29823.57,100% of Medicare,,,,,29823.57,100% of Medicare,,,,,29823.57,100% of Medicare,,,,,29823.57,100% of Medicare,,,,,29823.57,100% of Medicare,,,,,29823.57,100% of Medicare,,,,,29823.57,100% of Medicare,,,,,,29823.57,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Replacement of Lower Extremity A0803,A0803,LOCAL,,,,inpatient,,,77511.85,46507.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,62784.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,65885.07,percent of total billed charges,,,85,,65885.07,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,69760.67,percent of total billed charges,,,,,,,no IP contract,,80,,62009.48,percent of total billed charges,,,,,,,no IP contract,,50,,38755.93,percent of total billed charges,,,,,,no IP contract,,,78,,60459.24,percent of total billed charges,,,70,,54258.3,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,28639,100% of Medicare,,,,,28639,100% of Medicare,,,,,28639,100% of Medicare,,,,,28639,100% of Medicare,,,,,28639,100% of Medicare,,,,,28639,100% of Medicare,,,,,28639,100% of Medicare,,,,,28639,100% of Medicare,,,,,28639,100% of Medicare,,,,,28639,100% of Medicare,,,,,28639,100% of Medicare,,,,,,28639,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Replacement of Lower Extremity A0804,A0804,LOCAL,,,,inpatient,,,112498.4,67499.04,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,91123.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,95623.64,percent of total billed charges,,,85,,95623.64,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,101248.56,percent of total billed charges,,,,,,,no IP contract,,80,,89998.72,percent of total billed charges,,,,,,,no IP contract,,50,,56249.2,percent of total billed charges,,,,,,no IP contract,,,78,,87748.75,percent of total billed charges,,,70,,78748.88,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,34857.98,100% of Medicare,,,,,34857.98,100% of Medicare,,,,,34857.98,100% of Medicare,,,,,34857.98,100% of Medicare,,,,,34857.98,100% of Medicare,,,,,34857.98,100% of Medicare,,,,,34857.98,100% of Medicare,,,,,34857.98,100% of Medicare,,,,,34857.98,100% of Medicare,,,,,34857.98,100% of Medicare,,,,,34857.98,100% of Medicare,,,,,,34857.98,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Replacement of Lower Extremity A0805,A0805,LOCAL,,,,inpatient,,,168797.95,101278.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,136726.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,143478.26,percent of total billed charges,,,85,,143478.26,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,151918.16,percent of total billed charges,,,,,,,no IP contract,,80,,135038.36,percent of total billed charges,,,,,,,no IP contract,,50,,84398.98,percent of total billed charges,,,,,,no IP contract,,,78,,131662.4,percent of total billed charges,,,70,,118158.57,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,44378.85,100% of Medicare,,,,,44378.85,100% of Medicare,,,,,44378.85,100% of Medicare,,,,,44378.85,100% of Medicare,,,,,44378.85,100% of Medicare,,,,,44378.85,100% of Medicare,,,,,44378.85,100% of Medicare,,,,,44378.85,100% of Medicare,,,,,44378.85,100% of Medicare,,,,,44378.85,100% of Medicare,,,,,44378.85,100% of Medicare,,,,,,44378.85,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Other Orthopedic A0901,A0901,LOCAL,,,,inpatient,,,46510.81,27906.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,37673.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,39534.19,percent of total billed charges,,,85,,39534.19,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,41859.73,percent of total billed charges,,,,,,,no IP contract,,80,,37208.65,percent of total billed charges,,,,,,,no IP contract,,50,,23255.41,percent of total billed charges,,,,,,no IP contract,,,78,,36278.43,percent of total billed charges,,,70,,32557.57,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Other Orthopedic A0902,A0902,LOCAL,,,,inpatient,,,72453.7,43472.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,58687.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,61585.65,percent of total billed charges,,,85,,61585.65,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,65208.33,percent of total billed charges,,,,,,,no IP contract,,80,,57962.96,percent of total billed charges,,,,,,,no IP contract,,50,,36226.85,percent of total billed charges,,,,,,no IP contract,,,78,,56513.89,percent of total billed charges,,,70,,50717.59,percent of total billed charges,,,,,,,,,,,23907.75,100% of Medicare,,,,,23371.15,100% of Medicare,,,,,23371.15,100% of Medicare,,,,,23371.15,100% of Medicare,,,,,23371.15,100% of Medicare,,,,,23371.15,100% of Medicare,,,,,23371.15,100% of Medicare,,,,,23371.15,100% of Medicare,,,,,23371.15,100% of Medicare,,,,,23371.15,100% of Medicare,,,,,23371.15,100% of Medicare,,,,,23371.15,100% of Medicare,,,,,,23371.15,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,65208.33,
Other Orthopedic A0903,A0903,LOCAL,,,,inpatient,,,83581.26,50148.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,67700.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,71044.07,percent of total billed charges,,,85,,71044.07,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,75223.14,percent of total billed charges,,,,,,,no IP contract,,80,,66865.01,percent of total billed charges,,,,,,,no IP contract,,50,,41790.63,percent of total billed charges,,,,,,no IP contract,,,78,,65193.38,percent of total billed charges,,,70,,58506.88,percent of total billed charges,,,,,,,,,,,27240.16,100% of Medicare,,,,,27984.53,100% of Medicare,,,,,27984.53,100% of Medicare,,,,,27984.53,100% of Medicare,,,,,27984.53,100% of Medicare,,,,,27984.53,100% of Medicare,,,,,27984.53,100% of Medicare,,,,,27984.53,100% of Medicare,,,,,27984.53,100% of Medicare,,,,,27984.53,100% of Medicare,,,,,27984.53,100% of Medicare,,,,,27984.53,100% of Medicare,,,,,,27984.53,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,75223.14,
Other Orthopedic A0904,A0904,LOCAL,,,,inpatient,,,154300.62,92580.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,124983.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,131155.52,percent of total billed charges,,,85,,131155.52,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,138870.56,percent of total billed charges,,,,,,,no IP contract,,80,,123440.49,percent of total billed charges,,,,,,,no IP contract,,50,,77150.31,percent of total billed charges,,,,,,no IP contract,,,78,,120354.48,percent of total billed charges,,,70,,108010.43,percent of total billed charges,,,,,,,,,,,33933.02,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Amputation of Lower Extremity A1001,A1001,LOCAL,,,,inpatient,,,77076.64,46245.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,62432.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,65515.15,percent of total billed charges,,,85,,65515.15,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,69368.98,percent of total billed charges,,,,,,,no IP contract,,80,,61661.31,percent of total billed charges,,,,,,,no IP contract,,50,,38538.32,percent of total billed charges,,,,,,no IP contract,,,78,,60119.78,percent of total billed charges,,,70,,53953.65,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,27964.93,100% of Medicare,,,,,27964.93,100% of Medicare,,,,,27964.93,100% of Medicare,,,,,27964.93,100% of Medicare,,,,,27964.93,100% of Medicare,,,,,27964.93,100% of Medicare,,,,,27964.93,100% of Medicare,,,,,27964.93,100% of Medicare,,,,,27964.93,100% of Medicare,,,,,27964.93,100% of Medicare,,,,,27964.93,100% of Medicare,,,,,,27964.93,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Amputation of Lower Extremity A1002,A1002,LOCAL,,,,inpatient,,,81186.8,48712.08,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,65761.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,69008.78,percent of total billed charges,,,85,,69008.78,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,73068.12,percent of total billed charges,,,,,,,no IP contract,,80,,64949.44,percent of total billed charges,,,,,,,no IP contract,,50,,40593.4,percent of total billed charges,,,,,,no IP contract,,,78,,63325.71,percent of total billed charges,,,70,,56830.76,percent of total billed charges,,,,,,,,,,,24486.79,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Amputation of Lower Extremity A1003,A1003,LOCAL,,,,inpatient,,,81979.14,49187.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,66403.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,69682.27,percent of total billed charges,,,85,,69682.27,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,73781.22,percent of total billed charges,,,,,,,no IP contract,,80,,65583.31,percent of total billed charges,,,,,,,no IP contract,,50,,40989.57,percent of total billed charges,,,,,,no IP contract,,,78,,63943.73,percent of total billed charges,,,70,,57385.4,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,29175.68,100% of Medicare,,,,,29175.68,100% of Medicare,,,,,29175.68,100% of Medicare,,,,,29175.68,100% of Medicare,,,,,29175.68,100% of Medicare,,,,,29175.68,100% of Medicare,,,,,29175.68,100% of Medicare,,,,,29175.68,100% of Medicare,,,,,29175.68,100% of Medicare,,,,,29175.68,100% of Medicare,,,,,29175.68,100% of Medicare,,,,,,29175.68,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Amputation of Lower Extremity A1004,A1004,LOCAL,,,,inpatient,,,175999.41,105599.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,142559.52,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,149599.5,percent of total billed charges,,,85,,149599.5,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,158399.47,percent of total billed charges,,,,,,,no IP contract,,80,,140799.53,percent of total billed charges,,,,,,,no IP contract,,50,,87999.7,percent of total billed charges,,,,,,no IP contract,,,78,,137279.54,percent of total billed charges,,,70,,123199.59,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Amputation of Non-Lower Extremity A1101,A1101,LOCAL,,,,inpatient,,,72257,43354.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,58528.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,61418.45,percent of total billed charges,,,85,,61418.45,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,65031.3,percent of total billed charges,,,,,,,no IP contract,,80,,57805.6,percent of total billed charges,,,,,,,no IP contract,,50,,36128.5,percent of total billed charges,,,,,,no IP contract,,,78,,56360.46,percent of total billed charges,,,70,,50579.9,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,24579.91,100% of Medicare,,,,,24579.91,100% of Medicare,,,,,24579.91,100% of Medicare,,,,,24579.91,100% of Medicare,,,,,24579.91,100% of Medicare,,,,,24579.91,100% of Medicare,,,,,24579.91,100% of Medicare,,,,,24579.91,100% of Medicare,,,,,24579.91,100% of Medicare,,,,,24579.91,100% of Medicare,,,,,24579.91,100% of Medicare,,,,,,24579.91,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Osteoarthritis A1201,A1201,LOCAL,,,,inpatient,,,47818.85,28691.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,38733.27,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,40646.02,percent of total billed charges,,,85,,40646.02,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,43036.97,percent of total billed charges,,,,,,,no IP contract,,80,,38255.08,percent of total billed charges,,,,,,,no IP contract,,50,,23909.43,percent of total billed charges,,,,,,no IP contract,,,78,,37298.7,percent of total billed charges,,,70,,33473.2,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,23907.75,100% of Medicare,,,,,23907.75,100% of Medicare,,,,,23907.75,100% of Medicare,,,,,23907.75,100% of Medicare,,,,,23907.75,100% of Medicare,,,,,23907.75,100% of Medicare,,,,,23907.75,100% of Medicare,,,,,23907.75,100% of Medicare,,,,,23907.75,100% of Medicare,,,,,23907.75,100% of Medicare,,,,,23907.75,100% of Medicare,,,,,,23907.75,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
"Rheumatoid, Other Arthritis A1302",A1302,LOCAL,,,,inpatient,,,130388.5,78233.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,105614.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,110830.23,percent of total billed charges,,,85,,110830.23,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,117349.65,percent of total billed charges,,,,,,,no IP contract,,80,,104310.8,percent of total billed charges,,,,,,,no IP contract,,50,,65194.25,percent of total billed charges,,,,,,no IP contract,,,78,,101703.03,percent of total billed charges,,,70,,91271.95,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Cardiac A1401,A1401,LOCAL,,,,inpatient,,,78166.1,46899.66,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,63314.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,66441.19,percent of total billed charges,,,85,,66441.19,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,70349.49,percent of total billed charges,,,,,,,no IP contract,,80,,62532.88,percent of total billed charges,,,,,,,no IP contract,,50,,39083.05,percent of total billed charges,,,,,,no IP contract,,,78,,60969.56,percent of total billed charges,,,70,,54716.27,percent of total billed charges,,,,,,,,,,,17919.73,100% of Medicare,,,,,15870.17,100% of Medicare,,,,,15870.17,100% of Medicare,,,,,15870.17,100% of Medicare,,,,,15870.17,100% of Medicare,,,,,15870.17,100% of Medicare,,,,,15870.17,100% of Medicare,,,,,15870.17,100% of Medicare,,,,,15870.17,100% of Medicare,,,,,15870.17,100% of Medicare,,,,,15870.17,100% of Medicare,,,,,15870.17,100% of Medicare,,,,,,15870.17,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,70349.49,
Cardiac A1402,A1402,LOCAL,,,,inpatient,,,69227.08,41536.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,56073.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,58843.02,percent of total billed charges,,,85,,58843.02,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,62304.37,percent of total billed charges,,,,,,,no IP contract,,80,,55381.67,percent of total billed charges,,,,,,,no IP contract,,50,,34613.54,percent of total billed charges,,,,,,no IP contract,,,78,,53997.12,percent of total billed charges,,,70,,48458.96,percent of total billed charges,,,,,,,,,,,19265.97,100% of Medicare,,,,,31960.45,100% of Medicare,,,,,31960.45,100% of Medicare,,,,,31960.45,100% of Medicare,,,,,31960.45,100% of Medicare,,,,,31960.45,100% of Medicare,,,,,31960.45,100% of Medicare,,,,,31960.45,100% of Medicare,,,,,31960.45,100% of Medicare,,,,,31960.45,100% of Medicare,,,,,31960.45,100% of Medicare,,,,,31960.45,100% of Medicare,,,,,,31960.45,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,62304.37,
Cardiac A1403,A1403,LOCAL,,,,inpatient,,,92609.37,55565.62,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,75013.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,78717.96,percent of total billed charges,,,85,,78717.96,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,83348.43,percent of total billed charges,,,,,,,no IP contract,,80,,74087.49,percent of total billed charges,,,,,,,no IP contract,,50,,46304.68,percent of total billed charges,,,,,,no IP contract,,,78,,72235.31,percent of total billed charges,,,70,,64826.56,percent of total billed charges,,,,,,,,,,,25980.93,100% of Medicare,,,,,38331.54,100% of Medicare,,,,,38331.54,100% of Medicare,,,,,38331.54,100% of Medicare,,,,,38331.54,100% of Medicare,,,,,38331.54,100% of Medicare,,,,,38331.54,100% of Medicare,,,,,38331.54,100% of Medicare,,,,,38331.54,100% of Medicare,,,,,38331.54,100% of Medicare,,,,,38331.54,100% of Medicare,,,,,38331.54,100% of Medicare,,,,,,38331.54,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,83348.43,
Cardiac A1404,A1404,LOCAL,,,,inpatient,,,138698.7,83219.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,112345.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,117893.9,percent of total billed charges,,,85,,117893.9,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,124828.83,percent of total billed charges,,,,,,,no IP contract,,80,,110958.96,percent of total billed charges,,,,,,,no IP contract,,50,,69349.35,percent of total billed charges,,,,,,no IP contract,,,78,,108184.99,percent of total billed charges,,,70,,97089.09,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,50796.97,100% of Medicare,,,,,50796.97,100% of Medicare,,,,,50796.97,100% of Medicare,,,,,50796.97,100% of Medicare,,,,,50796.97,100% of Medicare,,,,,50796.97,100% of Medicare,,,,,50796.97,100% of Medicare,,,,,50796.97,100% of Medicare,,,,,50796.97,100% of Medicare,,,,,50796.97,100% of Medicare,,,,,50796.97,100% of Medicare,,,,,,50796.97,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Pulmonary A1501,A1501,LOCAL,,,,inpatient,,,110398.82,66239.29,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,89423.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,93838.99,percent of total billed charges,,,85,,93838.99,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,99358.94,percent of total billed charges,,,,,,,no IP contract,,80,,88319.05,percent of total billed charges,,,,,,,no IP contract,,50,,55199.41,percent of total billed charges,,,,,,no IP contract,,,78,,86111.08,percent of total billed charges,,,70,,77279.17,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Pulmonary A1502,A1502,LOCAL,,,,inpatient,,,107605.55,64563.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,87160.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,91464.72,percent of total billed charges,,,85,,91464.72,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,96845,percent of total billed charges,,,,,,,no IP contract,,80,,86084.44,percent of total billed charges,,,,,,,no IP contract,,50,,53802.78,percent of total billed charges,,,,,,no IP contract,,,78,,83932.33,percent of total billed charges,,,70,,75323.89,percent of total billed charges,,,,,,,,,,,33184.58,100% of Medicare,,,,,47099.62,100% of Medicare,,,,,47099.62,100% of Medicare,,,,,47099.62,100% of Medicare,,,,,47099.62,100% of Medicare,,,,,47099.62,100% of Medicare,,,,,47099.62,100% of Medicare,,,,,47099.62,100% of Medicare,,,,,47099.62,100% of Medicare,,,,,47099.62,100% of Medicare,,,,,47099.62,100% of Medicare,,,,,47099.62,100% of Medicare,,,,,,47099.62,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,96845,
Pulmonary A1503,A1503,LOCAL,,,,inpatient,,,147149.86,88289.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,119191.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,125077.38,percent of total billed charges,,,85,,125077.38,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,132434.87,percent of total billed charges,,,,,,,no IP contract,,80,,117719.88,percent of total billed charges,,,,,,,no IP contract,,50,,73574.93,percent of total billed charges,,,,,,no IP contract,,,78,,114776.89,percent of total billed charges,,,70,,103004.9,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,37446.28,100% of Medicare,,,,,37446.28,100% of Medicare,,,,,37446.28,100% of Medicare,,,,,37446.28,100% of Medicare,,,,,37446.28,100% of Medicare,,,,,37446.28,100% of Medicare,,,,,37446.28,100% of Medicare,,,,,37446.28,100% of Medicare,,,,,37446.28,100% of Medicare,,,,,37446.28,100% of Medicare,,,,,37446.28,100% of Medicare,,,,,,37446.28,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Pulmonary A1504,A1504,LOCAL,,,,inpatient,,,138518.13,83110.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,112199.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,117740.41,percent of total billed charges,,,85,,117740.41,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,124666.31,percent of total billed charges,,,,,,,no IP contract,,80,,110814.5,percent of total billed charges,,,,,,,no IP contract,,50,,69259.06,percent of total billed charges,,,,,,no IP contract,,,78,,108044.14,percent of total billed charges,,,70,,96962.69,percent of total billed charges,,,,,,,,,,,33006.42,100% of Medicare,,,,,38384.27,100% of Medicare,,,,,38384.27,100% of Medicare,,,,,38384.27,100% of Medicare,,,,,38384.27,100% of Medicare,,,,,38384.27,100% of Medicare,,,,,38384.27,100% of Medicare,,,,,38384.27,100% of Medicare,,,,,38384.27,100% of Medicare,,,,,38384.27,100% of Medicare,,,,,38384.27,100% of Medicare,,,,,38384.27,100% of Medicare,,,,,,38384.27,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,124666.31,
Pain Syndrome A1601,A1601,LOCAL,,,,inpatient,,,84157.05,50494.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,68167.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,71533.49,percent of total billed charges,,,85,,71533.49,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,75741.35,percent of total billed charges,,,,,,,no IP contract,,80,,67325.64,percent of total billed charges,,,,,,,no IP contract,,50,,42078.53,percent of total billed charges,,,,,,no IP contract,,,78,,65642.5,percent of total billed charges,,,70,,58909.94,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/o TBI or SCI A1701,A1701,LOCAL,,,,inpatient,,,64117.65,38470.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,51935.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,54500,percent of total billed charges,,,85,,54500,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,57705.88,percent of total billed charges,,,,,,,no IP contract,,80,,51294.12,percent of total billed charges,,,,,,,no IP contract,,50,,32058.82,percent of total billed charges,,,,,,no IP contract,,,78,,50011.76,percent of total billed charges,,,70,,44882.35,percent of total billed charges,,,,,,,,,,,16266.73,100% of Medicare,,,,,18767.98,100% of Medicare,,,,,18767.98,100% of Medicare,,,,,18767.98,100% of Medicare,,,,,18767.98,100% of Medicare,,,,,18767.98,100% of Medicare,,,,,18767.98,100% of Medicare,,,,,18767.98,100% of Medicare,,,,,18767.98,100% of Medicare,,,,,18767.98,100% of Medicare,,,,,18767.98,100% of Medicare,,,,,18767.98,100% of Medicare,,,,,,18767.98,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,57705.88,
Major Multi-Trauma w/o TBI or SCI A1702,A1702,LOCAL,,,,inpatient,,,105542.08,63325.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,85489.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,89710.77,percent of total billed charges,,,85,,89710.77,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,94987.87,percent of total billed charges,,,,,,,no IP contract,,80,,84433.67,percent of total billed charges,,,,,,,no IP contract,,50,,52771.04,percent of total billed charges,,,,,,no IP contract,,,78,,82322.82,percent of total billed charges,,,70,,73879.46,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/o TBI or SCI A1703,A1703,LOCAL,,,,inpatient,,,103949.25,62369.55,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,84198.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,88356.86,percent of total billed charges,,,85,,88356.86,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,93554.33,percent of total billed charges,,,,,,,no IP contract,,80,,83159.4,percent of total billed charges,,,,,,,no IP contract,,50,,51974.63,percent of total billed charges,,,,,,no IP contract,,,78,,81080.42,percent of total billed charges,,,70,,72764.48,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,29625.54,100% of Medicare,,,,,29625.54,100% of Medicare,,,,,29625.54,100% of Medicare,,,,,29625.54,100% of Medicare,,,,,29625.54,100% of Medicare,,,,,29625.54,100% of Medicare,,,,,29625.54,100% of Medicare,,,,,29625.54,100% of Medicare,,,,,29625.54,100% of Medicare,,,,,29625.54,100% of Medicare,,,,,29625.54,100% of Medicare,,,,,,29625.54,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/o TBI or SCI A1704,A1704,LOCAL,,,,inpatient,,,116426.34,69855.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,94305.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,98962.39,percent of total billed charges,,,85,,98962.39,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,104783.71,percent of total billed charges,,,,,,,no IP contract,,80,,93141.07,percent of total billed charges,,,,,,,no IP contract,,50,,58213.17,percent of total billed charges,,,,,,no IP contract,,,78,,90812.55,percent of total billed charges,,,70,,81498.44,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/o TBI or SCI A1705,A1705,LOCAL,,,,inpatient,,,157301.45,94380.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,127414.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,133706.23,percent of total billed charges,,,85,,133706.23,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,141571.31,percent of total billed charges,,,,,,,no IP contract,,80,,125841.16,percent of total billed charges,,,,,,,no IP contract,,50,,78650.73,percent of total billed charges,,,,,,no IP contract,,,78,,122695.13,percent of total billed charges,,,70,,110111.02,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/ TBI or SCI A1801,A1801,LOCAL,,,,inpatient,,,124642.95,74785.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,100960.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,105946.51,percent of total billed charges,,,85,,105946.51,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,112178.66,percent of total billed charges,,,,,,,no IP contract,,80,,99714.36,percent of total billed charges,,,,,,,no IP contract,,50,,62321.48,percent of total billed charges,,,,,,no IP contract,,,78,,97221.5,percent of total billed charges,,,70,,87250.07,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/ TBI or SCI A1802,A1802,LOCAL,,,,inpatient,,,106488.37,63893.02,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,86255.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,90515.11,percent of total billed charges,,,85,,90515.11,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,95839.53,percent of total billed charges,,,,,,,no IP contract,,80,,85190.69,percent of total billed charges,,,,,,,no IP contract,,50,,53244.18,percent of total billed charges,,,,,,no IP contract,,,78,,83060.93,percent of total billed charges,,,70,,74541.86,percent of total billed charges,,,,,,,,,,,46316.7,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/ TBI or SCI A1803,A1803,LOCAL,,,,inpatient,,,126807.63,76084.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,102714.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,107786.49,percent of total billed charges,,,85,,107786.49,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,114126.87,percent of total billed charges,,,,,,,no IP contract,,80,,101446.11,percent of total billed charges,,,,,,,no IP contract,,50,,63403.82,percent of total billed charges,,,,,,no IP contract,,,78,,98909.95,percent of total billed charges,,,70,,88765.34,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/ TBI or SCI A1804,A1804,LOCAL,,,,inpatient,,,142989.42,85793.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,115821.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,121541.01,percent of total billed charges,,,85,,121541.01,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,128690.48,percent of total billed charges,,,,,,,no IP contract,,80,,114391.54,percent of total billed charges,,,,,,,no IP contract,,50,,71494.71,percent of total billed charges,,,,,,no IP contract,,,78,,111531.75,percent of total billed charges,,,70,,100092.59,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,46915.86,100% of Medicare,,,,,46915.86,100% of Medicare,,,,,46915.86,100% of Medicare,,,,,46915.86,100% of Medicare,,,,,46915.86,100% of Medicare,,,,,46915.86,100% of Medicare,,,,,46915.86,100% of Medicare,,,,,46915.86,100% of Medicare,,,,,46915.86,100% of Medicare,,,,,46915.86,100% of Medicare,,,,,46915.86,100% of Medicare,,,,,,46915.86,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/ TBI or SCI A1805,A1805,LOCAL,,,,inpatient,,,192641.93,115585.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,156039.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,163745.64,percent of total billed charges,,,85,,163745.64,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,173377.74,percent of total billed charges,,,,,,,no IP contract,,80,,154113.55,percent of total billed charges,,,,,,,no IP contract,,50,,96320.97,percent of total billed charges,,,,,,no IP contract,,,78,,150260.71,percent of total billed charges,,,70,,134849.35,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,87932.83,100% of Medicare,,,,,87932.83,100% of Medicare,,,,,87932.83,100% of Medicare,,,,,87932.83,100% of Medicare,,,,,87932.83,100% of Medicare,,,,,87932.83,100% of Medicare,,,,,87932.83,100% of Medicare,,,,,87932.83,100% of Medicare,,,,,87932.83,100% of Medicare,,,,,87932.83,100% of Medicare,,,,,87932.83,100% of Medicare,,,,,,87932.83,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/ TBI or SCI A1806,A1806,LOCAL,,,,inpatient,,,234196.33,140517.8,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,189699.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,199066.88,percent of total billed charges,,,85,,199066.88,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,210776.7,percent of total billed charges,,,,,,,no IP contract,,80,,187357.07,percent of total billed charges,,,,,,,no IP contract,,50,,117098.17,percent of total billed charges,,,,,,no IP contract,,,78,,182673.14,percent of total billed charges,,,70,,163937.43,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Guillain-Barre Syndrome A1902,A1902,LOCAL,,,,inpatient,,,70890.38,42534.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,57421.21,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,60256.83,percent of total billed charges,,,85,,60256.83,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,63801.35,percent of total billed charges,,,,,,,no IP contract,,80,,56712.31,percent of total billed charges,,,,,,,no IP contract,,50,,35445.19,percent of total billed charges,,,,,,no IP contract,,,78,,55294.5,percent of total billed charges,,,70,,49623.27,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Guillain-Barre Syndrome A1903,A1903,LOCAL,,,,inpatient,,,138647.9,83188.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,112304.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,117850.72,percent of total billed charges,,,85,,117850.72,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,124783.11,percent of total billed charges,,,,,,,no IP contract,,80,,110918.32,percent of total billed charges,,,,,,,no IP contract,,50,,69323.95,percent of total billed charges,,,,,,no IP contract,,,78,,108145.36,percent of total billed charges,,,70,,97053.53,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,46728.37,100% of Medicare,,,,,46728.37,100% of Medicare,,,,,46728.37,100% of Medicare,,,,,46728.37,100% of Medicare,,,,,46728.37,100% of Medicare,,,,,46728.37,100% of Medicare,,,,,46728.37,100% of Medicare,,,,,46728.37,100% of Medicare,,,,,46728.37,100% of Medicare,,,,,46728.37,100% of Medicare,,,,,46728.37,100% of Medicare,,,,,,46728.37,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Guillain-Barre Syndrome A1904,A1904,LOCAL,,,,inpatient,,,123487.5,74092.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,100024.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,104964.38,percent of total billed charges,,,85,,104964.38,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,111138.75,percent of total billed charges,,,,,,,no IP contract,,80,,98790,percent of total billed charges,,,,,,,no IP contract,,50,,61743.75,percent of total billed charges,,,,,,no IP contract,,,78,,96320.25,percent of total billed charges,,,70,,86441.25,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Miscellaneous A2003,A2003,LOCAL,,,,inpatient,,,92859.92,55715.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,75216.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,78930.93,percent of total billed charges,,,85,,78930.93,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,83573.92,percent of total billed charges,,,,,,,no IP contract,,80,,74287.93,percent of total billed charges,,,,,,,no IP contract,,50,,46429.96,percent of total billed charges,,,,,,no IP contract,,,78,,72430.73,percent of total billed charges,,,70,,65001.94,percent of total billed charges,,,,,,,,,,,27705.65,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Burns A2101,A2101,LOCAL,,,,inpatient,,,102243.74,61346.24,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,82817.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,86907.18,percent of total billed charges,,,85,,86907.18,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,92019.36,percent of total billed charges,,,,,,,no IP contract,,80,,81794.99,percent of total billed charges,,,,,,,no IP contract,,50,,51121.87,percent of total billed charges,,,,,,no IP contract,,,78,,79750.11,percent of total billed charges,,,70,,71570.62,percent of total billed charges,,,,,,,,,,,33674.09,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Burns A2102,A2102,LOCAL,,,,inpatient,,,184571.27,110742.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,149502.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,156885.58,percent of total billed charges,,,85,,156885.58,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,166114.14,percent of total billed charges,,,,,,,no IP contract,,80,,147657.01,percent of total billed charges,,,,,,,no IP contract,,50,,92285.63,percent of total billed charges,,,,,,no IP contract,,,78,,143965.59,percent of total billed charges,,,70,,129199.89,percent of total billed charges,,,,,,,,,,,38300.97,100% of Medicare,,,,,69422.37,100% of Medicare,,,,,69422.37,100% of Medicare,,,,,69422.37,100% of Medicare,,,,,69422.37,100% of Medicare,,,,,69422.37,100% of Medicare,,,,,69422.37,100% of Medicare,,,,,69422.37,100% of Medicare,,,,,69422.37,100% of Medicare,,,,,69422.37,100% of Medicare,,,,,69422.37,100% of Medicare,,,,,69422.37,100% of Medicare,,,,,,69422.37,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,166114.14,
Stroke B0102,B0102,LOCAL,,,,inpatient,,,74848.2,44908.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,60627.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,63620.97,percent of total billed charges,,,85,,63620.97,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,67363.38,percent of total billed charges,,,,,,,no IP contract,,80,,59878.56,percent of total billed charges,,,,,,,no IP contract,,50,,37424.1,percent of total billed charges,,,,,,no IP contract,,,78,,58381.6,percent of total billed charges,,,70,,52393.74,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,2137.52,100% of Medicare,,,,,2137.52,100% of Medicare,,,,,2137.52,100% of Medicare,,,,,2137.52,100% of Medicare,,,,,2137.52,100% of Medicare,,,,,2137.52,100% of Medicare,,,,,2137.52,100% of Medicare,,,,,2137.52,100% of Medicare,,,,,2137.52,100% of Medicare,,,,,2137.52,100% of Medicare,,,,,2137.52,100% of Medicare,,,,,,2137.52,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Stroke B0103,B0103,LOCAL,,,,inpatient,,,120207.45,72124.47,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,97368.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,102176.33,percent of total billed charges,,,85,,102176.33,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,108186.71,percent of total billed charges,,,,,,,no IP contract,,80,,96165.96,percent of total billed charges,,,,,,,no IP contract,,50,,60103.73,percent of total billed charges,,,,,,no IP contract,,,78,,93761.81,percent of total billed charges,,,70,,84145.22,percent of total billed charges,,,,,,,,,,,36431.01,100% of Medicare,,,,,38693.82,100% of Medicare,,,,,38693.82,100% of Medicare,,,,,38693.82,100% of Medicare,,,,,38693.82,100% of Medicare,,,,,38693.82,100% of Medicare,,,,,38693.82,100% of Medicare,,,,,38693.82,100% of Medicare,,,,,38693.82,100% of Medicare,,,,,38693.82,100% of Medicare,,,,,38693.82,100% of Medicare,,,,,38693.82,100% of Medicare,,,,,,38693.82,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,108186.71,
Stroke B0104,B0104,LOCAL,,,,inpatient,,,106852.94,64111.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,86550.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,90825,percent of total billed charges,,,85,,90825,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,96167.65,percent of total billed charges,,,,,,,no IP contract,,80,,85482.35,percent of total billed charges,,,,,,,no IP contract,,50,,53426.47,percent of total billed charges,,,,,,no IP contract,,,78,,83345.3,percent of total billed charges,,,70,,74797.06,percent of total billed charges,,,,,,,,,,,27814.53,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Stroke B0105,B0105,LOCAL,,,,inpatient,,,217493.25,130495.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,176169.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,184869.26,percent of total billed charges,,,85,,184869.26,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,195743.93,percent of total billed charges,,,,,,,no IP contract,,80,,173994.6,percent of total billed charges,,,,,,,no IP contract,,50,,108746.63,percent of total billed charges,,,,,,no IP contract,,,78,,169644.74,percent of total billed charges,,,70,,152245.28,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Stroke B0106,B0106,LOCAL,,,,inpatient,,,218340.46,131004.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,176855.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,185589.39,percent of total billed charges,,,85,,185589.39,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,196506.42,percent of total billed charges,,,,,,,no IP contract,,80,,174672.37,percent of total billed charges,,,,,,,no IP contract,,50,,109170.23,percent of total billed charges,,,,,,no IP contract,,,78,,170305.56,percent of total billed charges,,,70,,152838.33,percent of total billed charges,,,,,,,,,,,70067.22,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Traumatic Brain Injury B0202,B0202,LOCAL,,,,inpatient,,,42804.98,25682.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,34672.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,36384.23,percent of total billed charges,,,85,,36384.23,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,38524.48,percent of total billed charges,,,,,,,no IP contract,,80,,34243.98,percent of total billed charges,,,,,,,no IP contract,,50,,21402.49,percent of total billed charges,,,,,,no IP contract,,,78,,33387.88,percent of total billed charges,,,70,,29963.48,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,20222.45,100% of Medicare,,,,,20222.45,100% of Medicare,,,,,20222.45,100% of Medicare,,,,,20222.45,100% of Medicare,,,,,20222.45,100% of Medicare,,,,,20222.45,100% of Medicare,,,,,20222.45,100% of Medicare,,,,,20222.45,100% of Medicare,,,,,20222.45,100% of Medicare,,,,,20222.45,100% of Medicare,,,,,20222.45,100% of Medicare,,,,,,20222.45,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Traumatic Brain Injury B0203,B0203,LOCAL,,,,inpatient,,,138833.33,83300,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,112454.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,118008.33,percent of total billed charges,,,85,,118008.33,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,124949.99,percent of total billed charges,,,,,,,no IP contract,,80,,111066.66,percent of total billed charges,,,,,,,no IP contract,,50,,69416.66,percent of total billed charges,,,,,,no IP contract,,,78,,108289.99,percent of total billed charges,,,70,,97183.33,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Traumatic Brain Injury B0204,B0204,LOCAL,,,,inpatient,,,120232.89,72139.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,97388.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,102197.96,percent of total billed charges,,,85,,102197.96,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,108209.6,percent of total billed charges,,,,,,,no IP contract,,80,,96186.31,percent of total billed charges,,,,,,,no IP contract,,50,,60116.45,percent of total billed charges,,,,,,no IP contract,,,78,,93781.66,percent of total billed charges,,,70,,84163.02,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,41147.49,100% of Medicare,,,,,41147.49,100% of Medicare,,,,,41147.49,100% of Medicare,,,,,41147.49,100% of Medicare,,,,,41147.49,100% of Medicare,,,,,41147.49,100% of Medicare,,,,,41147.49,100% of Medicare,,,,,41147.49,100% of Medicare,,,,,41147.49,100% of Medicare,,,,,41147.49,100% of Medicare,,,,,41147.49,100% of Medicare,,,,,,41147.49,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Traumatic Brain Injury B0205,B0205,LOCAL,,,,inpatient,,,338473.51,203084.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,274163.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,287702.48,percent of total billed charges,,,85,,287702.48,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,304626.16,percent of total billed charges,,,,,,,no IP contract,,80,,270778.81,percent of total billed charges,,,,,,,no IP contract,,50,,169236.76,percent of total billed charges,,,,,,no IP contract,,,78,,264009.34,percent of total billed charges,,,70,,236931.46,percent of total billed charges,,,,,,,,,,,34121.13,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Non-traumatic Brain Injury B0301,B0301,LOCAL,,,,inpatient,,,101781.58,61068.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,82443.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,86514.34,percent of total billed charges,,,85,,86514.34,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,91603.42,percent of total billed charges,,,,,,,no IP contract,,80,,81425.26,percent of total billed charges,,,,,,,no IP contract,,50,,50890.79,percent of total billed charges,,,,,,no IP contract,,,78,,79389.63,percent of total billed charges,,,70,,71247.1,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,34050.23,100% of Medicare,,,,,34050.23,100% of Medicare,,,,,34050.23,100% of Medicare,,,,,34050.23,100% of Medicare,,,,,34050.23,100% of Medicare,,,,,34050.23,100% of Medicare,,,,,34050.23,100% of Medicare,,,,,34050.23,100% of Medicare,,,,,34050.23,100% of Medicare,,,,,34050.23,100% of Medicare,,,,,34050.23,100% of Medicare,,,,,,34050.23,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Non-traumatic Brain Injury B0302,B0302,LOCAL,,,,inpatient,,,101296.39,60777.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,82050.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,86101.93,percent of total billed charges,,,85,,86101.93,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,91166.75,percent of total billed charges,,,,,,,no IP contract,,80,,81037.11,percent of total billed charges,,,,,,,no IP contract,,50,,50648.19,percent of total billed charges,,,,,,no IP contract,,,78,,79011.18,percent of total billed charges,,,70,,70907.47,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,35158.11,100% of Medicare,,,,,35158.11,100% of Medicare,,,,,35158.11,100% of Medicare,,,,,35158.11,100% of Medicare,,,,,35158.11,100% of Medicare,,,,,35158.11,100% of Medicare,,,,,35158.11,100% of Medicare,,,,,35158.11,100% of Medicare,,,,,35158.11,100% of Medicare,,,,,35158.11,100% of Medicare,,,,,35158.11,100% of Medicare,,,,,,35158.11,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Non-traumatic Brain Injury B0303,B0303,LOCAL,,,,inpatient,,,158474.75,95084.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,128364.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,134703.54,percent of total billed charges,,,85,,134703.54,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,142627.28,percent of total billed charges,,,,,,,no IP contract,,80,,126779.8,percent of total billed charges,,,,,,,no IP contract,,50,,79237.38,percent of total billed charges,,,,,,no IP contract,,,78,,123610.31,percent of total billed charges,,,70,,110932.33,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Non-traumatic Brain Injury B0304,B0304,LOCAL,,,,inpatient,,,94401.9,56641.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,76465.54,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,80241.62,percent of total billed charges,,,85,,80241.62,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,84961.71,percent of total billed charges,,,,,,,no IP contract,,80,,75521.52,percent of total billed charges,,,,,,,no IP contract,,50,,47200.95,percent of total billed charges,,,,,,no IP contract,,,78,,73633.48,percent of total billed charges,,,70,,66081.33,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Non-traumatic Brain Injury B0305,B0305,LOCAL,,,,inpatient,,,359157.24,215494.35,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,290917.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,305283.66,percent of total billed charges,,,85,,305283.66,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,323241.52,percent of total billed charges,,,,,,,no IP contract,,80,,287325.8,percent of total billed charges,,,,,,,no IP contract,,50,,179578.62,percent of total billed charges,,,,,,no IP contract,,,78,,280142.65,percent of total billed charges,,,70,,251410.07,percent of total billed charges,,,,,,,,,,,79300.04,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Traumatic Spinal Cord B0401,B0401,LOCAL,,,,inpatient,,,72600.45,43560.27,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,58806.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,61710.38,percent of total billed charges,,,85,,61710.38,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,65340.41,percent of total billed charges,,,,,,,no IP contract,,80,,58080.36,percent of total billed charges,,,,,,,no IP contract,,50,,36300.23,percent of total billed charges,,,,,,no IP contract,,,78,,56628.35,percent of total billed charges,,,70,,50820.32,percent of total billed charges,,,,,,,,,,,31035.48,100% of Medicare,,,,,29063.53,100% of Medicare,,,,,29063.53,100% of Medicare,,,,,29063.53,100% of Medicare,,,,,29063.53,100% of Medicare,,,,,29063.53,100% of Medicare,,,,,29063.53,100% of Medicare,,,,,29063.53,100% of Medicare,,,,,29063.53,100% of Medicare,,,,,29063.53,100% of Medicare,,,,,29063.53,100% of Medicare,,,,,29063.53,100% of Medicare,,,,,,29063.53,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,65340.41,
Traumatic Spinal Cord B0403,B0403,LOCAL,,,,inpatient,,,199735.75,119841.45,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,161785.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,169775.39,percent of total billed charges,,,85,,169775.39,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,179762.18,percent of total billed charges,,,,,,,no IP contract,,80,,159788.6,percent of total billed charges,,,,,,,no IP contract,,50,,99867.88,percent of total billed charges,,,,,,no IP contract,,,78,,155793.89,percent of total billed charges,,,70,,139815.03,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Traumatic Spinal Cord B0404,B0404,LOCAL,,,,inpatient,,,419143.03,251485.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,339505.85,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,356271.57,percent of total billed charges,,,85,,356271.57,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,377228.72,percent of total billed charges,,,,,,,no IP contract,,80,,335314.42,percent of total billed charges,,,,,,,no IP contract,,50,,209571.51,percent of total billed charges,,,,,,no IP contract,,,78,,326931.56,percent of total billed charges,,,70,,293400.12,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Traumatic Spinal Cord B0405,B0405,LOCAL,,,,inpatient,,,251572.68,150943.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,203773.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,213836.77,percent of total billed charges,,,85,,213836.77,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,226415.41,percent of total billed charges,,,,,,,no IP contract,,80,,201258.14,percent of total billed charges,,,,,,,no IP contract,,50,,125786.34,percent of total billed charges,,,,,,no IP contract,,,78,,196226.69,percent of total billed charges,,,70,,176100.87,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Traumatic Spinal Cord B0407,B0407,LOCAL,,,,inpatient,,,358162.28,214897.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,290111.45,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,304437.94,percent of total billed charges,,,85,,304437.94,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,322346.06,percent of total billed charges,,,,,,,no IP contract,,80,,286529.83,percent of total billed charges,,,,,,,no IP contract,,50,,179081.14,percent of total billed charges,,,,,,no IP contract,,,78,,279366.58,percent of total billed charges,,,70,,250713.6,percent of total billed charges,,,,,,,,,,,87932.83,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Non-traumatic Spinal Cord B0501,B0501,LOCAL,,,,inpatient,,,99854.7,59912.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,80882.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,84876.5,percent of total billed charges,,,85,,84876.5,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,89869.23,percent of total billed charges,,,,,,,no IP contract,,80,,79883.76,percent of total billed charges,,,,,,,no IP contract,,50,,49927.35,percent of total billed charges,,,,,,no IP contract,,,78,,77886.67,percent of total billed charges,,,70,,69898.29,percent of total billed charges,,,,,,,,,,,29860.23,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Non-traumatic Spinal Cord B0505,B0505,LOCAL,,,,inpatient,,,241756.14,145053.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,195822.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,205492.72,percent of total billed charges,,,85,,205492.72,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,217580.53,percent of total billed charges,,,,,,,no IP contract,,80,,193404.91,percent of total billed charges,,,,,,,no IP contract,,50,,120878.07,percent of total billed charges,,,,,,no IP contract,,,78,,188569.79,percent of total billed charges,,,70,,169229.3,percent of total billed charges,,,,,,,,,,,49349.23,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Neurological Conditions B0603,B0603,LOCAL,,,,inpatient,,,109093.23,65455.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,88365.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,92729.24,percent of total billed charges,,,85,,92729.24,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,98183.9,percent of total billed charges,,,,,,,no IP contract,,80,,87274.58,percent of total billed charges,,,,,,,no IP contract,,50,,54546.61,percent of total billed charges,,,,,,no IP contract,,,78,,85092.72,percent of total billed charges,,,70,,76365.26,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,30891.38,100% of Medicare,,,,,30891.38,100% of Medicare,,,,,30891.38,100% of Medicare,,,,,30891.38,100% of Medicare,,,,,30891.38,100% of Medicare,,,,,30891.38,100% of Medicare,,,,,30891.38,100% of Medicare,,,,,30891.38,100% of Medicare,,,,,30891.38,100% of Medicare,,,,,30891.38,100% of Medicare,,,,,30891.38,100% of Medicare,,,,,,30891.38,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Neurological Conditions B0604,B0604,LOCAL,,,,inpatient,,,217008.32,130204.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,175776.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,184457.07,percent of total billed charges,,,85,,184457.07,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,195307.48,percent of total billed charges,,,,,,,no IP contract,,80,,173606.65,percent of total billed charges,,,,,,,no IP contract,,50,,108504.16,percent of total billed charges,,,,,,no IP contract,,,78,,169266.49,percent of total billed charges,,,70,,151905.82,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Fracture of Lower Extremity B0703,B0703,LOCAL,,,,inpatient,,,95789.33,57473.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,77589.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,81420.93,percent of total billed charges,,,85,,81420.93,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,86210.4,percent of total billed charges,,,,,,,no IP contract,,80,,76631.46,percent of total billed charges,,,,,,,no IP contract,,50,,47894.67,percent of total billed charges,,,,,,no IP contract,,,78,,74715.68,percent of total billed charges,,,70,,67052.53,percent of total billed charges,,,,,,,,,,,42076.73,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Fracture of Lower Extremity B0704,B0704,LOCAL,,,,inpatient,,,71428.31,42856.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,57856.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,60714.06,percent of total billed charges,,,85,,60714.06,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,64285.48,percent of total billed charges,,,,,,,no IP contract,,80,,57142.65,percent of total billed charges,,,,,,,no IP contract,,50,,35714.16,percent of total billed charges,,,,,,no IP contract,,,78,,55714.08,percent of total billed charges,,,70,,49999.82,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,19935.64,100% of Medicare,,,,,19935.64,100% of Medicare,,,,,19935.64,100% of Medicare,,,,,19935.64,100% of Medicare,,,,,19935.64,100% of Medicare,,,,,19935.64,100% of Medicare,,,,,19935.64,100% of Medicare,,,,,19935.64,100% of Medicare,,,,,19935.64,100% of Medicare,,,,,19935.64,100% of Medicare,,,,,19935.64,100% of Medicare,,,,,,19935.64,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Other Orthopedic B0901,B0901,LOCAL,,,,inpatient,,,137218.5,82331.1,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,111146.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,116635.73,percent of total billed charges,,,85,,116635.73,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,123496.65,percent of total billed charges,,,,,,,no IP contract,,80,,109774.8,percent of total billed charges,,,,,,,no IP contract,,50,,68609.25,percent of total billed charges,,,,,,no IP contract,,,78,,107030.43,percent of total billed charges,,,70,,96052.95,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,53937.55,100% of Medicare,,,,,53937.55,100% of Medicare,,,,,53937.55,100% of Medicare,,,,,53937.55,100% of Medicare,,,,,53937.55,100% of Medicare,,,,,53937.55,100% of Medicare,,,,,53937.55,100% of Medicare,,,,,53937.55,100% of Medicare,,,,,53937.55,100% of Medicare,,,,,53937.55,100% of Medicare,,,,,53937.55,100% of Medicare,,,,,,53937.55,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Other Orthopedic B0903,B0903,LOCAL,,,,inpatient,,,148469.85,89081.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,120260.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,126199.37,percent of total billed charges,,,85,,126199.37,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,133622.87,percent of total billed charges,,,,,,,no IP contract,,80,,118775.88,percent of total billed charges,,,,,,,no IP contract,,50,,74234.93,percent of total billed charges,,,,,,no IP contract,,,78,,115806.48,percent of total billed charges,,,70,,103928.9,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Other Orthopedic B0904,B0904,LOCAL,,,,inpatient,,,163759.15,98255.49,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,132644.91,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,139195.28,percent of total billed charges,,,85,,139195.28,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,147383.24,percent of total billed charges,,,,,,,no IP contract,,80,,131007.32,percent of total billed charges,,,,,,,no IP contract,,50,,81879.58,percent of total billed charges,,,,,,no IP contract,,,78,,127732.14,percent of total billed charges,,,70,,114631.41,percent of total billed charges,,,,,,,,,,,46728.37,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Amputation of Lower Extremity B1002,B1002,LOCAL,,,,inpatient,,,172008.55,103205.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,139326.93,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,146207.27,percent of total billed charges,,,85,,146207.27,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,154807.7,percent of total billed charges,,,,,,,no IP contract,,80,,137606.84,percent of total billed charges,,,,,,,no IP contract,,50,,86004.28,percent of total billed charges,,,,,,no IP contract,,,78,,134166.67,percent of total billed charges,,,70,,120405.99,percent of total billed charges,,,,,,,,,,,44848.59,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Amputation of Lower Extremity B1003,B1003,LOCAL,,,,inpatient,,,131074.85,78644.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,106170.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,111413.62,percent of total billed charges,,,85,,111413.62,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,117967.37,percent of total billed charges,,,,,,,no IP contract,,80,,104859.88,percent of total billed charges,,,,,,,no IP contract,,50,,65537.43,percent of total billed charges,,,,,,no IP contract,,,78,,102238.38,percent of total billed charges,,,70,,91752.4,percent of total billed charges,,,,,,,,,,,28999.99,100% of Medicare,,,,,44608.67,100% of Medicare,,,,,44608.67,100% of Medicare,,,,,44608.67,100% of Medicare,,,,,44608.67,100% of Medicare,,,,,44608.67,100% of Medicare,,,,,44608.67,100% of Medicare,,,,,44608.67,100% of Medicare,,,,,44608.67,100% of Medicare,,,,,44608.67,100% of Medicare,,,,,44608.67,100% of Medicare,,,,,44608.67,100% of Medicare,,,,,,44608.67,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,117967.37,
Amputation of Lower Extremity B1004,B1004,LOCAL,,,,inpatient,,,122888.54,73733.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,99539.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,104455.26,percent of total billed charges,,,85,,104455.26,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,110599.68,percent of total billed charges,,,,,,,no IP contract,,80,,98310.83,percent of total billed charges,,,,,,,no IP contract,,50,,61444.27,percent of total billed charges,,,,,,no IP contract,,,78,,95853.06,percent of total billed charges,,,70,,86021.98,percent of total billed charges,,,,,,,,,,,9888.76,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Cardiac B1401,B1401,LOCAL,,,,inpatient,,,51466.35,30879.81,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,41687.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,43746.4,percent of total billed charges,,,85,,43746.4,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,46319.72,percent of total billed charges,,,,,,,no IP contract,,80,,41173.08,percent of total billed charges,,,,,,,no IP contract,,50,,25733.18,percent of total billed charges,,,,,,no IP contract,,,78,,40143.75,percent of total billed charges,,,70,,36026.45,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Cardiac B1402,B1402,LOCAL,,,,inpatient,,,91275.1,54765.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,73932.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,77583.84,percent of total billed charges,,,85,,77583.84,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,82147.59,percent of total billed charges,,,,,,,no IP contract,,80,,73020.08,percent of total billed charges,,,,,,,no IP contract,,50,,45637.55,percent of total billed charges,,,,,,no IP contract,,,78,,71194.58,percent of total billed charges,,,70,,63892.57,percent of total billed charges,,,,,,,,,,,32439.6,100% of Medicare,,,,,28805.47,100% of Medicare,,,,,28805.47,100% of Medicare,,,,,28805.47,100% of Medicare,,,,,28805.47,100% of Medicare,,,,,28805.47,100% of Medicare,,,,,28805.47,100% of Medicare,,,,,28805.47,100% of Medicare,,,,,28805.47,100% of Medicare,,,,,28805.47,100% of Medicare,,,,,28805.47,100% of Medicare,,,,,28805.47,100% of Medicare,,,,,,28805.47,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,82147.59,
Cardiac B1403,B1403,LOCAL,,,,inpatient,,,131171.39,78702.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,106248.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,111495.68,percent of total billed charges,,,85,,111495.68,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,118054.25,percent of total billed charges,,,,,,,no IP contract,,80,,104937.11,percent of total billed charges,,,,,,,no IP contract,,50,,65585.7,percent of total billed charges,,,,,,no IP contract,,,78,,102313.68,percent of total billed charges,,,70,,91819.97,percent of total billed charges,,,,,,,,,,,38693.82,100% of Medicare,,,,,45582.5,100% of Medicare,,,,,45582.5,100% of Medicare,,,,,45582.5,100% of Medicare,,,,,45582.5,100% of Medicare,,,,,45582.5,100% of Medicare,,,,,45582.5,100% of Medicare,,,,,45582.5,100% of Medicare,,,,,45582.5,100% of Medicare,,,,,45582.5,100% of Medicare,,,,,45582.5,100% of Medicare,,,,,45582.5,100% of Medicare,,,,,,45582.5,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,118054.25,
Cardiac B1404,B1404,LOCAL,,,,inpatient,,,134559.97,80735.98,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,108993.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,114375.97,percent of total billed charges,,,85,,114375.97,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,121103.97,percent of total billed charges,,,,,,,no IP contract,,80,,107647.97,percent of total billed charges,,,,,,,no IP contract,,50,,67279.98,percent of total billed charges,,,,,,no IP contract,,,78,,104956.77,percent of total billed charges,,,70,,94191.98,percent of total billed charges,,,,,,,,,,,56586.08,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Pulmonary B1501,B1501,LOCAL,,,,inpatient,,,232461.65,139476.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,188293.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,197592.4,percent of total billed charges,,,85,,197592.4,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,209215.49,percent of total billed charges,,,,,,,no IP contract,,80,,185969.32,percent of total billed charges,,,,,,,no IP contract,,50,,116230.83,percent of total billed charges,,,,,,no IP contract,,,78,,181320.09,percent of total billed charges,,,70,,162723.16,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Pulmonary B1502,B1502,LOCAL,,,,inpatient,,,154475.54,92685.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,125125.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,131304.21,percent of total billed charges,,,85,,131304.21,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,139027.98,percent of total billed charges,,,,,,,no IP contract,,80,,123580.43,percent of total billed charges,,,,,,,no IP contract,,50,,77237.77,percent of total billed charges,,,,,,no IP contract,,,78,,120490.92,percent of total billed charges,,,70,,108132.88,percent of total billed charges,,,,,,,,,,,40496.83,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Pulmonary B1503,B1503,LOCAL,,,,inpatient,,,169939.8,101963.88,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,137651.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,144448.83,percent of total billed charges,,,85,,144448.83,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,152945.82,percent of total billed charges,,,,,,,no IP contract,,80,,135951.84,percent of total billed charges,,,,,,,no IP contract,,50,,84969.9,percent of total billed charges,,,,,,no IP contract,,,78,,132553.04,percent of total billed charges,,,70,,118957.86,percent of total billed charges,,,,,,,,,,,31520.63,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Pulmonary B1504,B1504,LOCAL,,,,inpatient,,,199806.41,119883.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,161843.19,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,169835.45,percent of total billed charges,,,85,,169835.45,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,179825.77,percent of total billed charges,,,,,,,no IP contract,,80,,159845.13,percent of total billed charges,,,,,,,no IP contract,,50,,99903.21,percent of total billed charges,,,,,,no IP contract,,,78,,155849,percent of total billed charges,,,70,,139864.49,percent of total billed charges,,,,,,,,,,,47495.49,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/o TBI or SCI B1704,B1704,LOCAL,,,,inpatient,,,140702.2,84421.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,113968.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,119596.87,percent of total billed charges,,,85,,119596.87,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,126631.98,percent of total billed charges,,,,,,,no IP contract,,80,,112561.76,percent of total billed charges,,,,,,,no IP contract,,50,,70351.1,percent of total billed charges,,,,,,no IP contract,,,78,,109747.72,percent of total billed charges,,,70,,98491.54,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,31520.63,100% of Medicare,,,,,31520.63,100% of Medicare,,,,,31520.63,100% of Medicare,,,,,31520.63,100% of Medicare,,,,,31520.63,100% of Medicare,,,,,31520.63,100% of Medicare,,,,,31520.63,100% of Medicare,,,,,31520.63,100% of Medicare,,,,,31520.63,100% of Medicare,,,,,31520.63,100% of Medicare,,,,,31520.63,100% of Medicare,,,,,,31520.63,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/ TBI or SCI B1801,B1801,LOCAL,,,,inpatient,,,123571.25,74142.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,100092.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,105035.56,percent of total billed charges,,,85,,105035.56,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,111214.13,percent of total billed charges,,,,,,,no IP contract,,80,,98857,percent of total billed charges,,,,,,,no IP contract,,50,,61785.63,percent of total billed charges,,,,,,no IP contract,,,78,,96385.58,percent of total billed charges,,,70,,86499.88,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/ TBI or SCI B1802,B1802,LOCAL,,,,inpatient,,,115986.48,69591.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,93949.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,98588.5,percent of total billed charges,,,85,,98588.5,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,104387.83,percent of total billed charges,,,,,,,no IP contract,,80,,92789.18,percent of total billed charges,,,,,,,no IP contract,,50,,57993.24,percent of total billed charges,,,,,,no IP contract,,,78,,90469.45,percent of total billed charges,,,70,,81190.53,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,32782.68,100% of Medicare,,,,,32782.68,100% of Medicare,,,,,32782.68,100% of Medicare,,,,,32782.68,100% of Medicare,,,,,32782.68,100% of Medicare,,,,,32782.68,100% of Medicare,,,,,32782.68,100% of Medicare,,,,,32782.68,100% of Medicare,,,,,32782.68,100% of Medicare,,,,,32782.68,100% of Medicare,,,,,32782.68,100% of Medicare,,,,,,32782.68,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/ TBI or SCI B1803,B1803,LOCAL,,,,inpatient,,,144855.28,86913.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,117332.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,123126.99,percent of total billed charges,,,85,,123126.99,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,130369.75,percent of total billed charges,,,,,,,no IP contract,,80,,115884.22,percent of total billed charges,,,,,,,no IP contract,,50,,72427.64,percent of total billed charges,,,,,,no IP contract,,,78,,112987.12,percent of total billed charges,,,70,,101398.7,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/ TBI or SCI B1804,B1804,LOCAL,,,,inpatient,,,176821.28,106092.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,143225.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,150298.08,percent of total billed charges,,,85,,150298.08,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,159139.15,percent of total billed charges,,,,,,,no IP contract,,80,,141457.02,percent of total billed charges,,,,,,,no IP contract,,50,,88410.64,percent of total billed charges,,,,,,no IP contract,,,78,,137920.59,percent of total billed charges,,,70,,123774.89,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,67123.63,100% of Medicare,,,,,67123.63,100% of Medicare,,,,,67123.63,100% of Medicare,,,,,67123.63,100% of Medicare,,,,,67123.63,100% of Medicare,,,,,67123.63,100% of Medicare,,,,,67123.63,100% of Medicare,,,,,67123.63,100% of Medicare,,,,,67123.63,100% of Medicare,,,,,67123.63,100% of Medicare,,,,,67123.63,100% of Medicare,,,,,,67123.63,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/ TBI or SCI B1805,B1805,LOCAL,,,,inpatient,,,149905.84,89943.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,121423.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,127419.96,percent of total billed charges,,,85,,127419.96,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,134915.25,percent of total billed charges,,,,,,,no IP contract,,80,,119924.67,percent of total billed charges,,,,,,,no IP contract,,50,,74952.92,percent of total billed charges,,,,,,no IP contract,,,78,,116926.55,percent of total billed charges,,,70,,104934.09,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/ TBI or SCI B1806,B1806,LOCAL,,,,inpatient,,,323834.6,194300.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,262306.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,275259.41,percent of total billed charges,,,85,,275259.41,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,291451.14,percent of total billed charges,,,,,,,no IP contract,,80,,259067.68,percent of total billed charges,,,,,,,no IP contract,,50,,161917.3,percent of total billed charges,,,,,,no IP contract,,,78,,252590.99,percent of total billed charges,,,70,,226684.22,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Guillain-Barre Syndrome B1904,B1904,LOCAL,,,,inpatient,,,258523.58,155114.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,209404.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,219745.05,percent of total billed charges,,,85,,219745.05,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,232671.23,percent of total billed charges,,,,,,,no IP contract,,80,,206818.87,percent of total billed charges,,,,,,,no IP contract,,50,,129261.79,percent of total billed charges,,,,,,no IP contract,,,78,,201648.4,percent of total billed charges,,,70,,180966.51,percent of total billed charges,,,,,,,,,,,95974.05,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Miscellaneous B2001,B2001,LOCAL,,,,inpatient,,,84294.75,50576.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,68278.75,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,71650.54,percent of total billed charges,,,85,,71650.54,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,75865.28,percent of total billed charges,,,,,,,no IP contract,,80,,67435.8,percent of total billed charges,,,,,,,no IP contract,,50,,42147.38,percent of total billed charges,,,,,,no IP contract,,,78,,65749.91,percent of total billed charges,,,70,,59006.33,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,30411.68,100% of Medicare,,,,,30411.68,100% of Medicare,,,,,30411.68,100% of Medicare,,,,,30411.68,100% of Medicare,,,,,30411.68,100% of Medicare,,,,,30411.68,100% of Medicare,,,,,30411.68,100% of Medicare,,,,,30411.68,100% of Medicare,,,,,30411.68,100% of Medicare,,,,,30411.68,100% of Medicare,,,,,30411.68,100% of Medicare,,,,,,30411.68,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Miscellaneous B2002,B2002,LOCAL,,,,inpatient,,,110406.01,66243.61,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,89428.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,93845.11,percent of total billed charges,,,85,,93845.11,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,99365.41,percent of total billed charges,,,,,,,no IP contract,,80,,88324.81,percent of total billed charges,,,,,,,no IP contract,,50,,55203,percent of total billed charges,,,,,,no IP contract,,,78,,86116.69,percent of total billed charges,,,70,,77284.21,percent of total billed charges,,,,,,,,,,,34050.23,100% of Medicare,,,,,35247.24,100% of Medicare,,,,,35247.24,100% of Medicare,,,,,35247.24,100% of Medicare,,,,,35247.24,100% of Medicare,,,,,35247.24,100% of Medicare,,,,,35247.24,100% of Medicare,,,,,35247.24,100% of Medicare,,,,,35247.24,100% of Medicare,,,,,35247.24,100% of Medicare,,,,,35247.24,100% of Medicare,,,,,35247.24,100% of Medicare,,,,,,35247.24,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,99365.41,
Miscellaneous B2003,B2003,LOCAL,,,,inpatient,,,128677.87,77206.72,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,104229.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,109376.19,percent of total billed charges,,,85,,109376.19,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,115810.09,percent of total billed charges,,,,,,,no IP contract,,80,,102942.3,percent of total billed charges,,,,,,,no IP contract,,50,,64338.94,percent of total billed charges,,,,,,no IP contract,,,78,,100368.74,percent of total billed charges,,,70,,90074.51,percent of total billed charges,,,,,,,,,,,34857.98,100% of Medicare,,,,,39233.89,100% of Medicare,,,,,39233.89,100% of Medicare,,,,,39233.89,100% of Medicare,,,,,39233.89,100% of Medicare,,,,,39233.89,100% of Medicare,,,,,39233.89,100% of Medicare,,,,,39233.89,100% of Medicare,,,,,39233.89,100% of Medicare,,,,,39233.89,100% of Medicare,,,,,39233.89,100% of Medicare,,,,,39233.89,100% of Medicare,,,,,,39233.89,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,115810.09,
Miscellaneous B2004,B2004,LOCAL,,,,inpatient,,,149767.2,89860.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,121311.43,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,127302.12,percent of total billed charges,,,85,,127302.12,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,134790.48,percent of total billed charges,,,,,,,no IP contract,,80,,119813.76,percent of total billed charges,,,,,,,no IP contract,,50,,74883.6,percent of total billed charges,,,,,,no IP contract,,,78,,116818.42,percent of total billed charges,,,70,,104837.04,percent of total billed charges,,,,,,,,,,,14485.8,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Miscellaneous B2005,B2005,LOCAL,,,,inpatient,,,194740.42,116844.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,157739.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,165529.35,percent of total billed charges,,,85,,165529.35,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,175266.38,percent of total billed charges,,,,,,,no IP contract,,80,,155792.33,percent of total billed charges,,,,,,,no IP contract,,50,,97370.21,percent of total billed charges,,,,,,no IP contract,,,78,,151897.53,percent of total billed charges,,,70,,136318.29,percent of total billed charges,,,,,,,,,,,58527.9,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Burns B2101,B2101,LOCAL,,,,inpatient,,,127467.6,76480.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,103248.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,108347.46,percent of total billed charges,,,85,,108347.46,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,114720.84,percent of total billed charges,,,,,,,no IP contract,,80,,101974.08,percent of total billed charges,,,,,,,no IP contract,,50,,63733.8,percent of total billed charges,,,,,,no IP contract,,,78,,99424.73,percent of total billed charges,,,70,,89227.32,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,40391.26,100% of Medicare,,,,,40391.26,100% of Medicare,,,,,40391.26,100% of Medicare,,,,,40391.26,100% of Medicare,,,,,40391.26,100% of Medicare,,,,,40391.26,100% of Medicare,,,,,40391.26,100% of Medicare,,,,,40391.26,100% of Medicare,,,,,40391.26,100% of Medicare,,,,,40391.26,100% of Medicare,,,,,40391.26,100% of Medicare,,,,,,40391.26,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Burns B2102,B2102,LOCAL,,,,inpatient,,,299699.99,179820,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,242756.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,254744.99,percent of total billed charges,,,85,,254744.99,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,269729.99,percent of total billed charges,,,,,,,no IP contract,,80,,239759.99,percent of total billed charges,,,,,,,no IP contract,,50,,149850,percent of total billed charges,,,,,,no IP contract,,,78,,233765.99,percent of total billed charges,,,70,,209789.99,percent of total billed charges,,,,,,,,,,,69422.37,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Stroke C0103,C0103,LOCAL,,,,inpatient,,,124445.35,74667.21,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,100800.73,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,105778.55,percent of total billed charges,,,85,,105778.55,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,112000.82,percent of total billed charges,,,,,,,no IP contract,,80,,99556.28,percent of total billed charges,,,,,,,no IP contract,,50,,62222.68,percent of total billed charges,,,,,,no IP contract,,,78,,97067.37,percent of total billed charges,,,70,,87111.75,percent of total billed charges,,,,,,,,,,,30891.38,100% of Medicare,,,,,39934.49,100% of Medicare,,,,,39934.49,100% of Medicare,,,,,39934.49,100% of Medicare,,,,,39934.49,100% of Medicare,,,,,39934.49,100% of Medicare,,,,,39934.49,100% of Medicare,,,,,39934.49,100% of Medicare,,,,,39934.49,100% of Medicare,,,,,39934.49,100% of Medicare,,,,,39934.49,100% of Medicare,,,,,39934.49,100% of Medicare,,,,,,39934.49,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,112000.82,
Stroke C0104,C0104,LOCAL,,,,inpatient,,,136178.55,81707.13,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,110304.63,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,115751.77,percent of total billed charges,,,85,,115751.77,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,122560.7,percent of total billed charges,,,,,,,no IP contract,,80,,108942.84,percent of total billed charges,,,,,,,no IP contract,,50,,68089.28,percent of total billed charges,,,,,,no IP contract,,,78,,106219.27,percent of total billed charges,,,70,,95324.99,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,43636.99,100% of Medicare,,,,,43636.99,100% of Medicare,,,,,43636.99,100% of Medicare,,,,,43636.99,100% of Medicare,,,,,43636.99,100% of Medicare,,,,,43636.99,100% of Medicare,,,,,43636.99,100% of Medicare,,,,,43636.99,100% of Medicare,,,,,43636.99,100% of Medicare,,,,,43636.99,100% of Medicare,,,,,43636.99,100% of Medicare,,,,,,43636.99,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Stroke C0106,C0106,LOCAL,,,,inpatient,,,176281.86,105769.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,142788.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,149839.58,percent of total billed charges,,,85,,149839.58,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,158653.67,percent of total billed charges,,,,,,,no IP contract,,80,,141025.49,percent of total billed charges,,,,,,,no IP contract,,50,,88140.93,percent of total billed charges,,,,,,no IP contract,,,78,,137499.85,percent of total billed charges,,,70,,123397.3,percent of total billed charges,,,,,,,,,,,44027.61,100% of Medicare,,,,,52179.86,100% of Medicare,,,,,52179.86,100% of Medicare,,,,,52179.86,100% of Medicare,,,,,52179.86,100% of Medicare,,,,,52179.86,100% of Medicare,,,,,52179.86,100% of Medicare,,,,,52179.86,100% of Medicare,,,,,52179.86,100% of Medicare,,,,,52179.86,100% of Medicare,,,,,52179.86,100% of Medicare,,,,,52179.86,100% of Medicare,,,,,,52179.86,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,158653.67,
Traumatic Brain Injury C0201,C0201,LOCAL,,,,inpatient,,,50701.58,30420.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,41068.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,43096.35,percent of total billed charges,,,85,,43096.35,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,45631.43,percent of total billed charges,,,,,,,no IP contract,,80,,40561.27,percent of total billed charges,,,,,,,no IP contract,,50,,25350.79,percent of total billed charges,,,,,,no IP contract,,,78,,39547.24,percent of total billed charges,,,70,,35491.11,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,23842.67,100% of Medicare,,,,,23842.67,100% of Medicare,,,,,23842.67,100% of Medicare,,,,,23842.67,100% of Medicare,,,,,23842.67,100% of Medicare,,,,,23842.67,100% of Medicare,,,,,23842.67,100% of Medicare,,,,,23842.67,100% of Medicare,,,,,23842.67,100% of Medicare,,,,,23842.67,100% of Medicare,,,,,23842.67,100% of Medicare,,,,,,23842.67,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Traumatic Brain Injury C0202,C0202,LOCAL,,,,inpatient,,,107019.9,64211.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,86686.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,90966.92,percent of total billed charges,,,85,,90966.92,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,96317.91,percent of total billed charges,,,,,,,no IP contract,,80,,85615.92,percent of total billed charges,,,,,,,no IP contract,,50,,53509.95,percent of total billed charges,,,,,,no IP contract,,,78,,83475.52,percent of total billed charges,,,70,,74913.93,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,39017.32,100% of Medicare,,,,,39017.32,100% of Medicare,,,,,39017.32,100% of Medicare,,,,,39017.32,100% of Medicare,,,,,39017.32,100% of Medicare,,,,,39017.32,100% of Medicare,,,,,39017.32,100% of Medicare,,,,,39017.32,100% of Medicare,,,,,39017.32,100% of Medicare,,,,,39017.32,100% of Medicare,,,,,39017.32,100% of Medicare,,,,,,39017.32,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Traumatic Brain Injury C0203,C0203,LOCAL,,,,inpatient,,,128178.19,76906.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,103824.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,108951.46,percent of total billed charges,,,85,,108951.46,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,115360.37,percent of total billed charges,,,,,,,no IP contract,,80,,102542.55,percent of total billed charges,,,,,,,no IP contract,,50,,64089.09,percent of total billed charges,,,,,,no IP contract,,,78,,99978.99,percent of total billed charges,,,70,,89724.73,percent of total billed charges,,,,,,,,,,,35182.88,100% of Medicare,,,,,48351.3,100% of Medicare,,,,,48351.3,100% of Medicare,,,,,48351.3,100% of Medicare,,,,,48351.3,100% of Medicare,,,,,48351.3,100% of Medicare,,,,,48351.3,100% of Medicare,,,,,48351.3,100% of Medicare,,,,,48351.3,100% of Medicare,,,,,48351.3,100% of Medicare,,,,,48351.3,100% of Medicare,,,,,48351.3,100% of Medicare,,,,,,48351.3,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,115360.37,
Traumatic Brain Injury C0204,C0204,LOCAL,,,,inpatient,,,162007.75,97204.65,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,131226.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,137706.59,percent of total billed charges,,,85,,137706.59,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,145806.98,percent of total billed charges,,,,,,,no IP contract,,80,,129606.2,percent of total billed charges,,,,,,,no IP contract,,50,,81003.88,percent of total billed charges,,,,,,no IP contract,,,78,,126366.05,percent of total billed charges,,,70,,113405.43,percent of total billed charges,,,,,,,,,,,39792.83,100% of Medicare,,,,,70067.22,100% of Medicare,,,,,70067.22,100% of Medicare,,,,,70067.22,100% of Medicare,,,,,70067.22,100% of Medicare,,,,,70067.22,100% of Medicare,,,,,70067.22,100% of Medicare,,,,,70067.22,100% of Medicare,,,,,70067.22,100% of Medicare,,,,,70067.22,100% of Medicare,,,,,70067.22,100% of Medicare,,,,,70067.22,100% of Medicare,,,,,,70067.22,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,145806.98,
Traumatic Brain Injury C0205,C0205,LOCAL,,,,inpatient,,,216023.85,129614.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,174979.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,183620.27,percent of total billed charges,,,85,,183620.27,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,194421.46,percent of total billed charges,,,,,,,no IP contract,,80,,172819.08,percent of total billed charges,,,,,,,no IP contract,,50,,108011.92,percent of total billed charges,,,,,,no IP contract,,,78,,168498.6,percent of total billed charges,,,70,,151216.69,percent of total billed charges,,,,,,,,,,,56346.74,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Non-traumatic Brain Injury C0301,C0301,LOCAL,,,,inpatient,,,69817.35,41890.41,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,56552.05,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,59344.75,percent of total billed charges,,,85,,59344.75,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,62835.62,percent of total billed charges,,,,,,,no IP contract,,80,,55853.88,percent of total billed charges,,,,,,,no IP contract,,50,,34908.68,percent of total billed charges,,,,,,no IP contract,,,78,,54457.53,percent of total billed charges,,,70,,48872.15,percent of total billed charges,,,,,,,,,,,19923.48,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Non-traumatic Brain Injury C0302,C0302,LOCAL,,,,inpatient,,,94509.46,56705.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,76552.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,80333.04,percent of total billed charges,,,85,,80333.04,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,85058.51,percent of total billed charges,,,,,,,no IP contract,,80,,75607.57,percent of total billed charges,,,,,,,no IP contract,,50,,47254.73,percent of total billed charges,,,,,,no IP contract,,,78,,73717.38,percent of total billed charges,,,70,,66156.62,percent of total billed charges,,,,,,,,,,,20680.45,100% of Medicare,,,,,32775.66,100% of Medicare,,,,,32775.66,100% of Medicare,,,,,32775.66,100% of Medicare,,,,,32775.66,100% of Medicare,,,,,32775.66,100% of Medicare,,,,,32775.66,100% of Medicare,,,,,32775.66,100% of Medicare,,,,,32775.66,100% of Medicare,,,,,32775.66,100% of Medicare,,,,,32775.66,100% of Medicare,,,,,32775.66,100% of Medicare,,,,,,32775.66,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,85058.51,
Non-traumatic Brain Injury C0303,C0303,LOCAL,,,,inpatient,,,106767.85,64060.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,86481.96,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,90752.68,percent of total billed charges,,,85,,90752.68,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,96091.07,percent of total billed charges,,,,,,,no IP contract,,80,,85414.28,percent of total billed charges,,,,,,,no IP contract,,50,,53383.93,percent of total billed charges,,,,,,no IP contract,,,78,,83278.93,percent of total billed charges,,,70,,74737.5,percent of total billed charges,,,,,,,,,,,28113.87,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Non-traumatic Brain Injury C0304,C0304,LOCAL,,,,inpatient,,,76865.05,46119.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,62260.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,65335.29,percent of total billed charges,,,85,,65335.29,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,69178.55,percent of total billed charges,,,,,,,no IP contract,,80,,61492.04,percent of total billed charges,,,,,,,no IP contract,,50,,38432.53,percent of total billed charges,,,,,,no IP contract,,,78,,59954.74,percent of total billed charges,,,70,,53805.54,percent of total billed charges,,,,,,,,,,,20648.95,100% of Medicare,,,,,25980.93,100% of Medicare,,,,,25980.93,100% of Medicare,,,,,25980.93,100% of Medicare,,,,,25980.93,100% of Medicare,,,,,25980.93,100% of Medicare,,,,,25980.93,100% of Medicare,,,,,25980.93,100% of Medicare,,,,,25980.93,100% of Medicare,,,,,25980.93,100% of Medicare,,,,,25980.93,100% of Medicare,,,,,25980.93,100% of Medicare,,,,,,25980.93,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,69178.55,
Non-traumatic Brain Injury C0305,C0305,LOCAL,,,,inpatient,,,155092.56,93055.54,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,125624.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,131828.68,percent of total billed charges,,,85,,131828.68,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,139583.31,percent of total billed charges,,,,,,,no IP contract,,80,,124074.05,percent of total billed charges,,,,,,,no IP contract,,50,,77546.28,percent of total billed charges,,,,,,no IP contract,,,78,,120972.2,percent of total billed charges,,,70,,108564.79,percent of total billed charges,,,,,,,,,,,44608.67,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Traumatic Spinal Cord C0401,C0401,LOCAL,,,,inpatient,,,95633.45,57380.07,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,77463.09,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,81288.43,percent of total billed charges,,,85,,81288.43,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,86070.11,percent of total billed charges,,,,,,,no IP contract,,80,,76506.76,percent of total billed charges,,,,,,,no IP contract,,50,,47816.73,percent of total billed charges,,,,,,no IP contract,,,78,,74594.09,percent of total billed charges,,,70,,66943.42,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,33184.58,100% of Medicare,,,,,33184.58,100% of Medicare,,,,,33184.58,100% of Medicare,,,,,33184.58,100% of Medicare,,,,,33184.58,100% of Medicare,,,,,33184.58,100% of Medicare,,,,,33184.58,100% of Medicare,,,,,33184.58,100% of Medicare,,,,,33184.58,100% of Medicare,,,,,33184.58,100% of Medicare,,,,,33184.58,100% of Medicare,,,,,,33184.58,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Traumatic Spinal Cord C0402,C0402,LOCAL,,,,inpatient,,,62975.55,37785.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,51010.2,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,53529.22,percent of total billed charges,,,85,,53529.22,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,56678,percent of total billed charges,,,,,,,no IP contract,,80,,50380.44,percent of total billed charges,,,,,,,no IP contract,,50,,31487.78,percent of total billed charges,,,,,,no IP contract,,,78,,49120.93,percent of total billed charges,,,70,,44082.89,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Traumatic Spinal Cord C0403,C0403,LOCAL,,,,inpatient,,,162669.75,97601.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,131762.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,138269.29,percent of total billed charges,,,85,,138269.29,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,146402.78,percent of total billed charges,,,,,,,no IP contract,,80,,130135.8,percent of total billed charges,,,,,,,no IP contract,,50,,81334.88,percent of total billed charges,,,,,,no IP contract,,,78,,126882.41,percent of total billed charges,,,70,,113868.83,percent of total billed charges,,,,,,,,,,,49806.76,100% of Medicare,,,,,84933.58,100% of Medicare,,,,,84933.58,100% of Medicare,,,,,84933.58,100% of Medicare,,,,,84933.58,100% of Medicare,,,,,84933.58,100% of Medicare,,,,,84933.58,100% of Medicare,,,,,84933.58,100% of Medicare,,,,,84933.58,100% of Medicare,,,,,84933.58,100% of Medicare,,,,,84933.58,100% of Medicare,,,,,84933.58,100% of Medicare,,,,,,84933.58,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,146402.78,
Traumatic Spinal Cord C0404,C0404,LOCAL,,,,inpatient,,,310749.82,186449.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,251707.35,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,264137.35,percent of total billed charges,,,85,,264137.35,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,279674.84,percent of total billed charges,,,,,,,no IP contract,,80,,248599.86,percent of total billed charges,,,,,,,no IP contract,,50,,155374.91,percent of total billed charges,,,,,,no IP contract,,,78,,242384.86,percent of total billed charges,,,70,,217524.87,percent of total billed charges,,,,,,,,,,,57869.24,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Traumatic Spinal Cord C0405,C0405,LOCAL,,,,inpatient,,,228377.91,137026.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,184986.1,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,194121.22,percent of total billed charges,,,85,,194121.22,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,205540.12,percent of total billed charges,,,,,,,no IP contract,,80,,182702.32,percent of total billed charges,,,,,,,no IP contract,,50,,114188.95,percent of total billed charges,,,,,,no IP contract,,,78,,178134.77,percent of total billed charges,,,70,,159864.53,percent of total billed charges,,,,,,,,,,,57732.29,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Traumatic Spinal Cord C0406,C0406,LOCAL,,,,inpatient,,,224839.27,134903.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,182119.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,191113.38,percent of total billed charges,,,85,,191113.38,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,202355.34,percent of total billed charges,,,,,,,no IP contract,,80,,179871.41,percent of total billed charges,,,,,,,no IP contract,,50,,112419.63,percent of total billed charges,,,,,,no IP contract,,,78,,175374.63,percent of total billed charges,,,70,,157387.49,percent of total billed charges,,,,,,,,,,,77677.73,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Traumatic Spinal Cord C0407,C0407,LOCAL,,,,inpatient,,,293864.96,176318.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,238030.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,249785.21,percent of total billed charges,,,85,,249785.21,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,264478.46,percent of total billed charges,,,,,,,no IP contract,,80,,235091.96,percent of total billed charges,,,,,,,no IP contract,,50,,146932.48,percent of total billed charges,,,,,,no IP contract,,,78,,229214.67,percent of total billed charges,,,70,,205705.47,percent of total billed charges,,,,,,,,,,,80534.06,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Non-traumatic Spinal Cord C0501,C0501,LOCAL,,,,inpatient,,,90872.28,54523.37,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,73606.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,77241.44,percent of total billed charges,,,85,,77241.44,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,81785.05,percent of total billed charges,,,,,,,no IP contract,,80,,72697.82,percent of total billed charges,,,,,,,no IP contract,,50,,45436.14,percent of total billed charges,,,,,,no IP contract,,,78,,70880.38,percent of total billed charges,,,70,,63610.6,percent of total billed charges,,,,,,,,,,,23693.87,100% of Medicare,,,,,33674.09,100% of Medicare,,,,,33674.09,100% of Medicare,,,,,33674.09,100% of Medicare,,,,,33674.09,100% of Medicare,,,,,33674.09,100% of Medicare,,,,,33674.09,100% of Medicare,,,,,33674.09,100% of Medicare,,,,,33674.09,100% of Medicare,,,,,33674.09,100% of Medicare,,,,,33674.09,100% of Medicare,,,,,33674.09,100% of Medicare,,,,,,33674.09,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,81785.05,
Non-traumatic Spinal Cord C0502,C0502,LOCAL,,,,inpatient,,,105433.12,63259.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,85400.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,89618.15,percent of total billed charges,,,85,,89618.15,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,94889.81,percent of total billed charges,,,,,,,no IP contract,,80,,84346.49,percent of total billed charges,,,,,,,no IP contract,,50,,52716.56,percent of total billed charges,,,,,,no IP contract,,,78,,82237.83,percent of total billed charges,,,70,,73803.18,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,38074.33,100% of Medicare,,,,,38074.33,100% of Medicare,,,,,38074.33,100% of Medicare,,,,,38074.33,100% of Medicare,,,,,38074.33,100% of Medicare,,,,,38074.33,100% of Medicare,,,,,38074.33,100% of Medicare,,,,,38074.33,100% of Medicare,,,,,38074.33,100% of Medicare,,,,,38074.33,100% of Medicare,,,,,38074.33,100% of Medicare,,,,,,38074.33,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Non-traumatic Spinal Cord C0503,C0503,LOCAL,,,,inpatient,,,180304.55,108182.73,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,146046.69,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,153258.87,percent of total billed charges,,,85,,153258.87,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,162274.1,percent of total billed charges,,,,,,,no IP contract,,80,,144243.64,percent of total billed charges,,,,,,,no IP contract,,50,,90152.28,percent of total billed charges,,,,,,no IP contract,,,78,,140637.55,percent of total billed charges,,,70,,126213.19,percent of total billed charges,,,,,,,,,,,93000.04,100% of Medicare,,,,,82456.12,100% of Medicare,,,,,82456.12,100% of Medicare,,,,,82456.12,100% of Medicare,,,,,82456.12,100% of Medicare,,,,,82456.12,100% of Medicare,,,,,82456.12,100% of Medicare,,,,,82456.12,100% of Medicare,,,,,82456.12,100% of Medicare,,,,,82456.12,100% of Medicare,,,,,82456.12,100% of Medicare,,,,,82456.12,100% of Medicare,,,,,,82456.12,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,162274.1,
Non-traumatic Spinal Cord C0504,C0504,LOCAL,,,,inpatient,,,163716.5,98229.9,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,132610.37,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,139159.03,percent of total billed charges,,,85,,139159.03,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,147344.85,percent of total billed charges,,,,,,,no IP contract,,80,,130973.2,percent of total billed charges,,,,,,,no IP contract,,50,,81858.25,percent of total billed charges,,,,,,no IP contract,,,78,,127698.87,percent of total billed charges,,,70,,114601.55,percent of total billed charges,,,,,,,,,,,38384.27,100% of Medicare,,,,,77677.73,100% of Medicare,,,,,77677.73,100% of Medicare,,,,,77677.73,100% of Medicare,,,,,77677.73,100% of Medicare,,,,,77677.73,100% of Medicare,,,,,77677.73,100% of Medicare,,,,,77677.73,100% of Medicare,,,,,77677.73,100% of Medicare,,,,,77677.73,100% of Medicare,,,,,77677.73,100% of Medicare,,,,,77677.73,100% of Medicare,,,,,,77677.73,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,147344.85,
Non-traumatic Spinal Cord C0505,C0505,LOCAL,,,,inpatient,,,181134.16,108680.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,146718.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,153964.04,percent of total billed charges,,,85,,153964.04,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,163020.74,percent of total billed charges,,,,,,,no IP contract,,80,,144907.33,percent of total billed charges,,,,,,,no IP contract,,50,,90567.08,percent of total billed charges,,,,,,no IP contract,,,78,,141284.64,percent of total billed charges,,,70,,126793.91,percent of total billed charges,,,,,,,,,,,54470.75,100% of Medicare,,,,,42368.25,100% of Medicare,,,,,42368.25,100% of Medicare,,,,,42368.25,100% of Medicare,,,,,42368.25,100% of Medicare,,,,,42368.25,100% of Medicare,,,,,42368.25,100% of Medicare,,,,,42368.25,100% of Medicare,,,,,42368.25,100% of Medicare,,,,,42368.25,100% of Medicare,,,,,42368.25,100% of Medicare,,,,,42368.25,100% of Medicare,,,,,,42368.25,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,163020.74,
Neurological Conditions C0601,C0601,LOCAL,,,,inpatient,,,90066.43,54039.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,72953.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,76556.47,percent of total billed charges,,,85,,76556.47,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,81059.79,percent of total billed charges,,,,,,,no IP contract,,80,,72053.15,percent of total billed charges,,,,,,,no IP contract,,50,,45033.22,percent of total billed charges,,,,,,no IP contract,,,78,,70251.82,percent of total billed charges,,,70,,63046.5,percent of total billed charges,,,,,,,,,,,23928.37,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Neurological Conditions C0602,C0602,LOCAL,,,,inpatient,,,89792.97,53875.78,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,72732.31,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,76324.03,percent of total billed charges,,,85,,76324.03,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,80813.68,percent of total billed charges,,,,,,,no IP contract,,80,,71834.38,percent of total billed charges,,,,,,,no IP contract,,50,,44896.49,percent of total billed charges,,,,,,no IP contract,,,78,,70038.52,percent of total billed charges,,,70,,62855.08,percent of total billed charges,,,,,,,,,,,29063.53,100% of Medicare,,,,,31902.09,100% of Medicare,,,,,31902.09,100% of Medicare,,,,,31902.09,100% of Medicare,,,,,31902.09,100% of Medicare,,,,,31902.09,100% of Medicare,,,,,31902.09,100% of Medicare,,,,,31902.09,100% of Medicare,,,,,31902.09,100% of Medicare,,,,,31902.09,100% of Medicare,,,,,31902.09,100% of Medicare,,,,,31902.09,100% of Medicare,,,,,,31902.09,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,80813.68,
Neurological Conditions C0603,C0603,LOCAL,,,,inpatient,,,111494.72,66896.83,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,90310.72,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,94770.51,percent of total billed charges,,,85,,94770.51,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,100345.25,percent of total billed charges,,,,,,,no IP contract,,80,,89195.77,percent of total billed charges,,,,,,,no IP contract,,50,,55747.36,percent of total billed charges,,,,,,no IP contract,,,78,,86965.88,percent of total billed charges,,,70,,78046.3,percent of total billed charges,,,,,,,,,,,34053.34,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Neurological Conditions C0604,C0604,LOCAL,,,,inpatient,,,130089.58,78053.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,105372.56,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,110576.14,percent of total billed charges,,,85,,110576.14,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,117080.62,percent of total billed charges,,,,,,,no IP contract,,80,,104071.66,percent of total billed charges,,,,,,,no IP contract,,50,,65044.79,percent of total billed charges,,,,,,no IP contract,,,78,,101469.87,percent of total billed charges,,,70,,91062.7,percent of total billed charges,,,,,,,,,,,32932.44,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Fracture of Lower Extremity C0702,C0702,LOCAL,,,,inpatient,,,111739.45,67043.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,90508.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,94978.53,percent of total billed charges,,,85,,94978.53,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,100565.51,percent of total billed charges,,,,,,,no IP contract,,80,,89391.56,percent of total billed charges,,,,,,,no IP contract,,50,,55869.73,percent of total billed charges,,,,,,no IP contract,,,78,,87156.77,percent of total billed charges,,,70,,78217.62,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,70880.2,100% of Medicare,,,,,70880.2,100% of Medicare,,,,,70880.2,100% of Medicare,,,,,70880.2,100% of Medicare,,,,,70880.2,100% of Medicare,,,,,70880.2,100% of Medicare,,,,,70880.2,100% of Medicare,,,,,70880.2,100% of Medicare,,,,,70880.2,100% of Medicare,,,,,70880.2,100% of Medicare,,,,,70880.2,100% of Medicare,,,,,,70880.2,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Fracture of Lower Extremity C0703,C0703,LOCAL,,,,inpatient,,,91509.95,54905.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,74123.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,77783.46,percent of total billed charges,,,85,,77783.46,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,82358.96,percent of total billed charges,,,,,,,no IP contract,,80,,73207.96,percent of total billed charges,,,,,,,no IP contract,,50,,45754.98,percent of total billed charges,,,,,,no IP contract,,,78,,71377.76,percent of total billed charges,,,70,,64056.97,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Replacement of Lower Extremity C0804,C0804,LOCAL,,,,inpatient,,,97557.6,58534.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,79021.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,82923.96,percent of total billed charges,,,85,,82923.96,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,87801.84,percent of total billed charges,,,,,,,no IP contract,,80,,78046.08,percent of total billed charges,,,,,,,no IP contract,,50,,48778.8,percent of total billed charges,,,,,,no IP contract,,,78,,76094.93,percent of total billed charges,,,70,,68290.32,percent of total billed charges,,,,,,,,,,,31243.46,100% of Medicare,,,,,34335.34,100% of Medicare,,,,,34335.34,100% of Medicare,,,,,34335.34,100% of Medicare,,,,,34335.34,100% of Medicare,,,,,34335.34,100% of Medicare,,,,,34335.34,100% of Medicare,,,,,34335.34,100% of Medicare,,,,,34335.34,100% of Medicare,,,,,34335.34,100% of Medicare,,,,,34335.34,100% of Medicare,,,,,34335.34,100% of Medicare,,,,,,34335.34,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,87801.84,
Replacement of Lower Extremity C0805,C0805,LOCAL,,,,inpatient,,,104105.8,62463.48,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,84325.7,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,88489.93,percent of total billed charges,,,85,,88489.93,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,93695.22,percent of total billed charges,,,,,,,no IP contract,,80,,83284.64,percent of total billed charges,,,,,,,no IP contract,,50,,52052.9,percent of total billed charges,,,,,,no IP contract,,,78,,81202.52,percent of total billed charges,,,70,,72874.06,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Other Orthopedic C0901,C0901,LOCAL,,,,inpatient,,,69442.55,41665.53,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,56248.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,59026.17,percent of total billed charges,,,85,,59026.17,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,62498.3,percent of total billed charges,,,,,,,no IP contract,,80,,55554.04,percent of total billed charges,,,,,,,no IP contract,,50,,34721.28,percent of total billed charges,,,,,,no IP contract,,,78,,54165.19,percent of total billed charges,,,70,,48609.79,percent of total billed charges,,,,,,,,,,,20222.45,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Other Orthopedic C0902,C0902,LOCAL,,,,inpatient,,,90181.43,54108.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,73046.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,76654.21,percent of total billed charges,,,85,,76654.21,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,81163.28,percent of total billed charges,,,,,,,no IP contract,,80,,72145.14,percent of total billed charges,,,,,,,no IP contract,,50,,45090.71,percent of total billed charges,,,,,,no IP contract,,,78,,70341.51,percent of total billed charges,,,70,,63127,percent of total billed charges,,,,,,,,,,,2137.52,100% of Medicare,,,,,46227.74,100% of Medicare,,,,,46227.74,100% of Medicare,,,,,46227.74,100% of Medicare,,,,,46227.74,100% of Medicare,,,,,46227.74,100% of Medicare,,,,,46227.74,100% of Medicare,,,,,46227.74,100% of Medicare,,,,,46227.74,100% of Medicare,,,,,46227.74,100% of Medicare,,,,,46227.74,100% of Medicare,,,,,46227.74,100% of Medicare,,,,,,46227.74,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,81163.28,
Other Orthopedic C0903,C0903,LOCAL,,,,inpatient,,,354526.4,212715.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,287166.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,301347.44,percent of total billed charges,,,85,,301347.44,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,319073.76,percent of total billed charges,,,,,,,no IP contract,,80,,283621.12,percent of total billed charges,,,,,,,no IP contract,,50,,177263.2,percent of total billed charges,,,,,,no IP contract,,,78,,276530.59,percent of total billed charges,,,70,,248168.48,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Other Orthopedic C0904,C0904,LOCAL,,,,inpatient,,,121374.95,72824.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,98313.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,103168.71,percent of total billed charges,,,85,,103168.71,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,109237.46,percent of total billed charges,,,,,,,no IP contract,,80,,97099.96,percent of total billed charges,,,,,,,no IP contract,,50,,60687.48,percent of total billed charges,,,,,,no IP contract,,,78,,94672.46,percent of total billed charges,,,70,,84962.47,percent of total billed charges,,,,,,,,,,,28292.65,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Amputation of Lower Extremity C1003,C1003,LOCAL,,,,inpatient,,,108730.02,65238.01,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,88071.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,92420.52,percent of total billed charges,,,85,,92420.52,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,97857.02,percent of total billed charges,,,,,,,no IP contract,,80,,86984.02,percent of total billed charges,,,,,,,no IP contract,,50,,54365.01,percent of total billed charges,,,,,,no IP contract,,,78,,84809.42,percent of total billed charges,,,70,,76111.01,percent of total billed charges,,,,,,,,,,,34335.34,100% of Medicare,,,,,9888.76,100% of Medicare,,,,,9888.76,100% of Medicare,,,,,9888.76,100% of Medicare,,,,,9888.76,100% of Medicare,,,,,9888.76,100% of Medicare,,,,,9888.76,100% of Medicare,,,,,9888.76,100% of Medicare,,,,,9888.76,100% of Medicare,,,,,9888.76,100% of Medicare,,,,,9888.76,100% of Medicare,,,,,9888.76,100% of Medicare,,,,,,9888.76,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,97857.02,
Amputation of Lower Extremity C1004,C1004,LOCAL,,,,inpatient,,,148285.27,88971.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,120111.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,126042.48,percent of total billed charges,,,85,,126042.48,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,133456.74,percent of total billed charges,,,,,,,no IP contract,,80,,118628.22,percent of total billed charges,,,,,,,no IP contract,,50,,74142.64,percent of total billed charges,,,,,,no IP contract,,,78,,115662.51,percent of total billed charges,,,70,,103799.69,percent of total billed charges,,,,,,,,,,,39233.89,100% of Medicare,,,,,38300.97,100% of Medicare,,,,,38300.97,100% of Medicare,,,,,38300.97,100% of Medicare,,,,,38300.97,100% of Medicare,,,,,38300.97,100% of Medicare,,,,,38300.97,100% of Medicare,,,,,38300.97,100% of Medicare,,,,,38300.97,100% of Medicare,,,,,38300.97,100% of Medicare,,,,,38300.97,100% of Medicare,,,,,38300.97,100% of Medicare,,,,,,38300.97,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,133456.74,
"Rheumatoid, Other Arthritis C1303",C1303,LOCAL,,,,inpatient,,,121122.05,72673.23,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,98108.86,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,102953.74,percent of total billed charges,,,85,,102953.74,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,109009.85,percent of total billed charges,,,,,,,no IP contract,,80,,96897.64,percent of total billed charges,,,,,,,no IP contract,,50,,60561.03,percent of total billed charges,,,,,,no IP contract,,,78,,94475.2,percent of total billed charges,,,70,,84785.44,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
"Rheumatoid, Other Arthritis C1304",C1304,LOCAL,,,,inpatient,,,227454.9,136472.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,184238.47,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,193336.67,percent of total billed charges,,,85,,193336.67,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,204709.41,percent of total billed charges,,,,,,,no IP contract,,80,,181963.92,percent of total billed charges,,,,,,,no IP contract,,50,,113727.45,percent of total billed charges,,,,,,no IP contract,,,78,,177414.82,percent of total billed charges,,,70,,159218.43,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
"Rheumatoid, Other Arthritis C1305",C1305,LOCAL,,,,inpatient,,,93328.2,55996.92,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,75595.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,79328.97,percent of total billed charges,,,85,,79328.97,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,83995.38,percent of total billed charges,,,,,,,no IP contract,,80,,74662.56,percent of total billed charges,,,,,,,no IP contract,,50,,46664.1,percent of total billed charges,,,,,,no IP contract,,,78,,72796,percent of total billed charges,,,70,,65329.74,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,42721.53,100% of Medicare,,,,,42721.53,100% of Medicare,,,,,42721.53,100% of Medicare,,,,,42721.53,100% of Medicare,,,,,42721.53,100% of Medicare,,,,,42721.53,100% of Medicare,,,,,42721.53,100% of Medicare,,,,,42721.53,100% of Medicare,,,,,42721.53,100% of Medicare,,,,,42721.53,100% of Medicare,,,,,42721.53,100% of Medicare,,,,,,42721.53,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Cardiac C1402,C1402,LOCAL,,,,inpatient,,,83918.28,50350.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,67973.81,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,71330.54,percent of total billed charges,,,85,,71330.54,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,75526.45,percent of total billed charges,,,,,,,no IP contract,,80,,67134.63,percent of total billed charges,,,,,,,no IP contract,,50,,41959.14,percent of total billed charges,,,,,,no IP contract,,,78,,65456.26,percent of total billed charges,,,70,,58742.8,percent of total billed charges,,,,,,,,,,,26552.74,100% of Medicare,,,,,24500.64,100% of Medicare,,,,,24500.64,100% of Medicare,,,,,24500.64,100% of Medicare,,,,,24500.64,100% of Medicare,,,,,24500.64,100% of Medicare,,,,,24500.64,100% of Medicare,,,,,24500.64,100% of Medicare,,,,,24500.64,100% of Medicare,,,,,24500.64,100% of Medicare,,,,,24500.64,100% of Medicare,,,,,24500.64,100% of Medicare,,,,,,24500.64,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,75526.45,
Cardiac C1403,C1403,LOCAL,,,,inpatient,,,96417.92,57850.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,78098.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,81955.23,percent of total billed charges,,,85,,81955.23,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,86776.12,percent of total billed charges,,,,,,,no IP contract,,80,,77134.33,percent of total billed charges,,,,,,,no IP contract,,50,,48208.96,percent of total billed charges,,,,,,no IP contract,,,78,,75205.97,percent of total billed charges,,,70,,67492.54,percent of total billed charges,,,,,,,,,,,30411.68,100% of Medicare,,,,,42728.03,100% of Medicare,,,,,42728.03,100% of Medicare,,,,,42728.03,100% of Medicare,,,,,42728.03,100% of Medicare,,,,,42728.03,100% of Medicare,,,,,42728.03,100% of Medicare,,,,,42728.03,100% of Medicare,,,,,42728.03,100% of Medicare,,,,,42728.03,100% of Medicare,,,,,42728.03,100% of Medicare,,,,,42728.03,100% of Medicare,,,,,,42728.03,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,86776.12,
Cardiac C1404,C1404,LOCAL,,,,inpatient,,,125773.52,75464.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,101876.55,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,106907.49,percent of total billed charges,,,85,,106907.49,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,113196.17,percent of total billed charges,,,,,,,no IP contract,,80,,100618.82,percent of total billed charges,,,,,,,no IP contract,,50,,62886.76,percent of total billed charges,,,,,,no IP contract,,,78,,98103.35,percent of total billed charges,,,70,,88041.47,percent of total billed charges,,,,,,,,,,,50352.16,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Pulmonary C1501,C1501,LOCAL,,,,inpatient,,,126362.9,75817.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,102353.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,107408.47,percent of total billed charges,,,85,,107408.47,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,113726.61,percent of total billed charges,,,,,,,no IP contract,,80,,101090.32,percent of total billed charges,,,,,,,no IP contract,,50,,63181.45,percent of total billed charges,,,,,,no IP contract,,,78,,98563.06,percent of total billed charges,,,70,,88454.03,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Pulmonary C1502,C1502,LOCAL,,,,inpatient,,,102528.07,61516.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,83047.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,87148.86,percent of total billed charges,,,85,,87148.86,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,92275.26,percent of total billed charges,,,,,,,no IP contract,,80,,82022.46,percent of total billed charges,,,,,,,no IP contract,,50,,51264.04,percent of total billed charges,,,,,,no IP contract,,,78,,79971.89,percent of total billed charges,,,70,,71769.65,percent of total billed charges,,,,,,,,,,,28805.47,100% of Medicare,,,,,33806.83,100% of Medicare,,,,,33806.83,100% of Medicare,,,,,33806.83,100% of Medicare,,,,,33806.83,100% of Medicare,,,,,33806.83,100% of Medicare,,,,,33806.83,100% of Medicare,,,,,33806.83,100% of Medicare,,,,,33806.83,100% of Medicare,,,,,33806.83,100% of Medicare,,,,,33806.83,100% of Medicare,,,,,33806.83,100% of Medicare,,,,,,33806.83,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,92275.26,
Pulmonary C1503,C1503,LOCAL,,,,inpatient,,,179862.9,107917.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,145688.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,152883.46,percent of total billed charges,,,85,,152883.46,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,161876.61,percent of total billed charges,,,,,,,no IP contract,,80,,143890.32,percent of total billed charges,,,,,,,no IP contract,,50,,89931.45,percent of total billed charges,,,,,,no IP contract,,,78,,140293.06,percent of total billed charges,,,70,,125904.03,percent of total billed charges,,,,,,,,,,,57095.15,100% of Medicare,,,,,95974.05,100% of Medicare,,,,,95974.05,100% of Medicare,,,,,95974.05,100% of Medicare,,,,,95974.05,100% of Medicare,,,,,95974.05,100% of Medicare,,,,,95974.05,100% of Medicare,,,,,95974.05,100% of Medicare,,,,,95974.05,100% of Medicare,,,,,95974.05,100% of Medicare,,,,,95974.05,100% of Medicare,,,,,95974.05,100% of Medicare,,,,,,95974.05,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,161876.61,
Pulmonary C1504,C1504,LOCAL,,,,inpatient,,,219313.89,131588.33,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,177644.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,186416.8,percent of total billed charges,,,85,,186416.8,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,197382.5,percent of total billed charges,,,,,,,no IP contract,,80,,175451.11,percent of total billed charges,,,,,,,no IP contract,,50,,109656.94,percent of total billed charges,,,,,,no IP contract,,,78,,171064.83,percent of total billed charges,,,70,,153519.72,percent of total billed charges,,,,,,,,,,,47436.63,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/o TBI or SCI C1701,C1701,LOCAL,,,,inpatient,,,139033.85,83420.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,112617.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,118178.77,percent of total billed charges,,,85,,118178.77,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,125130.47,percent of total billed charges,,,,,,,no IP contract,,80,,111227.08,percent of total billed charges,,,,,,,no IP contract,,50,,69516.93,percent of total billed charges,,,,,,no IP contract,,,78,,108446.4,percent of total billed charges,,,70,,97323.7,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/o TBI or SCI C1702,C1702,LOCAL,,,,inpatient,,,113261,67956.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,91741.41,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,96271.85,percent of total billed charges,,,85,,96271.85,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,101934.9,percent of total billed charges,,,,,,,no IP contract,,80,,90608.8,percent of total billed charges,,,,,,,no IP contract,,50,,56630.5,percent of total billed charges,,,,,,no IP contract,,,78,,88343.58,percent of total billed charges,,,70,,79282.7,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/o TBI or SCI C1705,C1705,LOCAL,,,,inpatient,,,154673.83,92804.3,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,125285.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,131472.75,percent of total billed charges,,,85,,131472.75,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,139206.44,percent of total billed charges,,,,,,,no IP contract,,80,,123739.06,percent of total billed charges,,,,,,,no IP contract,,50,,77336.91,percent of total billed charges,,,,,,no IP contract,,,78,,120645.58,percent of total billed charges,,,70,,108271.68,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,58527.9,100% of Medicare,,,,,58527.9,100% of Medicare,,,,,58527.9,100% of Medicare,,,,,58527.9,100% of Medicare,,,,,58527.9,100% of Medicare,,,,,58527.9,100% of Medicare,,,,,58527.9,100% of Medicare,,,,,58527.9,100% of Medicare,,,,,58527.9,100% of Medicare,,,,,58527.9,100% of Medicare,,,,,58527.9,100% of Medicare,,,,,,58527.9,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/ TBI or SCI C1801,C1801,LOCAL,,,,inpatient,,,69260.18,41556.11,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,56100.74,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,58871.15,percent of total billed charges,,,85,,58871.15,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,62334.16,percent of total billed charges,,,,,,,no IP contract,,80,,55408.14,percent of total billed charges,,,,,,,no IP contract,,50,,34630.09,percent of total billed charges,,,,,,no IP contract,,,78,,54022.94,percent of total billed charges,,,70,,48482.12,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,27661.26,100% of Medicare,,,,,27661.26,100% of Medicare,,,,,27661.26,100% of Medicare,,,,,27661.26,100% of Medicare,,,,,27661.26,100% of Medicare,,,,,27661.26,100% of Medicare,,,,,27661.26,100% of Medicare,,,,,27661.26,100% of Medicare,,,,,27661.26,100% of Medicare,,,,,27661.26,100% of Medicare,,,,,27661.26,100% of Medicare,,,,,,27661.26,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/ TBI or SCI C1802,C1802,LOCAL,,,,inpatient,,,128257.83,76954.7,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,103888.84,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,109019.16,percent of total billed charges,,,85,,109019.16,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,115432.05,percent of total billed charges,,,,,,,no IP contract,,80,,102606.27,percent of total billed charges,,,,,,,no IP contract,,50,,64128.92,percent of total billed charges,,,,,,no IP contract,,,78,,100041.11,percent of total billed charges,,,70,,89780.48,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/ TBI or SCI C1803,C1803,LOCAL,,,,inpatient,,,144466.05,86679.63,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,117017.5,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,122796.14,percent of total billed charges,,,85,,122796.14,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,130019.45,percent of total billed charges,,,,,,,no IP contract,,80,,115572.84,percent of total billed charges,,,,,,,no IP contract,,50,,72233.03,percent of total billed charges,,,,,,no IP contract,,,78,,112683.52,percent of total billed charges,,,70,,101126.24,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,44027.61,100% of Medicare,,,,,44027.61,100% of Medicare,,,,,44027.61,100% of Medicare,,,,,44027.61,100% of Medicare,,,,,44027.61,100% of Medicare,,,,,44027.61,100% of Medicare,,,,,44027.61,100% of Medicare,,,,,44027.61,100% of Medicare,,,,,44027.61,100% of Medicare,,,,,44027.61,100% of Medicare,,,,,44027.61,100% of Medicare,,,,,,44027.61,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/ TBI or SCI C1804,C1804,LOCAL,,,,inpatient,,,228403.1,137041.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,185006.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,194142.64,percent of total billed charges,,,85,,194142.64,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,205562.79,percent of total billed charges,,,,,,,no IP contract,,80,,182722.48,percent of total billed charges,,,,,,,no IP contract,,50,,114201.55,percent of total billed charges,,,,,,no IP contract,,,78,,178154.42,percent of total billed charges,,,70,,159882.17,percent of total billed charges,,,,,,,,,,,44378.85,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/ TBI or SCI C1805,C1805,LOCAL,,,,inpatient,,,202860.52,121716.31,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,164317.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,172431.44,percent of total billed charges,,,85,,172431.44,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,182574.47,percent of total billed charges,,,,,,,no IP contract,,80,,162288.41,percent of total billed charges,,,,,,,no IP contract,,50,,101430.26,percent of total billed charges,,,,,,no IP contract,,,78,,158231.2,percent of total billed charges,,,70,,142002.36,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/ TBI or SCI C1806,C1806,LOCAL,,,,inpatient,,,288544.82,173126.89,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,233721.3,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,245263.09,percent of total billed charges,,,85,,245263.09,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,259690.33,percent of total billed charges,,,,,,,no IP contract,,80,,230835.85,percent of total billed charges,,,,,,,no IP contract,,50,,144272.41,percent of total billed charges,,,,,,no IP contract,,,78,,225064.96,percent of total billed charges,,,70,,201981.37,percent of total billed charges,,,,,,,,,,,42368.25,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Guillain-Barre Syndrome C1901,C1901,LOCAL,,,,inpatient,,,44825.05,26895.03,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,36308.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,38101.29,percent of total billed charges,,,85,,38101.29,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,40342.55,percent of total billed charges,,,,,,,no IP contract,,80,,35860.04,percent of total billed charges,,,,,,,no IP contract,,50,,22412.53,percent of total billed charges,,,,,,no IP contract,,,78,,34963.54,percent of total billed charges,,,70,,31377.54,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,19923.48,100% of Medicare,,,,,19923.48,100% of Medicare,,,,,19923.48,100% of Medicare,,,,,19923.48,100% of Medicare,,,,,19923.48,100% of Medicare,,,,,19923.48,100% of Medicare,,,,,19923.48,100% of Medicare,,,,,19923.48,100% of Medicare,,,,,19923.48,100% of Medicare,,,,,19923.48,100% of Medicare,,,,,19923.48,100% of Medicare,,,,,,19923.48,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Guillain-Barre Syndrome C1903,C1903,LOCAL,,,,inpatient,,,172757.1,103654.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,139933.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,146843.54,percent of total billed charges,,,85,,146843.54,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,155481.39,percent of total billed charges,,,,,,,no IP contract,,80,,138205.68,percent of total billed charges,,,,,,,no IP contract,,50,,86378.55,percent of total billed charges,,,,,,no IP contract,,,78,,134750.54,percent of total billed charges,,,70,,120929.97,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,49349.23,100% of Medicare,,,,,49349.23,100% of Medicare,,,,,49349.23,100% of Medicare,,,,,49349.23,100% of Medicare,,,,,49349.23,100% of Medicare,,,,,49349.23,100% of Medicare,,,,,49349.23,100% of Medicare,,,,,49349.23,100% of Medicare,,,,,49349.23,100% of Medicare,,,,,49349.23,100% of Medicare,,,,,49349.23,100% of Medicare,,,,,,49349.23,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Guillain-Barre Syndrome C1904,C1904,LOCAL,,,,inpatient,,,245366.45,147219.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,198746.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,208561.48,percent of total billed charges,,,85,,208561.48,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,220829.81,percent of total billed charges,,,,,,,no IP contract,,80,,196293.16,percent of total billed charges,,,,,,,no IP contract,,50,,122683.23,percent of total billed charges,,,,,,no IP contract,,,78,,191385.83,percent of total billed charges,,,70,,171756.52,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Miscellaneous C2001,C2001,LOCAL,,,,inpatient,,,98767.65,59260.59,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,80001.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,83952.5,percent of total billed charges,,,85,,83952.5,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,88890.89,percent of total billed charges,,,,,,,no IP contract,,80,,79014.12,percent of total billed charges,,,,,,,no IP contract,,50,,49383.83,percent of total billed charges,,,,,,no IP contract,,,78,,77038.77,percent of total billed charges,,,70,,69137.36,percent of total billed charges,,,,,,,,,,,21987.49,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Miscellaneous C2002,C2002,LOCAL,,,,inpatient,,,106826.07,64095.64,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,86529.12,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,90802.16,percent of total billed charges,,,85,,90802.16,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,96143.46,percent of total billed charges,,,,,,,no IP contract,,80,,85460.86,percent of total billed charges,,,,,,,no IP contract,,50,,53413.04,percent of total billed charges,,,,,,no IP contract,,,78,,83324.34,percent of total billed charges,,,70,,74778.25,percent of total billed charges,,,,,,,,,,,28881.99,100% of Medicare,,,,,28292.65,100% of Medicare,,,,,28292.65,100% of Medicare,,,,,28292.65,100% of Medicare,,,,,28292.65,100% of Medicare,,,,,28292.65,100% of Medicare,,,,,28292.65,100% of Medicare,,,,,28292.65,100% of Medicare,,,,,28292.65,100% of Medicare,,,,,28292.65,100% of Medicare,,,,,28292.65,100% of Medicare,,,,,28292.65,100% of Medicare,,,,,,28292.65,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,96143.46,
Miscellaneous C2003,C2003,LOCAL,,,,inpatient,,,116333.81,69800.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,94230.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,98883.74,percent of total billed charges,,,85,,98883.74,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,104700.43,percent of total billed charges,,,,,,,no IP contract,,80,,93067.05,percent of total billed charges,,,,,,,no IP contract,,50,,58166.9,percent of total billed charges,,,,,,no IP contract,,,78,,90740.37,percent of total billed charges,,,70,,81433.67,percent of total billed charges,,,,,,,,,,,33155.9,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Miscellaneous C2004,C2004,LOCAL,,,,inpatient,,,103921.18,62352.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,84176.16,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,88333,percent of total billed charges,,,85,,88333,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,93529.06,percent of total billed charges,,,,,,,no IP contract,,80,,83136.95,percent of total billed charges,,,,,,,no IP contract,,50,,51960.59,percent of total billed charges,,,,,,no IP contract,,,78,,81058.52,percent of total billed charges,,,70,,72744.83,percent of total billed charges,,,,,,,,,,,38331.54,100% of Medicare,,,,,36020.37,100% of Medicare,,,,,36020.37,100% of Medicare,,,,,36020.37,100% of Medicare,,,,,36020.37,100% of Medicare,,,,,36020.37,100% of Medicare,,,,,36020.37,100% of Medicare,,,,,36020.37,100% of Medicare,,,,,36020.37,100% of Medicare,,,,,36020.37,100% of Medicare,,,,,36020.37,100% of Medicare,,,,,36020.37,100% of Medicare,,,,,,36020.37,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,93529.06,
Miscellaneous C2005,C2005,LOCAL,,,,inpatient,,,143385.29,86031.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,116142.08,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,121877.49,percent of total billed charges,,,85,,121877.49,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,129046.76,percent of total billed charges,,,,,,,no IP contract,,80,,114708.23,percent of total billed charges,,,,,,,no IP contract,,50,,71692.64,percent of total billed charges,,,,,,no IP contract,,,78,,111840.52,percent of total billed charges,,,70,,100369.7,percent of total billed charges,,,,,,,,,,,47783.83,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Burns C2102,C2102,LOCAL,,,,inpatient,,,130243.29,78145.97,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,105497.06,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,110706.8,percent of total billed charges,,,85,,110706.8,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,117218.96,percent of total billed charges,,,,,,,no IP contract,,80,,104194.63,percent of total billed charges,,,,,,,no IP contract,,50,,65121.65,percent of total billed charges,,,,,,no IP contract,,,78,,101589.77,percent of total billed charges,,,70,,91170.3,percent of total billed charges,,,,,,,,,,,32782.68,100% of Medicare,,,,,46364.98,100% of Medicare,,,,,46364.98,100% of Medicare,,,,,46364.98,100% of Medicare,,,,,46364.98,100% of Medicare,,,,,46364.98,100% of Medicare,,,,,46364.98,100% of Medicare,,,,,46364.98,100% of Medicare,,,,,46364.98,100% of Medicare,,,,,46364.98,100% of Medicare,,,,,46364.98,100% of Medicare,,,,,46364.98,100% of Medicare,,,,,,46364.98,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,117218.96,
Stroke D0101,D0101,LOCAL,,,,inpatient,,,66883.7,40130.22,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,54175.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56851.15,percent of total billed charges,,,85,,56851.15,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,60195.33,percent of total billed charges,,,,,,,no IP contract,,80,,53506.96,percent of total billed charges,,,,,,,no IP contract,,50,,33441.85,percent of total billed charges,,,,,,no IP contract,,,78,,52169.29,percent of total billed charges,,,70,,46818.59,percent of total billed charges,,,,,,,,,,,20414.98,100% of Medicare,,,,,27039.92,100% of Medicare,,,,,27039.92,100% of Medicare,,,,,27039.92,100% of Medicare,,,,,27039.92,100% of Medicare,,,,,27039.92,100% of Medicare,,,,,27039.92,100% of Medicare,,,,,27039.92,100% of Medicare,,,,,27039.92,100% of Medicare,,,,,27039.92,100% of Medicare,,,,,27039.92,100% of Medicare,,,,,27039.92,100% of Medicare,,,,,,27039.92,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,60195.33,
Stroke D0102,D0102,LOCAL,,,,inpatient,,,77142.86,46285.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,62485.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,65571.43,percent of total billed charges,,,85,,65571.43,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,69428.57,percent of total billed charges,,,,,,,no IP contract,,80,,61714.29,percent of total billed charges,,,,,,,no IP contract,,50,,38571.43,percent of total billed charges,,,,,,no IP contract,,,78,,60171.43,percent of total billed charges,,,70,,54000,percent of total billed charges,,,,,,,,,,,17393.63,100% of Medicare,,,,,27705.65,100% of Medicare,,,,,27705.65,100% of Medicare,,,,,27705.65,100% of Medicare,,,,,27705.65,100% of Medicare,,,,,27705.65,100% of Medicare,,,,,27705.65,100% of Medicare,,,,,27705.65,100% of Medicare,,,,,27705.65,100% of Medicare,,,,,27705.65,100% of Medicare,,,,,27705.65,100% of Medicare,,,,,27705.65,100% of Medicare,,,,,,27705.65,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,69428.57,
Stroke D0103,D0103,LOCAL,,,,inpatient,,,99096.51,59457.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,80268.17,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,84232.03,percent of total billed charges,,,85,,84232.03,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,89186.86,percent of total billed charges,,,,,,,no IP contract,,80,,79277.21,percent of total billed charges,,,,,,,no IP contract,,50,,49548.25,percent of total billed charges,,,,,,no IP contract,,,78,,77295.28,percent of total billed charges,,,70,,69367.56,percent of total billed charges,,,,,,,,,,,29823.57,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Stroke D0104,D0104,LOCAL,,,,inpatient,,,114942.39,68965.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,93103.33,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,97701.03,percent of total billed charges,,,85,,97701.03,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,103448.15,percent of total billed charges,,,,,,,no IP contract,,80,,91953.91,percent of total billed charges,,,,,,,no IP contract,,50,,57471.19,percent of total billed charges,,,,,,no IP contract,,,78,,89655.06,percent of total billed charges,,,70,,80459.67,percent of total billed charges,,,,,,,,,,,36020.37,100% of Medicare,,,,,36201.88,100% of Medicare,,,,,36201.88,100% of Medicare,,,,,36201.88,100% of Medicare,,,,,36201.88,100% of Medicare,,,,,36201.88,100% of Medicare,,,,,36201.88,100% of Medicare,,,,,36201.88,100% of Medicare,,,,,36201.88,100% of Medicare,,,,,36201.88,100% of Medicare,,,,,36201.88,100% of Medicare,,,,,36201.88,100% of Medicare,,,,,,36201.88,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,103448.15,
Stroke D0105,D0105,LOCAL,,,,inpatient,,,101971.77,61183.06,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,82597.13,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,86676.01,percent of total billed charges,,,85,,86676.01,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,91774.59,percent of total billed charges,,,,,,,no IP contract,,80,,81577.42,percent of total billed charges,,,,,,,no IP contract,,50,,50985.89,percent of total billed charges,,,,,,no IP contract,,,78,,79537.98,percent of total billed charges,,,70,,71380.24,percent of total billed charges,,,,,,,,,,,46227.74,100% of Medicare,,,,,34053.34,100% of Medicare,,,,,34053.34,100% of Medicare,,,,,34053.34,100% of Medicare,,,,,34053.34,100% of Medicare,,,,,34053.34,100% of Medicare,,,,,34053.34,100% of Medicare,,,,,34053.34,100% of Medicare,,,,,34053.34,100% of Medicare,,,,,34053.34,100% of Medicare,,,,,34053.34,100% of Medicare,,,,,34053.34,100% of Medicare,,,,,,34053.34,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,91774.59,
Stroke D0106,D0106,LOCAL,,,,inpatient,,,164443.67,98666.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,133199.38,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,139777.12,percent of total billed charges,,,85,,139777.12,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,147999.31,percent of total billed charges,,,,,,,no IP contract,,80,,131554.94,percent of total billed charges,,,,,,,no IP contract,,50,,82221.84,percent of total billed charges,,,,,,no IP contract,,,78,,128266.07,percent of total billed charges,,,70,,115110.57,percent of total billed charges,,,,,,,,,,,50796.97,100% of Medicare,,,,,57732.29,100% of Medicare,,,,,57732.29,100% of Medicare,,,,,57732.29,100% of Medicare,,,,,57732.29,100% of Medicare,,,,,57732.29,100% of Medicare,,,,,57732.29,100% of Medicare,,,,,57732.29,100% of Medicare,,,,,57732.29,100% of Medicare,,,,,57732.29,100% of Medicare,,,,,57732.29,100% of Medicare,,,,,57732.29,100% of Medicare,,,,,,57732.29,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,147999.31,
Traumatic Brain Injury D0201,D0201,LOCAL,,,,inpatient,,,53041.45,31824.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,42963.57,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,45085.23,percent of total billed charges,,,85,,45085.23,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,47737.31,percent of total billed charges,,,,,,,no IP contract,,80,,42433.16,percent of total billed charges,,,,,,,no IP contract,,50,,26520.73,percent of total billed charges,,,,,,no IP contract,,,78,,41372.33,percent of total billed charges,,,70,,37129.02,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,17919.73,100% of Medicare,,,,,17919.73,100% of Medicare,,,,,17919.73,100% of Medicare,,,,,17919.73,100% of Medicare,,,,,17919.73,100% of Medicare,,,,,17919.73,100% of Medicare,,,,,17919.73,100% of Medicare,,,,,17919.73,100% of Medicare,,,,,17919.73,100% of Medicare,,,,,17919.73,100% of Medicare,,,,,17919.73,100% of Medicare,,,,,,17919.73,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Traumatic Brain Injury D0202,D0202,LOCAL,,,,inpatient,,,105445.54,63267.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,85410.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,89628.71,percent of total billed charges,,,85,,89628.71,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,94900.99,percent of total billed charges,,,,,,,no IP contract,,80,,84356.43,percent of total billed charges,,,,,,,no IP contract,,50,,52722.77,percent of total billed charges,,,,,,no IP contract,,,78,,82247.52,percent of total billed charges,,,70,,73811.88,percent of total billed charges,,,,,,,,,,,28628.61,100% of Medicare,,,,,36431.01,100% of Medicare,,,,,36431.01,100% of Medicare,,,,,36431.01,100% of Medicare,,,,,36431.01,100% of Medicare,,,,,36431.01,100% of Medicare,,,,,36431.01,100% of Medicare,,,,,36431.01,100% of Medicare,,,,,36431.01,100% of Medicare,,,,,36431.01,100% of Medicare,,,,,36431.01,100% of Medicare,,,,,36431.01,100% of Medicare,,,,,,36431.01,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,94900.99,
Traumatic Brain Injury D0203,D0203,LOCAL,,,,inpatient,,,115475.66,69285.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,93535.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,98154.31,percent of total billed charges,,,85,,98154.31,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,103928.09,percent of total billed charges,,,,,,,no IP contract,,80,,92380.53,percent of total billed charges,,,,,,,no IP contract,,50,,57737.83,percent of total billed charges,,,,,,no IP contract,,,78,,90071.01,percent of total billed charges,,,70,,80832.96,percent of total billed charges,,,,,,,,,,,29625.54,100% of Medicare,,,,,32932.44,100% of Medicare,,,,,32932.44,100% of Medicare,,,,,32932.44,100% of Medicare,,,,,32932.44,100% of Medicare,,,,,32932.44,100% of Medicare,,,,,32932.44,100% of Medicare,,,,,32932.44,100% of Medicare,,,,,32932.44,100% of Medicare,,,,,32932.44,100% of Medicare,,,,,32932.44,100% of Medicare,,,,,32932.44,100% of Medicare,,,,,,32932.44,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,103928.09,
Traumatic Brain Injury D0204,D0204,LOCAL,,,,inpatient,,,141000.83,84600.5,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,114210.67,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,119850.7,percent of total billed charges,,,85,,119850.7,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,126900.74,percent of total billed charges,,,,,,,no IP contract,,80,,112800.66,percent of total billed charges,,,,,,,no IP contract,,50,,70500.41,percent of total billed charges,,,,,,no IP contract,,,78,,109980.65,percent of total billed charges,,,70,,98700.58,percent of total billed charges,,,,,,,,,,,39934.49,100% of Medicare,,,,,44848.59,100% of Medicare,,,,,44848.59,100% of Medicare,,,,,44848.59,100% of Medicare,,,,,44848.59,100% of Medicare,,,,,44848.59,100% of Medicare,,,,,44848.59,100% of Medicare,,,,,44848.59,100% of Medicare,,,,,44848.59,100% of Medicare,,,,,44848.59,100% of Medicare,,,,,44848.59,100% of Medicare,,,,,44848.59,100% of Medicare,,,,,,44848.59,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,126900.74,
Traumatic Brain Injury D0205,D0205,LOCAL,,,,inpatient,,,107888.07,64732.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,87389.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,91704.86,percent of total billed charges,,,85,,91704.86,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,97099.27,percent of total billed charges,,,,,,,no IP contract,,80,,86310.46,percent of total billed charges,,,,,,,no IP contract,,50,,53944.04,percent of total billed charges,,,,,,no IP contract,,,78,,84152.7,percent of total billed charges,,,70,,75521.65,percent of total billed charges,,,,,,,,,,,42728.03,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Non-traumatic Brain Injury D0301,D0301,LOCAL,,,,inpatient,,,68044.73,40826.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,55116.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,57838.02,percent of total billed charges,,,85,,57838.02,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,61240.25,percent of total billed charges,,,,,,,no IP contract,,80,,54435.78,percent of total billed charges,,,,,,,no IP contract,,50,,34022.36,percent of total billed charges,,,,,,no IP contract,,,78,,53074.89,percent of total billed charges,,,70,,47631.31,percent of total billed charges,,,,,,,,,,,26609.71,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Non-traumatic Brain Injury D0302,D0302,LOCAL,,,,inpatient,,,88441.95,53065.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,71637.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,75175.66,percent of total billed charges,,,85,,75175.66,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,79597.76,percent of total billed charges,,,,,,,no IP contract,,80,,70753.56,percent of total billed charges,,,,,,,no IP contract,,50,,44220.98,percent of total billed charges,,,,,,no IP contract,,,78,,68984.72,percent of total billed charges,,,70,,61909.37,percent of total billed charges,,,,,,,,,,,23371.15,100% of Medicare,,,,,22340.33,100% of Medicare,,,,,22340.33,100% of Medicare,,,,,22340.33,100% of Medicare,,,,,22340.33,100% of Medicare,,,,,22340.33,100% of Medicare,,,,,22340.33,100% of Medicare,,,,,22340.33,100% of Medicare,,,,,22340.33,100% of Medicare,,,,,22340.33,100% of Medicare,,,,,22340.33,100% of Medicare,,,,,22340.33,100% of Medicare,,,,,,22340.33,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,79597.76,
Non-traumatic Brain Injury D0303,D0303,LOCAL,,,,inpatient,,,112293.11,67375.87,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,90957.42,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,95449.15,percent of total billed charges,,,85,,95449.15,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,101063.8,percent of total billed charges,,,,,,,no IP contract,,80,,89834.49,percent of total billed charges,,,,,,,no IP contract,,50,,56146.56,percent of total billed charges,,,,,,no IP contract,,,78,,87588.63,percent of total billed charges,,,70,,78605.18,percent of total billed charges,,,,,,,,,,,33806.83,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Non-traumatic Brain Injury D0304,D0304,LOCAL,,,,inpatient,,,156752.6,94051.56,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,126969.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,133239.71,percent of total billed charges,,,85,,133239.71,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,141077.34,percent of total billed charges,,,,,,,no IP contract,,80,,125402.08,percent of total billed charges,,,,,,,no IP contract,,50,,78376.3,percent of total billed charges,,,,,,no IP contract,,,78,,122267.03,percent of total billed charges,,,70,,109726.82,percent of total billed charges,,,,,,,,,,,45582.5,100% of Medicare,,,,,47495.49,100% of Medicare,,,,,47495.49,100% of Medicare,,,,,47495.49,100% of Medicare,,,,,47495.49,100% of Medicare,,,,,47495.49,100% of Medicare,,,,,47495.49,100% of Medicare,,,,,47495.49,100% of Medicare,,,,,47495.49,100% of Medicare,,,,,47495.49,100% of Medicare,,,,,47495.49,100% of Medicare,,,,,47495.49,100% of Medicare,,,,,,47495.49,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,141077.34,
Non-traumatic Brain Injury D0305,D0305,LOCAL,,,,inpatient,,,133001.59,79800.96,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,107731.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,113051.36,percent of total billed charges,,,85,,113051.36,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,119701.44,percent of total billed charges,,,,,,,no IP contract,,80,,106401.28,percent of total billed charges,,,,,,,no IP contract,,50,,66500.8,percent of total billed charges,,,,,,no IP contract,,,78,,103741.24,percent of total billed charges,,,70,,93101.12,percent of total billed charges,,,,,,,,,,,41147.49,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Traumatic Spinal Cord D0401,D0401,LOCAL,,,,inpatient,,,104215.78,62529.47,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,84414.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,88583.41,percent of total billed charges,,,85,,88583.41,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,93794.2,percent of total billed charges,,,,,,,no IP contract,,80,,83372.62,percent of total billed charges,,,,,,,no IP contract,,50,,52107.89,percent of total billed charges,,,,,,no IP contract,,,78,,81288.3,percent of total billed charges,,,70,,72951.04,percent of total billed charges,,,,,,,,,,,28527.98,100% of Medicare,,,,,30940.16,100% of Medicare,,,,,30940.16,100% of Medicare,,,,,30940.16,100% of Medicare,,,,,30940.16,100% of Medicare,,,,,30940.16,100% of Medicare,,,,,30940.16,100% of Medicare,,,,,30940.16,100% of Medicare,,,,,30940.16,100% of Medicare,,,,,30940.16,100% of Medicare,,,,,30940.16,100% of Medicare,,,,,30940.16,100% of Medicare,,,,,,30940.16,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,93794.2,
Traumatic Spinal Cord D0402,D0402,LOCAL,,,,inpatient,,,157760.53,94656.32,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,127786.03,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,134096.45,percent of total billed charges,,,85,,134096.45,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,141984.48,percent of total billed charges,,,,,,,no IP contract,,80,,126208.43,percent of total billed charges,,,,,,,no IP contract,,50,,78880.27,percent of total billed charges,,,,,,no IP contract,,,78,,123053.22,percent of total billed charges,,,70,,110432.37,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,56346.74,100% of Medicare,,,,,56346.74,100% of Medicare,,,,,56346.74,100% of Medicare,,,,,56346.74,100% of Medicare,,,,,56346.74,100% of Medicare,,,,,56346.74,100% of Medicare,,,,,56346.74,100% of Medicare,,,,,56346.74,100% of Medicare,,,,,56346.74,100% of Medicare,,,,,56346.74,100% of Medicare,,,,,56346.74,100% of Medicare,,,,,,56346.74,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Traumatic Spinal Cord D0403,D0403,LOCAL,,,,inpatient,,,126143.08,75685.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,102175.89,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,107221.62,percent of total billed charges,,,85,,107221.62,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,113528.77,percent of total billed charges,,,,,,,no IP contract,,80,,100914.46,percent of total billed charges,,,,,,,no IP contract,,50,,63071.54,percent of total billed charges,,,,,,no IP contract,,,78,,98391.6,percent of total billed charges,,,70,,88300.16,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,47783.83,100% of Medicare,,,,,47783.83,100% of Medicare,,,,,47783.83,100% of Medicare,,,,,47783.83,100% of Medicare,,,,,47783.83,100% of Medicare,,,,,47783.83,100% of Medicare,,,,,47783.83,100% of Medicare,,,,,47783.83,100% of Medicare,,,,,47783.83,100% of Medicare,,,,,47783.83,100% of Medicare,,,,,47783.83,100% of Medicare,,,,,,47783.83,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Traumatic Spinal Cord D0404,D0404,LOCAL,,,,inpatient,,,266751.24,160050.75,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,216068.51,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,226738.56,percent of total billed charges,,,85,,226738.56,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,240076.12,percent of total billed charges,,,,,,,no IP contract,,80,,213400.99,percent of total billed charges,,,,,,,no IP contract,,50,,133375.62,percent of total billed charges,,,,,,no IP contract,,,78,,208065.97,percent of total billed charges,,,70,,186725.87,percent of total billed charges,,,,,,,,,,,82456.12,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Traumatic Spinal Cord D0405,D0405,LOCAL,,,,inpatient,,,193191.41,115914.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,156485.04,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,164212.7,percent of total billed charges,,,85,,164212.7,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,173872.27,percent of total billed charges,,,,,,,no IP contract,,80,,154553.13,percent of total billed charges,,,,,,,no IP contract,,50,,96595.71,percent of total billed charges,,,,,,no IP contract,,,78,,150689.3,percent of total billed charges,,,70,,135233.99,percent of total billed charges,,,,,,,,,,,58143.02,100% of Medicare,,,,,79300.04,100% of Medicare,,,,,79300.04,100% of Medicare,,,,,79300.04,100% of Medicare,,,,,79300.04,100% of Medicare,,,,,79300.04,100% of Medicare,,,,,79300.04,100% of Medicare,,,,,79300.04,100% of Medicare,,,,,79300.04,100% of Medicare,,,,,79300.04,100% of Medicare,,,,,79300.04,100% of Medicare,,,,,79300.04,100% of Medicare,,,,,,79300.04,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,173872.27,
Traumatic Spinal Cord D0406,D0406,LOCAL,,,,inpatient,,,228381.23,137028.74,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,184988.8,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,194124.05,percent of total billed charges,,,85,,194124.05,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,205543.11,percent of total billed charges,,,,,,,no IP contract,,80,,182704.99,percent of total billed charges,,,,,,,no IP contract,,50,,114190.62,percent of total billed charges,,,,,,no IP contract,,,78,,178137.36,percent of total billed charges,,,70,,159866.86,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Traumatic Spinal Cord D0407,D0407,LOCAL,,,,inpatient,,,221714.77,133028.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,179588.97,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,188457.56,percent of total billed charges,,,85,,188457.56,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,199543.3,percent of total billed charges,,,,,,,no IP contract,,80,,177371.82,percent of total billed charges,,,,,,,no IP contract,,50,,110857.39,percent of total billed charges,,,,,,no IP contract,,,78,,172937.52,percent of total billed charges,,,70,,155200.34,percent of total billed charges,,,,,,,,,,,84933.58,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Non-traumatic Spinal Cord D0501,D0501,LOCAL,,,,inpatient,,,67944.45,40766.67,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,55035,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,57752.78,percent of total billed charges,,,85,,57752.78,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,61150,percent of total billed charges,,,,,,,no IP contract,,80,,54355.56,percent of total billed charges,,,,,,,no IP contract,,50,,33972.22,percent of total billed charges,,,,,,no IP contract,,,78,,52996.67,percent of total billed charges,,,70,,47561.11,percent of total billed charges,,,,,,,,,,,16624.86,100% of Medicare,,,,,26552.74,100% of Medicare,,,,,26552.74,100% of Medicare,,,,,26552.74,100% of Medicare,,,,,26552.74,100% of Medicare,,,,,26552.74,100% of Medicare,,,,,26552.74,100% of Medicare,,,,,26552.74,100% of Medicare,,,,,26552.74,100% of Medicare,,,,,26552.74,100% of Medicare,,,,,26552.74,100% of Medicare,,,,,26552.74,100% of Medicare,,,,,,26552.74,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,61150,
Non-traumatic Spinal Cord D0503,D0503,LOCAL,,,,inpatient,,,110381.18,66228.71,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,89408.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,93824.01,percent of total billed charges,,,85,,93824.01,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,99343.06,percent of total billed charges,,,,,,,no IP contract,,80,,88304.95,percent of total billed charges,,,,,,,no IP contract,,50,,55190.59,percent of total billed charges,,,,,,no IP contract,,,78,,86097.32,percent of total billed charges,,,70,,77266.83,percent of total billed charges,,,,,,,,,,,35158.11,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Non-traumatic Spinal Cord D0504,D0504,LOCAL,,,,inpatient,,,145157.08,87094.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,117577.24,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,123383.52,percent of total billed charges,,,85,,123383.52,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,130641.38,percent of total billed charges,,,,,,,no IP contract,,80,,116125.67,percent of total billed charges,,,,,,,no IP contract,,50,,72578.54,percent of total billed charges,,,,,,no IP contract,,,78,,113222.53,percent of total billed charges,,,70,,101609.96,percent of total billed charges,,,,,,,,,,,40391.26,100% of Medicare,,,,,93000.04,100% of Medicare,,,,,93000.04,100% of Medicare,,,,,93000.04,100% of Medicare,,,,,93000.04,100% of Medicare,,,,,93000.04,100% of Medicare,,,,,93000.04,100% of Medicare,,,,,93000.04,100% of Medicare,,,,,93000.04,100% of Medicare,,,,,93000.04,100% of Medicare,,,,,93000.04,100% of Medicare,,,,,93000.04,100% of Medicare,,,,,,93000.04,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,130641.38,
Non-traumatic Spinal Cord D0505,D0505,LOCAL,,,,inpatient,,,174752.94,104851.77,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,141549.88,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,148540,percent of total billed charges,,,85,,148540,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,157277.65,percent of total billed charges,,,,,,,no IP contract,,80,,139802.35,percent of total billed charges,,,,,,,no IP contract,,50,,87376.47,percent of total billed charges,,,,,,no IP contract,,,78,,136307.3,percent of total billed charges,,,70,,122327.06,percent of total billed charges,,,,,,,,,,,46915.86,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Fracture of Lower Extremity D0704,D0704,LOCAL,,,,inpatient,,,118248.08,70948.85,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,95780.95,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,100510.87,percent of total billed charges,,,85,,100510.87,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,106423.28,percent of total billed charges,,,,,,,no IP contract,,80,,94598.47,percent of total billed charges,,,,,,,no IP contract,,50,,59124.04,percent of total billed charges,,,,,,no IP contract,,,78,,92233.51,percent of total billed charges,,,70,,82773.66,percent of total billed charges,,,,,,,,,,,38074.33,100% of Medicare,,,,,28999.99,100% of Medicare,,,,,28999.99,100% of Medicare,,,,,28999.99,100% of Medicare,,,,,28999.99,100% of Medicare,,,,,28999.99,100% of Medicare,,,,,28999.99,100% of Medicare,,,,,28999.99,100% of Medicare,,,,,28999.99,100% of Medicare,,,,,28999.99,100% of Medicare,,,,,28999.99,100% of Medicare,,,,,28999.99,100% of Medicare,,,,,,28999.99,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,106423.28,
Replacement of Lower Extremity D0805,D0805,LOCAL,,,,inpatient,,,187856.58,112713.95,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,152163.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,159678.09,percent of total billed charges,,,85,,159678.09,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,169070.92,percent of total billed charges,,,,,,,no IP contract,,80,,150285.26,percent of total billed charges,,,,,,,no IP contract,,50,,93928.29,percent of total billed charges,,,,,,no IP contract,,,78,,146528.13,percent of total billed charges,,,70,,131499.6,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,84004.27,100% of Medicare,,,,,84004.27,100% of Medicare,,,,,84004.27,100% of Medicare,,,,,84004.27,100% of Medicare,,,,,84004.27,100% of Medicare,,,,,84004.27,100% of Medicare,,,,,84004.27,100% of Medicare,,,,,84004.27,100% of Medicare,,,,,84004.27,100% of Medicare,,,,,84004.27,100% of Medicare,,,,,84004.27,100% of Medicare,,,,,,84004.27,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Other Orthopedic D0901,D0901,LOCAL,,,,inpatient,,,66163.76,39698.26,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,53592.65,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,56239.2,percent of total billed charges,,,85,,56239.2,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,59547.38,percent of total billed charges,,,,,,,no IP contract,,80,,52931.01,percent of total billed charges,,,,,,,no IP contract,,50,,33081.88,percent of total billed charges,,,,,,no IP contract,,,78,,51607.73,percent of total billed charges,,,70,,46314.63,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,24168.41,100% of Medicare,,,,,24168.41,100% of Medicare,,,,,24168.41,100% of Medicare,,,,,24168.41,100% of Medicare,,,,,24168.41,100% of Medicare,,,,,24168.41,100% of Medicare,,,,,24168.41,100% of Medicare,,,,,24168.41,100% of Medicare,,,,,24168.41,100% of Medicare,,,,,24168.41,100% of Medicare,,,,,24168.41,100% of Medicare,,,,,,24168.41,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Other Orthopedic D0902,D0902,LOCAL,,,,inpatient,,,82981.9,49789.14,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,67215.34,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,70534.62,percent of total billed charges,,,85,,70534.62,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,74683.71,percent of total billed charges,,,,,,,no IP contract,,80,,66385.52,percent of total billed charges,,,,,,,no IP contract,,50,,41490.95,percent of total billed charges,,,,,,no IP contract,,,78,,64725.88,percent of total billed charges,,,70,,58087.33,percent of total billed charges,,,,,,,,,,,18767.98,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Other Orthopedic D0903,D0903,LOCAL,,,,inpatient,,,105682.45,63409.47,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,85602.78,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,89830.08,percent of total billed charges,,,85,,89830.08,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,95114.21,percent of total billed charges,,,,,,,no IP contract,,80,,84545.96,percent of total billed charges,,,,,,,no IP contract,,50,,52841.23,percent of total billed charges,,,,,,no IP contract,,,78,,82432.31,percent of total billed charges,,,70,,73977.72,percent of total billed charges,,,,,,,,,,,32775.66,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Other Orthopedic D0904,D0904,LOCAL,,,,inpatient,,,138426.86,83056.12,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,112125.76,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,117662.83,percent of total billed charges,,,85,,117662.83,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,124584.18,percent of total billed charges,,,,,,,no IP contract,,80,,110741.49,percent of total billed charges,,,,,,,no IP contract,,50,,69213.43,percent of total billed charges,,,,,,no IP contract,,,78,,107972.95,percent of total billed charges,,,70,,96898.8,percent of total billed charges,,,,,,,,,,,44097.64,100% of Medicare,,,,,49806.76,100% of Medicare,,,,,49806.76,100% of Medicare,,,,,49806.76,100% of Medicare,,,,,49806.76,100% of Medicare,,,,,49806.76,100% of Medicare,,,,,49806.76,100% of Medicare,,,,,49806.76,100% of Medicare,,,,,49806.76,100% of Medicare,,,,,49806.76,100% of Medicare,,,,,49806.76,100% of Medicare,,,,,49806.76,100% of Medicare,,,,,,49806.76,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,124584.18,
Amputation of Lower Extremity D1001,D1001,LOCAL,,,,inpatient,,,109694,65816.4,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,88852.14,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,93239.9,percent of total billed charges,,,85,,93239.9,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,98724.6,percent of total billed charges,,,,,,,no IP contract,,80,,87755.2,percent of total billed charges,,,,,,,no IP contract,,50,,54847,percent of total billed charges,,,,,,no IP contract,,,78,,85561.32,percent of total billed charges,,,70,,76785.8,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Amputation of Lower Extremity D1002,D1002,LOCAL,,,,inpatient,,,89759.19,53855.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,72704.94,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,76295.31,percent of total billed charges,,,85,,76295.31,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,80783.27,percent of total billed charges,,,,,,,no IP contract,,80,,71807.35,percent of total billed charges,,,,,,,no IP contract,,50,,44879.59,percent of total billed charges,,,,,,no IP contract,,,78,,70012.17,percent of total billed charges,,,70,,62831.43,percent of total billed charges,,,,,,,,,,,24060.33,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Amputation of Lower Extremity D1003,D1003,LOCAL,,,,inpatient,,,129929.98,77957.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,105243.29,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,110440.49,percent of total billed charges,,,85,,110440.49,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,116936.99,percent of total billed charges,,,,,,,no IP contract,,80,,103943.99,percent of total billed charges,,,,,,,no IP contract,,50,,64964.99,percent of total billed charges,,,,,,no IP contract,,,78,,101345.39,percent of total billed charges,,,70,,90950.99,percent of total billed charges,,,,,,,,,,,36201.88,100% of Medicare,,,,,14485.8,100% of Medicare,,,,,14485.8,100% of Medicare,,,,,14485.8,100% of Medicare,,,,,14485.8,100% of Medicare,,,,,14485.8,100% of Medicare,,,,,14485.8,100% of Medicare,,,,,14485.8,100% of Medicare,,,,,14485.8,100% of Medicare,,,,,14485.8,100% of Medicare,,,,,14485.8,100% of Medicare,,,,,14485.8,100% of Medicare,,,,,,14485.8,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,116936.99,
Amputation of Lower Extremity D1004,D1004,LOCAL,,,,inpatient,,,144993.66,86996.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,117444.87,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,123244.61,percent of total billed charges,,,85,,123244.61,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,130494.3,percent of total billed charges,,,,,,,no IP contract,,80,,115994.93,percent of total billed charges,,,,,,,no IP contract,,50,,72496.83,percent of total billed charges,,,,,,no IP contract,,,78,,113095.06,percent of total billed charges,,,70,,101495.56,percent of total billed charges,,,,,,,,,,,40037.46,100% of Medicare,,,,,57095.15,100% of Medicare,,,,,57095.15,100% of Medicare,,,,,57095.15,100% of Medicare,,,,,57095.15,100% of Medicare,,,,,57095.15,100% of Medicare,,,,,57095.15,100% of Medicare,,,,,57095.15,100% of Medicare,,,,,57095.15,100% of Medicare,,,,,57095.15,100% of Medicare,,,,,57095.15,100% of Medicare,,,,,57095.15,100% of Medicare,,,,,,57095.15,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,130494.3,
Amputation of Non-Lower Extremity D1102,D1102,LOCAL,,,,inpatient,,,191553.65,114932.19,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,155158.46,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,162820.6,percent of total billed charges,,,85,,162820.6,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,172398.29,percent of total billed charges,,,,,,,no IP contract,,80,,153242.92,percent of total billed charges,,,,,,,no IP contract,,50,,95776.83,percent of total billed charges,,,,,,no IP contract,,,78,,149411.85,percent of total billed charges,,,70,,134087.56,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,34121.13,100% of Medicare,,,,,34121.13,100% of Medicare,,,,,34121.13,100% of Medicare,,,,,34121.13,100% of Medicare,,,,,34121.13,100% of Medicare,,,,,34121.13,100% of Medicare,,,,,34121.13,100% of Medicare,,,,,34121.13,100% of Medicare,,,,,34121.13,100% of Medicare,,,,,34121.13,100% of Medicare,,,,,34121.13,100% of Medicare,,,,,,34121.13,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Amputation of Non-Lower Extremity D1103,D1103,LOCAL,,,,inpatient,,,306648.94,183989.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,248385.64,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,260651.6,percent of total billed charges,,,85,,260651.6,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,275984.04,percent of total billed charges,,,,,,,no IP contract,,80,,245319.15,percent of total billed charges,,,,,,,no IP contract,,50,,153324.47,percent of total billed charges,,,,,,no IP contract,,,78,,239186.17,percent of total billed charges,,,70,,214654.26,percent of total billed charges,,,,,,,,,,,84004.27,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
"Rheumatoid, Other Arthritis D1304",D1304,LOCAL,,,,inpatient,,,48894.85,29336.91,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,39604.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,41560.62,percent of total billed charges,,,85,,41560.62,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,44005.37,percent of total billed charges,,,,,,,no IP contract,,80,,39115.88,percent of total billed charges,,,,,,,no IP contract,,50,,24447.43,percent of total billed charges,,,,,,no IP contract,,,78,,38137.98,percent of total billed charges,,,70,,34226.4,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Cardiac D1401,D1401,LOCAL,,,,inpatient,,,69597.62,41758.57,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,56374.07,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,59157.97,percent of total billed charges,,,85,,59157.97,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,62637.85,percent of total billed charges,,,,,,,no IP contract,,80,,55678.09,percent of total billed charges,,,,,,,no IP contract,,50,,34798.81,percent of total billed charges,,,,,,no IP contract,,,78,,54286.14,percent of total billed charges,,,70,,48718.33,percent of total billed charges,,,,,,,,,,,18966.15,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Cardiac D1402,D1402,LOCAL,,,,inpatient,,,75782.08,45469.25,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,61383.49,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,64414.77,percent of total billed charges,,,85,,64414.77,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,68203.88,percent of total billed charges,,,,,,,no IP contract,,80,,60625.67,percent of total billed charges,,,,,,,no IP contract,,50,,37891.04,percent of total billed charges,,,,,,no IP contract,,,78,,59110.03,percent of total billed charges,,,70,,53047.46,percent of total billed charges,,,,,,,,,,,23842.67,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Cardiac D1403,D1403,LOCAL,,,,inpatient,,,92836.55,55701.93,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,75197.61,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,78911.07,percent of total billed charges,,,85,,78911.07,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,83552.9,percent of total billed charges,,,,,,,no IP contract,,80,,74269.24,percent of total billed charges,,,,,,,no IP contract,,50,,46418.28,percent of total billed charges,,,,,,no IP contract,,,78,,72412.51,percent of total billed charges,,,70,,64985.59,percent of total billed charges,,,,,,,,,,,27964.93,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Cardiac D1404,D1404,LOCAL,,,,inpatient,,,121440.25,72864.15,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,98366.6,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,103224.21,percent of total billed charges,,,85,,103224.21,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,109296.22,percent of total billed charges,,,,,,,no IP contract,,80,,97152.2,percent of total billed charges,,,,,,,no IP contract,,50,,60720.12,percent of total billed charges,,,,,,no IP contract,,,78,,94723.39,percent of total billed charges,,,70,,85008.17,percent of total billed charges,,,,,,,,,,,39017.32,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Pulmonary D1501,D1501,LOCAL,,,,inpatient,,,107814.03,64688.42,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,87329.36,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,91641.93,percent of total billed charges,,,85,,91641.93,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,97032.63,percent of total billed charges,,,,,,,no IP contract,,80,,86251.22,percent of total billed charges,,,,,,,no IP contract,,50,,53907.02,percent of total billed charges,,,,,,no IP contract,,,78,,84094.94,percent of total billed charges,,,70,,75469.82,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,36275.51,100% of Medicare,,,,,36275.51,100% of Medicare,,,,,36275.51,100% of Medicare,,,,,36275.51,100% of Medicare,,,,,36275.51,100% of Medicare,,,,,36275.51,100% of Medicare,,,,,36275.51,100% of Medicare,,,,,36275.51,100% of Medicare,,,,,36275.51,100% of Medicare,,,,,36275.51,100% of Medicare,,,,,36275.51,100% of Medicare,,,,,,36275.51,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Pulmonary D1502,D1502,LOCAL,,,,inpatient,,,129454.3,77672.58,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,104857.98,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,110036.16,percent of total billed charges,,,85,,110036.16,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,116508.87,percent of total billed charges,,,,,,,no IP contract,,80,,103563.44,percent of total billed charges,,,,,,,no IP contract,,50,,64727.15,percent of total billed charges,,,,,,no IP contract,,,78,,100974.35,percent of total billed charges,,,70,,90618.01,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Pulmonary D1503,D1503,LOCAL,,,,inpatient,,,130250.6,78150.36,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,105502.99,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,110713.01,percent of total billed charges,,,85,,110713.01,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,117225.54,percent of total billed charges,,,,,,,no IP contract,,80,,104200.48,percent of total billed charges,,,,,,,no IP contract,,50,,65125.3,percent of total billed charges,,,,,,no IP contract,,,78,,101595.47,percent of total billed charges,,,70,,91175.42,percent of total billed charges,,,,,,,,,,,35084.3,100% of Medicare,,,,,33933.02,100% of Medicare,,,,,33933.02,100% of Medicare,,,,,33933.02,100% of Medicare,,,,,33933.02,100% of Medicare,,,,,33933.02,100% of Medicare,,,,,33933.02,100% of Medicare,,,,,33933.02,100% of Medicare,,,,,33933.02,100% of Medicare,,,,,33933.02,100% of Medicare,,,,,33933.02,100% of Medicare,,,,,33933.02,100% of Medicare,,,,,,33933.02,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,117225.54,
Pulmonary D1504,D1504,LOCAL,,,,inpatient,,,162142,97285.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,131335.02,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,137820.7,percent of total billed charges,,,85,,137820.7,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,145927.8,percent of total billed charges,,,,,,,no IP contract,,80,,129713.6,percent of total billed charges,,,,,,,no IP contract,,50,,81071,percent of total billed charges,,,,,,no IP contract,,,78,,126470.76,percent of total billed charges,,,70,,113499.4,percent of total billed charges,,,,,,,,,,,11409.39,100% of Medicare,,,,,47436.63,100% of Medicare,,,,,47436.63,100% of Medicare,,,,,47436.63,100% of Medicare,,,,,47436.63,100% of Medicare,,,,,47436.63,100% of Medicare,,,,,47436.63,100% of Medicare,,,,,47436.63,100% of Medicare,,,,,47436.63,100% of Medicare,,,,,47436.63,100% of Medicare,,,,,47436.63,100% of Medicare,,,,,47436.63,100% of Medicare,,,,,,47436.63,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,145927.8,
Pain Syndrome D1601,D1601,LOCAL,,,,inpatient,,,84529.9,50717.94,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,68469.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,71850.42,percent of total billed charges,,,85,,71850.42,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,76076.91,percent of total billed charges,,,,,,,no IP contract,,80,,67623.92,percent of total billed charges,,,,,,,no IP contract,,50,,42264.95,percent of total billed charges,,,,,,no IP contract,,,78,,65933.32,percent of total billed charges,,,70,,59170.93,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,29928.42,100% of Medicare,,,,,29928.42,100% of Medicare,,,,,29928.42,100% of Medicare,,,,,29928.42,100% of Medicare,,,,,29928.42,100% of Medicare,,,,,29928.42,100% of Medicare,,,,,29928.42,100% of Medicare,,,,,29928.42,100% of Medicare,,,,,29928.42,100% of Medicare,,,,,29928.42,100% of Medicare,,,,,29928.42,100% of Medicare,,,,,,29928.42,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/ TBI or SCI D1801,D1801,LOCAL,,,,inpatient,,,121436.15,72861.69,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,98363.28,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,103220.73,percent of total billed charges,,,85,,103220.73,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,109292.54,percent of total billed charges,,,,,,,no IP contract,,80,,97148.92,percent of total billed charges,,,,,,,no IP contract,,50,,60718.08,percent of total billed charges,,,,,,no IP contract,,,78,,94720.2,percent of total billed charges,,,70,,85005.31,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,35329.05,100% of Medicare,,,,,35329.05,100% of Medicare,,,,,35329.05,100% of Medicare,,,,,35329.05,100% of Medicare,,,,,35329.05,100% of Medicare,,,,,35329.05,100% of Medicare,,,,,35329.05,100% of Medicare,,,,,35329.05,100% of Medicare,,,,,35329.05,100% of Medicare,,,,,35329.05,100% of Medicare,,,,,35329.05,100% of Medicare,,,,,,35329.05,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/ TBI or SCI D1802,D1802,LOCAL,,,,inpatient,,,99876.94,59926.16,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,80900.32,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,84895.4,percent of total billed charges,,,85,,84895.4,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,89889.25,percent of total billed charges,,,,,,,no IP contract,,80,,79901.55,percent of total billed charges,,,,,,,no IP contract,,50,,49938.47,percent of total billed charges,,,,,,no IP contract,,,78,,77904.01,percent of total billed charges,,,70,,69913.86,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,29170.22,100% of Medicare,,,,,29170.22,100% of Medicare,,,,,29170.22,100% of Medicare,,,,,29170.22,100% of Medicare,,,,,29170.22,100% of Medicare,,,,,29170.22,100% of Medicare,,,,,29170.22,100% of Medicare,,,,,29170.22,100% of Medicare,,,,,29170.22,100% of Medicare,,,,,29170.22,100% of Medicare,,,,,29170.22,100% of Medicare,,,,,,29170.22,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/ TBI or SCI D1803,D1803,LOCAL,,,,inpatient,,,130319.98,78191.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,105559.18,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,110771.98,percent of total billed charges,,,85,,110771.98,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,117287.98,percent of total billed charges,,,,,,,no IP contract,,80,,104255.98,percent of total billed charges,,,,,,,no IP contract,,50,,65159.99,percent of total billed charges,,,,,,no IP contract,,,78,,101649.58,percent of total billed charges,,,70,,91223.99,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,40496.83,100% of Medicare,,,,,40496.83,100% of Medicare,,,,,40496.83,100% of Medicare,,,,,40496.83,100% of Medicare,,,,,40496.83,100% of Medicare,,,,,40496.83,100% of Medicare,,,,,40496.83,100% of Medicare,,,,,40496.83,100% of Medicare,,,,,40496.83,100% of Medicare,,,,,40496.83,100% of Medicare,,,,,40496.83,100% of Medicare,,,,,,40496.83,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/ TBI or SCI D1804,D1804,LOCAL,,,,inpatient,,,104245.47,62547.28,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,84438.83,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,88608.65,percent of total billed charges,,,85,,88608.65,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,93820.92,percent of total billed charges,,,,,,,no IP contract,,80,,83396.38,percent of total billed charges,,,,,,,no IP contract,,50,,52122.73,percent of total billed charges,,,,,,no IP contract,,,78,,81311.47,percent of total billed charges,,,70,,72971.83,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,33155.9,100% of Medicare,,,,,33155.9,100% of Medicare,,,,,33155.9,100% of Medicare,,,,,33155.9,100% of Medicare,,,,,33155.9,100% of Medicare,,,,,33155.9,100% of Medicare,,,,,33155.9,100% of Medicare,,,,,33155.9,100% of Medicare,,,,,33155.9,100% of Medicare,,,,,33155.9,100% of Medicare,,,,,33155.9,100% of Medicare,,,,,,33155.9,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/ TBI or SCI D1805,D1805,LOCAL,,,,inpatient,,,191789.76,115073.86,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,155349.71,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,163021.3,percent of total billed charges,,,85,,163021.3,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,172610.79,percent of total billed charges,,,,,,,no IP contract,,80,,153431.81,percent of total billed charges,,,,,,,no IP contract,,50,,95894.88,percent of total billed charges,,,,,,no IP contract,,,78,,149596.02,percent of total billed charges,,,70,,134252.83,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Major Multi-Trauma w/ TBI or SCI D1806,D1806,LOCAL,,,,inpatient,,,256023.04,153613.82,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,207378.66,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,217619.58,percent of total billed charges,,,85,,217619.58,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,230420.73,percent of total billed charges,,,,,,,no IP contract,,80,,204818.43,percent of total billed charges,,,,,,,no IP contract,,50,,128011.52,percent of total billed charges,,,,,,no IP contract,,,78,,199697.97,percent of total billed charges,,,70,,179216.13,percent of total billed charges,,,,,,,,,,,67123.63,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Guillain-Barre Syndrome D1902,D1902,LOCAL,,,,inpatient,,,108901.95,65341.17,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,88210.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,92566.66,percent of total billed charges,,,85,,92566.66,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,98011.76,percent of total billed charges,,,,,,,no IP contract,,80,,87121.56,percent of total billed charges,,,,,,,no IP contract,,50,,54450.98,percent of total billed charges,,,,,,no IP contract,,,78,,84943.52,percent of total billed charges,,,70,,76231.37,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Guillain-Barre Syndrome D1904,D1904,LOCAL,,,,inpatient,,,189142.7,113485.62,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,153205.59,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,160771.3,percent of total billed charges,,,85,,160771.3,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,170228.43,percent of total billed charges,,,,,,,no IP contract,,80,,151314.16,percent of total billed charges,,,,,,,no IP contract,,50,,94571.35,percent of total billed charges,,,,,,no IP contract,,,78,,147531.31,percent of total billed charges,,,70,,132399.89,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Miscellaneous D2001,D2001,LOCAL,,,,inpatient,,,100267.38,60160.43,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,81216.58,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,85227.27,percent of total billed charges,,,85,,85227.27,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,90240.64,percent of total billed charges,,,,,,,no IP contract,,80,,80213.91,percent of total billed charges,,,,,,,no IP contract,,50,,50133.69,percent of total billed charges,,,,,,no IP contract,,,78,,78208.56,percent of total billed charges,,,70,,70187.17,percent of total billed charges,,,,,,,,,,,22340.33,100% of Medicare,,,,,40177.4,100% of Medicare,,,,,40177.4,100% of Medicare,,,,,40177.4,100% of Medicare,,,,,40177.4,100% of Medicare,,,,,40177.4,100% of Medicare,,,,,40177.4,100% of Medicare,,,,,40177.4,100% of Medicare,,,,,40177.4,100% of Medicare,,,,,40177.4,100% of Medicare,,,,,40177.4,100% of Medicare,,,,,40177.4,100% of Medicare,,,,,,40177.4,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,90240.64,
Miscellaneous D2002,D2002,LOCAL,,,,inpatient,,,84264.46,50558.68,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,68254.22,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,71624.79,percent of total billed charges,,,85,,71624.79,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,75838.02,percent of total billed charges,,,,,,,no IP contract,,80,,67411.57,percent of total billed charges,,,,,,,no IP contract,,50,,42132.23,percent of total billed charges,,,,,,no IP contract,,,78,,65726.28,percent of total billed charges,,,70,,58985.12,percent of total billed charges,,,,,,,,,,,27661.26,100% of Medicare,,,,,42076.73,100% of Medicare,,,,,42076.73,100% of Medicare,,,,,42076.73,100% of Medicare,,,,,42076.73,100% of Medicare,,,,,42076.73,100% of Medicare,,,,,42076.73,100% of Medicare,,,,,42076.73,100% of Medicare,,,,,42076.73,100% of Medicare,,,,,42076.73,100% of Medicare,,,,,42076.73,100% of Medicare,,,,,42076.73,100% of Medicare,,,,,,42076.73,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,75838.02,
Miscellaneous D2003,D2003,LOCAL,,,,inpatient,,,98548.46,59129.08,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,79824.25,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,83766.19,percent of total billed charges,,,85,,83766.19,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,88693.62,percent of total billed charges,,,,,,,no IP contract,,80,,78838.77,percent of total billed charges,,,,,,,no IP contract,,50,,49274.23,percent of total billed charges,,,,,,no IP contract,,,78,,76867.8,percent of total billed charges,,,70,,68983.92,percent of total billed charges,,,,,,,,,,,29928.42,100% of Medicare,,,,,25250.81,100% of Medicare,,,,,25250.81,100% of Medicare,,,,,25250.81,100% of Medicare,,,,,25250.81,100% of Medicare,,,,,25250.81,100% of Medicare,,,,,25250.81,100% of Medicare,,,,,25250.81,100% of Medicare,,,,,25250.81,100% of Medicare,,,,,25250.81,100% of Medicare,,,,,25250.81,100% of Medicare,,,,,25250.81,100% of Medicare,,,,,,25250.81,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,88693.62,
Miscellaneous D2004,D2004,LOCAL,,,,inpatient,,,127644.19,76586.51,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,103391.79,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,108497.56,percent of total billed charges,,,85,,108497.56,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,114879.77,percent of total billed charges,,,,,,,no IP contract,,80,,102115.35,percent of total billed charges,,,,,,,no IP contract,,50,,63822.1,percent of total billed charges,,,,,,no IP contract,,,78,,99562.47,percent of total billed charges,,,70,,89350.93,percent of total billed charges,,,,,,,,,,,70880.2,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Miscellaneous D2005,D2005,LOCAL,,,,inpatient,,,133777.66,80266.6,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,108359.9,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,113711.01,percent of total billed charges,,,85,,113711.01,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,120399.89,percent of total billed charges,,,,,,,no IP contract,,80,,107022.13,percent of total billed charges,,,,,,,no IP contract,,50,,66888.83,percent of total billed charges,,,,,,no IP contract,,,78,,104346.58,percent of total billed charges,,,70,,93644.36,percent of total billed charges,,,,,,,,,,,34613.61,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Burns D2101,D2101,LOCAL,,,,inpatient,,,137587.93,82552.76,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,111446.23,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,116949.74,percent of total billed charges,,,85,,116949.74,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,123829.14,percent of total billed charges,,,,,,,no IP contract,,80,,110070.35,percent of total billed charges,,,,,,,no IP contract,,50,,68793.97,percent of total billed charges,,,,,,no IP contract,,,78,,107318.59,percent of total billed charges,,,70,,96311.55,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,11409.39,100% of Medicare,,,,,11409.39,100% of Medicare,,,,,11409.39,100% of Medicare,,,,,11409.39,100% of Medicare,,,,,11409.39,100% of Medicare,,,,,11409.39,100% of Medicare,,,,,11409.39,100% of Medicare,,,,,11409.39,100% of Medicare,,,,,11409.39,100% of Medicare,,,,,11409.39,100% of Medicare,,,,,11409.39,100% of Medicare,,,,,,11409.39,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
Burns D2102,D2102,LOCAL,,,,inpatient,,,165269.98,99161.99,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,133868.68,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,140479.48,percent of total billed charges,,,85,,140479.48,percent of total billed charges,,3244.8,,,,per diem,If gross charges > 200000 then 3461.12 per day,,90,,148742.98,percent of total billed charges,,,,,,,no IP contract,,80,,132215.98,percent of total billed charges,,,,,,,no IP contract,,50,,82634.99,percent of total billed charges,,,,,,no IP contract,,,78,,128910.58,percent of total billed charges,,,70,,115688.98,percent of total billed charges,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,975,999999999,
00009-3475-01 - methylPREDNISolone 80 mg/mL Susp,J1040,HCPCS,00009-3475-01,NDC,,inpatient,1,ML,141.4,84.84,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,114.53,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,120.19,percent of total billed charges,,,85,,120.19,percent of total billed charges,,,49,,69.29,percent of total billed charges,,,90,,127.26,percent of total billed charges,,,,,,,no IP contract,,80,,113.12,percent of total billed charges,,,,,,,no IP contract,,50,,70.7,percent of total billed charges,,,,,,no IP contract,,,78,,110.29,percent of total billed charges,,,70,,98.98,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,69.29,3324,
Peak Flow Meter,S8096,HCPCS,,,,inpatient,,,122,73.2,2476.2,,,,per diem,"outlier if >202290.63 for 30 days,54.7% not to exceed 4037.74",2137.25,,,,per diem,"outlier >220496.78 for 30 days, 54.7% not to exceed 3543.75",3324,,,,per diem,,,,,,,no IP benefit,975,,,,per diem,"if gross charges > 60000, then 70% not to exceed 2000.00 per diem",1477,,,,per diem,61.4% if over 83200,1477,,,,per diem,57.4% if over 83200,,81,,98.82,percent of total billed charges,,3196,,,,per diem,,2242,,,,per diem,3008.72 IF Total charges > 214345.04,,85,,103.7,percent of total billed charges,,,85,,103.7,percent of total billed charges,,,49,,59.78,percent of total billed charges,,,90,,109.8,percent of total billed charges,,,,,,,no IP contract,,80,,97.6,percent of total billed charges,,,,,,,no IP contract,,50,,61,percent of total billed charges,,,,,,no IP contract,,,78,,95.16,percent of total billed charges,,,70,,85.4,percent of total billed charges,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,1369.76,,,,per diem,100% of IL Medicaid,59.78,3324,
00259-1605-01 - incobotulinumtoxinA 50 units REC I,J0588,HCPCS,00259-1605-01,NDC,,both,1,UN,1041.35,624.81,,45.5,,473.81,percent of total billed charges,,,45.3,,471.73,percent of total billed charges,,,51,,531.09,percent of total billed charges,,,,,,,,,80,,833.08,percent of total billed charges,,,61.4,,639.39,percent of total billed charges,,,57.4,,597.73,percent of total billed charges,,,81,,843.49,percent of total billed charges,,,51.5,,536.3,percent of total billed charges,,,57.6,,599.82,percent of total billed charges,,,85,,885.15,percent of total billed charges,,,85,,885.15,percent of total billed charges,,,49,,510.26,percent of total billed charges,,,90,,937.22,percent of total billed charges,,,65,,676.88,percent of total billed charges,,,80,,833.08,percent of total billed charges,,,55,,572.74,percent of total billed charges,,,55,,572.74,percent of total billed charges,,,65,,676.88,percent of total billed charges,,,78,,812.25,percent of total billed charges,,,70,,728.95,percent of total billed charges,,,,,,,,5.56,,,,100% of Medicare,,5.56,,,,100% of Medicare,,5.56,,,,100% of Medicare,,5.56,,,,100% of Medicare,,5.56,,,,100% of Medicare,,5.56,,,,100% of Medicare,,5.56,,,,100% of Medicare,,5.56,,,,100% of Medicare,,5.56,,,,100% of Medicare,,5.56,,,,100% of Medicare,,5.56,,,,100% of Medicare,,5.56,,,,100% of Medicare,,,5.56,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,5.56,937.22,
00259-1610-01 - incobotulinumtoxinA 100 units REC I,J0588,HCPCS,00259-1610-01,NDC,,both,1,UN,1983.95,1190.37,,45.5,,902.7,percent of total billed charges,,,45.3,,898.73,percent of total billed charges,,,51,,1011.81,percent of total billed charges,,,,,,,,,80,,1587.16,percent of total billed charges,,,61.4,,1218.15,percent of total billed charges,,,57.4,,1138.79,percent of total billed charges,,,81,,1607,percent of total billed charges,,,51.5,,1021.73,percent of total billed charges,,,57.6,,1142.76,percent of total billed charges,,,85,,1686.36,percent of total billed charges,,,85,,1686.36,percent of total billed charges,,,49,,972.14,percent of total billed charges,,,90,,1785.56,percent of total billed charges,,,65,,1289.57,percent of total billed charges,,,80,,1587.16,percent of total billed charges,,,55,,1091.17,percent of total billed charges,,,55,,1091.17,percent of total billed charges,,,65,,1289.57,percent of total billed charges,,,78,,1547.48,percent of total billed charges,,,70,,1388.77,percent of total billed charges,,,,,,,,5.56,,,,100% of Medicare,,5.56,,,,100% of Medicare,,5.56,,,,100% of Medicare,,5.56,,,,100% of Medicare,,5.56,,,,100% of Medicare,,5.56,,,,100% of Medicare,,5.56,,,,100% of Medicare,,5.56,,,,100% of Medicare,,5.56,,,,100% of Medicare,,5.56,,,,100% of Medicare,,5.56,,,,100% of Medicare,,5.56,,,,100% of Medicare,,,5.56,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,5.56,1785.56,
55513-0126-10 - epoetin alfa 2000 units/mL Soln,J0885,HCPCS,55513-0126-10,NDC,,both,1,ML,302.1,181.26,,45.5,,137.46,percent of total billed charges,,,45.3,,136.85,percent of total billed charges,,,51,,154.07,percent of total billed charges,,,,,,,,,80,,241.68,percent of total billed charges,,,61.4,,185.49,percent of total billed charges,,,57.4,,173.41,percent of total billed charges,,,81,,244.7,percent of total billed charges,,,51.5,,155.58,percent of total billed charges,,,57.6,,174.01,percent of total billed charges,,,85,,256.79,percent of total billed charges,,,85,,256.79,percent of total billed charges,,,49,,148.03,percent of total billed charges,,,90,,271.89,percent of total billed charges,,,65,,196.37,percent of total billed charges,,,80,,241.68,percent of total billed charges,,,55,,166.16,percent of total billed charges,,,55,,166.16,percent of total billed charges,,,65,,196.37,percent of total billed charges,,,78,,235.64,percent of total billed charges,,,70,,211.47,percent of total billed charges,,,,,,,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,,7.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,7.85,271.89,
55513-0144-10 - epoetin alfa 10000 units/mL Soln,J0885,HCPCS,55513-0144-10,NDC,,both,1,ML,1473.1,883.86,,45.5,,670.26,percent of total billed charges,,,45.3,,667.31,percent of total billed charges,,,51,,751.28,percent of total billed charges,,,,,,,,,80,,1178.48,percent of total billed charges,,,61.4,,904.48,percent of total billed charges,,,57.4,,845.56,percent of total billed charges,,,81,,1193.21,percent of total billed charges,,,51.5,,758.65,percent of total billed charges,,,57.6,,848.51,percent of total billed charges,,,85,,1252.14,percent of total billed charges,,,85,,1252.14,percent of total billed charges,,,49,,721.82,percent of total billed charges,,,90,,1325.79,percent of total billed charges,,,65,,957.52,percent of total billed charges,,,80,,1178.48,percent of total billed charges,,,55,,810.21,percent of total billed charges,,,55,,810.21,percent of total billed charges,,,65,,957.52,percent of total billed charges,,,78,,1149.02,percent of total billed charges,,,70,,1031.17,percent of total billed charges,,,,,,,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,,7.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,7.85,1325.79,
58406-0425-34 - etanercept 25 mg REC Inj,J1438,HCPCS,58406-0425-34,NDC,,both,1,EA,1667.1,1000.26,,45.5,,758.53,percent of total billed charges,,,45.3,,755.2,percent of total billed charges,,,51,,850.22,percent of total billed charges,,,,,,,,,80,,1333.68,percent of total billed charges,,,61.4,,1023.6,percent of total billed charges,,,57.4,,956.92,percent of total billed charges,,,81,,1350.35,percent of total billed charges,,,51.5,,858.56,percent of total billed charges,,,57.6,,960.25,percent of total billed charges,,,85,,1417.04,percent of total billed charges,,,85,,1417.04,percent of total billed charges,,,49,,816.88,percent of total billed charges,,,90,,1500.39,percent of total billed charges,,,65,,1083.62,percent of total billed charges,,,80,,1333.68,percent of total billed charges,,,55,,916.91,percent of total billed charges,,,55,,916.91,percent of total billed charges,,,65,,1083.62,percent of total billed charges,,,78,,1300.34,percent of total billed charges,,,70,,1166.97,percent of total billed charges,,,,,,,,824.33,,,,100% of Medicare,,824.33,,,,100% of Medicare,,824.33,,,,100% of Medicare,,824.33,,,,100% of Medicare,,824.33,,,,100% of Medicare,,824.33,,,,100% of Medicare,,824.33,,,,100% of Medicare,,824.33,,,,100% of Medicare,,824.33,,,,100% of Medicare,,824.33,,,,100% of Medicare,,824.33,,,,100% of Medicare,,824.33,,,,100% of Medicare,,,824.33,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,755.2,1500.39,
44206-0438-20 - immune globulin intravenous 10% Soln,J1459,HCPCS,44206-0438-20,NDC,,both,200,ML,22266.25,13359.75,,45.5,,10131.14,percent of total billed charges,,,45.3,,10086.61,percent of total billed charges,,,51,,11355.79,percent of total billed charges,,,,,,,,,80,,17813,percent of total billed charges,,,61.4,,13671.48,percent of total billed charges,,,57.4,,12780.83,percent of total billed charges,,,81,,18035.66,percent of total billed charges,,,51.5,,11467.12,percent of total billed charges,,,57.6,,12825.36,percent of total billed charges,,,85,,18926.31,percent of total billed charges,,,85,,18926.31,percent of total billed charges,,,49,,10910.46,percent of total billed charges,,,90,,20039.63,percent of total billed charges,,,65,,14473.06,percent of total billed charges,,,80,,17813,percent of total billed charges,,,55,,12246.44,percent of total billed charges,,,55,,12246.44,percent of total billed charges,,,65,,14473.06,percent of total billed charges,,,78,,17367.68,percent of total billed charges,,,70,,15586.38,percent of total billed charges,,,,,,,,50.64,,,,100% of Medicare,,50.64,,,,100% of Medicare,,50.64,,,,100% of Medicare,,50.64,,,,100% of Medicare,,50.64,,,,100% of Medicare,,50.64,,,,100% of Medicare,,50.64,,,,100% of Medicare,,50.64,,,,100% of Medicare,,50.64,,,,100% of Medicare,,50.64,,,,100% of Medicare,,50.64,,,,100% of Medicare,,50.64,,,,100% of Medicare,,,50.64,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,50.64,20039.63,
68982-0850-02 - immune globulin intravenous 10% Soln,J1568,HCPCS,68982-0850-02,NDC,,both,50,ML,4040.2,2424.12,,45.5,,1838.29,percent of total billed charges,,,45.3,,1830.21,percent of total billed charges,,,51,,2060.5,percent of total billed charges,,,,,,,,,80,,3232.16,percent of total billed charges,,,61.4,,2480.68,percent of total billed charges,,,57.4,,2319.07,percent of total billed charges,,,81,,3272.56,percent of total billed charges,,,51.5,,2080.7,percent of total billed charges,,,57.6,,2327.16,percent of total billed charges,,,85,,3434.17,percent of total billed charges,,,85,,3434.17,percent of total billed charges,,,49,,1979.7,percent of total billed charges,,,90,,3636.18,percent of total billed charges,,,65,,2626.13,percent of total billed charges,,,80,,3232.16,percent of total billed charges,,,55,,2222.11,percent of total billed charges,,,55,,2222.11,percent of total billed charges,,,65,,2626.13,percent of total billed charges,,,78,,3151.36,percent of total billed charges,,,70,,2828.14,percent of total billed charges,,,,,,,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,,51.07,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,51.07,3636.18,
68982-0850-03 - immune globulin intravenous 10% Soln,J1568,HCPCS,68982-0850-03,NDC,,both,100,ML,8005.3,4803.18,,45.5,,3642.41,percent of total billed charges,,,45.3,,3626.4,percent of total billed charges,,,51,,4082.7,percent of total billed charges,,,,,,,,,80,,6404.24,percent of total billed charges,,,61.4,,4915.25,percent of total billed charges,,,57.4,,4595.04,percent of total billed charges,,,81,,6484.29,percent of total billed charges,,,51.5,,4122.73,percent of total billed charges,,,57.6,,4611.05,percent of total billed charges,,,85,,6804.51,percent of total billed charges,,,85,,6804.51,percent of total billed charges,,,49,,3922.6,percent of total billed charges,,,90,,7204.77,percent of total billed charges,,,65,,5203.45,percent of total billed charges,,,80,,6404.24,percent of total billed charges,,,55,,4402.92,percent of total billed charges,,,55,,4402.92,percent of total billed charges,,,65,,5203.45,percent of total billed charges,,,78,,6244.13,percent of total billed charges,,,70,,5603.71,percent of total billed charges,,,,,,,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,,51.07,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,51.07,7204.77,
68982-0850-04 - immune globulin intravenous 10% Soln,J1568,HCPCS,68982-0850-04,NDC,,both,200,ML,15935.45,9561.27,,45.5,,7250.63,percent of total billed charges,,,45.3,,7218.76,percent of total billed charges,,,51,,8127.08,percent of total billed charges,,,,,,,,,80,,12748.36,percent of total billed charges,,,61.4,,9784.37,percent of total billed charges,,,57.4,,9146.95,percent of total billed charges,,,81,,12907.71,percent of total billed charges,,,51.5,,8206.76,percent of total billed charges,,,57.6,,9178.82,percent of total billed charges,,,85,,13545.13,percent of total billed charges,,,85,,13545.13,percent of total billed charges,,,49,,7808.37,percent of total billed charges,,,90,,14341.91,percent of total billed charges,,,65,,10358.04,percent of total billed charges,,,80,,12748.36,percent of total billed charges,,,55,,8764.5,percent of total billed charges,,,55,,8764.5,percent of total billed charges,,,65,,10358.04,percent of total billed charges,,,78,,12429.65,percent of total billed charges,,,70,,11154.82,percent of total billed charges,,,,,,,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,,51.07,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,51.07,14341.91,
68982-0850-05 - immune globulin intravenous 10% Soln,J1568,HCPCS,68982-0850-05,NDC,,both,300,ML,23865.6,14319.36,,45.5,,10858.85,percent of total billed charges,,,45.3,,10811.12,percent of total billed charges,,,51,,12171.46,percent of total billed charges,,,,,,,,,80,,19092.48,percent of total billed charges,,,61.4,,14653.48,percent of total billed charges,,,57.4,,13698.85,percent of total billed charges,,,81,,19331.14,percent of total billed charges,,,51.5,,12290.78,percent of total billed charges,,,57.6,,13746.59,percent of total billed charges,,,85,,20285.76,percent of total billed charges,,,85,,20285.76,percent of total billed charges,,,49,,11694.14,percent of total billed charges,,,90,,21479.04,percent of total billed charges,,,65,,15512.64,percent of total billed charges,,,80,,19092.48,percent of total billed charges,,,55,,13126.08,percent of total billed charges,,,55,,13126.08,percent of total billed charges,,,65,,15512.64,percent of total billed charges,,,78,,18615.17,percent of total billed charges,,,70,,16705.92,percent of total billed charges,,,,,,,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,51.07,,,,100% of Medicare,,,51.07,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,51.07,21479.04,
00944-2700-05 - immune globulin intravenous 10% Soln,J1569,HCPCS,00944-2700-05,NDC,,both,100,ML,10847.75,6508.65,,45.5,,4935.73,percent of total billed charges,,,45.3,,4914.03,percent of total billed charges,,,51,,5532.35,percent of total billed charges,,,,,,,,,80,,8678.2,percent of total billed charges,,,61.4,,6660.52,percent of total billed charges,,,57.4,,6226.61,percent of total billed charges,,,81,,8786.68,percent of total billed charges,,,51.5,,5586.59,percent of total billed charges,,,57.6,,6248.3,percent of total billed charges,,,85,,9220.59,percent of total billed charges,,,85,,9220.59,percent of total billed charges,,,49,,5315.4,percent of total billed charges,,,90,,9762.98,percent of total billed charges,,,65,,7051.04,percent of total billed charges,,,80,,8678.2,percent of total billed charges,,,55,,5966.26,percent of total billed charges,,,55,,5966.26,percent of total billed charges,,,65,,7051.04,percent of total billed charges,,,78,,8461.25,percent of total billed charges,,,70,,7593.43,percent of total billed charges,,,,,,,,51.8,,,,100% of Medicare,,51.8,,,,100% of Medicare,,51.8,,,,100% of Medicare,,51.8,,,,100% of Medicare,,51.8,,,,100% of Medicare,,51.8,,,,100% of Medicare,,51.8,,,,100% of Medicare,,51.8,,,,100% of Medicare,,51.8,,,,100% of Medicare,,51.8,,,,100% of Medicare,,51.8,,,,100% of Medicare,,51.8,,,,100% of Medicare,,,51.8,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,51.8,9762.98,
00944-2700-06 - immune globulin intravenous and subcutaneous 10% Soln,J1569,HCPCS,00944-2700-06,NDC,,both,200,ML,21683.1,13009.86,,45.5,,9865.81,percent of total billed charges,,,45.3,,9822.44,percent of total billed charges,,,51,,11058.38,percent of total billed charges,,,,,,,,,80,,17346.48,percent of total billed charges,,,61.4,,13313.42,percent of total billed charges,,,57.4,,12446.1,percent of total billed charges,,,81,,17563.31,percent of total billed charges,,,51.5,,11166.8,percent of total billed charges,,,57.6,,12489.47,percent of total billed charges,,,85,,18430.64,percent of total billed charges,,,85,,18430.64,percent of total billed charges,,,49,,10624.72,percent of total billed charges,,,90,,19514.79,percent of total billed charges,,,65,,14094.02,percent of total billed charges,,,80,,17346.48,percent of total billed charges,,,55,,11925.71,percent of total billed charges,,,55,,11925.71,percent of total billed charges,,,65,,14094.02,percent of total billed charges,,,78,,16912.82,percent of total billed charges,,,70,,15178.17,percent of total billed charges,,,,,,,,51.8,,,,100% of Medicare,,51.8,,,,100% of Medicare,,51.8,,,,100% of Medicare,,51.8,,,,100% of Medicare,,51.8,,,,100% of Medicare,,51.8,,,,100% of Medicare,,51.8,,,,100% of Medicare,,51.8,,,,100% of Medicare,,51.8,,,,100% of Medicare,,51.8,,,,100% of Medicare,,51.8,,,,100% of Medicare,,51.8,,,,100% of Medicare,,,51.8,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,51.8,19514.79,
00944-2700-07 - immune globulin intravenous and subcutaneous 10% Soln,J1569,HCPCS,00944-2700-07,NDC,,both,300,ML,34536.35,20721.81,,45.5,,15714.04,percent of total billed charges,,,45.3,,15644.97,percent of total billed charges,,,51,,17613.54,percent of total billed charges,,,,,,,,,80,,27629.08,percent of total billed charges,,,61.4,,21205.32,percent of total billed charges,,,57.4,,19823.86,percent of total billed charges,,,81,,27974.44,percent of total billed charges,,,51.5,,17786.22,percent of total billed charges,,,57.6,,19892.94,percent of total billed charges,,,85,,29355.9,percent of total billed charges,,,85,,29355.9,percent of total billed charges,,,49,,16922.81,percent of total billed charges,,,90,,31082.72,percent of total billed charges,,,65,,22448.63,percent of total billed charges,,,80,,27629.08,percent of total billed charges,,,55,,18994.99,percent of total billed charges,,,55,,18994.99,percent of total billed charges,,,65,,22448.63,percent of total billed charges,,,78,,26938.35,percent of total billed charges,,,70,,24175.45,percent of total billed charges,,,,,,,,51.8,,,,100% of Medicare,,51.8,,,20414.98,100% of Medicare,,51.8,,,20414.98,100% of Medicare,,51.8,,,20414.98,100% of Medicare,,51.8,,,20414.98,100% of Medicare,,51.8,,,20414.98,100% of Medicare,,51.8,,,20414.98,100% of Medicare,,51.8,,,20414.98,100% of Medicare,,51.8,,,20414.98,100% of Medicare,,51.8,,,20414.98,100% of Medicare,,51.8,,,20414.98,100% of Medicare,,51.8,,,20414.98,100% of Medicare,,,51.8,,,20414.98,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,51.8,31082.72,
55513-0880-02 - romosozumab 105 mg/1.17 mL Soln,J3111,HCPCS,55513-0880-02,NDC,,both,1.17,ML,9240.2,5544.12,,45.5,,4204.29,percent of total billed charges,,,45.3,,4185.81,percent of total billed charges,,,51,,4712.5,percent of total billed charges,,,,,,,,,80,,7392.16,percent of total billed charges,,,61.4,,5673.48,percent of total billed charges,,,57.4,,5303.87,percent of total billed charges,,,81,,7484.56,percent of total billed charges,,,51.5,,4758.7,percent of total billed charges,,,57.6,,5322.36,percent of total billed charges,,,85,,7854.17,percent of total billed charges,,,85,,7854.17,percent of total billed charges,,,49,,4527.7,percent of total billed charges,,,90,,8316.18,percent of total billed charges,,,65,,6006.13,percent of total billed charges,,,80,,7392.16,percent of total billed charges,,,55,,5082.11,percent of total billed charges,,,55,,5082.11,percent of total billed charges,,,65,,6006.13,percent of total billed charges,,,78,,7207.36,percent of total billed charges,,,70,,6468.14,percent of total billed charges,,,,,,,,11.64,,,,100% of Medicare,,11.64,,,,100% of Medicare,,11.64,,,,100% of Medicare,,11.64,,,,100% of Medicare,,11.64,,,,100% of Medicare,,11.64,,,,100% of Medicare,,11.64,,,,100% of Medicare,,11.64,,,,100% of Medicare,,11.64,,,,100% of Medicare,,11.64,,,,100% of Medicare,,11.64,,,,100% of Medicare,,11.64,,,,100% of Medicare,,,11.64,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,11.64,8316.18,
89130-2020-01 - sodium hyaluronate 20 mg/mL Soln,J7318,HCPCS,89130-2020-01,NDC,,both,3,ML,3997.9,2398.74,,45.5,,1819.04,percent of total billed charges,,,45.3,,1811.05,percent of total billed charges,,,51,,2038.93,percent of total billed charges,,,,,,,,,80,,3198.32,percent of total billed charges,,,61.4,,2454.71,percent of total billed charges,,,57.4,,2294.79,percent of total billed charges,,,81,,3238.3,percent of total billed charges,,,51.5,,2058.92,percent of total billed charges,,,57.6,,2302.79,percent of total billed charges,,,85,,3398.22,percent of total billed charges,,,85,,3398.22,percent of total billed charges,,,49,,1958.97,percent of total billed charges,,,90,,3598.11,percent of total billed charges,,,65,,2598.64,percent of total billed charges,,,80,,3198.32,percent of total billed charges,,,55,,2198.85,percent of total billed charges,,,55,,2198.85,percent of total billed charges,,,65,,2598.64,percent of total billed charges,,,78,,3118.36,percent of total billed charges,,,70,,2798.53,percent of total billed charges,,,,,,,,7.3,,,,100% of Medicare,,7.3,,,,100% of Medicare,,7.3,,,,100% of Medicare,,7.3,,,,100% of Medicare,,7.3,,,,100% of Medicare,,7.3,,,,100% of Medicare,,7.3,,,,100% of Medicare,,7.3,,,,100% of Medicare,,7.3,,,,100% of Medicare,,7.3,,,,100% of Medicare,,7.3,,,,100% of Medicare,,7.3,,,,100% of Medicare,,,7.3,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,7.3,3598.11,
55566-4100-01 - sodium hyaluronate 10 mg/mL Soln,J7323,HCPCS,55566-4100-01,NDC,,both,2,ML,1399.7,839.82,,45.5,,636.86,percent of total billed charges,,,45.3,,634.06,percent of total billed charges,,,51,,713.85,percent of total billed charges,,,,,,,,,80,,1119.76,percent of total billed charges,,,61.4,,859.42,percent of total billed charges,,,57.4,,803.43,percent of total billed charges,,,81,,1133.76,percent of total billed charges,,,51.5,,720.85,percent of total billed charges,,,57.6,,806.23,percent of total billed charges,,,85,,1189.75,percent of total billed charges,,,85,,1189.75,percent of total billed charges,,,49,,685.85,percent of total billed charges,,,90,,1259.73,percent of total billed charges,,,65,,909.81,percent of total billed charges,,,80,,1119.76,percent of total billed charges,,,55,,769.84,percent of total billed charges,,,55,,769.84,percent of total billed charges,,,65,,909.81,percent of total billed charges,,,78,,1091.77,percent of total billed charges,,,70,,979.79,percent of total billed charges,,,,,,,,126.46,,,,100% of Medicare,,126.46,,,,100% of Medicare,,126.46,,,,100% of Medicare,,126.46,,,,100% of Medicare,,126.46,,,,100% of Medicare,,126.46,,,,100% of Medicare,,126.46,,,,100% of Medicare,,126.46,,,,100% of Medicare,,126.46,,,,100% of Medicare,,126.46,,,,100% of Medicare,,126.46,,,,100% of Medicare,,126.46,,,,100% of Medicare,,,126.46,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,126.46,1259.73,
59676-0360-01 - hyaluronan 30 mg/2 mL Soln,J7324,HCPCS,59676-0360-01,NDC,,both,2,ML,1907.65,1144.59,,45.5,,867.98,percent of total billed charges,,,45.3,,864.17,percent of total billed charges,,,51,,972.9,percent of total billed charges,,,,,,,,,80,,1526.12,percent of total billed charges,,,61.4,,1171.3,percent of total billed charges,,,57.4,,1094.99,percent of total billed charges,,,81,,1545.2,percent of total billed charges,,,51.5,,982.44,percent of total billed charges,,,57.6,,1098.81,percent of total billed charges,,,85,,1621.5,percent of total billed charges,,,85,,1621.5,percent of total billed charges,,,49,,934.75,percent of total billed charges,,,90,,1716.89,percent of total billed charges,,,65,,1239.97,percent of total billed charges,,,80,,1526.12,percent of total billed charges,,,55,,1049.21,percent of total billed charges,,,55,,1049.21,percent of total billed charges,,,65,,1239.97,percent of total billed charges,,,78,,1487.97,percent of total billed charges,,,70,,1335.36,percent of total billed charges,,,,,,,,128.13,,,,100% of Medicare,,128.13,,,,100% of Medicare,,128.13,,,,100% of Medicare,,128.13,,,,100% of Medicare,,128.13,,,,100% of Medicare,,128.13,,,,100% of Medicare,,128.13,,,,100% of Medicare,,128.13,,,,100% of Medicare,,128.13,,,,100% of Medicare,,128.13,,,,100% of Medicare,,128.13,,,,100% of Medicare,,128.13,,,,100% of Medicare,,,128.13,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,128.13,1716.89,
58468-0090-01 - hylan G-F 20 8 mg/mL Soln,J7325,HCPCS,58468-0090-01,NDC,,both,2,ML,1822.4,1093.44,,45.5,,829.19,percent of total billed charges,,,45.3,,825.55,percent of total billed charges,,,51,,929.42,percent of total billed charges,,,,,,,,,80,,1457.92,percent of total billed charges,,,61.4,,1118.95,percent of total billed charges,,,57.4,,1046.06,percent of total billed charges,,,81,,1476.14,percent of total billed charges,,,51.5,,938.54,percent of total billed charges,,,57.6,,1049.7,percent of total billed charges,,,85,,1549.04,percent of total billed charges,,,85,,1549.04,percent of total billed charges,,,49,,892.98,percent of total billed charges,,,90,,1640.16,percent of total billed charges,,,65,,1184.56,percent of total billed charges,,,80,,1457.92,percent of total billed charges,,,55,,1002.32,percent of total billed charges,,,55,,1002.32,percent of total billed charges,,,65,,1184.56,percent of total billed charges,,,78,,1421.47,percent of total billed charges,,,70,,1275.68,percent of total billed charges,,,,,,,,9.54,,,,100% of Medicare,,9.54,,,,100% of Medicare,,9.54,,,,100% of Medicare,,9.54,,,,100% of Medicare,,9.54,,,,100% of Medicare,,9.54,,,,100% of Medicare,,9.54,,,,100% of Medicare,,9.54,,,,100% of Medicare,,9.54,,,,100% of Medicare,,9.54,,,,100% of Medicare,,9.54,,,,100% of Medicare,,9.54,,,,100% of Medicare,,,9.54,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,9.54,1640.16,
58468-0090-03 - hylan G-F 20 8 mg/mL Soln,J7325,HCPCS,58468-0090-03,NDC,,both,6,ML,5449.1,3269.46,,45.5,,2479.34,percent of total billed charges,,,45.3,,2468.44,percent of total billed charges,,,51,,2779.04,percent of total billed charges,,,,,,,,,80,,4359.28,percent of total billed charges,,,61.4,,3345.75,percent of total billed charges,,,57.4,,3127.78,percent of total billed charges,,,81,,4413.77,percent of total billed charges,,,51.5,,2806.29,percent of total billed charges,,,57.6,,3138.68,percent of total billed charges,,,85,,4631.74,percent of total billed charges,,,85,,4631.74,percent of total billed charges,,,49,,2670.06,percent of total billed charges,,,90,,4904.19,percent of total billed charges,,,65,,3541.92,percent of total billed charges,,,80,,4359.28,percent of total billed charges,,,55,,2997.01,percent of total billed charges,,,55,,2997.01,percent of total billed charges,,,65,,3541.92,percent of total billed charges,,,78,,4250.3,percent of total billed charges,,,70,,3814.37,percent of total billed charges,,,,,,,,9.54,,,,100% of Medicare,,9.54,,,,100% of Medicare,,9.54,,,,100% of Medicare,,9.54,,,,100% of Medicare,,9.54,,,,100% of Medicare,,9.54,,,,100% of Medicare,,9.54,,,,100% of Medicare,,9.54,,,,100% of Medicare,,9.54,,,,100% of Medicare,,9.54,,,,100% of Medicare,,9.54,,,,100% of Medicare,,9.54,,,,100% of Medicare,,,9.54,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,9.54,4904.19,
59676-0820-01 - hyaluronan 88 mg/4 mL Soln,J7327,HCPCS,59676-0820-01,NDC,,both,4,ML,15183.3,9109.98,,45.5,,6908.4,percent of total billed charges,,,45.3,,6878.03,percent of total billed charges,,,51,,7743.48,percent of total billed charges,,,,,,,,,80,,12146.64,percent of total billed charges,,,61.4,,9322.55,percent of total billed charges,,,57.4,,8715.21,percent of total billed charges,,,81,,12298.47,percent of total billed charges,,,51.5,,7819.4,percent of total billed charges,,,57.6,,8745.58,percent of total billed charges,,,85,,12905.81,percent of total billed charges,,,85,,12905.81,percent of total billed charges,,,49,,7439.82,percent of total billed charges,,,90,,13664.97,percent of total billed charges,,,65,,9869.15,percent of total billed charges,,,80,,12146.64,percent of total billed charges,,,55,,8350.82,percent of total billed charges,,,55,,8350.82,percent of total billed charges,,,65,,9869.15,percent of total billed charges,,,78,,11842.97,percent of total billed charges,,,70,,10628.31,percent of total billed charges,,,,,,,,712.14,,,,100% of Medicare,,712.14,,,,100% of Medicare,,712.14,,,,100% of Medicare,,712.14,,,,100% of Medicare,,712.14,,,,100% of Medicare,,712.14,,,,100% of Medicare,,712.14,,,,100% of Medicare,,712.14,,,,100% of Medicare,,712.14,,,,100% of Medicare,,712.14,,,,100% of Medicare,,712.14,,,,100% of Medicare,,712.14,,,,100% of Medicare,,,712.14,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,712.14,13664.97,
EXC FACE-MM B9+MARG 3.1-4 CM (11444),11444,CPT,,,,outpatient,,,2870,1722,,45.5,,1305.85,percent of total billed charges,,,45.3,,1300.11,percent of total billed charges,,,51,,1463.7,percent of total billed charges,,,,,,,,,80,,2296,percent of total billed charges,,,61.4,,1762.18,percent of total billed charges,,,57.4,,1647.38,percent of total billed charges,,,81,,2324.7,percent of total billed charges,,,51.5,,1478.05,percent of total billed charges,,,57.6,,1653.12,percent of total billed charges,,,85,,2439.5,percent of total billed charges,,,85,,2439.5,percent of total billed charges,,,49,,1406.3,percent of total billed charges,,,90,,2583,percent of total billed charges,,,65,,1865.5,percent of total billed charges,,,80,,2296,percent of total billed charges,,,55,,1578.5,percent of total billed charges,,,55,,1578.5,percent of total billed charges,,,65,,1865.5,percent of total billed charges,,,78,,2238.6,percent of total billed charges,,,70,,2009,percent of total billed charges,,,,,,,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,,1688.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1300.11,2583,
EXC H-F-NK-SP MAL+MARG 0.5 < (11620),11620,CPT,,,,outpatient,,,2870,1722,,45.5,,1305.85,percent of total billed charges,,,45.3,,1300.11,percent of total billed charges,,,51,,1463.7,percent of total billed charges,,,,,,,,,80,,2296,percent of total billed charges,,,61.4,,1762.18,percent of total billed charges,,,57.4,,1647.38,percent of total billed charges,,,81,,2324.7,percent of total billed charges,,,51.5,,1478.05,percent of total billed charges,,,57.6,,1653.12,percent of total billed charges,,,85,,2439.5,percent of total billed charges,,,85,,2439.5,percent of total billed charges,,,49,,1406.3,percent of total billed charges,,,90,,2583,percent of total billed charges,,,65,,1865.5,percent of total billed charges,,,80,,2296,percent of total billed charges,,,55,,1578.5,percent of total billed charges,,,55,,1578.5,percent of total billed charges,,,65,,1865.5,percent of total billed charges,,,78,,2238.6,percent of total billed charges,,,70,,2009,percent of total billed charges,,,,,,,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,,1688.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1300.11,2583,
EXC S/N/H/F/G MAL+MRG 1.1-2 (11622),11622,CPT,,,,outpatient,,,2933,1759.8,,45.5,,1334.52,percent of total billed charges,,,45.3,,1328.65,percent of total billed charges,,,51,,1495.83,percent of total billed charges,,,,,,,,,80,,2346.4,percent of total billed charges,,,61.4,,1800.86,percent of total billed charges,,,57.4,,1683.54,percent of total billed charges,,,81,,2375.73,percent of total billed charges,,,51.5,,1510.5,percent of total billed charges,,,57.6,,1689.41,percent of total billed charges,,,85,,2493.05,percent of total billed charges,,,85,,2493.05,percent of total billed charges,,,49,,1437.17,percent of total billed charges,,,90,,2639.7,percent of total billed charges,,,65,,1906.45,percent of total billed charges,,,80,,2346.4,percent of total billed charges,,,55,,1613.15,percent of total billed charges,,,55,,1613.15,percent of total billed charges,,,65,,1906.45,percent of total billed charges,,,78,,2287.74,percent of total billed charges,,,70,,2053.1,percent of total billed charges,,,,,,,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,,733.44,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,733.44,2639.7,
DEBRIDE NAIL 1-5 (11720),11720,CPT,,,,outpatient,,,241,144.6,,45.5,,109.66,percent of total billed charges,,,45.3,,109.17,percent of total billed charges,,,51,,122.91,percent of total billed charges,,,,,,,,,80,,192.8,percent of total billed charges,,,61.4,,147.97,percent of total billed charges,,,57.4,,138.33,percent of total billed charges,,,81,,195.21,percent of total billed charges,,,51.5,,124.12,percent of total billed charges,,,57.6,,138.82,percent of total billed charges,,,85,,204.85,percent of total billed charges,,,85,,204.85,percent of total billed charges,,,49,,118.09,percent of total billed charges,,,90,,216.9,percent of total billed charges,,,65,,156.65,percent of total billed charges,,,80,,192.8,percent of total billed charges,,,55,,132.55,percent of total billed charges,,,55,,132.55,percent of total billed charges,,,65,,156.65,percent of total billed charges,,,78,,187.98,percent of total billed charges,,,70,,168.7,percent of total billed charges,,,,,,,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,,61.92,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,61.92,216.9,
"Avulsion of nail plate, partial or complete, simple; single (11730)",11730,CPT,,,,outpatient,,,607,364.2,,45.5,,276.19,percent of total billed charges,,,45.3,,274.97,percent of total billed charges,,,51,,309.57,percent of total billed charges,,,,,,,,,80,,485.6,percent of total billed charges,,,61.4,,372.7,percent of total billed charges,,,57.4,,348.42,percent of total billed charges,,,81,,491.67,percent of total billed charges,,,51.5,,312.61,percent of total billed charges,,,57.6,,349.63,percent of total billed charges,,,85,,515.95,percent of total billed charges,,,85,,515.95,percent of total billed charges,,,49,,297.43,percent of total billed charges,,,90,,546.3,percent of total billed charges,,,65,,394.55,percent of total billed charges,,,80,,485.6,percent of total billed charges,,,55,,333.85,percent of total billed charges,,,55,,333.85,percent of total billed charges,,,65,,394.55,percent of total billed charges,,,78,,473.46,percent of total billed charges,,,70,,424.9,percent of total billed charges,,,,,,,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,34302.55125,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,,207.13,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,207.13,34302.55,
REPAIR NAIL BED (11760),11760,CPT,,,,outpatient,,,966,579.6,,45.5,,439.53,percent of total billed charges,,,45.3,,437.6,percent of total billed charges,,,51,,492.66,percent of total billed charges,,,,,,,,,80,,772.8,percent of total billed charges,,,61.4,,593.12,percent of total billed charges,,,57.4,,554.48,percent of total billed charges,,,81,,782.46,percent of total billed charges,,,51.5,,497.49,percent of total billed charges,,,57.6,,556.42,percent of total billed charges,,,85,,821.1,percent of total billed charges,,,85,,821.1,percent of total billed charges,,,49,,473.34,percent of total billed charges,,,90,,869.4,percent of total billed charges,,,65,,627.9,percent of total billed charges,,,80,,772.8,percent of total billed charges,,,55,,531.3,percent of total billed charges,,,55,,531.3,percent of total billed charges,,,65,,627.9,percent of total billed charges,,,78,,753.48,percent of total billed charges,,,70,,676.2,percent of total billed charges,,,,,,,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,,638.1,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,437.6,869.4,
Wedge Exc Nail Fold,11765,CPT,,,,outpatient,,,343,205.8,,45.5,,156.07,percent of total billed charges,,,45.3,,155.38,percent of total billed charges,,,51,,174.93,percent of total billed charges,,,,,,,,,80,,274.4,percent of total billed charges,,,61.4,,210.6,percent of total billed charges,,,57.4,,196.88,percent of total billed charges,,,81,,277.83,percent of total billed charges,,,51.5,,176.65,percent of total billed charges,,,57.6,,197.57,percent of total billed charges,,,85,,291.55,percent of total billed charges,,,85,,291.55,percent of total billed charges,,,49,,168.07,percent of total billed charges,,,90,,308.7,percent of total billed charges,,,65,,222.95,percent of total billed charges,,,80,,274.4,percent of total billed charges,,,55,,188.65,percent of total billed charges,,,55,,188.65,percent of total billed charges,,,65,,222.95,percent of total billed charges,,,78,,267.54,percent of total billed charges,,,70,,240.1,percent of total billed charges,,,,,,,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,,416.48,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,155.38,416.48,
Simple Repair S/N/A/G/TR/E; 2.5CM/< (12001),12001,CPT,,,,outpatient,,,455,273,,45.5,,207.03,percent of total billed charges,,,45.3,,206.12,percent of total billed charges,,,51,,232.05,percent of total billed charges,,,,,,,,,80,,364,percent of total billed charges,,,61.4,,279.37,percent of total billed charges,,,57.4,,261.17,percent of total billed charges,,,81,,368.55,percent of total billed charges,,,51.5,,234.33,percent of total billed charges,,,57.6,,262.08,percent of total billed charges,,,85,,386.75,percent of total billed charges,,,85,,386.75,percent of total billed charges,,,49,,222.95,percent of total billed charges,,,90,,409.5,percent of total billed charges,,,65,,295.75,percent of total billed charges,,,80,,364,percent of total billed charges,,,55,,250.25,percent of total billed charges,,,55,,250.25,percent of total billed charges,,,65,,295.75,percent of total billed charges,,,78,,354.9,percent of total billed charges,,,70,,318.5,percent of total billed charges,,,,,,,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,,207.13,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,206.12,409.5,
Simple Repair PS/N/A/G/TR/E; 2.6-7.5 CM,12002,CPT,,,,outpatient,,,491,294.6,,45.5,,223.41,percent of total billed charges,,,45.3,,222.42,percent of total billed charges,,,51,,250.41,percent of total billed charges,,,,,,,,,80,,392.8,percent of total billed charges,,,61.4,,301.47,percent of total billed charges,,,57.4,,281.83,percent of total billed charges,,,81,,397.71,percent of total billed charges,,,51.5,,252.87,percent of total billed charges,,,57.6,,282.82,percent of total billed charges,,,85,,417.35,percent of total billed charges,,,85,,417.35,percent of total billed charges,,,49,,240.59,percent of total billed charges,,,90,,441.9,percent of total billed charges,,,65,,319.15,percent of total billed charges,,,80,,392.8,percent of total billed charges,,,55,,270.05,percent of total billed charges,,,55,,270.05,percent of total billed charges,,,65,,319.15,percent of total billed charges,,,78,,382.98,percent of total billed charges,,,70,,343.7,percent of total billed charges,,,,,,,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,,207.13,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,207.13,441.9,
Simple repair S/N/G/TR/E; 7.6-12.5 CM,12004,CPT,,,,outpatient,,,541,324.6,,45.5,,246.16,percent of total billed charges,,,45.3,,245.07,percent of total billed charges,,,51,,275.91,percent of total billed charges,,,,,,,,,80,,432.8,percent of total billed charges,,,61.4,,332.17,percent of total billed charges,,,57.4,,310.53,percent of total billed charges,,,81,,438.21,percent of total billed charges,,,51.5,,278.62,percent of total billed charges,,,57.6,,311.62,percent of total billed charges,,,85,,459.85,percent of total billed charges,,,85,,459.85,percent of total billed charges,,,49,,265.09,percent of total billed charges,,,90,,486.9,percent of total billed charges,,,65,,351.65,percent of total billed charges,,,80,,432.8,percent of total billed charges,,,55,,297.55,percent of total billed charges,,,55,,297.55,percent of total billed charges,,,65,,351.65,percent of total billed charges,,,78,,421.98,percent of total billed charges,,,70,,378.7,percent of total billed charges,,,,,,,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,,207.13,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,207.13,486.9,
"Repair, Intermediate S/T/Ext/2.5 cm/<",12031,CPT,,,,outpatient,,,625,375,,45.5,,284.38,percent of total billed charges,,,45.3,,283.13,percent of total billed charges,,,51,,318.75,percent of total billed charges,,,,,,,,,80,,500,percent of total billed charges,,,61.4,,383.75,percent of total billed charges,,,57.4,,358.75,percent of total billed charges,,,81,,506.25,percent of total billed charges,,,51.5,,321.88,percent of total billed charges,,,57.6,,360,percent of total billed charges,,,85,,531.25,percent of total billed charges,,,85,,531.25,percent of total billed charges,,,49,,306.25,percent of total billed charges,,,90,,562.5,percent of total billed charges,,,65,,406.25,percent of total billed charges,,,80,,500,percent of total billed charges,,,55,,343.75,percent of total billed charges,,,55,,343.75,percent of total billed charges,,,65,,406.25,percent of total billed charges,,,78,,487.5,percent of total billed charges,,,70,,437.5,percent of total billed charges,,,,,,,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,,416.48,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,283.13,562.5,
INTMD WND REPAIR S/TR/EXT 7.6-12.5 CM (12034),12034,CPT,,,,outpatient,,,857,514.2,,45.5,,389.94,percent of total billed charges,,,45.3,,388.22,percent of total billed charges,,,51,,437.07,percent of total billed charges,,,,,,,,,80,,685.6,percent of total billed charges,,,61.4,,526.2,percent of total billed charges,,,57.4,,491.92,percent of total billed charges,,,81,,694.17,percent of total billed charges,,,51.5,,441.36,percent of total billed charges,,,57.6,,493.63,percent of total billed charges,,,85,,728.45,percent of total billed charges,,,85,,728.45,percent of total billed charges,,,49,,419.93,percent of total billed charges,,,90,,771.3,percent of total billed charges,,,65,,557.05,percent of total billed charges,,,80,,685.6,percent of total billed charges,,,55,,471.35,percent of total billed charges,,,55,,471.35,percent of total billed charges,,,65,,557.05,percent of total billed charges,,,78,,668.46,percent of total billed charges,,,70,,599.9,percent of total billed charges,,,,,,,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,,416.48,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,388.22,771.3,
INTMD WND REPAIR S/A/T/EXT (12035),12035,CPT,,,,outpatient,,,1124,674.4,,45.5,,511.42,percent of total billed charges,,,45.3,,509.17,percent of total billed charges,,,51,,573.24,percent of total billed charges,,,,,,,,,80,,899.2,percent of total billed charges,,,61.4,,690.14,percent of total billed charges,,,57.4,,645.18,percent of total billed charges,,,81,,910.44,percent of total billed charges,,,51.5,,578.86,percent of total billed charges,,,57.6,,647.42,percent of total billed charges,,,85,,955.4,percent of total billed charges,,,85,,955.4,percent of total billed charges,,,49,,550.76,percent of total billed charges,,,90,,1011.6,percent of total billed charges,,,65,,730.6,percent of total billed charges,,,80,,899.2,percent of total billed charges,,,55,,618.2,percent of total billed charges,,,55,,618.2,percent of total billed charges,,,65,,730.6,percent of total billed charges,,,78,,876.72,percent of total billed charges,,,70,,786.8,percent of total billed charges,,,,,,,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,,416.48,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,416.48,1011.6,
INTMD WND REPAIR S/A/T/EXT (12036),12036,CPT,,,,outpatient,,,1452,871.2,,45.5,,660.66,percent of total billed charges,,,45.3,,657.76,percent of total billed charges,,,51,,740.52,percent of total billed charges,,,,,,,,,80,,1161.6,percent of total billed charges,,,61.4,,891.53,percent of total billed charges,,,57.4,,833.45,percent of total billed charges,,,81,,1176.12,percent of total billed charges,,,51.5,,747.78,percent of total billed charges,,,57.6,,836.35,percent of total billed charges,,,85,,1234.2,percent of total billed charges,,,85,,1234.2,percent of total billed charges,,,49,,711.48,percent of total billed charges,,,90,,1306.8,percent of total billed charges,,,65,,943.8,percent of total billed charges,,,80,,1161.6,percent of total billed charges,,,55,,798.6,percent of total billed charges,,,55,,798.6,percent of total billed charges,,,65,,943.8,percent of total billed charges,,,78,,1132.56,percent of total billed charges,,,70,,1016.4,percent of total billed charges,,,,,,,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,,638.1,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,638.1,1306.8,
"Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm (12042",12042,CPT,,,,outpatient,,,1126,675.6,,45.5,,512.33,percent of total billed charges,,,45.3,,510.08,percent of total billed charges,,,51,,574.26,percent of total billed charges,,,,,,,,,80,,900.8,percent of total billed charges,,,61.4,,691.36,percent of total billed charges,,,57.4,,646.32,percent of total billed charges,,,81,,912.06,percent of total billed charges,,,51.5,,579.89,percent of total billed charges,,,57.6,,648.58,percent of total billed charges,,,85,,957.1,percent of total billed charges,,,85,,957.1,percent of total billed charges,,,49,,551.74,percent of total billed charges,,,90,,1013.4,percent of total billed charges,,,65,,731.9,percent of total billed charges,,,80,,900.8,percent of total billed charges,,,55,,619.3,percent of total billed charges,,,55,,619.3,percent of total billed charges,,,65,,731.9,percent of total billed charges,,,78,,878.28,percent of total billed charges,,,70,,788.2,percent of total billed charges,,,,,,,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,,416.48,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,416.48,1013.4,
"Repair, Complex, Trunk; 2.6 cm to 7.5 cm",13101,CPT,,,,outpatient,,,1834,1100.4,,45.5,,834.47,percent of total billed charges,,,45.3,,830.8,percent of total billed charges,,,51,,935.34,percent of total billed charges,,,,,,,,,80,,1467.2,percent of total billed charges,,,61.4,,1126.08,percent of total billed charges,,,57.4,,1052.72,percent of total billed charges,,,81,,1485.54,percent of total billed charges,,,51.5,,944.51,percent of total billed charges,,,57.6,,1056.38,percent of total billed charges,,,85,,1558.9,percent of total billed charges,,,85,,1558.9,percent of total billed charges,,,49,,898.66,percent of total billed charges,,,90,,1650.6,percent of total billed charges,,,65,,1192.1,percent of total billed charges,,,80,,1467.2,percent of total billed charges,,,55,,1008.7,percent of total billed charges,,,55,,1008.7,percent of total billed charges,,,65,,1192.1,percent of total billed charges,,,78,,1430.52,percent of total billed charges,,,70,,1283.8,percent of total billed charges,,,,,,,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,,638.1,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,638.1,1650.6,
"Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm (13121)",13121,CPT,,,,outpatient,,,1358,814.8,,45.5,,617.89,percent of total billed charges,,,45.3,,615.17,percent of total billed charges,,,51,,692.58,percent of total billed charges,,,,,,,,,80,,1086.4,percent of total billed charges,,,61.4,,833.81,percent of total billed charges,,,57.4,,779.49,percent of total billed charges,,,81,,1099.98,percent of total billed charges,,,51.5,,699.37,percent of total billed charges,,,57.6,,782.21,percent of total billed charges,,,85,,1154.3,percent of total billed charges,,,85,,1154.3,percent of total billed charges,,,49,,665.42,percent of total billed charges,,,90,,1222.2,percent of total billed charges,,,65,,882.7,percent of total billed charges,,,80,,1086.4,percent of total billed charges,,,55,,746.9,percent of total billed charges,,,55,,746.9,percent of total billed charges,,,65,,882.7,percent of total billed charges,,,78,,1059.24,percent of total billed charges,,,70,,950.6,percent of total billed charges,,,,,,,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,638.1,,,,100% of Medicare,,,638.1,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,615.17,1222.2,
"Secondary closure of surgical wound or dehiscence, extensive or complicated",13160,CPT,,,,outpatient,,,7537,4522.2,,45.5,,3429.34,percent of total billed charges,,,45.3,,3414.26,percent of total billed charges,,,51,,3843.87,percent of total billed charges,,,,,,,,,80,,6029.6,percent of total billed charges,,,61.4,,4627.72,percent of total billed charges,,,57.4,,4326.24,percent of total billed charges,,,81,,6104.97,percent of total billed charges,,,51.5,,3881.56,percent of total billed charges,,,57.6,,4341.31,percent of total billed charges,,,85,,6406.45,percent of total billed charges,,,85,,6406.45,percent of total billed charges,,,49,,3693.13,percent of total billed charges,,,90,,6783.3,percent of total billed charges,,,65,,4899.05,percent of total billed charges,,,80,,6029.6,percent of total billed charges,,,55,,4145.35,percent of total billed charges,,,55,,4145.35,percent of total billed charges,,,65,,4899.05,percent of total billed charges,,,78,,5878.86,percent of total billed charges,,,70,,5275.9,percent of total billed charges,,,,,,,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,,1906.83,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1906.83,6783.3,
ATT TRUNK; D 10 SQ CM/< (14000),14000,CPT,,,,outpatient,,,5176,3105.6,,45.5,,2355.08,percent of total billed charges,,,45.3,,2344.73,percent of total billed charges,,,51,,2639.76,percent of total billed charges,,,,,,,,,80,,4140.8,percent of total billed charges,,,61.4,,3178.06,percent of total billed charges,,,57.4,,2971.02,percent of total billed charges,,,81,,4192.56,percent of total billed charges,,,51.5,,2665.64,percent of total billed charges,,,57.6,,2981.38,percent of total billed charges,,,85,,4399.6,percent of total billed charges,,,85,,4399.6,percent of total billed charges,,,49,,2536.24,percent of total billed charges,,,90,,4658.4,percent of total billed charges,,,65,,3364.4,percent of total billed charges,,,80,,4140.8,percent of total billed charges,,,55,,2846.8,percent of total billed charges,,,55,,2846.8,percent of total billed charges,,,65,,3364.4,percent of total billed charges,,,78,,4037.28,percent of total billed charges,,,70,,3623.2,percent of total billed charges,,,,,,,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,30231.30538,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,,1906.83,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1906.83,30231.31,
ATT TRUNK; D 10.1-30 SQ (14001),14001,CPT,,,,outpatient,,,5412,3247.2,,45.5,,2462.46,percent of total billed charges,,,45.3,,2451.64,percent of total billed charges,,,51,,2760.12,percent of total billed charges,,,,,,,,,80,,4329.6,percent of total billed charges,,,61.4,,3322.97,percent of total billed charges,,,57.4,,3106.49,percent of total billed charges,,,81,,4383.72,percent of total billed charges,,,51.5,,2787.18,percent of total billed charges,,,57.6,,3117.31,percent of total billed charges,,,85,,4600.2,percent of total billed charges,,,85,,4600.2,percent of total billed charges,,,49,,2651.88,percent of total billed charges,,,90,,4870.8,percent of total billed charges,,,65,,3517.8,percent of total billed charges,,,80,,4329.6,percent of total billed charges,,,55,,2976.6,percent of total billed charges,,,55,,2976.6,percent of total billed charges,,,65,,3517.8,percent of total billed charges,,,78,,4221.36,percent of total billed charges,,,70,,3788.4,percent of total billed charges,,,,,,,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,38284.23033,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,,1906.83,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1906.83,38284.23,
ATT S/A/L; D 10 SQ CM/< (14020),14020,CPT,,,,outpatient,,,5176,3105.6,,45.5,,2355.08,percent of total billed charges,,,45.3,,2344.73,percent of total billed charges,,,51,,2639.76,percent of total billed charges,,,,,,,,,80,,4140.8,percent of total billed charges,,,61.4,,3178.06,percent of total billed charges,,,57.4,,2971.02,percent of total billed charges,,,81,,4192.56,percent of total billed charges,,,51.5,,2665.64,percent of total billed charges,,,57.6,,2981.38,percent of total billed charges,,,85,,4399.6,percent of total billed charges,,,85,,4399.6,percent of total billed charges,,,49,,2536.24,percent of total billed charges,,,90,,4658.4,percent of total billed charges,,,65,,3364.4,percent of total billed charges,,,80,,4140.8,percent of total billed charges,,,55,,2846.8,percent of total billed charges,,,55,,2846.8,percent of total billed charges,,,65,,3364.4,percent of total billed charges,,,78,,4037.28,percent of total billed charges,,,70,,3623.2,percent of total billed charges,,,,,,,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,22676.13192,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,,1906.83,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1906.83,22676.13,
ATT S/A/L; D 10.1-30 SQ CM (14021),14021,CPT,,,,outpatient,,,5412,3247.2,,45.5,,2462.46,percent of total billed charges,,,45.3,,2451.64,percent of total billed charges,,,51,,2760.12,percent of total billed charges,,,,,,,,,80,,4329.6,percent of total billed charges,,,61.4,,3322.97,percent of total billed charges,,,57.4,,3106.49,percent of total billed charges,,,81,,4383.72,percent of total billed charges,,,51.5,,2787.18,percent of total billed charges,,,57.6,,3117.31,percent of total billed charges,,,85,,4600.2,percent of total billed charges,,,85,,4600.2,percent of total billed charges,,,49,,2651.88,percent of total billed charges,,,90,,4870.8,percent of total billed charges,,,65,,3517.8,percent of total billed charges,,,80,,4329.6,percent of total billed charges,,,55,,2976.6,percent of total billed charges,,,55,,2976.6,percent of total billed charges,,,65,,3517.8,percent of total billed charges,,,78,,4221.36,percent of total billed charges,,,70,,3788.4,percent of total billed charges,,,,,,,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,30617.67188,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,,1906.83,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1906.83,30617.67,
ATT F/C/M/N/A/G/H/F; 10 SQ CM (14040),14040,CPT,,,,outpatient,,,5176,3105.6,,45.5,,2355.08,percent of total billed charges,,,45.3,,2344.73,percent of total billed charges,,,51,,2639.76,percent of total billed charges,,,,,,,,,80,,4140.8,percent of total billed charges,,,61.4,,3178.06,percent of total billed charges,,,57.4,,2971.02,percent of total billed charges,,,81,,4192.56,percent of total billed charges,,,51.5,,2665.64,percent of total billed charges,,,57.6,,2981.38,percent of total billed charges,,,85,,4399.6,percent of total billed charges,,,85,,4399.6,percent of total billed charges,,,49,,2536.24,percent of total billed charges,,,90,,4658.4,percent of total billed charges,,,65,,3364.4,percent of total billed charges,,,80,,4140.8,percent of total billed charges,,,55,,2846.8,percent of total billed charges,,,55,,2846.8,percent of total billed charges,,,65,,3364.4,percent of total billed charges,,,78,,4037.28,percent of total billed charges,,,70,,3623.2,percent of total billed charges,,,,,,,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,35597.98533,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,,1906.83,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1906.83,35597.99,
ATT F/C/M/N/A/G/H/F; 10.1-30SQCM (14041),14041,CPT,,,,outpatient,,,5412,3247.2,,45.5,,2462.46,percent of total billed charges,,,45.3,,2451.64,percent of total billed charges,,,51,,2760.12,percent of total billed charges,,,,,,,,,80,,4329.6,percent of total billed charges,,,61.4,,3322.97,percent of total billed charges,,,57.4,,3106.49,percent of total billed charges,,,81,,4383.72,percent of total billed charges,,,51.5,,2787.18,percent of total billed charges,,,57.6,,3117.31,percent of total billed charges,,,85,,4600.2,percent of total billed charges,,,85,,4600.2,percent of total billed charges,,,49,,2651.88,percent of total billed charges,,,90,,4870.8,percent of total billed charges,,,65,,3517.8,percent of total billed charges,,,80,,4329.6,percent of total billed charges,,,55,,2976.6,percent of total billed charges,,,55,,2976.6,percent of total billed charges,,,65,,3517.8,percent of total billed charges,,,78,,4221.36,percent of total billed charges,,,70,,3788.4,percent of total billed charges,,,,,,,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,20003.2425,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,,1906.83,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1906.83,20003.24,
ATT E/N/E/L; D 10 SQ CM (14060),14060,CPT,,,,outpatient,,,5176,3105.6,,45.5,,2355.08,percent of total billed charges,,,45.3,,2344.73,percent of total billed charges,,,51,,2639.76,percent of total billed charges,,,,,,,,,80,,4140.8,percent of total billed charges,,,61.4,,3178.06,percent of total billed charges,,,57.4,,2971.02,percent of total billed charges,,,81,,4192.56,percent of total billed charges,,,51.5,,2665.64,percent of total billed charges,,,57.6,,2981.38,percent of total billed charges,,,85,,4399.6,percent of total billed charges,,,85,,4399.6,percent of total billed charges,,,49,,2536.24,percent of total billed charges,,,90,,4658.4,percent of total billed charges,,,65,,3364.4,percent of total billed charges,,,80,,4140.8,percent of total billed charges,,,55,,2846.8,percent of total billed charges,,,55,,2846.8,percent of total billed charges,,,65,,3364.4,percent of total billed charges,,,78,,4037.28,percent of total billed charges,,,70,,3623.2,percent of total billed charges,,,,,,,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,27448.141,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,,1906.83,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1906.83,27448.14,
ATT E/N/E/L; D 10.1-30 (14061),14061,CPT,,,,outpatient,,,5412,3247.2,,45.5,,2462.46,percent of total billed charges,,,45.3,,2451.64,percent of total billed charges,,,51,,2760.12,percent of total billed charges,,,,,,,,,80,,4329.6,percent of total billed charges,,,61.4,,3322.97,percent of total billed charges,,,57.4,,3106.49,percent of total billed charges,,,81,,4383.72,percent of total billed charges,,,51.5,,2787.18,percent of total billed charges,,,57.6,,3117.31,percent of total billed charges,,,85,,4600.2,percent of total billed charges,,,85,,4600.2,percent of total billed charges,,,49,,2651.88,percent of total billed charges,,,90,,4870.8,percent of total billed charges,,,65,,3517.8,percent of total billed charges,,,80,,4329.6,percent of total billed charges,,,55,,2976.6,percent of total billed charges,,,55,,2976.6,percent of total billed charges,,,65,,3517.8,percent of total billed charges,,,78,,4221.36,percent of total billed charges,,,70,,3788.4,percent of total billed charges,,,,,,,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,29712.555,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,,1906.83,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1906.83,29712.56,
SKIN TISSUE REARRANGEMENT 30.1-60.0 SQ CM (14301),14301,CPT,,,,outpatient,,,7031,4218.6,,45.5,,3199.11,percent of total billed charges,,,45.3,,3185.04,percent of total billed charges,,,51,,3585.81,percent of total billed charges,,,,,,,,,80,,5624.8,percent of total billed charges,,,61.4,,4317.03,percent of total billed charges,,,57.4,,4035.79,percent of total billed charges,,,81,,5695.11,percent of total billed charges,,,51.5,,3620.97,percent of total billed charges,,,57.6,,4049.86,percent of total billed charges,,,85,,5976.35,percent of total billed charges,,,85,,5976.35,percent of total billed charges,,,49,,3445.19,percent of total billed charges,,,90,,6327.9,percent of total billed charges,,,65,,4570.15,percent of total billed charges,,,80,,5624.8,percent of total billed charges,,,55,,3867.05,percent of total billed charges,,,55,,3867.05,percent of total billed charges,,,65,,4570.15,percent of total billed charges,,,78,,5484.18,percent of total billed charges,,,70,,4921.7,percent of total billed charges,,,,,,,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,,3816.27,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,3185.04,6327.9,
SKIN TISSUE REARRANGE ADDL 30.0 SQ CM (14302),14302,CPT,,,,outpatient,,,6904,4142.4,,45.5,,3141.32,percent of total billed charges,,,45.3,,3127.51,percent of total billed charges,,,51,,3521.04,percent of total billed charges,,,,,,,,,80,,5523.2,percent of total billed charges,,,61.4,,4239.06,percent of total billed charges,,,57.4,,3962.9,percent of total billed charges,,,81,,5592.24,percent of total billed charges,,,51.5,,3555.56,percent of total billed charges,,,57.6,,3976.7,percent of total billed charges,,,85,,5868.4,percent of total billed charges,,,85,,5868.4,percent of total billed charges,,,49,,3382.96,percent of total billed charges,,,90,,6213.6,percent of total billed charges,,,65,,4487.6,percent of total billed charges,,,80,,5523.2,percent of total billed charges,,,55,,3797.2,percent of total billed charges,,,55,,3797.2,percent of total billed charges,,,65,,4487.6,percent of total billed charges,,,78,,5385.12,percent of total billed charges,,,70,,4832.8,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,3127.51,6213.6,
SKIN SPLT GRFT TRNK/ARM/LEG 100 SQ CM/1% BA (15100),15100,CPT,,,,outpatient,,,7119,4271.4,,45.5,,3239.15,percent of total billed charges,,,45.3,,3224.91,percent of total billed charges,,,51,,3630.69,percent of total billed charges,,,,,,,,,80,,5695.2,percent of total billed charges,,,61.4,,4371.07,percent of total billed charges,,,57.4,,4086.31,percent of total billed charges,,,81,,5766.39,percent of total billed charges,,,51.5,,3666.29,percent of total billed charges,,,57.6,,4100.54,percent of total billed charges,,,85,,6051.15,percent of total billed charges,,,85,,6051.15,percent of total billed charges,,,49,,3488.31,percent of total billed charges,,,90,,6407.1,percent of total billed charges,,,65,,4627.35,percent of total billed charges,,,80,,5695.2,percent of total billed charges,,,55,,3915.45,percent of total billed charges,,,55,,3915.45,percent of total billed charges,,,65,,4627.35,percent of total billed charges,,,78,,5552.82,percent of total billed charges,,,70,,4983.3,percent of total billed charges,,,,,,,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,,1906.83,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1906.83,6407.1,
SKIN SPLT GRFT T/A/L ADDL 100 SQ CM/1% BA (15101),15101,CPT,,,,outpatient,,,3501,2100.6,,45.5,,1592.96,percent of total billed charges,,,45.3,,1585.95,percent of total billed charges,,,51,,1785.51,percent of total billed charges,,,,,,,,,80,,2800.8,percent of total billed charges,,,61.4,,2149.61,percent of total billed charges,,,57.4,,2009.57,percent of total billed charges,,,81,,2835.81,percent of total billed charges,,,51.5,,1803.02,percent of total billed charges,,,57.6,,2016.58,percent of total billed charges,,,85,,2975.85,percent of total billed charges,,,85,,2975.85,percent of total billed charges,,,49,,1715.49,percent of total billed charges,,,90,,3150.9,percent of total billed charges,,,65,,2275.65,percent of total billed charges,,,80,,2800.8,percent of total billed charges,,,55,,1925.55,percent of total billed charges,,,55,,1925.55,percent of total billed charges,,,65,,2275.65,percent of total billed charges,,,78,,2730.78,percent of total billed charges,,,70,,2450.7,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1585.95,3150.9,
SKN SPLT A-GRFT FAC/NCK/HF/G 100 SQ CM/1% BA (15120),15120,CPT,,,,outpatient,,,8850,5310,,45.5,,4026.75,percent of total billed charges,,,45.3,,4009.05,percent of total billed charges,,,51,,4513.5,percent of total billed charges,,,,,,,,,80,,7080,percent of total billed charges,,,61.4,,5433.9,percent of total billed charges,,,57.4,,5079.9,percent of total billed charges,,,81,,7168.5,percent of total billed charges,,,51.5,,4557.75,percent of total billed charges,,,57.6,,5097.6,percent of total billed charges,,,85,,7522.5,percent of total billed charges,,,85,,7522.5,percent of total billed charges,,,49,,4336.5,percent of total billed charges,,,90,,7965,percent of total billed charges,,,65,,5752.5,percent of total billed charges,,,80,,7080,percent of total billed charges,,,55,,4867.5,percent of total billed charges,,,55,,4867.5,percent of total billed charges,,,65,,5752.5,percent of total billed charges,,,78,,6903,percent of total billed charges,,,70,,6195,percent of total billed charges,,,,,,,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,,3816.27,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,3816.27,7965,
SKN SPLT A-GRFT F/N/HF/G ADDL 100 SQ CM/1% BA (15121),15121,CPT,,,,outpatient,,,4973,2983.8,,45.5,,2262.72,percent of total billed charges,,,45.3,,2252.77,percent of total billed charges,,,51,,2536.23,percent of total billed charges,,,,,,,,,80,,3978.4,percent of total billed charges,,,61.4,,3053.42,percent of total billed charges,,,57.4,,2854.5,percent of total billed charges,,,81,,4028.13,percent of total billed charges,,,51.5,,2561.1,percent of total billed charges,,,57.6,,2864.45,percent of total billed charges,,,85,,4227.05,percent of total billed charges,,,85,,4227.05,percent of total billed charges,,,49,,2436.77,percent of total billed charges,,,90,,4475.7,percent of total billed charges,,,65,,3232.45,percent of total billed charges,,,80,,3978.4,percent of total billed charges,,,55,,2735.15,percent of total billed charges,,,55,,2735.15,percent of total billed charges,,,65,,3232.45,percent of total billed charges,,,78,,3878.94,percent of total billed charges,,,70,,3481.1,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,2252.77,4475.7,
SKIN FULL GRAFT SCLP/ARM/LEG =< 20 SQ CM (15220),15220,CPT,,,,outpatient,,,6024,3614.4,,45.5,,2740.92,percent of total billed charges,,,45.3,,2728.87,percent of total billed charges,,,51,,3072.24,percent of total billed charges,,,,,,,,,80,,4819.2,percent of total billed charges,,,61.4,,3698.74,percent of total billed charges,,,57.4,,3457.78,percent of total billed charges,,,81,,4879.44,percent of total billed charges,,,51.5,,3102.36,percent of total billed charges,,,57.6,,3469.82,percent of total billed charges,,,85,,5120.4,percent of total billed charges,,,85,,5120.4,percent of total billed charges,,,49,,2951.76,percent of total billed charges,,,90,,5421.6,percent of total billed charges,,,65,,3915.6,percent of total billed charges,,,80,,4819.2,percent of total billed charges,,,55,,3313.2,percent of total billed charges,,,55,,3313.2,percent of total billed charges,,,65,,3915.6,percent of total billed charges,,,78,,4698.72,percent of total billed charges,,,70,,4216.8,percent of total billed charges,,,,,,,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,,1906.83,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1906.83,5421.6,
SKIN FULL GRAFT S/A/L ADDL =<20 SQ CM (15221),15221,CPT,,,,outpatient,,,3615,2169,,45.5,,1644.83,percent of total billed charges,,,45.3,,1637.6,percent of total billed charges,,,51,,1843.65,percent of total billed charges,,,,,,,,,80,,2892,percent of total billed charges,,,61.4,,2219.61,percent of total billed charges,,,57.4,,2075.01,percent of total billed charges,,,81,,2928.15,percent of total billed charges,,,51.5,,1861.73,percent of total billed charges,,,57.6,,2082.24,percent of total billed charges,,,85,,3072.75,percent of total billed charges,,,85,,3072.75,percent of total billed charges,,,49,,1771.35,percent of total billed charges,,,90,,3253.5,percent of total billed charges,,,65,,2349.75,percent of total billed charges,,,80,,2892,percent of total billed charges,,,55,,1988.25,percent of total billed charges,,,55,,1988.25,percent of total billed charges,,,65,,2349.75,percent of total billed charges,,,78,,2819.7,percent of total billed charges,,,70,,2530.5,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1637.6,3253.5,
SKIN FULL GRFT FACE/GENIT/HF =< 20 SQ CM (15240),15240,CPT,,,,outpatient,,,6377,3826.2,,45.5,,2901.54,percent of total billed charges,,,45.3,,2888.78,percent of total billed charges,,,51,,3252.27,percent of total billed charges,,,,,,,,,80,,5101.6,percent of total billed charges,,,61.4,,3915.48,percent of total billed charges,,,57.4,,3660.4,percent of total billed charges,,,81,,5165.37,percent of total billed charges,,,51.5,,3284.16,percent of total billed charges,,,57.6,,3673.15,percent of total billed charges,,,85,,5420.45,percent of total billed charges,,,85,,5420.45,percent of total billed charges,,,49,,3124.73,percent of total billed charges,,,90,,5739.3,percent of total billed charges,,,65,,4145.05,percent of total billed charges,,,80,,5101.6,percent of total billed charges,,,55,,3507.35,percent of total billed charges,,,55,,3507.35,percent of total billed charges,,,65,,4145.05,percent of total billed charges,,,78,,4974.06,percent of total billed charges,,,70,,4463.9,percent of total billed charges,,,,,,,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,,1906.83,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1906.83,5739.3,
SKIN FULL GRAFT F/C/C/M/N/AX/G/H/F ADDL =<20 SQ CM (15241),15241,CPT,,,,outpatient,,,4983,2989.8,,45.5,,2267.27,percent of total billed charges,,,45.3,,2257.3,percent of total billed charges,,,51,,2541.33,percent of total billed charges,,,,,,,,,80,,3986.4,percent of total billed charges,,,61.4,,3059.56,percent of total billed charges,,,57.4,,2860.24,percent of total billed charges,,,81,,4036.23,percent of total billed charges,,,51.5,,2566.25,percent of total billed charges,,,57.6,,2870.21,percent of total billed charges,,,85,,4235.55,percent of total billed charges,,,85,,4235.55,percent of total billed charges,,,49,,2441.67,percent of total billed charges,,,90,,4484.7,percent of total billed charges,,,65,,3238.95,percent of total billed charges,,,80,,3986.4,percent of total billed charges,,,55,,2740.65,percent of total billed charges,,,55,,2740.65,percent of total billed charges,,,65,,3238.95,percent of total billed charges,,,78,,3886.74,percent of total billed charges,,,70,,3488.1,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,2257.3,4484.7,
SKIN SUB GRAFT TRNK/ARM/LEG (15271),15271,CPT,,,,outpatient,,,6109,3665.4,,45.5,,2779.6,percent of total billed charges,,,45.3,,2767.38,percent of total billed charges,,,51,,3115.59,percent of total billed charges,,,,,,,,,80,,4887.2,percent of total billed charges,,,61.4,,3750.93,percent of total billed charges,,,57.4,,3506.57,percent of total billed charges,,,81,,4948.29,percent of total billed charges,,,51.5,,3146.14,percent of total billed charges,,,57.6,,3518.78,percent of total billed charges,,,85,,5192.65,percent of total billed charges,,,85,,5192.65,percent of total billed charges,,,49,,2993.41,percent of total billed charges,,,90,,5498.1,percent of total billed charges,,,65,,3970.85,percent of total billed charges,,,80,,4887.2,percent of total billed charges,,,55,,3359.95,percent of total billed charges,,,55,,3359.95,percent of total billed charges,,,65,,3970.85,percent of total billed charges,,,78,,4765.02,percent of total billed charges,,,70,,4276.3,percent of total billed charges,,,,,,,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,,1906.83,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1906.83,5498.1,
SKIN SUB GRAFT T/A/L ADD-ON (15272),15272,CPT,,,,outpatient,,,910,546,,45.5,,414.05,percent of total billed charges,,,45.3,,412.23,percent of total billed charges,,,51,,464.1,percent of total billed charges,,,,,,,,,80,,728,percent of total billed charges,,,61.4,,558.74,percent of total billed charges,,,57.4,,522.34,percent of total billed charges,,,81,,737.1,percent of total billed charges,,,51.5,,468.65,percent of total billed charges,,,57.6,,524.16,percent of total billed charges,,,85,,773.5,percent of total billed charges,,,85,,773.5,percent of total billed charges,,,49,,445.9,percent of total billed charges,,,90,,819,percent of total billed charges,,,65,,591.5,percent of total billed charges,,,80,,728,percent of total billed charges,,,55,,500.5,percent of total billed charges,,,55,,500.5,percent of total billed charges,,,65,,591.5,percent of total billed charges,,,78,,709.8,percent of total billed charges,,,70,,637,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,412.23,819,
SKIN SUB GRAFT FACE/NK/HF/G (15275),15275,CPT,,,,outpatient,,,2329,1397.4,,45.5,,1059.7,percent of total billed charges,,,45.3,,1055.04,percent of total billed charges,,,51,,1187.79,percent of total billed charges,,,,,,,,,80,,1863.2,percent of total billed charges,,,61.4,,1430.01,percent of total billed charges,,,57.4,,1336.85,percent of total billed charges,,,81,,1886.49,percent of total billed charges,,,51.5,,1199.44,percent of total billed charges,,,57.6,,1341.5,percent of total billed charges,,,85,,1979.65,percent of total billed charges,,,85,,1979.65,percent of total billed charges,,,49,,1141.21,percent of total billed charges,,,90,,2096.1,percent of total billed charges,,,65,,1513.85,percent of total billed charges,,,80,,1863.2,percent of total billed charges,,,55,,1280.95,percent of total billed charges,,,55,,1280.95,percent of total billed charges,,,65,,1513.85,percent of total billed charges,,,78,,1816.62,percent of total billed charges,,,70,,1630.3,percent of total billed charges,,,,,,,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,,1906.83,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1055.04,2096.1,
SKIN SUB GRAFT F/N/HF/G ADDL (15276),15276,CPT,,,,outpatient,,,1221,732.6,,45.5,,555.56,percent of total billed charges,,,45.3,,553.11,percent of total billed charges,,,51,,622.71,percent of total billed charges,,,,,,,,,80,,976.8,percent of total billed charges,,,61.4,,749.69,percent of total billed charges,,,57.4,,700.85,percent of total billed charges,,,81,,989.01,percent of total billed charges,,,51.5,,628.82,percent of total billed charges,,,57.6,,703.3,percent of total billed charges,,,85,,1037.85,percent of total billed charges,,,85,,1037.85,percent of total billed charges,,,49,,598.29,percent of total billed charges,,,90,,1098.9,percent of total billed charges,,,65,,793.65,percent of total billed charges,,,80,,976.8,percent of total billed charges,,,55,,671.55,percent of total billed charges,,,55,,671.55,percent of total billed charges,,,65,,793.65,percent of total billed charges,,,78,,952.38,percent of total billed charges,,,70,,854.7,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,553.11,1098.9,
MUSCLE FLAP; LOWER EXTREMITY (15738),15738,CPT,,,,outpatient,,,7031,4218.6,,45.5,,3199.11,percent of total billed charges,,,45.3,,3185.04,percent of total billed charges,,,51,,3585.81,percent of total billed charges,,,,,,,,,80,,5624.8,percent of total billed charges,,,61.4,,4317.03,percent of total billed charges,,,57.4,,4035.79,percent of total billed charges,,,81,,5695.11,percent of total billed charges,,,51.5,,3620.97,percent of total billed charges,,,57.6,,4049.86,percent of total billed charges,,,85,,5976.35,percent of total billed charges,,,85,,5976.35,percent of total billed charges,,,49,,3445.19,percent of total billed charges,,,90,,6327.9,percent of total billed charges,,,65,,4570.15,percent of total billed charges,,,80,,5624.8,percent of total billed charges,,,55,,3867.05,percent of total billed charges,,,55,,3867.05,percent of total billed charges,,,65,,4570.15,percent of total billed charges,,,78,,5484.18,percent of total billed charges,,,70,,4921.7,percent of total billed charges,,,,,,,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,3816.27,,,,100% of Medicare,,,3816.27,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,3185.04,6327.9,
CC ONLY - Remove sutures/staples w/o anesthesia (15853),15853,CPT,,,,outpatient,,,141,84.6,,45.5,,64.16,percent of total billed charges,,,45.3,,63.87,percent of total billed charges,,,51,,71.91,percent of total billed charges,,,,,,,,,80,,112.8,percent of total billed charges,,,61.4,,86.57,percent of total billed charges,,,57.4,,80.93,percent of total billed charges,,,81,,114.21,percent of total billed charges,,,51.5,,72.62,percent of total billed charges,,,57.6,,81.22,percent of total billed charges,,,85,,119.85,percent of total billed charges,,,85,,119.85,percent of total billed charges,,,49,,69.09,percent of total billed charges,,,90,,126.9,percent of total billed charges,,,65,,91.65,percent of total billed charges,,,80,,112.8,percent of total billed charges,,,55,,77.55,percent of total billed charges,,,55,,77.55,percent of total billed charges,,,65,,91.65,percent of total billed charges,,,78,,109.98,percent of total billed charges,,,70,,98.7,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,63.87,126.9,
Remove sutures/staples w/o anesthesia (15853),15853,CPT,,,,outpatient,,,141,84.6,,45.5,,64.16,percent of total billed charges,,,45.3,,63.87,percent of total billed charges,,,51,,71.91,percent of total billed charges,,,,,,,,,80,,112.8,percent of total billed charges,,,61.4,,86.57,percent of total billed charges,,,57.4,,80.93,percent of total billed charges,,,81,,114.21,percent of total billed charges,,,51.5,,72.62,percent of total billed charges,,,57.6,,81.22,percent of total billed charges,,,85,,119.85,percent of total billed charges,,,85,,119.85,percent of total billed charges,,,49,,69.09,percent of total billed charges,,,90,,126.9,percent of total billed charges,,,65,,91.65,percent of total billed charges,,,80,,112.8,percent of total billed charges,,,55,,77.55,percent of total billed charges,,,55,,77.55,percent of total billed charges,,,65,,91.65,percent of total billed charges,,,78,,109.98,percent of total billed charges,,,70,,98.7,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,63.87,126.9,
ESC I P ULCER W OSTECT & FLAP (15946),15946,CPT,,,,outpatient,,,7031,4218.6,,45.5,,3199.11,percent of total billed charges,,,45.3,,3185.04,percent of total billed charges,,,51,,3585.81,percent of total billed charges,,,,,,,,,80,,5624.8,percent of total billed charges,,,61.4,,4317.03,percent of total billed charges,,,57.4,,4035.79,percent of total billed charges,,,81,,5695.11,percent of total billed charges,,,51.5,,3620.97,percent of total billed charges,,,57.6,,4049.86,percent of total billed charges,,,85,,5976.35,percent of total billed charges,,,85,,5976.35,percent of total billed charges,,,49,,3445.19,percent of total billed charges,,,90,,6327.9,percent of total billed charges,,,65,,4570.15,percent of total billed charges,,,80,,5624.8,percent of total billed charges,,,55,,3867.05,percent of total billed charges,,,55,,3867.05,percent of total billed charges,,,65,,4570.15,percent of total billed charges,,,78,,5484.18,percent of total billed charges,,,70,,4921.7,percent of total billed charges,,,,,,,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,1906.83,,,,100% of Medicare,,,1906.83,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1906.83,6327.9,
DESTRUCT B9 LESION 1-14 (17110),17110,CPT,,,,outpatient,,,375,225,,45.5,,170.63,percent of total billed charges,,,45.3,,169.88,percent of total billed charges,,,51,,191.25,percent of total billed charges,,,,,,,,,80,,300,percent of total billed charges,,,61.4,,230.25,percent of total billed charges,,,57.4,,215.25,percent of total billed charges,,,81,,303.75,percent of total billed charges,,,51.5,,193.13,percent of total billed charges,,,57.6,,216,percent of total billed charges,,,85,,318.75,percent of total billed charges,,,85,,318.75,percent of total billed charges,,,49,,183.75,percent of total billed charges,,,90,,337.5,percent of total billed charges,,,65,,243.75,percent of total billed charges,,,80,,300,percent of total billed charges,,,55,,206.25,percent of total billed charges,,,55,,206.25,percent of total billed charges,,,65,,243.75,percent of total billed charges,,,78,,292.5,percent of total billed charges,,,70,,262.5,percent of total billed charges,,,,,,,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,,207.13,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,169.88,337.5,
GRAFT MIRRAGEN 1.5 × 1.5 cm,A2002,HCPCS,,,,outpatient,,,1813,1087.8,,45.5,,824.92,percent of total billed charges,,,45.3,,821.29,percent of total billed charges,,,39,,707.07,percent of total billed charges,,,,,,,,,80,,1450.4,percent of total billed charges,,,61.4,,1113.18,percent of total billed charges,,,57.4,,1040.66,percent of total billed charges,,,81,,1468.53,percent of total billed charges,,,39,,707.07,percent of total billed charges,,,57.6,,1044.29,percent of total billed charges,,,85,,1541.05,percent of total billed charges,,,85,,1541.05,percent of total billed charges,,,49,,888.37,percent of total billed charges,,,90,,1631.7,percent of total billed charges,,,65,,1178.45,percent of total billed charges,,,80,,1450.4,percent of total billed charges,,,55,,997.15,percent of total billed charges,,,55,,997.15,percent of total billed charges,,,65,,1178.45,percent of total billed charges,,,78,,1414.14,percent of total billed charges,,,70,,1269.1,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,707.07,1631.7,
GRAFT MIRRAGEN 2.5cm X 2.5cm,A2002,HCPCS,,,,outpatient,,,2313,1387.8,,45.5,,1052.42,percent of total billed charges,,,45.3,,1047.79,percent of total billed charges,,,39,,902.07,percent of total billed charges,,,,,,,,,80,,1850.4,percent of total billed charges,,,61.4,,1420.18,percent of total billed charges,,,57.4,,1327.66,percent of total billed charges,,,81,,1873.53,percent of total billed charges,,,39,,902.07,percent of total billed charges,,,57.6,,1332.29,percent of total billed charges,,,85,,1966.05,percent of total billed charges,,,85,,1966.05,percent of total billed charges,,,49,,1133.37,percent of total billed charges,,,90,,2081.7,percent of total billed charges,,,65,,1503.45,percent of total billed charges,,,80,,1850.4,percent of total billed charges,,,55,,1272.15,percent of total billed charges,,,55,,1272.15,percent of total billed charges,,,65,,1503.45,percent of total billed charges,,,78,,1804.14,percent of total billed charges,,,70,,1619.1,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,902.07,2081.7,
GRAFT MIRRAGEN 3.5cm X 3.5cm,A2002,HCPCS,,,,outpatient,,,2790,1674,,45.5,,1269.45,percent of total billed charges,,,45.3,,1263.87,percent of total billed charges,,,39,,1088.1,percent of total billed charges,,,,,,,,,80,,2232,percent of total billed charges,,,61.4,,1713.06,percent of total billed charges,,,57.4,,1601.46,percent of total billed charges,,,81,,2259.9,percent of total billed charges,,,39,,1088.1,percent of total billed charges,,,57.6,,1607.04,percent of total billed charges,,,85,,2371.5,percent of total billed charges,,,85,,2371.5,percent of total billed charges,,,49,,1367.1,percent of total billed charges,,,90,,2511,percent of total billed charges,,,65,,1813.5,percent of total billed charges,,,80,,2232,percent of total billed charges,,,55,,1534.5,percent of total billed charges,,,55,,1534.5,percent of total billed charges,,,65,,1813.5,percent of total billed charges,,,78,,2176.2,percent of total billed charges,,,70,,1953,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1088.1,2511,
GRAFT MIRRAGEN 4.5cm x 4.5cm,A2002,HCPCS,,,,outpatient,,,3500,2100,,45.5,,1592.5,percent of total billed charges,,,45.3,,1585.5,percent of total billed charges,,,39,,1365,percent of total billed charges,,,,,,,,,80,,2800,percent of total billed charges,,,61.4,,2149,percent of total billed charges,,,57.4,,2009,percent of total billed charges,,,81,,2835,percent of total billed charges,,,39,,1365,percent of total billed charges,,,57.6,,2016,percent of total billed charges,,,85,,2975,percent of total billed charges,,,85,,2975,percent of total billed charges,,,49,,1715,percent of total billed charges,,,90,,3150,percent of total billed charges,,,65,,2275,percent of total billed charges,,,80,,2800,percent of total billed charges,,,55,,1925,percent of total billed charges,,,55,,1925,percent of total billed charges,,,65,,2275,percent of total billed charges,,,78,,2730,percent of total billed charges,,,70,,2450,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1365,3150,
GRAFT MirraSurg 2.5 cm x 15 cm,A2002,HCPCS,,,,outpatient,,,4590,2754,,45.5,,2088.45,percent of total billed charges,,,45.3,,2079.27,percent of total billed charges,,,39,,1790.1,percent of total billed charges,,,,,,,,,80,,3672,percent of total billed charges,,,61.4,,2818.26,percent of total billed charges,,,57.4,,2634.66,percent of total billed charges,,,81,,3717.9,percent of total billed charges,,,39,,1790.1,percent of total billed charges,,,57.6,,2643.84,percent of total billed charges,,,85,,3901.5,percent of total billed charges,,,85,,3901.5,percent of total billed charges,,,49,,2249.1,percent of total billed charges,,,90,,4131,percent of total billed charges,,,65,,2983.5,percent of total billed charges,,,80,,3672,percent of total billed charges,,,55,,2524.5,percent of total billed charges,,,55,,2524.5,percent of total billed charges,,,65,,2983.5,percent of total billed charges,,,78,,3580.2,percent of total billed charges,,,70,,3213,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1790.1,4131,
GRAFT MirraSurg 10 cm x 10 cm,A2002,HCPCS,,,,outpatient,,,9200,5520,,45.5,,4186,percent of total billed charges,,,45.3,,4167.6,percent of total billed charges,,,39,,3588,percent of total billed charges,,,,,,,,,80,,7360,percent of total billed charges,,,61.4,,5648.8,percent of total billed charges,,,57.4,,5280.8,percent of total billed charges,,,81,,7452,percent of total billed charges,,,39,,3588,percent of total billed charges,,,57.6,,5299.2,percent of total billed charges,,,85,,7820,percent of total billed charges,,,85,,7820,percent of total billed charges,,,49,,4508,percent of total billed charges,,,90,,8280,percent of total billed charges,,,65,,5980,percent of total billed charges,,,80,,7360,percent of total billed charges,,,55,,5060,percent of total billed charges,,,55,,5060,percent of total billed charges,,,65,,5980,percent of total billed charges,,,78,,7176,percent of total billed charges,,,70,,6440,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,3588,8280,
"Pessary, non rubber, any type",A4562,HCPCS,,,,outpatient,,,140,84,,45.5,,63.7,percent of total billed charges,,,45.3,,63.42,percent of total billed charges,,,51,,71.4,percent of total billed charges,,,,,,,,,80,,112,percent of total billed charges,,,61.4,,85.96,percent of total billed charges,,,57.4,,80.36,percent of total billed charges,,,81,,113.4,percent of total billed charges,,,51.5,,72.1,percent of total billed charges,,,57.6,,80.64,percent of total billed charges,,,85,,119,percent of total billed charges,,,85,,119,percent of total billed charges,,,49,,68.6,percent of total billed charges,,,90,,126,percent of total billed charges,,,65,,91,percent of total billed charges,,,80,,112,percent of total billed charges,,,55,,77,percent of total billed charges,,,55,,77,percent of total billed charges,,,65,,91,percent of total billed charges,,,78,,109.2,percent of total billed charges,,,70,,98,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,63.42,126,
"A4595 FES Electrode, each",A4595,HCPCS,,,,outpatient,,,44,26.4,,45.5,,20.02,percent of total billed charges,,,45.3,,19.93,percent of total billed charges,,,51,,22.44,percent of total billed charges,,,,,,,,,80,,35.2,percent of total billed charges,,,61.4,,27.02,percent of total billed charges,,,57.4,,25.26,percent of total billed charges,,,81,,35.64,percent of total billed charges,,,51.5,,22.66,percent of total billed charges,,,57.6,,25.34,percent of total billed charges,,,85,,37.4,percent of total billed charges,,,85,,37.4,percent of total billed charges,,,49,,21.56,percent of total billed charges,,,90,,39.6,percent of total billed charges,,,65,,28.6,percent of total billed charges,,,80,,35.2,percent of total billed charges,,,55,,24.2,percent of total billed charges,,,55,,24.2,percent of total billed charges,,,65,,28.6,percent of total billed charges,,,78,,34.32,percent of total billed charges,,,70,,30.8,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,19.93,39.6,
"Compression Burn Garment, bodysuit (head to foot), custom fabricated.",A6501,HCPCS,,,,outpatient,,,1517,910.2,,45.5,,690.24,percent of total billed charges,,,45.3,,687.2,percent of total billed charges,,,51,,773.67,percent of total billed charges,,,,,,,,,80,,1213.6,percent of total billed charges,,,61.4,,931.44,percent of total billed charges,,,57.4,,870.76,percent of total billed charges,,,81,,1228.77,percent of total billed charges,,,51.5,,781.26,percent of total billed charges,,,57.6,,873.79,percent of total billed charges,,,85,,1289.45,percent of total billed charges,,,85,,1289.45,percent of total billed charges,,,49,,743.33,percent of total billed charges,,,90,,1365.3,percent of total billed charges,,,65,,986.05,percent of total billed charges,,,80,,1213.6,percent of total billed charges,,,55,,834.35,percent of total billed charges,,,55,,834.35,percent of total billed charges,,,65,,986.05,percent of total billed charges,,,78,,1183.26,percent of total billed charges,,,70,,1061.9,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,687.2,1365.3,
"Compression Burn Garment, chin strap, custom fabricated.",A6502,HCPCS,,,,outpatient,,,173,103.8,,45.5,,78.72,percent of total billed charges,,,45.3,,78.37,percent of total billed charges,,,51,,88.23,percent of total billed charges,,,,,,,,,80,,138.4,percent of total billed charges,,,61.4,,106.22,percent of total billed charges,,,57.4,,99.3,percent of total billed charges,,,81,,140.13,percent of total billed charges,,,51.5,,89.1,percent of total billed charges,,,57.6,,99.65,percent of total billed charges,,,85,,147.05,percent of total billed charges,,,85,,147.05,percent of total billed charges,,,49,,84.77,percent of total billed charges,,,90,,155.7,percent of total billed charges,,,65,,112.45,percent of total billed charges,,,80,,138.4,percent of total billed charges,,,55,,95.15,percent of total billed charges,,,55,,95.15,percent of total billed charges,,,65,,112.45,percent of total billed charges,,,78,,134.94,percent of total billed charges,,,70,,121.1,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,78.37,155.7,
"Compression Burn Garment, facial hood, custom fabricated.",A6503,HCPCS,,,,outpatient,,,279,167.4,,45.5,,126.95,percent of total billed charges,,,45.3,,126.39,percent of total billed charges,,,51,,142.29,percent of total billed charges,,,,,,,,,80,,223.2,percent of total billed charges,,,61.4,,171.31,percent of total billed charges,,,57.4,,160.15,percent of total billed charges,,,81,,225.99,percent of total billed charges,,,51.5,,143.69,percent of total billed charges,,,57.6,,160.7,percent of total billed charges,,,85,,237.15,percent of total billed charges,,,85,,237.15,percent of total billed charges,,,49,,136.71,percent of total billed charges,,,90,,251.1,percent of total billed charges,,,65,,181.35,percent of total billed charges,,,80,,223.2,percent of total billed charges,,,55,,153.45,percent of total billed charges,,,55,,153.45,percent of total billed charges,,,65,,181.35,percent of total billed charges,,,78,,217.62,percent of total billed charges,,,70,,195.3,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,126.39,251.1,
"Compression Burn Garment, glove to wrist, custom fabricated.",A6504,HCPCS,,,,outpatient,,,227,136.2,,45.5,,103.29,percent of total billed charges,,,45.3,,102.83,percent of total billed charges,,,51,,115.77,percent of total billed charges,,,,,,,,,80,,181.6,percent of total billed charges,,,61.4,,139.38,percent of total billed charges,,,57.4,,130.3,percent of total billed charges,,,81,,183.87,percent of total billed charges,,,51.5,,116.91,percent of total billed charges,,,57.6,,130.75,percent of total billed charges,,,85,,192.95,percent of total billed charges,,,85,,192.95,percent of total billed charges,,,49,,111.23,percent of total billed charges,,,90,,204.3,percent of total billed charges,,,65,,147.55,percent of total billed charges,,,80,,181.6,percent of total billed charges,,,55,,124.85,percent of total billed charges,,,55,,124.85,percent of total billed charges,,,65,,147.55,percent of total billed charges,,,78,,177.06,percent of total billed charges,,,70,,158.9,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,102.83,204.3,
"Compression Burn Garment, glove to elbow, custom fabricated.",A6505,HCPCS,,,,outpatient,,,330,198,,45.5,,150.15,percent of total billed charges,,,45.3,,149.49,percent of total billed charges,,,51,,168.3,percent of total billed charges,,,,,,,,,80,,264,percent of total billed charges,,,61.4,,202.62,percent of total billed charges,,,57.4,,189.42,percent of total billed charges,,,81,,267.3,percent of total billed charges,,,51.5,,169.95,percent of total billed charges,,,57.6,,190.08,percent of total billed charges,,,85,,280.5,percent of total billed charges,,,85,,280.5,percent of total billed charges,,,49,,161.7,percent of total billed charges,,,90,,297,percent of total billed charges,,,65,,214.5,percent of total billed charges,,,80,,264,percent of total billed charges,,,55,,181.5,percent of total billed charges,,,55,,181.5,percent of total billed charges,,,65,,214.5,percent of total billed charges,,,78,,257.4,percent of total billed charges,,,70,,231,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,149.49,297,
"Compression Burn Garment, glove to axilla, custom fabricated.",A6506,HCPCS,,,,outpatient,,,370,222,,45.5,,168.35,percent of total billed charges,,,45.3,,167.61,percent of total billed charges,,,51,,188.7,percent of total billed charges,,,,,,,,,80,,296,percent of total billed charges,,,61.4,,227.18,percent of total billed charges,,,57.4,,212.38,percent of total billed charges,,,81,,299.7,percent of total billed charges,,,51.5,,190.55,percent of total billed charges,,,57.6,,213.12,percent of total billed charges,,,85,,314.5,percent of total billed charges,,,85,,314.5,percent of total billed charges,,,49,,181.3,percent of total billed charges,,,90,,333,percent of total billed charges,,,65,,240.5,percent of total billed charges,,,80,,296,percent of total billed charges,,,55,,203.5,percent of total billed charges,,,55,,203.5,percent of total billed charges,,,65,,240.5,percent of total billed charges,,,78,,288.6,percent of total billed charges,,,70,,259,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,167.61,333,
"Compression Burn Garment, foot to knee length, custom fabricated.",A6507,HCPCS,,,,outpatient,,,148,88.8,,45.5,,67.34,percent of total billed charges,,,45.3,,67.04,percent of total billed charges,,,51,,75.48,percent of total billed charges,,,,,,,,,80,,118.4,percent of total billed charges,,,61.4,,90.87,percent of total billed charges,,,57.4,,84.95,percent of total billed charges,,,81,,119.88,percent of total billed charges,,,51.5,,76.22,percent of total billed charges,,,57.6,,85.25,percent of total billed charges,,,85,,125.8,percent of total billed charges,,,85,,125.8,percent of total billed charges,,,49,,72.52,percent of total billed charges,,,90,,133.2,percent of total billed charges,,,65,,96.2,percent of total billed charges,,,80,,118.4,percent of total billed charges,,,55,,81.4,percent of total billed charges,,,55,,81.4,percent of total billed charges,,,65,,96.2,percent of total billed charges,,,78,,115.44,percent of total billed charges,,,70,,103.6,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,67.04,133.2,
"Compression Burn Garment, foot to thigh length, custom fabricated.",A6508,HCPCS,,,,outpatient,,,191,114.6,,45.5,,86.91,percent of total billed charges,,,45.3,,86.52,percent of total billed charges,,,51,,97.41,percent of total billed charges,,,,,,,,,80,,152.8,percent of total billed charges,,,61.4,,117.27,percent of total billed charges,,,57.4,,109.63,percent of total billed charges,,,81,,154.71,percent of total billed charges,,,51.5,,98.37,percent of total billed charges,,,57.6,,110.02,percent of total billed charges,,,85,,162.35,percent of total billed charges,,,85,,162.35,percent of total billed charges,,,49,,93.59,percent of total billed charges,,,90,,171.9,percent of total billed charges,,,65,,124.15,percent of total billed charges,,,80,,152.8,percent of total billed charges,,,55,,105.05,percent of total billed charges,,,55,,105.05,percent of total billed charges,,,65,,124.15,percent of total billed charges,,,78,,148.98,percent of total billed charges,,,70,,133.7,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,86.52,171.9,
"Compression Burn Garment, upper trunk to waist including arm openings (vest), custom fabricated.",A6509,HCPCS,,,,outpatient,,,278,166.8,,45.5,,126.49,percent of total billed charges,,,45.3,,125.93,percent of total billed charges,,,51,,141.78,percent of total billed charges,,,,,,,,,80,,222.4,percent of total billed charges,,,61.4,,170.69,percent of total billed charges,,,57.4,,159.57,percent of total billed charges,,,81,,225.18,percent of total billed charges,,,51.5,,143.17,percent of total billed charges,,,57.6,,160.13,percent of total billed charges,,,85,,236.3,percent of total billed charges,,,85,,236.3,percent of total billed charges,,,49,,136.22,percent of total billed charges,,,90,,250.2,percent of total billed charges,,,65,,180.7,percent of total billed charges,,,80,,222.4,percent of total billed charges,,,55,,152.9,percent of total billed charges,,,55,,152.9,percent of total billed charges,,,65,,180.7,percent of total billed charges,,,78,,216.84,percent of total billed charges,,,70,,194.6,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,125.93,250.2,
"Compression Burn Garment, trunk, including arms down to leg openings (leotard), custom fabricated.",A6510,HCPCS,,,,outpatient,,,522,313.2,,45.5,,237.51,percent of total billed charges,,,45.3,,236.47,percent of total billed charges,,,51,,266.22,percent of total billed charges,,,,,,,,,80,,417.6,percent of total billed charges,,,61.4,,320.51,percent of total billed charges,,,57.4,,299.63,percent of total billed charges,,,81,,422.82,percent of total billed charges,,,51.5,,268.83,percent of total billed charges,,,57.6,,300.67,percent of total billed charges,,,85,,443.7,percent of total billed charges,,,85,,443.7,percent of total billed charges,,,49,,255.78,percent of total billed charges,,,90,,469.8,percent of total billed charges,,,65,,339.3,percent of total billed charges,,,80,,417.6,percent of total billed charges,,,55,,287.1,percent of total billed charges,,,55,,287.1,percent of total billed charges,,,65,,339.3,percent of total billed charges,,,78,,407.16,percent of total billed charges,,,70,,365.4,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,236.47,469.8,
"Compression Burn Garment, lower trunk including leg openings (panty), custom fabricated.",A6511,HCPCS,,,,outpatient,,,270,162,,45.5,,122.85,percent of total billed charges,,,45.3,,122.31,percent of total billed charges,,,51,,137.7,percent of total billed charges,,,,,,,,,80,,216,percent of total billed charges,,,61.4,,165.78,percent of total billed charges,,,57.4,,154.98,percent of total billed charges,,,81,,218.7,percent of total billed charges,,,51.5,,139.05,percent of total billed charges,,,57.6,,155.52,percent of total billed charges,,,85,,229.5,percent of total billed charges,,,85,,229.5,percent of total billed charges,,,49,,132.3,percent of total billed charges,,,90,,243,percent of total billed charges,,,65,,175.5,percent of total billed charges,,,80,,216,percent of total billed charges,,,55,,148.5,percent of total billed charges,,,55,,148.5,percent of total billed charges,,,65,,175.5,percent of total billed charges,,,78,,210.6,percent of total billed charges,,,70,,189,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,122.31,243,
00270-5164-13 - gadobenate dimeglumine 529 mg/mL Soln,A9577,HCPCS,00270-5164-13,NDC,,both,1,ML,597.75,358.65,,45.5,,271.98,percent of total billed charges,,,45.3,,270.78,percent of total billed charges,,,51,,304.85,percent of total billed charges,,,,,,,,,80,,478.2,percent of total billed charges,,,61.4,,367.02,percent of total billed charges,,,57.4,,343.11,percent of total billed charges,,,81,,484.18,percent of total billed charges,,,51.5,,307.84,percent of total billed charges,,,57.6,,344.3,percent of total billed charges,,,85,,508.09,percent of total billed charges,,,85,,508.09,percent of total billed charges,,,49,,292.9,percent of total billed charges,,,90,,537.98,percent of total billed charges,,,65,,388.54,percent of total billed charges,,,80,,478.2,percent of total billed charges,,,55,,328.76,percent of total billed charges,,,55,,328.76,percent of total billed charges,,,65,,388.54,percent of total billed charges,,,78,,466.25,percent of total billed charges,,,70,,418.43,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,270.78,537.98,
00270-5164-14 - gadobenate dimeglumine 529 mg/mL Soln,A9577,HCPCS,00270-5164-14,NDC,,both,1,ML,870.45,522.27,,45.5,,396.05,percent of total billed charges,,,45.3,,394.31,percent of total billed charges,,,51,,443.93,percent of total billed charges,,,,,,,,,80,,696.36,percent of total billed charges,,,61.4,,534.46,percent of total billed charges,,,57.4,,499.64,percent of total billed charges,,,81,,705.06,percent of total billed charges,,,51.5,,448.28,percent of total billed charges,,,57.6,,501.38,percent of total billed charges,,,85,,739.88,percent of total billed charges,,,85,,739.88,percent of total billed charges,,,49,,426.52,percent of total billed charges,,,90,,783.41,percent of total billed charges,,,65,,565.79,percent of total billed charges,,,80,,696.36,percent of total billed charges,,,55,,478.75,percent of total billed charges,,,55,,478.75,percent of total billed charges,,,65,,565.79,percent of total billed charges,,,78,,678.95,percent of total billed charges,,,70,,609.32,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,394.31,783.41,
50419-0188-02 - gadopentetate dimeglumine 46.9% Soln,A9579,HCPCS,50419-0188-02,NDC,,both,20,ML,848.95,509.37,,45.5,,386.27,percent of total billed charges,,,45.3,,384.57,percent of total billed charges,,,51,,432.96,percent of total billed charges,,,,,,,,,80,,679.16,percent of total billed charges,,,61.4,,521.26,percent of total billed charges,,,57.4,,487.3,percent of total billed charges,,,81,,687.65,percent of total billed charges,,,51.5,,437.21,percent of total billed charges,,,57.6,,489,percent of total billed charges,,,85,,721.61,percent of total billed charges,,,85,,721.61,percent of total billed charges,,,49,,415.99,percent of total billed charges,,,90,,764.06,percent of total billed charges,,,65,,551.82,percent of total billed charges,,,80,,679.16,percent of total billed charges,,,55,,466.92,percent of total billed charges,,,55,,466.92,percent of total billed charges,,,65,,551.82,percent of total billed charges,,,78,,662.18,percent of total billed charges,,,70,,594.27,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,384.57,764.06,
50419-0325-12 - gadobutrol 604.72 mg/mL Soln,A9585,HCPCS,50419-0325-12,NDC,,both,1,ML,93.3,55.98,,45.5,,42.45,percent of total billed charges,,,45.3,,42.26,percent of total billed charges,,,51,,47.58,percent of total billed charges,,,,,,,,,80,,74.64,percent of total billed charges,,,61.4,,57.29,percent of total billed charges,,,57.4,,53.55,percent of total billed charges,,,81,,75.57,percent of total billed charges,,,51.5,,48.05,percent of total billed charges,,,57.6,,53.74,percent of total billed charges,,,85,,79.31,percent of total billed charges,,,85,,79.31,percent of total billed charges,,,49,,45.72,percent of total billed charges,,,90,,83.97,percent of total billed charges,,,65,,60.65,percent of total billed charges,,,80,,74.64,percent of total billed charges,,,55,,51.32,percent of total billed charges,,,55,,51.32,percent of total billed charges,,,65,,60.65,percent of total billed charges,,,78,,72.77,percent of total billed charges,,,70,,65.31,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,42.26,83.97,
50419-0325-13 - gadobutrol 604.72 mg/mL Soln,A9585,HCPCS,50419-0325-13,NDC,,both,1,ML,93.3,55.98,,45.5,,42.45,percent of total billed charges,,,45.3,,42.26,percent of total billed charges,,,51,,47.58,percent of total billed charges,,,,,,,,,80,,74.64,percent of total billed charges,,,61.4,,57.29,percent of total billed charges,,,57.4,,53.55,percent of total billed charges,,,81,,75.57,percent of total billed charges,,,51.5,,48.05,percent of total billed charges,,,57.6,,53.74,percent of total billed charges,,,85,,79.31,percent of total billed charges,,,85,,79.31,percent of total billed charges,,,49,,45.72,percent of total billed charges,,,90,,83.97,percent of total billed charges,,,65,,60.65,percent of total billed charges,,,80,,74.64,percent of total billed charges,,,55,,51.32,percent of total billed charges,,,55,,51.32,percent of total billed charges,,,65,,60.65,percent of total billed charges,,,78,,72.77,percent of total billed charges,,,70,,65.31,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,42.26,83.97,
50419-0325-15 - gadobutrol 604.72 mg/mL Soln,A9585,HCPCS,50419-0325-15,NDC,,both,1,ML,848.95,509.37,,45.5,,386.27,percent of total billed charges,,,45.3,,384.57,percent of total billed charges,,,51,,432.96,percent of total billed charges,,,,,,,,,80,,679.16,percent of total billed charges,,,61.4,,521.26,percent of total billed charges,,,57.4,,487.3,percent of total billed charges,,,81,,687.65,percent of total billed charges,,,51.5,,437.21,percent of total billed charges,,,57.6,,489,percent of total billed charges,,,85,,721.61,percent of total billed charges,,,85,,721.61,percent of total billed charges,,,49,,415.99,percent of total billed charges,,,90,,764.06,percent of total billed charges,,,65,,551.82,percent of total billed charges,,,80,,679.16,percent of total billed charges,,,55,,466.92,percent of total billed charges,,,55,,466.92,percent of total billed charges,,,65,,551.82,percent of total billed charges,,,78,,662.18,percent of total billed charges,,,70,,594.27,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,384.57,764.06,
Sprint PNS Single Lead C1778,C1778,HCPCS,,,,outpatient,,,11028,6616.8,,45.5,,5017.74,percent of total billed charges,,,45.3,,4995.68,percent of total billed charges,,,51,,5624.28,percent of total billed charges,,,,,,,,,80,,8822.4,percent of total billed charges,,,61.4,,6771.19,percent of total billed charges,,,57.4,,6330.07,percent of total billed charges,,,81,,8932.68,percent of total billed charges,,,51.5,,5679.42,percent of total billed charges,,,57.6,,6352.13,percent of total billed charges,,,85,,9373.8,percent of total billed charges,,,85,,9373.8,percent of total billed charges,,,49,,5403.72,percent of total billed charges,,,90,,9925.2,percent of total billed charges,,,65,,7168.2,percent of total billed charges,,,80,,8822.4,percent of total billed charges,,,55,,6065.4,percent of total billed charges,,,55,,6065.4,percent of total billed charges,,,65,,7168.2,percent of total billed charges,,,78,,8601.84,percent of total billed charges,,,70,,7719.6,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,4995.68,9925.2,
Sprint PNS Dual Lead C1778,C1778,HCPCS,,,,outpatient,,,17378,10426.8,,45.5,,7906.99,percent of total billed charges,,,45.3,,7872.23,percent of total billed charges,,,51,,8862.78,percent of total billed charges,,,,,,,,,80,,13902.4,percent of total billed charges,,,61.4,,10670.09,percent of total billed charges,,,57.4,,9974.97,percent of total billed charges,,,81,,14076.18,percent of total billed charges,,,51.5,,8949.67,percent of total billed charges,,,57.6,,10009.73,percent of total billed charges,,,85,,14771.3,percent of total billed charges,,,85,,14771.3,percent of total billed charges,,,49,,8515.22,percent of total billed charges,,,90,,15640.2,percent of total billed charges,,,65,,11295.7,percent of total billed charges,,,80,,13902.4,percent of total billed charges,,,55,,9557.9,percent of total billed charges,,,55,,9557.9,percent of total billed charges,,,65,,11295.7,percent of total billed charges,,,78,,13554.84,percent of total billed charges,,,70,,12164.6,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,7872.23,15640.2,
MCKA2-17-100-4 Coolief Multi Cooled RFA kit 2 probe,C1889,HCPCS,,,,outpatient,,,3000,1800,,45.5,,1365,percent of total billed charges,,,45.3,,1359,percent of total billed charges,,,39,,1170,percent of total billed charges,,,,,,,,,80,,2400,percent of total billed charges,,,61.4,,1842,percent of total billed charges,,,57.4,,1722,percent of total billed charges,,,81,,2430,percent of total billed charges,,,39,,1170,percent of total billed charges,,,57.6,,1728,percent of total billed charges,,,85,,2550,percent of total billed charges,,,85,,2550,percent of total billed charges,,,49,,1470,percent of total billed charges,,,90,,2700,percent of total billed charges,,,65,,1950,percent of total billed charges,,,80,,2400,percent of total billed charges,,,55,,1650,percent of total billed charges,,,55,,1650,percent of total billed charges,,,65,,1950,percent of total billed charges,,,78,,2340,percent of total billed charges,,,70,,2100,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1170,2700,
MCKA2-17-150-4 Coolief multi cooled RFA kit 2 probe,C1889,HCPCS,,,,outpatient,,,3000,1800,,45.5,,1365,percent of total billed charges,,,45.3,,1359,percent of total billed charges,,,39,,1170,percent of total billed charges,,,,,,,,,80,,2400,percent of total billed charges,,,61.4,,1842,percent of total billed charges,,,57.4,,1722,percent of total billed charges,,,81,,2430,percent of total billed charges,,,39,,1170,percent of total billed charges,,,57.6,,1728,percent of total billed charges,,,85,,2550,percent of total billed charges,,,85,,2550,percent of total billed charges,,,49,,1470,percent of total billed charges,,,90,,2700,percent of total billed charges,,,65,,1950,percent of total billed charges,,,80,,2400,percent of total billed charges,,,55,,1650,percent of total billed charges,,,55,,1650,percent of total billed charges,,,65,,1950,percent of total billed charges,,,78,,2340,percent of total billed charges,,,70,,2100,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1170,2700,
MCKA2-17-50-2 Coolief Multi Cooled RFA kit 2 probe,C1889,HCPCS,,,,outpatient,,,3000,1800,,45.5,,1365,percent of total billed charges,,,45.3,,1359,percent of total billed charges,,,39,,1170,percent of total billed charges,,,,,,,,,80,,2400,percent of total billed charges,,,61.4,,1842,percent of total billed charges,,,57.4,,1722,percent of total billed charges,,,81,,2430,percent of total billed charges,,,39,,1170,percent of total billed charges,,,57.6,,1728,percent of total billed charges,,,85,,2550,percent of total billed charges,,,85,,2550,percent of total billed charges,,,49,,1470,percent of total billed charges,,,90,,2700,percent of total billed charges,,,65,,1950,percent of total billed charges,,,80,,2400,percent of total billed charges,,,55,,1650,percent of total billed charges,,,55,,1650,percent of total billed charges,,,65,,1950,percent of total billed charges,,,78,,2340,percent of total billed charges,,,70,,2100,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1170,2700,
MCKA2-17-75-4 Coolief Multi Cooled kit RFA 2 probe,C1889,HCPCS,,,,outpatient,,,3000,1800,,45.5,,1365,percent of total billed charges,,,45.3,,1359,percent of total billed charges,,,39,,1170,percent of total billed charges,,,,,,,,,80,,2400,percent of total billed charges,,,61.4,,1842,percent of total billed charges,,,57.4,,1722,percent of total billed charges,,,81,,2430,percent of total billed charges,,,39,,1170,percent of total billed charges,,,57.6,,1728,percent of total billed charges,,,85,,2550,percent of total billed charges,,,85,,2550,percent of total billed charges,,,49,,1470,percent of total billed charges,,,90,,2700,percent of total billed charges,,,65,,1950,percent of total billed charges,,,80,,2400,percent of total billed charges,,,55,,1650,percent of total billed charges,,,55,,1650,percent of total billed charges,,,65,,1950,percent of total billed charges,,,78,,2340,percent of total billed charges,,,70,,2100,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1170,2700,
MCKA3 -17-150-4 Coolief multi cooled RFA kit 3 probe,C1889,HCPCS,,,,outpatient,,,4320,2592,,45.5,,1965.6,percent of total billed charges,,,45.3,,1956.96,percent of total billed charges,,,39,,1684.8,percent of total billed charges,,,,,,,,,80,,3456,percent of total billed charges,,,61.4,,2652.48,percent of total billed charges,,,57.4,,2479.68,percent of total billed charges,,,81,,3499.2,percent of total billed charges,,,39,,1684.8,percent of total billed charges,,,57.6,,2488.32,percent of total billed charges,,,85,,3672,percent of total billed charges,,,85,,3672,percent of total billed charges,,,49,,2116.8,percent of total billed charges,,,90,,3888,percent of total billed charges,,,65,,2808,percent of total billed charges,,,80,,3456,percent of total billed charges,,,55,,2376,percent of total billed charges,,,55,,2376,percent of total billed charges,,,65,,2808,percent of total billed charges,,,78,,3369.6,percent of total billed charges,,,70,,3024,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1684.8,3888,
MCKA3-17-100-4 Coolief Multi cooled RFA kit 3 probe,C1889,HCPCS,,,,outpatient,,,4320,2592,,45.5,,1965.6,percent of total billed charges,,,45.3,,1956.96,percent of total billed charges,,,39,,1684.8,percent of total billed charges,,,,,,,,,80,,3456,percent of total billed charges,,,61.4,,2652.48,percent of total billed charges,,,57.4,,2479.68,percent of total billed charges,,,81,,3499.2,percent of total billed charges,,,39,,1684.8,percent of total billed charges,,,57.6,,2488.32,percent of total billed charges,,,85,,3672,percent of total billed charges,,,85,,3672,percent of total billed charges,,,49,,2116.8,percent of total billed charges,,,90,,3888,percent of total billed charges,,,65,,2808,percent of total billed charges,,,80,,3456,percent of total billed charges,,,55,,2376,percent of total billed charges,,,55,,2376,percent of total billed charges,,,65,,2808,percent of total billed charges,,,78,,3369.6,percent of total billed charges,,,70,,3024,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1684.8,3888,
MCKA3-17-75-4 Coolief multi cooled RFA kit 3 probe,C1889,HCPCS,,,,outpatient,,,4320,2592,,45.5,,1965.6,percent of total billed charges,,,45.3,,1956.96,percent of total billed charges,,,39,,1684.8,percent of total billed charges,,,,,,,,,80,,3456,percent of total billed charges,,,61.4,,2652.48,percent of total billed charges,,,57.4,,2479.68,percent of total billed charges,,,81,,3499.2,percent of total billed charges,,,39,,1684.8,percent of total billed charges,,,57.6,,2488.32,percent of total billed charges,,,85,,3672,percent of total billed charges,,,85,,3672,percent of total billed charges,,,49,,2116.8,percent of total billed charges,,,90,,3888,percent of total billed charges,,,65,,2808,percent of total billed charges,,,80,,3456,percent of total billed charges,,,55,,2376,percent of total billed charges,,,55,,2376,percent of total billed charges,,,65,,2808,percent of total billed charges,,,78,,3369.6,percent of total billed charges,,,70,,3024,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1684.8,3888,
Nalu Trial Lead Kit C1897,C1897,HCPCS,,,,outpatient,,,2673,1603.8,,45.5,,1216.22,percent of total billed charges,,,45.3,,1210.87,percent of total billed charges,,,51,,1363.23,percent of total billed charges,,,,,,,,,80,,2138.4,percent of total billed charges,,,61.4,,1641.22,percent of total billed charges,,,57.4,,1534.3,percent of total billed charges,,,81,,2165.13,percent of total billed charges,,,51.5,,1376.6,percent of total billed charges,,,57.6,,1539.65,percent of total billed charges,,,85,,2272.05,percent of total billed charges,,,85,,2272.05,percent of total billed charges,,,49,,1309.77,percent of total billed charges,,,90,,2405.7,percent of total billed charges,,,65,,1737.45,percent of total billed charges,,,80,,2138.4,percent of total billed charges,,,55,,1470.15,percent of total billed charges,,,55,,1470.15,percent of total billed charges,,,65,,1737.45,percent of total billed charges,,,78,,2084.94,percent of total billed charges,,,70,,1871.1,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1210.87,2405.7,
00409-4921-34 - epinephrine 0.1 mg/mL Soln,J0171,HCPCS,00409-4921-34,NDC,,both,1,ML,31.25,18.75,,45.5,,14.22,percent of total billed charges,,,45.3,,14.16,percent of total billed charges,,,51,,15.94,percent of total billed charges,,,,,,,,,80,,25,percent of total billed charges,,,61.4,,19.19,percent of total billed charges,,,57.4,,17.94,percent of total billed charges,,,81,,25.31,percent of total billed charges,,,51.5,,16.09,percent of total billed charges,,,57.6,,18,percent of total billed charges,,,85,,26.56,percent of total billed charges,,,85,,26.56,percent of total billed charges,,,49,,15.31,percent of total billed charges,,,90,,28.13,percent of total billed charges,,,65,,20.31,percent of total billed charges,,,80,,25,percent of total billed charges,,,55,,17.19,percent of total billed charges,,,55,,17.19,percent of total billed charges,,,65,,20.31,percent of total billed charges,,,78,,24.38,percent of total billed charges,,,70,,21.88,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,14.16,28.13,
00409-4911-34 - atropine 0.1 mg/mL Soln,J0461,HCPCS,00409-4911-34,NDC,,both,10,ML,42.2,25.32,,45.5,,19.2,percent of total billed charges,,,45.3,,19.12,percent of total billed charges,,,51,,21.52,percent of total billed charges,,,,,,,,,80,,33.76,percent of total billed charges,,,61.4,,25.91,percent of total billed charges,,,57.4,,24.22,percent of total billed charges,,,81,,34.18,percent of total billed charges,,,51.5,,21.73,percent of total billed charges,,,57.6,,24.31,percent of total billed charges,,,85,,35.87,percent of total billed charges,,,85,,35.87,percent of total billed charges,,,49,,20.68,percent of total billed charges,,,90,,37.98,percent of total billed charges,,,65,,27.43,percent of total billed charges,,,80,,33.76,percent of total billed charges,,,55,,23.21,percent of total billed charges,,,55,,23.21,percent of total billed charges,,,65,,27.43,percent of total billed charges,,,78,,32.92,percent of total billed charges,,,70,,29.54,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,19.12,37.98,
00409-1159-02 - bupivacaine 0.25% preservative-free Soln,J0665,HCPCS,00409-1159-02,NDC,,both,30,ML,21.95,13.17,,45.5,,9.99,percent of total billed charges,,,45.3,,9.94,percent of total billed charges,,,51,,11.19,percent of total billed charges,,,,,,,,,80,,17.56,percent of total billed charges,,,61.4,,13.48,percent of total billed charges,,,57.4,,12.6,percent of total billed charges,,,81,,17.78,percent of total billed charges,,,51.5,,11.3,percent of total billed charges,,,57.6,,12.64,percent of total billed charges,,,85,,18.66,percent of total billed charges,,,85,,18.66,percent of total billed charges,,,49,,10.76,percent of total billed charges,,,90,,19.76,percent of total billed charges,,,65,,14.27,percent of total billed charges,,,80,,17.56,percent of total billed charges,,,55,,12.07,percent of total billed charges,,,55,,12.07,percent of total billed charges,,,65,,14.27,percent of total billed charges,,,78,,17.12,percent of total billed charges,,,70,,15.37,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG rate,100% of IL Medicaid,,,,,EAPG rate,100% of IL Medicaid,,,,,EAPG rate,100% of IL Medicaid,,,,,EAPG rate,100% of IL Medicaid,9.94,19.76,
00409-1159-10 - bupivacaine 0.25% preservative-free Soln,J0665,HCPCS,00409-1159-10,NDC,,both,30,ML,24.5,14.7,,45.5,,11.15,percent of total billed charges,,,45.3,,11.1,percent of total billed charges,,,51,,12.5,percent of total billed charges,,,,,,,,,80,,19.6,percent of total billed charges,,,61.4,,15.04,percent of total billed charges,,,57.4,,14.06,percent of total billed charges,,,81,,19.85,percent of total billed charges,,,51.5,,12.62,percent of total billed charges,,,57.6,,14.11,percent of total billed charges,,,85,,20.83,percent of total billed charges,,,85,,20.83,percent of total billed charges,,,49,,12.01,percent of total billed charges,,,90,,22.05,percent of total billed charges,,,65,,15.93,percent of total billed charges,,,80,,19.6,percent of total billed charges,,,55,,13.48,percent of total billed charges,,,55,,13.48,percent of total billed charges,,,65,,15.93,percent of total billed charges,,,78,,19.11,percent of total billed charges,,,70,,17.15,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG rate,100% of IL Medicaid,,,,,EAPG rate,100% of IL Medicaid,,,,,EAPG rate,100% of IL Medicaid,,,,,EAPG rate,100% of IL Medicaid,11.1,22.05,
00409-1159-01 - bupivacaine 0.25% preservative-free Soln,J0665,HCPCS,00409-1159-01,NDC,,both,10,ML,28.7,17.22,,45.5,,13.06,percent of total billed charges,,,45.3,,13,percent of total billed charges,,,51,,14.64,percent of total billed charges,,,,,,,,,80,,22.96,percent of total billed charges,,,61.4,,17.62,percent of total billed charges,,,57.4,,16.47,percent of total billed charges,,,81,,23.25,percent of total billed charges,,,51.5,,14.78,percent of total billed charges,,,57.6,,16.53,percent of total billed charges,,,85,,24.4,percent of total billed charges,,,85,,24.4,percent of total billed charges,,,49,,14.06,percent of total billed charges,,,90,,25.83,percent of total billed charges,,,65,,18.66,percent of total billed charges,,,80,,22.96,percent of total billed charges,,,55,,15.79,percent of total billed charges,,,55,,15.79,percent of total billed charges,,,65,,18.66,percent of total billed charges,,,78,,22.39,percent of total billed charges,,,70,,20.09,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,13,25.83,
00409-1162-10 - BUPivacaine 0.5% preservative-free Soln,J0665,HCPCS,00409-1162-10,NDC,,both,30,ML,29.55,17.73,,45.5,,13.45,percent of total billed charges,,,45.3,,13.39,percent of total billed charges,,,51,,15.07,percent of total billed charges,,,,,,,,,80,,23.64,percent of total billed charges,,,61.4,,18.14,percent of total billed charges,,,57.4,,16.96,percent of total billed charges,,,81,,23.94,percent of total billed charges,,,51.5,,15.22,percent of total billed charges,,,57.6,,17.02,percent of total billed charges,,,85,,25.12,percent of total billed charges,,,85,,25.12,percent of total billed charges,,,49,,14.48,percent of total billed charges,,,90,,26.6,percent of total billed charges,,,65,,19.21,percent of total billed charges,,,80,,23.64,percent of total billed charges,,,55,,16.25,percent of total billed charges,,,55,,16.25,percent of total billed charges,,,65,,19.21,percent of total billed charges,,,78,,23.05,percent of total billed charges,,,70,,20.69,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,13.39,26.6,
00409-1162-01 - bupivacaine 0.5% preservative-free Soln,J0665,HCPCS,00409-1162-01,NDC,,both,10,ML,32.1,19.26,,45.5,,14.61,percent of total billed charges,,,45.3,,14.54,percent of total billed charges,,,51,,16.37,percent of total billed charges,,,,,,,,,80,,25.68,percent of total billed charges,,,61.4,,19.71,percent of total billed charges,,,57.4,,18.43,percent of total billed charges,,,81,,26,percent of total billed charges,,,51.5,,16.53,percent of total billed charges,,,57.6,,18.49,percent of total billed charges,,,85,,27.29,percent of total billed charges,,,85,,27.29,percent of total billed charges,,,49,,15.73,percent of total billed charges,,,90,,28.89,percent of total billed charges,,,65,,20.87,percent of total billed charges,,,80,,25.68,percent of total billed charges,,,55,,17.66,percent of total billed charges,,,55,,17.66,percent of total billed charges,,,65,,20.87,percent of total billed charges,,,78,,25.04,percent of total billed charges,,,70,,22.47,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,14.54,28.89,
00143-9983-03 - cefazolin 10 g REC I,J0690,HCPCS,00143-9983-03,NDC,,both,0.1,EA,95.1,57.06,,45.5,,43.27,percent of total billed charges,,,45.3,,43.08,percent of total billed charges,,,51,,48.5,percent of total billed charges,,,,,,,,,80,,76.08,percent of total billed charges,,,61.4,,58.39,percent of total billed charges,,,57.4,,54.59,percent of total billed charges,,,81,,77.03,percent of total billed charges,,,51.5,,48.98,percent of total billed charges,,,57.6,,54.78,percent of total billed charges,,,85,,80.84,percent of total billed charges,,,85,,80.84,percent of total billed charges,,,49,,46.6,percent of total billed charges,,,90,,85.59,percent of total billed charges,,,65,,61.82,percent of total billed charges,,,80,,76.08,percent of total billed charges,,,55,,52.31,percent of total billed charges,,,55,,52.31,percent of total billed charges,,,65,,61.82,percent of total billed charges,,,78,,74.18,percent of total billed charges,,,70,,66.57,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,43.08,85.59,
00517-0720-01 - betamethasone 6 mg/mL Susp,J0702,HCPCS,00517-0720-01,NDC,,both,1,ML,346.5,207.9,,45.5,,157.66,percent of total billed charges,,,45.3,,156.96,percent of total billed charges,,,51,,176.72,percent of total billed charges,,,,,,,,,80,,277.2,percent of total billed charges,,,61.4,,212.75,percent of total billed charges,,,57.4,,198.89,percent of total billed charges,,,81,,280.67,percent of total billed charges,,,51.5,,178.45,percent of total billed charges,,,57.6,,199.58,percent of total billed charges,,,85,,294.53,percent of total billed charges,,,85,,294.53,percent of total billed charges,,,49,,169.79,percent of total billed charges,,,90,,311.85,percent of total billed charges,,,65,,225.23,percent of total billed charges,,,80,,277.2,percent of total billed charges,,,55,,190.58,percent of total billed charges,,,55,,190.58,percent of total billed charges,,,65,,225.23,percent of total billed charges,,,78,,270.27,percent of total billed charges,,,70,,242.55,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,156.96,311.85,
25021-0115-04 - clindamycin 150 mg/mL Soln,J0736,HCPCS,25021-0115-04,NDC,,both,1,ML,18.2,10.92,,45.5,,8.28,percent of total billed charges,,,45.3,,8.24,percent of total billed charges,,,51,,9.28,percent of total billed charges,,,,,,,,,80,,14.56,percent of total billed charges,,,61.4,,11.17,percent of total billed charges,,,57.4,,10.45,percent of total billed charges,,,81,,14.74,percent of total billed charges,,,51.5,,9.37,percent of total billed charges,,,57.6,,10.48,percent of total billed charges,,,85,,15.47,percent of total billed charges,,,85,,15.47,percent of total billed charges,,,49,,8.92,percent of total billed charges,,,90,,16.38,percent of total billed charges,,,65,,11.83,percent of total billed charges,,,80,,14.56,percent of total billed charges,,,55,,10.01,percent of total billed charges,,,55,,10.01,percent of total billed charges,,,65,,11.83,percent of total billed charges,,,78,,14.2,percent of total billed charges,,,70,,12.74,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG rate,100% of IL Medicaid,,,,,EAPG rate,100% of IL Medicaid,,,,,EAPG rate,100% of IL Medicaid,,,,,EAPG rate,100% of IL Medicaid,8.24,16.38,
63323-0506-01 - dexamethasone 10 mg/mL preservative-free Soln,J1100,HCPCS,63323-0506-01,NDC,,both,1,ML,50.2,30.12,,45.5,,22.84,percent of total billed charges,,,45.3,,22.74,percent of total billed charges,,,51,,25.6,percent of total billed charges,,,,,,,,,80,,40.16,percent of total billed charges,,,61.4,,30.82,percent of total billed charges,,,57.4,,28.81,percent of total billed charges,,,81,,40.66,percent of total billed charges,,,51.5,,25.85,percent of total billed charges,,,57.6,,28.92,percent of total billed charges,,,85,,42.67,percent of total billed charges,,,85,,42.67,percent of total billed charges,,,49,,24.6,percent of total billed charges,,,90,,45.18,percent of total billed charges,,,65,,32.63,percent of total billed charges,,,80,,40.16,percent of total billed charges,,,55,,27.61,percent of total billed charges,,,55,,27.61,percent of total billed charges,,,65,,32.63,percent of total billed charges,,,78,,39.16,percent of total billed charges,,,70,,35.14,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,22.74,45.18,
76045-0109-10 - dexamethasone 10 mg/mL preservative-free Soln,J1100,HCPCS,76045-0109-10,NDC,,both,1,ML,67.85,40.71,,45.5,,30.87,percent of total billed charges,,,45.3,,30.74,percent of total billed charges,,,51,,34.6,percent of total billed charges,,,,,,,,,80,,54.28,percent of total billed charges,,,61.4,,41.66,percent of total billed charges,,,57.4,,38.95,percent of total billed charges,,,81,,54.96,percent of total billed charges,,,51.5,,34.94,percent of total billed charges,,,57.6,,39.08,percent of total billed charges,,,85,,57.67,percent of total billed charges,,,85,,57.67,percent of total billed charges,,,49,,33.25,percent of total billed charges,,,90,,61.07,percent of total billed charges,,,65,,44.1,percent of total billed charges,,,80,,54.28,percent of total billed charges,,,55,,37.32,percent of total billed charges,,,55,,37.32,percent of total billed charges,,,65,,44.1,percent of total billed charges,,,78,,52.92,percent of total billed charges,,,70,,47.5,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,30.74,61.07,
00075-0623-00 - enoxaparin 100 mg/mL Soln,J1650,HCPCS,00075-0623-00,NDC,,both,1,ML,846.75,508.05,,45.5,,385.27,percent of total billed charges,,,45.3,,383.58,percent of total billed charges,,,51,,431.84,percent of total billed charges,,,,,,,,,80,,677.4,percent of total billed charges,,,61.4,,519.9,percent of total billed charges,,,57.4,,486.03,percent of total billed charges,,,81,,685.87,percent of total billed charges,,,51.5,,436.08,percent of total billed charges,,,57.6,,487.73,percent of total billed charges,,,85,,719.74,percent of total billed charges,,,85,,719.74,percent of total billed charges,,,49,,414.91,percent of total billed charges,,,90,,762.08,percent of total billed charges,,,65,,550.39,percent of total billed charges,,,80,,677.4,percent of total billed charges,,,55,,465.71,percent of total billed charges,,,55,,465.71,percent of total billed charges,,,65,,550.39,percent of total billed charges,,,78,,660.47,percent of total billed charges,,,70,,592.73,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,383.58,762.08,
00075-2915-01 - enoxaparin 150 mg/mL Soln,J1650,HCPCS,00075-2915-01,NDC,,both,1,ML,1266.15,759.69,,45.5,,576.1,percent of total billed charges,,,45.3,,573.57,percent of total billed charges,,,51,,645.74,percent of total billed charges,,,,,,,,,80,,1012.92,percent of total billed charges,,,61.4,,777.42,percent of total billed charges,,,57.4,,726.77,percent of total billed charges,,,81,,1025.58,percent of total billed charges,,,51.5,,652.07,percent of total billed charges,,,57.6,,729.3,percent of total billed charges,,,85,,1076.23,percent of total billed charges,,,85,,1076.23,percent of total billed charges,,,49,,620.41,percent of total billed charges,,,90,,1139.54,percent of total billed charges,,,65,,823,percent of total billed charges,,,80,,1012.92,percent of total billed charges,,,55,,696.38,percent of total billed charges,,,55,,696.38,percent of total billed charges,,,65,,823,percent of total billed charges,,,78,,987.6,percent of total billed charges,,,70,,886.31,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,573.57,1139.54,
00009-0011-03 - hydrocortisone 100 mg preservative-free REC I,J1720,HCPCS,00009-0011-03,NDC,,both,2,ML,78.55,47.13,,45.5,,35.74,percent of total billed charges,,,45.3,,35.58,percent of total billed charges,,,51,,40.06,percent of total billed charges,,,,,,,,,80,,62.84,percent of total billed charges,,,61.4,,48.23,percent of total billed charges,,,57.4,,45.09,percent of total billed charges,,,81,,63.63,percent of total billed charges,,,51.5,,40.45,percent of total billed charges,,,57.6,,45.24,percent of total billed charges,,,85,,66.77,percent of total billed charges,,,85,,66.77,percent of total billed charges,,,49,,38.49,percent of total billed charges,,,90,,70.7,percent of total billed charges,,,65,,51.06,percent of total billed charges,,,80,,62.84,percent of total billed charges,,,55,,43.2,percent of total billed charges,,,55,,43.2,percent of total billed charges,,,65,,51.06,percent of total billed charges,,,78,,61.27,percent of total billed charges,,,70,,54.99,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,35.58,70.7,
00469-3250-10 - micafungin 50 mg REC I,J2248,HCPCS,00469-3250-10,NDC,,both,5,ML,1032.05,619.23,,45.5,,469.58,percent of total billed charges,,,45.3,,467.52,percent of total billed charges,,,51,,526.35,percent of total billed charges,,,,,,,,,80,,825.64,percent of total billed charges,,,61.4,,633.68,percent of total billed charges,,,57.4,,592.4,percent of total billed charges,,,81,,835.96,percent of total billed charges,,,51.5,,531.51,percent of total billed charges,,,57.6,,594.46,percent of total billed charges,,,85,,877.24,percent of total billed charges,,,85,,877.24,percent of total billed charges,,,49,,505.7,percent of total billed charges,,,90,,928.85,percent of total billed charges,,,65,,670.83,percent of total billed charges,,,80,,825.64,percent of total billed charges,,,55,,567.63,percent of total billed charges,,,55,,567.63,percent of total billed charges,,,65,,670.83,percent of total billed charges,,,78,,805,percent of total billed charges,,,70,,722.44,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,467.52,928.85,
00469-3211-10 - micafungin 100 mg REC I,J2248,HCPCS,00469-3211-10,NDC,,both,5,ML,1944.4,1166.64,,45.5,,884.7,percent of total billed charges,,,45.3,,880.81,percent of total billed charges,,,51,,991.64,percent of total billed charges,,,,,,,,,80,,1555.52,percent of total billed charges,,,61.4,,1193.86,percent of total billed charges,,,57.4,,1116.09,percent of total billed charges,,,81,,1574.96,percent of total billed charges,,,51.5,,1001.37,percent of total billed charges,,,57.6,,1119.97,percent of total billed charges,,,85,,1652.74,percent of total billed charges,,,85,,1652.74,percent of total billed charges,,,49,,952.76,percent of total billed charges,,,90,,1749.96,percent of total billed charges,,,65,,1263.86,percent of total billed charges,,,80,,1555.52,percent of total billed charges,,,55,,1069.42,percent of total billed charges,,,55,,1069.42,percent of total billed charges,,,65,,1263.86,percent of total billed charges,,,78,,1516.63,percent of total billed charges,,,70,,1361.08,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,880.81,1749.96,
63323-0285-10 - ropivacaine 0.2% Soln,J2795,HCPCS,63323-0285-10,NDC,,both,10,ML,56.55,33.93,,45.5,,25.73,percent of total billed charges,,,45.3,,25.62,percent of total billed charges,,,51,,28.84,percent of total billed charges,,,,,,,,,80,,45.24,percent of total billed charges,,,61.4,,34.72,percent of total billed charges,,,57.4,,32.46,percent of total billed charges,,,81,,45.81,percent of total billed charges,,,51.5,,29.12,percent of total billed charges,,,57.6,,32.57,percent of total billed charges,,,85,,48.07,percent of total billed charges,,,85,,48.07,percent of total billed charges,,,49,,27.71,percent of total billed charges,,,90,,50.9,percent of total billed charges,,,65,,36.76,percent of total billed charges,,,80,,45.24,percent of total billed charges,,,55,,31.1,percent of total billed charges,,,55,,31.1,percent of total billed charges,,,65,,36.76,percent of total billed charges,,,78,,44.11,percent of total billed charges,,,70,,39.59,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,25.62,50.9,
63323-0286-30 - ropivacaine 0.5% Soln,J2795,HCPCS,63323-0286-30,NDC,,both,30,ML,229.35,137.61,,45.5,,104.35,percent of total billed charges,,,45.3,,103.9,percent of total billed charges,,,51,,116.97,percent of total billed charges,,,,,,,,,80,,183.48,percent of total billed charges,,,61.4,,140.82,percent of total billed charges,,,57.4,,131.65,percent of total billed charges,,,81,,185.77,percent of total billed charges,,,51.5,,118.12,percent of total billed charges,,,57.6,,132.11,percent of total billed charges,,,85,,194.95,percent of total billed charges,,,85,,194.95,percent of total billed charges,,,49,,112.38,percent of total billed charges,,,90,,206.42,percent of total billed charges,,,65,,149.08,percent of total billed charges,,,80,,183.48,percent of total billed charges,,,55,,126.14,percent of total billed charges,,,55,,126.14,percent of total billed charges,,,65,,149.08,percent of total billed charges,,,78,,178.89,percent of total billed charges,,,70,,160.55,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,103.9,206.42,
00003-0293-05 - triamcinolone acetonide 40 mg/mL Susp,J3301,HCPCS,00003-0293-05,NDC,,both,1,ML,88,52.8,,45.5,,40.04,percent of total billed charges,,,45.3,,39.86,percent of total billed charges,,,51,,44.88,percent of total billed charges,,,,,,,,,80,,70.4,percent of total billed charges,,,61.4,,54.03,percent of total billed charges,,,57.4,,50.51,percent of total billed charges,,,81,,71.28,percent of total billed charges,,,51.5,,45.32,percent of total billed charges,,,57.6,,50.69,percent of total billed charges,,,85,,74.8,percent of total billed charges,,,85,,74.8,percent of total billed charges,,,49,,43.12,percent of total billed charges,,,90,,79.2,percent of total billed charges,,,65,,57.2,percent of total billed charges,,,80,,70.4,percent of total billed charges,,,55,,48.4,percent of total billed charges,,,55,,48.4,percent of total billed charges,,,65,,57.2,percent of total billed charges,,,78,,68.64,percent of total billed charges,,,70,,61.6,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,39.86,79.2,
70121-1651-01 - triamcinolone acetonide 40 mg/mL Susp,J3301,HCPCS,70121-1651-01,NDC,,both,1,ML,95.3,57.18,,45.5,,43.36,percent of total billed charges,,,45.3,,43.17,percent of total billed charges,,,51,,48.6,percent of total billed charges,,,,,,,,,80,,76.24,percent of total billed charges,,,61.4,,58.51,percent of total billed charges,,,57.4,,54.7,percent of total billed charges,,,81,,77.19,percent of total billed charges,,,51.5,,49.08,percent of total billed charges,,,57.6,,54.89,percent of total billed charges,,,85,,81.01,percent of total billed charges,,,85,,81.01,percent of total billed charges,,,49,,46.7,percent of total billed charges,,,90,,85.77,percent of total billed charges,,,65,,61.95,percent of total billed charges,,,80,,76.24,percent of total billed charges,,,55,,52.42,percent of total billed charges,,,55,,52.42,percent of total billed charges,,,65,,61.95,percent of total billed charges,,,78,,74.33,percent of total billed charges,,,70,,66.71,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,43.17,85.77,
00003-0293-28 - triamcinolone acetonide 40 mg/mL Susp,J3301,HCPCS,00003-0293-28,NDC,,both,10,ML,605.35,363.21,,45.5,,275.43,percent of total billed charges,,,45.3,,274.22,percent of total billed charges,,,51,,308.73,percent of total billed charges,,,,,,,,,80,,484.28,percent of total billed charges,,,61.4,,371.68,percent of total billed charges,,,57.4,,347.47,percent of total billed charges,,,81,,490.33,percent of total billed charges,,,51.5,,311.76,percent of total billed charges,,,57.6,,348.68,percent of total billed charges,,,85,,514.55,percent of total billed charges,,,85,,514.55,percent of total billed charges,,,49,,296.62,percent of total billed charges,,,90,,544.82,percent of total billed charges,,,65,,393.48,percent of total billed charges,,,80,,484.28,percent of total billed charges,,,55,,332.94,percent of total billed charges,,,55,,332.94,percent of total billed charges,,,65,,393.48,percent of total billed charges,,,78,,472.17,percent of total billed charges,,,70,,423.75,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,274.22,544.82,
00409-1162-02 - bupivacaine 0.5% preservative-free Soln,J3490,HCPCS,00409-1162-02,NDC,,both,1,UN,16.9,10.14,,45.5,,7.69,percent of total billed charges,,,45.3,,7.66,percent of total billed charges,,,51,,8.62,percent of total billed charges,,,,,,,,,80,,13.52,percent of total billed charges,,,61.4,,10.38,percent of total billed charges,,,57.4,,9.7,percent of total billed charges,,,81,,13.69,percent of total billed charges,,,51.5,,8.7,percent of total billed charges,,,57.6,,9.73,percent of total billed charges,,,85,,14.37,percent of total billed charges,,,85,,14.37,percent of total billed charges,,,49,,8.28,percent of total billed charges,,,90,,15.21,percent of total billed charges,,,65,,10.99,percent of total billed charges,,,80,,13.52,percent of total billed charges,,,55,,9.3,percent of total billed charges,,,55,,9.3,percent of total billed charges,,,65,,10.99,percent of total billed charges,,,78,,13.18,percent of total billed charges,,,70,,11.83,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG rate,100% of IL Medicaid,,,,,EAPG rate,100% of IL Medicaid,,,,,EAPG rate,100% of IL Medicaid,,,,,EAPG rate,100% of IL Medicaid,7.66,15.21,
89130-3111-01 - sodium hyaluronate 8.4 mg/mL Soln,J7328,HCPCS,89130-3111-01,NDC,,both,2,ML,1420.5,852.3,,45.5,,646.33,percent of total billed charges,,,45.3,,643.49,percent of total billed charges,,,51,,724.46,percent of total billed charges,,,,,,,,,80,,1136.4,percent of total billed charges,,,61.4,,872.19,percent of total billed charges,,,57.4,,815.37,percent of total billed charges,,,81,,1150.61,percent of total billed charges,,,51.5,,731.56,percent of total billed charges,,,57.6,,818.21,percent of total billed charges,,,85,,1207.43,percent of total billed charges,,,85,,1207.43,percent of total billed charges,,,49,,696.05,percent of total billed charges,,,90,,1278.45,percent of total billed charges,,,65,,923.33,percent of total billed charges,,,80,,1136.4,percent of total billed charges,,,55,,781.28,percent of total billed charges,,,55,,781.28,percent of total billed charges,,,65,,923.33,percent of total billed charges,,,78,,1107.99,percent of total billed charges,,,70,,994.35,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,643.49,1278.45,
00078-0248-15 - cycloSPORINE microemulsion 100 mg Cap,J7502,HCPCS,00078-0248-15,NDC,,both,1,EA,52.4,31.44,,45.5,,23.84,percent of total billed charges,,,45.3,,23.74,percent of total billed charges,,,51,,26.72,percent of total billed charges,,,,,,,,,80,,41.92,percent of total billed charges,,,61.4,,32.17,percent of total billed charges,,,57.4,,30.08,percent of total billed charges,,,81,,42.44,percent of total billed charges,,,51.5,,26.99,percent of total billed charges,,,57.6,,30.18,percent of total billed charges,,,85,,44.54,percent of total billed charges,,,85,,44.54,percent of total billed charges,,,49,,25.68,percent of total billed charges,,,90,,47.16,percent of total billed charges,,,65,,34.06,percent of total billed charges,,,80,,41.92,percent of total billed charges,,,55,,28.82,percent of total billed charges,,,55,,28.82,percent of total billed charges,,,65,,34.06,percent of total billed charges,,,78,,40.87,percent of total billed charges,,,70,,36.68,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,23.74,47.16,
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE 17250,17250,CPT,,,,outpatient,,,510,306,,45.5,,232.05,percent of total billed charges,,,45.3,,231.03,percent of total billed charges,,,51,,260.1,percent of total billed charges,,,,,,,,,80,,408,percent of total billed charges,,,61.4,,313.14,percent of total billed charges,,,57.4,,292.74,percent of total billed charges,,,81,,413.1,percent of total billed charges,,,51.5,,262.65,percent of total billed charges,,,57.6,,293.76,percent of total billed charges,,,85,,433.5,percent of total billed charges,,,85,,433.5,percent of total billed charges,,,49,,249.9,percent of total billed charges,,,90,,459,percent of total billed charges,,,65,,331.5,percent of total billed charges,,,80,,408,percent of total billed charges,,,55,,280.5,percent of total billed charges,,,55,,280.5,percent of total billed charges,,,65,,331.5,percent of total billed charges,,,78,,397.8,percent of total billed charges,,,70,,357,percent of total billed charges,,,,,,,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,,207.13,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,207.13,459,
EXPL P WND; EXTREM (20103),20103,CPT,,,,outpatient,,,3782,2269.2,,45.5,,1720.81,percent of total billed charges,,,45.3,,1713.25,percent of total billed charges,,,51,,1928.82,percent of total billed charges,,,,,,,,,80,,3025.6,percent of total billed charges,,,61.4,,2322.15,percent of total billed charges,,,57.4,,2170.87,percent of total billed charges,,,81,,3063.42,percent of total billed charges,,,51.5,,1947.73,percent of total billed charges,,,57.6,,2178.43,percent of total billed charges,,,85,,3214.7,percent of total billed charges,,,85,,3214.7,percent of total billed charges,,,49,,1853.18,percent of total billed charges,,,90,,3403.8,percent of total billed charges,,,65,,2458.3,percent of total billed charges,,,80,,3025.6,percent of total billed charges,,,55,,2080.1,percent of total billed charges,,,55,,2080.1,percent of total billed charges,,,65,,2458.3,percent of total billed charges,,,78,,2949.96,percent of total billed charges,,,70,,2647.4,percent of total billed charges,,,,,,,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,,1688.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1688.97,3403.8,
MUSCLE BX; SUPERF (20200),20200,CPT,,,,outpatient,,,5225,3135,,45.5,,2377.38,percent of total billed charges,,,45.3,,2366.93,percent of total billed charges,,,51,,2664.75,percent of total billed charges,,,,,,,,,80,,4180,percent of total billed charges,,,61.4,,3208.15,percent of total billed charges,,,57.4,,2999.15,percent of total billed charges,,,81,,4232.25,percent of total billed charges,,,51.5,,2690.88,percent of total billed charges,,,57.6,,3009.6,percent of total billed charges,,,85,,4441.25,percent of total billed charges,,,85,,4441.25,percent of total billed charges,,,49,,2560.25,percent of total billed charges,,,90,,4702.5,percent of total billed charges,,,65,,3396.25,percent of total billed charges,,,80,,4180,percent of total billed charges,,,55,,2873.75,percent of total billed charges,,,55,,2873.75,percent of total billed charges,,,65,,3396.25,percent of total billed charges,,,78,,4075.5,percent of total billed charges,,,70,,3657.5,percent of total billed charges,,,,,,,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,,1688.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1688.97,4702.5,
63323-0492-27 - lidocaine 1% preservative-free Soln,J2003,HCPCS,63323-0492-27,NDC,,both,2,ML,30.05,18.03,,45.5,,13.67,percent of total billed charges,,,45.3,,13.61,percent of total billed charges,,,51,,15.33,percent of total billed charges,,,,,,,,,80,,24.04,percent of total billed charges,,,61.4,,18.45,percent of total billed charges,,,57.4,,17.25,percent of total billed charges,,,81,,24.34,percent of total billed charges,,,51.5,,15.48,percent of total billed charges,,,57.6,,17.31,percent of total billed charges,,,85,,25.54,percent of total billed charges,,,85,,25.54,percent of total billed charges,,,49,,14.72,percent of total billed charges,,,90,,27.05,percent of total billed charges,,,65,,19.53,percent of total billed charges,,,80,,24.04,percent of total billed charges,,,55,,16.53,percent of total billed charges,,,55,,16.53,percent of total billed charges,,,65,,19.53,percent of total billed charges,,,78,,23.44,percent of total billed charges,,,70,,21.04,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,13.61,27.05,
63323-0495-07 - lidocaine 2% preservative-free Soln,J2003,HCPCS,63323-0495-07,NDC,,both,5,ML,38,22.8,,45.5,,17.29,percent of total billed charges,,,45.3,,17.21,percent of total billed charges,,,51,,19.38,percent of total billed charges,,,,,,,,,80,,30.4,percent of total billed charges,,,61.4,,23.33,percent of total billed charges,,,57.4,,21.81,percent of total billed charges,,,81,,30.78,percent of total billed charges,,,51.5,,19.57,percent of total billed charges,,,57.6,,21.89,percent of total billed charges,,,85,,32.3,percent of total billed charges,,,85,,32.3,percent of total billed charges,,,49,,18.62,percent of total billed charges,,,90,,34.2,percent of total billed charges,,,65,,24.7,percent of total billed charges,,,80,,30.4,percent of total billed charges,,,55,,20.9,percent of total billed charges,,,55,,20.9,percent of total billed charges,,,65,,24.7,percent of total billed charges,,,78,,29.64,percent of total billed charges,,,70,,26.6,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,17.21,34.2,
63323-0492-57 - lidocaine 5 mL Injection,J2003,HCPCS,63323-0492-57,NDC,,both,5,ML,43.45,26.07,,45.5,,19.77,percent of total billed charges,,,45.3,,19.68,percent of total billed charges,,,51,,22.16,percent of total billed charges,,,,,,,,,80,,34.76,percent of total billed charges,,,61.4,,26.68,percent of total billed charges,,,57.4,,24.94,percent of total billed charges,,,81,,35.19,percent of total billed charges,,,51.5,,22.38,percent of total billed charges,,,57.6,,25.03,percent of total billed charges,,,85,,36.93,percent of total billed charges,,,85,,36.93,percent of total billed charges,,,49,,21.29,percent of total billed charges,,,90,,39.11,percent of total billed charges,,,65,,28.24,percent of total billed charges,,,80,,34.76,percent of total billed charges,,,55,,23.9,percent of total billed charges,,,55,,23.9,percent of total billed charges,,,65,,28.24,percent of total billed charges,,,78,,33.89,percent of total billed charges,,,70,,30.42,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG rate,100% of IL Medicaid,,,,,EAPG rate,100% of IL Medicaid,,,,,EAPG rate,100% of IL Medicaid,,,,,EAPG rate,100% of IL Medicaid,19.68,39.11,
00409-4283-01 - lidocaine 4% preservative-free Soln,J2003,HCPCS,00409-4283-01,NDC,,both,5,ML,52.3,31.38,,45.5,,23.8,percent of total billed charges,,,45.3,,23.69,percent of total billed charges,,,51,,26.67,percent of total billed charges,,,,,,,,,80,,41.84,percent of total billed charges,,,61.4,,32.11,percent of total billed charges,,,57.4,,30.02,percent of total billed charges,,,81,,42.36,percent of total billed charges,,,51.5,,26.93,percent of total billed charges,,,57.6,,30.12,percent of total billed charges,,,85,,44.46,percent of total billed charges,,,85,,44.46,percent of total billed charges,,,49,,25.63,percent of total billed charges,,,90,,47.07,percent of total billed charges,,,65,,34,percent of total billed charges,,,80,,41.84,percent of total billed charges,,,55,,28.77,percent of total billed charges,,,55,,28.77,percent of total billed charges,,,65,,34,percent of total billed charges,,,78,,40.79,percent of total billed charges,,,70,,36.61,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,23.69,47.07,
BONE BX TR/NDL; SUPERF (20220),20220,CPT,,,,outpatient,,,2470,1482,,45.5,,1123.85,percent of total billed charges,,,45.3,,1118.91,percent of total billed charges,,,51,,1259.7,percent of total billed charges,,,,,,,,,80,,1976,percent of total billed charges,,,61.4,,1516.58,percent of total billed charges,,,57.4,,1417.78,percent of total billed charges,,,81,,2000.7,percent of total billed charges,,,51.5,,1272.05,percent of total billed charges,,,57.6,,1422.72,percent of total billed charges,,,85,,2099.5,percent of total billed charges,,,85,,2099.5,percent of total billed charges,,,49,,1210.3,percent of total billed charges,,,90,,2223,percent of total billed charges,,,65,,1605.5,percent of total billed charges,,,80,,1976,percent of total billed charges,,,55,,1358.5,percent of total billed charges,,,55,,1358.5,percent of total billed charges,,,65,,1605.5,percent of total billed charges,,,78,,1926.6,percent of total billed charges,,,70,,1729,percent of total billed charges,,,,,,,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,44970,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,,1688.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1118.91,44970,
OPEN SUPERF BONE BX (20240),20240,CPT,,,,outpatient,,,7734,4640.4,,45.5,,3518.97,percent of total billed charges,,,45.3,,3503.5,percent of total billed charges,,,51,,3944.34,percent of total billed charges,,,,,,,,,80,,6187.2,percent of total billed charges,,,61.4,,4748.68,percent of total billed charges,,,57.4,,4439.32,percent of total billed charges,,,81,,6264.54,percent of total billed charges,,,51.5,,3983.01,percent of total billed charges,,,57.6,,4454.78,percent of total billed charges,,,85,,6573.9,percent of total billed charges,,,85,,6573.9,percent of total billed charges,,,49,,3789.66,percent of total billed charges,,,90,,6960.6,percent of total billed charges,,,65,,5027.1,percent of total billed charges,,,80,,6187.2,percent of total billed charges,,,55,,4253.7,percent of total billed charges,,,55,,4253.7,percent of total billed charges,,,65,,5027.1,percent of total billed charges,,,78,,6032.52,percent of total billed charges,,,70,,5413.8,percent of total billed charges,,,,,,,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,,2983.46,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,2983.46,6960.6,
Removal of foreign body in muscle or tendon sheath; simple (20520),20520,CPT,,,,outpatient,,,2863,1717.8,,45.5,,1302.67,percent of total billed charges,,,45.3,,1296.94,percent of total billed charges,,,51,,1460.13,percent of total billed charges,,,,,,,,,80,,2290.4,percent of total billed charges,,,61.4,,1757.88,percent of total billed charges,,,57.4,,1643.36,percent of total billed charges,,,81,,2319.03,percent of total billed charges,,,51.5,,1474.45,percent of total billed charges,,,57.6,,1649.09,percent of total billed charges,,,85,,2433.55,percent of total billed charges,,,85,,2433.55,percent of total billed charges,,,49,,1402.87,percent of total billed charges,,,90,,2576.7,percent of total billed charges,,,65,,1860.95,percent of total billed charges,,,80,,2290.4,percent of total billed charges,,,55,,1574.65,percent of total billed charges,,,55,,1574.65,percent of total billed charges,,,65,,1860.95,percent of total billed charges,,,78,,2233.14,percent of total billed charges,,,70,,2004.1,percent of total billed charges,,,,,,,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,,1688.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1296.94,2576.7,
Injection Therapeutic Carpal Tunnel Charge (20526),20526,CPT,,,,outpatient,,,1101,660.6,,45.5,,500.96,percent of total billed charges,,,45.3,,498.75,percent of total billed charges,,,51,,561.51,percent of total billed charges,,,,,,,,,80,,880.8,percent of total billed charges,,,61.4,,676.01,percent of total billed charges,,,57.4,,631.97,percent of total billed charges,,,81,,891.81,percent of total billed charges,,,51.5,,567.02,percent of total billed charges,,,57.6,,634.18,percent of total billed charges,,,85,,935.85,percent of total billed charges,,,85,,935.85,percent of total billed charges,,,49,,539.49,percent of total billed charges,,,90,,990.9,percent of total billed charges,,,65,,715.65,percent of total billed charges,,,80,,880.8,percent of total billed charges,,,55,,605.55,percent of total billed charges,,,55,,605.55,percent of total billed charges,,,65,,715.65,percent of total billed charges,,,78,,858.78,percent of total billed charges,,,70,,770.7,percent of total billed charges,,,,,,,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,,307.71,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,307.71,990.9,
Injection Therapeutic Carpal Tunnel-Bilateral Charge (20526-50),20526,CPT,,,50,outpatient,,,1651,990.6,,45.5,,751.21,percent of total billed charges,,,45.3,,747.9,percent of total billed charges,,,51,,842.01,percent of total billed charges,,,,,,,,,80,,1320.8,percent of total billed charges,,,61.4,,1013.71,percent of total billed charges,,,57.4,,947.67,percent of total billed charges,,,81,,1337.31,percent of total billed charges,,,51.5,,850.27,percent of total billed charges,,,57.6,,950.98,percent of total billed charges,,,85,,1403.35,percent of total billed charges,,,85,,1403.35,percent of total billed charges,,,49,,808.99,percent of total billed charges,,,90,,1485.9,percent of total billed charges,,,65,,1073.15,percent of total billed charges,,,80,,1320.8,percent of total billed charges,,,55,,908.05,percent of total billed charges,,,55,,908.05,percent of total billed charges,,,65,,1073.15,percent of total billed charges,,,78,,1287.78,percent of total billed charges,,,70,,1155.7,percent of total billed charges,,,,,,,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,,461.57,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,461.57,1485.9,
CC ONLY - Injection Trigger Point(s): 3 or more Muscle(s) Charge (20553),20553,CPT,,,,outpatient,,,1308,784.8,,45.5,,595.14,percent of total billed charges,,,45.3,,592.52,percent of total billed charges,,,51,,667.08,percent of total billed charges,,,,,,,,,80,,1046.4,percent of total billed charges,,,61.4,,803.11,percent of total billed charges,,,57.4,,750.79,percent of total billed charges,,,81,,1059.48,percent of total billed charges,,,51.5,,673.62,percent of total billed charges,,,57.6,,753.41,percent of total billed charges,,,85,,1111.8,percent of total billed charges,,,85,,1111.8,percent of total billed charges,,,49,,640.92,percent of total billed charges,,,90,,1177.2,percent of total billed charges,,,65,,850.2,percent of total billed charges,,,80,,1046.4,percent of total billed charges,,,55,,719.4,percent of total billed charges,,,55,,719.4,percent of total billed charges,,,65,,850.2,percent of total billed charges,,,78,,1020.24,percent of total billed charges,,,70,,915.6,percent of total billed charges,,,,,,,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,,307.71,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,307.71,1177.2,
Injection Trigger Point(s): 3 or more Muscle(s) Charge (20553),20553,CPT,,,,outpatient,,,1308,784.8,,45.5,,595.14,percent of total billed charges,,,45.3,,592.52,percent of total billed charges,,,51,,667.08,percent of total billed charges,,,,,,,,,80,,1046.4,percent of total billed charges,,,61.4,,803.11,percent of total billed charges,,,57.4,,750.79,percent of total billed charges,,,81,,1059.48,percent of total billed charges,,,51.5,,673.62,percent of total billed charges,,,57.6,,753.41,percent of total billed charges,,,85,,1111.8,percent of total billed charges,,,85,,1111.8,percent of total billed charges,,,49,,640.92,percent of total billed charges,,,90,,1177.2,percent of total billed charges,,,65,,850.2,percent of total billed charges,,,80,,1046.4,percent of total billed charges,,,55,,719.4,percent of total billed charges,,,55,,719.4,percent of total billed charges,,,65,,850.2,percent of total billed charges,,,78,,1020.24,percent of total billed charges,,,70,,915.6,percent of total billed charges,,,,,,,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,,307.71,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,307.71,1177.2,
NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES (20560),20560,CPT,,,,outpatient,,,68,40.8,,45.5,,30.94,percent of total billed charges,,,45.3,,30.8,percent of total billed charges,,,51,,34.68,percent of total billed charges,,,,,,,,,80,,54.4,percent of total billed charges,,,61.4,,41.75,percent of total billed charges,,,57.4,,39.03,percent of total billed charges,,,81,,55.08,percent of total billed charges,,,51.5,,35.02,percent of total billed charges,,,57.6,,39.17,percent of total billed charges,,,85,,57.8,percent of total billed charges,,,85,,57.8,percent of total billed charges,,,49,,33.32,percent of total billed charges,,,90,,61.2,percent of total billed charges,,,65,,44.2,percent of total billed charges,,,80,,54.4,percent of total billed charges,,,55,,37.4,percent of total billed charges,,,55,,37.4,percent of total billed charges,,,65,,44.2,percent of total billed charges,,,78,,53.04,percent of total billed charges,,,70,,47.6,percent of total billed charges,,,,,,,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,,25.53,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,25.53,61.2,
NEEDLE INSERTION W/O INJECTION 3 OR MORE MUSCLES (20561),20561,CPT,,,,outpatient,,,85,51,,45.5,,38.68,percent of total billed charges,,,45.3,,38.51,percent of total billed charges,,,51,,43.35,percent of total billed charges,,,,,,,,,80,,68,percent of total billed charges,,,61.4,,52.19,percent of total billed charges,,,57.4,,48.79,percent of total billed charges,,,81,,68.85,percent of total billed charges,,,51.5,,43.78,percent of total billed charges,,,57.6,,48.96,percent of total billed charges,,,85,,72.25,percent of total billed charges,,,85,,72.25,percent of total billed charges,,,49,,41.65,percent of total billed charges,,,90,,76.5,percent of total billed charges,,,65,,55.25,percent of total billed charges,,,80,,68,percent of total billed charges,,,55,,46.75,percent of total billed charges,,,55,,46.75,percent of total billed charges,,,65,,55.25,percent of total billed charges,,,78,,66.3,percent of total billed charges,,,70,,59.5,percent of total billed charges,,,,,,,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,,25.53,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,25.53,76.5,
Arthrocentesis Small Joint Charge (20600),20600,CPT,,,,outpatient,,,794,476.4,,45.5,,361.27,percent of total billed charges,,,45.3,,359.68,percent of total billed charges,,,51,,404.94,percent of total billed charges,,,,,,,,,80,,635.2,percent of total billed charges,,,61.4,,487.52,percent of total billed charges,,,57.4,,455.76,percent of total billed charges,,,81,,643.14,percent of total billed charges,,,51.5,,408.91,percent of total billed charges,,,57.6,,457.34,percent of total billed charges,,,85,,674.9,percent of total billed charges,,,85,,674.9,percent of total billed charges,,,49,,389.06,percent of total billed charges,,,90,,714.6,percent of total billed charges,,,65,,516.1,percent of total billed charges,,,80,,635.2,percent of total billed charges,,,55,,436.7,percent of total billed charges,,,55,,436.7,percent of total billed charges,,,65,,516.1,percent of total billed charges,,,78,,619.32,percent of total billed charges,,,70,,555.8,percent of total billed charges,,,,,,,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,20476.67727,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,,307.71,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,307.71,20476.68,
Arthrocentesis Small Joint - Bilateral Charge (20600-50),20600,CPT,,,50,outpatient,,,1192,715.2,,45.5,,542.36,percent of total billed charges,,,45.3,,539.98,percent of total billed charges,,,51,,607.92,percent of total billed charges,,,,,,,,,80,,953.6,percent of total billed charges,,,61.4,,731.89,percent of total billed charges,,,57.4,,684.21,percent of total billed charges,,,81,,965.52,percent of total billed charges,,,51.5,,613.88,percent of total billed charges,,,57.6,,686.59,percent of total billed charges,,,85,,1013.2,percent of total billed charges,,,85,,1013.2,percent of total billed charges,,,49,,584.08,percent of total billed charges,,,90,,1072.8,percent of total billed charges,,,65,,774.8,percent of total billed charges,,,80,,953.6,percent of total billed charges,,,55,,655.6,percent of total billed charges,,,55,,655.6,percent of total billed charges,,,65,,774.8,percent of total billed charges,,,78,,929.76,percent of total billed charges,,,70,,834.4,percent of total billed charges,,,,,,,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,10368.825,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,,461.57,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,461.57,10368.83,
DRAIN/INJ SMALL JOINT/BURSA W/US (20604),20604,CPT,,,,outpatient,,,819,491.4,,45.5,,372.65,percent of total billed charges,,,45.3,,371.01,percent of total billed charges,,,51,,417.69,percent of total billed charges,,,,,,,,,80,,655.2,percent of total billed charges,,,61.4,,502.87,percent of total billed charges,,,57.4,,470.11,percent of total billed charges,,,81,,663.39,percent of total billed charges,,,51.5,,421.79,percent of total billed charges,,,57.6,,471.74,percent of total billed charges,,,85,,696.15,percent of total billed charges,,,85,,696.15,percent of total billed charges,,,49,,401.31,percent of total billed charges,,,90,,737.1,percent of total billed charges,,,65,,532.35,percent of total billed charges,,,80,,655.2,percent of total billed charges,,,55,,450.45,percent of total billed charges,,,55,,450.45,percent of total billed charges,,,65,,532.35,percent of total billed charges,,,78,,638.82,percent of total billed charges,,,70,,573.3,percent of total billed charges,,,,,,,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,,307.71,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,307.71,737.1,
"DRAIN_INJ SMALL JOINT_BURSA W_US, Bilateral (20604-50)",20604,CPT,,,50,outpatient,,,1228,736.8,,45.5,,558.74,percent of total billed charges,,,45.3,,556.28,percent of total billed charges,,,51,,626.28,percent of total billed charges,,,,,,,,,80,,982.4,percent of total billed charges,,,61.4,,753.99,percent of total billed charges,,,57.4,,704.87,percent of total billed charges,,,81,,994.68,percent of total billed charges,,,51.5,,632.42,percent of total billed charges,,,57.6,,707.33,percent of total billed charges,,,85,,1043.8,percent of total billed charges,,,85,,1043.8,percent of total billed charges,,,49,,601.72,percent of total billed charges,,,90,,1105.2,percent of total billed charges,,,65,,798.2,percent of total billed charges,,,80,,982.4,percent of total billed charges,,,55,,675.4,percent of total billed charges,,,55,,675.4,percent of total billed charges,,,65,,798.2,percent of total billed charges,,,78,,957.84,percent of total billed charges,,,70,,859.6,percent of total billed charges,,,,,,,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,,461.57,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,461.57,1105.2,
Arthrocentesis Intermediate Joint Charge (20605),20605,CPT,,,,outpatient,,,1244,746.4,,45.5,,566.02,percent of total billed charges,,,45.3,,563.53,percent of total billed charges,,,51,,634.44,percent of total billed charges,,,,,,,,,80,,995.2,percent of total billed charges,,,61.4,,763.82,percent of total billed charges,,,57.4,,714.06,percent of total billed charges,,,81,,1007.64,percent of total billed charges,,,51.5,,640.66,percent of total billed charges,,,57.6,,716.54,percent of total billed charges,,,85,,1057.4,percent of total billed charges,,,85,,1057.4,percent of total billed charges,,,49,,609.56,percent of total billed charges,,,90,,1119.6,percent of total billed charges,,,65,,808.6,percent of total billed charges,,,80,,995.2,percent of total billed charges,,,55,,684.2,percent of total billed charges,,,55,,684.2,percent of total billed charges,,,65,,808.6,percent of total billed charges,,,78,,970.32,percent of total billed charges,,,70,,870.8,percent of total billed charges,,,,,,,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,27692.988,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,,307.71,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,307.71,27692.99,
Arthrocentesis Intermediate Joint - Bilateral Charge (20605-50),20605,CPT,,,50,outpatient,,,1867,1120.2,,45.5,,849.49,percent of total billed charges,,,45.3,,845.75,percent of total billed charges,,,51,,952.17,percent of total billed charges,,,,,,,,,80,,1493.6,percent of total billed charges,,,61.4,,1146.34,percent of total billed charges,,,57.4,,1071.66,percent of total billed charges,,,81,,1512.27,percent of total billed charges,,,51.5,,961.51,percent of total billed charges,,,57.6,,1075.39,percent of total billed charges,,,85,,1586.95,percent of total billed charges,,,85,,1586.95,percent of total billed charges,,,49,,914.83,percent of total billed charges,,,90,,1680.3,percent of total billed charges,,,65,,1213.55,percent of total billed charges,,,80,,1493.6,percent of total billed charges,,,55,,1026.85,percent of total billed charges,,,55,,1026.85,percent of total billed charges,,,65,,1213.55,percent of total billed charges,,,78,,1456.26,percent of total billed charges,,,70,,1306.9,percent of total billed charges,,,,,,,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,,461.57,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,461.57,1680.3,
DRAIN/INJ INTER JOINT/BURSA W/US (20606),20606,CPT,,,,outpatient,,,844,506.4,,45.5,,384.02,percent of total billed charges,,,45.3,,382.33,percent of total billed charges,,,51,,430.44,percent of total billed charges,,,,,,,,,80,,675.2,percent of total billed charges,,,61.4,,518.22,percent of total billed charges,,,57.4,,484.46,percent of total billed charges,,,81,,683.64,percent of total billed charges,,,51.5,,434.66,percent of total billed charges,,,57.6,,486.14,percent of total billed charges,,,85,,717.4,percent of total billed charges,,,85,,717.4,percent of total billed charges,,,49,,413.56,percent of total billed charges,,,90,,759.6,percent of total billed charges,,,65,,548.6,percent of total billed charges,,,80,,675.2,percent of total billed charges,,,55,,464.2,percent of total billed charges,,,55,,464.2,percent of total billed charges,,,65,,548.6,percent of total billed charges,,,78,,658.32,percent of total billed charges,,,70,,590.8,percent of total billed charges,,,,,,,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,,721.9,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,382.33,759.6,
"DRAIN/INJ INTER JOINT/BURSA W/US,Bilateral (20606-50)",20606,CPT,,,50,outpatient,,,1267,760.2,,45.5,,576.49,percent of total billed charges,,,45.3,,573.95,percent of total billed charges,,,51,,646.17,percent of total billed charges,,,,,,,,,80,,1013.6,percent of total billed charges,,,61.4,,777.94,percent of total billed charges,,,57.4,,727.26,percent of total billed charges,,,81,,1026.27,percent of total billed charges,,,51.5,,652.51,percent of total billed charges,,,57.6,,729.79,percent of total billed charges,,,85,,1076.95,percent of total billed charges,,,85,,1076.95,percent of total billed charges,,,49,,620.83,percent of total billed charges,,,90,,1140.3,percent of total billed charges,,,65,,823.55,percent of total billed charges,,,80,,1013.6,percent of total billed charges,,,55,,696.85,percent of total billed charges,,,55,,696.85,percent of total billed charges,,,65,,823.55,percent of total billed charges,,,78,,988.26,percent of total billed charges,,,70,,886.9,percent of total billed charges,,,,,,,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,,1082.85,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,573.95,1140.3,
Arthrocentesis Major Joint Charge (20610),20610,CPT,,,,outpatient,,,859,515.4,,45.5,,390.85,percent of total billed charges,,,45.3,,389.13,percent of total billed charges,,,51,,438.09,percent of total billed charges,,,,,,,,,80,,687.2,percent of total billed charges,,,61.4,,527.43,percent of total billed charges,,,57.4,,493.07,percent of total billed charges,,,81,,695.79,percent of total billed charges,,,51.5,,442.39,percent of total billed charges,,,57.6,,494.78,percent of total billed charges,,,85,,730.15,percent of total billed charges,,,85,,730.15,percent of total billed charges,,,49,,420.91,percent of total billed charges,,,90,,773.1,percent of total billed charges,,,65,,558.35,percent of total billed charges,,,80,,687.2,percent of total billed charges,,,55,,472.45,percent of total billed charges,,,55,,472.45,percent of total billed charges,,,65,,558.35,percent of total billed charges,,,78,,670.02,percent of total billed charges,,,70,,601.3,percent of total billed charges,,,,,,,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,33907.2,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,,307.71,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,307.71,33907.2,
CC ONLY - Arthrocentesis Major Joint Charge (20610),20610,CPT,,,,outpatient,,,859,515.4,,45.5,,390.85,percent of total billed charges,,,45.3,,389.13,percent of total billed charges,,,51,,438.09,percent of total billed charges,,,,,,,,,80,,687.2,percent of total billed charges,,,61.4,,527.43,percent of total billed charges,,,57.4,,493.07,percent of total billed charges,,,81,,695.79,percent of total billed charges,,,51.5,,442.39,percent of total billed charges,,,57.6,,494.78,percent of total billed charges,,,85,,730.15,percent of total billed charges,,,85,,730.15,percent of total billed charges,,,49,,420.91,percent of total billed charges,,,90,,773.1,percent of total billed charges,,,65,,558.35,percent of total billed charges,,,80,,687.2,percent of total billed charges,,,55,,472.45,percent of total billed charges,,,55,,472.45,percent of total billed charges,,,65,,558.35,percent of total billed charges,,,78,,670.02,percent of total billed charges,,,70,,601.3,percent of total billed charges,,,,,,,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,59774.47,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,,307.71,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,307.71,59774.47,
Arthrocentesis Major Joint Bilateral Charge (20610-50),20610,CPT,,,50,both,,,1288,772.8,,45.5,,586.04,percent of total billed charges,,,45.3,,583.46,percent of total billed charges,,,51,,656.88,percent of total billed charges,,,,,,,,,80,,1030.4,percent of total billed charges,,,61.4,,790.83,percent of total billed charges,,,57.4,,739.31,percent of total billed charges,,,81,,1043.28,percent of total billed charges,,,51.5,,663.32,percent of total billed charges,,,57.6,,741.89,percent of total billed charges,,,85,,1094.8,percent of total billed charges,,,85,,1094.8,percent of total billed charges,,,49,,631.12,percent of total billed charges,,,90,,1159.2,percent of total billed charges,,,65,,837.2,percent of total billed charges,,,80,,1030.4,percent of total billed charges,,,55,,708.4,percent of total billed charges,,,55,,708.4,percent of total billed charges,,,65,,837.2,percent of total billed charges,,,78,,1004.64,percent of total billed charges,,,70,,901.6,percent of total billed charges,,,,,,,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,32821.88,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,,461.57,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,461.57,32821.88,
Aspiration/Injection Ganglion Cyst Charge (20612),20612,CPT,,,,outpatient,,,943,565.8,,45.5,,429.07,percent of total billed charges,,,45.3,,427.18,percent of total billed charges,,,51,,480.93,percent of total billed charges,,,,,,,,,80,,754.4,percent of total billed charges,,,61.4,,579,percent of total billed charges,,,57.4,,541.28,percent of total billed charges,,,81,,763.83,percent of total billed charges,,,51.5,,485.65,percent of total billed charges,,,57.6,,543.17,percent of total billed charges,,,85,,801.55,percent of total billed charges,,,85,,801.55,percent of total billed charges,,,49,,462.07,percent of total billed charges,,,90,,848.7,percent of total billed charges,,,65,,612.95,percent of total billed charges,,,80,,754.4,percent of total billed charges,,,55,,518.65,percent of total billed charges,,,55,,518.65,percent of total billed charges,,,65,,612.95,percent of total billed charges,,,78,,735.54,percent of total billed charges,,,70,,660.1,percent of total billed charges,,,,,,,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,21271.74,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,,307.71,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,307.71,21271.74,
Plate Removal,20680,CPT,,,,outpatient,,,7438,4462.8,,45.5,,3384.29,percent of total billed charges,,,45.3,,3369.41,percent of total billed charges,,,51,,3793.38,percent of total billed charges,,,,,,,,,80,,5950.4,percent of total billed charges,,,61.4,,4566.93,percent of total billed charges,,,57.4,,4269.41,percent of total billed charges,,,81,,6024.78,percent of total billed charges,,,51.5,,3830.57,percent of total billed charges,,,57.6,,4284.29,percent of total billed charges,,,85,,6322.3,percent of total billed charges,,,85,,6322.3,percent of total billed charges,,,49,,3644.62,percent of total billed charges,,,90,,6694.2,percent of total billed charges,,,65,,4834.7,percent of total billed charges,,,80,,5950.4,percent of total billed charges,,,55,,4090.9,percent of total billed charges,,,55,,4090.9,percent of total billed charges,,,65,,4834.7,percent of total billed charges,,,78,,5801.64,percent of total billed charges,,,70,,5206.6,percent of total billed charges,,,,,,,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,,2983.46,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,2983.46,6694.2,
EXC ABD LES SC 3 CM/> (22903),22903,CPT,,,,outpatient,,,7774,4664.4,,45.5,,3537.17,percent of total billed charges,,,45.3,,3521.62,percent of total billed charges,,,51,,3964.74,percent of total billed charges,,,,,,,,,80,,6219.2,percent of total billed charges,,,61.4,,4773.24,percent of total billed charges,,,57.4,,4462.28,percent of total billed charges,,,81,,6296.94,percent of total billed charges,,,51.5,,4003.61,percent of total billed charges,,,57.6,,4477.82,percent of total billed charges,,,85,,6607.9,percent of total billed charges,,,85,,6607.9,percent of total billed charges,,,49,,3809.26,percent of total billed charges,,,90,,6996.6,percent of total billed charges,,,65,,5053.1,percent of total billed charges,,,80,,6219.2,percent of total billed charges,,,55,,4275.7,percent of total billed charges,,,55,,4275.7,percent of total billed charges,,,65,,5053.1,percent of total billed charges,,,78,,6063.72,percent of total billed charges,,,70,,5441.8,percent of total billed charges,,,,,,,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,,2983.46,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,2983.46,6996.6,
EXC SHOULDER LES SC 3 CM/> (23071),23071,CPT,,,,outpatient,,,7774,4664.4,,45.5,,3537.17,percent of total billed charges,,,45.3,,3521.62,percent of total billed charges,,,51,,3964.74,percent of total billed charges,,,,,,,,,80,,6219.2,percent of total billed charges,,,61.4,,4773.24,percent of total billed charges,,,57.4,,4462.28,percent of total billed charges,,,81,,6296.94,percent of total billed charges,,,51.5,,4003.61,percent of total billed charges,,,57.6,,4477.82,percent of total billed charges,,,85,,6607.9,percent of total billed charges,,,85,,6607.9,percent of total billed charges,,,49,,3809.26,percent of total billed charges,,,90,,6996.6,percent of total billed charges,,,65,,5053.1,percent of total billed charges,,,80,,6219.2,percent of total billed charges,,,55,,4275.7,percent of total billed charges,,,55,,4275.7,percent of total billed charges,,,65,,5053.1,percent of total billed charges,,,78,,6063.72,percent of total billed charges,,,70,,5441.8,percent of total billed charges,,,,,,,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,,1688.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1688.97,6996.6,
EXC BC/B Tumor Clav/Scapula,23140,CPT,,,,outpatient,,,7968,4780.8,,45.5,,3625.44,percent of total billed charges,,,45.3,,3609.5,percent of total billed charges,,,51,,4063.68,percent of total billed charges,,,,,,,,,80,,6374.4,percent of total billed charges,,,61.4,,4892.35,percent of total billed charges,,,57.4,,4573.63,percent of total billed charges,,,81,,6454.08,percent of total billed charges,,,51.5,,4103.52,percent of total billed charges,,,57.6,,4589.57,percent of total billed charges,,,85,,6772.8,percent of total billed charges,,,85,,6772.8,percent of total billed charges,,,49,,3904.32,percent of total billed charges,,,90,,7171.2,percent of total billed charges,,,65,,5179.2,percent of total billed charges,,,80,,6374.4,percent of total billed charges,,,55,,4382.4,percent of total billed charges,,,55,,4382.4,percent of total billed charges,,,65,,5179.2,percent of total billed charges,,,78,,6215.04,percent of total billed charges,,,70,,5577.6,percent of total billed charges,,,,,,,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,,3382.25,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,3382.25,7171.2,
"EXC BC/B Tumor Clav/Scapula, Bilateral",23140,CPT,,,50,outpatient,,,11953,7171.8,,45.5,,5438.62,percent of total billed charges,,,45.3,,5414.71,percent of total billed charges,,,51,,6096.03,percent of total billed charges,,,,,,,,,80,,9562.4,percent of total billed charges,,,61.4,,7339.14,percent of total billed charges,,,57.4,,6861.02,percent of total billed charges,,,81,,9681.93,percent of total billed charges,,,51.5,,6155.8,percent of total billed charges,,,57.6,,6884.93,percent of total billed charges,,,85,,10160.05,percent of total billed charges,,,85,,10160.05,percent of total billed charges,,,49,,5856.97,percent of total billed charges,,,90,,10757.7,percent of total billed charges,,,65,,7769.45,percent of total billed charges,,,80,,9562.4,percent of total billed charges,,,55,,6574.15,percent of total billed charges,,,55,,6574.15,percent of total billed charges,,,65,,7769.45,percent of total billed charges,,,78,,9323.34,percent of total billed charges,,,70,,8367.1,percent of total billed charges,,,,,,,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,,5073.37,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,5073.37,10757.7,
OP TX SCLAV DISL ACUTE/CHR (23530),23530,CPT,,,,outpatient,,,16255,9753,,45.5,,7396.03,percent of total billed charges,,,45.3,,7363.52,percent of total billed charges,,,51,,8290.05,percent of total billed charges,,,,,,,,,80,,13004,percent of total billed charges,,,61.4,,9980.57,percent of total billed charges,,,57.4,,9330.37,percent of total billed charges,,,81,,13166.55,percent of total billed charges,,,51.5,,8371.33,percent of total billed charges,,,57.6,,9362.88,percent of total billed charges,,,85,,13816.75,percent of total billed charges,,,85,,13816.75,percent of total billed charges,,,49,,7964.95,percent of total billed charges,,,90,,14629.5,percent of total billed charges,,,65,,10565.75,percent of total billed charges,,,80,,13004,percent of total billed charges,,,55,,8940.25,percent of total billed charges,,,55,,8940.25,percent of total billed charges,,,65,,10565.75,percent of total billed charges,,,78,,12678.9,percent of total billed charges,,,70,,11378.5,percent of total billed charges,,,,,,,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,,7446.77,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,7363.52,14629.5,
DEEP I&D - UA/ELBOW (23930),23930,CPT,,,,outpatient,,,6756,4053.6,,45.5,,3073.98,percent of total billed charges,,,45.3,,3060.47,percent of total billed charges,,,51,,3445.56,percent of total billed charges,,,,,,,,,80,,5404.8,percent of total billed charges,,,61.4,,4148.18,percent of total billed charges,,,57.4,,3877.94,percent of total billed charges,,,81,,5472.36,percent of total billed charges,,,51.5,,3479.34,percent of total billed charges,,,57.6,,3891.46,percent of total billed charges,,,85,,5742.6,percent of total billed charges,,,85,,5742.6,percent of total billed charges,,,49,,3310.44,percent of total billed charges,,,90,,6080.4,percent of total billed charges,,,65,,4391.4,percent of total billed charges,,,80,,5404.8,percent of total billed charges,,,55,,3715.8,percent of total billed charges,,,55,,3715.8,percent of total billed charges,,,65,,4391.4,percent of total billed charges,,,78,,5269.68,percent of total billed charges,,,70,,4729.2,percent of total billed charges,,,,,,,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,,2983.46,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,2983.46,6080.4,
OP TX ELBOW PA FX/DISLOC (24586),24586,CPT,,,,outpatient,,,24099,14459.4,,45.5,,10965.05,percent of total billed charges,,,45.3,,10916.85,percent of total billed charges,,,51,,12290.49,percent of total billed charges,,,,,,,,,80,,19279.2,percent of total billed charges,,,61.4,,14796.79,percent of total billed charges,,,57.4,,13832.83,percent of total billed charges,,,81,,19520.19,percent of total billed charges,,,51.5,,12410.99,percent of total billed charges,,,57.6,,13881.02,percent of total billed charges,,,85,,20484.15,percent of total billed charges,,,85,,20484.15,percent of total billed charges,,,49,,11808.51,percent of total billed charges,,,90,,21689.1,percent of total billed charges,,,65,,15664.35,percent of total billed charges,,,80,,19279.2,percent of total billed charges,,,55,,13254.45,percent of total billed charges,,,55,,13254.45,percent of total billed charges,,,65,,15664.35,percent of total billed charges,,,78,,18797.22,percent of total billed charges,,,70,,16869.3,percent of total billed charges,,,,,,,,13412.63,,,,100% of Medicare,,13412.63,,,,100% of Medicare,,13412.63,,,,100% of Medicare,,13412.63,,,,100% of Medicare,,13412.63,,,,100% of Medicare,,13412.63,,,,100% of Medicare,,13412.63,,,,100% of Medicare,,13412.63,,,,100% of Medicare,,13412.63,,,,100% of Medicare,,13412.63,,,,100% of Medicare,,13412.63,,,,100% of Medicare,,13412.63,,,,100% of Medicare,,,13412.63,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,10916.85,21689.1,
"INTERCARPAL FUSION, WO BONE GRAFT (25820)",25820,CPT,,,,outpatient,,,15211,9126.6,,45.5,,6921.01,percent of total billed charges,,,45.3,,6890.58,percent of total billed charges,,,51,,7757.61,percent of total billed charges,,,,,,,,,80,,12168.8,percent of total billed charges,,,61.4,,9339.55,percent of total billed charges,,,57.4,,8731.11,percent of total billed charges,,,81,,12320.91,percent of total billed charges,,,51.5,,7833.67,percent of total billed charges,,,57.6,,8761.54,percent of total billed charges,,,85,,12929.35,percent of total billed charges,,,85,,12929.35,percent of total billed charges,,,49,,7453.39,percent of total billed charges,,,90,,13689.9,percent of total billed charges,,,65,,9887.15,percent of total billed charges,,,80,,12168.8,percent of total billed charges,,,55,,8366.05,percent of total billed charges,,,55,,8366.05,percent of total billed charges,,,65,,9887.15,percent of total billed charges,,,78,,11864.58,percent of total billed charges,,,70,,10647.7,percent of total billed charges,,,,,,,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,,7446.77,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,6890.58,13689.9,
"Drainage of palmar bursa; single, bursa (26025)",26025,CPT,,,,outpatient,,,4396,2637.6,,45.5,,2000.18,percent of total billed charges,,,45.3,,1991.39,percent of total billed charges,,,51,,2241.96,percent of total billed charges,,,,,,,,,80,,3516.8,percent of total billed charges,,,61.4,,2699.14,percent of total billed charges,,,57.4,,2523.3,percent of total billed charges,,,81,,3560.76,percent of total billed charges,,,51.5,,2263.94,percent of total billed charges,,,57.6,,2532.1,percent of total billed charges,,,85,,3736.6,percent of total billed charges,,,85,,3736.6,percent of total billed charges,,,49,,2154.04,percent of total billed charges,,,90,,3956.4,percent of total billed charges,,,65,,2857.4,percent of total billed charges,,,80,,3516.8,percent of total billed charges,,,55,,2417.8,percent of total billed charges,,,55,,2417.8,percent of total billed charges,,,65,,2857.4,percent of total billed charges,,,78,,3428.88,percent of total billed charges,,,70,,3077.2,percent of total billed charges,,,,,,,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,,3382.25,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1991.39,3956.4,
Drain Palmar Bursa; Complicated,26030,CPT,,,,outpatient,,,5062,3037.2,,45.5,,2303.21,percent of total billed charges,,,45.3,,2293.09,percent of total billed charges,,,51,,2581.62,percent of total billed charges,,,,,,,,,80,,4049.6,percent of total billed charges,,,61.4,,3108.07,percent of total billed charges,,,57.4,,2905.59,percent of total billed charges,,,81,,4100.22,percent of total billed charges,,,51.5,,2606.93,percent of total billed charges,,,57.6,,2915.71,percent of total billed charges,,,85,,4302.7,percent of total billed charges,,,85,,4302.7,percent of total billed charges,,,49,,2480.38,percent of total billed charges,,,90,,4555.8,percent of total billed charges,,,65,,3290.3,percent of total billed charges,,,80,,4049.6,percent of total billed charges,,,55,,2784.1,percent of total billed charges,,,55,,2784.1,percent of total billed charges,,,65,,3290.3,percent of total billed charges,,,78,,3948.36,percent of total billed charges,,,70,,3543.4,percent of total billed charges,,,,,,,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,,3382.25,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,2293.09,4555.8,
EXPL/REM FB IPH JOINT EA (26080),26080,CPT,,,,outpatient,,,5384,3230.4,,45.5,,2449.72,percent of total billed charges,,,45.3,,2438.95,percent of total billed charges,,,51,,2745.84,percent of total billed charges,,,,,,,,,80,,4307.2,percent of total billed charges,,,61.4,,3305.78,percent of total billed charges,,,57.4,,3090.42,percent of total billed charges,,,81,,4361.04,percent of total billed charges,,,51.5,,2772.76,percent of total billed charges,,,57.6,,3101.18,percent of total billed charges,,,85,,4576.4,percent of total billed charges,,,85,,4576.4,percent of total billed charges,,,49,,2638.16,percent of total billed charges,,,90,,4845.6,percent of total billed charges,,,65,,3499.6,percent of total billed charges,,,80,,4307.2,percent of total billed charges,,,55,,2961.2,percent of total billed charges,,,55,,2961.2,percent of total billed charges,,,65,,3499.6,percent of total billed charges,,,78,,4199.52,percent of total billed charges,,,70,,3768.8,percent of total billed charges,,,,,,,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,,1668.3,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1668.3,4845.6,
TREAT KNUCKLE DISLOCATION (26715),26715,CPT,,,,outpatient,,,8865,5319,,45.5,,4033.58,percent of total billed charges,,,45.3,,4015.85,percent of total billed charges,,,51,,4521.15,percent of total billed charges,,,,,,,,,80,,7092,percent of total billed charges,,,61.4,,5443.11,percent of total billed charges,,,57.4,,5088.51,percent of total billed charges,,,81,,7180.65,percent of total billed charges,,,51.5,,4565.48,percent of total billed charges,,,57.6,,5106.24,percent of total billed charges,,,85,,7535.25,percent of total billed charges,,,85,,7535.25,percent of total billed charges,,,49,,4343.85,percent of total billed charges,,,90,,7978.5,percent of total billed charges,,,65,,5762.25,percent of total billed charges,,,80,,7092,percent of total billed charges,,,55,,4875.75,percent of total billed charges,,,55,,4875.75,percent of total billed charges,,,65,,5762.25,percent of total billed charges,,,78,,6914.7,percent of total billed charges,,,70,,6205.5,percent of total billed charges,,,,,,,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,,3382.25,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,3382.25,7978.5,
"Open Tx distal Phalang FX ,each",26765,CPT,,,,outpatient,,,9208,5524.8,,45.5,,4189.64,percent of total billed charges,,,45.3,,4171.22,percent of total billed charges,,,51,,4696.08,percent of total billed charges,,,,,,,,,80,,7366.4,percent of total billed charges,,,61.4,,5653.71,percent of total billed charges,,,57.4,,5285.39,percent of total billed charges,,,81,,7458.48,percent of total billed charges,,,51.5,,4742.12,percent of total billed charges,,,57.6,,5303.81,percent of total billed charges,,,85,,7826.8,percent of total billed charges,,,85,,7826.8,percent of total billed charges,,,49,,4511.92,percent of total billed charges,,,90,,8287.2,percent of total billed charges,,,65,,5985.2,percent of total billed charges,,,80,,7366.4,percent of total billed charges,,,55,,5064.4,percent of total billed charges,,,55,,5064.4,percent of total billed charges,,,65,,5985.2,percent of total billed charges,,,78,,7182.24,percent of total billed charges,,,70,,6445.6,percent of total billed charges,,,,,,,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,,3382.25,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,3382.25,8287.2,
TREAT FINGER DISLOCATION (26785),26785,CPT,,,,outpatient,,,8865,5319,,45.5,,4033.58,percent of total billed charges,,,45.3,,4015.85,percent of total billed charges,,,51,,4521.15,percent of total billed charges,,,,,,,,,80,,7092,percent of total billed charges,,,61.4,,5443.11,percent of total billed charges,,,57.4,,5088.51,percent of total billed charges,,,81,,7180.65,percent of total billed charges,,,51.5,,4565.48,percent of total billed charges,,,57.6,,5106.24,percent of total billed charges,,,85,,7535.25,percent of total billed charges,,,85,,7535.25,percent of total billed charges,,,49,,4343.85,percent of total billed charges,,,90,,7978.5,percent of total billed charges,,,65,,5762.25,percent of total billed charges,,,80,,7092,percent of total billed charges,,,55,,4875.75,percent of total billed charges,,,55,,4875.75,percent of total billed charges,,,65,,5762.25,percent of total billed charges,,,78,,6914.7,percent of total billed charges,,,70,,6205.5,percent of total billed charges,,,,,,,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,,3382.25,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,3382.25,7978.5,
REMOVAL OF TAIL BONE (27080),27080,CPT,,,,outpatient,,,10739,6443.4,,45.5,,4886.25,percent of total billed charges,,,45.3,,4864.77,percent of total billed charges,,,51,,5476.89,percent of total billed charges,,,,,,,,,80,,8591.2,percent of total billed charges,,,61.4,,6593.75,percent of total billed charges,,,57.4,,6164.19,percent of total billed charges,,,81,,8698.59,percent of total billed charges,,,51.5,,5530.59,percent of total billed charges,,,57.6,,6185.66,percent of total billed charges,,,85,,9128.15,percent of total billed charges,,,85,,9128.15,percent of total billed charges,,,49,,5262.11,percent of total billed charges,,,90,,9665.1,percent of total billed charges,,,65,,6980.35,percent of total billed charges,,,80,,8591.2,percent of total billed charges,,,55,,5906.45,percent of total billed charges,,,55,,5906.45,percent of total billed charges,,,65,,6980.35,percent of total billed charges,,,78,,8376.42,percent of total billed charges,,,70,,7517.3,percent of total billed charges,,,,,,,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,,3382.25,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,3382.25,9665.1,
Sacroiliac Joint Injection 27096 G0260,27096,CPT,G0259,HCPCS,,outpatient,,,1265,759,,45.5,,575.58,percent of total billed charges,,,45.3,,573.05,percent of total billed charges,,,51,,645.15,percent of total billed charges,,,,,,,,,80,,1012,percent of total billed charges,,,61.4,,776.71,percent of total billed charges,,,57.4,,726.11,percent of total billed charges,,,81,,1024.65,percent of total billed charges,,,51.5,,651.48,percent of total billed charges,,,57.6,,728.64,percent of total billed charges,,,85,,1075.25,percent of total billed charges,,,85,,1075.25,percent of total billed charges,,,49,,619.85,percent of total billed charges,,,90,,1138.5,percent of total billed charges,,,65,,822.25,percent of total billed charges,,,80,,1012,percent of total billed charges,,,55,,695.75,percent of total billed charges,,,55,,695.75,percent of total billed charges,,,65,,822.25,percent of total billed charges,,,78,,986.7,percent of total billed charges,,,70,,885.5,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,573.05,1138.5,
Sacroiliac Joint Injection w anesthesia 27096 G0260,27096,CPT,G0260,HCPCS,,outpatient,,,2389,1433.4,,45.5,,1087,percent of total billed charges,,,45.3,,1082.22,percent of total billed charges,,,51,,1218.39,percent of total billed charges,,,,,,,,,80,,1911.2,percent of total billed charges,,,61.4,,1466.85,percent of total billed charges,,,57.4,,1371.29,percent of total billed charges,,,81,,1935.09,percent of total billed charges,,,51.5,,1230.34,percent of total billed charges,,,57.6,,1376.06,percent of total billed charges,,,85,,2030.65,percent of total billed charges,,,85,,2030.65,percent of total billed charges,,,49,,1170.61,percent of total billed charges,,,90,,2150.1,percent of total billed charges,,,65,,1552.85,percent of total billed charges,,,80,,1911.2,percent of total billed charges,,,55,,1313.95,percent of total billed charges,,,55,,1313.95,percent of total billed charges,,,65,,1552.85,percent of total billed charges,,,78,,1863.42,percent of total billed charges,,,70,,1672.3,percent of total billed charges,,,,,,,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,,721.9,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,721.9,2150.1,
Sacroiliac Joint Injection-Bilateral arthrography (27096/G0259),27096,CPT,G0259,HCPCS,50,outpatient,,,2650,1590,,45.5,,1205.75,percent of total billed charges,,,45.3,,1200.45,percent of total billed charges,,,51,,1351.5,percent of total billed charges,,,,,,,,,80,,2120,percent of total billed charges,,,61.4,,1627.1,percent of total billed charges,,,57.4,,1521.1,percent of total billed charges,,,81,,2146.5,percent of total billed charges,,,51.5,,1364.75,percent of total billed charges,,,57.6,,1526.4,percent of total billed charges,,,85,,2252.5,percent of total billed charges,,,85,,2252.5,percent of total billed charges,,,49,,1298.5,percent of total billed charges,,,90,,2385,percent of total billed charges,,,65,,1722.5,percent of total billed charges,,,80,,2120,percent of total billed charges,,,55,,1457.5,percent of total billed charges,,,55,,1457.5,percent of total billed charges,,,65,,1722.5,percent of total billed charges,,,78,,2067,percent of total billed charges,,,70,,1855,percent of total billed charges,,,,,,,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1200.45,2385,
Sacroiliac Joint Injection-Bilateral w/ anesthesia (27096/G0260),27096,CPT,G0260,HCPCS,50,outpatient,,,2650,1590,,45.5,,1205.75,percent of total billed charges,,,45.3,,1200.45,percent of total billed charges,,,51,,1351.5,percent of total billed charges,,,,,,,,,80,,2120,percent of total billed charges,,,61.4,,1627.1,percent of total billed charges,,,57.4,,1521.1,percent of total billed charges,,,81,,2146.5,percent of total billed charges,,,51.5,,1364.75,percent of total billed charges,,,57.6,,1526.4,percent of total billed charges,,,85,,2252.5,percent of total billed charges,,,85,,2252.5,percent of total billed charges,,,49,,1298.5,percent of total billed charges,,,90,,2385,percent of total billed charges,,,65,,1722.5,percent of total billed charges,,,80,,2120,percent of total billed charges,,,55,,1457.5,percent of total billed charges,,,55,,1457.5,percent of total billed charges,,,65,,1722.5,percent of total billed charges,,,78,,2067,percent of total billed charges,,,70,,1855,percent of total billed charges,,,,,,,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,,1082.85,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1082.85,2385,
CL TX OF ACETABULUM X(S); WO MAN,27220,CPT,,,,outpatient,,,547,328.2,,45.5,,248.89,percent of total billed charges,,,45.3,,247.79,percent of total billed charges,,,51,,278.97,percent of total billed charges,,,,,,,,,80,,437.6,percent of total billed charges,,,61.4,,335.86,percent of total billed charges,,,57.4,,313.98,percent of total billed charges,,,81,,443.07,percent of total billed charges,,,51.5,,281.71,percent of total billed charges,,,57.6,,315.07,percent of total billed charges,,,85,,464.95,percent of total billed charges,,,85,,464.95,percent of total billed charges,,,49,,268.03,percent of total billed charges,,,90,,492.3,percent of total billed charges,,,65,,355.55,percent of total billed charges,,,80,,437.6,percent of total billed charges,,,55,,300.85,percent of total billed charges,,,55,,300.85,percent of total billed charges,,,65,,355.55,percent of total billed charges,,,78,,426.66,percent of total billed charges,,,70,,382.9,percent of total billed charges,,,,,,,,250.06,,,,100% of Medicare,,250.06,,,,100% of Medicare,,250.06,,,,100% of Medicare,,250.06,,,,100% of Medicare,,250.06,,,,100% of Medicare,,250.06,,,,100% of Medicare,,250.06,,,,100% of Medicare,,250.06,,,,100% of Medicare,,250.06,,,,100% of Medicare,,250.06,,,,100% of Medicare,,250.06,,,,100% of Medicare,,250.06,,,,100% of Medicare,,,250.06,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,247.79,492.3,
"Incision and Drainage, deep abscess, bursa, or hematoma, thigh or knee region",27301,CPT,,,,outpatient,,,6832,4099.2,,45.5,,3108.56,percent of total billed charges,,,45.3,,3094.9,percent of total billed charges,,,51,,3484.32,percent of total billed charges,,,,,,,,,80,,5465.6,percent of total billed charges,,,61.4,,4194.85,percent of total billed charges,,,57.4,,3921.57,percent of total billed charges,,,81,,5533.92,percent of total billed charges,,,51.5,,3518.48,percent of total billed charges,,,57.6,,3935.23,percent of total billed charges,,,85,,5807.2,percent of total billed charges,,,85,,5807.2,percent of total billed charges,,,49,,3347.68,percent of total billed charges,,,90,,6148.8,percent of total billed charges,,,65,,4440.8,percent of total billed charges,,,80,,5465.6,percent of total billed charges,,,55,,3757.6,percent of total billed charges,,,55,,3757.6,percent of total billed charges,,,65,,4440.8,percent of total billed charges,,,78,,5328.96,percent of total billed charges,,,70,,4782.4,percent of total billed charges,,,,,,,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,,2983.46,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,2983.46,6148.8,
"Incision and Drainage, deep abscess, bursa or hematoma, thigh or knee region, bilateral",27301,CPT,,,50,outpatient,,,11854,7112.4,,45.5,,5393.57,percent of total billed charges,,,45.3,,5369.86,percent of total billed charges,,,51,,6045.54,percent of total billed charges,,,,,,,,,80,,9483.2,percent of total billed charges,,,61.4,,7278.36,percent of total billed charges,,,57.4,,6804.2,percent of total billed charges,,,81,,9601.74,percent of total billed charges,,,51.5,,6104.81,percent of total billed charges,,,57.6,,6827.9,percent of total billed charges,,,85,,10075.9,percent of total billed charges,,,85,,10075.9,percent of total billed charges,,,49,,5808.46,percent of total billed charges,,,90,,10668.6,percent of total billed charges,,,65,,7705.1,percent of total billed charges,,,80,,9483.2,percent of total billed charges,,,55,,6519.7,percent of total billed charges,,,55,,6519.7,percent of total billed charges,,,65,,7705.1,percent of total billed charges,,,78,,9246.12,percent of total billed charges,,,70,,8297.8,percent of total billed charges,,,,,,,,4475.19,,,,150% of Medicare,,4475.19,,,,150% of Medicare,,4475.19,,,,150% of Medicare,,4475.19,,,,150% of Medicare,,4475.19,,,,150% of Medicare,,4475.19,,,,150% of Medicare,,4475.19,,,,150% of Medicare,,4475.19,,,,150% of Medicare,,4475.19,,,,150% of Medicare,,4475.19,,,,150% of Medicare,,4475.19,,,,150% of Medicare,,4475.19,,,,150% of Medicare,,,4475.19,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,4475.19,10668.6,
Incise Thigh Tendon and Fascia,27305,CPT,,,,outpatient,,,8968,5380.8,,45.5,,4080.44,percent of total billed charges,,,45.3,,4062.5,percent of total billed charges,,,51,,4573.68,percent of total billed charges,,,,,,,,,80,,7174.4,percent of total billed charges,,,61.4,,5506.35,percent of total billed charges,,,57.4,,5147.63,percent of total billed charges,,,81,,7264.08,percent of total billed charges,,,51.5,,4618.52,percent of total billed charges,,,57.6,,5165.57,percent of total billed charges,,,85,,7622.8,percent of total billed charges,,,85,,7622.8,percent of total billed charges,,,49,,4394.32,percent of total billed charges,,,90,,8071.2,percent of total billed charges,,,65,,5829.2,percent of total billed charges,,,80,,7174.4,percent of total billed charges,,,55,,4932.4,percent of total billed charges,,,55,,4932.4,percent of total billed charges,,,65,,5829.2,percent of total billed charges,,,78,,6995.04,percent of total billed charges,,,70,,6277.6,percent of total billed charges,,,,,,,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,,3382.25,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,3382.25,8071.2,
"Incise Thigh Tendon and Fascia, Bilateral",27305,CPT,,,50,outpatient,,,13450,8070,,45.5,,6119.75,percent of total billed charges,,,45.3,,6092.85,percent of total billed charges,,,51,,6859.5,percent of total billed charges,,,,,,,,,80,,10760,percent of total billed charges,,,61.4,,8258.3,percent of total billed charges,,,57.4,,7720.3,percent of total billed charges,,,81,,10894.5,percent of total billed charges,,,51.5,,6926.75,percent of total billed charges,,,57.6,,7747.2,percent of total billed charges,,,85,,11432.5,percent of total billed charges,,,85,,11432.5,percent of total billed charges,,,49,,6590.5,percent of total billed charges,,,90,,12105,percent of total billed charges,,,65,,8742.5,percent of total billed charges,,,80,,10760,percent of total billed charges,,,55,,7397.5,percent of total billed charges,,,55,,7397.5,percent of total billed charges,,,65,,8742.5,percent of total billed charges,,,78,,10491,percent of total billed charges,,,70,,9415,percent of total billed charges,,,,,,,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,,5073.37,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,5073.37,12105,
EXC THIGH/KNEE LES SC < 3 CM (27327),27327,CPT,,,,outpatient,,,4330,2598,,45.5,,1970.15,percent of total billed charges,,,45.3,,1961.49,percent of total billed charges,,,51,,2208.3,percent of total billed charges,,,,,,,,,80,,3464,percent of total billed charges,,,61.4,,2658.62,percent of total billed charges,,,57.4,,2485.42,percent of total billed charges,,,81,,3507.3,percent of total billed charges,,,51.5,,2229.95,percent of total billed charges,,,57.6,,2494.08,percent of total billed charges,,,85,,3680.5,percent of total billed charges,,,85,,3680.5,percent of total billed charges,,,49,,2121.7,percent of total billed charges,,,90,,3897,percent of total billed charges,,,65,,2814.5,percent of total billed charges,,,80,,3464,percent of total billed charges,,,55,,2381.5,percent of total billed charges,,,55,,2381.5,percent of total billed charges,,,65,,2814.5,percent of total billed charges,,,78,,3377.4,percent of total billed charges,,,70,,3031,percent of total billed charges,,,,,,,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,,1688.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1688.97,3897,
EXC THIGH/KNEE TUM DEEP <5CM (27328),27328,CPT,,,,outpatient,,,5762,3457.2,,45.5,,2621.71,percent of total billed charges,,,45.3,,2610.19,percent of total billed charges,,,51,,2938.62,percent of total billed charges,,,,,,,,,80,,4609.6,percent of total billed charges,,,61.4,,3537.87,percent of total billed charges,,,57.4,,3307.39,percent of total billed charges,,,81,,4667.22,percent of total billed charges,,,51.5,,2967.43,percent of total billed charges,,,57.6,,3318.91,percent of total billed charges,,,85,,4897.7,percent of total billed charges,,,85,,4897.7,percent of total billed charges,,,49,,2823.38,percent of total billed charges,,,90,,5185.8,percent of total billed charges,,,65,,3745.3,percent of total billed charges,,,80,,4609.6,percent of total billed charges,,,55,,3169.1,percent of total billed charges,,,55,,3169.1,percent of total billed charges,,,65,,3745.3,percent of total billed charges,,,78,,4494.36,percent of total billed charges,,,70,,4033.4,percent of total billed charges,,,,,,,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,,2983.46,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,2610.19,5185.8,
"EXC THIGH/KNEE TUM DEEP <5CM, Bilateral (27328-50)",27328,CPT,,,50,outpatient,,,8641,5184.6,,45.5,,3931.66,percent of total billed charges,,,45.3,,3914.37,percent of total billed charges,,,51,,4406.91,percent of total billed charges,,,,,,,,,80,,6912.8,percent of total billed charges,,,61.4,,5305.57,percent of total billed charges,,,57.4,,4959.93,percent of total billed charges,,,81,,6999.21,percent of total billed charges,,,51.5,,4450.12,percent of total billed charges,,,57.6,,4977.22,percent of total billed charges,,,85,,7344.85,percent of total billed charges,,,85,,7344.85,percent of total billed charges,,,49,,4234.09,percent of total billed charges,,,90,,7776.9,percent of total billed charges,,,65,,5616.65,percent of total billed charges,,,80,,6912.8,percent of total billed charges,,,55,,4752.55,percent of total billed charges,,,55,,4752.55,percent of total billed charges,,,65,,5616.65,percent of total billed charges,,,78,,6739.98,percent of total billed charges,,,70,,6048.7,percent of total billed charges,,,,,,,,4475.19,,,,150% of Medicare,,4475.19,,,,150% of Medicare,,4475.19,,,,150% of Medicare,,4475.19,,,,150% of Medicare,,4475.19,,,,150% of Medicare,,4475.19,,,,150% of Medicare,,4475.19,,,,150% of Medicare,,4475.19,,,,150% of Medicare,,4475.19,,,,150% of Medicare,,4475.19,,,,150% of Medicare,,4475.19,,,,150% of Medicare,,4475.19,,,,150% of Medicare,,,4475.19,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,3914.37,7776.9,
"Removal of foreign body, deep, thigh region or knee area (27372)",27372,CPT,,,,outpatient,,,7969,4781.4,,45.5,,3625.9,percent of total billed charges,,,45.3,,3609.96,percent of total billed charges,,,51,,4064.19,percent of total billed charges,,,,,,,,,80,,6375.2,percent of total billed charges,,,61.4,,4892.97,percent of total billed charges,,,57.4,,4574.21,percent of total billed charges,,,81,,6454.89,percent of total billed charges,,,51.5,,4104.04,percent of total billed charges,,,57.6,,4590.14,percent of total billed charges,,,85,,6773.65,percent of total billed charges,,,85,,6773.65,percent of total billed charges,,,49,,3904.81,percent of total billed charges,,,90,,7172.1,percent of total billed charges,,,65,,5179.85,percent of total billed charges,,,80,,6375.2,percent of total billed charges,,,55,,4382.95,percent of total billed charges,,,55,,4382.95,percent of total billed charges,,,65,,5179.85,percent of total billed charges,,,78,,6215.82,percent of total billed charges,,,70,,5578.3,percent of total billed charges,,,,,,,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,,2983.46,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,2983.46,7172.1,
Suture of Infrapatellar Tendon; Primary,27380,CPT,,,,outpatient,,,9585,5751,,45.5,,4361.18,percent of total billed charges,,,45.3,,4342.01,percent of total billed charges,,,51,,4888.35,percent of total billed charges,,,,,,,,,80,,7668,percent of total billed charges,,,61.4,,5885.19,percent of total billed charges,,,57.4,,5501.79,percent of total billed charges,,,81,,7763.85,percent of total billed charges,,,51.5,,4936.28,percent of total billed charges,,,57.6,,5520.96,percent of total billed charges,,,85,,8147.25,percent of total billed charges,,,85,,8147.25,percent of total billed charges,,,49,,4696.65,percent of total billed charges,,,90,,8626.5,percent of total billed charges,,,65,,6230.25,percent of total billed charges,,,80,,7668,percent of total billed charges,,,55,,5271.75,percent of total billed charges,,,55,,5271.75,percent of total billed charges,,,65,,6230.25,percent of total billed charges,,,78,,7476.3,percent of total billed charges,,,70,,6709.5,percent of total billed charges,,,,,,,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,,7446.77,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,4342.01,8626.5,
"Suture of Infrapatellar Tendon; Primary, Bilateral",27380,CPT,,,50,outpatient,,,13450,8070,,45.5,,6119.75,percent of total billed charges,,,45.3,,6092.85,percent of total billed charges,,,51,,6859.5,percent of total billed charges,,,,,,,,,80,,10760,percent of total billed charges,,,61.4,,8258.3,percent of total billed charges,,,57.4,,7720.3,percent of total billed charges,,,81,,10894.5,percent of total billed charges,,,51.5,,6926.75,percent of total billed charges,,,57.6,,7747.2,percent of total billed charges,,,85,,11432.5,percent of total billed charges,,,85,,11432.5,percent of total billed charges,,,49,,6590.5,percent of total billed charges,,,90,,12105,percent of total billed charges,,,65,,8742.5,percent of total billed charges,,,80,,10760,percent of total billed charges,,,55,,7397.5,percent of total billed charges,,,55,,7397.5,percent of total billed charges,,,65,,8742.5,percent of total billed charges,,,78,,10491,percent of total billed charges,,,70,,9415,percent of total billed charges,,,,,,,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,,11170.15,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,6092.85,12105,
"Revise thigh muscle/tendons, Bilateral(Rectus Transfer)",27400,CPT,,,50,outpatient,,,24618,14770.8,,45.5,,11201.19,percent of total billed charges,,,45.3,,11151.95,percent of total billed charges,,,51,,12555.18,percent of total billed charges,,,,,,,,,80,,19694.4,percent of total billed charges,,,61.4,,15115.45,percent of total billed charges,,,57.4,,14130.73,percent of total billed charges,,,81,,19940.58,percent of total billed charges,,,51.5,,12678.27,percent of total billed charges,,,57.6,,14179.97,percent of total billed charges,,,85,,20925.3,percent of total billed charges,,,85,,20925.3,percent of total billed charges,,,49,,12062.82,percent of total billed charges,,,90,,22156.2,percent of total billed charges,,,65,,16001.7,percent of total billed charges,,,80,,19694.4,percent of total billed charges,,,55,,13539.9,percent of total billed charges,,,55,,13539.9,percent of total billed charges,,,65,,16001.7,percent of total billed charges,,,78,,19202.04,percent of total billed charges,,,70,,17232.6,percent of total billed charges,,,,,,,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,,11170.15,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,11151.95,22156.2,
"Arrest, epiphyseal, any method (eg, epiphysiodesis); distal femur Bilateral (27475-50)",27475,CPT,,,50,outpatient,,,16129,9677.4,,45.5,,7338.7,percent of total billed charges,,,45.3,,7306.44,percent of total billed charges,,,51,,8225.79,percent of total billed charges,,,,,,,,,80,,12903.2,percent of total billed charges,,,61.4,,9903.21,percent of total billed charges,,,57.4,,9258.05,percent of total billed charges,,,81,,13064.49,percent of total billed charges,,,51.5,,8306.44,percent of total billed charges,,,57.6,,9290.3,percent of total billed charges,,,85,,13709.65,percent of total billed charges,,,85,,13709.65,percent of total billed charges,,,49,,7903.21,percent of total billed charges,,,90,,14516.1,percent of total billed charges,,,65,,10483.85,percent of total billed charges,,,80,,12903.2,percent of total billed charges,,,55,,8870.95,percent of total billed charges,,,55,,8870.95,percent of total billed charges,,,65,,10483.85,percent of total billed charges,,,78,,12580.62,percent of total billed charges,,,70,,11290.3,percent of total billed charges,,,,,,,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,18678.6,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,,11170.15,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,7306.44,18678.6,
CL TX FEMUR FX OR EPIPHYS SEP (27510),27510,CPT,,,,outpatient,,,1793,1075.8,,45.5,,815.82,percent of total billed charges,,,45.3,,812.23,percent of total billed charges,,,51,,914.43,percent of total billed charges,,,,,,,,,80,,1434.4,percent of total billed charges,,,61.4,,1100.9,percent of total billed charges,,,57.4,,1029.18,percent of total billed charges,,,81,,1452.33,percent of total billed charges,,,51.5,,923.4,percent of total billed charges,,,57.6,,1032.77,percent of total billed charges,,,85,,1524.05,percent of total billed charges,,,85,,1524.05,percent of total billed charges,,,49,,878.57,percent of total billed charges,,,90,,1613.7,percent of total billed charges,,,65,,1165.45,percent of total billed charges,,,80,,1434.4,percent of total billed charges,,,55,,986.15,percent of total billed charges,,,55,,986.15,percent of total billed charges,,,65,,1165.45,percent of total billed charges,,,78,,1398.54,percent of total billed charges,,,70,,1255.1,percent of total billed charges,,,,,,,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,,1668.3,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,812.23,1668.3,
CL TX FEMUR FX OR EPIPHYS SEP;Bilateral (27510-50),27510,CPT,,,50,outpatient,,,2586,1551.6,,45.5,,1176.63,percent of total billed charges,,,45.3,,1171.46,percent of total billed charges,,,51,,1318.86,percent of total billed charges,,,,,,,,,80,,2068.8,percent of total billed charges,,,61.4,,1587.8,percent of total billed charges,,,57.4,,1484.36,percent of total billed charges,,,81,,2094.66,percent of total billed charges,,,51.5,,1331.79,percent of total billed charges,,,57.6,,1489.54,percent of total billed charges,,,85,,2198.1,percent of total billed charges,,,85,,2198.1,percent of total billed charges,,,49,,1267.14,percent of total billed charges,,,90,,2327.4,percent of total billed charges,,,65,,1680.9,percent of total billed charges,,,80,,2068.8,percent of total billed charges,,,55,,1422.3,percent of total billed charges,,,55,,1422.3,percent of total billed charges,,,65,,1680.9,percent of total billed charges,,,78,,2017.08,percent of total billed charges,,,70,,1810.2,percent of total billed charges,,,,,,,,2502.45,,,,150% of Medicare,,2502.45,,,,150% of Medicare,,2502.45,,,,150% of Medicare,,2502.45,,,,150% of Medicare,,2502.45,,,,150% of Medicare,,2502.45,,,,150% of Medicare,,2502.45,,,,150% of Medicare,,2502.45,,,,150% of Medicare,,2502.45,,,,150% of Medicare,,2502.45,,,,150% of Medicare,,2502.45,,,,150% of Medicare,,2502.45,,,,150% of Medicare,,,2502.45,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1171.46,2502.45,
"Incision and Drainage; Leg, Ankle, Deep Abscess, or Hematoma",27603,CPT,,,,outpatient,,,7405,4443,,45.5,,3369.28,percent of total billed charges,,,45.3,,3354.47,percent of total billed charges,,,51,,3776.55,percent of total billed charges,,,,,,,,,80,,5924,percent of total billed charges,,,61.4,,4546.67,percent of total billed charges,,,57.4,,4250.47,percent of total billed charges,,,81,,5998.05,percent of total billed charges,,,51.5,,3813.58,percent of total billed charges,,,57.6,,4265.28,percent of total billed charges,,,85,,6294.25,percent of total billed charges,,,85,,6294.25,percent of total billed charges,,,49,,3628.45,percent of total billed charges,,,90,,6664.5,percent of total billed charges,,,65,,4813.25,percent of total billed charges,,,80,,5924,percent of total billed charges,,,55,,4072.75,percent of total billed charges,,,55,,4072.75,percent of total billed charges,,,65,,4813.25,percent of total billed charges,,,78,,5775.9,percent of total billed charges,,,70,,5183.5,percent of total billed charges,,,,,,,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,2983.46,,,,100% of Medicare,,,2983.46,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,2983.46,6664.5,
Percutaneous TAL gen anesthesia - bilateral,27606,CPT,,,50,outpatient,,,11180,6708,,45.5,,5086.9,percent of total billed charges,,,45.3,,5064.54,percent of total billed charges,,,51,,5701.8,percent of total billed charges,,,,,,,,,80,,8944,percent of total billed charges,,,61.4,,6864.52,percent of total billed charges,,,57.4,,6417.32,percent of total billed charges,,,81,,9055.8,percent of total billed charges,,,51.5,,5757.7,percent of total billed charges,,,57.6,,6439.68,percent of total billed charges,,,85,,9503,percent of total billed charges,,,85,,9503,percent of total billed charges,,,49,,5478.2,percent of total billed charges,,,90,,10062,percent of total billed charges,,,65,,7267,percent of total billed charges,,,80,,8944,percent of total billed charges,,,55,,6149,percent of total billed charges,,,55,,6149,percent of total billed charges,,,65,,7267,percent of total billed charges,,,78,,8720.4,percent of total billed charges,,,70,,7826,percent of total billed charges,,,,,,,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,,5073.37,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,5064.54,10062,
EXC LEG/ANKLE TUM < 3 CM (27618),27618,CPT,,,,outpatient,,,5540,3324,,45.5,,2520.7,percent of total billed charges,,,45.3,,2509.62,percent of total billed charges,,,51,,2825.4,percent of total billed charges,,,,,,,,,80,,4432,percent of total billed charges,,,61.4,,3401.56,percent of total billed charges,,,57.4,,3179.96,percent of total billed charges,,,81,,4487.4,percent of total billed charges,,,51.5,,2853.1,percent of total billed charges,,,57.6,,3191.04,percent of total billed charges,,,85,,4709,percent of total billed charges,,,85,,4709,percent of total billed charges,,,49,,2714.6,percent of total billed charges,,,90,,4986,percent of total billed charges,,,65,,3601,percent of total billed charges,,,80,,4432,percent of total billed charges,,,55,,3047,percent of total billed charges,,,55,,3047,percent of total billed charges,,,65,,3601,percent of total billed charges,,,78,,4321.2,percent of total billed charges,,,70,,3878,percent of total billed charges,,,,,,,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,1688.97,,,,100% of Medicare,,,1688.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1688.97,4986,
LNGTHN.SHORTN MULTI LEG/ANKLE TENDONS EA BILATERAL (27686-50),27686,CPT,,,50,outpatient,,,16464,9878.4,,45.5,,7491.12,percent of total billed charges,,,45.3,,7458.19,percent of total billed charges,,,51,,8396.64,percent of total billed charges,,,,,,,,,80,,13171.2,percent of total billed charges,,,61.4,,10108.9,percent of total billed charges,,,57.4,,9450.34,percent of total billed charges,,,81,,13335.84,percent of total billed charges,,,51.5,,8478.96,percent of total billed charges,,,57.6,,9483.26,percent of total billed charges,,,85,,13994.4,percent of total billed charges,,,85,,13994.4,percent of total billed charges,,,49,,8067.36,percent of total billed charges,,,90,,14817.6,percent of total billed charges,,,65,,10701.6,percent of total billed charges,,,80,,13171.2,percent of total billed charges,,,55,,9055.2,percent of total billed charges,,,55,,9055.2,percent of total billed charges,,,65,,10701.6,percent of total billed charges,,,78,,12841.92,percent of total billed charges,,,70,,11524.8,percent of total billed charges,,,,,,,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,,5073.37,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,5073.37,14817.6,
SUPERF TRANF/TRASPL SGL TENDON Bilateral (27690-50),27690,CPT,,,50,outpatient,,,23187,13912.2,,45.5,,10550.09,percent of total billed charges,,,45.3,,10503.71,percent of total billed charges,,,51,,11825.37,percent of total billed charges,,,,,,,,,80,,18549.6,percent of total billed charges,,,61.4,,14236.82,percent of total billed charges,,,57.4,,13309.34,percent of total billed charges,,,81,,18781.47,percent of total billed charges,,,51.5,,11941.31,percent of total billed charges,,,57.6,,13355.71,percent of total billed charges,,,85,,19708.95,percent of total billed charges,,,85,,19708.95,percent of total billed charges,,,49,,11361.63,percent of total billed charges,,,90,,20868.3,percent of total billed charges,,,65,,15071.55,percent of total billed charges,,,80,,18549.6,percent of total billed charges,,,55,,12752.85,percent of total billed charges,,,55,,12752.85,percent of total billed charges,,,65,,15071.55,percent of total billed charges,,,78,,18085.86,percent of total billed charges,,,70,,16230.9,percent of total billed charges,,,,,,,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,,11170.15,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,10503.71,20868.3,
"Arrest, epiphysiodesis, open; distal fibula (27732)",27732,CPT,,,,outpatient,,,10980,6588,,45.5,,4995.9,percent of total billed charges,,,45.3,,4973.94,percent of total billed charges,,,51,,5599.8,percent of total billed charges,,,,,,,,,80,,8784,percent of total billed charges,,,61.4,,6741.72,percent of total billed charges,,,57.4,,6302.52,percent of total billed charges,,,81,,8893.8,percent of total billed charges,,,51.5,,5654.7,percent of total billed charges,,,57.6,,6324.48,percent of total billed charges,,,85,,9333,percent of total billed charges,,,85,,9333,percent of total billed charges,,,49,,5380.2,percent of total billed charges,,,90,,9882,percent of total billed charges,,,65,,7137,percent of total billed charges,,,80,,8784,percent of total billed charges,,,55,,6039,percent of total billed charges,,,55,,6039,percent of total billed charges,,,65,,7137,percent of total billed charges,,,78,,8564.4,percent of total billed charges,,,70,,7686,percent of total billed charges,,,,,,,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,,3382.25,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,3382.25,9882,
DEEP DISSECT FOOT INF; SGL BURSA SP (28002),28002,CPT,,,,outpatient,,,4447,2668.2,,45.5,,2023.39,percent of total billed charges,,,45.3,,2014.49,percent of total billed charges,,,51,,2267.97,percent of total billed charges,,,,,,,,,80,,3557.6,percent of total billed charges,,,61.4,,2730.46,percent of total billed charges,,,57.4,,2552.58,percent of total billed charges,,,81,,3602.07,percent of total billed charges,,,51.5,,2290.21,percent of total billed charges,,,57.6,,2561.47,percent of total billed charges,,,85,,3779.95,percent of total billed charges,,,85,,3779.95,percent of total billed charges,,,49,,2179.03,percent of total billed charges,,,90,,4002.3,percent of total billed charges,,,65,,2890.55,percent of total billed charges,,,80,,3557.6,percent of total billed charges,,,55,,2445.85,percent of total billed charges,,,55,,2445.85,percent of total billed charges,,,65,,2890.55,percent of total billed charges,,,78,,3468.66,percent of total billed charges,,,70,,3112.9,percent of total billed charges,,,,,,,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,,1668.3,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1668.3,4002.3,
DEEP DISSECT FOOT INF; MULTI AREAS (28003),28003,CPT,,,,outpatient,,,7393,4435.8,,45.5,,3363.82,percent of total billed charges,,,45.3,,3349.03,percent of total billed charges,,,51,,3770.43,percent of total billed charges,,,,,,,,,80,,5914.4,percent of total billed charges,,,61.4,,4539.3,percent of total billed charges,,,57.4,,4243.58,percent of total billed charges,,,81,,5988.33,percent of total billed charges,,,51.5,,3807.4,percent of total billed charges,,,57.6,,4258.37,percent of total billed charges,,,85,,6284.05,percent of total billed charges,,,85,,6284.05,percent of total billed charges,,,49,,3622.57,percent of total billed charges,,,90,,6653.7,percent of total billed charges,,,65,,4805.45,percent of total billed charges,,,80,,5914.4,percent of total billed charges,,,55,,4066.15,percent of total billed charges,,,55,,4066.15,percent of total billed charges,,,65,,4805.45,percent of total billed charges,,,78,,5766.54,percent of total billed charges,,,70,,5175.1,percent of total billed charges,,,,,,,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,,3382.25,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,3349.03,6653.7,
Deep Inc Foot w Op Bone Cortex,28005,CPT,,,,outpatient,,,7836,4701.6,,45.5,,3565.38,percent of total billed charges,,,45.3,,3549.71,percent of total billed charges,,,51,,3996.36,percent of total billed charges,,,,,,,,,80,,6268.8,percent of total billed charges,,,61.4,,4811.3,percent of total billed charges,,,57.4,,4497.86,percent of total billed charges,,,81,,6347.16,percent of total billed charges,,,51.5,,4035.54,percent of total billed charges,,,57.6,,4513.54,percent of total billed charges,,,85,,6660.6,percent of total billed charges,,,85,,6660.6,percent of total billed charges,,,49,,3839.64,percent of total billed charges,,,90,,7052.4,percent of total billed charges,,,65,,5093.4,percent of total billed charges,,,80,,6268.8,percent of total billed charges,,,55,,4309.8,percent of total billed charges,,,55,,4309.8,percent of total billed charges,,,65,,5093.4,percent of total billed charges,,,78,,6112.08,percent of total billed charges,,,70,,5485.2,percent of total billed charges,,,,,,,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,,3382.25,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,3382.25,7052.4,
EXC FOOT CYST/GANGLION (28090),28090,CPT,,,,outpatient,,,7487,4492.2,,45.5,,3406.59,percent of total billed charges,,,45.3,,3391.61,percent of total billed charges,,,51,,3818.37,percent of total billed charges,,,,,,,,,80,,5989.6,percent of total billed charges,,,61.4,,4597.02,percent of total billed charges,,,57.4,,4297.54,percent of total billed charges,,,81,,6064.47,percent of total billed charges,,,51.5,,3855.81,percent of total billed charges,,,57.6,,4312.51,percent of total billed charges,,,85,,6363.95,percent of total billed charges,,,85,,6363.95,percent of total billed charges,,,49,,3668.63,percent of total billed charges,,,90,,6738.3,percent of total billed charges,,,65,,4866.55,percent of total billed charges,,,80,,5989.6,percent of total billed charges,,,55,,4117.85,percent of total billed charges,,,55,,4117.85,percent of total billed charges,,,65,,4866.55,percent of total billed charges,,,78,,5839.86,percent of total billed charges,,,70,,5240.9,percent of total billed charges,,,,,,,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,1668.3,,,,100% of Medicare,,,1668.3,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1668.3,6738.3,
PARTL EXC ANKLE OR HEEL BONE (28120),28120,CPT,,,,outpatient,,,7487,4492.2,,45.5,,3406.59,percent of total billed charges,,,45.3,,3391.61,percent of total billed charges,,,51,,3818.37,percent of total billed charges,,,,,,,,,80,,5989.6,percent of total billed charges,,,61.4,,4597.02,percent of total billed charges,,,57.4,,4297.54,percent of total billed charges,,,81,,6064.47,percent of total billed charges,,,51.5,,3855.81,percent of total billed charges,,,57.6,,4312.51,percent of total billed charges,,,85,,6363.95,percent of total billed charges,,,85,,6363.95,percent of total billed charges,,,49,,3668.63,percent of total billed charges,,,90,,6738.3,percent of total billed charges,,,65,,4866.55,percent of total billed charges,,,80,,5989.6,percent of total billed charges,,,55,,4117.85,percent of total billed charges,,,55,,4117.85,percent of total billed charges,,,65,,4866.55,percent of total billed charges,,,78,,5839.86,percent of total billed charges,,,70,,5240.9,percent of total billed charges,,,,,,,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,,3382.25,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,3382.25,6738.3,
"Removal of FB, foot; subcutaneous (28190)",28190,CPT,,,,outpatient,,,2802,1681.2,,45.5,,1274.91,percent of total billed charges,,,45.3,,1269.31,percent of total billed charges,,,51,,1429.02,percent of total billed charges,,,,,,,,,80,,2241.6,percent of total billed charges,,,61.4,,1720.43,percent of total billed charges,,,57.4,,1608.35,percent of total billed charges,,,81,,2269.62,percent of total billed charges,,,51.5,,1443.03,percent of total billed charges,,,57.6,,1613.95,percent of total billed charges,,,85,,2381.7,percent of total billed charges,,,85,,2381.7,percent of total billed charges,,,49,,1372.98,percent of total billed charges,,,90,,2521.8,percent of total billed charges,,,65,,1821.3,percent of total billed charges,,,80,,2241.6,percent of total billed charges,,,55,,1541.1,percent of total billed charges,,,55,,1541.1,percent of total billed charges,,,65,,1821.3,percent of total billed charges,,,78,,2185.56,percent of total billed charges,,,70,,1961.4,percent of total billed charges,,,,,,,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,733.44,,,,100% of Medicare,,,733.44,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,733.44,2521.8,
"Removal of FB, foot, Bilateral; subcut. (28190-50)",28190,CPT,,,50,outpatient,,,4204,2522.4,,45.5,,1912.82,percent of total billed charges,,,45.3,,1904.41,percent of total billed charges,,,51,,2144.04,percent of total billed charges,,,,,,,,,80,,3363.2,percent of total billed charges,,,61.4,,2581.26,percent of total billed charges,,,57.4,,2413.1,percent of total billed charges,,,81,,3405.24,percent of total billed charges,,,51.5,,2165.06,percent of total billed charges,,,57.6,,2421.5,percent of total billed charges,,,85,,3573.4,percent of total billed charges,,,85,,3573.4,percent of total billed charges,,,49,,2059.96,percent of total billed charges,,,90,,3783.6,percent of total billed charges,,,65,,2732.6,percent of total billed charges,,,80,,3363.2,percent of total billed charges,,,55,,2312.2,percent of total billed charges,,,55,,2312.2,percent of total billed charges,,,65,,2732.6,percent of total billed charges,,,78,,3279.12,percent of total billed charges,,,70,,2942.8,percent of total billed charges,,,,,,,,1100.15,,,,150% of Medicare,,1100.15,,,,150% of Medicare,,1100.15,,,,150% of Medicare,,1100.15,,,,150% of Medicare,,1100.15,,,,150% of Medicare,,1100.15,,,,150% of Medicare,,1100.15,,,,150% of Medicare,,1100.15,,,,150% of Medicare,,1100.15,,,,150% of Medicare,,1100.15,,,,150% of Medicare,,1100.15,,,,150% of Medicare,,1100.15,,,,150% of Medicare,,,1100.15,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1100.15,3783.6,
ADV POST TIBIAL TENDON W EXC NAVICLR BONE (28238),28238,CPT,,,,outpatient,,,17587,10552.2,,45.5,,8002.09,percent of total billed charges,,,45.3,,7966.91,percent of total billed charges,,,51,,8969.37,percent of total billed charges,,,,,,,,,80,,14069.6,percent of total billed charges,,,61.4,,10798.42,percent of total billed charges,,,57.4,,10094.94,percent of total billed charges,,,81,,14245.47,percent of total billed charges,,,51.5,,9057.31,percent of total billed charges,,,57.6,,10130.11,percent of total billed charges,,,85,,14948.95,percent of total billed charges,,,85,,14948.95,percent of total billed charges,,,49,,8617.63,percent of total billed charges,,,90,,15828.3,percent of total billed charges,,,65,,11431.55,percent of total billed charges,,,80,,14069.6,percent of total billed charges,,,55,,9672.85,percent of total billed charges,,,55,,9672.85,percent of total billed charges,,,65,,11431.55,percent of total billed charges,,,78,,13717.86,percent of total billed charges,,,70,,12310.9,percent of total billed charges,,,,,,,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,7446.77,,,,100% of Medicare,,,7446.77,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,7446.77,15828.3,
"ADV POST TIBIAL TENDON W EXC NAVICLR BONE,Bilateral (28238-50)",28238,CPT,,,50,outpatient,,,29645,17787,,45.5,,13488.48,percent of total billed charges,,,45.3,,13429.19,percent of total billed charges,,,51,,15118.95,percent of total billed charges,,,,,,,,,80,,23716,percent of total billed charges,,,61.4,,18202.03,percent of total billed charges,,,57.4,,17016.23,percent of total billed charges,,,81,,24012.45,percent of total billed charges,,,51.5,,15267.18,percent of total billed charges,,,57.6,,17075.52,percent of total billed charges,,,85,,25198.25,percent of total billed charges,,,85,,25198.25,percent of total billed charges,,,49,,14526.05,percent of total billed charges,,,90,,26680.5,percent of total billed charges,,,65,,19269.25,percent of total billed charges,,,80,,23716,percent of total billed charges,,,55,,16304.75,percent of total billed charges,,,55,,16304.75,percent of total billed charges,,,65,,19269.25,percent of total billed charges,,,78,,23123.1,percent of total billed charges,,,70,,20751.5,percent of total billed charges,,,,,,,,11170.15,,,,150% of Medicare,,11170.15,,,999999999,100% of Medicare,,11170.15,,,999999999,100% of Medicare,,11170.15,,,999999999,100% of Medicare,,11170.15,,,999999999,100% of Medicare,,11170.15,,,999999999,100% of Medicare,,11170.15,,,999999999,100% of Medicare,,11170.15,,,999999999,100% of Medicare,,11170.15,,,999999999,100% of Medicare,,11170.15,,,999999999,100% of Medicare,,11170.15,,,999999999,100% of Medicare,,11170.15,,,999999999,100% of Medicare,,,11170.15,,,999999999,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,11170.15,999999999,
"DIVIDE PLANTAR FASCIA & MSCL,BILATERAL (28250-50)",28250,CPT,,,50,outpatient,,,11231,6738.6,,45.5,,5110.11,percent of total billed charges,,,45.3,,5087.64,percent of total billed charges,,,51,,5727.81,percent of total billed charges,,,,,,,,,80,,8984.8,percent of total billed charges,,,61.4,,6895.83,percent of total billed charges,,,57.4,,6446.59,percent of total billed charges,,,81,,9097.11,percent of total billed charges,,,51.5,,5783.97,percent of total billed charges,,,57.6,,6469.06,percent of total billed charges,,,85,,9546.35,percent of total billed charges,,,85,,9546.35,percent of total billed charges,,,49,,5503.19,percent of total billed charges,,,90,,10107.9,percent of total billed charges,,,65,,7300.15,percent of total billed charges,,,80,,8984.8,percent of total billed charges,,,55,,6177.05,percent of total billed charges,,,55,,6177.05,percent of total billed charges,,,65,,7300.15,percent of total billed charges,,,78,,8760.18,percent of total billed charges,,,70,,7861.7,percent of total billed charges,,,,,,,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,5073.37,,,,150% of Medicare,,,5073.37,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,5073.37,10107.9,
EXTENSIVE MIDFOOT CAPSULOTOMY;Bilateral (28262-50),28262,CPT,,,50,outpatient,,,11231,6738.6,,45.5,,5110.11,percent of total billed charges,,,45.3,,5087.64,percent of total billed charges,,,51,,5727.81,percent of total billed charges,,,,,,,,,80,,8984.8,percent of total billed charges,,,61.4,,6895.83,percent of total billed charges,,,57.4,,6446.59,percent of total billed charges,,,81,,9097.11,percent of total billed charges,,,51.5,,5783.97,percent of total billed charges,,,57.6,,6469.06,percent of total billed charges,,,85,,9546.35,percent of total billed charges,,,85,,9546.35,percent of total billed charges,,,49,,5503.19,percent of total billed charges,,,90,,10107.9,percent of total billed charges,,,65,,7300.15,percent of total billed charges,,,80,,8984.8,percent of total billed charges,,,55,,6177.05,percent of total billed charges,,,55,,6177.05,percent of total billed charges,,,65,,7300.15,percent of total billed charges,,,78,,8760.18,percent of total billed charges,,,70,,7861.7,percent of total billed charges,,,,,,,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,,11170.15,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,5087.64,11170.15,
"Osteotomy Oscalcis, Bilateral",28300,CPT,,,50,outpatient,,,19166,11499.6,,45.5,,8720.53,percent of total billed charges,,,45.3,,8682.2,percent of total billed charges,,,51,,9774.66,percent of total billed charges,,,,,,,,,80,,15332.8,percent of total billed charges,,,61.4,,11767.92,percent of total billed charges,,,57.4,,11001.28,percent of total billed charges,,,81,,15524.46,percent of total billed charges,,,51.5,,9870.49,percent of total billed charges,,,57.6,,11039.62,percent of total billed charges,,,85,,16291.1,percent of total billed charges,,,85,,16291.1,percent of total billed charges,,,49,,9391.34,percent of total billed charges,,,90,,17249.4,percent of total billed charges,,,65,,12457.9,percent of total billed charges,,,80,,15332.8,percent of total billed charges,,,55,,10541.3,percent of total billed charges,,,55,,10541.3,percent of total billed charges,,,65,,12457.9,percent of total billed charges,,,78,,14949.48,percent of total billed charges,,,70,,13416.2,percent of total billed charges,,,,,,,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,,11170.15,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,8682.2,17249.4,
OSTEOTOMY MIDT BONE;Bilateral (28304-50),28304,CPT,,,50,outpatient,,,29648,17788.8,,45.5,,13489.84,percent of total billed charges,,,45.3,,13430.54,percent of total billed charges,,,51,,15120.48,percent of total billed charges,,,,,,,,,80,,23718.4,percent of total billed charges,,,61.4,,18203.87,percent of total billed charges,,,57.4,,17017.95,percent of total billed charges,,,81,,24014.88,percent of total billed charges,,,51.5,,15268.72,percent of total billed charges,,,57.6,,17077.25,percent of total billed charges,,,85,,25200.8,percent of total billed charges,,,85,,25200.8,percent of total billed charges,,,49,,14527.52,percent of total billed charges,,,90,,26683.2,percent of total billed charges,,,65,,19271.2,percent of total billed charges,,,80,,23718.4,percent of total billed charges,,,55,,16306.4,percent of total billed charges,,,55,,16306.4,percent of total billed charges,,,65,,19271.2,percent of total billed charges,,,78,,23125.44,percent of total billed charges,,,70,,20753.6,percent of total billed charges,,,,,,,,11170.15,,,,150% of Medicare,,11170.15,,,11170.53,100% of Medicare,,11170.15,,,11170.53,100% of Medicare,,11170.15,,,11170.53,100% of Medicare,,11170.15,,,11170.53,100% of Medicare,,11170.15,,,11170.53,100% of Medicare,,11170.15,,,11170.53,100% of Medicare,,11170.15,,,11170.53,100% of Medicare,,11170.15,,,11170.53,100% of Medicare,,11170.15,,,11170.53,100% of Medicare,,11170.15,,,11170.53,100% of Medicare,,11170.15,,,11170.53,100% of Medicare,,,11170.15,,,11170.53,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,11170.15,26683.2,
"Cuboid Osteotomy with Autograft, Bilateral",28305,CPT,,,50,outpatient,,,5801,3480.6,,45.5,,2639.46,percent of total billed charges,,,45.3,,2627.85,percent of total billed charges,,,51,,2958.51,percent of total billed charges,,,,,,,,,80,,4640.8,percent of total billed charges,,,61.4,,3561.81,percent of total billed charges,,,57.4,,3329.77,percent of total billed charges,,,81,,4698.81,percent of total billed charges,,,51.5,,2987.52,percent of total billed charges,,,57.6,,3341.38,percent of total billed charges,,,85,,4930.85,percent of total billed charges,,,85,,4930.85,percent of total billed charges,,,49,,2842.49,percent of total billed charges,,,90,,5220.9,percent of total billed charges,,,65,,3770.65,percent of total billed charges,,,80,,4640.8,percent of total billed charges,,,55,,3190.55,percent of total billed charges,,,55,,3190.55,percent of total billed charges,,,65,,3770.65,percent of total billed charges,,,78,,4524.78,percent of total billed charges,,,70,,4060.7,percent of total billed charges,,,,,,,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,11170.15,,,,150% of Medicare,,,11170.15,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,2627.85,11170.15,
PERC SK FIX IP JNT DISL; W MANIP (28666),28666,CPT,,,,outpatient,,,7017,4210.2,,45.5,,3192.74,percent of total billed charges,,,45.3,,3178.7,percent of total billed charges,,,51,,3578.67,percent of total billed charges,,,,,,,,,80,,5613.6,percent of total billed charges,,,61.4,,4308.44,percent of total billed charges,,,57.4,,4027.76,percent of total billed charges,,,81,,5683.77,percent of total billed charges,,,51.5,,3613.76,percent of total billed charges,,,57.6,,4041.79,percent of total billed charges,,,85,,5964.45,percent of total billed charges,,,85,,5964.45,percent of total billed charges,,,49,,3438.33,percent of total billed charges,,,90,,6315.3,percent of total billed charges,,,65,,4561.05,percent of total billed charges,,,80,,5613.6,percent of total billed charges,,,55,,3859.35,percent of total billed charges,,,55,,3859.35,percent of total billed charges,,,65,,4561.05,percent of total billed charges,,,78,,5473.26,percent of total billed charges,,,70,,4911.9,percent of total billed charges,,,,,,,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,3382.25,,,,100% of Medicare,,,3382.25,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,3178.7,6315.3,
"Arthrodesis Great Toe, MP Joint,Bilateral (28750-50)",28750,CPT,,,50,outpatient,,,29648,17788.8,,45.5,,13489.84,percent of total billed charges,,,45.3,,13430.54,percent of total billed charges,,,51,,15120.48,percent of total billed charges,,,,,,,,,80,,23718.4,percent of total billed charges,,,61.4,,18203.87,percent of total billed charges,,,57.4,,17017.95,percent of total billed charges,,,81,,24014.88,percent of total billed charges,,,51.5,,15268.72,percent of total billed charges,,,57.6,,17077.25,percent of total billed charges,,,85,,25200.8,percent of total billed charges,,,85,,25200.8,percent of total billed charges,,,49,,14527.52,percent of total billed charges,,,90,,26683.2,percent of total billed charges,,,65,,19271.2,percent of total billed charges,,,80,,23718.4,percent of total billed charges,,,55,,16306.4,percent of total billed charges,,,55,,16306.4,percent of total billed charges,,,65,,19271.2,percent of total billed charges,,,78,,23125.44,percent of total billed charges,,,70,,20753.6,percent of total billed charges,,,,,,,,11170.15,,,,150% of Medicare,,11170.15,,,999999999,100% of Medicare,,11170.15,,,999999999,100% of Medicare,,11170.15,,,999999999,100% of Medicare,,11170.15,,,999999999,100% of Medicare,,11170.15,,,999999999,100% of Medicare,,11170.15,,,999999999,100% of Medicare,,11170.15,,,999999999,100% of Medicare,,11170.15,,,999999999,100% of Medicare,,11170.15,,,999999999,100% of Medicare,,11170.15,,,999999999,100% of Medicare,,11170.15,,,999999999,100% of Medicare,,,11170.15,,,999999999,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,11170.15,999999999,
OT Long Arm Cast Units,29065,CPT,,,GO,both,,,265,159,,45.5,,120.58,percent of total billed charges,,,45.3,,120.05,percent of total billed charges,,,51,,135.15,percent of total billed charges,,,,,,,,,80,,212,percent of total billed charges,,,61.4,,162.71,percent of total billed charges,,,57.4,,152.11,percent of total billed charges,,,81,,214.65,percent of total billed charges,,,51.5,,136.48,percent of total billed charges,,,57.6,,152.64,percent of total billed charges,,,85,,225.25,percent of total billed charges,,,85,,225.25,percent of total billed charges,,,49,,129.85,percent of total billed charges,,,90,,238.5,percent of total billed charges,,,65,,172.25,percent of total billed charges,,,80,,212,percent of total billed charges,,,55,,145.75,percent of total billed charges,,,55,,145.75,percent of total billed charges,,,65,,172.25,percent of total billed charges,,,78,,206.7,percent of total billed charges,,,70,,185.5,percent of total billed charges,,,,,,,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,,276.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,120.05,276.85,
OT Finger Cast Units,29086,CPT,,,GO,both,,,177,106.2,,45.5,,80.54,percent of total billed charges,,,45.3,,80.18,percent of total billed charges,,,51,,90.27,percent of total billed charges,,,,,,,,,80,,141.6,percent of total billed charges,,,61.4,,108.68,percent of total billed charges,,,57.4,,101.6,percent of total billed charges,,,81,,143.37,percent of total billed charges,,,51.5,,91.16,percent of total billed charges,,,57.6,,101.95,percent of total billed charges,,,85,,150.45,percent of total billed charges,,,85,,150.45,percent of total billed charges,,,49,,86.73,percent of total billed charges,,,90,,159.3,percent of total billed charges,,,65,,115.05,percent of total billed charges,,,80,,141.6,percent of total billed charges,,,55,,97.35,percent of total billed charges,,,55,,97.35,percent of total billed charges,,,65,,115.05,percent of total billed charges,,,78,,138.06,percent of total billed charges,,,70,,123.9,percent of total billed charges,,,,,,,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,,164.48,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,80.18,164.48,
PT Long Arm Splint Application Units,29105,CPT,,,GP,both,,,459,275.4,,45.5,,208.85,percent of total billed charges,,,45.3,,207.93,percent of total billed charges,,,51,,234.09,percent of total billed charges,,,,,,,,,80,,367.2,percent of total billed charges,,,61.4,,281.83,percent of total billed charges,,,57.4,,263.47,percent of total billed charges,,,81,,371.79,percent of total billed charges,,,51.5,,236.39,percent of total billed charges,,,57.6,,264.38,percent of total billed charges,,,85,,390.15,percent of total billed charges,,,85,,390.15,percent of total billed charges,,,49,,224.91,percent of total billed charges,,,90,,413.1,percent of total billed charges,,,65,,298.35,percent of total billed charges,,,80,,367.2,percent of total billed charges,,,55,,252.45,percent of total billed charges,,,55,,252.45,percent of total billed charges,,,65,,298.35,percent of total billed charges,,,78,,358.02,percent of total billed charges,,,70,,321.3,percent of total billed charges,,,,,,,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,,164.48,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,164.48,413.1,
OT Long Arm Splint Application Units,29105,CPT,,,GO,both,,,485,291,,45.5,,220.68,percent of total billed charges,,,45.3,,219.71,percent of total billed charges,,,51,,247.35,percent of total billed charges,,,,,,,,,80,,388,percent of total billed charges,,,61.4,,297.79,percent of total billed charges,,,57.4,,278.39,percent of total billed charges,,,81,,392.85,percent of total billed charges,,,51.5,,249.78,percent of total billed charges,,,57.6,,279.36,percent of total billed charges,,,85,,412.25,percent of total billed charges,,,85,,412.25,percent of total billed charges,,,49,,237.65,percent of total billed charges,,,90,,436.5,percent of total billed charges,,,65,,315.25,percent of total billed charges,,,80,,388,percent of total billed charges,,,55,,266.75,percent of total billed charges,,,55,,266.75,percent of total billed charges,,,65,,315.25,percent of total billed charges,,,78,,378.3,percent of total billed charges,,,70,,339.5,percent of total billed charges,,,,,,,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,,164.48,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,164.48,436.5,
OT Static Short Arm Splint App Units,29125,CPT,,,GO,both,,,252,151.2,,45.5,,114.66,percent of total billed charges,,,45.3,,114.16,percent of total billed charges,,,51,,128.52,percent of total billed charges,,,,,,,,,80,,201.6,percent of total billed charges,,,61.4,,154.73,percent of total billed charges,,,57.4,,144.65,percent of total billed charges,,,81,,204.12,percent of total billed charges,,,51.5,,129.78,percent of total billed charges,,,57.6,,145.15,percent of total billed charges,,,85,,214.2,percent of total billed charges,,,85,,214.2,percent of total billed charges,,,49,,123.48,percent of total billed charges,,,90,,226.8,percent of total billed charges,,,65,,163.8,percent of total billed charges,,,80,,201.6,percent of total billed charges,,,55,,138.6,percent of total billed charges,,,55,,138.6,percent of total billed charges,,,65,,163.8,percent of total billed charges,,,78,,196.56,percent of total billed charges,,,70,,176.4,percent of total billed charges,,,,,,,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,,134.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,114.16,226.8,
OT Dynamic Short Arm Splint App Units,29126,CPT,,,GO,both,,,592,355.2,,45.5,,269.36,percent of total billed charges,,,45.3,,268.18,percent of total billed charges,,,51,,301.92,percent of total billed charges,,,,,,,,,80,,473.6,percent of total billed charges,,,61.4,,363.49,percent of total billed charges,,,57.4,,339.81,percent of total billed charges,,,81,,479.52,percent of total billed charges,,,51.5,,304.88,percent of total billed charges,,,57.6,,340.99,percent of total billed charges,,,85,,503.2,percent of total billed charges,,,85,,503.2,percent of total billed charges,,,49,,290.08,percent of total billed charges,,,90,,532.8,percent of total billed charges,,,65,,384.8,percent of total billed charges,,,80,,473.6,percent of total billed charges,,,55,,325.6,percent of total billed charges,,,55,,325.6,percent of total billed charges,,,65,,384.8,percent of total billed charges,,,78,,461.76,percent of total billed charges,,,70,,414.4,percent of total billed charges,,,,,,,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,,134.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,134.37,532.8,
PT Dynamic Short Arm Splint App Units,29126,CPT,,,GP,both,,,592,355.2,,45.5,,269.36,percent of total billed charges,,,45.3,,268.18,percent of total billed charges,,,51,,301.92,percent of total billed charges,,,,,,,,,80,,473.6,percent of total billed charges,,,61.4,,363.49,percent of total billed charges,,,57.4,,339.81,percent of total billed charges,,,81,,479.52,percent of total billed charges,,,51.5,,304.88,percent of total billed charges,,,57.6,,340.99,percent of total billed charges,,,85,,503.2,percent of total billed charges,,,85,,503.2,percent of total billed charges,,,49,,290.08,percent of total billed charges,,,90,,532.8,percent of total billed charges,,,65,,384.8,percent of total billed charges,,,80,,473.6,percent of total billed charges,,,55,,325.6,percent of total billed charges,,,55,,325.6,percent of total billed charges,,,65,,384.8,percent of total billed charges,,,78,,461.76,percent of total billed charges,,,70,,414.4,percent of total billed charges,,,,,,,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,,134.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,134.37,532.8,
PT Static Short Arm Splint App Units,29126,CPT,,,GP,both,,,592,355.2,,45.5,,269.36,percent of total billed charges,,,45.3,,268.18,percent of total billed charges,,,51,,301.92,percent of total billed charges,,,,,,,,,80,,473.6,percent of total billed charges,,,61.4,,363.49,percent of total billed charges,,,57.4,,339.81,percent of total billed charges,,,81,,479.52,percent of total billed charges,,,51.5,,304.88,percent of total billed charges,,,57.6,,340.99,percent of total billed charges,,,85,,503.2,percent of total billed charges,,,85,,503.2,percent of total billed charges,,,49,,290.08,percent of total billed charges,,,90,,532.8,percent of total billed charges,,,65,,384.8,percent of total billed charges,,,80,,473.6,percent of total billed charges,,,55,,325.6,percent of total billed charges,,,55,,325.6,percent of total billed charges,,,65,,384.8,percent of total billed charges,,,78,,461.76,percent of total billed charges,,,70,,414.4,percent of total billed charges,,,,,,,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,,134.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,134.37,532.8,
OT Static Finger Splint App Units,29130,CPT,,,GO,both,,,504,302.4,,45.5,,229.32,percent of total billed charges,,,45.3,,228.31,percent of total billed charges,,,51,,257.04,percent of total billed charges,,,,,,,,,80,,403.2,percent of total billed charges,,,61.4,,309.46,percent of total billed charges,,,57.4,,289.3,percent of total billed charges,,,81,,408.24,percent of total billed charges,,,51.5,,259.56,percent of total billed charges,,,57.6,,290.3,percent of total billed charges,,,85,,428.4,percent of total billed charges,,,85,,428.4,percent of total billed charges,,,49,,246.96,percent of total billed charges,,,90,,453.6,percent of total billed charges,,,65,,327.6,percent of total billed charges,,,80,,403.2,percent of total billed charges,,,55,,277.2,percent of total billed charges,,,55,,277.2,percent of total billed charges,,,65,,327.6,percent of total billed charges,,,78,,393.12,percent of total billed charges,,,70,,352.8,percent of total billed charges,,,,,,,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,,134.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,134.37,453.6,
PT Static Finger Splint App Units,29130,CPT,,,GP,both,,,504,302.4,,45.5,,229.32,percent of total billed charges,,,45.3,,228.31,percent of total billed charges,,,51,,257.04,percent of total billed charges,,,,,,,,,80,,403.2,percent of total billed charges,,,61.4,,309.46,percent of total billed charges,,,57.4,,289.3,percent of total billed charges,,,81,,408.24,percent of total billed charges,,,51.5,,259.56,percent of total billed charges,,,57.6,,290.3,percent of total billed charges,,,85,,428.4,percent of total billed charges,,,85,,428.4,percent of total billed charges,,,49,,246.96,percent of total billed charges,,,90,,453.6,percent of total billed charges,,,65,,327.6,percent of total billed charges,,,80,,403.2,percent of total billed charges,,,55,,277.2,percent of total billed charges,,,55,,277.2,percent of total billed charges,,,65,,327.6,percent of total billed charges,,,78,,393.12,percent of total billed charges,,,70,,352.8,percent of total billed charges,,,,,,,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,,134.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,134.37,453.6,
PT Dynamic Finger Splint App Units,29131,CPT,,,GP,both,,,213,127.8,,45.5,,96.92,percent of total billed charges,,,45.3,,96.49,percent of total billed charges,,,51,,108.63,percent of total billed charges,,,,,,,,,80,,170.4,percent of total billed charges,,,61.4,,130.78,percent of total billed charges,,,57.4,,122.26,percent of total billed charges,,,81,,172.53,percent of total billed charges,,,51.5,,109.7,percent of total billed charges,,,57.6,,122.69,percent of total billed charges,,,85,,181.05,percent of total billed charges,,,85,,181.05,percent of total billed charges,,,49,,104.37,percent of total billed charges,,,90,,191.7,percent of total billed charges,,,65,,138.45,percent of total billed charges,,,80,,170.4,percent of total billed charges,,,55,,117.15,percent of total billed charges,,,55,,117.15,percent of total billed charges,,,65,,138.45,percent of total billed charges,,,78,,166.14,percent of total billed charges,,,70,,149.1,percent of total billed charges,,,,,,,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,,61.92,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,61.92,191.7,
OT Dynamic Finger Splint App Units,29131,CPT,,,GO,both,,,225,135,,45.5,,102.38,percent of total billed charges,,,45.3,,101.93,percent of total billed charges,,,51,,114.75,percent of total billed charges,,,,,,,,,80,,180,percent of total billed charges,,,61.4,,138.15,percent of total billed charges,,,57.4,,129.15,percent of total billed charges,,,81,,182.25,percent of total billed charges,,,51.5,,115.88,percent of total billed charges,,,57.6,,129.6,percent of total billed charges,,,85,,191.25,percent of total billed charges,,,85,,191.25,percent of total billed charges,,,49,,110.25,percent of total billed charges,,,90,,202.5,percent of total billed charges,,,65,,146.25,percent of total billed charges,,,80,,180,percent of total billed charges,,,55,,123.75,percent of total billed charges,,,55,,123.75,percent of total billed charges,,,65,,146.25,percent of total billed charges,,,78,,175.5,percent of total billed charges,,,70,,157.5,percent of total billed charges,,,,,,,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,,61.92,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,61.92,202.5,
PT Taping/Thorax Units,29200,CPT,,,GP,both,,,284,170.4,,45.5,,129.22,percent of total billed charges,,,45.3,,128.65,percent of total billed charges,,,51,,144.84,percent of total billed charges,,,,,,,,,80,,227.2,percent of total billed charges,,,61.4,,174.38,percent of total billed charges,,,57.4,,163.02,percent of total billed charges,,,81,,230.04,percent of total billed charges,,,51.5,,146.26,percent of total billed charges,,,57.6,,163.58,percent of total billed charges,,,85,,241.4,percent of total billed charges,,,85,,241.4,percent of total billed charges,,,49,,139.16,percent of total billed charges,,,90,,255.6,percent of total billed charges,,,65,,184.6,percent of total billed charges,,,80,,227.2,percent of total billed charges,,,55,,156.2,percent of total billed charges,,,55,,156.2,percent of total billed charges,,,65,,184.6,percent of total billed charges,,,78,,221.52,percent of total billed charges,,,70,,198.8,percent of total billed charges,,,,,,,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,,164.48,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,128.65,255.6,
OT Strapping Shoulder Units,29240,CPT,,,GO,both,,,252,151.2,,45.5,,114.66,percent of total billed charges,,,45.3,,114.16,percent of total billed charges,,,51,,128.52,percent of total billed charges,,,,,,,,,80,,201.6,percent of total billed charges,,,61.4,,154.73,percent of total billed charges,,,57.4,,144.65,percent of total billed charges,,,81,,204.12,percent of total billed charges,,,51.5,,129.78,percent of total billed charges,,,57.6,,145.15,percent of total billed charges,,,85,,214.2,percent of total billed charges,,,85,,214.2,percent of total billed charges,,,49,,123.48,percent of total billed charges,,,90,,226.8,percent of total billed charges,,,65,,163.8,percent of total billed charges,,,80,,201.6,percent of total billed charges,,,55,,138.6,percent of total billed charges,,,55,,138.6,percent of total billed charges,,,65,,163.8,percent of total billed charges,,,78,,196.56,percent of total billed charges,,,70,,176.4,percent of total billed charges,,,,,,,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,,134.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,114.16,226.8,
PT Strapping Shoulder Units,29240,CPT,,,GP,both,,,252,151.2,,45.5,,114.66,percent of total billed charges,,,45.3,,114.16,percent of total billed charges,,,51,,128.52,percent of total billed charges,,,,,,,,,80,,201.6,percent of total billed charges,,,61.4,,154.73,percent of total billed charges,,,57.4,,144.65,percent of total billed charges,,,81,,204.12,percent of total billed charges,,,51.5,,129.78,percent of total billed charges,,,57.6,,145.15,percent of total billed charges,,,85,,214.2,percent of total billed charges,,,85,,214.2,percent of total billed charges,,,49,,123.48,percent of total billed charges,,,90,,226.8,percent of total billed charges,,,65,,163.8,percent of total billed charges,,,80,,201.6,percent of total billed charges,,,55,,138.6,percent of total billed charges,,,55,,138.6,percent of total billed charges,,,65,,163.8,percent of total billed charges,,,78,,196.56,percent of total billed charges,,,70,,176.4,percent of total billed charges,,,,,,,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,,134.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,114.16,226.8,
OT Strapping Elbow/Wrist Units,29260,CPT,,,GO,both,,,252,151.2,,45.5,,114.66,percent of total billed charges,,,45.3,,114.16,percent of total billed charges,,,51,,128.52,percent of total billed charges,,,,,,,,,80,,201.6,percent of total billed charges,,,61.4,,154.73,percent of total billed charges,,,57.4,,144.65,percent of total billed charges,,,81,,204.12,percent of total billed charges,,,51.5,,129.78,percent of total billed charges,,,57.6,,145.15,percent of total billed charges,,,85,,214.2,percent of total billed charges,,,85,,214.2,percent of total billed charges,,,49,,123.48,percent of total billed charges,,,90,,226.8,percent of total billed charges,,,65,,163.8,percent of total billed charges,,,80,,201.6,percent of total billed charges,,,55,,138.6,percent of total billed charges,,,55,,138.6,percent of total billed charges,,,65,,163.8,percent of total billed charges,,,78,,196.56,percent of total billed charges,,,70,,176.4,percent of total billed charges,,,,,,,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,,61.92,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,61.92,226.8,
PT Strapping Elbow/Wrist Units,29260,CPT,,,GP,both,,,252,151.2,,45.5,,114.66,percent of total billed charges,,,45.3,,114.16,percent of total billed charges,,,51,,128.52,percent of total billed charges,,,,,,,,,80,,201.6,percent of total billed charges,,,61.4,,154.73,percent of total billed charges,,,57.4,,144.65,percent of total billed charges,,,81,,204.12,percent of total billed charges,,,51.5,,129.78,percent of total billed charges,,,57.6,,145.15,percent of total billed charges,,,85,,214.2,percent of total billed charges,,,85,,214.2,percent of total billed charges,,,49,,123.48,percent of total billed charges,,,90,,226.8,percent of total billed charges,,,65,,163.8,percent of total billed charges,,,80,,201.6,percent of total billed charges,,,55,,138.6,percent of total billed charges,,,55,,138.6,percent of total billed charges,,,65,,163.8,percent of total billed charges,,,78,,196.56,percent of total billed charges,,,70,,176.4,percent of total billed charges,,,,,,,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,,61.92,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,61.92,226.8,
OT Strapping Hand/Finger Units,29280,CPT,,,GO,both,,,252,151.2,,45.5,,114.66,percent of total billed charges,,,45.3,,114.16,percent of total billed charges,,,51,,128.52,percent of total billed charges,,,,,,,,,80,,201.6,percent of total billed charges,,,61.4,,154.73,percent of total billed charges,,,57.4,,144.65,percent of total billed charges,,,81,,204.12,percent of total billed charges,,,51.5,,129.78,percent of total billed charges,,,57.6,,145.15,percent of total billed charges,,,85,,214.2,percent of total billed charges,,,85,,214.2,percent of total billed charges,,,49,,123.48,percent of total billed charges,,,90,,226.8,percent of total billed charges,,,65,,163.8,percent of total billed charges,,,80,,201.6,percent of total billed charges,,,55,,138.6,percent of total billed charges,,,55,,138.6,percent of total billed charges,,,65,,163.8,percent of total billed charges,,,78,,196.56,percent of total billed charges,,,70,,176.4,percent of total billed charges,,,,,,,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,,61.92,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,61.92,226.8,
PT Strapping Hand/Finger Units,29280,CPT,,,GP,both,,,252,151.2,,45.5,,114.66,percent of total billed charges,,,45.3,,114.16,percent of total billed charges,,,51,,128.52,percent of total billed charges,,,,,,,,,80,,201.6,percent of total billed charges,,,61.4,,154.73,percent of total billed charges,,,57.4,,144.65,percent of total billed charges,,,81,,204.12,percent of total billed charges,,,51.5,,129.78,percent of total billed charges,,,57.6,,145.15,percent of total billed charges,,,85,,214.2,percent of total billed charges,,,85,,214.2,percent of total billed charges,,,49,,123.48,percent of total billed charges,,,90,,226.8,percent of total billed charges,,,65,,163.8,percent of total billed charges,,,80,,201.6,percent of total billed charges,,,55,,138.6,percent of total billed charges,,,55,,138.6,percent of total billed charges,,,65,,163.8,percent of total billed charges,,,78,,196.56,percent of total billed charges,,,70,,176.4,percent of total billed charges,,,,,,,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,,61.92,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,61.92,226.8,
Long Leg Cast,29345,CPT,,,,outpatient,,,980,588,,45.5,,445.9,percent of total billed charges,,,45.3,,443.94,percent of total billed charges,,,51,,499.8,percent of total billed charges,,,,,,,,,80,,784,percent of total billed charges,,,61.4,,601.72,percent of total billed charges,,,57.4,,562.52,percent of total billed charges,,,81,,793.8,percent of total billed charges,,,51.5,,504.7,percent of total billed charges,,,57.6,,564.48,percent of total billed charges,,,85,,833,percent of total billed charges,,,85,,833,percent of total billed charges,,,49,,480.2,percent of total billed charges,,,90,,882,percent of total billed charges,,,65,,637,percent of total billed charges,,,80,,784,percent of total billed charges,,,55,,539,percent of total billed charges,,,55,,539,percent of total billed charges,,,65,,637,percent of total billed charges,,,78,,764.4,percent of total billed charges,,,70,,686,percent of total billed charges,,,,,,,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,,276.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,276.85,882,
Long Leg Cast Bilateral,29345,CPT,,,50,outpatient,,,1468,880.8,,45.5,,667.94,percent of total billed charges,,,45.3,,665,percent of total billed charges,,,51,,748.68,percent of total billed charges,,,,,,,,,80,,1174.4,percent of total billed charges,,,61.4,,901.35,percent of total billed charges,,,57.4,,842.63,percent of total billed charges,,,81,,1189.08,percent of total billed charges,,,51.5,,756.02,percent of total billed charges,,,57.6,,845.57,percent of total billed charges,,,85,,1247.8,percent of total billed charges,,,85,,1247.8,percent of total billed charges,,,49,,719.32,percent of total billed charges,,,90,,1321.2,percent of total billed charges,,,65,,954.2,percent of total billed charges,,,80,,1174.4,percent of total billed charges,,,55,,807.4,percent of total billed charges,,,55,,807.4,percent of total billed charges,,,65,,954.2,percent of total billed charges,,,78,,1145.04,percent of total billed charges,,,70,,1027.6,percent of total billed charges,,,,,,,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,,415.27,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,415.27,1321.2,
PT Long Leg Cast Application Units,29358,CPT,,,GP,both,,,251,150.6,,45.5,,114.21,percent of total billed charges,,,45.3,,113.7,percent of total billed charges,,,51,,128.01,percent of total billed charges,,,,,,,,,80,,200.8,percent of total billed charges,,,61.4,,154.11,percent of total billed charges,,,57.4,,144.07,percent of total billed charges,,,81,,203.31,percent of total billed charges,,,51.5,,129.27,percent of total billed charges,,,57.6,,144.58,percent of total billed charges,,,85,,213.35,percent of total billed charges,,,85,,213.35,percent of total billed charges,,,49,,122.99,percent of total billed charges,,,90,,225.9,percent of total billed charges,,,65,,163.15,percent of total billed charges,,,80,,200.8,percent of total billed charges,,,55,,138.05,percent of total billed charges,,,55,,138.05,percent of total billed charges,,,65,,163.15,percent of total billed charges,,,78,,195.78,percent of total billed charges,,,70,,175.7,percent of total billed charges,,,,,,,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,,276.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,113.7,276.85,
PT Cylindrical Cast Application Units,29365,CPT,,,GP,both,,,251,150.6,,45.5,,114.21,percent of total billed charges,,,45.3,,113.7,percent of total billed charges,,,51,,128.01,percent of total billed charges,,,,,,,,,80,,200.8,percent of total billed charges,,,61.4,,154.11,percent of total billed charges,,,57.4,,144.07,percent of total billed charges,,,81,,203.31,percent of total billed charges,,,51.5,,129.27,percent of total billed charges,,,57.6,,144.58,percent of total billed charges,,,85,,213.35,percent of total billed charges,,,85,,213.35,percent of total billed charges,,,49,,122.99,percent of total billed charges,,,90,,225.9,percent of total billed charges,,,65,,163.15,percent of total billed charges,,,80,,200.8,percent of total billed charges,,,55,,138.05,percent of total billed charges,,,55,,138.05,percent of total billed charges,,,65,,163.15,percent of total billed charges,,,78,,195.78,percent of total billed charges,,,70,,175.7,percent of total billed charges,,,,,,,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,,276.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,113.7,276.85,
Cylinder Cast (29365),29365,CPT,,,,outpatient,,,864,518.4,,45.5,,393.12,percent of total billed charges,,,45.3,,391.39,percent of total billed charges,,,51,,440.64,percent of total billed charges,,,,,,,,,80,,691.2,percent of total billed charges,,,61.4,,530.5,percent of total billed charges,,,57.4,,495.94,percent of total billed charges,,,81,,699.84,percent of total billed charges,,,51.5,,444.96,percent of total billed charges,,,57.6,,497.66,percent of total billed charges,,,85,,734.4,percent of total billed charges,,,85,,734.4,percent of total billed charges,,,49,,423.36,percent of total billed charges,,,90,,777.6,percent of total billed charges,,,65,,561.6,percent of total billed charges,,,80,,691.2,percent of total billed charges,,,55,,475.2,percent of total billed charges,,,55,,475.2,percent of total billed charges,,,65,,561.6,percent of total billed charges,,,78,,673.92,percent of total billed charges,,,70,,604.8,percent of total billed charges,,,,,,,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,,276.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,276.85,777.6,
PT Patellar Tendon Bearing Cast App Unit,29435,CPT,,,GP,both,,,346,207.6,,45.5,,157.43,percent of total billed charges,,,45.3,,156.74,percent of total billed charges,,,51,,176.46,percent of total billed charges,,,,,,,,,80,,276.8,percent of total billed charges,,,61.4,,212.44,percent of total billed charges,,,57.4,,198.6,percent of total billed charges,,,81,,280.26,percent of total billed charges,,,51.5,,178.19,percent of total billed charges,,,57.6,,199.3,percent of total billed charges,,,85,,294.1,percent of total billed charges,,,85,,294.1,percent of total billed charges,,,49,,169.54,percent of total billed charges,,,90,,311.4,percent of total billed charges,,,65,,224.9,percent of total billed charges,,,80,,276.8,percent of total billed charges,,,55,,190.3,percent of total billed charges,,,55,,190.3,percent of total billed charges,,,65,,224.9,percent of total billed charges,,,78,,269.88,percent of total billed charges,,,70,,242.2,percent of total billed charges,,,,,,,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,,276.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,156.74,311.4,
PT Rigid Total Contact Leg Cast App Unit,29445,CPT,,,GP,both,,,346,207.6,,45.5,,157.43,percent of total billed charges,,,45.3,,156.74,percent of total billed charges,,,51,,176.46,percent of total billed charges,,,,,,,,,80,,276.8,percent of total billed charges,,,61.4,,212.44,percent of total billed charges,,,57.4,,198.6,percent of total billed charges,,,81,,280.26,percent of total billed charges,,,51.5,,178.19,percent of total billed charges,,,57.6,,199.3,percent of total billed charges,,,85,,294.1,percent of total billed charges,,,85,,294.1,percent of total billed charges,,,49,,169.54,percent of total billed charges,,,90,,311.4,percent of total billed charges,,,65,,224.9,percent of total billed charges,,,80,,276.8,percent of total billed charges,,,55,,190.3,percent of total billed charges,,,55,,190.3,percent of total billed charges,,,65,,224.9,percent of total billed charges,,,78,,269.88,percent of total billed charges,,,70,,242.2,percent of total billed charges,,,,,,,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,,276.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,156.74,311.4,
PT Club Foot w/Molding/Manip App Units,29450,CPT,,,GP,both,,,154,92.4,,45.5,,70.07,percent of total billed charges,,,45.3,,69.76,percent of total billed charges,,,51,,78.54,percent of total billed charges,,,,,,,,,80,,123.2,percent of total billed charges,,,61.4,,94.56,percent of total billed charges,,,57.4,,88.4,percent of total billed charges,,,81,,124.74,percent of total billed charges,,,51.5,,79.31,percent of total billed charges,,,57.6,,88.7,percent of total billed charges,,,85,,130.9,percent of total billed charges,,,85,,130.9,percent of total billed charges,,,49,,75.46,percent of total billed charges,,,90,,138.6,percent of total billed charges,,,65,,100.1,percent of total billed charges,,,80,,123.2,percent of total billed charges,,,55,,84.7,percent of total billed charges,,,55,,84.7,percent of total billed charges,,,65,,100.1,percent of total billed charges,,,78,,120.12,percent of total billed charges,,,70,,107.8,percent of total billed charges,,,,,,,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,,164.48,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,69.76,164.48,
Clubfoot Cast (29450),29450,CPT,,,,outpatient,,,466,279.6,,45.5,,212.03,percent of total billed charges,,,45.3,,211.1,percent of total billed charges,,,51,,237.66,percent of total billed charges,,,,,,,,,80,,372.8,percent of total billed charges,,,61.4,,286.12,percent of total billed charges,,,57.4,,267.48,percent of total billed charges,,,81,,377.46,percent of total billed charges,,,51.5,,239.99,percent of total billed charges,,,57.6,,268.42,percent of total billed charges,,,85,,396.1,percent of total billed charges,,,85,,396.1,percent of total billed charges,,,49,,228.34,percent of total billed charges,,,90,,419.4,percent of total billed charges,,,65,,302.9,percent of total billed charges,,,80,,372.8,percent of total billed charges,,,55,,256.3,percent of total billed charges,,,55,,256.3,percent of total billed charges,,,65,,302.9,percent of total billed charges,,,78,,363.48,percent of total billed charges,,,70,,326.2,percent of total billed charges,,,,,,,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,,164.48,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,164.48,419.4,
Clubfoot Cast Bilateral,29450,CPT,,,50,outpatient,,,680,408,,45.5,,309.4,percent of total billed charges,,,45.3,,308.04,percent of total billed charges,,,51,,346.8,percent of total billed charges,,,,,,,,,80,,544,percent of total billed charges,,,61.4,,417.52,percent of total billed charges,,,57.4,,390.32,percent of total billed charges,,,81,,550.8,percent of total billed charges,,,51.5,,350.2,percent of total billed charges,,,57.6,,391.68,percent of total billed charges,,,85,,578,percent of total billed charges,,,85,,578,percent of total billed charges,,,49,,333.2,percent of total billed charges,,,90,,612,percent of total billed charges,,,65,,442,percent of total billed charges,,,80,,544,percent of total billed charges,,,55,,374,percent of total billed charges,,,55,,374,percent of total billed charges,,,65,,442,percent of total billed charges,,,78,,530.4,percent of total billed charges,,,70,,476,percent of total billed charges,,,,,,,,246.73,,,,150% of Medicare,,246.73,,,,150% of Medicare,,246.73,,,,150% of Medicare,,246.73,,,,150% of Medicare,,246.73,,,,150% of Medicare,,246.73,,,,150% of Medicare,,246.73,,,,150% of Medicare,,246.73,,,,150% of Medicare,,246.73,,,,150% of Medicare,,246.73,,,,150% of Medicare,,246.73,,,,150% of Medicare,,246.73,,,,150% of Medicare,,,246.73,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,246.73,612,
PT Long Leg Splint App Units,29505,CPT,,,GP,both,,,434,260.4,,45.5,,197.47,percent of total billed charges,,,45.3,,196.6,percent of total billed charges,,,51,,221.34,percent of total billed charges,,,,,,,,,80,,347.2,percent of total billed charges,,,61.4,,266.48,percent of total billed charges,,,57.4,,249.12,percent of total billed charges,,,81,,351.54,percent of total billed charges,,,51.5,,223.51,percent of total billed charges,,,57.6,,249.98,percent of total billed charges,,,85,,368.9,percent of total billed charges,,,85,,368.9,percent of total billed charges,,,49,,212.66,percent of total billed charges,,,90,,390.6,percent of total billed charges,,,65,,282.1,percent of total billed charges,,,80,,347.2,percent of total billed charges,,,55,,238.7,percent of total billed charges,,,55,,238.7,percent of total billed charges,,,65,,282.1,percent of total billed charges,,,78,,338.52,percent of total billed charges,,,70,,303.8,percent of total billed charges,,,,,,,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,,164.48,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,164.48,390.6,
PT Short Leg Splint App Units,29515,CPT,,,GP,both,,,346,207.6,,45.5,,157.43,percent of total billed charges,,,45.3,,156.74,percent of total billed charges,,,51,,176.46,percent of total billed charges,,,,,,,,,80,,276.8,percent of total billed charges,,,61.4,,212.44,percent of total billed charges,,,57.4,,198.6,percent of total billed charges,,,81,,280.26,percent of total billed charges,,,51.5,,178.19,percent of total billed charges,,,57.6,,199.3,percent of total billed charges,,,85,,294.1,percent of total billed charges,,,85,,294.1,percent of total billed charges,,,49,,169.54,percent of total billed charges,,,90,,311.4,percent of total billed charges,,,65,,224.9,percent of total billed charges,,,80,,276.8,percent of total billed charges,,,55,,190.3,percent of total billed charges,,,55,,190.3,percent of total billed charges,,,65,,224.9,percent of total billed charges,,,78,,269.88,percent of total billed charges,,,70,,242.2,percent of total billed charges,,,,,,,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,,164.48,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,156.74,311.4,
PT Strapping Hip Units,29520,CPT,,,GP,both,,,239,143.4,,45.5,,108.75,percent of total billed charges,,,45.3,,108.27,percent of total billed charges,,,51,,121.89,percent of total billed charges,,,,,,,,,80,,191.2,percent of total billed charges,,,61.4,,146.75,percent of total billed charges,,,57.4,,137.19,percent of total billed charges,,,81,,193.59,percent of total billed charges,,,51.5,,123.09,percent of total billed charges,,,57.6,,137.66,percent of total billed charges,,,85,,203.15,percent of total billed charges,,,85,,203.15,percent of total billed charges,,,49,,117.11,percent of total billed charges,,,90,,215.1,percent of total billed charges,,,65,,155.35,percent of total billed charges,,,80,,191.2,percent of total billed charges,,,55,,131.45,percent of total billed charges,,,55,,131.45,percent of total billed charges,,,65,,155.35,percent of total billed charges,,,78,,186.42,percent of total billed charges,,,70,,167.3,percent of total billed charges,,,,,,,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,,134.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,108.27,215.1,
PT Strapping Knee Units,29530,CPT,,,GP,both,,,239,143.4,,45.5,,108.75,percent of total billed charges,,,45.3,,108.27,percent of total billed charges,,,51,,121.89,percent of total billed charges,,,,,,,,,80,,191.2,percent of total billed charges,,,61.4,,146.75,percent of total billed charges,,,57.4,,137.19,percent of total billed charges,,,81,,193.59,percent of total billed charges,,,51.5,,123.09,percent of total billed charges,,,57.6,,137.66,percent of total billed charges,,,85,,203.15,percent of total billed charges,,,85,,203.15,percent of total billed charges,,,49,,117.11,percent of total billed charges,,,90,,215.1,percent of total billed charges,,,65,,155.35,percent of total billed charges,,,80,,191.2,percent of total billed charges,,,55,,131.45,percent of total billed charges,,,55,,131.45,percent of total billed charges,,,65,,155.35,percent of total billed charges,,,78,,186.42,percent of total billed charges,,,70,,167.3,percent of total billed charges,,,,,,,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,,134.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,108.27,215.1,
PT Strapping Ankle/Foot Units,29540,CPT,,,GP,both,,,239,143.4,,45.5,,108.75,percent of total billed charges,,,45.3,,108.27,percent of total billed charges,,,51,,121.89,percent of total billed charges,,,,,,,,,80,,191.2,percent of total billed charges,,,61.4,,146.75,percent of total billed charges,,,57.4,,137.19,percent of total billed charges,,,81,,193.59,percent of total billed charges,,,51.5,,123.09,percent of total billed charges,,,57.6,,137.66,percent of total billed charges,,,85,,203.15,percent of total billed charges,,,85,,203.15,percent of total billed charges,,,49,,117.11,percent of total billed charges,,,90,,215.1,percent of total billed charges,,,65,,155.35,percent of total billed charges,,,80,,191.2,percent of total billed charges,,,55,,131.45,percent of total billed charges,,,55,,131.45,percent of total billed charges,,,65,,155.35,percent of total billed charges,,,78,,186.42,percent of total billed charges,,,70,,167.3,percent of total billed charges,,,,,,,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,,164.48,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,108.27,215.1,
PT Strapping Toes Units,29550,CPT,,,GP,both,,,239,143.4,,45.5,,108.75,percent of total billed charges,,,45.3,,108.27,percent of total billed charges,,,51,,121.89,percent of total billed charges,,,,,,,,,80,,191.2,percent of total billed charges,,,61.4,,146.75,percent of total billed charges,,,57.4,,137.19,percent of total billed charges,,,81,,193.59,percent of total billed charges,,,51.5,,123.09,percent of total billed charges,,,57.6,,137.66,percent of total billed charges,,,85,,203.15,percent of total billed charges,,,85,,203.15,percent of total billed charges,,,49,,117.11,percent of total billed charges,,,90,,215.1,percent of total billed charges,,,65,,155.35,percent of total billed charges,,,80,,191.2,percent of total billed charges,,,55,,131.45,percent of total billed charges,,,55,,131.45,percent of total billed charges,,,65,,155.35,percent of total billed charges,,,78,,186.42,percent of total billed charges,,,70,,167.3,percent of total billed charges,,,,,,,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,,61.92,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,61.92,215.1,
PT Unna Boot Units,29580,CPT,,,GP,both,,,262,157.2,,45.5,,119.21,percent of total billed charges,,,45.3,,118.69,percent of total billed charges,,,51,,133.62,percent of total billed charges,,,,,,,,,80,,209.6,percent of total billed charges,,,61.4,,160.87,percent of total billed charges,,,57.4,,150.39,percent of total billed charges,,,81,,212.22,percent of total billed charges,,,51.5,,134.93,percent of total billed charges,,,57.6,,150.91,percent of total billed charges,,,85,,222.7,percent of total billed charges,,,85,,222.7,percent of total billed charges,,,49,,128.38,percent of total billed charges,,,90,,235.8,percent of total billed charges,,,65,,170.3,percent of total billed charges,,,80,,209.6,percent of total billed charges,,,55,,144.1,percent of total billed charges,,,55,,144.1,percent of total billed charges,,,65,,170.3,percent of total billed charges,,,78,,204.36,percent of total billed charges,,,70,,183.4,percent of total billed charges,,,,,,,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,,164.48,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,118.69,235.8,
Venous Stasis Four Layer Wrap,29580,CPT,,,,outpatient,,,374,224.4,,45.5,,170.17,percent of total billed charges,,,45.3,,169.42,percent of total billed charges,,,51,,190.74,percent of total billed charges,,,,,,,,,80,,299.2,percent of total billed charges,,,61.4,,229.64,percent of total billed charges,,,57.4,,214.68,percent of total billed charges,,,81,,302.94,percent of total billed charges,,,51.5,,192.61,percent of total billed charges,,,57.6,,215.42,percent of total billed charges,,,85,,317.9,percent of total billed charges,,,85,,317.9,percent of total billed charges,,,49,,183.26,percent of total billed charges,,,90,,336.6,percent of total billed charges,,,65,,243.1,percent of total billed charges,,,80,,299.2,percent of total billed charges,,,55,,205.7,percent of total billed charges,,,55,,205.7,percent of total billed charges,,,65,,243.1,percent of total billed charges,,,78,,291.72,percent of total billed charges,,,70,,261.8,percent of total billed charges,,,,,,,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,,164.48,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,164.48,336.6,
"Apply Multlay Comprs LWR Leg, Bilateral (29581)",29581,CPT,,,50,outpatient,,,491,294.6,,45.5,,223.41,percent of total billed charges,,,45.3,,222.42,percent of total billed charges,,,51,,250.41,percent of total billed charges,,,,,,,,,80,,392.8,percent of total billed charges,,,61.4,,301.47,percent of total billed charges,,,57.4,,281.83,percent of total billed charges,,,81,,397.71,percent of total billed charges,,,51.5,,252.87,percent of total billed charges,,,57.6,,282.82,percent of total billed charges,,,85,,417.35,percent of total billed charges,,,85,,417.35,percent of total billed charges,,,49,,240.59,percent of total billed charges,,,90,,441.9,percent of total billed charges,,,65,,319.15,percent of total billed charges,,,80,,392.8,percent of total billed charges,,,55,,270.05,percent of total billed charges,,,55,,270.05,percent of total billed charges,,,65,,319.15,percent of total billed charges,,,78,,382.98,percent of total billed charges,,,70,,343.7,percent of total billed charges,,,,,,,,246.73,,,,150% of Medicare,,246.73,,,,150% of Medicare,,246.73,,,,150% of Medicare,,246.73,,,,150% of Medicare,,246.73,,,,150% of Medicare,,246.73,,,70150.3,150% of Medicare,,246.73,,,,150% of Medicare,,246.73,,,,150% of Medicare,,246.73,,,,150% of Medicare,,246.73,,,,150% of Medicare,,246.73,,,,150% of Medicare,,246.73,,,,150% of Medicare,,,246.73,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,222.42,70150.3,
Apply Multlay Comprs LWR Leg (29581),29581,CPT,,,,outpatient,,,491,294.6,,45.5,,223.41,percent of total billed charges,,,45.3,,222.42,percent of total billed charges,,,51,,250.41,percent of total billed charges,,,,,,,,,80,,392.8,percent of total billed charges,,,61.4,,301.47,percent of total billed charges,,,57.4,,281.83,percent of total billed charges,,,81,,397.71,percent of total billed charges,,,51.5,,252.87,percent of total billed charges,,,57.6,,282.82,percent of total billed charges,,,85,,417.35,percent of total billed charges,,,85,,417.35,percent of total billed charges,,,49,,240.59,percent of total billed charges,,,90,,441.9,percent of total billed charges,,,65,,319.15,percent of total billed charges,,,80,,392.8,percent of total billed charges,,,55,,270.05,percent of total billed charges,,,55,,270.05,percent of total billed charges,,,65,,319.15,percent of total billed charges,,,78,,382.98,percent of total billed charges,,,70,,343.7,percent of total billed charges,,,,,,,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,40559.435,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,,164.48,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,164.48,40559.44,
REM Shoulder Or Hip Spica,29710,CPT,,,,outpatient,,,655,393,,45.5,,298.03,percent of total billed charges,,,45.3,,296.72,percent of total billed charges,,,51,,334.05,percent of total billed charges,,,,,,,,,80,,524,percent of total billed charges,,,61.4,,402.17,percent of total billed charges,,,57.4,,375.97,percent of total billed charges,,,81,,530.55,percent of total billed charges,,,51.5,,337.33,percent of total billed charges,,,57.6,,377.28,percent of total billed charges,,,85,,556.75,percent of total billed charges,,,85,,556.75,percent of total billed charges,,,49,,320.95,percent of total billed charges,,,90,,589.5,percent of total billed charges,,,65,,425.75,percent of total billed charges,,,80,,524,percent of total billed charges,,,55,,360.25,percent of total billed charges,,,55,,360.25,percent of total billed charges,,,65,,425.75,percent of total billed charges,,,78,,510.9,percent of total billed charges,,,70,,458.5,percent of total billed charges,,,,,,,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,276.85,,,,100% of Medicare,,,276.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,276.85,589.5,
"REM Shoulder Or Hip Spica, Bilateral",29710,CPT,,,50,outpatient,,,1905,1143,,45.5,,866.78,percent of total billed charges,,,45.3,,862.97,percent of total billed charges,,,51,,971.55,percent of total billed charges,,,,,,,,,80,,1524,percent of total billed charges,,,61.4,,1169.67,percent of total billed charges,,,57.4,,1093.47,percent of total billed charges,,,81,,1543.05,percent of total billed charges,,,51.5,,981.08,percent of total billed charges,,,57.6,,1097.28,percent of total billed charges,,,85,,1619.25,percent of total billed charges,,,85,,1619.25,percent of total billed charges,,,49,,933.45,percent of total billed charges,,,90,,1714.5,percent of total billed charges,,,65,,1238.25,percent of total billed charges,,,80,,1524,percent of total billed charges,,,55,,1047.75,percent of total billed charges,,,55,,1047.75,percent of total billed charges,,,65,,1238.25,percent of total billed charges,,,78,,1485.9,percent of total billed charges,,,70,,1333.5,percent of total billed charges,,,,,,,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,415.27,,,,150% of Medicare,,,415.27,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,415.27,1714.5,
Casting/Strapping Procedure,29799,CPT,,,,outpatient,,,434,260.4,,45.5,,197.47,percent of total billed charges,,,45.3,,196.6,percent of total billed charges,,,51,,221.34,percent of total billed charges,,,,,,,,,80,,347.2,percent of total billed charges,,,61.4,,266.48,percent of total billed charges,,,57.4,,249.12,percent of total billed charges,,,81,,351.54,percent of total billed charges,,,51.5,,223.51,percent of total billed charges,,,57.6,,249.98,percent of total billed charges,,,85,,368.9,percent of total billed charges,,,85,,368.9,percent of total billed charges,,,49,,212.66,percent of total billed charges,,,90,,390.6,percent of total billed charges,,,65,,282.1,percent of total billed charges,,,80,,347.2,percent of total billed charges,,,55,,238.7,percent of total billed charges,,,55,,238.7,percent of total billed charges,,,65,,282.1,percent of total billed charges,,,78,,338.52,percent of total billed charges,,,70,,303.8,percent of total billed charges,,,,,,,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,41858.32,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,164.48,,,,100% of Medicare,,,164.48,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,164.48,41858.32,
Change of Windpipe Airway (31502),31502,CPT,,,,outpatient,,,582,349.2,,45.5,,264.81,percent of total billed charges,,,45.3,,263.65,percent of total billed charges,,,51,,296.82,percent of total billed charges,,,,,,,,,80,,465.6,percent of total billed charges,,,61.4,,357.35,percent of total billed charges,,,57.4,,334.07,percent of total billed charges,,,81,,471.42,percent of total billed charges,,,51.5,,299.73,percent of total billed charges,,,57.6,,335.23,percent of total billed charges,,,85,,494.7,percent of total billed charges,,,85,,494.7,percent of total billed charges,,,49,,285.18,percent of total billed charges,,,90,,523.8,percent of total billed charges,,,65,,378.3,percent of total billed charges,,,80,,465.6,percent of total billed charges,,,55,,320.1,percent of total billed charges,,,55,,320.1,percent of total billed charges,,,65,,378.3,percent of total billed charges,,,78,,453.96,percent of total billed charges,,,70,,407.4,percent of total billed charges,,,,,,,,242.07,,,,100% of Medicare,,242.07,,,,100% of Medicare,,242.07,,,,100% of Medicare,,242.07,,,,100% of Medicare,,242.07,,,,100% of Medicare,,242.07,,,,100% of Medicare,,242.07,,,,100% of Medicare,,242.07,,,,100% of Medicare,,242.07,,,,100% of Medicare,,242.07,,,,100% of Medicare,,242.07,,,,100% of Medicare,,242.07,,,,100% of Medicare,,,242.07,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,242.07,523.8,
Laryngoscopy Indirect Diagnostic (31505),31505,CPT,,,,outpatient,,,326,195.6,,45.5,,148.33,percent of total billed charges,,,45.3,,147.68,percent of total billed charges,,,51,,166.26,percent of total billed charges,,,,,,,,,80,,260.8,percent of total billed charges,,,61.4,,200.16,percent of total billed charges,,,57.4,,187.12,percent of total billed charges,,,81,,264.06,percent of total billed charges,,,51.5,,167.89,percent of total billed charges,,,57.6,,187.78,percent of total billed charges,,,85,,277.1,percent of total billed charges,,,85,,277.1,percent of total billed charges,,,49,,159.74,percent of total billed charges,,,90,,293.4,percent of total billed charges,,,65,,211.9,percent of total billed charges,,,80,,260.8,percent of total billed charges,,,55,,179.3,percent of total billed charges,,,55,,179.3,percent of total billed charges,,,65,,211.9,percent of total billed charges,,,78,,254.28,percent of total billed charges,,,70,,228.2,percent of total billed charges,,,,,,,,202.38,,,,100% of Medicare,,202.38,,,,100% of Medicare,,202.38,,,,100% of Medicare,,202.38,,,,100% of Medicare,,202.38,,,,100% of Medicare,,202.38,,,,100% of Medicare,,202.38,,,,100% of Medicare,,202.38,,,,100% of Medicare,,202.38,,,,100% of Medicare,,202.38,,,,100% of Medicare,,202.38,,,,100% of Medicare,,202.38,,,,100% of Medicare,,,202.38,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,147.68,293.4,
COLLECTION: Venous Draw,36415,CPT,,,,both,,,38,22.8,,45.5,,17.29,percent of total billed charges,,,45.3,,17.21,percent of total billed charges,,,51,,19.38,percent of total billed charges,,,,,,,,,80,,30.4,percent of total billed charges,,,61.4,,23.33,percent of total billed charges,,,57.4,,21.81,percent of total billed charges,,,81,,30.78,percent of total billed charges,,,51.5,,19.57,percent of total billed charges,,,57.6,,21.89,percent of total billed charges,,,85,,32.3,percent of total billed charges,,,85,,32.3,percent of total billed charges,,,49,,18.62,percent of total billed charges,,,90,,34.2,percent of total billed charges,,,65,,24.7,percent of total billed charges,,,80,,30.4,percent of total billed charges,,,55,,20.9,percent of total billed charges,,,55,,20.9,percent of total billed charges,,,65,,24.7,percent of total billed charges,,,78,,29.64,percent of total billed charges,,,70,,26.6,percent of total billed charges,,,,,,,,8.83,,,,100% of Medicare,,8.83,,,,100% of Medicare,,8.83,,,,100% of Medicare,,8.83,,,,100% of Medicare,,8.83,,,,100% of Medicare,,8.83,,,,100% of Medicare,,8.83,,,,100% of Medicare,,8.83,,,,100% of Medicare,,8.83,,,,100% of Medicare,,8.83,,,,100% of Medicare,,8.83,,,,100% of Medicare,,8.83,,,,100% of Medicare,,,8.83,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,8.83,34.2,
Collection: Venous Draw,36415,CPT,,,,both,,,38,22.8,,45.5,,17.29,percent of total billed charges,,,45.3,,17.21,percent of total billed charges,,,51,,19.38,percent of total billed charges,,,,,,,,,80,,30.4,percent of total billed charges,,,61.4,,23.33,percent of total billed charges,,,57.4,,21.81,percent of total billed charges,,,81,,30.78,percent of total billed charges,,,51.5,,19.57,percent of total billed charges,,,57.6,,21.89,percent of total billed charges,,,85,,32.3,percent of total billed charges,,,85,,32.3,percent of total billed charges,,,49,,18.62,percent of total billed charges,,,90,,34.2,percent of total billed charges,,,65,,24.7,percent of total billed charges,,,80,,30.4,percent of total billed charges,,,55,,20.9,percent of total billed charges,,,55,,20.9,percent of total billed charges,,,65,,24.7,percent of total billed charges,,,78,,29.64,percent of total billed charges,,,70,,26.6,percent of total billed charges,,,,,,,,8.83,,,,100% of Medicare,,8.83,,,,100% of Medicare,,8.83,,,,100% of Medicare,,8.83,,,,100% of Medicare,,8.83,,,,100% of Medicare,,8.83,,,,100% of Medicare,,8.83,,,,100% of Medicare,,8.83,,,,100% of Medicare,,8.83,,,,100% of Medicare,,8.83,,,,100% of Medicare,,8.83,,,,100% of Medicare,,8.83,,,,100% of Medicare,,,8.83,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,8.83,34.2,
Insert Non-Tunnel CV Cath age 5 Yr/>,36556,CPT,,,,outpatient,,,3631,2178.6,,45.5,,1652.11,percent of total billed charges,,,45.3,,1644.84,percent of total billed charges,,,51,,1851.81,percent of total billed charges,,,,,,,,,80,,2904.8,percent of total billed charges,,,61.4,,2229.43,percent of total billed charges,,,57.4,,2084.19,percent of total billed charges,,,81,,2941.11,percent of total billed charges,,,51.5,,1869.97,percent of total billed charges,,,57.6,,2091.46,percent of total billed charges,,,85,,3086.35,percent of total billed charges,,,85,,3086.35,percent of total billed charges,,,49,,1779.19,percent of total billed charges,,,90,,3267.9,percent of total billed charges,,,65,,2360.15,percent of total billed charges,,,80,,2904.8,percent of total billed charges,,,55,,1997.05,percent of total billed charges,,,55,,1997.05,percent of total billed charges,,,65,,2360.15,percent of total billed charges,,,78,,2832.18,percent of total billed charges,,,70,,2541.7,percent of total billed charges,,,,,,,,3281.02,,,,100% of Medicare,,3281.02,,,,100% of Medicare,,3281.02,,,,100% of Medicare,,3281.02,,,,100% of Medicare,,3281.02,,,,100% of Medicare,,3281.02,,,,100% of Medicare,,3281.02,,,,100% of Medicare,,3281.02,,,,100% of Medicare,,3281.02,,,,100% of Medicare,,3281.02,,,,100% of Medicare,,3281.02,,,,100% of Medicare,,3281.02,,,,100% of Medicare,,,3281.02,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1644.84,3281.02,
"Salivary Gland Procedure, unlisted",42699,CPT,,,,outpatient,,,1010,606,,45.5,,459.55,percent of total billed charges,,,45.3,,457.53,percent of total billed charges,,,51,,515.1,percent of total billed charges,,,,,,,,,80,,808,percent of total billed charges,,,61.4,,620.14,percent of total billed charges,,,57.4,,579.74,percent of total billed charges,,,81,,818.1,percent of total billed charges,,,51.5,,520.15,percent of total billed charges,,,57.6,,581.76,percent of total billed charges,,,85,,858.5,percent of total billed charges,,,85,,858.5,percent of total billed charges,,,49,,494.9,percent of total billed charges,,,90,,909,percent of total billed charges,,,65,,656.5,percent of total billed charges,,,80,,808,percent of total billed charges,,,55,,555.5,percent of total billed charges,,,55,,555.5,percent of total billed charges,,,65,,656.5,percent of total billed charges,,,78,,787.8,percent of total billed charges,,,70,,707,percent of total billed charges,,,,,,,,242.07,,,,100% of Medicare,,242.07,,,,100% of Medicare,,242.07,,,,100% of Medicare,,242.07,,,,100% of Medicare,,242.07,,,,100% of Medicare,,242.07,,,,100% of Medicare,,242.07,,,,100% of Medicare,,242.07,,,,100% of Medicare,,242.07,,,,100% of Medicare,,242.07,,,,100% of Medicare,,242.07,,,,100% of Medicare,,242.07,,,,100% of Medicare,,,242.07,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,242.07,909,
"Reposition Gastric Feeding Tube, through the duodenum",43761,CPT,,,,both,,,3441,2064.6,,45.5,,1565.66,percent of total billed charges,,,45.3,,1558.77,percent of total billed charges,,,51,,1754.91,percent of total billed charges,,,,,,,,,80,,2752.8,percent of total billed charges,,,61.4,,2112.77,percent of total billed charges,,,57.4,,1975.13,percent of total billed charges,,,81,,2787.21,percent of total billed charges,,,51.5,,1772.12,percent of total billed charges,,,57.6,,1982.02,percent of total billed charges,,,85,,2924.85,percent of total billed charges,,,85,,2924.85,percent of total billed charges,,,49,,1686.09,percent of total billed charges,,,90,,3096.9,percent of total billed charges,,,65,,2236.65,percent of total billed charges,,,80,,2752.8,percent of total billed charges,,,55,,1892.55,percent of total billed charges,,,55,,1892.55,percent of total billed charges,,,65,,2236.65,percent of total billed charges,,,78,,2683.98,percent of total billed charges,,,70,,2408.7,percent of total billed charges,,,,,,,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,,253.53,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,253.53,3096.9,
RPLC GTUBE NO REVJ TRC (43762),43762,CPT,,,,both,,,1147,688.2,,45.5,,521.89,percent of total billed charges,,,45.3,,519.59,percent of total billed charges,,,51,,584.97,percent of total billed charges,,,,,,,,,80,,917.6,percent of total billed charges,,,61.4,,704.26,percent of total billed charges,,,57.4,,658.38,percent of total billed charges,,,81,,929.07,percent of total billed charges,,,51.5,,590.71,percent of total billed charges,,,57.6,,660.67,percent of total billed charges,,,85,,974.95,percent of total billed charges,,,85,,974.95,percent of total billed charges,,,49,,562.03,percent of total billed charges,,,90,,1032.3,percent of total billed charges,,,65,,745.55,percent of total billed charges,,,80,,917.6,percent of total billed charges,,,55,,630.85,percent of total billed charges,,,55,,630.85,percent of total billed charges,,,65,,745.55,percent of total billed charges,,,78,,894.66,percent of total billed charges,,,70,,802.9,percent of total billed charges,,,,,,,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,,253.53,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,253.53,1032.3,
Diagnostic Anoscopy Charge-46600,46600,CPT,,,,outpatient,,,258,154.8,,45.5,,117.39,percent of total billed charges,,,45.3,,116.87,percent of total billed charges,,,51,,131.58,percent of total billed charges,,,,,,,,,80,,206.4,percent of total billed charges,,,61.4,,158.41,percent of total billed charges,,,57.4,,148.09,percent of total billed charges,,,81,,208.98,percent of total billed charges,,,51.5,,132.87,percent of total billed charges,,,57.6,,148.61,percent of total billed charges,,,85,,219.3,percent of total billed charges,,,85,,219.3,percent of total billed charges,,,49,,126.42,percent of total billed charges,,,90,,232.2,percent of total billed charges,,,65,,167.7,percent of total billed charges,,,80,,206.4,percent of total billed charges,,,55,,141.9,percent of total billed charges,,,55,,141.9,percent of total billed charges,,,65,,167.7,percent of total billed charges,,,78,,201.24,percent of total billed charges,,,70,,180.6,percent of total billed charges,,,,,,,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,,134.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,116.87,232.2,
Simple Cystometrogram (51725),51725,CPT,,,TC,outpatient,,,1232,739.2,,45.5,,560.56,percent of total billed charges,,,45.3,,558.1,percent of total billed charges,,,51,,628.32,percent of total billed charges,,,,,,,,,80,,985.6,percent of total billed charges,,,61.4,,756.45,percent of total billed charges,,,57.4,,707.17,percent of total billed charges,,,81,,997.92,percent of total billed charges,,,51.5,,634.48,percent of total billed charges,,,57.6,,709.63,percent of total billed charges,,,85,,1047.2,percent of total billed charges,,,85,,1047.2,percent of total billed charges,,,49,,603.68,percent of total billed charges,,,90,,1108.8,percent of total billed charges,,,65,,800.8,percent of total billed charges,,,80,,985.6,percent of total billed charges,,,55,,677.6,percent of total billed charges,,,55,,677.6,percent of total billed charges,,,65,,800.8,percent of total billed charges,,,78,,960.96,percent of total billed charges,,,70,,862.4,percent of total billed charges,,,,,,,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,,253.53,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,253.53,1108.8,
Complex Cystometrogram (51726),51726,CPT,,,TC,outpatient,,,1315,789,,45.5,,598.33,percent of total billed charges,,,45.3,,595.7,percent of total billed charges,,,51,,670.65,percent of total billed charges,,,,,,,,,80,,1052,percent of total billed charges,,,61.4,,807.41,percent of total billed charges,,,57.4,,754.81,percent of total billed charges,,,81,,1065.15,percent of total billed charges,,,51.5,,677.23,percent of total billed charges,,,57.6,,757.44,percent of total billed charges,,,85,,1117.75,percent of total billed charges,,,85,,1117.75,percent of total billed charges,,,49,,644.35,percent of total billed charges,,,90,,1183.5,percent of total billed charges,,,65,,854.75,percent of total billed charges,,,80,,1052,percent of total billed charges,,,55,,723.25,percent of total billed charges,,,55,,723.25,percent of total billed charges,,,65,,854.75,percent of total billed charges,,,78,,1025.7,percent of total billed charges,,,70,,920.5,percent of total billed charges,,,,,,,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,,253.53,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,253.53,1183.5,
Cystometrogram w/ UP,51727,CPT,,,TC,outpatient,,,1232,739.2,,45.5,,560.56,percent of total billed charges,,,45.3,,558.1,percent of total billed charges,,,51,,628.32,percent of total billed charges,,,,,,,,,80,,985.6,percent of total billed charges,,,61.4,,756.45,percent of total billed charges,,,57.4,,707.17,percent of total billed charges,,,81,,997.92,percent of total billed charges,,,51.5,,634.48,percent of total billed charges,,,57.6,,709.63,percent of total billed charges,,,85,,1047.2,percent of total billed charges,,,85,,1047.2,percent of total billed charges,,,49,,603.68,percent of total billed charges,,,90,,1108.8,percent of total billed charges,,,65,,800.8,percent of total billed charges,,,80,,985.6,percent of total billed charges,,,55,,677.6,percent of total billed charges,,,55,,677.6,percent of total billed charges,,,65,,800.8,percent of total billed charges,,,78,,960.96,percent of total billed charges,,,70,,862.4,percent of total billed charges,,,,,,,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,,695.78,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,558.1,1108.8,
Complex Cystometrogram w/ VP (51728),51728,CPT,,,TC,outpatient,,,1315,789,,45.5,,598.33,percent of total billed charges,,,45.3,,595.7,percent of total billed charges,,,51,,670.65,percent of total billed charges,,,,,,,,,80,,1052,percent of total billed charges,,,61.4,,807.41,percent of total billed charges,,,57.4,,754.81,percent of total billed charges,,,81,,1065.15,percent of total billed charges,,,51.5,,677.23,percent of total billed charges,,,57.6,,757.44,percent of total billed charges,,,85,,1117.75,percent of total billed charges,,,85,,1117.75,percent of total billed charges,,,49,,644.35,percent of total billed charges,,,90,,1183.5,percent of total billed charges,,,65,,854.75,percent of total billed charges,,,80,,1052,percent of total billed charges,,,55,,723.25,percent of total billed charges,,,55,,723.25,percent of total billed charges,,,65,,854.75,percent of total billed charges,,,78,,1025.7,percent of total billed charges,,,70,,920.5,percent of total billed charges,,,,,,,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,,695.78,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,595.7,1183.5,
Complex Cystometrogram w/ VP & UP (51729),51729,CPT,,,TC,outpatient,,,1374,824.4,,45.5,,625.17,percent of total billed charges,,,45.3,,622.42,percent of total billed charges,,,51,,700.74,percent of total billed charges,,,,,,,,,80,,1099.2,percent of total billed charges,,,61.4,,843.64,percent of total billed charges,,,57.4,,788.68,percent of total billed charges,,,81,,1112.94,percent of total billed charges,,,51.5,,707.61,percent of total billed charges,,,57.6,,791.42,percent of total billed charges,,,85,,1167.9,percent of total billed charges,,,85,,1167.9,percent of total billed charges,,,49,,673.26,percent of total billed charges,,,90,,1236.6,percent of total billed charges,,,65,,893.1,percent of total billed charges,,,80,,1099.2,percent of total billed charges,,,55,,755.7,percent of total billed charges,,,55,,755.7,percent of total billed charges,,,65,,893.1,percent of total billed charges,,,78,,1071.72,percent of total billed charges,,,70,,961.8,percent of total billed charges,,,,,,,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,695.78,,,,100% of Medicare,,,695.78,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,622.42,1236.6,
Simple Uroflowmetry (51736),51736,CPT,,,TC,outpatient,,,397,238.2,,45.5,,180.64,percent of total billed charges,,,45.3,,179.84,percent of total billed charges,,,51,,202.47,percent of total billed charges,,,,,,,,,80,,317.6,percent of total billed charges,,,61.4,,243.76,percent of total billed charges,,,57.4,,227.88,percent of total billed charges,,,81,,321.57,percent of total billed charges,,,51.5,,204.46,percent of total billed charges,,,57.6,,228.67,percent of total billed charges,,,85,,337.45,percent of total billed charges,,,85,,337.45,percent of total billed charges,,,49,,194.53,percent of total billed charges,,,90,,357.3,percent of total billed charges,,,65,,258.05,percent of total billed charges,,,80,,317.6,percent of total billed charges,,,55,,218.35,percent of total billed charges,,,55,,218.35,percent of total billed charges,,,65,,258.05,percent of total billed charges,,,78,,309.66,percent of total billed charges,,,70,,277.9,percent of total billed charges,,,,,,,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,,134.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,134.37,357.3,
Complex Uroflowmetry,51741,CPT,,,TC,outpatient,,,457,274.2,,45.5,,207.94,percent of total billed charges,,,45.3,,207.02,percent of total billed charges,,,51,,233.07,percent of total billed charges,,,,,,,,,80,,365.6,percent of total billed charges,,,61.4,,280.6,percent of total billed charges,,,57.4,,262.32,percent of total billed charges,,,81,,370.17,percent of total billed charges,,,51.5,,235.36,percent of total billed charges,,,57.6,,263.23,percent of total billed charges,,,85,,388.45,percent of total billed charges,,,85,,388.45,percent of total billed charges,,,49,,223.93,percent of total billed charges,,,90,,411.3,percent of total billed charges,,,65,,297.05,percent of total billed charges,,,80,,365.6,percent of total billed charges,,,55,,251.35,percent of total billed charges,,,55,,251.35,percent of total billed charges,,,65,,297.05,percent of total billed charges,,,78,,356.46,percent of total billed charges,,,70,,319.9,percent of total billed charges,,,,,,,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,,324.61,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,207.02,411.3,
"EMG Anal/Urethr Sphinct, Not Needle (51784)",51784,CPT,,,TC,outpatient,,,446,267.6,,45.5,,202.93,percent of total billed charges,,,45.3,,202.04,percent of total billed charges,,,51,,227.46,percent of total billed charges,,,,,,,,,80,,356.8,percent of total billed charges,,,61.4,,273.84,percent of total billed charges,,,57.4,,256,percent of total billed charges,,,81,,361.26,percent of total billed charges,,,51.5,,229.69,percent of total billed charges,,,57.6,,256.9,percent of total billed charges,,,85,,379.1,percent of total billed charges,,,85,,379.1,percent of total billed charges,,,49,,218.54,percent of total billed charges,,,90,,401.4,percent of total billed charges,,,65,,289.9,percent of total billed charges,,,80,,356.8,percent of total billed charges,,,55,,245.3,percent of total billed charges,,,55,,245.3,percent of total billed charges,,,65,,289.9,percent of total billed charges,,,78,,347.88,percent of total billed charges,,,70,,312.2,percent of total billed charges,,,,,,,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,,163.1,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,163.1,401.4,
"Needle EMG, Anal/Urethral Sphincter (51785)",51785,CPT,,,TC,outpatient,,,822,493.2,,45.5,,374.01,percent of total billed charges,,,45.3,,372.37,percent of total billed charges,,,51,,419.22,percent of total billed charges,,,,,,,,,80,,657.6,percent of total billed charges,,,61.4,,504.71,percent of total billed charges,,,57.4,,471.83,percent of total billed charges,,,81,,665.82,percent of total billed charges,,,51.5,,423.33,percent of total billed charges,,,57.6,,473.47,percent of total billed charges,,,85,,698.7,percent of total billed charges,,,85,,698.7,percent of total billed charges,,,49,,402.78,percent of total billed charges,,,90,,739.8,percent of total billed charges,,,65,,534.3,percent of total billed charges,,,80,,657.6,percent of total billed charges,,,55,,452.1,percent of total billed charges,,,55,,452.1,percent of total billed charges,,,65,,534.3,percent of total billed charges,,,78,,641.16,percent of total billed charges,,,70,,575.4,percent of total billed charges,,,,,,,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,253.53,,,,100% of Medicare,,,253.53,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,253.53,739.8,
Urinary Reflex Study (51792),51792,CPT,,,TC,outpatient,,,446,267.6,,45.5,,202.93,percent of total billed charges,,,45.3,,202.04,percent of total billed charges,,,51,,227.46,percent of total billed charges,,,,,,,,,80,,356.8,percent of total billed charges,,,61.4,,273.84,percent of total billed charges,,,57.4,,256,percent of total billed charges,,,81,,361.26,percent of total billed charges,,,51.5,,229.69,percent of total billed charges,,,57.6,,256.9,percent of total billed charges,,,85,,379.1,percent of total billed charges,,,85,,379.1,percent of total billed charges,,,49,,218.54,percent of total billed charges,,,90,,401.4,percent of total billed charges,,,65,,289.9,percent of total billed charges,,,80,,356.8,percent of total billed charges,,,55,,245.3,percent of total billed charges,,,55,,245.3,percent of total billed charges,,,65,,289.9,percent of total billed charges,,,78,,347.88,percent of total billed charges,,,70,,312.2,percent of total billed charges,,,,,,,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,,61.92,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,61.92,401.4,
Intra-abdominal Pressure Test (51797),51797,CPT,,,TC,outpatient,,,822,493.2,,45.5,,374.01,percent of total billed charges,,,45.3,,372.37,percent of total billed charges,,,51,,419.22,percent of total billed charges,,,,,,,,,80,,657.6,percent of total billed charges,,,61.4,,504.71,percent of total billed charges,,,57.4,,471.83,percent of total billed charges,,,81,,665.82,percent of total billed charges,,,51.5,,423.33,percent of total billed charges,,,57.6,,473.47,percent of total billed charges,,,85,,698.7,percent of total billed charges,,,85,,698.7,percent of total billed charges,,,49,,402.78,percent of total billed charges,,,90,,739.8,percent of total billed charges,,,65,,534.3,percent of total billed charges,,,80,,657.6,percent of total billed charges,,,55,,452.1,percent of total billed charges,,,55,,452.1,percent of total billed charges,,,65,,534.3,percent of total billed charges,,,78,,641.16,percent of total billed charges,,,70,,575.4,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,372.37,739.8,
Fit or Insert Pessary,57160,CPT,,,,outpatient,,,473,283.8,,45.5,,215.22,percent of total billed charges,,,45.3,,214.27,percent of total billed charges,,,51,,241.23,percent of total billed charges,,,,,,,,,80,,378.4,percent of total billed charges,,,61.4,,290.42,percent of total billed charges,,,57.4,,271.5,percent of total billed charges,,,81,,383.13,percent of total billed charges,,,51.5,,243.6,percent of total billed charges,,,57.6,,272.45,percent of total billed charges,,,85,,402.05,percent of total billed charges,,,85,,402.05,percent of total billed charges,,,49,,231.77,percent of total billed charges,,,90,,425.7,percent of total billed charges,,,65,,307.45,percent of total billed charges,,,80,,378.4,percent of total billed charges,,,55,,260.15,percent of total billed charges,,,55,,260.15,percent of total billed charges,,,65,,307.45,percent of total billed charges,,,78,,368.94,percent of total billed charges,,,70,,331.1,percent of total billed charges,,,,,,,,209.7,,,,100% of Medicare,,209.7,,,,100% of Medicare,,209.7,,,,100% of Medicare,,209.7,,,,100% of Medicare,,209.7,,,,100% of Medicare,,209.7,,,,100% of Medicare,,209.7,,,,100% of Medicare,,209.7,,,,100% of Medicare,,209.7,,,,100% of Medicare,,209.7,,,,100% of Medicare,,209.7,,,,100% of Medicare,,209.7,,,,100% of Medicare,,,209.7,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,209.7,425.7,
Drain Cerebrospinal Fluid,62272,CPT,,,,outpatient,,,1532,919.2,,45.5,,697.06,percent of total billed charges,,,45.3,,694,percent of total billed charges,,,51,,781.32,percent of total billed charges,,,,,,,,,80,,1225.6,percent of total billed charges,,,61.4,,940.65,percent of total billed charges,,,57.4,,879.37,percent of total billed charges,,,81,,1240.92,percent of total billed charges,,,51.5,,788.98,percent of total billed charges,,,57.6,,882.43,percent of total billed charges,,,85,,1302.2,percent of total billed charges,,,85,,1302.2,percent of total billed charges,,,49,,750.68,percent of total billed charges,,,90,,1378.8,percent of total billed charges,,,65,,995.8,percent of total billed charges,,,80,,1225.6,percent of total billed charges,,,55,,842.6,percent of total billed charges,,,55,,842.6,percent of total billed charges,,,65,,995.8,percent of total billed charges,,,78,,1194.96,percent of total billed charges,,,70,,1072.4,percent of total billed charges,,,,,,,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,,721.9,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,694,1378.8,
Inj Epidural Blood or Clot Patch,62273,CPT,,,,outpatient,,,1756,1053.6,,45.5,,798.98,percent of total billed charges,,,45.3,,795.47,percent of total billed charges,,,51,,895.56,percent of total billed charges,,,,,,,,,80,,1404.8,percent of total billed charges,,,61.4,,1078.18,percent of total billed charges,,,57.4,,1007.94,percent of total billed charges,,,81,,1422.36,percent of total billed charges,,,51.5,,904.34,percent of total billed charges,,,57.6,,1011.46,percent of total billed charges,,,85,,1492.6,percent of total billed charges,,,85,,1492.6,percent of total billed charges,,,49,,860.44,percent of total billed charges,,,90,,1580.4,percent of total billed charges,,,65,,1141.4,percent of total billed charges,,,80,,1404.8,percent of total billed charges,,,55,,965.8,percent of total billed charges,,,55,,965.8,percent of total billed charges,,,65,,1141.4,percent of total billed charges,,,78,,1369.68,percent of total billed charges,,,70,,1229.2,percent of total billed charges,,,,,,,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,,721.9,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,721.9,1580.4,
INJ NEUROLYTIC; EPIDURAL LUMB/CAUDAL (62282),62282,CPT,,,,outpatient,,,5364,3218.4,,45.5,,2440.62,percent of total billed charges,,,45.3,,2429.89,percent of total billed charges,,,51,,2735.64,percent of total billed charges,,,,,,,,,80,,4291.2,percent of total billed charges,,,61.4,,3293.5,percent of total billed charges,,,57.4,,3078.94,percent of total billed charges,,,81,,4344.84,percent of total billed charges,,,51.5,,2762.46,percent of total billed charges,,,57.6,,3089.66,percent of total billed charges,,,85,,4559.4,percent of total billed charges,,,85,,4559.4,percent of total billed charges,,,49,,2628.36,percent of total billed charges,,,90,,4827.6,percent of total billed charges,,,65,,3486.6,percent of total billed charges,,,80,,4291.2,percent of total billed charges,,,55,,2950.2,percent of total billed charges,,,55,,2950.2,percent of total billed charges,,,65,,3486.6,percent of total billed charges,,,78,,4183.92,percent of total billed charges,,,70,,3754.8,percent of total billed charges,,,,,,,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,,928.06,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,928.06,4827.6,
Percutaneous Disc Decompression (62287),62287,CPT,,,,outpatient,,,15185,9111,,45.5,,6909.18,percent of total billed charges,,,45.3,,6878.81,percent of total billed charges,,,51,,7744.35,percent of total billed charges,,,,,,,,,80,,12148,percent of total billed charges,,,61.4,,9323.59,percent of total billed charges,,,57.4,,8716.19,percent of total billed charges,,,81,,12299.85,percent of total billed charges,,,51.5,,7820.28,percent of total billed charges,,,57.6,,8746.56,percent of total billed charges,,,85,,12907.25,percent of total billed charges,,,85,,12907.25,percent of total billed charges,,,49,,7440.65,percent of total billed charges,,,90,,13666.5,percent of total billed charges,,,65,,9870.25,percent of total billed charges,,,80,,12148,percent of total billed charges,,,55,,8351.75,percent of total billed charges,,,55,,8351.75,percent of total billed charges,,,65,,9870.25,percent of total billed charges,,,78,,11844.3,percent of total billed charges,,,70,,10629.5,percent of total billed charges,,,,,,,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,,2035.61,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,2035.61,13666.5,
C-sp Disc. Add'l level x___,62291,CPT,,,,both,,,2242,1345.2,,45.5,,1020.11,percent of total billed charges,,,45.3,,1015.63,percent of total billed charges,,,51,,1143.42,percent of total billed charges,,,,,,,,,80,,1793.6,percent of total billed charges,,,61.4,,1376.59,percent of total billed charges,,,57.4,,1286.91,percent of total billed charges,,,81,,1816.02,percent of total billed charges,,,51.5,,1154.63,percent of total billed charges,,,57.6,,1291.39,percent of total billed charges,,,85,,1905.7,percent of total billed charges,,,85,,1905.7,percent of total billed charges,,,49,,1098.58,percent of total billed charges,,,90,,2017.8,percent of total billed charges,,,65,,1457.3,percent of total billed charges,,,80,,1793.6,percent of total billed charges,,,55,,1233.1,percent of total billed charges,,,55,,1233.1,percent of total billed charges,,,65,,1457.3,percent of total billed charges,,,78,,1748.76,percent of total billed charges,,,70,,1569.4,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1015.63,2017.8,
T-sp Disc. Add'l level x___,62291,CPT,,,,both,,,2242,1345.2,,45.5,,1020.11,percent of total billed charges,,,45.3,,1015.63,percent of total billed charges,,,51,,1143.42,percent of total billed charges,,,,,,,,,80,,1793.6,percent of total billed charges,,,61.4,,1376.59,percent of total billed charges,,,57.4,,1286.91,percent of total billed charges,,,81,,1816.02,percent of total billed charges,,,51.5,,1154.63,percent of total billed charges,,,57.6,,1291.39,percent of total billed charges,,,85,,1905.7,percent of total billed charges,,,85,,1905.7,percent of total billed charges,,,49,,1098.58,percent of total billed charges,,,90,,2017.8,percent of total billed charges,,,65,,1457.3,percent of total billed charges,,,80,,1793.6,percent of total billed charges,,,55,,1233.1,percent of total billed charges,,,55,,1233.1,percent of total billed charges,,,65,,1457.3,percent of total billed charges,,,78,,1748.76,percent of total billed charges,,,70,,1569.4,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1015.63,2017.8,
"NJX INTERLAMINAR CRV/THR, C without imaging guidance (62320)",62320,CPT,,,,outpatient,,,2019,1211.4,,45.5,,918.65,percent of total billed charges,,,45.3,,914.61,percent of total billed charges,,,51,,1029.69,percent of total billed charges,,,,,,,,,80,,1615.2,percent of total billed charges,,,61.4,,1239.67,percent of total billed charges,,,57.4,,1158.91,percent of total billed charges,,,81,,1635.39,percent of total billed charges,,,51.5,,1039.79,percent of total billed charges,,,57.6,,1162.94,percent of total billed charges,,,85,,1716.15,percent of total billed charges,,,85,,1716.15,percent of total billed charges,,,49,,989.31,percent of total billed charges,,,90,,1817.1,percent of total billed charges,,,65,,1312.35,percent of total billed charges,,,80,,1615.2,percent of total billed charges,,,55,,1110.45,percent of total billed charges,,,55,,1110.45,percent of total billed charges,,,65,,1312.35,percent of total billed charges,,,78,,1574.82,percent of total billed charges,,,70,,1413.3,percent of total billed charges,,,,,,,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,,721.9,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,721.9,1817.1,
"CC ONLY - NJX INTERLAMINAR CRV/THRC, with imaging guidance (62321)",62321,CPT,,,,outpatient,,,2812,1687.2,,45.5,,1279.46,percent of total billed charges,,,45.3,,1273.84,percent of total billed charges,,,51,,1434.12,percent of total billed charges,,,,,,,,,80,,2249.6,percent of total billed charges,,,61.4,,1726.57,percent of total billed charges,,,57.4,,1614.09,percent of total billed charges,,,81,,2277.72,percent of total billed charges,,,51.5,,1448.18,percent of total billed charges,,,57.6,,1619.71,percent of total billed charges,,,85,,2390.2,percent of total billed charges,,,85,,2390.2,percent of total billed charges,,,49,,1377.88,percent of total billed charges,,,90,,2530.8,percent of total billed charges,,,65,,1827.8,percent of total billed charges,,,80,,2249.6,percent of total billed charges,,,55,,1546.6,percent of total billed charges,,,55,,1546.6,percent of total billed charges,,,65,,1827.8,percent of total billed charges,,,78,,2193.36,percent of total billed charges,,,70,,1968.4,percent of total billed charges,,,,,,,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,,721.9,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,721.9,2530.8,
"NJX INTERLAMINAR CRV/THRC, with imaging guidance (62321)",62321,CPT,,,,outpatient,,,2812,1687.2,,45.5,,1279.46,percent of total billed charges,,,45.3,,1273.84,percent of total billed charges,,,51,,1434.12,percent of total billed charges,,,,,,,,,80,,2249.6,percent of total billed charges,,,61.4,,1726.57,percent of total billed charges,,,57.4,,1614.09,percent of total billed charges,,,81,,2277.72,percent of total billed charges,,,51.5,,1448.18,percent of total billed charges,,,57.6,,1619.71,percent of total billed charges,,,85,,2390.2,percent of total billed charges,,,85,,2390.2,percent of total billed charges,,,49,,1377.88,percent of total billed charges,,,90,,2530.8,percent of total billed charges,,,65,,1827.8,percent of total billed charges,,,80,,2249.6,percent of total billed charges,,,55,,1546.6,percent of total billed charges,,,55,,1546.6,percent of total billed charges,,,65,,1827.8,percent of total billed charges,,,78,,2193.36,percent of total billed charges,,,70,,1968.4,percent of total billed charges,,,,,,,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,,721.9,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,721.9,2530.8,
"NJX INTERLAMINAR LMBR/SAC, without imaging guidance (62322)",62322,CPT,,,,outpatient,,,2019,1211.4,,45.5,,918.65,percent of total billed charges,,,45.3,,914.61,percent of total billed charges,,,51,,1029.69,percent of total billed charges,,,,,,,,,80,,1615.2,percent of total billed charges,,,61.4,,1239.67,percent of total billed charges,,,57.4,,1158.91,percent of total billed charges,,,81,,1635.39,percent of total billed charges,,,51.5,,1039.79,percent of total billed charges,,,57.6,,1162.94,percent of total billed charges,,,85,,1716.15,percent of total billed charges,,,85,,1716.15,percent of total billed charges,,,49,,989.31,percent of total billed charges,,,90,,1817.1,percent of total billed charges,,,65,,1312.35,percent of total billed charges,,,80,,1615.2,percent of total billed charges,,,55,,1110.45,percent of total billed charges,,,55,,1110.45,percent of total billed charges,,,65,,1312.35,percent of total billed charges,,,78,,1574.82,percent of total billed charges,,,70,,1413.3,percent of total billed charges,,,,,,,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,,928.06,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,914.61,1817.1,
"CC ONLY - NJX INTERLAMINAR LMBR/SAC, with imaging guidance (62323)",62323,CPT,,,,outpatient,,,1874,1124.4,,45.5,,852.67,percent of total billed charges,,,45.3,,848.92,percent of total billed charges,,,51,,955.74,percent of total billed charges,,,,,,,,,80,,1499.2,percent of total billed charges,,,61.4,,1150.64,percent of total billed charges,,,57.4,,1075.68,percent of total billed charges,,,81,,1517.94,percent of total billed charges,,,51.5,,965.11,percent of total billed charges,,,57.6,,1079.42,percent of total billed charges,,,85,,1592.9,percent of total billed charges,,,85,,1592.9,percent of total billed charges,,,49,,918.26,percent of total billed charges,,,90,,1686.6,percent of total billed charges,,,65,,1218.1,percent of total billed charges,,,80,,1499.2,percent of total billed charges,,,55,,1030.7,percent of total billed charges,,,55,,1030.7,percent of total billed charges,,,65,,1218.1,percent of total billed charges,,,78,,1461.72,percent of total billed charges,,,70,,1311.8,percent of total billed charges,,,,,,,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,,721.9,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,721.9,1686.6,
"NJX INTERLAMINAR LMBR/SAC, with imaging guidance (62323)",62323,CPT,,,,outpatient,,,1874,1124.4,,45.5,,852.67,percent of total billed charges,,,45.3,,848.92,percent of total billed charges,,,51,,955.74,percent of total billed charges,,,,,,,,,80,,1499.2,percent of total billed charges,,,61.4,,1150.64,percent of total billed charges,,,57.4,,1075.68,percent of total billed charges,,,81,,1517.94,percent of total billed charges,,,51.5,,965.11,percent of total billed charges,,,57.6,,1079.42,percent of total billed charges,,,85,,1592.9,percent of total billed charges,,,85,,1592.9,percent of total billed charges,,,49,,918.26,percent of total billed charges,,,90,,1686.6,percent of total billed charges,,,65,,1218.1,percent of total billed charges,,,80,,1499.2,percent of total billed charges,,,55,,1030.7,percent of total billed charges,,,55,,1030.7,percent of total billed charges,,,65,,1218.1,percent of total billed charges,,,78,,1461.72,percent of total billed charges,,,70,,1311.8,percent of total billed charges,,,,,,,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,,721.9,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,721.9,1686.6,
"NJX INTERLAMINAR CRV/THRC, incl indw cath/cont fusion, wo imagine guide (62324)",62324,CPT,,,,outpatient,,,2543,1525.8,,45.5,,1157.07,percent of total billed charges,,,45.3,,1151.98,percent of total billed charges,,,51,,1296.93,percent of total billed charges,,,,,,,,,80,,2034.4,percent of total billed charges,,,61.4,,1561.4,percent of total billed charges,,,57.4,,1459.68,percent of total billed charges,,,81,,2059.83,percent of total billed charges,,,51.5,,1309.65,percent of total billed charges,,,57.6,,1464.77,percent of total billed charges,,,85,,2161.55,percent of total billed charges,,,85,,2161.55,percent of total billed charges,,,49,,1246.07,percent of total billed charges,,,90,,2288.7,percent of total billed charges,,,65,,1652.95,percent of total billed charges,,,80,,2034.4,percent of total billed charges,,,55,,1398.65,percent of total billed charges,,,55,,1398.65,percent of total billed charges,,,65,,1652.95,percent of total billed charges,,,78,,1983.54,percent of total billed charges,,,70,,1780.1,percent of total billed charges,,,,,,,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,,928.06,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,928.06,2288.7,
"NJX INTERLAMINAR CRV/THRC, incl indw cath, cont infusion, wt image guide (62325)",62325,CPT,,,,outpatient,,,2598,1558.8,,45.5,,1182.09,percent of total billed charges,,,45.3,,1176.89,percent of total billed charges,,,51,,1324.98,percent of total billed charges,,,,,,,,,80,,2078.4,percent of total billed charges,,,61.4,,1595.17,percent of total billed charges,,,57.4,,1491.25,percent of total billed charges,,,81,,2104.38,percent of total billed charges,,,51.5,,1337.97,percent of total billed charges,,,57.6,,1496.45,percent of total billed charges,,,85,,2208.3,percent of total billed charges,,,85,,2208.3,percent of total billed charges,,,49,,1273.02,percent of total billed charges,,,90,,2338.2,percent of total billed charges,,,65,,1688.7,percent of total billed charges,,,80,,2078.4,percent of total billed charges,,,55,,1428.9,percent of total billed charges,,,55,,1428.9,percent of total billed charges,,,65,,1688.7,percent of total billed charges,,,78,,2026.44,percent of total billed charges,,,70,,1818.6,percent of total billed charges,,,,,,,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,,928.06,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,928.06,2338.2,
"NJX INTERLAMINAR LMBR/SAC,incl ind cath, cont infusion, wo image guide (62326)",62326,CPT,,,,outpatient,,,2543,1525.8,,45.5,,1157.07,percent of total billed charges,,,45.3,,1151.98,percent of total billed charges,,,51,,1296.93,percent of total billed charges,,,,,,,,,80,,2034.4,percent of total billed charges,,,61.4,,1561.4,percent of total billed charges,,,57.4,,1459.68,percent of total billed charges,,,81,,2059.83,percent of total billed charges,,,51.5,,1309.65,percent of total billed charges,,,57.6,,1464.77,percent of total billed charges,,,85,,2161.55,percent of total billed charges,,,85,,2161.55,percent of total billed charges,,,49,,1246.07,percent of total billed charges,,,90,,2288.7,percent of total billed charges,,,65,,1652.95,percent of total billed charges,,,80,,2034.4,percent of total billed charges,,,55,,1398.65,percent of total billed charges,,,55,,1398.65,percent of total billed charges,,,65,,1652.95,percent of total billed charges,,,78,,1983.54,percent of total billed charges,,,70,,1780.1,percent of total billed charges,,,,,,,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,,928.06,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,928.06,2288.7,
"NJX INTERLAMINAR LMBR/SAC,incl indw cath, cont infusion, wt image guide (62327)",62327,CPT,,,,outpatient,,,2598,1558.8,,45.5,,1182.09,percent of total billed charges,,,45.3,,1176.89,percent of total billed charges,,,51,,1324.98,percent of total billed charges,,,,,,,,,80,,2078.4,percent of total billed charges,,,61.4,,1595.17,percent of total billed charges,,,57.4,,1491.25,percent of total billed charges,,,81,,2104.38,percent of total billed charges,,,51.5,,1337.97,percent of total billed charges,,,57.6,,1496.45,percent of total billed charges,,,85,,2208.3,percent of total billed charges,,,85,,2208.3,percent of total billed charges,,,49,,1273.02,percent of total billed charges,,,90,,2338.2,percent of total billed charges,,,65,,1688.7,percent of total billed charges,,,80,,2078.4,percent of total billed charges,,,55,,1428.9,percent of total billed charges,,,55,,1428.9,percent of total billed charges,,,65,,1688.7,percent of total billed charges,,,78,,2026.44,percent of total billed charges,,,70,,1818.6,percent of total billed charges,,,,,,,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,,928.06,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,928.06,2338.2,
REM PREV IMPL EPID CATH (62355),62355,CPT,,,,outpatient,,,6917,4150.2,,45.5,,3147.24,percent of total billed charges,,,45.3,,3133.4,percent of total billed charges,,,51,,3527.67,percent of total billed charges,,,,,,,,,80,,5533.6,percent of total billed charges,,,61.4,,4247.04,percent of total billed charges,,,57.4,,3970.36,percent of total billed charges,,,81,,5602.77,percent of total billed charges,,,51.5,,3562.26,percent of total billed charges,,,57.6,,3984.19,percent of total billed charges,,,85,,5879.45,percent of total billed charges,,,85,,5879.45,percent of total billed charges,,,49,,3389.33,percent of total billed charges,,,90,,6225.3,percent of total billed charges,,,65,,4496.05,percent of total billed charges,,,80,,5533.6,percent of total billed charges,,,55,,3804.35,percent of total billed charges,,,55,,3804.35,percent of total billed charges,,,65,,4496.05,percent of total billed charges,,,78,,5395.26,percent of total billed charges,,,70,,4841.9,percent of total billed charges,,,,,,,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,,2035.61,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,2035.61,6225.3,
REM Sq RSVR/Pump For Prev Epid DR Inf,62365,CPT,,,,outpatient,,,15185,9111,,45.5,,6909.18,percent of total billed charges,,,45.3,,6878.81,percent of total billed charges,,,51,,7744.35,percent of total billed charges,,,,,,,,,80,,12148,percent of total billed charges,,,61.4,,9323.59,percent of total billed charges,,,57.4,,8716.19,percent of total billed charges,,,81,,12299.85,percent of total billed charges,,,51.5,,7820.28,percent of total billed charges,,,57.6,,8746.56,percent of total billed charges,,,85,,12907.25,percent of total billed charges,,,85,,12907.25,percent of total billed charges,,,49,,7440.65,percent of total billed charges,,,90,,13666.5,percent of total billed charges,,,65,,9870.25,percent of total billed charges,,,80,,12148,percent of total billed charges,,,55,,8351.75,percent of total billed charges,,,55,,8351.75,percent of total billed charges,,,65,,9870.25,percent of total billed charges,,,78,,11844.3,percent of total billed charges,,,70,,10629.5,percent of total billed charges,,,,,,,,6675.73,,,,100% of Medicare,,6675.73,,,,100% of Medicare,,6675.73,,,,100% of Medicare,,6675.73,,,,100% of Medicare,,6675.73,,,,100% of Medicare,,6675.73,,,,100% of Medicare,,6675.73,,,,100% of Medicare,,6675.73,,,,100% of Medicare,,6675.73,,,,100% of Medicare,,6675.73,,,,100% of Medicare,,6675.73,,,,100% of Medicare,,6675.73,,,,100% of Medicare,,,6675.73,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,6675.73,13666.5,
CC ONLY - Pump Analysis without Reprogramming Charge (62367),62367,CPT,,,,outpatient,,,1108,664.8,,45.5,,504.14,percent of total billed charges,,,45.3,,501.92,percent of total billed charges,,,51,,565.08,percent of total billed charges,,,,,,,,,80,,886.4,percent of total billed charges,,,61.4,,680.31,percent of total billed charges,,,57.4,,635.99,percent of total billed charges,,,81,,897.48,percent of total billed charges,,,51.5,,570.62,percent of total billed charges,,,57.6,,638.21,percent of total billed charges,,,85,,941.8,percent of total billed charges,,,85,,941.8,percent of total billed charges,,,49,,542.92,percent of total billed charges,,,90,,997.2,percent of total billed charges,,,65,,720.2,percent of total billed charges,,,80,,886.4,percent of total billed charges,,,55,,609.4,percent of total billed charges,,,55,,609.4,percent of total billed charges,,,65,,720.2,percent of total billed charges,,,78,,864.24,percent of total billed charges,,,70,,775.6,percent of total billed charges,,,,,,,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,,312.63,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,312.63,997.2,
Pump Analysis without Reprogramming Charge (62367),62367,CPT,,,,both,,,1108,664.8,,45.5,,504.14,percent of total billed charges,,,45.3,,501.92,percent of total billed charges,,,51,,565.08,percent of total billed charges,,,,,,,,,80,,886.4,percent of total billed charges,,,61.4,,680.31,percent of total billed charges,,,57.4,,635.99,percent of total billed charges,,,81,,897.48,percent of total billed charges,,,51.5,,570.62,percent of total billed charges,,,57.6,,638.21,percent of total billed charges,,,85,,941.8,percent of total billed charges,,,85,,941.8,percent of total billed charges,,,49,,542.92,percent of total billed charges,,,90,,997.2,percent of total billed charges,,,65,,720.2,percent of total billed charges,,,80,,886.4,percent of total billed charges,,,55,,609.4,percent of total billed charges,,,55,,609.4,percent of total billed charges,,,65,,720.2,percent of total billed charges,,,78,,864.24,percent of total billed charges,,,70,,775.6,percent of total billed charges,,,,,,,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,,312.63,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,312.63,997.2,
Anal SP inf pmp wt reprog/refill (62369),62369,CPT,,,,both,,,896,537.6,,45.5,,407.68,percent of total billed charges,,,45.3,,405.89,percent of total billed charges,,,51,,456.96,percent of total billed charges,,,,,,,,,80,,716.8,percent of total billed charges,,,61.4,,550.14,percent of total billed charges,,,57.4,,514.3,percent of total billed charges,,,81,,725.76,percent of total billed charges,,,51.5,,461.44,percent of total billed charges,,,57.6,,516.1,percent of total billed charges,,,85,,761.6,percent of total billed charges,,,85,,761.6,percent of total billed charges,,,49,,439.04,percent of total billed charges,,,90,,806.4,percent of total billed charges,,,65,,582.4,percent of total billed charges,,,80,,716.8,percent of total billed charges,,,55,,492.8,percent of total billed charges,,,55,,492.8,percent of total billed charges,,,65,,582.4,percent of total billed charges,,,78,,698.88,percent of total billed charges,,,70,,627.2,percent of total billed charges,,,,,,,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,312.63,,,,100% of Medicare,,,312.63,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,312.63,806.4,
Implant Neuroelectrodes; Epidural (63650),63650,CPT,,,,outpatient,,,20604,12362.4,,45.5,,9374.82,percent of total billed charges,,,45.3,,9333.61,percent of total billed charges,,,51,,10508.04,percent of total billed charges,,,,,,,,,80,,16483.2,percent of total billed charges,,,61.4,,12650.86,percent of total billed charges,,,57.4,,11826.7,percent of total billed charges,,,81,,16689.24,percent of total billed charges,,,51.5,,10611.06,percent of total billed charges,,,57.6,,11867.9,percent of total billed charges,,,85,,17513.4,percent of total billed charges,,,85,,17513.4,percent of total billed charges,,,49,,10095.96,percent of total billed charges,,,90,,18543.6,percent of total billed charges,,,65,,13392.6,percent of total billed charges,,,80,,16483.2,percent of total billed charges,,,55,,11332.2,percent of total billed charges,,,55,,11332.2,percent of total billed charges,,,65,,13392.6,percent of total billed charges,,,78,,16071.12,percent of total billed charges,,,70,,14422.8,percent of total billed charges,,,,,,,,6841.3,,,,100% of Medicare,,6841.3,,,,100% of Medicare,,6841.3,,,,100% of Medicare,,6841.3,,,,100% of Medicare,,6841.3,,,,100% of Medicare,,6841.3,,,,100% of Medicare,,6841.3,,,,100% of Medicare,,6841.3,,,,100% of Medicare,,6841.3,,,,100% of Medicare,,6841.3,,,,100% of Medicare,,6841.3,,,,100% of Medicare,,6841.3,,,,100% of Medicare,,,6841.3,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,6841.3,18543.6,
Revise/Remove IMP spinal neurostim gen w/detach electrode array 63685,63685,CPT,,,,outpatient,,,27250,16350,,45.5,,12398.75,percent of total billed charges,,,45.3,,12344.25,percent of total billed charges,,,51,,13897.5,percent of total billed charges,,,,,,,,,80,,21800,percent of total billed charges,,,61.4,,16731.5,percent of total billed charges,,,57.4,,15641.5,percent of total billed charges,,,81,,22072.5,percent of total billed charges,,,51.5,,14033.75,percent of total billed charges,,,57.6,,15696,percent of total billed charges,,,85,,23162.5,percent of total billed charges,,,85,,23162.5,percent of total billed charges,,,49,,13352.5,percent of total billed charges,,,90,,24525,percent of total billed charges,,,65,,17712.5,percent of total billed charges,,,80,,21800,percent of total billed charges,,,55,,14987.5,percent of total billed charges,,,55,,14987.5,percent of total billed charges,,,65,,17712.5,percent of total billed charges,,,78,,21255,percent of total billed charges,,,70,,19075,percent of total billed charges,,,,,,,,31766.28,,,,100% of Medicare,,31766.28,,,999999999,100% of Medicare,,31766.28,,,999999999,100% of Medicare,,31766.28,,,999999999,100% of Medicare,,31766.28,,,999999999,100% of Medicare,,31766.28,,,999999999,100% of Medicare,,31766.28,,,999999999,100% of Medicare,,31766.28,,,999999999,100% of Medicare,,31766.28,,,999999999,100% of Medicare,,31766.28,,,999999999,100% of Medicare,,31766.28,,,999999999,100% of Medicare,,31766.28,,,999999999,100% of Medicare,,,31766.28,,,999999999,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,12344.25,999999999,
REVJ/RMVL IMPLNT SPINAL NEUROSTIM GEN W/DETACH CNNCT ELECT ARRAY,63688,CPT,,,,outpatient,,,13907,8344.2,,45.5,,6327.69,percent of total billed charges,,,45.3,,6299.87,percent of total billed charges,,,51,,7092.57,percent of total billed charges,,,,,,,,,80,,11125.6,percent of total billed charges,,,61.4,,8538.9,percent of total billed charges,,,57.4,,7982.62,percent of total billed charges,,,81,,11264.67,percent of total billed charges,,,51.5,,7162.11,percent of total billed charges,,,57.6,,8010.43,percent of total billed charges,,,85,,11820.95,percent of total billed charges,,,85,,11820.95,percent of total billed charges,,,49,,6814.43,percent of total billed charges,,,90,,12516.3,percent of total billed charges,,,65,,9039.55,percent of total billed charges,,,80,,11125.6,percent of total billed charges,,,55,,7648.85,percent of total billed charges,,,55,,7648.85,percent of total billed charges,,,65,,9039.55,percent of total billed charges,,,78,,10847.46,percent of total billed charges,,,70,,9734.9,percent of total billed charges,,,,,,,,3584.89,,,,100% of Medicare,,3584.89,,,,100% of Medicare,,3584.89,,,,100% of Medicare,,3584.89,,,,100% of Medicare,,3584.89,,,,100% of Medicare,,3584.89,,,,100% of Medicare,,3584.89,,,,100% of Medicare,,3584.89,,,,100% of Medicare,,3584.89,,,,100% of Medicare,,3584.89,,,,100% of Medicare,,3584.89,,,,100% of Medicare,,3584.89,,,,100% of Medicare,,,3584.89,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,3584.89,12516.3,
"Injection, anesthetic agent; trigeminal nerve, any division or branch (64400)",64400,CPT,,,,outpatient,,,819,491.4,,45.5,,372.65,percent of total billed charges,,,45.3,,371.01,percent of total billed charges,,,51,,417.69,percent of total billed charges,,,,,,,,,80,,655.2,percent of total billed charges,,,61.4,,502.87,percent of total billed charges,,,57.4,,470.11,percent of total billed charges,,,81,,663.39,percent of total billed charges,,,51.5,,421.79,percent of total billed charges,,,57.6,,471.74,percent of total billed charges,,,85,,696.15,percent of total billed charges,,,85,,696.15,percent of total billed charges,,,49,,401.31,percent of total billed charges,,,90,,737.1,percent of total billed charges,,,65,,532.35,percent of total billed charges,,,80,,655.2,percent of total billed charges,,,55,,450.45,percent of total billed charges,,,55,,450.45,percent of total billed charges,,,65,,532.35,percent of total billed charges,,,78,,638.82,percent of total billed charges,,,70,,573.3,percent of total billed charges,,,,,,,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,,307.71,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,307.71,737.1,
Greater Occipital Nerve Injection Charge - 64405,64405,CPT,,,,outpatient,,,1880,1128,,45.5,,855.4,percent of total billed charges,,,45.3,,851.64,percent of total billed charges,,,51,,958.8,percent of total billed charges,,,,,,,,,80,,1504,percent of total billed charges,,,61.4,,1154.32,percent of total billed charges,,,57.4,,1079.12,percent of total billed charges,,,81,,1522.8,percent of total billed charges,,,51.5,,968.2,percent of total billed charges,,,57.6,,1082.88,percent of total billed charges,,,85,,1598,percent of total billed charges,,,85,,1598,percent of total billed charges,,,49,,921.2,percent of total billed charges,,,90,,1692,percent of total billed charges,,,65,,1222,percent of total billed charges,,,80,,1504,percent of total billed charges,,,55,,1034,percent of total billed charges,,,55,,1034,percent of total billed charges,,,65,,1222,percent of total billed charges,,,78,,1466.4,percent of total billed charges,,,70,,1316,percent of total billed charges,,,,,,,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,,307.71,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,307.71,1692,
Greater Occipital Nerve Injection Bilateral - 6440550,64405,CPT,,,50,outpatient,,,2820,1692,,45.5,,1283.1,percent of total billed charges,,,45.3,,1277.46,percent of total billed charges,,,51,,1438.2,percent of total billed charges,,,,,,,,,80,,2256,percent of total billed charges,,,61.4,,1731.48,percent of total billed charges,,,57.4,,1618.68,percent of total billed charges,,,81,,2284.2,percent of total billed charges,,,51.5,,1452.3,percent of total billed charges,,,57.6,,1624.32,percent of total billed charges,,,85,,2397,percent of total billed charges,,,85,,2397,percent of total billed charges,,,49,,1381.8,percent of total billed charges,,,90,,2538,percent of total billed charges,,,65,,1833,percent of total billed charges,,,80,,2256,percent of total billed charges,,,55,,1551,percent of total billed charges,,,55,,1551,percent of total billed charges,,,65,,1833,percent of total billed charges,,,78,,2199.6,percent of total billed charges,,,70,,1974,percent of total billed charges,,,,,,,,461.57,,,,100% of Medicare,,461.57,,,,100% of Medicare,,461.57,,,,100% of Medicare,,461.57,,,,100% of Medicare,,461.57,,,,100% of Medicare,,461.57,,,,100% of Medicare,,461.57,,,,100% of Medicare,,461.57,,,,100% of Medicare,,461.57,,,,100% of Medicare,,461.57,,,,100% of Medicare,,461.57,,,,100% of Medicare,,461.57,,,,100% of Medicare,,,461.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,461.57,2538,
INJ AA&/STRD AXILLARY NERVE w/IMG GUIDE (64417),64417,CPT,,,,outpatient,,,2579,1547.4,,45.5,,1173.45,percent of total billed charges,,,45.3,,1168.29,percent of total billed charges,,,51,,1315.29,percent of total billed charges,,,,,,,,,80,,2063.2,percent of total billed charges,,,61.4,,1583.51,percent of total billed charges,,,57.4,,1480.35,percent of total billed charges,,,81,,2088.99,percent of total billed charges,,,51.5,,1328.19,percent of total billed charges,,,57.6,,1485.5,percent of total billed charges,,,85,,2192.15,percent of total billed charges,,,85,,2192.15,percent of total billed charges,,,49,,1263.71,percent of total billed charges,,,90,,2321.1,percent of total billed charges,,,65,,1676.35,percent of total billed charges,,,80,,2063.2,percent of total billed charges,,,55,,1418.45,percent of total billed charges,,,55,,1418.45,percent of total billed charges,,,65,,1676.35,percent of total billed charges,,,78,,2011.62,percent of total billed charges,,,70,,1805.3,percent of total billed charges,,,,,,,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,,928.06,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,928.06,2321.1,
INJ ANESTH; SUPRASCAPULAR NERVE (64418),64418,CPT,,,,outpatient,,,1859,1115.4,,45.5,,845.85,percent of total billed charges,,,45.3,,842.13,percent of total billed charges,,,51,,948.09,percent of total billed charges,,,,,,,,,80,,1487.2,percent of total billed charges,,,61.4,,1141.43,percent of total billed charges,,,57.4,,1067.07,percent of total billed charges,,,81,,1505.79,percent of total billed charges,,,51.5,,957.39,percent of total billed charges,,,57.6,,1070.78,percent of total billed charges,,,85,,1580.15,percent of total billed charges,,,85,,1580.15,percent of total billed charges,,,49,,910.91,percent of total billed charges,,,90,,1673.1,percent of total billed charges,,,65,,1208.35,percent of total billed charges,,,80,,1487.2,percent of total billed charges,,,55,,1022.45,percent of total billed charges,,,55,,1022.45,percent of total billed charges,,,65,,1208.35,percent of total billed charges,,,78,,1450.02,percent of total billed charges,,,70,,1301.3,percent of total billed charges,,,,,,,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,,721.9,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,721.9,1673.1,
"Injection, anesthetic agent; intercostal nerve, single",64420,CPT,,,,outpatient,,,1376,825.6,,45.5,,626.08,percent of total billed charges,,,45.3,,623.33,percent of total billed charges,,,51,,701.76,percent of total billed charges,,,,,,,,,80,,1100.8,percent of total billed charges,,,61.4,,844.86,percent of total billed charges,,,57.4,,789.82,percent of total billed charges,,,81,,1114.56,percent of total billed charges,,,51.5,,708.64,percent of total billed charges,,,57.6,,792.58,percent of total billed charges,,,85,,1169.6,percent of total billed charges,,,85,,1169.6,percent of total billed charges,,,49,,674.24,percent of total billed charges,,,90,,1238.4,percent of total billed charges,,,65,,894.4,percent of total billed charges,,,80,,1100.8,percent of total billed charges,,,55,,756.8,percent of total billed charges,,,55,,756.8,percent of total billed charges,,,65,,894.4,percent of total billed charges,,,78,,1073.28,percent of total billed charges,,,70,,963.2,percent of total billed charges,,,,,,,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,,721.9,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,623.33,1238.4,
"Inj Anesth; Intercost Nrv, Multi/Region",64421,CPT,,,,outpatient,,,2371,1422.6,,45.5,,1078.81,percent of total billed charges,,,45.3,,1074.06,percent of total billed charges,,,51,,1209.21,percent of total billed charges,,,,,,,,,80,,1896.8,percent of total billed charges,,,61.4,,1455.79,percent of total billed charges,,,57.4,,1360.95,percent of total billed charges,,,81,,1920.51,percent of total billed charges,,,51.5,,1221.07,percent of total billed charges,,,57.6,,1365.7,percent of total billed charges,,,85,,2015.35,percent of total billed charges,,,85,,2015.35,percent of total billed charges,,,49,,1161.79,percent of total billed charges,,,90,,2133.9,percent of total billed charges,,,65,,1541.15,percent of total billed charges,,,80,,1896.8,percent of total billed charges,,,55,,1304.05,percent of total billed charges,,,55,,1304.05,percent of total billed charges,,,65,,1541.15,percent of total billed charges,,,78,,1849.38,percent of total billed charges,,,70,,1659.7,percent of total billed charges,,,,,,,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,,928.06,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,928.06,2133.9,
"Inj Anesth; Intercost Nrv, Multi/Region, Bilateral",64421,CPT,,,50,outpatient,,,3557,2134.2,,45.5,,1618.44,percent of total billed charges,,,45.3,,1611.32,percent of total billed charges,,,51,,1814.07,percent of total billed charges,,,,,,,,,80,,2845.6,percent of total billed charges,,,61.4,,2184,percent of total billed charges,,,57.4,,2041.72,percent of total billed charges,,,81,,2881.17,percent of total billed charges,,,51.5,,1831.86,percent of total billed charges,,,57.6,,2048.83,percent of total billed charges,,,85,,3023.45,percent of total billed charges,,,85,,3023.45,percent of total billed charges,,,49,,1742.93,percent of total billed charges,,,90,,3201.3,percent of total billed charges,,,65,,2312.05,percent of total billed charges,,,80,,2845.6,percent of total billed charges,,,55,,1956.35,percent of total billed charges,,,55,,1956.35,percent of total billed charges,,,65,,2312.05,percent of total billed charges,,,78,,2774.46,percent of total billed charges,,,70,,2489.9,percent of total billed charges,,,,,,,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,,1392.08,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1392.08,3201.3,
Nerve Block Ilioning/Iliohypogastric,64425,CPT,,,,outpatient,,,1265,759,,45.5,,575.58,percent of total billed charges,,,45.3,,573.05,percent of total billed charges,,,51,,645.15,percent of total billed charges,,,,,,,,,80,,1012,percent of total billed charges,,,61.4,,776.71,percent of total billed charges,,,57.4,,726.11,percent of total billed charges,,,81,,1024.65,percent of total billed charges,,,51.5,,651.48,percent of total billed charges,,,57.6,,728.64,percent of total billed charges,,,85,,1075.25,percent of total billed charges,,,85,,1075.25,percent of total billed charges,,,49,,619.85,percent of total billed charges,,,90,,1138.5,percent of total billed charges,,,65,,822.25,percent of total billed charges,,,80,,1012,percent of total billed charges,,,55,,695.75,percent of total billed charges,,,55,,695.75,percent of total billed charges,,,65,,822.25,percent of total billed charges,,,78,,986.7,percent of total billed charges,,,70,,885.5,percent of total billed charges,,,,,,,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,,721.9,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,573.05,1138.5,
Nerve Block Ilioing/Iliohypogastric  Bilateral,64425,CPT,,,50,outpatient,,,2020,1212,,45.5,,919.1,percent of total billed charges,,,45.3,,915.06,percent of total billed charges,,,51,,1030.2,percent of total billed charges,,,,,,,,,80,,1616,percent of total billed charges,,,61.4,,1240.28,percent of total billed charges,,,57.4,,1159.48,percent of total billed charges,,,81,,1636.2,percent of total billed charges,,,51.5,,1040.3,percent of total billed charges,,,57.6,,1163.52,percent of total billed charges,,,85,,1717,percent of total billed charges,,,85,,1717,percent of total billed charges,,,49,,989.8,percent of total billed charges,,,90,,1818,percent of total billed charges,,,65,,1313,percent of total billed charges,,,80,,1616,percent of total billed charges,,,55,,1111,percent of total billed charges,,,55,,1111,percent of total billed charges,,,65,,1313,percent of total billed charges,,,78,,1575.6,percent of total billed charges,,,70,,1414,percent of total billed charges,,,,,,,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,,1082.85,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,915.06,1818,
INJ ANESTH; PUDENDAL NERVE (64430),64430,CPT,,,,outpatient,,,2998,1798.8,,45.5,,1364.09,percent of total billed charges,,,45.3,,1358.09,percent of total billed charges,,,51,,1528.98,percent of total billed charges,,,,,,,,,80,,2398.4,percent of total billed charges,,,61.4,,1840.77,percent of total billed charges,,,57.4,,1720.85,percent of total billed charges,,,81,,2428.38,percent of total billed charges,,,51.5,,1543.97,percent of total billed charges,,,57.6,,1726.85,percent of total billed charges,,,85,,2548.3,percent of total billed charges,,,85,,2548.3,percent of total billed charges,,,49,,1469.02,percent of total billed charges,,,90,,2698.2,percent of total billed charges,,,65,,1948.7,percent of total billed charges,,,80,,2398.4,percent of total billed charges,,,55,,1648.9,percent of total billed charges,,,55,,1648.9,percent of total billed charges,,,65,,1948.7,percent of total billed charges,,,78,,2338.44,percent of total billed charges,,,70,,2098.6,percent of total billed charges,,,,,,,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,,928.06,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,928.06,2698.2,
CC ONLY - Other Nerve Block Peripheral or Branch Charge (64450),64450,CPT,,,,outpatient,,,1653,991.8,,45.5,,752.12,percent of total billed charges,,,45.3,,748.81,percent of total billed charges,,,51,,843.03,percent of total billed charges,,,,,,,,,80,,1322.4,percent of total billed charges,,,61.4,,1014.94,percent of total billed charges,,,57.4,,948.82,percent of total billed charges,,,81,,1338.93,percent of total billed charges,,,51.5,,851.3,percent of total billed charges,,,57.6,,952.13,percent of total billed charges,,,85,,1405.05,percent of total billed charges,,,85,,1405.05,percent of total billed charges,,,49,,809.97,percent of total billed charges,,,90,,1487.7,percent of total billed charges,,,65,,1074.45,percent of total billed charges,,,80,,1322.4,percent of total billed charges,,,55,,909.15,percent of total billed charges,,,55,,909.15,percent of total billed charges,,,65,,1074.45,percent of total billed charges,,,78,,1289.34,percent of total billed charges,,,70,,1157.1,percent of total billed charges,,,,,,,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,,721.9,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,721.9,1487.7,
Other Nerve Block Peripheral or Branch Charge (64450),64450,CPT,,,,outpatient,,,1653,991.8,,45.5,,752.12,percent of total billed charges,,,45.3,,748.81,percent of total billed charges,,,51,,843.03,percent of total billed charges,,,,,,,,,80,,1322.4,percent of total billed charges,,,61.4,,1014.94,percent of total billed charges,,,57.4,,948.82,percent of total billed charges,,,81,,1338.93,percent of total billed charges,,,51.5,,851.3,percent of total billed charges,,,57.6,,952.13,percent of total billed charges,,,85,,1405.05,percent of total billed charges,,,85,,1405.05,percent of total billed charges,,,49,,809.97,percent of total billed charges,,,90,,1487.7,percent of total billed charges,,,65,,1074.45,percent of total billed charges,,,80,,1322.4,percent of total billed charges,,,55,,909.15,percent of total billed charges,,,55,,909.15,percent of total billed charges,,,65,,1074.45,percent of total billed charges,,,78,,1289.34,percent of total billed charges,,,70,,1157.1,percent of total billed charges,,,,,,,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,,721.9,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,721.9,1487.7,
Other Nerve Block Peripheral or Branch BiL Charge (64450-50),64450,CPT,,,50,outpatient,,,2480,1488,,45.5,,1128.4,percent of total billed charges,,,45.3,,1123.44,percent of total billed charges,,,51,,1264.8,percent of total billed charges,,,,,,,,,80,,1984,percent of total billed charges,,,61.4,,1522.72,percent of total billed charges,,,57.4,,1423.52,percent of total billed charges,,,81,,2008.8,percent of total billed charges,,,51.5,,1277.2,percent of total billed charges,,,57.6,,1428.48,percent of total billed charges,,,85,,2108,percent of total billed charges,,,85,,2108,percent of total billed charges,,,49,,1215.2,percent of total billed charges,,,90,,2232,percent of total billed charges,,,65,,1612,percent of total billed charges,,,80,,1984,percent of total billed charges,,,55,,1364,percent of total billed charges,,,55,,1364,percent of total billed charges,,,65,,1612,percent of total billed charges,,,78,,1934.4,percent of total billed charges,,,70,,1736,percent of total billed charges,,,,,,,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,,1082.85,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1082.85,2232,
CC ONLY - INJECTION AA&/STRD NERVES NRVTG SI JOINT W/IMG (64451),64451,CPT,,,,outpatient,,,1939,1163.4,,45.5,,882.25,percent of total billed charges,,,45.3,,878.37,percent of total billed charges,,,51,,988.89,percent of total billed charges,,,,,,,,,80,,1551.2,percent of total billed charges,,,61.4,,1190.55,percent of total billed charges,,,57.4,,1112.99,percent of total billed charges,,,81,,1570.59,percent of total billed charges,,,51.5,,998.59,percent of total billed charges,,,57.6,,1116.86,percent of total billed charges,,,85,,1648.15,percent of total billed charges,,,85,,1648.15,percent of total billed charges,,,49,,950.11,percent of total billed charges,,,90,,1745.1,percent of total billed charges,,,65,,1260.35,percent of total billed charges,,,80,,1551.2,percent of total billed charges,,,55,,1066.45,percent of total billed charges,,,55,,1066.45,percent of total billed charges,,,65,,1260.35,percent of total billed charges,,,78,,1512.42,percent of total billed charges,,,70,,1357.3,percent of total billed charges,,,,,,,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,42253.048,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,,721.9,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,721.9,42253.05,
INJECTION AA&/STRD NERVES NRVTG SI JOINT W/IMG (64451),64451,CPT,,,,outpatient,,,1939,1163.4,,45.5,,882.25,percent of total billed charges,,,45.3,,878.37,percent of total billed charges,,,51,,988.89,percent of total billed charges,,,,,,,,,80,,1551.2,percent of total billed charges,,,61.4,,1190.55,percent of total billed charges,,,57.4,,1112.99,percent of total billed charges,,,81,,1570.59,percent of total billed charges,,,51.5,,998.59,percent of total billed charges,,,57.6,,1116.86,percent of total billed charges,,,85,,1648.15,percent of total billed charges,,,85,,1648.15,percent of total billed charges,,,49,,950.11,percent of total billed charges,,,90,,1745.1,percent of total billed charges,,,65,,1260.35,percent of total billed charges,,,80,,1551.2,percent of total billed charges,,,55,,1066.45,percent of total billed charges,,,55,,1066.45,percent of total billed charges,,,65,,1260.35,percent of total billed charges,,,78,,1512.42,percent of total billed charges,,,70,,1357.3,percent of total billed charges,,,,,,,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,,721.9,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,721.9,1745.1,
INJECTION AA&/STRD NERVES NRVTG SI JOINT W/IMG Bilateral (64451-50),64451,CPT,,,50,outpatient,,,2909,1745.4,,45.5,,1323.6,percent of total billed charges,,,45.3,,1317.78,percent of total billed charges,,,51,,1483.59,percent of total billed charges,,,,,,,,,80,,2327.2,percent of total billed charges,,,61.4,,1786.13,percent of total billed charges,,,57.4,,1669.77,percent of total billed charges,,,81,,2356.29,percent of total billed charges,,,51.5,,1498.14,percent of total billed charges,,,57.6,,1675.58,percent of total billed charges,,,85,,2472.65,percent of total billed charges,,,85,,2472.65,percent of total billed charges,,,49,,1425.41,percent of total billed charges,,,90,,2618.1,percent of total billed charges,,,65,,1890.85,percent of total billed charges,,,80,,2327.2,percent of total billed charges,,,55,,1599.95,percent of total billed charges,,,55,,1599.95,percent of total billed charges,,,65,,1890.85,percent of total billed charges,,,78,,2269.02,percent of total billed charges,,,70,,2036.3,percent of total billed charges,,,,,,,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,,1082.85,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1082.85,2618.1,
INJECTION AA&/STRD GENICULAR NRV BRANCHES W/IMG (64454),64454,CPT,,,,outpatient,,,1939,1163.4,,45.5,,882.25,percent of total billed charges,,,45.3,,878.37,percent of total billed charges,,,51,,988.89,percent of total billed charges,,,,,,,,,80,,1551.2,percent of total billed charges,,,61.4,,1190.55,percent of total billed charges,,,57.4,,1112.99,percent of total billed charges,,,81,,1570.59,percent of total billed charges,,,51.5,,998.59,percent of total billed charges,,,57.6,,1116.86,percent of total billed charges,,,85,,1648.15,percent of total billed charges,,,85,,1648.15,percent of total billed charges,,,49,,950.11,percent of total billed charges,,,90,,1745.1,percent of total billed charges,,,65,,1260.35,percent of total billed charges,,,80,,1551.2,percent of total billed charges,,,55,,1066.45,percent of total billed charges,,,55,,1066.45,percent of total billed charges,,,65,,1260.35,percent of total billed charges,,,78,,1512.42,percent of total billed charges,,,70,,1357.3,percent of total billed charges,,,,,,,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,,721.9,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,721.9,1745.1,
INJECTION AA&/STRD GENICULAR NRV BRANCHES W/IMG Bilateral (64454-50),64454,CPT,,,50,outpatient,,,2908,1744.8,,45.5,,1323.14,percent of total billed charges,,,45.3,,1317.32,percent of total billed charges,,,51,,1483.08,percent of total billed charges,,,,,,,,,80,,2326.4,percent of total billed charges,,,61.4,,1785.51,percent of total billed charges,,,57.4,,1669.19,percent of total billed charges,,,81,,2355.48,percent of total billed charges,,,51.5,,1497.62,percent of total billed charges,,,57.6,,1675.01,percent of total billed charges,,,85,,2471.8,percent of total billed charges,,,85,,2471.8,percent of total billed charges,,,49,,1424.92,percent of total billed charges,,,90,,2617.2,percent of total billed charges,,,65,,1890.2,percent of total billed charges,,,80,,2326.4,percent of total billed charges,,,55,,1599.4,percent of total billed charges,,,55,,1599.4,percent of total billed charges,,,65,,1890.2,percent of total billed charges,,,78,,2268.24,percent of total billed charges,,,70,,2035.6,percent of total billed charges,,,,,,,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,,1082.85,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1082.85,2617.2,
Injection(s) Plantar digital nerve(s) (Morton's Neuroma),64455,CPT,,,,outpatient,,,802,481.2,,45.5,,364.91,percent of total billed charges,,,45.3,,363.31,percent of total billed charges,,,51,,409.02,percent of total billed charges,,,,,,,,,80,,641.6,percent of total billed charges,,,61.4,,492.43,percent of total billed charges,,,57.4,,460.35,percent of total billed charges,,,81,,649.62,percent of total billed charges,,,51.5,,413.03,percent of total billed charges,,,57.6,,461.95,percent of total billed charges,,,85,,681.7,percent of total billed charges,,,85,,681.7,percent of total billed charges,,,49,,392.98,percent of total billed charges,,,90,,721.8,percent of total billed charges,,,65,,521.3,percent of total billed charges,,,80,,641.6,percent of total billed charges,,,55,,441.1,percent of total billed charges,,,55,,441.1,percent of total billed charges,,,65,,521.3,percent of total billed charges,,,78,,625.56,percent of total billed charges,,,70,,561.4,percent of total billed charges,,,,,,,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,,307.71,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,307.71,721.8,
Cervical-Thoracic Transforaminal (64479),64479,CPT,,,,outpatient,,,2903,1741.8,,45.5,,1320.87,percent of total billed charges,,,45.3,,1315.06,percent of total billed charges,,,51,,1480.53,percent of total billed charges,,,,,,,,,80,,2322.4,percent of total billed charges,,,61.4,,1782.44,percent of total billed charges,,,57.4,,1666.32,percent of total billed charges,,,81,,2351.43,percent of total billed charges,,,51.5,,1495.05,percent of total billed charges,,,57.6,,1672.13,percent of total billed charges,,,85,,2467.55,percent of total billed charges,,,85,,2467.55,percent of total billed charges,,,49,,1422.47,percent of total billed charges,,,90,,2612.7,percent of total billed charges,,,65,,1886.95,percent of total billed charges,,,80,,2322.4,percent of total billed charges,,,55,,1596.65,percent of total billed charges,,,55,,1596.65,percent of total billed charges,,,65,,1886.95,percent of total billed charges,,,78,,2264.34,percent of total billed charges,,,70,,2032.1,percent of total billed charges,,,,,,,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,,928.06,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,928.06,2612.7,
Cervical-Thoracic Transforaminal-Bilateral (64479),64479,CPT,,,50,outpatient,,,4400,2640,,45.5,,2002,percent of total billed charges,,,45.3,,1993.2,percent of total billed charges,,,51,,2244,percent of total billed charges,,,,,,,,,80,,3520,percent of total billed charges,,,61.4,,2701.6,percent of total billed charges,,,57.4,,2525.6,percent of total billed charges,,,81,,3564,percent of total billed charges,,,51.5,,2266,percent of total billed charges,,,57.6,,2534.4,percent of total billed charges,,,85,,3740,percent of total billed charges,,,85,,3740,percent of total billed charges,,,49,,2156,percent of total billed charges,,,90,,3960,percent of total billed charges,,,65,,2860,percent of total billed charges,,,80,,3520,percent of total billed charges,,,55,,2420,percent of total billed charges,,,55,,2420,percent of total billed charges,,,65,,2860,percent of total billed charges,,,78,,3432,percent of total billed charges,,,70,,3080,percent of total billed charges,,,,,,,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,,1392.08,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1392.08,3960,
Cervical-Thoracic Transforaminal-additional level (64480),64480,CPT,,,,outpatient,,,1788,1072.8,,45.5,,813.54,percent of total billed charges,,,45.3,,809.96,percent of total billed charges,,,51,,911.88,percent of total billed charges,,,,,,,,,80,,1430.4,percent of total billed charges,,,61.4,,1097.83,percent of total billed charges,,,57.4,,1026.31,percent of total billed charges,,,81,,1448.28,percent of total billed charges,,,51.5,,920.82,percent of total billed charges,,,57.6,,1029.89,percent of total billed charges,,,85,,1519.8,percent of total billed charges,,,85,,1519.8,percent of total billed charges,,,49,,876.12,percent of total billed charges,,,90,,1609.2,percent of total billed charges,,,65,,1162.2,percent of total billed charges,,,80,,1430.4,percent of total billed charges,,,55,,983.4,percent of total billed charges,,,55,,983.4,percent of total billed charges,,,65,,1162.2,percent of total billed charges,,,78,,1394.64,percent of total billed charges,,,70,,1251.6,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,809.96,1609.2,
T-spine TFESI add'l level x___,64480,CPT,,,,both,,,2073,1243.8,,45.5,,943.22,percent of total billed charges,,,45.3,,939.07,percent of total billed charges,,,51,,1057.23,percent of total billed charges,,,,,,,,,80,,1658.4,percent of total billed charges,,,61.4,,1272.82,percent of total billed charges,,,57.4,,1189.9,percent of total billed charges,,,81,,1679.13,percent of total billed charges,,,51.5,,1067.6,percent of total billed charges,,,57.6,,1194.05,percent of total billed charges,,,85,,1762.05,percent of total billed charges,,,85,,1762.05,percent of total billed charges,,,49,,1015.77,percent of total billed charges,,,90,,1865.7,percent of total billed charges,,,65,,1347.45,percent of total billed charges,,,80,,1658.4,percent of total billed charges,,,55,,1140.15,percent of total billed charges,,,55,,1140.15,percent of total billed charges,,,65,,1347.45,percent of total billed charges,,,78,,1616.94,percent of total billed charges,,,70,,1451.1,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,939.07,1865.7,
Cervical-Thoracic Transforaminal-additional level bilateral (64480-50),64480,CPT,,,50,outpatient,,,2276,1365.6,,45.5,,1035.58,percent of total billed charges,,,45.3,,1031.03,percent of total billed charges,,,51,,1160.76,percent of total billed charges,,,,,,,,,80,,1820.8,percent of total billed charges,,,61.4,,1397.46,percent of total billed charges,,,57.4,,1306.42,percent of total billed charges,,,81,,1843.56,percent of total billed charges,,,51.5,,1172.14,percent of total billed charges,,,57.6,,1310.98,percent of total billed charges,,,85,,1934.6,percent of total billed charges,,,85,,1934.6,percent of total billed charges,,,49,,1115.24,percent of total billed charges,,,90,,2048.4,percent of total billed charges,,,65,,1479.4,percent of total billed charges,,,80,,1820.8,percent of total billed charges,,,55,,1251.8,percent of total billed charges,,,55,,1251.8,percent of total billed charges,,,65,,1479.4,percent of total billed charges,,,78,,1775.28,percent of total billed charges,,,70,,1593.2,percent of total billed charges,,,,,,,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1031.03,2048.4,
Lumbar Epidural (64483),64483,CPT,,,,outpatient,,,3550,2130,,45.5,,1615.25,percent of total billed charges,,,45.3,,1608.15,percent of total billed charges,,,51,,1810.5,percent of total billed charges,,,,,,,,,80,,2840,percent of total billed charges,,,61.4,,2179.7,percent of total billed charges,,,57.4,,2037.7,percent of total billed charges,,,81,,2875.5,percent of total billed charges,,,51.5,,1828.25,percent of total billed charges,,,57.6,,2044.8,percent of total billed charges,,,85,,3017.5,percent of total billed charges,,,85,,3017.5,percent of total billed charges,,,49,,1739.5,percent of total billed charges,,,90,,3195,percent of total billed charges,,,65,,2307.5,percent of total billed charges,,,80,,2840,percent of total billed charges,,,55,,1952.5,percent of total billed charges,,,55,,1952.5,percent of total billed charges,,,65,,2307.5,percent of total billed charges,,,78,,2769,percent of total billed charges,,,70,,2485,percent of total billed charges,,,,,,,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,,928.06,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,928.06,3195,
Lumbosacral Transforaminal (64483),64483,CPT,,,,outpatient,,,3550,2130,,45.5,,1615.25,percent of total billed charges,,,45.3,,1608.15,percent of total billed charges,,,51,,1810.5,percent of total billed charges,,,,,,,,,80,,2840,percent of total billed charges,,,61.4,,2179.7,percent of total billed charges,,,57.4,,2037.7,percent of total billed charges,,,81,,2875.5,percent of total billed charges,,,51.5,,1828.25,percent of total billed charges,,,57.6,,2044.8,percent of total billed charges,,,85,,3017.5,percent of total billed charges,,,85,,3017.5,percent of total billed charges,,,49,,1739.5,percent of total billed charges,,,90,,3195,percent of total billed charges,,,65,,2307.5,percent of total billed charges,,,80,,2840,percent of total billed charges,,,55,,1952.5,percent of total billed charges,,,55,,1952.5,percent of total billed charges,,,65,,2307.5,percent of total billed charges,,,78,,2769,percent of total billed charges,,,70,,2485,percent of total billed charges,,,,,,,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,,928.06,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,928.06,3195,
Lumbosacral Transforaminal-Bilateral (64483),64483,CPT,,,50,outpatient,,,5830,3498,,45.5,,2652.65,percent of total billed charges,,,45.3,,2640.99,percent of total billed charges,,,51,,2973.3,percent of total billed charges,,,,,,,,,80,,4664,percent of total billed charges,,,61.4,,3579.62,percent of total billed charges,,,57.4,,3346.42,percent of total billed charges,,,81,,4722.3,percent of total billed charges,,,51.5,,3002.45,percent of total billed charges,,,57.6,,3358.08,percent of total billed charges,,,85,,4955.5,percent of total billed charges,,,85,,4955.5,percent of total billed charges,,,49,,2856.7,percent of total billed charges,,,90,,5247,percent of total billed charges,,,65,,3789.5,percent of total billed charges,,,80,,4664,percent of total billed charges,,,55,,3206.5,percent of total billed charges,,,55,,3206.5,percent of total billed charges,,,65,,3789.5,percent of total billed charges,,,78,,4547.4,percent of total billed charges,,,70,,4081,percent of total billed charges,,,,,,,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,,1392.08,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1392.08,5247,
Lumbar TFESI add'l level x___,64484,CPT,,,,both,,,1733,1039.8,,45.5,,788.52,percent of total billed charges,,,45.3,,785.05,percent of total billed charges,,,51,,883.83,percent of total billed charges,,,,,,,,,80,,1386.4,percent of total billed charges,,,61.4,,1064.06,percent of total billed charges,,,57.4,,994.74,percent of total billed charges,,,81,,1403.73,percent of total billed charges,,,51.5,,892.5,percent of total billed charges,,,57.6,,998.21,percent of total billed charges,,,85,,1473.05,percent of total billed charges,,,85,,1473.05,percent of total billed charges,,,49,,849.17,percent of total billed charges,,,90,,1559.7,percent of total billed charges,,,65,,1126.45,percent of total billed charges,,,80,,1386.4,percent of total billed charges,,,55,,953.15,percent of total billed charges,,,55,,953.15,percent of total billed charges,,,65,,1126.45,percent of total billed charges,,,78,,1351.74,percent of total billed charges,,,70,,1213.1,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,785.05,1559.7,
Lumbar Transforaminal Epidural Injection-Additional Level (64484),64484,CPT,,,,outpatient,,,1733,1039.8,,45.5,,788.52,percent of total billed charges,,,45.3,,785.05,percent of total billed charges,,,51,,883.83,percent of total billed charges,,,,,,,,,80,,1386.4,percent of total billed charges,,,61.4,,1064.06,percent of total billed charges,,,57.4,,994.74,percent of total billed charges,,,81,,1403.73,percent of total billed charges,,,51.5,,892.5,percent of total billed charges,,,57.6,,998.21,percent of total billed charges,,,85,,1473.05,percent of total billed charges,,,85,,1473.05,percent of total billed charges,,,49,,849.17,percent of total billed charges,,,90,,1559.7,percent of total billed charges,,,65,,1126.45,percent of total billed charges,,,80,,1386.4,percent of total billed charges,,,55,,953.15,percent of total billed charges,,,55,,953.15,percent of total billed charges,,,65,,1126.45,percent of total billed charges,,,78,,1351.74,percent of total billed charges,,,70,,1213.1,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,785.05,1559.7,
Lumbar Transforaminal Epidural Inj-Add'l Level BiL (64484-50),64484,CPT,,,50,outpatient,,,2599,1559.4,,45.5,,1182.55,percent of total billed charges,,,45.3,,1177.35,percent of total billed charges,,,51,,1325.49,percent of total billed charges,,,,,,,,,80,,2079.2,percent of total billed charges,,,61.4,,1595.79,percent of total billed charges,,,57.4,,1491.83,percent of total billed charges,,,81,,2105.19,percent of total billed charges,,,51.5,,1338.49,percent of total billed charges,,,57.6,,1497.02,percent of total billed charges,,,85,,2209.15,percent of total billed charges,,,85,,2209.15,percent of total billed charges,,,49,,1273.51,percent of total billed charges,,,90,,2339.1,percent of total billed charges,,,65,,1689.35,percent of total billed charges,,,80,,2079.2,percent of total billed charges,,,55,,1429.45,percent of total billed charges,,,55,,1429.45,percent of total billed charges,,,65,,1689.35,percent of total billed charges,,,78,,2027.22,percent of total billed charges,,,70,,1819.3,percent of total billed charges,,,,,,,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1177.35,2339.1,
"Transversus abdominis plane (TAP) Block, by injection, Unilateral (64486)",64486,CPT,,,,outpatient,,,1832,1099.2,,45.5,,833.56,percent of total billed charges,,,45.3,,829.9,percent of total billed charges,,,51,,934.32,percent of total billed charges,,,,,,,,,80,,1465.6,percent of total billed charges,,,61.4,,1124.85,percent of total billed charges,,,57.4,,1051.57,percent of total billed charges,,,81,,1483.92,percent of total billed charges,,,51.5,,943.48,percent of total billed charges,,,57.6,,1055.23,percent of total billed charges,,,85,,1557.2,percent of total billed charges,,,85,,1557.2,percent of total billed charges,,,49,,897.68,percent of total billed charges,,,90,,1648.8,percent of total billed charges,,,65,,1190.8,percent of total billed charges,,,80,,1465.6,percent of total billed charges,,,55,,1007.6,percent of total billed charges,,,55,,1007.6,percent of total billed charges,,,65,,1190.8,percent of total billed charges,,,78,,1428.96,percent of total billed charges,,,70,,1282.4,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,829.9,1648.8,
"Transversus abdominis plane (TAP) block, injection, Bilateral (64488)",64488,CPT,,,,outpatient,,,2622,1573.2,,45.5,,1193.01,percent of total billed charges,,,45.3,,1187.77,percent of total billed charges,,,51,,1337.22,percent of total billed charges,,,,,,,,,80,,2097.6,percent of total billed charges,,,61.4,,1609.91,percent of total billed charges,,,57.4,,1505.03,percent of total billed charges,,,81,,2123.82,percent of total billed charges,,,51.5,,1350.33,percent of total billed charges,,,57.6,,1510.27,percent of total billed charges,,,85,,2228.7,percent of total billed charges,,,85,,2228.7,percent of total billed charges,,,49,,1284.78,percent of total billed charges,,,90,,2359.8,percent of total billed charges,,,65,,1704.3,percent of total billed charges,,,80,,2097.6,percent of total billed charges,,,55,,1442.1,percent of total billed charges,,,55,,1442.1,percent of total billed charges,,,65,,1704.3,percent of total billed charges,,,78,,2045.16,percent of total billed charges,,,70,,1835.4,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1187.77,2359.8,
Inj Paravert F Jnt C/T One Level (64490),64490,CPT,,,,outpatient,,,3900,2340,,45.5,,1774.5,percent of total billed charges,,,45.3,,1766.7,percent of total billed charges,,,51,,1989,percent of total billed charges,,,,,,,,,80,,3120,percent of total billed charges,,,61.4,,2394.6,percent of total billed charges,,,57.4,,2238.6,percent of total billed charges,,,81,,3159,percent of total billed charges,,,51.5,,2008.5,percent of total billed charges,,,57.6,,2246.4,percent of total billed charges,,,85,,3315,percent of total billed charges,,,85,,3315,percent of total billed charges,,,49,,1911,percent of total billed charges,,,90,,3510,percent of total billed charges,,,65,,2535,percent of total billed charges,,,80,,3120,percent of total billed charges,,,55,,2145,percent of total billed charges,,,55,,2145,percent of total billed charges,,,65,,2535,percent of total billed charges,,,78,,3042,percent of total billed charges,,,70,,2730,percent of total billed charges,,,,,,,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,,928.06,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,928.06,3510,
Inj Paravert F Jnt C/T One Level-Bilateral (64490-50),64490,CPT,,,50,outpatient,,,5849,3509.4,,45.5,,2661.3,percent of total billed charges,,,45.3,,2649.6,percent of total billed charges,,,51,,2982.99,percent of total billed charges,,,,,,,,,80,,4679.2,percent of total billed charges,,,61.4,,3591.29,percent of total billed charges,,,57.4,,3357.33,percent of total billed charges,,,81,,4737.69,percent of total billed charges,,,51.5,,3012.24,percent of total billed charges,,,57.6,,3369.02,percent of total billed charges,,,85,,4971.65,percent of total billed charges,,,85,,4971.65,percent of total billed charges,,,49,,2866.01,percent of total billed charges,,,90,,5264.1,percent of total billed charges,,,65,,3801.85,percent of total billed charges,,,80,,4679.2,percent of total billed charges,,,55,,3216.95,percent of total billed charges,,,55,,3216.95,percent of total billed charges,,,65,,3801.85,percent of total billed charges,,,78,,4562.22,percent of total billed charges,,,70,,4094.3,percent of total billed charges,,,,,,,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,,1392.08,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1392.08,5264.1,
Inj Paravert F Jnt C/T Two Levels (64491),64491,CPT,,,,outpatient,,,1499,899.4,,45.5,,682.05,percent of total billed charges,,,45.3,,679.05,percent of total billed charges,,,51,,764.49,percent of total billed charges,,,,,,,,,80,,1199.2,percent of total billed charges,,,61.4,,920.39,percent of total billed charges,,,57.4,,860.43,percent of total billed charges,,,81,,1214.19,percent of total billed charges,,,51.5,,771.99,percent of total billed charges,,,57.6,,863.42,percent of total billed charges,,,85,,1274.15,percent of total billed charges,,,85,,1274.15,percent of total billed charges,,,49,,734.51,percent of total billed charges,,,90,,1349.1,percent of total billed charges,,,65,,974.35,percent of total billed charges,,,80,,1199.2,percent of total billed charges,,,55,,824.45,percent of total billed charges,,,55,,824.45,percent of total billed charges,,,65,,974.35,percent of total billed charges,,,78,,1169.22,percent of total billed charges,,,70,,1049.3,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,679.05,1349.1,
Inj Paravert F Jnt C/T Two Levels-Bilateral (64491-50),64491,CPT,,,50,outpatient,,,2248,1348.8,,45.5,,1022.84,percent of total billed charges,,,45.3,,1018.34,percent of total billed charges,,,51,,1146.48,percent of total billed charges,,,,,,,,,80,,1798.4,percent of total billed charges,,,61.4,,1380.27,percent of total billed charges,,,57.4,,1290.35,percent of total billed charges,,,81,,1820.88,percent of total billed charges,,,51.5,,1157.72,percent of total billed charges,,,57.6,,1294.85,percent of total billed charges,,,85,,1910.8,percent of total billed charges,,,85,,1910.8,percent of total billed charges,,,49,,1101.52,percent of total billed charges,,,90,,2023.2,percent of total billed charges,,,65,,1461.2,percent of total billed charges,,,80,,1798.4,percent of total billed charges,,,55,,1236.4,percent of total billed charges,,,55,,1236.4,percent of total billed charges,,,65,,1461.2,percent of total billed charges,,,78,,1753.44,percent of total billed charges,,,70,,1573.6,percent of total billed charges,,,,,,,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1018.34,2023.2,
Inj Paravert F Jnt C/T Three Levels (64492),64492,CPT,,,,outpatient,,,1206,723.6,,45.5,,548.73,percent of total billed charges,,,45.3,,546.32,percent of total billed charges,,,51,,615.06,percent of total billed charges,,,,,,,,,80,,964.8,percent of total billed charges,,,61.4,,740.48,percent of total billed charges,,,57.4,,692.24,percent of total billed charges,,,81,,976.86,percent of total billed charges,,,51.5,,621.09,percent of total billed charges,,,57.6,,694.66,percent of total billed charges,,,85,,1025.1,percent of total billed charges,,,85,,1025.1,percent of total billed charges,,,49,,590.94,percent of total billed charges,,,90,,1085.4,percent of total billed charges,,,65,,783.9,percent of total billed charges,,,80,,964.8,percent of total billed charges,,,55,,663.3,percent of total billed charges,,,55,,663.3,percent of total billed charges,,,65,,783.9,percent of total billed charges,,,78,,940.68,percent of total billed charges,,,70,,844.2,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,546.32,1085.4,
Inj Paravert F Jnt C/T Three Levels-Bilateral (64492-50),64492,CPT,,,50,outpatient,,,2082,1249.2,,45.5,,947.31,percent of total billed charges,,,45.3,,943.15,percent of total billed charges,,,51,,1061.82,percent of total billed charges,,,,,,,,,80,,1665.6,percent of total billed charges,,,61.4,,1278.35,percent of total billed charges,,,57.4,,1195.07,percent of total billed charges,,,81,,1686.42,percent of total billed charges,,,51.5,,1072.23,percent of total billed charges,,,57.6,,1199.23,percent of total billed charges,,,85,,1769.7,percent of total billed charges,,,85,,1769.7,percent of total billed charges,,,49,,1020.18,percent of total billed charges,,,90,,1873.8,percent of total billed charges,,,65,,1353.3,percent of total billed charges,,,80,,1665.6,percent of total billed charges,,,55,,1145.1,percent of total billed charges,,,55,,1145.1,percent of total billed charges,,,65,,1353.3,percent of total billed charges,,,78,,1623.96,percent of total billed charges,,,70,,1457.4,percent of total billed charges,,,,,,,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,943.15,1873.8,
Inj Paravert F Jnt L/S One Level (64493),64493,CPT,,,,outpatient,,,3097,1858.2,,45.5,,1409.14,percent of total billed charges,,,45.3,,1402.94,percent of total billed charges,,,51,,1579.47,percent of total billed charges,,,,,,,,,80,,2477.6,percent of total billed charges,,,61.4,,1901.56,percent of total billed charges,,,57.4,,1777.68,percent of total billed charges,,,81,,2508.57,percent of total billed charges,,,51.5,,1594.96,percent of total billed charges,,,57.6,,1783.87,percent of total billed charges,,,85,,2632.45,percent of total billed charges,,,85,,2632.45,percent of total billed charges,,,49,,1517.53,percent of total billed charges,,,90,,2787.3,percent of total billed charges,,,65,,2013.05,percent of total billed charges,,,80,,2477.6,percent of total billed charges,,,55,,1703.35,percent of total billed charges,,,55,,1703.35,percent of total billed charges,,,65,,2013.05,percent of total billed charges,,,78,,2415.66,percent of total billed charges,,,70,,2167.9,percent of total billed charges,,,,,,,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,,928.06,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,928.06,2787.3,
Inj Paravert F Jnt L/S One Level-Bilateral (64493-50),64493,CPT,,,50,outpatient,,,4645,2787,,45.5,,2113.48,percent of total billed charges,,,45.3,,2104.19,percent of total billed charges,,,51,,2368.95,percent of total billed charges,,,,,,,,,80,,3716,percent of total billed charges,,,61.4,,2852.03,percent of total billed charges,,,57.4,,2666.23,percent of total billed charges,,,81,,3762.45,percent of total billed charges,,,51.5,,2392.18,percent of total billed charges,,,57.6,,2675.52,percent of total billed charges,,,85,,3948.25,percent of total billed charges,,,85,,3948.25,percent of total billed charges,,,49,,2276.05,percent of total billed charges,,,90,,4180.5,percent of total billed charges,,,65,,3019.25,percent of total billed charges,,,80,,3716,percent of total billed charges,,,55,,2554.75,percent of total billed charges,,,55,,2554.75,percent of total billed charges,,,65,,3019.25,percent of total billed charges,,,78,,3623.1,percent of total billed charges,,,70,,3251.5,percent of total billed charges,,,,,,,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,,1392.08,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1392.08,4180.5,
Inj Paravert F Jnt L/S Two Levels (64494),64494,CPT,,,,outpatient,,,1146,687.6,,45.5,,521.43,percent of total billed charges,,,45.3,,519.14,percent of total billed charges,,,51,,584.46,percent of total billed charges,,,,,,,,,80,,916.8,percent of total billed charges,,,61.4,,703.64,percent of total billed charges,,,57.4,,657.8,percent of total billed charges,,,81,,928.26,percent of total billed charges,,,51.5,,590.19,percent of total billed charges,,,57.6,,660.1,percent of total billed charges,,,85,,974.1,percent of total billed charges,,,85,,974.1,percent of total billed charges,,,49,,561.54,percent of total billed charges,,,90,,1031.4,percent of total billed charges,,,65,,744.9,percent of total billed charges,,,80,,916.8,percent of total billed charges,,,55,,630.3,percent of total billed charges,,,55,,630.3,percent of total billed charges,,,65,,744.9,percent of total billed charges,,,78,,893.88,percent of total billed charges,,,70,,802.2,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,519.14,1031.4,
Inj Paravert F Jnt L/S Two Levels-Bilateral (64494-50),64494,CPT,,,50,outpatient,,,1719,1031.4,,45.5,,782.15,percent of total billed charges,,,45.3,,778.71,percent of total billed charges,,,51,,876.69,percent of total billed charges,,,,,,,,,80,,1375.2,percent of total billed charges,,,61.4,,1055.47,percent of total billed charges,,,57.4,,986.71,percent of total billed charges,,,81,,1392.39,percent of total billed charges,,,51.5,,885.29,percent of total billed charges,,,57.6,,990.14,percent of total billed charges,,,85,,1461.15,percent of total billed charges,,,85,,1461.15,percent of total billed charges,,,49,,842.31,percent of total billed charges,,,90,,1547.1,percent of total billed charges,,,65,,1117.35,percent of total billed charges,,,80,,1375.2,percent of total billed charges,,,55,,945.45,percent of total billed charges,,,55,,945.45,percent of total billed charges,,,65,,1117.35,percent of total billed charges,,,78,,1340.82,percent of total billed charges,,,70,,1203.3,percent of total billed charges,,,,,,,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,778.71,1547.1,
Inj Paravert F Jnt L/S Three Levels (64495),64495,CPT,,,,outpatient,,,954,572.4,,45.5,,434.07,percent of total billed charges,,,45.3,,432.16,percent of total billed charges,,,51,,486.54,percent of total billed charges,,,,,,,,,80,,763.2,percent of total billed charges,,,61.4,,585.76,percent of total billed charges,,,57.4,,547.6,percent of total billed charges,,,81,,772.74,percent of total billed charges,,,51.5,,491.31,percent of total billed charges,,,57.6,,549.5,percent of total billed charges,,,85,,810.9,percent of total billed charges,,,85,,810.9,percent of total billed charges,,,49,,467.46,percent of total billed charges,,,90,,858.6,percent of total billed charges,,,65,,620.1,percent of total billed charges,,,80,,763.2,percent of total billed charges,,,55,,524.7,percent of total billed charges,,,55,,524.7,percent of total billed charges,,,65,,620.1,percent of total billed charges,,,78,,744.12,percent of total billed charges,,,70,,667.8,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,432.16,858.6,
Inj Paravert F Jnt L/S Three Levels-Bilateral (64495-50),64495,CPT,,,50,outpatient,,,1430,858,,45.5,,650.65,percent of total billed charges,,,45.3,,647.79,percent of total billed charges,,,51,,729.3,percent of total billed charges,,,,,,,,,80,,1144,percent of total billed charges,,,61.4,,878.02,percent of total billed charges,,,57.4,,820.82,percent of total billed charges,,,81,,1158.3,percent of total billed charges,,,51.5,,736.45,percent of total billed charges,,,57.6,,823.68,percent of total billed charges,,,85,,1215.5,percent of total billed charges,,,85,,1215.5,percent of total billed charges,,,49,,700.7,percent of total billed charges,,,90,,1287,percent of total billed charges,,,65,,929.5,percent of total billed charges,,,80,,1144,percent of total billed charges,,,55,,786.5,percent of total billed charges,,,55,,786.5,percent of total billed charges,,,65,,929.5,percent of total billed charges,,,78,,1115.4,percent of total billed charges,,,70,,1001,percent of total billed charges,,,,,,,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,647.79,1287,
INJ ANESTH; SPHENOPALATINE GANGLION (64505),64505,CPT,,,,outpatient,,,1232,739.2,,45.5,,560.56,percent of total billed charges,,,45.3,,558.1,percent of total billed charges,,,51,,628.32,percent of total billed charges,,,,,,,,,80,,985.6,percent of total billed charges,,,61.4,,756.45,percent of total billed charges,,,57.4,,707.17,percent of total billed charges,,,81,,997.92,percent of total billed charges,,,51.5,,634.48,percent of total billed charges,,,57.6,,709.63,percent of total billed charges,,,85,,1047.2,percent of total billed charges,,,85,,1047.2,percent of total billed charges,,,49,,603.68,percent of total billed charges,,,90,,1108.8,percent of total billed charges,,,65,,800.8,percent of total billed charges,,,80,,985.6,percent of total billed charges,,,55,,677.6,percent of total billed charges,,,55,,677.6,percent of total billed charges,,,65,,800.8,percent of total billed charges,,,78,,960.96,percent of total billed charges,,,70,,862.4,percent of total billed charges,,,,,,,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,,307.71,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,307.71,1108.8,
"Injection, Anesthetic Agent; Stellate Ganglion",64510,CPT,,,,outpatient,,,2667,1600.2,,45.5,,1213.49,percent of total billed charges,,,45.3,,1208.15,percent of total billed charges,,,51,,1360.17,percent of total billed charges,,,,,,,,,80,,2133.6,percent of total billed charges,,,61.4,,1637.54,percent of total billed charges,,,57.4,,1530.86,percent of total billed charges,,,81,,2160.27,percent of total billed charges,,,51.5,,1373.51,percent of total billed charges,,,57.6,,1536.19,percent of total billed charges,,,85,,2266.95,percent of total billed charges,,,85,,2266.95,percent of total billed charges,,,49,,1306.83,percent of total billed charges,,,90,,2400.3,percent of total billed charges,,,65,,1733.55,percent of total billed charges,,,80,,2133.6,percent of total billed charges,,,55,,1466.85,percent of total billed charges,,,55,,1466.85,percent of total billed charges,,,65,,1733.55,percent of total billed charges,,,78,,2080.26,percent of total billed charges,,,70,,1866.9,percent of total billed charges,,,,,,,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,,928.06,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,928.06,2400.3,
NB INJ HYPOGAS PLXS (64517),64517,CPT,,,,outpatient,,,2998,1798.8,,45.5,,1364.09,percent of total billed charges,,,45.3,,1358.09,percent of total billed charges,,,51,,1528.98,percent of total billed charges,,,,,,,,,80,,2398.4,percent of total billed charges,,,61.4,,1840.77,percent of total billed charges,,,57.4,,1720.85,percent of total billed charges,,,81,,2428.38,percent of total billed charges,,,51.5,,1543.97,percent of total billed charges,,,57.6,,1726.85,percent of total billed charges,,,85,,2548.3,percent of total billed charges,,,85,,2548.3,percent of total billed charges,,,49,,1469.02,percent of total billed charges,,,90,,2698.2,percent of total billed charges,,,65,,1948.7,percent of total billed charges,,,80,,2398.4,percent of total billed charges,,,55,,1648.9,percent of total billed charges,,,55,,1648.9,percent of total billed charges,,,65,,1948.7,percent of total billed charges,,,78,,2338.44,percent of total billed charges,,,70,,2098.6,percent of total billed charges,,,,,,,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,,928.06,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,928.06,2698.2,
"Injection, Anesthetic Agent; Lumbar or Thoracic (paravertebral sympathetic)",64520,CPT,,,,outpatient,,,2398,1438.8,,45.5,,1091.09,percent of total billed charges,,,45.3,,1086.29,percent of total billed charges,,,51,,1222.98,percent of total billed charges,,,,,,,,,80,,1918.4,percent of total billed charges,,,61.4,,1472.37,percent of total billed charges,,,57.4,,1376.45,percent of total billed charges,,,81,,1942.38,percent of total billed charges,,,51.5,,1234.97,percent of total billed charges,,,57.6,,1381.25,percent of total billed charges,,,85,,2038.3,percent of total billed charges,,,85,,2038.3,percent of total billed charges,,,49,,1175.02,percent of total billed charges,,,90,,2158.2,percent of total billed charges,,,65,,1558.7,percent of total billed charges,,,80,,1918.4,percent of total billed charges,,,55,,1318.9,percent of total billed charges,,,55,,1318.9,percent of total billed charges,,,65,,1558.7,percent of total billed charges,,,78,,1870.44,percent of total billed charges,,,70,,1678.6,percent of total billed charges,,,,,,,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,,928.06,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,928.06,2158.2,
IMPLANT NEUROELECTRODES; PERIPHERAL NRV (64555),64555,CPT,,,,outpatient,,,17955,10773,,45.5,,8169.53,percent of total billed charges,,,45.3,,8133.62,percent of total billed charges,,,51,,9157.05,percent of total billed charges,,,,,,,,,80,,14364,percent of total billed charges,,,61.4,,11024.37,percent of total billed charges,,,57.4,,10306.17,percent of total billed charges,,,81,,14543.55,percent of total billed charges,,,51.5,,9246.83,percent of total billed charges,,,57.6,,10342.08,percent of total billed charges,,,85,,15261.75,percent of total billed charges,,,85,,15261.75,percent of total billed charges,,,49,,8797.95,percent of total billed charges,,,90,,16159.5,percent of total billed charges,,,65,,11670.75,percent of total billed charges,,,80,,14364,percent of total billed charges,,,55,,9875.25,percent of total billed charges,,,55,,9875.25,percent of total billed charges,,,65,,11670.75,percent of total billed charges,,,78,,14004.9,percent of total billed charges,,,70,,12568.5,percent of total billed charges,,,,,,,,6841.3,,,,100% of Medicare,,6841.3,,,,100% of Medicare,,6841.3,,,,100% of Medicare,,6841.3,,,,100% of Medicare,,6841.3,,,,100% of Medicare,,6841.3,,,,100% of Medicare,,6841.3,,,,100% of Medicare,,6841.3,,,,100% of Medicare,,6841.3,,,,100% of Medicare,,6841.3,,,,100% of Medicare,,6841.3,,,,100% of Medicare,,6841.3,,,,100% of Medicare,,,6841.3,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,6841.3,16159.5,
INSERT/RPLCMT PERIPHL/SACRAL/GAST NEUROSTIM GEN W/POCKET AND CONNECT 64590,64590,CPT,,,,outpatient,,,19928,11956.8,,45.5,,9067.24,percent of total billed charges,,,45.3,,9027.38,percent of total billed charges,,,51,,10163.28,percent of total billed charges,,,,,,,,,80,,15942.4,percent of total billed charges,,,61.4,,12235.79,percent of total billed charges,,,57.4,,11438.67,percent of total billed charges,,,81,,16141.68,percent of total billed charges,,,51.5,,10262.92,percent of total billed charges,,,57.6,,11478.53,percent of total billed charges,,,85,,16938.8,percent of total billed charges,,,85,,16938.8,percent of total billed charges,,,49,,9764.72,percent of total billed charges,,,90,,17935.2,percent of total billed charges,,,65,,12953.2,percent of total billed charges,,,80,,15942.4,percent of total billed charges,,,55,,10960.4,percent of total billed charges,,,55,,10960.4,percent of total billed charges,,,65,,12953.2,percent of total billed charges,,,78,,15543.84,percent of total billed charges,,,70,,13949.6,percent of total billed charges,,,,,,,,22354.06,,,,100% of Medicare,,22354.06,,,,100% of Medicare,,22354.06,,,,100% of Medicare,,22354.06,,,,100% of Medicare,,22354.06,,,,100% of Medicare,,22354.06,,,,100% of Medicare,,22354.06,,,,100% of Medicare,,22354.06,,,,100% of Medicare,,22354.06,,,,100% of Medicare,,22354.06,,,,100% of Medicare,,22354.06,,,,100% of Medicare,,22354.06,,,,100% of Medicare,,,22354.06,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,9027.38,22354.06,
Insert/replace perq electrode array PN w/intgd neurostim Initial array 64596,64596,CPT,,,,outpatient,,,22867,13720.2,,45.5,,10404.49,percent of total billed charges,,,45.3,,10358.75,percent of total billed charges,,,51,,11662.17,percent of total billed charges,,,,,,,,,80,,18293.6,percent of total billed charges,,,61.4,,14040.34,percent of total billed charges,,,57.4,,13125.66,percent of total billed charges,,,81,,18522.27,percent of total billed charges,,,51.5,,11776.51,percent of total billed charges,,,57.6,,13171.39,percent of total billed charges,,,85,,19436.95,percent of total billed charges,,,85,,19436.95,percent of total billed charges,,,49,,11204.83,percent of total billed charges,,,90,,20580.3,percent of total billed charges,,,65,,14863.55,percent of total billed charges,,,80,,18293.6,percent of total billed charges,,,55,,12576.85,percent of total billed charges,,,55,,12576.85,percent of total billed charges,,,65,,14863.55,percent of total billed charges,,,78,,17836.26,percent of total billed charges,,,70,,16006.9,percent of total billed charges,,,,,,,,12999.3,,,,100% of Medicare,,12999.3,,,,100% of Medicare,,12999.3,,,,100% of Medicare,,12999.3,,,,100% of Medicare,,12999.3,,,,100% of Medicare,,12999.3,,,,100% of Medicare,,12999.3,,,,100% of Medicare,,12999.3,,,,100% of Medicare,,12999.3,,,,100% of Medicare,,12999.3,,,,100% of Medicare,,12999.3,,,,100% of Medicare,,12999.3,,,,100% of Medicare,,,12999.3,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,10358.75,20580.3,
Insert/replace perq electrode array PN w/intgd neurostim Each addl array 64597,64597,CPT,,,,outpatient,,,11433,6859.8,,45.5,,5202.02,percent of total billed charges,,,45.3,,5179.15,percent of total billed charges,,,51,,5830.83,percent of total billed charges,,,,,,,,,80,,9146.4,percent of total billed charges,,,61.4,,7019.86,percent of total billed charges,,,57.4,,6562.54,percent of total billed charges,,,81,,9260.73,percent of total billed charges,,,51.5,,5888,percent of total billed charges,,,57.6,,6585.41,percent of total billed charges,,,85,,9718.05,percent of total billed charges,,,85,,9718.05,percent of total billed charges,,,49,,5602.17,percent of total billed charges,,,90,,10289.7,percent of total billed charges,,,65,,7431.45,percent of total billed charges,,,80,,9146.4,percent of total billed charges,,,55,,6288.15,percent of total billed charges,,,55,,6288.15,percent of total billed charges,,,65,,7431.45,percent of total billed charges,,,78,,8917.74,percent of total billed charges,,,70,,8003.1,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,5179.15,10289.7,
Revise/remove neurostim electrode array PN w/intgrated neurostim 64598,64598,CPT,,,,outpatient,,,7139,4283.4,,45.5,,3248.25,percent of total billed charges,,,45.3,,3233.97,percent of total billed charges,,,51,,3640.89,percent of total billed charges,,,,,,,,,80,,5711.2,percent of total billed charges,,,61.4,,4383.35,percent of total billed charges,,,57.4,,4097.79,percent of total billed charges,,,81,,5782.59,percent of total billed charges,,,51.5,,3676.59,percent of total billed charges,,,57.6,,4112.06,percent of total billed charges,,,85,,6068.15,percent of total billed charges,,,85,,6068.15,percent of total billed charges,,,49,,3498.11,percent of total billed charges,,,90,,6425.1,percent of total billed charges,,,65,,4640.35,percent of total billed charges,,,80,,5711.2,percent of total billed charges,,,55,,3926.45,percent of total billed charges,,,55,,3926.45,percent of total billed charges,,,65,,4640.35,percent of total billed charges,,,78,,5568.42,percent of total billed charges,,,70,,4997.3,percent of total billed charges,,,,,,,,3584.89,,,,100% of Medicare,,3584.89,,,,100% of Medicare,,3584.89,,,,100% of Medicare,,3584.89,,,,100% of Medicare,,3584.89,,,,100% of Medicare,,3584.89,,,,100% of Medicare,,3584.89,,,,100% of Medicare,,3584.89,,,,100% of Medicare,,3584.89,,,,100% of Medicare,,3584.89,,,,100% of Medicare,,3584.89,,,,100% of Medicare,,3584.89,,,,100% of Medicare,,,3584.89,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,3233.97,6425.1,
Chemodenerv Saliv Glands (64611),64611,CPT,,,,outpatient,,,842,505.2,,45.5,,383.11,percent of total billed charges,,,45.3,,381.43,percent of total billed charges,,,51,,429.42,percent of total billed charges,,,,,,,,,80,,673.6,percent of total billed charges,,,61.4,,516.99,percent of total billed charges,,,57.4,,483.31,percent of total billed charges,,,81,,682.02,percent of total billed charges,,,51.5,,433.63,percent of total billed charges,,,57.6,,484.99,percent of total billed charges,,,85,,715.7,percent of total billed charges,,,85,,715.7,percent of total billed charges,,,49,,412.58,percent of total billed charges,,,90,,757.8,percent of total billed charges,,,65,,547.3,percent of total billed charges,,,80,,673.6,percent of total billed charges,,,55,,463.1,percent of total billed charges,,,55,,463.1,percent of total billed charges,,,65,,547.3,percent of total billed charges,,,78,,656.76,percent of total billed charges,,,70,,589.4,percent of total billed charges,,,,,,,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,,307.71,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,307.71,757.8,
Chemodenervation-Face (64612),64612,CPT,,,,outpatient,,,1279,767.4,,45.5,,581.95,percent of total billed charges,,,45.3,,579.39,percent of total billed charges,,,51,,652.29,percent of total billed charges,,,,,,,,,80,,1023.2,percent of total billed charges,,,61.4,,785.31,percent of total billed charges,,,57.4,,734.15,percent of total billed charges,,,81,,1035.99,percent of total billed charges,,,51.5,,658.69,percent of total billed charges,,,57.6,,736.7,percent of total billed charges,,,85,,1087.15,percent of total billed charges,,,85,,1087.15,percent of total billed charges,,,49,,626.71,percent of total billed charges,,,90,,1151.1,percent of total billed charges,,,65,,831.35,percent of total billed charges,,,80,,1023.2,percent of total billed charges,,,55,,703.45,percent of total billed charges,,,55,,703.45,percent of total billed charges,,,65,,831.35,percent of total billed charges,,,78,,997.62,percent of total billed charges,,,70,,895.3,percent of total billed charges,,,,,,,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,,307.71,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,307.71,1151.1,
"DESTROY NERVE FACE MUSCLE, BILATERAL (64612-50)",64612,CPT,,,50,outpatient,,,1918,1150.8,,45.5,,872.69,percent of total billed charges,,,45.3,,868.85,percent of total billed charges,,,51,,978.18,percent of total billed charges,,,,,,,,,80,,1534.4,percent of total billed charges,,,61.4,,1177.65,percent of total billed charges,,,57.4,,1100.93,percent of total billed charges,,,81,,1553.58,percent of total billed charges,,,51.5,,987.77,percent of total billed charges,,,57.6,,1104.77,percent of total billed charges,,,85,,1630.3,percent of total billed charges,,,85,,1630.3,percent of total billed charges,,,49,,939.82,percent of total billed charges,,,90,,1726.2,percent of total billed charges,,,65,,1246.7,percent of total billed charges,,,80,,1534.4,percent of total billed charges,,,55,,1054.9,percent of total billed charges,,,55,,1054.9,percent of total billed charges,,,65,,1246.7,percent of total billed charges,,,78,,1496.04,percent of total billed charges,,,70,,1342.6,percent of total billed charges,,,,,,,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,,461.57,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,461.57,1726.2,
CHEMODENERV MUSC MIGRAINE (64615),64615,CPT,,,,outpatient,,,968,580.8,,45.5,,440.44,percent of total billed charges,,,45.3,,438.5,percent of total billed charges,,,51,,493.68,percent of total billed charges,,,,,,,,,80,,774.4,percent of total billed charges,,,61.4,,594.35,percent of total billed charges,,,57.4,,555.63,percent of total billed charges,,,81,,784.08,percent of total billed charges,,,51.5,,498.52,percent of total billed charges,,,57.6,,557.57,percent of total billed charges,,,85,,822.8,percent of total billed charges,,,85,,822.8,percent of total billed charges,,,49,,474.32,percent of total billed charges,,,90,,871.2,percent of total billed charges,,,65,,629.2,percent of total billed charges,,,80,,774.4,percent of total billed charges,,,55,,532.4,percent of total billed charges,,,55,,532.4,percent of total billed charges,,,65,,629.2,percent of total billed charges,,,78,,755.04,percent of total billed charges,,,70,,677.6,percent of total billed charges,,,,,,,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,,307.71,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,307.71,871.2,
CHEMODENERV MUSC NECK DYSTON (64616),64616,CPT,,,,outpatient,,,1225,735,,45.5,,557.38,percent of total billed charges,,,45.3,,554.93,percent of total billed charges,,,51,,624.75,percent of total billed charges,,,,,,,,,80,,980,percent of total billed charges,,,61.4,,752.15,percent of total billed charges,,,57.4,,703.15,percent of total billed charges,,,81,,992.25,percent of total billed charges,,,51.5,,630.88,percent of total billed charges,,,57.6,,705.6,percent of total billed charges,,,85,,1041.25,percent of total billed charges,,,85,,1041.25,percent of total billed charges,,,49,,600.25,percent of total billed charges,,,90,,1102.5,percent of total billed charges,,,65,,796.25,percent of total billed charges,,,80,,980,percent of total billed charges,,,55,,673.75,percent of total billed charges,,,55,,673.75,percent of total billed charges,,,65,,796.25,percent of total billed charges,,,78,,955.5,percent of total billed charges,,,70,,857.5,percent of total billed charges,,,,,,,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,,307.71,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,307.71,1102.5,
"CHEMODENERV MUSC NECK DYSTON,Bilateral (64616-50)",64616,CPT,,,50,outpatient,,,1837,1102.2,,45.5,,835.84,percent of total billed charges,,,45.3,,832.16,percent of total billed charges,,,51,,936.87,percent of total billed charges,,,,,,,,,80,,1469.6,percent of total billed charges,,,61.4,,1127.92,percent of total billed charges,,,57.4,,1054.44,percent of total billed charges,,,81,,1487.97,percent of total billed charges,,,51.5,,946.06,percent of total billed charges,,,57.6,,1058.11,percent of total billed charges,,,85,,1561.45,percent of total billed charges,,,85,,1561.45,percent of total billed charges,,,49,,900.13,percent of total billed charges,,,90,,1653.3,percent of total billed charges,,,65,,1194.05,percent of total billed charges,,,80,,1469.6,percent of total billed charges,,,55,,1010.35,percent of total billed charges,,,55,,1010.35,percent of total billed charges,,,65,,1194.05,percent of total billed charges,,,78,,1432.86,percent of total billed charges,,,70,,1285.9,percent of total billed charges,,,,,,,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,461.57,,,,150% of Medicare,,,461.57,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,461.57,1653.3,
CHEMODENER MUSCLE LARYNX EMG (64617),64617,CPT,,,,outpatient,,,1602,961.2,,45.5,,728.91,percent of total billed charges,,,45.3,,725.71,percent of total billed charges,,,51,,817.02,percent of total billed charges,,,,,,,,,80,,1281.6,percent of total billed charges,,,61.4,,983.63,percent of total billed charges,,,57.4,,919.55,percent of total billed charges,,,81,,1297.62,percent of total billed charges,,,51.5,,825.03,percent of total billed charges,,,57.6,,922.75,percent of total billed charges,,,85,,1361.7,percent of total billed charges,,,85,,1361.7,percent of total billed charges,,,49,,784.98,percent of total billed charges,,,90,,1441.8,percent of total billed charges,,,65,,1041.3,percent of total billed charges,,,80,,1281.6,percent of total billed charges,,,55,,881.1,percent of total billed charges,,,55,,881.1,percent of total billed charges,,,65,,1041.3,percent of total billed charges,,,78,,1249.56,percent of total billed charges,,,70,,1121.4,percent of total billed charges,,,,,,,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,,721.9,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,721.9,1441.8,
"CHEMODENER MUSCLE LARYNX EMG,Bilateral (64617-50)",64617,CPT,,,50,outpatient,,,1840,1104,,45.5,,837.2,percent of total billed charges,,,45.3,,833.52,percent of total billed charges,,,51,,938.4,percent of total billed charges,,,,,,,,,80,,1472,percent of total billed charges,,,61.4,,1129.76,percent of total billed charges,,,57.4,,1056.16,percent of total billed charges,,,81,,1490.4,percent of total billed charges,,,51.5,,947.6,percent of total billed charges,,,57.6,,1059.84,percent of total billed charges,,,85,,1564,percent of total billed charges,,,85,,1564,percent of total billed charges,,,49,,901.6,percent of total billed charges,,,90,,1656,percent of total billed charges,,,65,,1196,percent of total billed charges,,,80,,1472,percent of total billed charges,,,55,,1012,percent of total billed charges,,,55,,1012,percent of total billed charges,,,65,,1196,percent of total billed charges,,,78,,1435.2,percent of total billed charges,,,70,,1288,percent of total billed charges,,,,,,,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,1082.85,,,,150% of Medicare,,,1082.85,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,833.52,1656,
DESTR W NEUROLYTIC; INTERCOSTAL NRV (64620),64620,CPT,,,,outpatient,,,6917,4150.2,,45.5,,3147.24,percent of total billed charges,,,45.3,,3133.4,percent of total billed charges,,,51,,3527.67,percent of total billed charges,,,,,,,,,80,,5533.6,percent of total billed charges,,,61.4,,4247.04,percent of total billed charges,,,57.4,,3970.36,percent of total billed charges,,,81,,5602.77,percent of total billed charges,,,51.5,,3562.26,percent of total billed charges,,,57.6,,3984.19,percent of total billed charges,,,85,,5879.45,percent of total billed charges,,,85,,5879.45,percent of total billed charges,,,49,,3389.33,percent of total billed charges,,,90,,6225.3,percent of total billed charges,,,65,,4496.05,percent of total billed charges,,,80,,5533.6,percent of total billed charges,,,55,,3804.35,percent of total billed charges,,,55,,3804.35,percent of total billed charges,,,65,,4496.05,percent of total billed charges,,,78,,5395.26,percent of total billed charges,,,70,,4841.9,percent of total billed charges,,,,,,,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,,928.06,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,928.06,6225.3,
DESTRUCTION NEUROLYTIC AGT GENICULAR NERVE W/IMG (64624),64624,CPT,,,,outpatient,,,6655,3993,,45.5,,3028.03,percent of total billed charges,,,45.3,,3014.72,percent of total billed charges,,,51,,3394.05,percent of total billed charges,,,,,,,,,80,,5324,percent of total billed charges,,,61.4,,4086.17,percent of total billed charges,,,57.4,,3819.97,percent of total billed charges,,,81,,5390.55,percent of total billed charges,,,51.5,,3427.33,percent of total billed charges,,,57.6,,3833.28,percent of total billed charges,,,85,,5656.75,percent of total billed charges,,,85,,5656.75,percent of total billed charges,,,49,,3260.95,percent of total billed charges,,,90,,5989.5,percent of total billed charges,,,65,,4325.75,percent of total billed charges,,,80,,5324,percent of total billed charges,,,55,,3660.25,percent of total billed charges,,,55,,3660.25,percent of total billed charges,,,65,,4325.75,percent of total billed charges,,,78,,5190.9,percent of total billed charges,,,70,,4658.5,percent of total billed charges,,,,,,,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,,2035.61,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,2035.61,5989.5,
DESTRUCTION NEUROLYTIC AGT GENICULAR NERVE W/IMG Bilateral (64624-50),64624,CPT,,,50,outpatient,,,9983,5989.8,,45.5,,4542.27,percent of total billed charges,,,45.3,,4522.3,percent of total billed charges,,,51,,5091.33,percent of total billed charges,,,,,,,,,80,,7986.4,percent of total billed charges,,,61.4,,6129.56,percent of total billed charges,,,57.4,,5730.24,percent of total billed charges,,,81,,8086.23,percent of total billed charges,,,51.5,,5141.25,percent of total billed charges,,,57.6,,5750.21,percent of total billed charges,,,85,,8485.55,percent of total billed charges,,,85,,8485.55,percent of total billed charges,,,49,,4891.67,percent of total billed charges,,,90,,8984.7,percent of total billed charges,,,65,,6488.95,percent of total billed charges,,,80,,7986.4,percent of total billed charges,,,55,,5490.65,percent of total billed charges,,,55,,5490.65,percent of total billed charges,,,65,,6488.95,percent of total billed charges,,,78,,7786.74,percent of total billed charges,,,70,,6988.1,percent of total billed charges,,,,,,,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,,3053.41,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,3053.41,8984.7,
CC ONLY - RADIOFREQUENCY ABLTJ NRV NRVTG SI JT W/IMG GDN (64625),64625,CPT,,,,outpatient,,,5334,3200.4,,45.5,,2426.97,percent of total billed charges,,,45.3,,2416.3,percent of total billed charges,,,51,,2720.34,percent of total billed charges,,,,,,,,,80,,4267.2,percent of total billed charges,,,61.4,,3275.08,percent of total billed charges,,,57.4,,3061.72,percent of total billed charges,,,81,,4320.54,percent of total billed charges,,,51.5,,2747.01,percent of total billed charges,,,57.6,,3072.38,percent of total billed charges,,,85,,4533.9,percent of total billed charges,,,85,,4533.9,percent of total billed charges,,,49,,2613.66,percent of total billed charges,,,90,,4800.6,percent of total billed charges,,,65,,3467.1,percent of total billed charges,,,80,,4267.2,percent of total billed charges,,,55,,2933.7,percent of total billed charges,,,55,,2933.7,percent of total billed charges,,,65,,3467.1,percent of total billed charges,,,78,,4160.52,percent of total billed charges,,,70,,3733.8,percent of total billed charges,,,,,,,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,,2035.61,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,2035.61,4800.6,
RADIOFREQUENCY ABLTJ NRV NRVTG SI JT W/IMG GDN (64625),64625,CPT,,,,outpatient,,,5334,3200.4,,45.5,,2426.97,percent of total billed charges,,,45.3,,2416.3,percent of total billed charges,,,51,,2720.34,percent of total billed charges,,,,,,,,,80,,4267.2,percent of total billed charges,,,61.4,,3275.08,percent of total billed charges,,,57.4,,3061.72,percent of total billed charges,,,81,,4320.54,percent of total billed charges,,,51.5,,2747.01,percent of total billed charges,,,57.6,,3072.38,percent of total billed charges,,,85,,4533.9,percent of total billed charges,,,85,,4533.9,percent of total billed charges,,,49,,2613.66,percent of total billed charges,,,90,,4800.6,percent of total billed charges,,,65,,3467.1,percent of total billed charges,,,80,,4267.2,percent of total billed charges,,,55,,2933.7,percent of total billed charges,,,55,,2933.7,percent of total billed charges,,,65,,3467.1,percent of total billed charges,,,78,,4160.52,percent of total billed charges,,,70,,3733.8,percent of total billed charges,,,,,,,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,,2035.61,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,2035.61,4800.6,
RADIOFREQUENCY ABLTJ NRV NRVTG SI JT W/IMG GDN Bilateral (64625-50),64625,CPT,,,50,outpatient,,,8002,4801.2,,45.5,,3640.91,percent of total billed charges,,,45.3,,3624.91,percent of total billed charges,,,51,,4081.02,percent of total billed charges,,,,,,,,,80,,6401.6,percent of total billed charges,,,61.4,,4913.23,percent of total billed charges,,,57.4,,4593.15,percent of total billed charges,,,81,,6481.62,percent of total billed charges,,,51.5,,4121.03,percent of total billed charges,,,57.6,,4609.15,percent of total billed charges,,,85,,6801.7,percent of total billed charges,,,85,,6801.7,percent of total billed charges,,,49,,3920.98,percent of total billed charges,,,90,,7201.8,percent of total billed charges,,,65,,5201.3,percent of total billed charges,,,80,,6401.6,percent of total billed charges,,,55,,4401.1,percent of total billed charges,,,55,,4401.1,percent of total billed charges,,,65,,5201.3,percent of total billed charges,,,78,,6241.56,percent of total billed charges,,,70,,5601.4,percent of total billed charges,,,,,,,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,,3053.41,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,3053.41,7201.8,
Destroy Cer/Thor Facet Joint (64633),64633,CPT,,,,outpatient,,,2304,1382.4,,45.5,,1048.32,percent of total billed charges,,,45.3,,1043.71,percent of total billed charges,,,51,,1175.04,percent of total billed charges,,,,,,,,,80,,1843.2,percent of total billed charges,,,61.4,,1414.66,percent of total billed charges,,,57.4,,1322.5,percent of total billed charges,,,81,,1866.24,percent of total billed charges,,,51.5,,1186.56,percent of total billed charges,,,57.6,,1327.1,percent of total billed charges,,,85,,1958.4,percent of total billed charges,,,85,,1958.4,percent of total billed charges,,,49,,1128.96,percent of total billed charges,,,90,,2073.6,percent of total billed charges,,,65,,1497.6,percent of total billed charges,,,80,,1843.2,percent of total billed charges,,,55,,1267.2,percent of total billed charges,,,55,,1267.2,percent of total billed charges,,,65,,1497.6,percent of total billed charges,,,78,,1797.12,percent of total billed charges,,,70,,1612.8,percent of total billed charges,,,,,,,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,,2035.61,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1043.71,2073.6,
"DESTROY CERV/THOR FACET JNT, Bilateral (64633-50)",64633,CPT,,,50,outpatient,,,3456,2073.6,,45.5,,1572.48,percent of total billed charges,,,45.3,,1565.57,percent of total billed charges,,,51,,1762.56,percent of total billed charges,,,,,,,,,80,,2764.8,percent of total billed charges,,,61.4,,2121.98,percent of total billed charges,,,57.4,,1983.74,percent of total billed charges,,,81,,2799.36,percent of total billed charges,,,51.5,,1779.84,percent of total billed charges,,,57.6,,1990.66,percent of total billed charges,,,85,,2937.6,percent of total billed charges,,,85,,2937.6,percent of total billed charges,,,49,,1693.44,percent of total billed charges,,,90,,3110.4,percent of total billed charges,,,65,,2246.4,percent of total billed charges,,,80,,2764.8,percent of total billed charges,,,55,,1900.8,percent of total billed charges,,,55,,1900.8,percent of total billed charges,,,65,,2246.4,percent of total billed charges,,,78,,2695.68,percent of total billed charges,,,70,,2419.2,percent of total billed charges,,,,,,,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,,3053.41,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1565.57,3110.4,
DESTROY C/TH FACET JNT ADDL (64634),64634,CPT,,,,outpatient,,,1354,812.4,,45.5,,616.07,percent of total billed charges,,,45.3,,613.36,percent of total billed charges,,,51,,690.54,percent of total billed charges,,,,,,,,,80,,1083.2,percent of total billed charges,,,61.4,,831.36,percent of total billed charges,,,57.4,,777.2,percent of total billed charges,,,81,,1096.74,percent of total billed charges,,,51.5,,697.31,percent of total billed charges,,,57.6,,779.9,percent of total billed charges,,,85,,1150.9,percent of total billed charges,,,85,,1150.9,percent of total billed charges,,,49,,663.46,percent of total billed charges,,,90,,1218.6,percent of total billed charges,,,65,,880.1,percent of total billed charges,,,80,,1083.2,percent of total billed charges,,,55,,744.7,percent of total billed charges,,,55,,744.7,percent of total billed charges,,,65,,880.1,percent of total billed charges,,,78,,1056.12,percent of total billed charges,,,70,,947.8,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,613.36,1218.6,
"DESTROY C/TH FACET JNT ADDL, Bilateral (64634-50)",64634,CPT,,,50,outpatient,,,2030,1218,,45.5,,923.65,percent of total billed charges,,,45.3,,919.59,percent of total billed charges,,,51,,1035.3,percent of total billed charges,,,,,,,,,80,,1624,percent of total billed charges,,,61.4,,1246.42,percent of total billed charges,,,57.4,,1165.22,percent of total billed charges,,,81,,1644.3,percent of total billed charges,,,51.5,,1045.45,percent of total billed charges,,,57.6,,1169.28,percent of total billed charges,,,85,,1725.5,percent of total billed charges,,,85,,1725.5,percent of total billed charges,,,49,,994.7,percent of total billed charges,,,90,,1827,percent of total billed charges,,,65,,1319.5,percent of total billed charges,,,80,,1624,percent of total billed charges,,,55,,1116.5,percent of total billed charges,,,55,,1116.5,percent of total billed charges,,,65,,1319.5,percent of total billed charges,,,78,,1583.4,percent of total billed charges,,,70,,1421,percent of total billed charges,,,,,,,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,919.59,1827,
Destroy lumb/sac Facet Joint (64635),64635,CPT,,,,outpatient,,,3972,2383.2,,45.5,,1807.26,percent of total billed charges,,,45.3,,1799.32,percent of total billed charges,,,51,,2025.72,percent of total billed charges,,,,,,,,,80,,3177.6,percent of total billed charges,,,61.4,,2438.81,percent of total billed charges,,,57.4,,2279.93,percent of total billed charges,,,81,,3217.32,percent of total billed charges,,,51.5,,2045.58,percent of total billed charges,,,57.6,,2287.87,percent of total billed charges,,,85,,3376.2,percent of total billed charges,,,85,,3376.2,percent of total billed charges,,,49,,1946.28,percent of total billed charges,,,90,,3574.8,percent of total billed charges,,,65,,2581.8,percent of total billed charges,,,80,,3177.6,percent of total billed charges,,,55,,2184.6,percent of total billed charges,,,55,,2184.6,percent of total billed charges,,,65,,2581.8,percent of total billed charges,,,78,,3098.16,percent of total billed charges,,,70,,2780.4,percent of total billed charges,,,,,,,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,,2035.61,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1799.32,3574.8,
"Destroy L/S facet joint, bilateral (64635-50)",64635,CPT,,,50,outpatient,,,5958,3574.8,,45.5,,2710.89,percent of total billed charges,,,45.3,,2698.97,percent of total billed charges,,,51,,3038.58,percent of total billed charges,,,,,,,,,80,,4766.4,percent of total billed charges,,,61.4,,3658.21,percent of total billed charges,,,57.4,,3419.89,percent of total billed charges,,,81,,4825.98,percent of total billed charges,,,51.5,,3068.37,percent of total billed charges,,,57.6,,3431.81,percent of total billed charges,,,85,,5064.3,percent of total billed charges,,,85,,5064.3,percent of total billed charges,,,49,,2919.42,percent of total billed charges,,,90,,5362.2,percent of total billed charges,,,65,,3872.7,percent of total billed charges,,,80,,4766.4,percent of total billed charges,,,55,,3276.9,percent of total billed charges,,,55,,3276.9,percent of total billed charges,,,65,,3872.7,percent of total billed charges,,,78,,4647.24,percent of total billed charges,,,70,,4170.6,percent of total billed charges,,,,,,,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,3053.41,,,,150% of Medicare,,,3053.41,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,2698.97,5362.2,
Destroy L/S Facet joint each add'l (64636),64636,CPT,,,,outpatient,,,2304,1382.4,,45.5,,1048.32,percent of total billed charges,,,45.3,,1043.71,percent of total billed charges,,,51,,1175.04,percent of total billed charges,,,,,,,,,80,,1843.2,percent of total billed charges,,,61.4,,1414.66,percent of total billed charges,,,57.4,,1322.5,percent of total billed charges,,,81,,1866.24,percent of total billed charges,,,51.5,,1186.56,percent of total billed charges,,,57.6,,1327.1,percent of total billed charges,,,85,,1958.4,percent of total billed charges,,,85,,1958.4,percent of total billed charges,,,49,,1128.96,percent of total billed charges,,,90,,2073.6,percent of total billed charges,,,65,,1497.6,percent of total billed charges,,,80,,1843.2,percent of total billed charges,,,55,,1267.2,percent of total billed charges,,,55,,1267.2,percent of total billed charges,,,65,,1497.6,percent of total billed charges,,,78,,1797.12,percent of total billed charges,,,70,,1612.8,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1043.71,2073.6,
"Destroy L/S Facet Joint B, ea add'l (64636-50)",64636,CPT,,,50,outpatient,,,3456,2073.6,,45.5,,1572.48,percent of total billed charges,,,45.3,,1565.57,percent of total billed charges,,,51,,1762.56,percent of total billed charges,,,,,,,,,80,,2764.8,percent of total billed charges,,,61.4,,2121.98,percent of total billed charges,,,57.4,,1983.74,percent of total billed charges,,,81,,2799.36,percent of total billed charges,,,51.5,,1779.84,percent of total billed charges,,,57.6,,1990.66,percent of total billed charges,,,85,,2937.6,percent of total billed charges,,,85,,2937.6,percent of total billed charges,,,49,,1693.44,percent of total billed charges,,,90,,3110.4,percent of total billed charges,,,65,,2246.4,percent of total billed charges,,,80,,2764.8,percent of total billed charges,,,55,,1900.8,percent of total billed charges,,,55,,1900.8,percent of total billed charges,,,65,,2246.4,percent of total billed charges,,,78,,2695.68,percent of total billed charges,,,70,,2419.2,percent of total billed charges,,,,,,,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1565.57,3110.4,
CC ONLY - Nerve Destruction Other Peripheral or Branch Charge (64640),64640,CPT,,,,outpatient,,,3242,1945.2,,45.5,,1475.11,percent of total billed charges,,,45.3,,1468.63,percent of total billed charges,,,51,,1653.42,percent of total billed charges,,,,,,,,,80,,2593.6,percent of total billed charges,,,61.4,,1990.59,percent of total billed charges,,,57.4,,1860.91,percent of total billed charges,,,81,,2626.02,percent of total billed charges,,,51.5,,1669.63,percent of total billed charges,,,57.6,,1867.39,percent of total billed charges,,,85,,2755.7,percent of total billed charges,,,85,,2755.7,percent of total billed charges,,,49,,1588.58,percent of total billed charges,,,90,,2917.8,percent of total billed charges,,,65,,2107.3,percent of total billed charges,,,80,,2593.6,percent of total billed charges,,,55,,1783.1,percent of total billed charges,,,55,,1783.1,percent of total billed charges,,,65,,2107.3,percent of total billed charges,,,78,,2528.76,percent of total billed charges,,,70,,2269.4,percent of total billed charges,,,,,,,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,,928.06,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,928.06,2917.8,
Nerve Destruction Other Peripheral or Branch Charge (64640),64640,CPT,,,,outpatient,,,3242,1945.2,,45.5,,1475.11,percent of total billed charges,,,45.3,,1468.63,percent of total billed charges,,,51,,1653.42,percent of total billed charges,,,,,,,,,80,,2593.6,percent of total billed charges,,,61.4,,1990.59,percent of total billed charges,,,57.4,,1860.91,percent of total billed charges,,,81,,2626.02,percent of total billed charges,,,51.5,,1669.63,percent of total billed charges,,,57.6,,1867.39,percent of total billed charges,,,85,,2755.7,percent of total billed charges,,,85,,2755.7,percent of total billed charges,,,49,,1588.58,percent of total billed charges,,,90,,2917.8,percent of total billed charges,,,65,,2107.3,percent of total billed charges,,,80,,2593.6,percent of total billed charges,,,55,,1783.1,percent of total billed charges,,,55,,1783.1,percent of total billed charges,,,65,,2107.3,percent of total billed charges,,,78,,2528.76,percent of total billed charges,,,70,,2269.4,percent of total billed charges,,,,,,,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,928.06,,,,100% of Medicare,,,928.06,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,928.06,2917.8,
Nerve Destruction Other Peripheral or Branch Charge BIlateral (64640),64640,CPT,,,50,outpatient,,,4863,2917.8,,45.5,,2212.67,percent of total billed charges,,,45.3,,2202.94,percent of total billed charges,,,51,,2480.13,percent of total billed charges,,,,,,,,,80,,3890.4,percent of total billed charges,,,61.4,,2985.88,percent of total billed charges,,,57.4,,2791.36,percent of total billed charges,,,81,,3939.03,percent of total billed charges,,,51.5,,2504.45,percent of total billed charges,,,57.6,,2801.09,percent of total billed charges,,,85,,4133.55,percent of total billed charges,,,85,,4133.55,percent of total billed charges,,,49,,2382.87,percent of total billed charges,,,90,,4376.7,percent of total billed charges,,,65,,3160.95,percent of total billed charges,,,80,,3890.4,percent of total billed charges,,,55,,2674.65,percent of total billed charges,,,55,,2674.65,percent of total billed charges,,,65,,3160.95,percent of total billed charges,,,78,,3793.14,percent of total billed charges,,,70,,3404.1,percent of total billed charges,,,,,,,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,1392.08,,,,150% of Medicare,,,1392.08,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1392.08,4376.7,
CHEMODENERV TRUNK MUSC 1-5 (64646),64646,CPT,,,,outpatient,,,1454,872.4,,45.5,,661.57,percent of total billed charges,,,45.3,,658.66,percent of total billed charges,,,51,,741.54,percent of total billed charges,,,,,,,,,80,,1163.2,percent of total billed charges,,,61.4,,892.76,percent of total billed charges,,,57.4,,834.6,percent of total billed charges,,,81,,1177.74,percent of total billed charges,,,51.5,,748.81,percent of total billed charges,,,57.6,,837.5,percent of total billed charges,,,85,,1235.9,percent of total billed charges,,,85,,1235.9,percent of total billed charges,,,49,,712.46,percent of total billed charges,,,90,,1308.6,percent of total billed charges,,,65,,945.1,percent of total billed charges,,,80,,1163.2,percent of total billed charges,,,55,,799.7,percent of total billed charges,,,55,,799.7,percent of total billed charges,,,65,,945.1,percent of total billed charges,,,78,,1134.12,percent of total billed charges,,,70,,1017.8,percent of total billed charges,,,,,,,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,,721.9,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,658.66,1308.6,
CHEMODENERV TRUNK MUSC 6/> (64647),64647,CPT,,,,outpatient,,,1840,1104,,45.5,,837.2,percent of total billed charges,,,45.3,,833.52,percent of total billed charges,,,51,,938.4,percent of total billed charges,,,,,,,,,80,,1472,percent of total billed charges,,,61.4,,1129.76,percent of total billed charges,,,57.4,,1056.16,percent of total billed charges,,,81,,1490.4,percent of total billed charges,,,51.5,,947.6,percent of total billed charges,,,57.6,,1059.84,percent of total billed charges,,,85,,1564,percent of total billed charges,,,85,,1564,percent of total billed charges,,,49,,901.6,percent of total billed charges,,,90,,1656,percent of total billed charges,,,65,,1196,percent of total billed charges,,,80,,1472,percent of total billed charges,,,55,,1012,percent of total billed charges,,,55,,1012,percent of total billed charges,,,65,,1196,percent of total billed charges,,,78,,1435.2,percent of total billed charges,,,70,,1288,percent of total billed charges,,,,,,,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,721.9,,,,100% of Medicare,,,721.9,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,721.9,1656,
CHEMODENERV ECCRINE GLANDS OTHER AREAS (64653),64653,CPT,,,,outpatient,,,862,517.2,,45.5,,392.21,percent of total billed charges,,,45.3,,390.49,percent of total billed charges,,,51,,439.62,percent of total billed charges,,,,,,,,,80,,689.6,percent of total billed charges,,,61.4,,529.27,percent of total billed charges,,,57.4,,494.79,percent of total billed charges,,,81,,698.22,percent of total billed charges,,,51.5,,443.93,percent of total billed charges,,,57.6,,496.51,percent of total billed charges,,,85,,732.7,percent of total billed charges,,,85,,732.7,percent of total billed charges,,,49,,422.38,percent of total billed charges,,,90,,775.8,percent of total billed charges,,,65,,560.3,percent of total billed charges,,,80,,689.6,percent of total billed charges,,,55,,474.1,percent of total billed charges,,,55,,474.1,percent of total billed charges,,,65,,560.3,percent of total billed charges,,,78,,672.36,percent of total billed charges,,,70,,603.4,percent of total billed charges,,,,,,,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,,307.71,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,307.71,775.8,
Neuroplasty; ulnar nerve,64718,CPT,,,,outpatient,,,6635,3981,,45.5,,3018.93,percent of total billed charges,,,45.3,,3005.66,percent of total billed charges,,,51,,3383.85,percent of total billed charges,,,,,,,,,80,,5308,percent of total billed charges,,,61.4,,4073.89,percent of total billed charges,,,57.4,,3808.49,percent of total billed charges,,,81,,5374.35,percent of total billed charges,,,51.5,,3417.03,percent of total billed charges,,,57.6,,3821.76,percent of total billed charges,,,85,,5639.75,percent of total billed charges,,,85,,5639.75,percent of total billed charges,,,49,,3251.15,percent of total billed charges,,,90,,5971.5,percent of total billed charges,,,65,,4312.75,percent of total billed charges,,,80,,5308,percent of total billed charges,,,55,,3649.25,percent of total billed charges,,,55,,3649.25,percent of total billed charges,,,65,,4312.75,percent of total billed charges,,,78,,5175.3,percent of total billed charges,,,70,,4644.5,percent of total billed charges,,,,,,,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,,2035.61,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,2035.61,5971.5,
"UNLISTED CODE, PELVIC FLOOR INJ (64999)",64999,CPT,,,,outpatient,,,2160,1296,,45.5,,982.8,percent of total billed charges,,,45.3,,978.48,percent of total billed charges,,,51,,1101.6,percent of total billed charges,,,,,,,,,80,,1728,percent of total billed charges,,,61.4,,1326.24,percent of total billed charges,,,57.4,,1239.84,percent of total billed charges,,,81,,1749.6,percent of total billed charges,,,51.5,,1112.4,percent of total billed charges,,,57.6,,1244.16,percent of total billed charges,,,85,,1836,percent of total billed charges,,,85,,1836,percent of total billed charges,,,49,,1058.4,percent of total billed charges,,,90,,1944,percent of total billed charges,,,65,,1404,percent of total billed charges,,,80,,1728,percent of total billed charges,,,55,,1188,percent of total billed charges,,,55,,1188,percent of total billed charges,,,65,,1404,percent of total billed charges,,,78,,1684.8,percent of total billed charges,,,70,,1512,percent of total billed charges,,,,,,,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,,307.71,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,307.71,1944,
OPP Ganglion Impar Block 64999,64999,CPT,,,,outpatient,,,3936,2361.6,,45.5,,1790.88,percent of total billed charges,,,45.3,,1783.01,percent of total billed charges,,,51,,2007.36,percent of total billed charges,,,,,,,,,80,,3148.8,percent of total billed charges,,,61.4,,2416.7,percent of total billed charges,,,57.4,,2259.26,percent of total billed charges,,,81,,3188.16,percent of total billed charges,,,51.5,,2027.04,percent of total billed charges,,,57.6,,2267.14,percent of total billed charges,,,85,,3345.6,percent of total billed charges,,,85,,3345.6,percent of total billed charges,,,49,,1928.64,percent of total billed charges,,,90,,3542.4,percent of total billed charges,,,65,,2558.4,percent of total billed charges,,,80,,3148.8,percent of total billed charges,,,55,,2164.8,percent of total billed charges,,,55,,2164.8,percent of total billed charges,,,65,,2558.4,percent of total billed charges,,,78,,3070.08,percent of total billed charges,,,70,,2755.2,percent of total billed charges,,,,,,,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,,307.71,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,307.71,3542.4,
"Unlisted Procedure, Nervous System",64999,CPT,,,,outpatient,,,3936,2361.6,,45.5,,1790.88,percent of total billed charges,,,45.3,,1783.01,percent of total billed charges,,,51,,2007.36,percent of total billed charges,,,,,,,,,80,,3148.8,percent of total billed charges,,,61.4,,2416.7,percent of total billed charges,,,57.4,,2259.26,percent of total billed charges,,,81,,3188.16,percent of total billed charges,,,51.5,,2027.04,percent of total billed charges,,,57.6,,2267.14,percent of total billed charges,,,85,,3345.6,percent of total billed charges,,,85,,3345.6,percent of total billed charges,,,49,,1928.64,percent of total billed charges,,,90,,3542.4,percent of total billed charges,,,65,,2558.4,percent of total billed charges,,,80,,3148.8,percent of total billed charges,,,55,,2164.8,percent of total billed charges,,,55,,2164.8,percent of total billed charges,,,65,,2558.4,percent of total billed charges,,,78,,3070.08,percent of total billed charges,,,70,,2755.2,percent of total billed charges,,,,,,,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,307.71,,,,100% of Medicare,,,307.71,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,307.71,3542.4,
Removal Impacted Ceruman,69210,CPT,,,,outpatient,,,296,177.6,,45.5,,134.68,percent of total billed charges,,,45.3,,134.09,percent of total billed charges,,,51,,150.96,percent of total billed charges,,,,,,,,,80,,236.8,percent of total billed charges,,,61.4,,181.74,percent of total billed charges,,,57.4,,169.9,percent of total billed charges,,,81,,239.76,percent of total billed charges,,,51.5,,152.44,percent of total billed charges,,,57.6,,170.5,percent of total billed charges,,,85,,251.6,percent of total billed charges,,,85,,251.6,percent of total billed charges,,,49,,145.04,percent of total billed charges,,,90,,266.4,percent of total billed charges,,,65,,192.4,percent of total billed charges,,,80,,236.8,percent of total billed charges,,,55,,162.8,percent of total billed charges,,,55,,162.8,percent of total billed charges,,,65,,192.4,percent of total billed charges,,,78,,230.88,percent of total billed charges,,,70,,207.2,percent of total billed charges,,,,,,,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,,61.92,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,61.92,266.4,
XR Mandible Partial Less Than 4 Views,70100,CPT,,,,both,,,587,352.2,,45.5,,267.09,percent of total billed charges,,,45.3,,265.91,percent of total billed charges,,,51,,299.37,percent of total billed charges,,,,,,,,,80,,469.6,percent of total billed charges,,,61.4,,360.42,percent of total billed charges,,,57.4,,336.94,percent of total billed charges,,,81,,475.47,percent of total billed charges,,,51.5,,302.31,percent of total billed charges,,365,,,,fee schedule,,,85,,498.95,percent of total billed charges,,,85,,498.95,percent of total billed charges,,,49,,287.63,percent of total billed charges,,,90,,528.3,percent of total billed charges,,,65,,381.55,percent of total billed charges,,,80,,469.6,percent of total billed charges,,,55,,322.85,percent of total billed charges,,,55,,322.85,percent of total billed charges,,,65,,381.55,percent of total billed charges,,,78,,457.86,percent of total billed charges,,,70,,410.9,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,528.3,
XR Mandible Complete Minimum 4 Views,70110,CPT,,,,both,,,609,365.4,,45.5,,277.1,percent of total billed charges,,,45.3,,275.88,percent of total billed charges,,,51,,310.59,percent of total billed charges,,,,,,,,,80,,487.2,percent of total billed charges,,,61.4,,373.93,percent of total billed charges,,,57.4,,349.57,percent of total billed charges,,,81,,493.29,percent of total billed charges,,,51.5,,313.64,percent of total billed charges,,365,,,,fee schedule,,,85,,517.65,percent of total billed charges,,,85,,517.65,percent of total billed charges,,,49,,298.41,percent of total billed charges,,,90,,548.1,percent of total billed charges,,,65,,395.85,percent of total billed charges,,,80,,487.2,percent of total billed charges,,,55,,334.95,percent of total billed charges,,,55,,334.95,percent of total billed charges,,,65,,395.85,percent of total billed charges,,,78,,475.02,percent of total billed charges,,,70,,426.3,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,548.1,
XR Mastoids Complete Left,70130,CPT,,,LT,both,,,450,270,,45.5,,204.75,percent of total billed charges,,,45.3,,203.85,percent of total billed charges,,,51,,229.5,percent of total billed charges,,,,,,,,,80,,360,percent of total billed charges,,,61.4,,276.3,percent of total billed charges,,,57.4,,258.3,percent of total billed charges,,,81,,364.5,percent of total billed charges,,,51.5,,231.75,percent of total billed charges,,365,,,,fee schedule,,,85,,382.5,percent of total billed charges,,,85,,382.5,percent of total billed charges,,,49,,220.5,percent of total billed charges,,,90,,405,percent of total billed charges,,,65,,292.5,percent of total billed charges,,,80,,360,percent of total billed charges,,,55,,247.5,percent of total billed charges,,,55,,247.5,percent of total billed charges,,,65,,292.5,percent of total billed charges,,,78,,351,percent of total billed charges,,,70,,315,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,405,
XR Mastoids Complete Right,70130,CPT,,,RT,both,,,450,270,,45.5,,204.75,percent of total billed charges,,,45.3,,203.85,percent of total billed charges,,,51,,229.5,percent of total billed charges,,,,,,,,,80,,360,percent of total billed charges,,,61.4,,276.3,percent of total billed charges,,,57.4,,258.3,percent of total billed charges,,,81,,364.5,percent of total billed charges,,,51.5,,231.75,percent of total billed charges,,365,,,,fee schedule,,,85,,382.5,percent of total billed charges,,,85,,382.5,percent of total billed charges,,,49,,220.5,percent of total billed charges,,,90,,405,percent of total billed charges,,,65,,292.5,percent of total billed charges,,,80,,360,percent of total billed charges,,,55,,247.5,percent of total billed charges,,,55,,247.5,percent of total billed charges,,,65,,292.5,percent of total billed charges,,,78,,351,percent of total billed charges,,,70,,315,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,405,
XR Zygomas,70140,CPT,,,,both,,,529,317.4,,45.5,,240.7,percent of total billed charges,,,45.3,,239.64,percent of total billed charges,,,51,,269.79,percent of total billed charges,,,,,,,,,80,,423.2,percent of total billed charges,,,61.4,,324.81,percent of total billed charges,,,57.4,,303.65,percent of total billed charges,,,81,,428.49,percent of total billed charges,,,51.5,,272.44,percent of total billed charges,,365,,,,fee schedule,,,85,,449.65,percent of total billed charges,,,85,,449.65,percent of total billed charges,,,49,,259.21,percent of total billed charges,,,90,,476.1,percent of total billed charges,,,65,,343.85,percent of total billed charges,,,80,,423.2,percent of total billed charges,,,55,,290.95,percent of total billed charges,,,55,,290.95,percent of total billed charges,,,65,,343.85,percent of total billed charges,,,78,,412.62,percent of total billed charges,,,70,,370.3,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,476.1,
XR Facial Bones Minimum 3 Views,70150,CPT,,,,both,,,960,576,,45.5,,436.8,percent of total billed charges,,,45.3,,434.88,percent of total billed charges,,,51,,489.6,percent of total billed charges,,,,,,,,,80,,768,percent of total billed charges,,,61.4,,589.44,percent of total billed charges,,,57.4,,551.04,percent of total billed charges,,,81,,777.6,percent of total billed charges,,,51.5,,494.4,percent of total billed charges,,365,,,,fee schedule,,,85,,816,percent of total billed charges,,,85,,816,percent of total billed charges,,,49,,470.4,percent of total billed charges,,,90,,864,percent of total billed charges,,,65,,624,percent of total billed charges,,,80,,768,percent of total billed charges,,,55,,528,percent of total billed charges,,,55,,528,percent of total billed charges,,,65,,624,percent of total billed charges,,,78,,748.8,percent of total billed charges,,,70,,672,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,864,
XR Nasal Bones Minimum 3 Views,70160,CPT,,,,both,,,388,232.8,,45.5,,176.54,percent of total billed charges,,,45.3,,175.76,percent of total billed charges,,,51,,197.88,percent of total billed charges,,,,,,,,,80,,310.4,percent of total billed charges,,,61.4,,238.23,percent of total billed charges,,,57.4,,222.71,percent of total billed charges,,,81,,314.28,percent of total billed charges,,,51.5,,199.82,percent of total billed charges,,365,,,,fee schedule,,,85,,329.8,percent of total billed charges,,,85,,329.8,percent of total billed charges,,,49,,190.12,percent of total billed charges,,,90,,349.2,percent of total billed charges,,,65,,252.2,percent of total billed charges,,,80,,310.4,percent of total billed charges,,,55,,213.4,percent of total billed charges,,,55,,213.4,percent of total billed charges,,,65,,252.2,percent of total billed charges,,,78,,302.64,percent of total billed charges,,,70,,271.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,365,
XR Optic Foramina Left,70190,CPT,,,LT,both,,,341,204.6,,45.5,,155.16,percent of total billed charges,,,45.3,,154.47,percent of total billed charges,,,51,,173.91,percent of total billed charges,,,,,,,,,80,,272.8,percent of total billed charges,,,61.4,,209.37,percent of total billed charges,,,57.4,,195.73,percent of total billed charges,,,81,,276.21,percent of total billed charges,,,51.5,,175.62,percent of total billed charges,,365,,,,fee schedule,,,85,,289.85,percent of total billed charges,,,85,,289.85,percent of total billed charges,,,49,,167.09,percent of total billed charges,,,90,,306.9,percent of total billed charges,,,65,,221.65,percent of total billed charges,,,80,,272.8,percent of total billed charges,,,55,,187.55,percent of total billed charges,,,55,,187.55,percent of total billed charges,,,65,,221.65,percent of total billed charges,,,78,,265.98,percent of total billed charges,,,70,,238.7,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,365,
XR Optic Foramina Right,70190,CPT,,,RT,both,,,341,204.6,,45.5,,155.16,percent of total billed charges,,,45.3,,154.47,percent of total billed charges,,,51,,173.91,percent of total billed charges,,,,,,,,,80,,272.8,percent of total billed charges,,,61.4,,209.37,percent of total billed charges,,,57.4,,195.73,percent of total billed charges,,,81,,276.21,percent of total billed charges,,,51.5,,175.62,percent of total billed charges,,365,,,,fee schedule,,,85,,289.85,percent of total billed charges,,,85,,289.85,percent of total billed charges,,,49,,167.09,percent of total billed charges,,,90,,306.9,percent of total billed charges,,,65,,221.65,percent of total billed charges,,,80,,272.8,percent of total billed charges,,,55,,187.55,percent of total billed charges,,,55,,187.55,percent of total billed charges,,,65,,221.65,percent of total billed charges,,,78,,265.98,percent of total billed charges,,,70,,238.7,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,365,
XR Orbits Complete Left,70200,CPT,,,LT,both,,,954,572.4,,45.5,,434.07,percent of total billed charges,,,45.3,,432.16,percent of total billed charges,,,51,,486.54,percent of total billed charges,,,,,,,,,80,,763.2,percent of total billed charges,,,61.4,,585.76,percent of total billed charges,,,57.4,,547.6,percent of total billed charges,,,81,,772.74,percent of total billed charges,,,51.5,,491.31,percent of total billed charges,,365,,,,fee schedule,,,85,,810.9,percent of total billed charges,,,85,,810.9,percent of total billed charges,,,49,,467.46,percent of total billed charges,,,90,,858.6,percent of total billed charges,,,65,,620.1,percent of total billed charges,,,80,,763.2,percent of total billed charges,,,55,,524.7,percent of total billed charges,,,55,,524.7,percent of total billed charges,,,65,,620.1,percent of total billed charges,,,78,,744.12,percent of total billed charges,,,70,,667.8,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,858.6,
XR Orbits Complete Right,70200,CPT,,,RT,both,,,954,572.4,,45.5,,434.07,percent of total billed charges,,,45.3,,432.16,percent of total billed charges,,,51,,486.54,percent of total billed charges,,,,,,,,,80,,763.2,percent of total billed charges,,,61.4,,585.76,percent of total billed charges,,,57.4,,547.6,percent of total billed charges,,,81,,772.74,percent of total billed charges,,,51.5,,491.31,percent of total billed charges,,365,,,,fee schedule,,,85,,810.9,percent of total billed charges,,,85,,810.9,percent of total billed charges,,,49,,467.46,percent of total billed charges,,,90,,858.6,percent of total billed charges,,,65,,620.1,percent of total billed charges,,,80,,763.2,percent of total billed charges,,,55,,524.7,percent of total billed charges,,,55,,524.7,percent of total billed charges,,,65,,620.1,percent of total billed charges,,,78,,744.12,percent of total billed charges,,,70,,667.8,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,858.6,
XR Sinuses Paranasal < 3 Views,70210,CPT,,,,both,,,318,190.8,,45.5,,144.69,percent of total billed charges,,,45.3,,144.05,percent of total billed charges,,,51,,162.18,percent of total billed charges,,,,,,,,,80,,254.4,percent of total billed charges,,,61.4,,195.25,percent of total billed charges,,,57.4,,182.53,percent of total billed charges,,,81,,257.58,percent of total billed charges,,,51.5,,163.77,percent of total billed charges,,365,,,,fee schedule,,,85,,270.3,percent of total billed charges,,,85,,270.3,percent of total billed charges,,,49,,155.82,percent of total billed charges,,,90,,286.2,percent of total billed charges,,,65,,206.7,percent of total billed charges,,,80,,254.4,percent of total billed charges,,,55,,174.9,percent of total billed charges,,,55,,174.9,percent of total billed charges,,,65,,206.7,percent of total billed charges,,,78,,248.04,percent of total billed charges,,,70,,222.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,365,
XR Sinuses Paranasal Complete,70220,CPT,,,,both,,,954,572.4,,45.5,,434.07,percent of total billed charges,,,45.3,,432.16,percent of total billed charges,,,51,,486.54,percent of total billed charges,,,,,,,,,80,,763.2,percent of total billed charges,,,61.4,,585.76,percent of total billed charges,,,57.4,,547.6,percent of total billed charges,,,81,,772.74,percent of total billed charges,,,51.5,,491.31,percent of total billed charges,,365,,,,fee schedule,,,85,,810.9,percent of total billed charges,,,85,,810.9,percent of total billed charges,,,49,,467.46,percent of total billed charges,,,90,,858.6,percent of total billed charges,,,65,,620.1,percent of total billed charges,,,80,,763.2,percent of total billed charges,,,55,,524.7,percent of total billed charges,,,55,,524.7,percent of total billed charges,,,65,,620.1,percent of total billed charges,,,78,,744.12,percent of total billed charges,,,70,,667.8,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,858.6,
XR Skull < 4 Views,70250,CPT,,,,both,,,619,371.4,,45.5,,281.65,percent of total billed charges,,,45.3,,280.41,percent of total billed charges,,,51,,315.69,percent of total billed charges,,,,,,,,,80,,495.2,percent of total billed charges,,,61.4,,380.07,percent of total billed charges,,,57.4,,355.31,percent of total billed charges,,,81,,501.39,percent of total billed charges,,,51.5,,318.79,percent of total billed charges,,365,,,,fee schedule,,,85,,526.15,percent of total billed charges,,,85,,526.15,percent of total billed charges,,,49,,303.31,percent of total billed charges,,,90,,557.1,percent of total billed charges,,,65,,402.35,percent of total billed charges,,,80,,495.2,percent of total billed charges,,,55,,340.45,percent of total billed charges,,,55,,340.45,percent of total billed charges,,,65,,402.35,percent of total billed charges,,,78,,482.82,percent of total billed charges,,,70,,433.3,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,557.1,
XR Skull Complete,70260,CPT,,,,both,,,816,489.6,,45.5,,371.28,percent of total billed charges,,,45.3,,369.65,percent of total billed charges,,,51,,416.16,percent of total billed charges,,,,,,,,,80,,652.8,percent of total billed charges,,,61.4,,501.02,percent of total billed charges,,,57.4,,468.38,percent of total billed charges,,,81,,660.96,percent of total billed charges,,,51.5,,420.24,percent of total billed charges,,365,,,,fee schedule,,,85,,693.6,percent of total billed charges,,,85,,693.6,percent of total billed charges,,,49,,399.84,percent of total billed charges,,,90,,734.4,percent of total billed charges,,,65,,530.4,percent of total billed charges,,,80,,652.8,percent of total billed charges,,,55,,448.8,percent of total billed charges,,,55,,448.8,percent of total billed charges,,,65,,530.4,percent of total billed charges,,,78,,636.48,percent of total billed charges,,,70,,571.2,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,734.4,
XR TMJ Open and Closed Bilateral,70330,CPT,,,,both,,,719,431.4,,45.5,,327.15,percent of total billed charges,,,45.3,,325.71,percent of total billed charges,,,51,,366.69,percent of total billed charges,,,,,,,,,80,,575.2,percent of total billed charges,,,61.4,,441.47,percent of total billed charges,,,57.4,,412.71,percent of total billed charges,,,81,,582.39,percent of total billed charges,,,51.5,,370.29,percent of total billed charges,,365,,,,fee schedule,,,85,,611.15,percent of total billed charges,,,85,,611.15,percent of total billed charges,,,49,,352.31,percent of total billed charges,,,90,,647.1,percent of total billed charges,,,65,,467.35,percent of total billed charges,,,80,,575.2,percent of total billed charges,,,55,,395.45,percent of total billed charges,,,55,,395.45,percent of total billed charges,,,65,,467.35,percent of total billed charges,,,78,,560.82,percent of total billed charges,,,70,,503.3,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,647.1,
MRI TMJ W&W/O Contrast,70336,CPT,,,,both,,,2930,1758,,45.5,,1333.15,percent of total billed charges,,,45.3,,1327.29,percent of total billed charges,,,51,,1494.3,percent of total billed charges,,,,,,,,,80,,2344,percent of total billed charges,,,61.4,,1799.02,percent of total billed charges,,,57.4,,1681.82,percent of total billed charges,,,81,,2373.3,percent of total billed charges,,,51.5,,1508.95,percent of total billed charges,,,57.6,,1687.68,percent of total billed charges,,,85,,2490.5,percent of total billed charges,,,85,,2490.5,percent of total billed charges,,,49,,1435.7,percent of total billed charges,,,90,,2637,percent of total billed charges,,,65,,1904.5,percent of total billed charges,,,80,,2344,percent of total billed charges,,,55,,1611.5,percent of total billed charges,,,55,,1611.5,percent of total billed charges,,,65,,1904.5,percent of total billed charges,,,78,,2285.4,percent of total billed charges,,,70,,2051,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,251.97,2637,
MRI TMJ W/O Contrast,70336,CPT,,,,both,,,2930,1758,,45.5,,1333.15,percent of total billed charges,,,45.3,,1327.29,percent of total billed charges,,,51,,1494.3,percent of total billed charges,,,,,,,,,80,,2344,percent of total billed charges,,,61.4,,1799.02,percent of total billed charges,,,57.4,,1681.82,percent of total billed charges,,,81,,2373.3,percent of total billed charges,,,51.5,,1508.95,percent of total billed charges,,,57.6,,1687.68,percent of total billed charges,,,85,,2490.5,percent of total billed charges,,,85,,2490.5,percent of total billed charges,,,49,,1435.7,percent of total billed charges,,,90,,2637,percent of total billed charges,,,65,,1904.5,percent of total billed charges,,,80,,2344,percent of total billed charges,,,55,,1611.5,percent of total billed charges,,,55,,1611.5,percent of total billed charges,,,65,,1904.5,percent of total billed charges,,,78,,2285.4,percent of total billed charges,,,70,,2051,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,251.97,2637,
XR Neck Soft Tissue,70360,CPT,,,,both,,,425,255,,45.5,,193.38,percent of total billed charges,,,45.3,,192.53,percent of total billed charges,,,51,,216.75,percent of total billed charges,,,,,,,,,80,,340,percent of total billed charges,,,61.4,,260.95,percent of total billed charges,,,57.4,,243.95,percent of total billed charges,,,81,,344.25,percent of total billed charges,,,51.5,,218.88,percent of total billed charges,,365,,,,fee schedule,,,85,,361.25,percent of total billed charges,,,85,,361.25,percent of total billed charges,,,49,,208.25,percent of total billed charges,,,90,,382.5,percent of total billed charges,,,65,,276.25,percent of total billed charges,,,80,,340,percent of total billed charges,,,55,,233.75,percent of total billed charges,,,55,,233.75,percent of total billed charges,,,65,,276.25,percent of total billed charges,,,78,,331.5,percent of total billed charges,,,70,,297.5,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,382.5,
CT Head/Brain W/O Contrast,70450,CPT,,,,both,,,3452,2071.2,,45.5,,1570.66,percent of total billed charges,,,45.3,,1563.76,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,2761.6,percent of total billed charges,,,61.4,,2119.53,percent of total billed charges,,,57.4,,1981.45,percent of total billed charges,,,81,,2796.12,percent of total billed charges,,735,,,,fee schedule,,,57.6,,1988.35,percent of total billed charges,,,85,,2934.2,percent of total billed charges,,,85,,2934.2,percent of total billed charges,,,49,,1691.48,percent of total billed charges,,,90,,3106.8,percent of total billed charges,,,65,,2243.8,percent of total billed charges,,,80,,2761.6,percent of total billed charges,,,55,,1898.6,percent of total billed charges,,,55,,1898.6,percent of total billed charges,,,65,,2243.8,percent of total billed charges,,,78,,2692.56,percent of total billed charges,,,70,,2416.4,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,3106.8,
CT Head/Brain W/ Contrast,70460,CPT,,,,both,,,4013,2407.8,,45.5,,1825.92,percent of total billed charges,,,45.3,,1817.89,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3210.4,percent of total billed charges,,,61.4,,2463.98,percent of total billed charges,,,57.4,,2303.46,percent of total billed charges,,,81,,3250.53,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2311.49,percent of total billed charges,,,85,,3411.05,percent of total billed charges,,,85,,3411.05,percent of total billed charges,,,49,,1966.37,percent of total billed charges,,,90,,3611.7,percent of total billed charges,,,65,,2608.45,percent of total billed charges,,,80,,3210.4,percent of total billed charges,,,55,,2207.15,percent of total billed charges,,,55,,2207.15,percent of total billed charges,,,65,,2608.45,percent of total billed charges,,,78,,3130.14,percent of total billed charges,,,70,,2809.1,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,185.57,3611.7,
CT Head/Brain W/&W/O Contrast,70470,CPT,,,,both,,,4828,2896.8,,45.5,,2196.74,percent of total billed charges,,,45.3,,2187.08,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3862.4,percent of total billed charges,,,61.4,,2964.39,percent of total billed charges,,,57.4,,2771.27,percent of total billed charges,,,81,,3910.68,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2780.93,percent of total billed charges,,,85,,4103.8,percent of total billed charges,,,85,,4103.8,percent of total billed charges,,,49,,2365.72,percent of total billed charges,,,90,,4345.2,percent of total billed charges,,,65,,3138.2,percent of total billed charges,,,80,,3862.4,percent of total billed charges,,,55,,2655.4,percent of total billed charges,,,55,,2655.4,percent of total billed charges,,,65,,3138.2,percent of total billed charges,,,78,,3765.84,percent of total billed charges,,,70,,3379.6,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,185.57,4345.2,
CT Orbit/Ear/Fossa W/O Contrast,70480,CPT,,,,both,,,4177,2506.2,,45.5,,1900.54,percent of total billed charges,,,45.3,,1892.18,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3341.6,percent of total billed charges,,,61.4,,2564.68,percent of total billed charges,,,57.4,,2397.6,percent of total billed charges,,,81,,3383.37,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2405.95,percent of total billed charges,,,85,,3550.45,percent of total billed charges,,,85,,3550.45,percent of total billed charges,,,49,,2046.73,percent of total billed charges,,,90,,3759.3,percent of total billed charges,,,65,,2715.05,percent of total billed charges,,,80,,3341.6,percent of total billed charges,,,55,,2297.35,percent of total billed charges,,,55,,2297.35,percent of total billed charges,,,65,,2715.05,percent of total billed charges,,,78,,3258.06,percent of total billed charges,,,70,,2923.9,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,3759.3,
CT Temp Bone W/O Contrast-70480,70480,CPT,,,,both,,,4177,2506.2,,45.5,,1900.54,percent of total billed charges,,,45.3,,1892.18,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3341.6,percent of total billed charges,,,61.4,,2564.68,percent of total billed charges,,,57.4,,2397.6,percent of total billed charges,,,81,,3383.37,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2405.95,percent of total billed charges,,,85,,3550.45,percent of total billed charges,,,85,,3550.45,percent of total billed charges,,,49,,2046.73,percent of total billed charges,,,90,,3759.3,percent of total billed charges,,,65,,2715.05,percent of total billed charges,,,80,,3341.6,percent of total billed charges,,,55,,2297.35,percent of total billed charges,,,55,,2297.35,percent of total billed charges,,,65,,2715.05,percent of total billed charges,,,78,,3258.06,percent of total billed charges,,,70,,2923.9,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,3759.3,
CT Orbit/Ear/Fossa W/ Contrast,70481,CPT,,,,both,,,4385,2631,,45.5,,1995.18,percent of total billed charges,,,45.3,,1986.41,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3508,percent of total billed charges,,,61.4,,2692.39,percent of total billed charges,,,57.4,,2516.99,percent of total billed charges,,,81,,3551.85,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2525.76,percent of total billed charges,,,85,,3727.25,percent of total billed charges,,,85,,3727.25,percent of total billed charges,,,49,,2148.65,percent of total billed charges,,,90,,3946.5,percent of total billed charges,,,65,,2850.25,percent of total billed charges,,,80,,3508,percent of total billed charges,,,55,,2411.75,percent of total billed charges,,,55,,2411.75,percent of total billed charges,,,65,,2850.25,percent of total billed charges,,,78,,3420.3,percent of total billed charges,,,70,,3069.5,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,185.57,3946.5,
CT Temp Bone W/ Contrast-70481,70481,CPT,,,,both,,,4385,2631,,45.5,,1995.18,percent of total billed charges,,,45.3,,1986.41,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3508,percent of total billed charges,,,61.4,,2692.39,percent of total billed charges,,,57.4,,2516.99,percent of total billed charges,,,81,,3551.85,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2525.76,percent of total billed charges,,,85,,3727.25,percent of total billed charges,,,85,,3727.25,percent of total billed charges,,,49,,2148.65,percent of total billed charges,,,90,,3946.5,percent of total billed charges,,,65,,2850.25,percent of total billed charges,,,80,,3508,percent of total billed charges,,,55,,2411.75,percent of total billed charges,,,55,,2411.75,percent of total billed charges,,,65,,2850.25,percent of total billed charges,,,78,,3420.3,percent of total billed charges,,,70,,3069.5,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,185.57,3946.5,
CT Orbit/Ear/Fossa W/&W/O Contrast,70482,CPT,,,,both,,,4481,2688.6,,45.5,,2038.86,percent of total billed charges,,,45.3,,2029.89,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3584.8,percent of total billed charges,,,61.4,,2751.33,percent of total billed charges,,,57.4,,2572.09,percent of total billed charges,,,81,,3629.61,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2581.06,percent of total billed charges,,,85,,3808.85,percent of total billed charges,,,85,,3808.85,percent of total billed charges,,,49,,2195.69,percent of total billed charges,,,90,,4032.9,percent of total billed charges,,,65,,2912.65,percent of total billed charges,,,80,,3584.8,percent of total billed charges,,,55,,2464.55,percent of total billed charges,,,55,,2464.55,percent of total billed charges,,,65,,2912.65,percent of total billed charges,,,78,,3495.18,percent of total billed charges,,,70,,3136.7,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,185.57,4032.9,
CT Temp Bone W&W/O Cont-70482,70482,CPT,,,,both,,,4481,2688.6,,45.5,,2038.86,percent of total billed charges,,,45.3,,2029.89,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3584.8,percent of total billed charges,,,61.4,,2751.33,percent of total billed charges,,,57.4,,2572.09,percent of total billed charges,,,81,,3629.61,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2581.06,percent of total billed charges,,,85,,3808.85,percent of total billed charges,,,85,,3808.85,percent of total billed charges,,,49,,2195.69,percent of total billed charges,,,90,,4032.9,percent of total billed charges,,,65,,2912.65,percent of total billed charges,,,80,,3584.8,percent of total billed charges,,,55,,2464.55,percent of total billed charges,,,55,,2464.55,percent of total billed charges,,,65,,2912.65,percent of total billed charges,,,78,,3495.18,percent of total billed charges,,,70,,3136.7,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,185.57,4032.9,
CT Maxillofacial W/O Contrast,70486,CPT,,,,both,,,3625,2175,,45.5,,1649.38,percent of total billed charges,,,45.3,,1642.13,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,2900,percent of total billed charges,,,61.4,,2225.75,percent of total billed charges,,,57.4,,2080.75,percent of total billed charges,,,81,,2936.25,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2088,percent of total billed charges,,,85,,3081.25,percent of total billed charges,,,85,,3081.25,percent of total billed charges,,,49,,1776.25,percent of total billed charges,,,90,,3262.5,percent of total billed charges,,,65,,2356.25,percent of total billed charges,,,80,,2900,percent of total billed charges,,,55,,1993.75,percent of total billed charges,,,55,,1993.75,percent of total billed charges,,,65,,2356.25,percent of total billed charges,,,78,,2827.5,percent of total billed charges,,,70,,2537.5,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,3262.5,
CT Maxillofacial W/ Contrast,70487,CPT,,,,both,,,4141,2484.6,,45.5,,1884.16,percent of total billed charges,,,45.3,,1875.87,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3312.8,percent of total billed charges,,,61.4,,2542.57,percent of total billed charges,,,57.4,,2376.93,percent of total billed charges,,,81,,3354.21,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2385.22,percent of total billed charges,,,85,,3519.85,percent of total billed charges,,,85,,3519.85,percent of total billed charges,,,49,,2029.09,percent of total billed charges,,,90,,3726.9,percent of total billed charges,,,65,,2691.65,percent of total billed charges,,,80,,3312.8,percent of total billed charges,,,55,,2277.55,percent of total billed charges,,,55,,2277.55,percent of total billed charges,,,65,,2691.65,percent of total billed charges,,,78,,3229.98,percent of total billed charges,,,70,,2898.7,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,185.57,3726.9,
CT Maxillofacial W/&W/O Contrast,70488,CPT,,,,both,,,4481,2688.6,,45.5,,2038.86,percent of total billed charges,,,45.3,,2029.89,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3584.8,percent of total billed charges,,,61.4,,2751.33,percent of total billed charges,,,57.4,,2572.09,percent of total billed charges,,,81,,3629.61,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2581.06,percent of total billed charges,,,85,,3808.85,percent of total billed charges,,,85,,3808.85,percent of total billed charges,,,49,,2195.69,percent of total billed charges,,,90,,4032.9,percent of total billed charges,,,65,,2912.65,percent of total billed charges,,,80,,3584.8,percent of total billed charges,,,55,,2464.55,percent of total billed charges,,,55,,2464.55,percent of total billed charges,,,65,,2912.65,percent of total billed charges,,,78,,3495.18,percent of total billed charges,,,70,,3136.7,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,185.57,4032.9,
CT Soft Tissue Neck W/O Contrast,70490,CPT,,,,both,,,3455,2073,,45.5,,1572.03,percent of total billed charges,,,45.3,,1565.12,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,2764,percent of total billed charges,,,61.4,,2121.37,percent of total billed charges,,,57.4,,1983.17,percent of total billed charges,,,81,,2798.55,percent of total billed charges,,735,,,,fee schedule,,,57.6,,1990.08,percent of total billed charges,,,85,,2936.75,percent of total billed charges,,,85,,2936.75,percent of total billed charges,,,49,,1692.95,percent of total billed charges,,,90,,3109.5,percent of total billed charges,,,65,,2245.75,percent of total billed charges,,,80,,2764,percent of total billed charges,,,55,,1900.25,percent of total billed charges,,,55,,1900.25,percent of total billed charges,,,65,,2245.75,percent of total billed charges,,,78,,2694.9,percent of total billed charges,,,70,,2418.5,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,3109.5,
CT Soft Tissue Neck W/ Contrast,70491,CPT,,,,both,,,4094,2456.4,,45.5,,1862.77,percent of total billed charges,,,45.3,,1854.58,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3275.2,percent of total billed charges,,,61.4,,2513.72,percent of total billed charges,,,57.4,,2349.96,percent of total billed charges,,,81,,3316.14,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2358.14,percent of total billed charges,,,85,,3479.9,percent of total billed charges,,,85,,3479.9,percent of total billed charges,,,49,,2006.06,percent of total billed charges,,,90,,3684.6,percent of total billed charges,,,65,,2661.1,percent of total billed charges,,,80,,3275.2,percent of total billed charges,,,55,,2251.7,percent of total billed charges,,,55,,2251.7,percent of total billed charges,,,65,,2661.1,percent of total billed charges,,,78,,3193.32,percent of total billed charges,,,70,,2865.8,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,185.57,3684.6,
CT Soft Tissue Neck W/&W/O Contrast,70492,CPT,,,,both,,,4822,2893.2,,45.5,,2194.01,percent of total billed charges,,,45.3,,2184.37,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3857.6,percent of total billed charges,,,61.4,,2960.71,percent of total billed charges,,,57.4,,2767.83,percent of total billed charges,,,81,,3905.82,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2777.47,percent of total billed charges,,,85,,4098.7,percent of total billed charges,,,85,,4098.7,percent of total billed charges,,,49,,2362.78,percent of total billed charges,,,90,,4339.8,percent of total billed charges,,,65,,3134.3,percent of total billed charges,,,80,,3857.6,percent of total billed charges,,,55,,2652.1,percent of total billed charges,,,55,,2652.1,percent of total billed charges,,,65,,3134.3,percent of total billed charges,,,78,,3761.16,percent of total billed charges,,,70,,3375.4,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,185.57,4339.8,
CT Angiography Head,70496,CPT,,,,both,,,4598,2758.8,,45.5,,2092.09,percent of total billed charges,,,45.3,,2082.89,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3678.4,percent of total billed charges,,,61.4,,2823.17,percent of total billed charges,,,57.4,,2639.25,percent of total billed charges,,,81,,3724.38,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2648.45,percent of total billed charges,,,85,,3908.3,percent of total billed charges,,,85,,3908.3,percent of total billed charges,,,49,,2253.02,percent of total billed charges,,,90,,4138.2,percent of total billed charges,,,65,,2988.7,percent of total billed charges,,,80,,3678.4,percent of total billed charges,,,55,,2528.9,percent of total billed charges,,,55,,2528.9,percent of total billed charges,,,65,,2988.7,percent of total billed charges,,,78,,3586.44,percent of total billed charges,,,70,,3218.6,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,185.57,4138.2,
CT Angiography Neck,70498,CPT,,,,both,,,4675,2805,,45.5,,2127.13,percent of total billed charges,,,45.3,,2117.78,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3740,percent of total billed charges,,,61.4,,2870.45,percent of total billed charges,,,57.4,,2683.45,percent of total billed charges,,,81,,3786.75,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2692.8,percent of total billed charges,,,85,,3973.75,percent of total billed charges,,,85,,3973.75,percent of total billed charges,,,49,,2290.75,percent of total billed charges,,,90,,4207.5,percent of total billed charges,,,65,,3038.75,percent of total billed charges,,,80,,3740,percent of total billed charges,,,55,,2571.25,percent of total billed charges,,,55,,2571.25,percent of total billed charges,,,65,,3038.75,percent of total billed charges,,,78,,3646.5,percent of total billed charges,,,70,,3272.5,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,185.57,4207.5,
MRI Pituitary W&W/O Contrast,70553,CPT,,,,both,,,7498,4498.8,,45.5,,3411.59,percent of total billed charges,,,45.3,,3396.59,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,5998.4,percent of total billed charges,,,61.4,,4603.77,percent of total billed charges,,,57.4,,4303.85,percent of total billed charges,,,81,,6073.38,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,4318.85,percent of total billed charges,,,85,,6373.3,percent of total billed charges,,,85,,6373.3,percent of total billed charges,,,49,,3674.02,percent of total billed charges,,,90,,6748.2,percent of total billed charges,,,65,,4873.7,percent of total billed charges,,,80,,5998.4,percent of total billed charges,,,55,,4123.9,percent of total billed charges,,,55,,4123.9,percent of total billed charges,,,65,,4873.7,percent of total billed charges,,,78,,5848.44,percent of total billed charges,,,70,,5248.6,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,372.28,6748.2,
XR Chest 1 View,71045,CPT,,,,both,,,500,300,,45.5,,227.5,percent of total billed charges,,,45.3,,226.5,percent of total billed charges,,,51,,255,percent of total billed charges,,,,,,,,,80,,400,percent of total billed charges,,,61.4,,307,percent of total billed charges,,,57.4,,287,percent of total billed charges,,,81,,405,percent of total billed charges,,,51.5,,257.5,percent of total billed charges,,365,,,,fee schedule,,,85,,425,percent of total billed charges,,,85,,425,percent of total billed charges,,,49,,245,percent of total billed charges,,,90,,450,percent of total billed charges,,,65,,325,percent of total billed charges,,,80,,400,percent of total billed charges,,,55,,275,percent of total billed charges,,,55,,275,percent of total billed charges,,,65,,325,percent of total billed charges,,,78,,390,percent of total billed charges,,,70,,350,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,450,
XR Chest 2 View,71046,CPT,,,,both,,,793,475.8,,45.5,,360.82,percent of total billed charges,,,45.3,,359.23,percent of total billed charges,,,51,,404.43,percent of total billed charges,,,,,,,,,80,,634.4,percent of total billed charges,,,61.4,,486.9,percent of total billed charges,,,57.4,,455.18,percent of total billed charges,,,81,,642.33,percent of total billed charges,,,51.5,,408.4,percent of total billed charges,,365,,,,fee schedule,,,85,,674.05,percent of total billed charges,,,85,,674.05,percent of total billed charges,,,49,,388.57,percent of total billed charges,,,90,,713.7,percent of total billed charges,,,65,,515.45,percent of total billed charges,,,80,,634.4,percent of total billed charges,,,55,,436.15,percent of total billed charges,,,55,,436.15,percent of total billed charges,,,65,,515.45,percent of total billed charges,,,78,,618.54,percent of total billed charges,,,70,,555.1,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,713.7,
XR Chest 3 View,71047,CPT,,,,both,,,810,486,,45.5,,368.55,percent of total billed charges,,,45.3,,366.93,percent of total billed charges,,,51,,413.1,percent of total billed charges,,,,,,,,,80,,648,percent of total billed charges,,,61.4,,497.34,percent of total billed charges,,,57.4,,464.94,percent of total billed charges,,,81,,656.1,percent of total billed charges,,,51.5,,417.15,percent of total billed charges,,365,,,,fee schedule,,,85,,688.5,percent of total billed charges,,,85,,688.5,percent of total billed charges,,,49,,396.9,percent of total billed charges,,,90,,729,percent of total billed charges,,,65,,526.5,percent of total billed charges,,,80,,648,percent of total billed charges,,,55,,445.5,percent of total billed charges,,,55,,445.5,percent of total billed charges,,,65,,526.5,percent of total billed charges,,,78,,631.8,percent of total billed charges,,,70,,567,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,729,
XR Chest 4 View,71048,CPT,,,,both,,,850,510,,45.5,,386.75,percent of total billed charges,,,45.3,,385.05,percent of total billed charges,,,51,,433.5,percent of total billed charges,,,,,,,,,80,,680,percent of total billed charges,,,61.4,,521.9,percent of total billed charges,,,57.4,,487.9,percent of total billed charges,,,81,,688.5,percent of total billed charges,,,51.5,,437.75,percent of total billed charges,,365,,,,fee schedule,,,85,,722.5,percent of total billed charges,,,85,,722.5,percent of total billed charges,,,49,,416.5,percent of total billed charges,,,90,,765,percent of total billed charges,,,65,,552.5,percent of total billed charges,,,80,,680,percent of total billed charges,,,55,,467.5,percent of total billed charges,,,55,,467.5,percent of total billed charges,,,65,,552.5,percent of total billed charges,,,78,,663,percent of total billed charges,,,70,,595,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,765,
XR Ribs 2 Views Left,71100,CPT,,,LT,both,,,464,278.4,,45.5,,211.12,percent of total billed charges,,,45.3,,210.19,percent of total billed charges,,,51,,236.64,percent of total billed charges,,,,,,,,,80,,371.2,percent of total billed charges,,,61.4,,284.9,percent of total billed charges,,,57.4,,266.34,percent of total billed charges,,,81,,375.84,percent of total billed charges,,,51.5,,238.96,percent of total billed charges,,365,,,,fee schedule,,,85,,394.4,percent of total billed charges,,,85,,394.4,percent of total billed charges,,,49,,227.36,percent of total billed charges,,,90,,417.6,percent of total billed charges,,,65,,301.6,percent of total billed charges,,,80,,371.2,percent of total billed charges,,,55,,255.2,percent of total billed charges,,,55,,255.2,percent of total billed charges,,,65,,301.6,percent of total billed charges,,,78,,361.92,percent of total billed charges,,,70,,324.8,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,417.6,
XR Ribs 2 Views Right,71100,CPT,,,RT,both,,,464,278.4,,45.5,,211.12,percent of total billed charges,,,45.3,,210.19,percent of total billed charges,,,51,,236.64,percent of total billed charges,,,,,,,,,80,,371.2,percent of total billed charges,,,61.4,,284.9,percent of total billed charges,,,57.4,,266.34,percent of total billed charges,,,81,,375.84,percent of total billed charges,,,51.5,,238.96,percent of total billed charges,,365,,,,fee schedule,,,85,,394.4,percent of total billed charges,,,85,,394.4,percent of total billed charges,,,49,,227.36,percent of total billed charges,,,90,,417.6,percent of total billed charges,,,65,,301.6,percent of total billed charges,,,80,,371.2,percent of total billed charges,,,55,,255.2,percent of total billed charges,,,55,,255.2,percent of total billed charges,,,65,,301.6,percent of total billed charges,,,78,,361.92,percent of total billed charges,,,70,,324.8,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,417.6,
XR Ribs w/ PA Chest Left,71101,CPT,,,LT,both,,,837,502.2,,45.5,,380.84,percent of total billed charges,,,45.3,,379.16,percent of total billed charges,,,51,,426.87,percent of total billed charges,,,,,,,,,80,,669.6,percent of total billed charges,,,61.4,,513.92,percent of total billed charges,,,57.4,,480.44,percent of total billed charges,,,81,,677.97,percent of total billed charges,,,51.5,,431.06,percent of total billed charges,,365,,,,fee schedule,,,85,,711.45,percent of total billed charges,,,85,,711.45,percent of total billed charges,,,49,,410.13,percent of total billed charges,,,90,,753.3,percent of total billed charges,,,65,,544.05,percent of total billed charges,,,80,,669.6,percent of total billed charges,,,55,,460.35,percent of total billed charges,,,55,,460.35,percent of total billed charges,,,65,,544.05,percent of total billed charges,,,78,,652.86,percent of total billed charges,,,70,,585.9,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,753.3,
XR Ribs w/ PA Chest Right,71101,CPT,,,RT,both,,,837,502.2,,45.5,,380.84,percent of total billed charges,,,45.3,,379.16,percent of total billed charges,,,51,,426.87,percent of total billed charges,,,,,,,,,80,,669.6,percent of total billed charges,,,61.4,,513.92,percent of total billed charges,,,57.4,,480.44,percent of total billed charges,,,81,,677.97,percent of total billed charges,,,51.5,,431.06,percent of total billed charges,,365,,,,fee schedule,,,85,,711.45,percent of total billed charges,,,85,,711.45,percent of total billed charges,,,49,,410.13,percent of total billed charges,,,90,,753.3,percent of total billed charges,,,65,,544.05,percent of total billed charges,,,80,,669.6,percent of total billed charges,,,55,,460.35,percent of total billed charges,,,55,,460.35,percent of total billed charges,,,65,,544.05,percent of total billed charges,,,78,,652.86,percent of total billed charges,,,70,,585.9,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,753.3,
XR Ribs w/ PA Chest Bilateral,71111,CPT,,,50,both,,,1333,799.8,,45.5,,606.52,percent of total billed charges,,,45.3,,603.85,percent of total billed charges,,,51,,679.83,percent of total billed charges,,,,,,,,,80,,1066.4,percent of total billed charges,,,61.4,,818.46,percent of total billed charges,,,57.4,,765.14,percent of total billed charges,,,81,,1079.73,percent of total billed charges,,,51.5,,686.5,percent of total billed charges,,365,,,,fee schedule,,,85,,1133.05,percent of total billed charges,,,85,,1133.05,percent of total billed charges,,,49,,653.17,percent of total billed charges,,,90,,1199.7,percent of total billed charges,,,65,,866.45,percent of total billed charges,,,80,,1066.4,percent of total billed charges,,,55,,733.15,percent of total billed charges,,,55,,733.15,percent of total billed charges,,,65,,866.45,percent of total billed charges,,,78,,1039.74,percent of total billed charges,,,70,,933.1,percent of total billed charges,,,,,,,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,,166.28,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,166.28,1199.7,
XR Sternum Minimum 2 Views,71120,CPT,,,,both,,,436,261.6,,45.5,,198.38,percent of total billed charges,,,45.3,,197.51,percent of total billed charges,,,51,,222.36,percent of total billed charges,,,,,,,,,80,,348.8,percent of total billed charges,,,61.4,,267.7,percent of total billed charges,,,57.4,,250.26,percent of total billed charges,,,81,,353.16,percent of total billed charges,,,51.5,,224.54,percent of total billed charges,,365,,,,fee schedule,,,85,,370.6,percent of total billed charges,,,85,,370.6,percent of total billed charges,,,49,,213.64,percent of total billed charges,,,90,,392.4,percent of total billed charges,,,65,,283.4,percent of total billed charges,,,80,,348.8,percent of total billed charges,,,55,,239.8,percent of total billed charges,,,55,,239.8,percent of total billed charges,,,65,,283.4,percent of total billed charges,,,78,,340.08,percent of total billed charges,,,70,,305.2,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,392.4,
XR Sternoclavicular Joint(s),71130,CPT,,,,both,,,292,175.2,,45.5,,132.86,percent of total billed charges,,,45.3,,132.28,percent of total billed charges,,,51,,148.92,percent of total billed charges,,,,,,,,,80,,233.6,percent of total billed charges,,,61.4,,179.29,percent of total billed charges,,,57.4,,167.61,percent of total billed charges,,,81,,236.52,percent of total billed charges,,735,,,,fee schedule,,365,,,,fee schedule,,,85,,248.2,percent of total billed charges,,,85,,248.2,percent of total billed charges,,,49,,143.08,percent of total billed charges,,,90,,262.8,percent of total billed charges,,,65,,189.8,percent of total billed charges,,,80,,233.6,percent of total billed charges,,,55,,160.6,percent of total billed charges,,,55,,160.6,percent of total billed charges,,,65,,189.8,percent of total billed charges,,,78,,227.76,percent of total billed charges,,,70,,204.4,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,735,
CT Thorax W/O Con Lung CA Screen,71250,CPT,,,,both,,,3647,2188.2,,45.5,,1659.39,percent of total billed charges,,,45.3,,1652.09,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,2917.6,percent of total billed charges,,,61.4,,2239.26,percent of total billed charges,,,57.4,,2093.38,percent of total billed charges,,,81,,2954.07,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2100.67,percent of total billed charges,,,85,,3099.95,percent of total billed charges,,,85,,3099.95,percent of total billed charges,,,49,,1787.03,percent of total billed charges,,,90,,3282.3,percent of total billed charges,,,65,,2370.55,percent of total billed charges,,,80,,2917.6,percent of total billed charges,,,55,,2005.85,percent of total billed charges,,,55,,2005.85,percent of total billed charges,,,65,,2370.55,percent of total billed charges,,,78,,2844.66,percent of total billed charges,,,70,,2552.9,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,3282.3,
CT Thorax W/O Con Lung CA Screen:Ep,71250,CPT,,,,both,,,3647,2188.2,,45.5,,1659.39,percent of total billed charges,,,45.3,,1652.09,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,2917.6,percent of total billed charges,,,61.4,,2239.26,percent of total billed charges,,,57.4,,2093.38,percent of total billed charges,,,81,,2954.07,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2100.67,percent of total billed charges,,,85,,3099.95,percent of total billed charges,,,85,,3099.95,percent of total billed charges,,,49,,1787.03,percent of total billed charges,,,90,,3282.3,percent of total billed charges,,,65,,2370.55,percent of total billed charges,,,80,,2917.6,percent of total billed charges,,,55,,2005.85,percent of total billed charges,,,55,,2005.85,percent of total billed charges,,,65,,2370.55,percent of total billed charges,,,78,,2844.66,percent of total billed charges,,,70,,2552.9,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,3282.3,
CT Thorax W/O Contrast-71250,71250,CPT,,,,both,,,3647,2188.2,,45.5,,1659.39,percent of total billed charges,,,45.3,,1652.09,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,2917.6,percent of total billed charges,,,61.4,,2239.26,percent of total billed charges,,,57.4,,2093.38,percent of total billed charges,,,81,,2954.07,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2100.67,percent of total billed charges,,,85,,3099.95,percent of total billed charges,,,85,,3099.95,percent of total billed charges,,,49,,1787.03,percent of total billed charges,,,90,,3282.3,percent of total billed charges,,,65,,2370.55,percent of total billed charges,,,80,,2917.6,percent of total billed charges,,,55,,2005.85,percent of total billed charges,,,55,,2005.85,percent of total billed charges,,,65,,2370.55,percent of total billed charges,,,78,,2844.66,percent of total billed charges,,,70,,2552.9,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,3282.3,
CT Thorax W/ Contrast,71260,CPT,,,,both,,,4262,2557.2,,45.5,,1939.21,percent of total billed charges,,,45.3,,1930.69,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3409.6,percent of total billed charges,,,61.4,,2616.87,percent of total billed charges,,,57.4,,2446.39,percent of total billed charges,,,81,,3452.22,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2454.91,percent of total billed charges,,,85,,3622.7,percent of total billed charges,,,85,,3622.7,percent of total billed charges,,,49,,2088.38,percent of total billed charges,,,90,,3835.8,percent of total billed charges,,,65,,2770.3,percent of total billed charges,,,80,,3409.6,percent of total billed charges,,,55,,2344.1,percent of total billed charges,,,55,,2344.1,percent of total billed charges,,,65,,2770.3,percent of total billed charges,,,78,,3324.36,percent of total billed charges,,,70,,2983.4,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,185.57,3835.8,
CT Thorax W/&W/O Contrast,71270,CPT,,,,both,,,5283,3169.8,,45.5,,2403.77,percent of total billed charges,,,45.3,,2393.2,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,4226.4,percent of total billed charges,,,61.4,,3243.76,percent of total billed charges,,,57.4,,3032.44,percent of total billed charges,,,81,,4279.23,percent of total billed charges,,735,,,,fee schedule,,,57.6,,3043.01,percent of total billed charges,,,85,,4490.55,percent of total billed charges,,,85,,4490.55,percent of total billed charges,,,49,,2588.67,percent of total billed charges,,,90,,4754.7,percent of total billed charges,,,65,,3433.95,percent of total billed charges,,,80,,4226.4,percent of total billed charges,,,55,,2905.65,percent of total billed charges,,,55,,2905.65,percent of total billed charges,,,65,,3433.95,percent of total billed charges,,,78,,4120.74,percent of total billed charges,,,70,,3698.1,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,185.57,4754.7,
CT Angiography Chest,71275,CPT,,,,both,,,5240,3144,,45.5,,2384.2,percent of total billed charges,,,45.3,,2373.72,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,4192,percent of total billed charges,,,61.4,,3217.36,percent of total billed charges,,,57.4,,3007.76,percent of total billed charges,,,81,,4244.4,percent of total billed charges,,735,,,,fee schedule,,,57.6,,3018.24,percent of total billed charges,,,85,,4454,percent of total billed charges,,,85,,4454,percent of total billed charges,,,49,,2567.6,percent of total billed charges,,,90,,4716,percent of total billed charges,,,65,,3406,percent of total billed charges,,,80,,4192,percent of total billed charges,,,55,,2882,percent of total billed charges,,,55,,2882,percent of total billed charges,,,65,,3406,percent of total billed charges,,,78,,4087.2,percent of total billed charges,,,70,,3668,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,185.57,4716,
CT Angiography Chest PE-71275,71275,CPT,,,,both,,,5240,3144,,45.5,,2384.2,percent of total billed charges,,,45.3,,2373.72,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,4192,percent of total billed charges,,,61.4,,3217.36,percent of total billed charges,,,57.4,,3007.76,percent of total billed charges,,,81,,4244.4,percent of total billed charges,,735,,,,fee schedule,,,57.6,,3018.24,percent of total billed charges,,,85,,4454,percent of total billed charges,,,85,,4454,percent of total billed charges,,,49,,2567.6,percent of total billed charges,,,90,,4716,percent of total billed charges,,,65,,3406,percent of total billed charges,,,80,,4192,percent of total billed charges,,,55,,2882,percent of total billed charges,,,55,,2882,percent of total billed charges,,,65,,3406,percent of total billed charges,,,78,,4087.2,percent of total billed charges,,,70,,3668,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,185.57,4716,
MRA Chest  W/O Contrast,71555,CPT,C8910,HCPCS,,both,,,4798,2878.8,,45.5,,2183.09,percent of total billed charges,,,45.3,,2173.49,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3838.4,percent of total billed charges,,,61.4,,2945.97,percent of total billed charges,,,57.4,,2754.05,percent of total billed charges,,,81,,3886.38,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2763.65,percent of total billed charges,,,85,,4078.3,percent of total billed charges,,,85,,4078.3,percent of total billed charges,,,49,,2351.02,percent of total billed charges,,,90,,4318.2,percent of total billed charges,,,65,,3118.7,percent of total billed charges,,,80,,3838.4,percent of total billed charges,,,55,,2638.9,percent of total billed charges,,,55,,2638.9,percent of total billed charges,,,65,,3118.7,percent of total billed charges,,,78,,3742.44,percent of total billed charges,,,70,,3358.6,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,251.97,4318.2,
MRA Chest W/ Contrast,71555,CPT,C8909,HCPCS,,both,,,5039,3023.4,,45.5,,2292.75,percent of total billed charges,,,45.3,,2282.67,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4031.2,percent of total billed charges,,,61.4,,3093.95,percent of total billed charges,,,57.4,,2892.39,percent of total billed charges,,,81,,4081.59,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2902.46,percent of total billed charges,,,85,,4283.15,percent of total billed charges,,,85,,4283.15,percent of total billed charges,,,49,,2469.11,percent of total billed charges,,,90,,4535.1,percent of total billed charges,,,65,,3275.35,percent of total billed charges,,,80,,4031.2,percent of total billed charges,,,55,,2771.45,percent of total billed charges,,,55,,2771.45,percent of total billed charges,,,65,,3275.35,percent of total billed charges,,,78,,3930.42,percent of total billed charges,,,70,,3527.3,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,372.28,4535.1,
XR Spine 1 View Cervical,72020,CPT,,,,both,,,524,314.4,,45.5,,238.42,percent of total billed charges,,,45.3,,237.37,percent of total billed charges,,,51,,267.24,percent of total billed charges,,,,,,,,,80,,419.2,percent of total billed charges,,,61.4,,321.74,percent of total billed charges,,,57.4,,300.78,percent of total billed charges,,,81,,424.44,percent of total billed charges,,,51.5,,269.86,percent of total billed charges,,365,,,,fee schedule,,,85,,445.4,percent of total billed charges,,,85,,445.4,percent of total billed charges,,,49,,256.76,percent of total billed charges,,,90,,471.6,percent of total billed charges,,,65,,340.6,percent of total billed charges,,,80,,419.2,percent of total billed charges,,,55,,288.2,percent of total billed charges,,,55,,288.2,percent of total billed charges,,,65,,340.6,percent of total billed charges,,,78,,408.72,percent of total billed charges,,,70,,366.8,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,471.6,
XR Spine 1 View Lumbar,72020,CPT,,,,both,,,524,314.4,,45.5,,238.42,percent of total billed charges,,,45.3,,237.37,percent of total billed charges,,,51,,267.24,percent of total billed charges,,,,,,,,,80,,419.2,percent of total billed charges,,,61.4,,321.74,percent of total billed charges,,,57.4,,300.78,percent of total billed charges,,,81,,424.44,percent of total billed charges,,,51.5,,269.86,percent of total billed charges,,365,,,,fee schedule,,,85,,445.4,percent of total billed charges,,,85,,445.4,percent of total billed charges,,,49,,256.76,percent of total billed charges,,,90,,471.6,percent of total billed charges,,,65,,340.6,percent of total billed charges,,,80,,419.2,percent of total billed charges,,,55,,288.2,percent of total billed charges,,,55,,288.2,percent of total billed charges,,,65,,340.6,percent of total billed charges,,,78,,408.72,percent of total billed charges,,,70,,366.8,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,471.6,
XR Spine 1 View Thoracic,72020,CPT,,,,both,,,524,314.4,,45.5,,238.42,percent of total billed charges,,,45.3,,237.37,percent of total billed charges,,,51,,267.24,percent of total billed charges,,,,,,,,,80,,419.2,percent of total billed charges,,,61.4,,321.74,percent of total billed charges,,,57.4,,300.78,percent of total billed charges,,,81,,424.44,percent of total billed charges,,,51.5,,269.86,percent of total billed charges,,365,,,,fee schedule,,,85,,445.4,percent of total billed charges,,,85,,445.4,percent of total billed charges,,,49,,256.76,percent of total billed charges,,,90,,471.6,percent of total billed charges,,,65,,340.6,percent of total billed charges,,,80,,419.2,percent of total billed charges,,,55,,288.2,percent of total billed charges,,,55,,288.2,percent of total billed charges,,,65,,340.6,percent of total billed charges,,,78,,408.72,percent of total billed charges,,,70,,366.8,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,471.6,
XR Spine Thoracolumbar AP Only,72020,CPT,,,,both,,,524,314.4,,45.5,,238.42,percent of total billed charges,,,45.3,,237.37,percent of total billed charges,,,51,,267.24,percent of total billed charges,,,,,,,,,80,,419.2,percent of total billed charges,,,61.4,,321.74,percent of total billed charges,,,57.4,,300.78,percent of total billed charges,,,81,,424.44,percent of total billed charges,,,51.5,,269.86,percent of total billed charges,,365,,,,fee schedule,,,85,,445.4,percent of total billed charges,,,85,,445.4,percent of total billed charges,,,49,,256.76,percent of total billed charges,,,90,,471.6,percent of total billed charges,,,65,,340.6,percent of total billed charges,,,80,,419.2,percent of total billed charges,,,55,,288.2,percent of total billed charges,,,55,,288.2,percent of total billed charges,,,65,,340.6,percent of total billed charges,,,78,,408.72,percent of total billed charges,,,70,,366.8,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,471.6,
XR Spine Cervical 2 or 3 Views,72040,CPT,,,,both,,,835,501,,45.5,,379.93,percent of total billed charges,,,45.3,,378.26,percent of total billed charges,,,51,,425.85,percent of total billed charges,,,,,,,,,80,,668,percent of total billed charges,,,61.4,,512.69,percent of total billed charges,,,57.4,,479.29,percent of total billed charges,,,81,,676.35,percent of total billed charges,,,51.5,,430.03,percent of total billed charges,,365,,,,fee schedule,,,85,,709.75,percent of total billed charges,,,85,,709.75,percent of total billed charges,,,49,,409.15,percent of total billed charges,,,90,,751.5,percent of total billed charges,,,65,,542.75,percent of total billed charges,,,80,,668,percent of total billed charges,,,55,,459.25,percent of total billed charges,,,55,,459.25,percent of total billed charges,,,65,,542.75,percent of total billed charges,,,78,,651.3,percent of total billed charges,,,70,,584.5,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,751.5,
XR Spine Cervical Flexion/Extension Only,72040,CPT,,,,both,,,840,504,,45.5,,382.2,percent of total billed charges,,,45.3,,380.52,percent of total billed charges,,,51,,428.4,percent of total billed charges,,,,,,,,,80,,672,percent of total billed charges,,,61.4,,515.76,percent of total billed charges,,,57.4,,482.16,percent of total billed charges,,,81,,680.4,percent of total billed charges,,,51.5,,432.6,percent of total billed charges,,365,,,,fee schedule,,,85,,714,percent of total billed charges,,,85,,714,percent of total billed charges,,,49,,411.6,percent of total billed charges,,,90,,756,percent of total billed charges,,,65,,546,percent of total billed charges,,,80,,672,percent of total billed charges,,,55,,462,percent of total billed charges,,,55,,462,percent of total billed charges,,,65,,546,percent of total billed charges,,,78,,655.2,percent of total billed charges,,,70,,588,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,756,
XR Spine Cervical w/ Obliques,72050,CPT,,,,both,,,617,370.2,,45.5,,280.74,percent of total billed charges,,,45.3,,279.5,percent of total billed charges,,,51,,314.67,percent of total billed charges,,,,,,,,,80,,493.6,percent of total billed charges,,,61.4,,378.84,percent of total billed charges,,,57.4,,354.16,percent of total billed charges,,,81,,499.77,percent of total billed charges,,,51.5,,317.76,percent of total billed charges,,365,,,,fee schedule,,,85,,524.45,percent of total billed charges,,,85,,524.45,percent of total billed charges,,,49,,302.33,percent of total billed charges,,,90,,555.3,percent of total billed charges,,,65,,401.05,percent of total billed charges,,,80,,493.6,percent of total billed charges,,,55,,339.35,percent of total billed charges,,,55,,339.35,percent of total billed charges,,,65,,401.05,percent of total billed charges,,,78,,481.26,percent of total billed charges,,,70,,431.9,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,555.3,
XR Spine Cervical 4 Views,72050,CPT,,,,both,,,860,516,,45.5,,391.3,percent of total billed charges,,,45.3,,389.58,percent of total billed charges,,,51,,438.6,percent of total billed charges,,,,,,,,,80,,688,percent of total billed charges,,,61.4,,528.04,percent of total billed charges,,,57.4,,493.64,percent of total billed charges,,,81,,696.6,percent of total billed charges,,,51.5,,442.9,percent of total billed charges,,365,,,,fee schedule,,,85,,731,percent of total billed charges,,,85,,731,percent of total billed charges,,,49,,421.4,percent of total billed charges,,,90,,774,percent of total billed charges,,,65,,559,percent of total billed charges,,,80,,688,percent of total billed charges,,,55,,473,percent of total billed charges,,,55,,473,percent of total billed charges,,,65,,559,percent of total billed charges,,,78,,670.8,percent of total billed charges,,,70,,602,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,774,
XR Spine Cervical 5 Views,72050,CPT,,,,both,,,860,516,,45.5,,391.3,percent of total billed charges,,,45.3,,389.58,percent of total billed charges,,,51,,438.6,percent of total billed charges,,,,,,,,,80,,688,percent of total billed charges,,,61.4,,528.04,percent of total billed charges,,,57.4,,493.64,percent of total billed charges,,,81,,696.6,percent of total billed charges,,,51.5,,442.9,percent of total billed charges,,365,,,,fee schedule,,,85,,731,percent of total billed charges,,,85,,731,percent of total billed charges,,,49,,421.4,percent of total billed charges,,,90,,774,percent of total billed charges,,,65,,559,percent of total billed charges,,,80,,688,percent of total billed charges,,,55,,473,percent of total billed charges,,,55,,473,percent of total billed charges,,,65,,559,percent of total billed charges,,,78,,670.8,percent of total billed charges,,,70,,602,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,774,
XR Cervical Spine with Flexion/Extension,72052,CPT,,,,both,,,1030,618,,45.5,,468.65,percent of total billed charges,,,45.3,,466.59,percent of total billed charges,,,51,,525.3,percent of total billed charges,,,,,,,,,80,,824,percent of total billed charges,,,61.4,,632.42,percent of total billed charges,,,57.4,,591.22,percent of total billed charges,,,81,,834.3,percent of total billed charges,,,51.5,,530.45,percent of total billed charges,,365,,,,fee schedule,,,85,,875.5,percent of total billed charges,,,85,,875.5,percent of total billed charges,,,49,,504.7,percent of total billed charges,,,90,,927,percent of total billed charges,,,65,,669.5,percent of total billed charges,,,80,,824,percent of total billed charges,,,55,,566.5,percent of total billed charges,,,55,,566.5,percent of total billed charges,,,65,,669.5,percent of total billed charges,,,78,,803.4,percent of total billed charges,,,70,,721,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,927,
XR Spine Thoracic 3 Views,72072,CPT,,,,both,,,858,514.8,,45.5,,390.39,percent of total billed charges,,,45.3,,388.67,percent of total billed charges,,,51,,437.58,percent of total billed charges,,,,,,,,,80,,686.4,percent of total billed charges,,,61.4,,526.81,percent of total billed charges,,,57.4,,492.49,percent of total billed charges,,,81,,694.98,percent of total billed charges,,,51.5,,441.87,percent of total billed charges,,365,,,,fee schedule,,,85,,729.3,percent of total billed charges,,,85,,729.3,percent of total billed charges,,,49,,420.42,percent of total billed charges,,,90,,772.2,percent of total billed charges,,,65,,557.7,percent of total billed charges,,,80,,686.4,percent of total billed charges,,,55,,471.9,percent of total billed charges,,,55,,471.9,percent of total billed charges,,,65,,557.7,percent of total billed charges,,,78,,669.24,percent of total billed charges,,,70,,600.6,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,772.2,
XR Spine Thoracic Flex/Ext,72072,CPT,,,,both,,,858,514.8,,45.5,,390.39,percent of total billed charges,,,45.3,,388.67,percent of total billed charges,,,51,,437.58,percent of total billed charges,,,,,,,,,80,,686.4,percent of total billed charges,,,61.4,,526.81,percent of total billed charges,,,57.4,,492.49,percent of total billed charges,,,81,,694.98,percent of total billed charges,,,51.5,,441.87,percent of total billed charges,,365,,,,fee schedule,,,85,,729.3,percent of total billed charges,,,85,,729.3,percent of total billed charges,,,49,,420.42,percent of total billed charges,,,90,,772.2,percent of total billed charges,,,65,,557.7,percent of total billed charges,,,80,,686.4,percent of total billed charges,,,55,,471.9,percent of total billed charges,,,55,,471.9,percent of total billed charges,,,65,,557.7,percent of total billed charges,,,78,,669.24,percent of total billed charges,,,70,,600.6,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,772.2,
XR Exam Scoliosis 1 View Only,72081,CPT,,,,both,,,355,213,,45.5,,161.53,percent of total billed charges,,,45.3,,160.82,percent of total billed charges,,,51,,181.05,percent of total billed charges,,,,,,,,,80,,284,percent of total billed charges,,,61.4,,217.97,percent of total billed charges,,,57.4,,203.77,percent of total billed charges,,,81,,287.55,percent of total billed charges,,,51.5,,182.83,percent of total billed charges,,365,,,,fee schedule,,,85,,301.75,percent of total billed charges,,,85,,301.75,percent of total billed charges,,,49,,173.95,percent of total billed charges,,,90,,319.5,percent of total billed charges,,,65,,230.75,percent of total billed charges,,,80,,284,percent of total billed charges,,,55,,195.25,percent of total billed charges,,,55,,195.25,percent of total billed charges,,,65,,230.75,percent of total billed charges,,,78,,276.9,percent of total billed charges,,,70,,248.5,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,365,
XR Exam Scoliosis 4 Views,72083,CPT,,,,both,,,970,582,,45.5,,441.35,percent of total billed charges,,,45.3,,439.41,percent of total billed charges,,,51,,494.7,percent of total billed charges,,,,,,,,,80,,776,percent of total billed charges,,,61.4,,595.58,percent of total billed charges,,,57.4,,556.78,percent of total billed charges,,,81,,785.7,percent of total billed charges,,,51.5,,499.55,percent of total billed charges,,365,,,,fee schedule,,,85,,824.5,percent of total billed charges,,,85,,824.5,percent of total billed charges,,,49,,475.3,percent of total billed charges,,,90,,873,percent of total billed charges,,,65,,630.5,percent of total billed charges,,,80,,776,percent of total billed charges,,,55,,533.5,percent of total billed charges,,,55,,533.5,percent of total billed charges,,,65,,630.5,percent of total billed charges,,,78,,756.6,percent of total billed charges,,,70,,679,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,873,
XR Spine Lumbosacral w/ Obliques,72110,CPT,,,,both,,,1071,642.6,,45.5,,487.31,percent of total billed charges,,,45.3,,485.16,percent of total billed charges,,,51,,546.21,percent of total billed charges,,,,,,,,,80,,856.8,percent of total billed charges,,,61.4,,657.59,percent of total billed charges,,,57.4,,614.75,percent of total billed charges,,,81,,867.51,percent of total billed charges,,,51.5,,551.57,percent of total billed charges,,365,,,,fee schedule,,,85,,910.35,percent of total billed charges,,,85,,910.35,percent of total billed charges,,,49,,524.79,percent of total billed charges,,,90,,963.9,percent of total billed charges,,,65,,696.15,percent of total billed charges,,,80,,856.8,percent of total billed charges,,,55,,589.05,percent of total billed charges,,,55,,589.05,percent of total billed charges,,,65,,696.15,percent of total billed charges,,,78,,835.38,percent of total billed charges,,,70,,749.7,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,963.9,
XR Spine Lumbosacral Complete w/ Flex/Ext,72114,CPT,,,,both,,,1168,700.8,,45.5,,531.44,percent of total billed charges,,,45.3,,529.1,percent of total billed charges,,,51,,595.68,percent of total billed charges,,,,,,,,,80,,934.4,percent of total billed charges,,,61.4,,717.15,percent of total billed charges,,,57.4,,670.43,percent of total billed charges,,,81,,946.08,percent of total billed charges,,,51.5,,601.52,percent of total billed charges,,365,,,,fee schedule,,,85,,992.8,percent of total billed charges,,,85,,992.8,percent of total billed charges,,,49,,572.32,percent of total billed charges,,,90,,1051.2,percent of total billed charges,,,65,,759.2,percent of total billed charges,,,80,,934.4,percent of total billed charges,,,55,,642.4,percent of total billed charges,,,55,,642.4,percent of total billed charges,,,65,,759.2,percent of total billed charges,,,78,,911.04,percent of total billed charges,,,70,,817.6,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,1051.2,
CT C-Spine W/O Contrast,72125,CPT,,,,both,,,4113,2467.8,,45.5,,1871.42,percent of total billed charges,,,45.3,,1863.19,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3290.4,percent of total billed charges,,,61.4,,2525.38,percent of total billed charges,,,57.4,,2360.86,percent of total billed charges,,,81,,3331.53,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2369.09,percent of total billed charges,,,85,,3496.05,percent of total billed charges,,,85,,3496.05,percent of total billed charges,,,49,,2015.37,percent of total billed charges,,,90,,3701.7,percent of total billed charges,,,65,,2673.45,percent of total billed charges,,,80,,3290.4,percent of total billed charges,,,55,,2262.15,percent of total billed charges,,,55,,2262.15,percent of total billed charges,,,65,,2673.45,percent of total billed charges,,,78,,3208.14,percent of total billed charges,,,70,,2879.1,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,3701.7,
CT C-Spine W/ Contrast,72126,CPT,,,,both,,,4410,2646,,45.5,,2006.55,percent of total billed charges,,,45.3,,1997.73,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3528,percent of total billed charges,,,61.4,,2707.74,percent of total billed charges,,,57.4,,2531.34,percent of total billed charges,,,81,,3572.1,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2540.16,percent of total billed charges,,,85,,3748.5,percent of total billed charges,,,85,,3748.5,percent of total billed charges,,,49,,2160.9,percent of total billed charges,,,90,,3969,percent of total billed charges,,,65,,2866.5,percent of total billed charges,,,80,,3528,percent of total billed charges,,,55,,2425.5,percent of total billed charges,,,55,,2425.5,percent of total billed charges,,,65,,2866.5,percent of total billed charges,,,78,,3439.8,percent of total billed charges,,,70,,3087,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,372.28,3969,
CT C-Spine W/&W/O Contrast,72127,CPT,,,,both,,,5291,3174.6,,45.5,,2407.41,percent of total billed charges,,,45.3,,2396.82,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,4232.8,percent of total billed charges,,,61.4,,3248.67,percent of total billed charges,,,57.4,,3037.03,percent of total billed charges,,,81,,4285.71,percent of total billed charges,,735,,,,fee schedule,,,57.6,,3047.62,percent of total billed charges,,,85,,4497.35,percent of total billed charges,,,85,,4497.35,percent of total billed charges,,,49,,2592.59,percent of total billed charges,,,90,,4761.9,percent of total billed charges,,,65,,3439.15,percent of total billed charges,,,80,,4232.8,percent of total billed charges,,,55,,2910.05,percent of total billed charges,,,55,,2910.05,percent of total billed charges,,,65,,3439.15,percent of total billed charges,,,78,,4126.98,percent of total billed charges,,,70,,3703.7,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,185.57,4761.9,
CT T-Spine W/O Contrast,72128,CPT,,,,both,,,3765,2259,,45.5,,1713.08,percent of total billed charges,,,45.3,,1705.55,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3012,percent of total billed charges,,,61.4,,2311.71,percent of total billed charges,,,57.4,,2161.11,percent of total billed charges,,,81,,3049.65,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2168.64,percent of total billed charges,,,85,,3200.25,percent of total billed charges,,,85,,3200.25,percent of total billed charges,,,49,,1844.85,percent of total billed charges,,,90,,3388.5,percent of total billed charges,,,65,,2447.25,percent of total billed charges,,,80,,3012,percent of total billed charges,,,55,,2070.75,percent of total billed charges,,,55,,2070.75,percent of total billed charges,,,65,,2447.25,percent of total billed charges,,,78,,2936.7,percent of total billed charges,,,70,,2635.5,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,3388.5,
CT T-Spine W/ Contrast,72129,CPT,,,,both,,,4218,2530.8,,45.5,,1919.19,percent of total billed charges,,,45.3,,1910.75,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3374.4,percent of total billed charges,,,61.4,,2589.85,percent of total billed charges,,,57.4,,2421.13,percent of total billed charges,,,81,,3416.58,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2429.57,percent of total billed charges,,,85,,3585.3,percent of total billed charges,,,85,,3585.3,percent of total billed charges,,,49,,2066.82,percent of total billed charges,,,90,,3796.2,percent of total billed charges,,,65,,2741.7,percent of total billed charges,,,80,,3374.4,percent of total billed charges,,,55,,2319.9,percent of total billed charges,,,55,,2319.9,percent of total billed charges,,,65,,2741.7,percent of total billed charges,,,78,,3290.04,percent of total billed charges,,,70,,2952.6,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,185.57,3796.2,
CT T-Spine W/&W/O Contrast,72130,CPT,,,,both,,,5148,3088.8,,45.5,,2342.34,percent of total billed charges,,,45.3,,2332.04,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,4118.4,percent of total billed charges,,,61.4,,3160.87,percent of total billed charges,,,57.4,,2954.95,percent of total billed charges,,,81,,4169.88,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2965.25,percent of total billed charges,,,85,,4375.8,percent of total billed charges,,,85,,4375.8,percent of total billed charges,,,49,,2522.52,percent of total billed charges,,,90,,4633.2,percent of total billed charges,,,65,,3346.2,percent of total billed charges,,,80,,4118.4,percent of total billed charges,,,55,,2831.4,percent of total billed charges,,,55,,2831.4,percent of total billed charges,,,65,,3346.2,percent of total billed charges,,,78,,4015.44,percent of total billed charges,,,70,,3603.6,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,185.57,4633.2,
CT L-Spine W/O Contrast,72131,CPT,,,,both,,,3925,2355,,45.5,,1785.88,percent of total billed charges,,,45.3,,1778.03,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3140,percent of total billed charges,,,61.4,,2409.95,percent of total billed charges,,,57.4,,2252.95,percent of total billed charges,,,81,,3179.25,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2260.8,percent of total billed charges,,,85,,3336.25,percent of total billed charges,,,85,,3336.25,percent of total billed charges,,,49,,1923.25,percent of total billed charges,,,90,,3532.5,percent of total billed charges,,,65,,2551.25,percent of total billed charges,,,80,,3140,percent of total billed charges,,,55,,2158.75,percent of total billed charges,,,55,,2158.75,percent of total billed charges,,,65,,2551.25,percent of total billed charges,,,78,,3061.5,percent of total billed charges,,,70,,2747.5,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,3532.5,
CT L-Spine W/ Contrast,72132,CPT,,,,both,,,4450,2670,,45.5,,2024.75,percent of total billed charges,,,45.3,,2015.85,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3560,percent of total billed charges,,,61.4,,2732.3,percent of total billed charges,,,57.4,,2554.3,percent of total billed charges,,,81,,3604.5,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2563.2,percent of total billed charges,,,85,,3782.5,percent of total billed charges,,,85,,3782.5,percent of total billed charges,,,49,,2180.5,percent of total billed charges,,,90,,4005,percent of total billed charges,,,65,,2892.5,percent of total billed charges,,,80,,3560,percent of total billed charges,,,55,,2447.5,percent of total billed charges,,,55,,2447.5,percent of total billed charges,,,65,,2892.5,percent of total billed charges,,,78,,3471,percent of total billed charges,,,70,,3115,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,372.28,4005,
CT L-Spine W/&W/O Contrast,72133,CPT,,,,both,,,5924,3554.4,,45.5,,2695.42,percent of total billed charges,,,45.3,,2683.57,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,4739.2,percent of total billed charges,,,61.4,,3637.34,percent of total billed charges,,,57.4,,3400.38,percent of total billed charges,,,81,,4798.44,percent of total billed charges,,735,,,,fee schedule,,,57.6,,3412.22,percent of total billed charges,,,85,,5035.4,percent of total billed charges,,,85,,5035.4,percent of total billed charges,,,49,,2902.76,percent of total billed charges,,,90,,5331.6,percent of total billed charges,,,65,,3850.6,percent of total billed charges,,,80,,4739.2,percent of total billed charges,,,55,,3258.2,percent of total billed charges,,,55,,3258.2,percent of total billed charges,,,65,,3850.6,percent of total billed charges,,,78,,4620.72,percent of total billed charges,,,70,,4146.8,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,185.57,5331.6,
MRA Spinal Canal  W/O Contrast,72159,CPT,C8932,HCPCS,,both,,,2790,1674,,45.5,,1269.45,percent of total billed charges,,,45.3,,1263.87,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,2232,percent of total billed charges,,,61.4,,1713.06,percent of total billed charges,,,57.4,,1601.46,percent of total billed charges,,,81,,2259.9,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,1607.04,percent of total billed charges,,,85,,2371.5,percent of total billed charges,,,85,,2371.5,percent of total billed charges,,,49,,1367.1,percent of total billed charges,,,90,,2511,percent of total billed charges,,,65,,1813.5,percent of total billed charges,,,80,,2232,percent of total billed charges,,,55,,1534.5,percent of total billed charges,,,55,,1534.5,percent of total billed charges,,,65,,1813.5,percent of total billed charges,,,78,,2176.2,percent of total billed charges,,,70,,1953,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,251.97,2511,
MRA Spinal Canal W/ Contrast,72159,CPT,C8931,HCPCS,,both,,,3295,1977,,45.5,,1499.23,percent of total billed charges,,,45.3,,1492.64,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,2636,percent of total billed charges,,,61.4,,2023.13,percent of total billed charges,,,57.4,,1891.33,percent of total billed charges,,,81,,2668.95,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,1897.92,percent of total billed charges,,,85,,2800.75,percent of total billed charges,,,85,,2800.75,percent of total billed charges,,,49,,1614.55,percent of total billed charges,,,90,,2965.5,percent of total billed charges,,,65,,2141.75,percent of total billed charges,,,80,,2636,percent of total billed charges,,,55,,1812.25,percent of total billed charges,,,55,,1812.25,percent of total billed charges,,,65,,2141.75,percent of total billed charges,,,78,,2570.1,percent of total billed charges,,,70,,2306.5,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,372.28,2965.5,
MRA Spinal Canal W&W/O Contrast,72159,CPT,C8933,HCPCS,,both,,,3473,2083.8,,45.5,,1580.22,percent of total billed charges,,,45.3,,1573.27,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,2778.4,percent of total billed charges,,,61.4,,2132.42,percent of total billed charges,,,57.4,,1993.5,percent of total billed charges,,,81,,2813.13,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2000.45,percent of total billed charges,,,85,,2952.05,percent of total billed charges,,,85,,2952.05,percent of total billed charges,,,49,,1701.77,percent of total billed charges,,,90,,3125.7,percent of total billed charges,,,65,,2257.45,percent of total billed charges,,,80,,2778.4,percent of total billed charges,,,55,,1910.15,percent of total billed charges,,,55,,1910.15,percent of total billed charges,,,65,,2257.45,percent of total billed charges,,,78,,2708.94,percent of total billed charges,,,70,,2431.1,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,372.28,3125.7,
XR Pelvis Judet Series,72190,CPT,,,,both,,,728,436.8,,45.5,,331.24,percent of total billed charges,,,45.3,,329.78,percent of total billed charges,,,51,,371.28,percent of total billed charges,,,,,,,,,80,,582.4,percent of total billed charges,,,61.4,,446.99,percent of total billed charges,,,57.4,,417.87,percent of total billed charges,,,81,,589.68,percent of total billed charges,,,51.5,,374.92,percent of total billed charges,,365,,,,fee schedule,,,85,,618.8,percent of total billed charges,,,85,,618.8,percent of total billed charges,,,49,,356.72,percent of total billed charges,,,90,,655.2,percent of total billed charges,,,65,,473.2,percent of total billed charges,,,80,,582.4,percent of total billed charges,,,55,,400.4,percent of total billed charges,,,55,,400.4,percent of total billed charges,,,65,,473.2,percent of total billed charges,,,78,,567.84,percent of total billed charges,,,70,,509.6,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,655.2,
"WHFO With Joint(s), Custom Fabricated",L3806,HCPCS,,,,outpatient,,,3896,2337.6,,45.5,,1772.68,percent of total billed charges,,,45.3,,1764.89,percent of total billed charges,,,39,,1519.44,percent of total billed charges,,,,,,,,,80,,3116.8,percent of total billed charges,,,61.4,,2392.14,percent of total billed charges,,,57.4,,2236.3,percent of total billed charges,,,81,,3155.76,percent of total billed charges,,,39,,1519.44,percent of total billed charges,,,57.6,,2244.1,percent of total billed charges,,,85,,3311.6,percent of total billed charges,,,85,,3311.6,percent of total billed charges,,,49,,1909.04,percent of total billed charges,,,90,,3506.4,percent of total billed charges,,,65,,2532.4,percent of total billed charges,,,80,,3116.8,percent of total billed charges,,,55,,2142.8,percent of total billed charges,,,55,,2142.8,percent of total billed charges,,,65,,2532.4,percent of total billed charges,,,78,,3038.88,percent of total billed charges,,,70,,2727.2,percent of total billed charges,,,,,,,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,,498.07,,,,100% of Medicare,7.25,,,,EAPG Rate,100% of IL Medicaid,7.25,,,,EAPG Rate,100% of IL Medicaid,7.25,,,,EAPG Rate,100% of IL Medicaid,7.25,,,,EAPG Rate,100% of IL Medicaid,7.25,3506.4,
"Initial, BK ""PTB"" type socket, non-alignable sys, pylon, no cover, SACH foot, plaster socket",L5500,HCPCS,,,,outpatient,,,3968,2380.8,,45.5,,1805.44,percent of total billed charges,,,45.3,,1797.5,percent of total billed charges,,,39,,1547.52,percent of total billed charges,,,,,,,,,80,,3174.4,percent of total billed charges,,,61.4,,2436.35,percent of total billed charges,,,57.4,,2277.63,percent of total billed charges,,,81,,3214.08,percent of total billed charges,,,39,,1547.52,percent of total billed charges,,,57.6,,2285.57,percent of total billed charges,,,85,,3372.8,percent of total billed charges,,,85,,3372.8,percent of total billed charges,,,49,,1944.32,percent of total billed charges,,,90,,3571.2,percent of total billed charges,,,65,,2579.2,percent of total billed charges,,,80,,3174.4,percent of total billed charges,,,55,,2182.4,percent of total billed charges,,,55,,2182.4,percent of total billed charges,,,65,,2579.2,percent of total billed charges,,,78,,3095.04,percent of total billed charges,,,70,,2777.6,percent of total billed charges,,,,,,,,1780.23,,,,100% of Medicare,,1780.23,,,,100% of Medicare,,1780.23,,,,100% of Medicare,,1780.23,,,,100% of Medicare,,1780.23,,,,100% of Medicare,,1780.23,,,,100% of Medicare,,1780.23,,,,100% of Medicare,,1780.23,,,,100% of Medicare,,1780.23,,,,100% of Medicare,,1780.23,,,,100% of Medicare,,1780.23,,,,100% of Medicare,,1780.23,,,,100% of Medicare,,,1780.23,,,,100% of Medicare,22.17,,,,EAPG Rate,100% of IL Medicaid,22.17,,,,EAPG Rate,100% of IL Medicaid,22.17,,,,EAPG Rate,100% of IL Medicaid,22.17,,,,EAPG Rate,100% of IL Medicaid,22.17,3571.2,
"L3975 SEWHO, Shoulder cap design, w/o JTs",L3975,HCPCS,,,,outpatient,,,4017,2410.2,,45.5,,1827.74,percent of total billed charges,,,45.3,,1819.7,percent of total billed charges,,,39,,1566.63,percent of total billed charges,,,,,,,,,80,,3213.6,percent of total billed charges,,,61.4,,2466.44,percent of total billed charges,,,57.4,,2305.76,percent of total billed charges,,,81,,3253.77,percent of total billed charges,,,39,,1566.63,percent of total billed charges,,,57.6,,2313.79,percent of total billed charges,,,85,,3414.45,percent of total billed charges,,,85,,3414.45,percent of total billed charges,,,49,,1968.33,percent of total billed charges,,,90,,3615.3,percent of total billed charges,,,65,,2611.05,percent of total billed charges,,,80,,3213.6,percent of total billed charges,,,55,,2209.35,percent of total billed charges,,,55,,2209.35,percent of total billed charges,,,65,,2611.05,percent of total billed charges,,,78,,3133.26,percent of total billed charges,,,70,,2811.9,percent of total billed charges,,,,,,,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,,1842.32,,,,100% of Medicare,32.32,,,,EAPG Rate,100% of IL Medicaid,32.32,,,,EAPG Rate,100% of IL Medicaid,32.32,,,,EAPG Rate,100% of IL Medicaid,32.32,,,,EAPG Rate,100% of IL Medicaid,32.32,3615.3,
"L3976 SEWHFO, Airplane design, w/o JTs",L3976,HCPCS,,,,outpatient,,,4017,2410.2,,45.5,,1827.74,percent of total billed charges,,,45.3,,1819.7,percent of total billed charges,,,39,,1566.63,percent of total billed charges,,,,,,,,,80,,3213.6,percent of total billed charges,,,61.4,,2466.44,percent of total billed charges,,,57.4,,2305.76,percent of total billed charges,,,81,,3253.77,percent of total billed charges,,,39,,1566.63,percent of total billed charges,,,57.6,,2313.79,percent of total billed charges,,,85,,3414.45,percent of total billed charges,,,85,,3414.45,percent of total billed charges,,,49,,1968.33,percent of total billed charges,,,90,,3615.3,percent of total billed charges,,,65,,2611.05,percent of total billed charges,,,80,,3213.6,percent of total billed charges,,,55,,2209.35,percent of total billed charges,,,55,,2209.35,percent of total billed charges,,,65,,2611.05,percent of total billed charges,,,78,,3133.26,percent of total billed charges,,,70,,2811.9,percent of total billed charges,,,,,,,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,,1842.32,,,,100% of Medicare,32.32,,,,EAPG Rate,100% of IL Medicaid,32.32,,,,EAPG Rate,100% of IL Medicaid,32.32,,,,EAPG Rate,100% of IL Medicaid,32.32,,,,EAPG Rate,100% of IL Medicaid,32.32,3615.3,
"Custom shaped protective cover, knee disartic",L5706,HCPCS,,,,outpatient,,,4019,2411.4,,45.5,,1828.65,percent of total billed charges,,,45.3,,1820.61,percent of total billed charges,,,39,,1567.41,percent of total billed charges,,,,,,,,,80,,3215.2,percent of total billed charges,,,61.4,,2467.67,percent of total billed charges,,,57.4,,2306.91,percent of total billed charges,,,81,,3255.39,percent of total billed charges,,,39,,1567.41,percent of total billed charges,,,57.6,,2314.94,percent of total billed charges,,,85,,3416.15,percent of total billed charges,,,85,,3416.15,percent of total billed charges,,,49,,1969.31,percent of total billed charges,,,90,,3617.1,percent of total billed charges,,,65,,2612.35,percent of total billed charges,,,80,,3215.2,percent of total billed charges,,,55,,2210.45,percent of total billed charges,,,55,,2210.45,percent of total billed charges,,,65,,2612.35,percent of total billed charges,,,78,,3134.82,percent of total billed charges,,,70,,2813.3,percent of total billed charges,,,,,,,,1350.12,,,,100% of Medicare,,1350.12,,,,100% of Medicare,,1350.12,,,,100% of Medicare,,1350.12,,,,100% of Medicare,,1350.12,,,,100% of Medicare,,1350.12,,,,100% of Medicare,,1350.12,,,,100% of Medicare,,1350.12,,,,100% of Medicare,,1350.12,,,,100% of Medicare,,1350.12,,,,100% of Medicare,,1350.12,,,,100% of Medicare,,1350.12,,,,100% of Medicare,,,1350.12,,,,100% of Medicare,32.74,,,,EAPG Rate,100% of IL Medicaid,32.74,,,,EAPG Rate,100% of IL Medicaid,32.74,,,,EAPG Rate,100% of IL Medicaid,32.74,,,,EAPG Rate,100% of IL Medicaid,32.74,3617.1,
"Addition, endo sys, hip disartic, ultra-light material (titanium, carbon fiber or equal)",L5960,HCPCS,,,,outpatient,,,4037,2422.2,,45.5,,1836.84,percent of total billed charges,,,45.3,,1828.76,percent of total billed charges,,,39,,1574.43,percent of total billed charges,,,,,,,,,80,,3229.6,percent of total billed charges,,,61.4,,2478.72,percent of total billed charges,,,57.4,,2317.24,percent of total billed charges,,,81,,3269.97,percent of total billed charges,,,39,,1574.43,percent of total billed charges,,,57.6,,2325.31,percent of total billed charges,,,85,,3431.45,percent of total billed charges,,,85,,3431.45,percent of total billed charges,,,49,,1978.13,percent of total billed charges,,,90,,3633.3,percent of total billed charges,,,65,,2624.05,percent of total billed charges,,,80,,3229.6,percent of total billed charges,,,55,,2220.35,percent of total billed charges,,,55,,2220.35,percent of total billed charges,,,65,,2624.05,percent of total billed charges,,,78,,3148.86,percent of total billed charges,,,70,,2825.9,percent of total billed charges,,,,,,,,1396.26,,,,100% of Medicare,,1396.26,,,,100% of Medicare,,1396.26,,,,100% of Medicare,,1396.26,,,,100% of Medicare,,1396.26,,,,100% of Medicare,,1396.26,,,,100% of Medicare,,1396.26,,,,100% of Medicare,,1396.26,,,,100% of Medicare,,1396.26,,,,100% of Medicare,,1396.26,,,,100% of Medicare,,1396.26,,,,100% of Medicare,,1396.26,,,,100% of Medicare,,,1396.26,,,,100% of Medicare,36.47,,,,EAPG Rate,100% of IL Medicaid,36.47,,,,EAPG Rate,100% of IL Medicaid,36.47,,,,EAPG Rate,100% of IL Medicaid,36.47,,,,EAPG Rate,100% of IL Medicaid,36.47,3633.3,
"Addition, endo sys, hip disartic, flexible protective outer surface covering system",L5966,HCPCS,,,,outpatient,,,4073,2443.8,,45.5,,1853.22,percent of total billed charges,,,45.3,,1845.07,percent of total billed charges,,,39,,1588.47,percent of total billed charges,,,,,,,,,80,,3258.4,percent of total billed charges,,,61.4,,2500.82,percent of total billed charges,,,57.4,,2337.9,percent of total billed charges,,,81,,3299.13,percent of total billed charges,,,39,,1588.47,percent of total billed charges,,,57.6,,2346.05,percent of total billed charges,,,85,,3462.05,percent of total billed charges,,,85,,3462.05,percent of total billed charges,,,49,,1995.77,percent of total billed charges,,,90,,3665.7,percent of total billed charges,,,65,,2647.45,percent of total billed charges,,,80,,3258.4,percent of total billed charges,,,55,,2240.15,percent of total billed charges,,,55,,2240.15,percent of total billed charges,,,65,,2647.45,percent of total billed charges,,,78,,3176.94,percent of total billed charges,,,70,,2851.1,percent of total billed charges,,,,,,,,1743.25,,,,100% of Medicare,,1743.25,,,,100% of Medicare,,1743.25,,,,100% of Medicare,,1743.25,,,,100% of Medicare,,1743.25,,,,100% of Medicare,,1743.25,,,,100% of Medicare,,1743.25,,,,100% of Medicare,,1743.25,,,,100% of Medicare,,1743.25,,,,100% of Medicare,,1743.25,,,,100% of Medicare,,1743.25,,,,100% of Medicare,,1743.25,,,,100% of Medicare,,,1743.25,,,,100% of Medicare,43.93,,,,EAPG Rate,100% of IL Medicaid,43.93,,,,EAPG Rate,100% of IL Medicaid,43.93,,,,EAPG Rate,100% of IL Medicaid,43.93,,,,EAPG Rate,100% of IL Medicaid,43.93,3665.7,
"Addition, endo sys, AK, flexible protective outer surface covering system",L5964,HCPCS,,,,outpatient,,,4111,2466.6,,45.5,,1870.51,percent of total billed charges,,,45.3,,1862.28,percent of total billed charges,,,39,,1603.29,percent of total billed charges,,,,,,,,,80,,3288.8,percent of total billed charges,,,61.4,,2524.15,percent of total billed charges,,,57.4,,2359.71,percent of total billed charges,,,81,,3329.91,percent of total billed charges,,,39,,1603.29,percent of total billed charges,,,57.6,,2367.94,percent of total billed charges,,,85,,3494.35,percent of total billed charges,,,85,,3494.35,percent of total billed charges,,,49,,2014.39,percent of total billed charges,,,90,,3699.9,percent of total billed charges,,,65,,2672.15,percent of total billed charges,,,80,,3288.8,percent of total billed charges,,,55,,2261.05,percent of total billed charges,,,55,,2261.05,percent of total billed charges,,,65,,2672.15,percent of total billed charges,,,78,,3206.58,percent of total billed charges,,,70,,2877.7,percent of total billed charges,,,,,,,,1353.27,,,,100% of Medicare,,1353.27,,,,100% of Medicare,,1353.27,,,,100% of Medicare,,1353.27,,,,100% of Medicare,,1353.27,,,,100% of Medicare,,1353.27,,,,100% of Medicare,,1353.27,,,,100% of Medicare,,1353.27,,,,100% of Medicare,,1353.27,,,,100% of Medicare,,1353.27,,,,100% of Medicare,,1353.27,,,,100% of Medicare,,1353.27,,,,100% of Medicare,,,1353.27,,,,100% of Medicare,51.8,,,,EAPG Rate,100% of IL Medicaid,51.8,,,,EAPG Rate,100% of IL Medicaid,51.8,,,,EAPG Rate,100% of IL Medicaid,51.8,,,,EAPG Rate,100% of IL Medicaid,51.8,3699.9,
"Thoracic-Lumbar-Sacral Orthosis 2-Piece Rigid Shell, Sagittal-Coronal",L0491,HCPCS,,,,outpatient,,,4131,2478.6,,45.5,,1879.61,percent of total billed charges,,,45.3,,1871.34,percent of total billed charges,,,39,,1611.09,percent of total billed charges,,,,,,,,,80,,3304.8,percent of total billed charges,,,61.4,,2536.43,percent of total billed charges,,,57.4,,2371.19,percent of total billed charges,,,81,,3346.11,percent of total billed charges,,,39,,1611.09,percent of total billed charges,,,57.6,,2379.46,percent of total billed charges,,,85,,3511.35,percent of total billed charges,,,85,,3511.35,percent of total billed charges,,,49,,2024.19,percent of total billed charges,,,90,,3717.9,percent of total billed charges,,,65,,2685.15,percent of total billed charges,,,80,,3304.8,percent of total billed charges,,,55,,2272.05,percent of total billed charges,,,55,,2272.05,percent of total billed charges,,,65,,2685.15,percent of total billed charges,,,78,,3222.18,percent of total billed charges,,,70,,2891.7,percent of total billed charges,,,,,,,,925.33,,,,100% of Medicare,,925.33,,,,100% of Medicare,,925.33,,,,100% of Medicare,,925.33,,,,100% of Medicare,,925.33,,,,100% of Medicare,,925.33,,,,100% of Medicare,,925.33,,,,100% of Medicare,,925.33,,,,100% of Medicare,,925.33,,,,100% of Medicare,,925.33,,,,100% of Medicare,,925.33,,,,100% of Medicare,,925.33,,,,100% of Medicare,,,925.33,,,,100% of Medicare,55.94,,,,EAPG Rate,100% of IL Medicaid,55.94,,,,EAPG Rate,100% of IL Medicaid,55.94,,,,EAPG Rate,100% of IL Medicaid,55.94,,,,EAPG Rate,100% of IL Medicaid,55.94,3717.9,
"L5705 Custom shaped protective cover, AK",L5705,HCPCS,,,,outpatient,,,4203,2521.8,,45.5,,1912.37,percent of total billed charges,,,45.3,,1903.96,percent of total billed charges,,,39,,1639.17,percent of total billed charges,,,,,,,,,80,,3362.4,percent of total billed charges,,,61.4,,2580.64,percent of total billed charges,,,57.4,,2412.52,percent of total billed charges,,,81,,3404.43,percent of total billed charges,,,39,,1639.17,percent of total billed charges,,,57.6,,2420.93,percent of total billed charges,,,85,,3572.55,percent of total billed charges,,,85,,3572.55,percent of total billed charges,,,49,,2059.47,percent of total billed charges,,,90,,3782.7,percent of total billed charges,,,65,,2731.95,percent of total billed charges,,,80,,3362.4,percent of total billed charges,,,55,,2311.65,percent of total billed charges,,,55,,2311.65,percent of total billed charges,,,65,,2731.95,percent of total billed charges,,,78,,3278.34,percent of total billed charges,,,70,,2942.1,percent of total billed charges,,,,,,,,1384.22,,,,100% of Medicare,,1384.22,,,,100% of Medicare,,1384.22,,,,100% of Medicare,,1384.22,,,,100% of Medicare,,1384.22,,,,100% of Medicare,,1384.22,,,,100% of Medicare,,1384.22,,,,100% of Medicare,,1384.22,,,,100% of Medicare,,1384.22,,,,100% of Medicare,,1384.22,,,,100% of Medicare,,1384.22,,,,100% of Medicare,,1384.22,,,,100% of Medicare,,,1384.22,,,,100% of Medicare,70.86,,,,EAPG Rate,100% of IL Medicaid,70.86,,,,EAPG Rate,100% of IL Medicaid,70.86,,,,EAPG Rate,100% of IL Medicaid,70.86,,,,EAPG Rate,100% of IL Medicaid,70.86,3782.7,
CT Pelvis W/O Contrast,72192,CPT,,,,both,,,2769,1661.4,,45.5,,1259.9,percent of total billed charges,,,45.3,,1254.36,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,2215.2,percent of total billed charges,,,61.4,,1700.17,percent of total billed charges,,,57.4,,1589.41,percent of total billed charges,,,81,,2242.89,percent of total billed charges,,735,,,,fee schedule,,,57.6,,1594.94,percent of total billed charges,,,85,,2353.65,percent of total billed charges,,,85,,2353.65,percent of total billed charges,,,49,,1356.81,percent of total billed charges,,,90,,2492.1,percent of total billed charges,,,65,,1799.85,percent of total billed charges,,,80,,2215.2,percent of total billed charges,,,55,,1522.95,percent of total billed charges,,,55,,1522.95,percent of total billed charges,,,65,,1799.85,percent of total billed charges,,,78,,2159.82,percent of total billed charges,,,70,,1938.3,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,2492.1,
CT Pelvis W/ Contrast,72193,CPT,,,,both,,,4114,2468.4,,45.5,,1871.87,percent of total billed charges,,,45.3,,1863.64,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3291.2,percent of total billed charges,,,61.4,,2526,percent of total billed charges,,,57.4,,2361.44,percent of total billed charges,,,81,,3332.34,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2369.66,percent of total billed charges,,,85,,3496.9,percent of total billed charges,,,85,,3496.9,percent of total billed charges,,,49,,2015.86,percent of total billed charges,,,90,,3702.6,percent of total billed charges,,,65,,2674.1,percent of total billed charges,,,80,,3291.2,percent of total billed charges,,,55,,2262.7,percent of total billed charges,,,55,,2262.7,percent of total billed charges,,,65,,2674.1,percent of total billed charges,,,78,,3208.92,percent of total billed charges,,,70,,2879.8,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,185.57,3702.6,
CT Pelvis W/&W/O Contrast,72194,CPT,,,,both,,,4897,2938.2,,45.5,,2228.14,percent of total billed charges,,,45.3,,2218.34,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3917.6,percent of total billed charges,,,61.4,,3006.76,percent of total billed charges,,,57.4,,2810.88,percent of total billed charges,,,81,,3966.57,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2820.67,percent of total billed charges,,,85,,4162.45,percent of total billed charges,,,85,,4162.45,percent of total billed charges,,,49,,2399.53,percent of total billed charges,,,90,,4407.3,percent of total billed charges,,,65,,3183.05,percent of total billed charges,,,80,,3917.6,percent of total billed charges,,,55,,2693.35,percent of total billed charges,,,55,,2693.35,percent of total billed charges,,,65,,3183.05,percent of total billed charges,,,78,,3819.66,percent of total billed charges,,,70,,3427.9,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,185.57,4407.3,
MRA Pelvis  W/O Contrast,72198,CPT,C8919,HCPCS,,both,,,3573,2143.8,,45.5,,1625.72,percent of total billed charges,,,45.3,,1618.57,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,2858.4,percent of total billed charges,,,61.4,,2193.82,percent of total billed charges,,,57.4,,2050.9,percent of total billed charges,,,81,,2894.13,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2058.05,percent of total billed charges,,,85,,3037.05,percent of total billed charges,,,85,,3037.05,percent of total billed charges,,,49,,1750.77,percent of total billed charges,,,90,,3215.7,percent of total billed charges,,,65,,2322.45,percent of total billed charges,,,80,,2858.4,percent of total billed charges,,,55,,1965.15,percent of total billed charges,,,55,,1965.15,percent of total billed charges,,,65,,2322.45,percent of total billed charges,,,78,,2786.94,percent of total billed charges,,,70,,2501.1,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,251.97,3215.7,
MRA Pelvis W/ Contrast,72198,CPT,C8918,HCPCS,,both,,,4428,2656.8,,45.5,,2014.74,percent of total billed charges,,,45.3,,2005.88,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3542.4,percent of total billed charges,,,61.4,,2718.79,percent of total billed charges,,,57.4,,2541.67,percent of total billed charges,,,81,,3586.68,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2550.53,percent of total billed charges,,,85,,3763.8,percent of total billed charges,,,85,,3763.8,percent of total billed charges,,,49,,2169.72,percent of total billed charges,,,90,,3985.2,percent of total billed charges,,,65,,2878.2,percent of total billed charges,,,80,,3542.4,percent of total billed charges,,,55,,2435.4,percent of total billed charges,,,55,,2435.4,percent of total billed charges,,,65,,2878.2,percent of total billed charges,,,78,,3453.84,percent of total billed charges,,,70,,3099.6,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,372.28,3985.2,
"Prep, BK ""PTB"" type socket, non-alignable sys, pylon, no cover, SACH foot, thermoplastic or equal",L5520,HCPCS,,,,outpatient,,,4245,2547,,45.5,,1931.48,percent of total billed charges,,,45.3,,1922.99,percent of total billed charges,,,39,,1655.55,percent of total billed charges,,,,,,,,,80,,3396,percent of total billed charges,,,61.4,,2606.43,percent of total billed charges,,,57.4,,2436.63,percent of total billed charges,,,81,,3438.45,percent of total billed charges,,,39,,1655.55,percent of total billed charges,,,57.6,,2445.12,percent of total billed charges,,,85,,3608.25,percent of total billed charges,,,85,,3608.25,percent of total billed charges,,,49,,2080.05,percent of total billed charges,,,90,,3820.5,percent of total billed charges,,,65,,2759.25,percent of total billed charges,,,80,,3396,percent of total billed charges,,,55,,2334.75,percent of total billed charges,,,55,,2334.75,percent of total billed charges,,,65,,2759.25,percent of total billed charges,,,78,,3311.1,percent of total billed charges,,,70,,2971.5,percent of total billed charges,,,,,,,,1905.61,,,,100% of Medicare,,1905.61,,,,100% of Medicare,,1905.61,,,,100% of Medicare,,1905.61,,,,100% of Medicare,,1905.61,,,,100% of Medicare,,1905.61,,,,100% of Medicare,,1905.61,,,,100% of Medicare,,1905.61,,,,100% of Medicare,,1905.61,,,,100% of Medicare,,1905.61,,,,100% of Medicare,,1905.61,,,,100% of Medicare,,1905.61,,,,100% of Medicare,,,1905.61,,,,100% of Medicare,79.56,,,,EAPG Rate,100% of IL Medicaid,79.56,,,,EAPG Rate,100% of IL Medicaid,79.56,,,,EAPG Rate,100% of IL Medicaid,79.56,,,,EAPG Rate,100% of IL Medicaid,79.56,3820.5,
"Collar, Molded to Model",L0170,HCPCS,,,,outpatient,,,4327,2596.2,,45.5,,1968.79,percent of total billed charges,,,45.3,,1960.13,percent of total billed charges,,,39,,1687.53,percent of total billed charges,,,,,,,,,80,,3461.6,percent of total billed charges,,,61.4,,2656.78,percent of total billed charges,,,57.4,,2483.7,percent of total billed charges,,,81,,3504.87,percent of total billed charges,,,39,,1687.53,percent of total billed charges,,,57.6,,2492.35,percent of total billed charges,,,85,,3677.95,percent of total billed charges,,,85,,3677.95,percent of total billed charges,,,49,,2120.23,percent of total billed charges,,,90,,3894.3,percent of total billed charges,,,65,,2812.55,percent of total billed charges,,,80,,3461.6,percent of total billed charges,,,55,,2379.85,percent of total billed charges,,,55,,2379.85,percent of total billed charges,,,65,,2812.55,percent of total billed charges,,,78,,3375.06,percent of total billed charges,,,70,,3028.9,percent of total billed charges,,,,,,,,968.74,,,,100% of Medicare,,968.74,,,,100% of Medicare,,968.74,,,,100% of Medicare,,968.74,,,,100% of Medicare,,968.74,,,,100% of Medicare,,968.74,,,,100% of Medicare,,968.74,,,,100% of Medicare,,968.74,,,,100% of Medicare,,968.74,,,,100% of Medicare,,968.74,,,,100% of Medicare,,968.74,,,,100% of Medicare,,968.74,,,,100% of Medicare,,,968.74,,,,100% of Medicare,96.55,,,,EAPG Rate,100% of IL Medicaid,96.55,,,,EAPG Rate,100% of IL Medicaid,96.55,,,,EAPG Rate,100% of IL Medicaid,96.55,,,,EAPG Rate,100% of IL Medicaid,96.55,3894.3,
"L5616 Addition to LE, endo sys, AK, universal multiplex sys, friction swing phase control",L5616,HCPCS,,,,outpatient,,,4337,2602.2,,45.5,,1973.34,percent of total billed charges,,,45.3,,1964.66,percent of total billed charges,,,39,,1691.43,percent of total billed charges,,,,,,,,,80,,3469.6,percent of total billed charges,,,61.4,,2662.92,percent of total billed charges,,,57.4,,2489.44,percent of total billed charges,,,81,,3512.97,percent of total billed charges,,,39,,1691.43,percent of total billed charges,,,57.6,,2498.11,percent of total billed charges,,,85,,3686.45,percent of total billed charges,,,85,,3686.45,percent of total billed charges,,,49,,2125.13,percent of total billed charges,,,90,,3903.3,percent of total billed charges,,,65,,2819.05,percent of total billed charges,,,80,,3469.6,percent of total billed charges,,,55,,2385.35,percent of total billed charges,,,55,,2385.35,percent of total billed charges,,,65,,2819.05,percent of total billed charges,,,78,,3382.86,percent of total billed charges,,,70,,3035.9,percent of total billed charges,,,,,,,,1773.59,,,,100% of Medicare,,1773.59,,,,100% of Medicare,,1773.59,,,,100% of Medicare,,1773.59,,,,100% of Medicare,,1773.59,,,,100% of Medicare,,1773.59,,,,100% of Medicare,,1773.59,,,,100% of Medicare,,1773.59,,,,100% of Medicare,,1773.59,,,,100% of Medicare,,1773.59,,,,100% of Medicare,,1773.59,,,,100% of Medicare,,1773.59,,,,100% of Medicare,,,1773.59,,,,100% of Medicare,98.63,,,,EAPG Rate,100% of IL Medicaid,98.63,,,,EAPG Rate,100% of IL Medicaid,98.63,,,,EAPG Rate,100% of IL Medicaid,98.63,,,,EAPG Rate,100% of IL Medicaid,98.63,3903.3,
"L5999 - Lower extremity prosthesis, not otherwise specified",L5999,HCPCS,,,,both,,,4356.51,2613.91,,45.5,,1982.21,percent of total billed charges,,,45.3,,1973.5,percent of total billed charges,,,39,,1699.04,percent of total billed charges,,,,,,,,,80,,3485.21,percent of total billed charges,,,61.4,,2674.9,percent of total billed charges,,,57.4,,2500.64,percent of total billed charges,,,81,,3528.77,percent of total billed charges,,,51.5,,2243.6,percent of total billed charges,,,57.6,,2509.35,percent of total billed charges,,,85,,3703.03,percent of total billed charges,,,85,,3703.03,percent of total billed charges,,,49,,2134.69,percent of total billed charges,,,90,,3920.86,percent of total billed charges,,,65,,2831.73,percent of total billed charges,,,80,,3485.21,percent of total billed charges,,,55,,2396.08,percent of total billed charges,,,55,,2396.08,percent of total billed charges,,,65,,2831.73,percent of total billed charges,,,78,,3398.08,percent of total billed charges,,,70,,3049.56,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,102.67,,,,EAPG rate,100% of IL Medicaid,102.67,,,,EAPG rate,100% of IL Medicaid,102.67,,,,EAPG rate,100% of IL Medicaid,102.67,,,,EAPG rate,100% of IL Medicaid,102.67,3920.86,
"Wrist-Hand-Finger Orthosis, Dynamic Flexor Hinge, Wrist or Finger Driven",L3900,HCPCS,,,,outpatient,,,4364,2618.4,,45.5,,1985.62,percent of total billed charges,,,45.3,,1976.89,percent of total billed charges,,,39,,1701.96,percent of total billed charges,,,,,,,,,80,,3491.2,percent of total billed charges,,,61.4,,2679.5,percent of total billed charges,,,57.4,,2504.94,percent of total billed charges,,,81,,3534.84,percent of total billed charges,,,39,,1701.96,percent of total billed charges,,,57.6,,2513.66,percent of total billed charges,,,85,,3709.4,percent of total billed charges,,,85,,3709.4,percent of total billed charges,,,49,,2138.36,percent of total billed charges,,,90,,3927.6,percent of total billed charges,,,65,,2836.6,percent of total billed charges,,,80,,3491.2,percent of total billed charges,,,55,,2400.2,percent of total billed charges,,,55,,2400.2,percent of total billed charges,,,65,,2836.6,percent of total billed charges,,,78,,3403.92,percent of total billed charges,,,70,,3054.8,percent of total billed charges,,,,,,,,1776.32,,,,100% of Medicare,,1776.32,,,,100% of Medicare,,1776.32,,,,100% of Medicare,,1776.32,,,,100% of Medicare,,1776.32,,,,100% of Medicare,,1776.32,,,,100% of Medicare,,1776.32,,,,100% of Medicare,,1776.32,,,,100% of Medicare,,1776.32,,,,100% of Medicare,,1776.32,,,,100% of Medicare,,1776.32,,,,100% of Medicare,,1776.32,,,,100% of Medicare,,,1776.32,,,,100% of Medicare,104.22,,,,EAPG Rate,100% of IL Medicaid,104.22,,,,EAPG Rate,100% of IL Medicaid,104.22,,,,EAPG Rate,100% of IL Medicaid,104.22,,,,EAPG Rate,100% of IL Medicaid,104.22,3927.6,
"Knee Orthosis, Double Upright, Medial/Lateral Rotational Control, Custom Fitted",L1845,HCPCS,,,,outpatient,,,4375,2625,,45.5,,1990.63,percent of total billed charges,,,45.3,,1981.88,percent of total billed charges,,,39,,1706.25,percent of total billed charges,,,,,,,,,80,,3500,percent of total billed charges,,,61.4,,2686.25,percent of total billed charges,,,57.4,,2511.25,percent of total billed charges,,,81,,3543.75,percent of total billed charges,,,39,,1706.25,percent of total billed charges,,,57.6,,2520,percent of total billed charges,,,85,,3718.75,percent of total billed charges,,,85,,3718.75,percent of total billed charges,,,49,,2143.75,percent of total billed charges,,,90,,3937.5,percent of total billed charges,,,65,,2843.75,percent of total billed charges,,,80,,3500,percent of total billed charges,,,55,,2406.25,percent of total billed charges,,,55,,2406.25,percent of total billed charges,,,65,,2843.75,percent of total billed charges,,,78,,3412.5,percent of total billed charges,,,70,,3062.5,percent of total billed charges,,,,,,,,1009.29,,,,100% of Medicare,,1009.29,,,,100% of Medicare,,1009.29,,,,100% of Medicare,,1009.29,,,,100% of Medicare,,1009.29,,,,100% of Medicare,,1009.29,,,,100% of Medicare,,1009.29,,,,100% of Medicare,,1009.29,,,,100% of Medicare,,1009.29,,,,100% of Medicare,,1009.29,,,,100% of Medicare,,1009.29,,,,100% of Medicare,,1009.29,,,,100% of Medicare,,,1009.29,,,,100% of Medicare,106.5,,,,EAPG Rate,100% of IL Medicaid,106.5,,,,EAPG Rate,100% of IL Medicaid,106.5,,,,EAPG Rate,100% of IL Medicaid,106.5,,,,EAPG Rate,100% of IL Medicaid,106.5,3937.5,
"L3967 SEWHO, Airplane Design, w/o JTs, Custom Fab",L3967,HCPCS,,,,outpatient,,,4393,2635.8,,45.5,,1998.82,percent of total billed charges,,,45.3,,1990.03,percent of total billed charges,,,39,,1713.27,percent of total billed charges,,,,,,,,,80,,3514.4,percent of total billed charges,,,61.4,,2697.3,percent of total billed charges,,,57.4,,2521.58,percent of total billed charges,,,81,,3558.33,percent of total billed charges,,,39,,1713.27,percent of total billed charges,,,57.6,,2530.37,percent of total billed charges,,,85,,3734.05,percent of total billed charges,,,85,,3734.05,percent of total billed charges,,,49,,2152.57,percent of total billed charges,,,90,,3953.7,percent of total billed charges,,,65,,2855.45,percent of total billed charges,,,80,,3514.4,percent of total billed charges,,,55,,2416.15,percent of total billed charges,,,55,,2416.15,percent of total billed charges,,,65,,2855.45,percent of total billed charges,,,78,,3426.54,percent of total billed charges,,,70,,3075.1,percent of total billed charges,,,,,,,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,,2175.13,,,,100% of Medicare,110.23,,,,EAPG Rate,100% of IL Medicaid,110.23,,,,EAPG Rate,100% of IL Medicaid,110.23,,,,EAPG Rate,100% of IL Medicaid,110.23,,,,EAPG Rate,100% of IL Medicaid,110.23,3953.7,
MRV Pelvis W&W/O Contrast,72198,CPT,C8920,HCPCS,,both,,,5418,3250.8,,45.5,,2465.19,percent of total billed charges,,,45.3,,2454.35,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4334.4,percent of total billed charges,,,61.4,,3326.65,percent of total billed charges,,,57.4,,3109.93,percent of total billed charges,,,81,,4388.58,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3120.77,percent of total billed charges,,,85,,4605.3,percent of total billed charges,,,85,,4605.3,percent of total billed charges,,,49,,2654.82,percent of total billed charges,,,90,,4876.2,percent of total billed charges,,,65,,3521.7,percent of total billed charges,,,80,,4334.4,percent of total billed charges,,,55,,2979.9,percent of total billed charges,,,55,,2979.9,percent of total billed charges,,,65,,3521.7,percent of total billed charges,,,78,,4226.04,percent of total billed charges,,,70,,3792.6,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,372.28,4876.2,
XR Sacroiliac Joints Minimum 3 Views,72202,CPT,,,,both,,,814,488.4,,45.5,,370.37,percent of total billed charges,,,45.3,,368.74,percent of total billed charges,,,51,,415.14,percent of total billed charges,,,,,,,,,80,,651.2,percent of total billed charges,,,61.4,,499.8,percent of total billed charges,,,57.4,,467.24,percent of total billed charges,,,81,,659.34,percent of total billed charges,,,51.5,,419.21,percent of total billed charges,,365,,,,fee schedule,,,85,,691.9,percent of total billed charges,,,85,,691.9,percent of total billed charges,,,49,,398.86,percent of total billed charges,,,90,,732.6,percent of total billed charges,,,65,,529.1,percent of total billed charges,,,80,,651.2,percent of total billed charges,,,55,,447.7,percent of total billed charges,,,55,,447.7,percent of total billed charges,,,65,,529.1,percent of total billed charges,,,78,,634.92,percent of total billed charges,,,70,,569.8,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,732.6,
"Scoliosis Procedures, Body Jacket Molded to Patient",L1300,HCPCS,,,,outpatient,,,4414,2648.4,,45.5,,2008.37,percent of total billed charges,,,45.3,,1999.54,percent of total billed charges,,,39,,1721.46,percent of total billed charges,,,,,,,,,80,,3531.2,percent of total billed charges,,,61.4,,2710.2,percent of total billed charges,,,57.4,,2533.64,percent of total billed charges,,,81,,3575.34,percent of total billed charges,,,39,,1721.46,percent of total billed charges,,,57.6,,2542.46,percent of total billed charges,,,85,,3751.9,percent of total billed charges,,,85,,3751.9,percent of total billed charges,,,49,,2162.86,percent of total billed charges,,,90,,3972.6,percent of total billed charges,,,65,,2869.1,percent of total billed charges,,,80,,3531.2,percent of total billed charges,,,55,,2427.7,percent of total billed charges,,,55,,2427.7,percent of total billed charges,,,65,,2869.1,percent of total billed charges,,,78,,3442.92,percent of total billed charges,,,70,,3089.8,percent of total billed charges,,,,,,,,2076.54,,,,100% of Medicare,,2076.54,,,,100% of Medicare,,2076.54,,,,100% of Medicare,,2076.54,,,,100% of Medicare,,2076.54,,,,100% of Medicare,,2076.54,,,,100% of Medicare,,2076.54,,,,100% of Medicare,,2076.54,,,,100% of Medicare,,2076.54,,,,100% of Medicare,,2076.54,,,,100% of Medicare,,2076.54,,,,100% of Medicare,,2076.54,,,,100% of Medicare,,,2076.54,,,,100% of Medicare,114.58,,,,EAPG Rate,100% of IL Medicaid,114.58,,,,EAPG Rate,100% of IL Medicaid,114.58,,,,EAPG Rate,100% of IL Medicaid,114.58,,,,EAPG Rate,100% of IL Medicaid,114.58,3972.6,
"Immediate postsurg/early fitting, app of initial rigid drsg incl fit/align/susp and 1 cast change be",L5400,HCPCS,,,,outpatient,,,4416,2649.6,,45.5,,2009.28,percent of total billed charges,,,45.3,,2000.45,percent of total billed charges,,,39,,1722.24,percent of total billed charges,,,,,,,,,80,,3532.8,percent of total billed charges,,,61.4,,2711.42,percent of total billed charges,,,57.4,,2534.78,percent of total billed charges,,,81,,3576.96,percent of total billed charges,,,39,,1722.24,percent of total billed charges,,,57.6,,2543.62,percent of total billed charges,,,85,,3753.6,percent of total billed charges,,,85,,3753.6,percent of total billed charges,,,49,,2163.84,percent of total billed charges,,,90,,3974.4,percent of total billed charges,,,65,,2870.4,percent of total billed charges,,,80,,3532.8,percent of total billed charges,,,55,,2428.8,percent of total billed charges,,,55,,2428.8,percent of total billed charges,,,65,,2870.4,percent of total billed charges,,,78,,3444.48,percent of total billed charges,,,70,,3091.2,percent of total billed charges,,,,,,,,1926.05,,,,100% of Medicare,,1926.05,,,,100% of Medicare,,1926.05,,,,100% of Medicare,,1926.05,,,,100% of Medicare,,1926.05,,,,100% of Medicare,,1926.05,,,,100% of Medicare,,1926.05,,,,100% of Medicare,,1926.05,,,,100% of Medicare,,1926.05,,,,100% of Medicare,,1926.05,,,,100% of Medicare,,1926.05,,,,100% of Medicare,,1926.05,,,,100% of Medicare,,,1926.05,,,,100% of Medicare,115,,,,EAPG Rate,100% of IL Medicaid,115,,,,EAPG Rate,100% of IL Medicaid,115,,,,EAPG Rate,100% of IL Medicaid,115,,,,EAPG Rate,100% of IL Medicaid,115,3974.4,
"Elbow Orthosis, Double Upright w/ Forearm/Arm Cuffs, Extension/Flexion Assist",L3730,HCPCS,,,,outpatient,,,4437,2662.2,,45.5,,2018.84,percent of total billed charges,,,45.3,,2009.96,percent of total billed charges,,,39,,1730.43,percent of total billed charges,,,,,,,,,80,,3549.6,percent of total billed charges,,,61.4,,2724.32,percent of total billed charges,,,57.4,,2546.84,percent of total billed charges,,,81,,3593.97,percent of total billed charges,,,39,,1730.43,percent of total billed charges,,,57.6,,2555.71,percent of total billed charges,,,85,,3771.45,percent of total billed charges,,,85,,3771.45,percent of total billed charges,,,49,,2174.13,percent of total billed charges,,,90,,3993.3,percent of total billed charges,,,65,,2884.05,percent of total billed charges,,,80,,3549.6,percent of total billed charges,,,55,,2440.35,percent of total billed charges,,,55,,2440.35,percent of total billed charges,,,65,,2884.05,percent of total billed charges,,,78,,3460.86,percent of total billed charges,,,70,,3105.9,percent of total billed charges,,,,,,,,993.78,,,,100% of Medicare,,993.78,,,,100% of Medicare,,993.78,,,,100% of Medicare,,993.78,,,,100% of Medicare,,993.78,,,,100% of Medicare,,993.78,,,,100% of Medicare,,993.78,,,,100% of Medicare,,993.78,,,,100% of Medicare,,993.78,,,,100% of Medicare,,993.78,,,,100% of Medicare,,993.78,,,,100% of Medicare,,993.78,,,,100% of Medicare,,,993.78,,,,100% of Medicare,119.35,,,,EAPG Rate,100% of IL Medicaid,119.35,,,,EAPG Rate,100% of IL Medicaid,119.35,,,,EAPG Rate,100% of IL Medicaid,119.35,,,,EAPG Rate,100% of IL Medicaid,119.35,3993.3,
"Addition LE, user adj mech limb volume mgmt system",L5783,HCPCS,,,,outpatient,,,4495,2697,,45.5,,2045.23,percent of total billed charges,,,45.3,,2036.24,percent of total billed charges,,,39,,1753.05,percent of total billed charges,,,,,,,,,80,,3596,percent of total billed charges,,,61.4,,2759.93,percent of total billed charges,,,57.4,,2580.13,percent of total billed charges,,,81,,3640.95,percent of total billed charges,,,39,,1753.05,percent of total billed charges,,,57.6,,2589.12,percent of total billed charges,,,85,,3820.75,percent of total billed charges,,,85,,3820.75,percent of total billed charges,,,49,,2202.55,percent of total billed charges,,,90,,4045.5,percent of total billed charges,,,65,,2921.75,percent of total billed charges,,,80,,3596,percent of total billed charges,,,55,,2472.25,percent of total billed charges,,,55,,2472.25,percent of total billed charges,,,65,,2921.75,percent of total billed charges,,,78,,3506.1,percent of total billed charges,,,70,,3146.5,percent of total billed charges,,,,,,,,3088.3,,,,100% of Medicare,,3088.3,,,,100% of Medicare,,3088.3,,,,100% of Medicare,,3088.3,,,,100% of Medicare,,3088.3,,,,100% of Medicare,,3088.3,,,,100% of Medicare,,3088.3,,,,100% of Medicare,,3088.3,,,,100% of Medicare,,3088.3,,,,100% of Medicare,,3088.3,,,,100% of Medicare,,3088.3,,,,100% of Medicare,,3088.3,,,,100% of Medicare,,,3088.3,,,,100% of Medicare,131.36,,,,EAPG Rate,100% of IL Medicaid,131.36,,,,EAPG Rate,100% of IL Medicaid,131.36,,,,EAPG Rate,100% of IL Medicaid,131.36,,,,EAPG Rate,100% of IL Medicaid,131.36,4045.5,
"L3971 SEWHO, Shoulder cap design, Incl Nontorsion JTs/bands/turnbuckles",L3971,HCPCS,,,,outpatient,,,4501,2700.6,,45.5,,2047.96,percent of total billed charges,,,45.3,,2038.95,percent of total billed charges,,,39,,1755.39,percent of total billed charges,,,,,,,,,80,,3600.8,percent of total billed charges,,,61.4,,2763.61,percent of total billed charges,,,57.4,,2583.57,percent of total billed charges,,,81,,3645.81,percent of total billed charges,,,39,,1755.39,percent of total billed charges,,,57.6,,2592.58,percent of total billed charges,,,85,,3825.85,percent of total billed charges,,,85,,3825.85,percent of total billed charges,,,49,,2205.49,percent of total billed charges,,,90,,4050.9,percent of total billed charges,,,65,,2925.65,percent of total billed charges,,,80,,3600.8,percent of total billed charges,,,55,,2475.55,percent of total billed charges,,,55,,2475.55,percent of total billed charges,,,65,,2925.65,percent of total billed charges,,,78,,3510.78,percent of total billed charges,,,70,,3150.7,percent of total billed charges,,,,,,,,2064.71,,,,100% of Medicare,,2064.71,,,,100% of Medicare,,2064.71,,,,100% of Medicare,,2064.71,,,,100% of Medicare,,2064.71,,,,100% of Medicare,,2064.71,,,,100% of Medicare,,2064.71,,,,100% of Medicare,,2064.71,,,,100% of Medicare,,2064.71,,,,100% of Medicare,,2064.71,,,,100% of Medicare,,2064.71,,,,100% of Medicare,,2064.71,,,,100% of Medicare,,,2064.71,,,,100% of Medicare,132.61,,,,EAPG Rate,100% of IL Medicaid,132.61,,,,EAPG Rate,100% of IL Medicaid,132.61,,,,EAPG Rate,100% of IL Medicaid,132.61,,,,EAPG Rate,100% of IL Medicaid,132.61,4050.9,
"L3977 SEWHFO, Shoulder cap design, Incl nontorsion Jts/bands/turnbuckles",L3977,HCPCS,,,,outpatient,,,4501,2700.6,,45.5,,2047.96,percent of total billed charges,,,45.3,,2038.95,percent of total billed charges,,,39,,1755.39,percent of total billed charges,,,,,,,,,80,,3600.8,percent of total billed charges,,,61.4,,2763.61,percent of total billed charges,,,57.4,,2583.57,percent of total billed charges,,,81,,3645.81,percent of total billed charges,,,39,,1755.39,percent of total billed charges,,,57.6,,2592.58,percent of total billed charges,,,85,,3825.85,percent of total billed charges,,,85,,3825.85,percent of total billed charges,,,49,,2205.49,percent of total billed charges,,,90,,4050.9,percent of total billed charges,,,65,,2925.65,percent of total billed charges,,,80,,3600.8,percent of total billed charges,,,55,,2475.55,percent of total billed charges,,,55,,2475.55,percent of total billed charges,,,65,,2925.65,percent of total billed charges,,,78,,3510.78,percent of total billed charges,,,70,,3150.7,percent of total billed charges,,,,,,,,2064.71,,,,100% of Medicare,,2064.71,,,,100% of Medicare,,2064.71,,,,100% of Medicare,,2064.71,,,,100% of Medicare,,2064.71,,,,100% of Medicare,,2064.71,,,,100% of Medicare,,2064.71,,,,100% of Medicare,,2064.71,,,,100% of Medicare,,2064.71,,,,100% of Medicare,,2064.71,,,,100% of Medicare,,2064.71,,,,100% of Medicare,,2064.71,,,,100% of Medicare,,,2064.71,,,,100% of Medicare,132.61,,,,EAPG Rate,100% of IL Medicaid,132.61,,,,EAPG Rate,100% of IL Medicaid,132.61,,,,EAPG Rate,100% of IL Medicaid,132.61,,,,EAPG Rate,100% of IL Medicaid,132.61,4050.9,
"Ankle-Foot Orthosis, Spiral, Plastic or Other Material, Prefabricated",L1951,HCPCS,,,,outpatient,,,4518,2710.8,,45.5,,2055.69,percent of total billed charges,,,45.3,,2046.65,percent of total billed charges,,,39,,1762.02,percent of total billed charges,,,,,,,,,80,,3614.4,percent of total billed charges,,,61.4,,2774.05,percent of total billed charges,,,57.4,,2593.33,percent of total billed charges,,,81,,3659.58,percent of total billed charges,,,39,,1762.02,percent of total billed charges,,,57.6,,2602.37,percent of total billed charges,,,85,,3840.3,percent of total billed charges,,,85,,3840.3,percent of total billed charges,,,49,,2213.82,percent of total billed charges,,,90,,4066.2,percent of total billed charges,,,65,,2936.7,percent of total billed charges,,,80,,3614.4,percent of total billed charges,,,55,,2484.9,percent of total billed charges,,,55,,2484.9,percent of total billed charges,,,65,,2936.7,percent of total billed charges,,,78,,3524.04,percent of total billed charges,,,70,,3162.6,percent of total billed charges,,,,,,,,1011.85,,,,100% of Medicare,,1011.85,,,,100% of Medicare,,1011.85,,,,100% of Medicare,,1011.85,,,,100% of Medicare,,1011.85,,,,100% of Medicare,,1011.85,,,29959.136,100% of Medicare,,1011.85,,,,100% of Medicare,,1011.85,,,,100% of Medicare,,1011.85,,,,100% of Medicare,,1011.85,,,,100% of Medicare,,1011.85,,,,100% of Medicare,,1011.85,,,,100% of Medicare,,,1011.85,,,,100% of Medicare,136.13,,,,EAPG Rate,100% of IL Medicaid,136.13,,,,EAPG Rate,100% of IL Medicaid,136.13,,,,EAPG Rate,100% of IL Medicaid,136.13,,,,EAPG Rate,100% of IL Medicaid,136.13,29959.14,
"Immediate postsurg/early fitting, app of initial rigid drsg, including fit/align/susp/, and 1 cast c",L6382,HCPCS,,,,outpatient,,,4533,2719.8,,45.5,,2062.52,percent of total billed charges,,,45.3,,2053.45,percent of total billed charges,,,39,,1767.87,percent of total billed charges,,,,,,,,,80,,3626.4,percent of total billed charges,,,61.4,,2783.26,percent of total billed charges,,,57.4,,2601.94,percent of total billed charges,,,81,,3671.73,percent of total billed charges,,,39,,1767.87,percent of total billed charges,,,57.6,,2611.01,percent of total billed charges,,,85,,3853.05,percent of total billed charges,,,85,,3853.05,percent of total billed charges,,,49,,2221.17,percent of total billed charges,,,90,,4079.7,percent of total billed charges,,,65,,2946.45,percent of total billed charges,,,80,,3626.4,percent of total billed charges,,,55,,2493.15,percent of total billed charges,,,55,,2493.15,percent of total billed charges,,,65,,2946.45,percent of total billed charges,,,78,,3535.74,percent of total billed charges,,,70,,3173.1,percent of total billed charges,,,,,,,,2035.34,,,,100% of Medicare,,2035.34,,,,100% of Medicare,,2035.34,,,,100% of Medicare,,2035.34,,,,100% of Medicare,,2035.34,,,,100% of Medicare,,2035.34,,,,100% of Medicare,,2035.34,,,,100% of Medicare,,2035.34,,,,100% of Medicare,,2035.34,,,,100% of Medicare,,2035.34,,,,100% of Medicare,,2035.34,,,,100% of Medicare,,2035.34,,,,100% of Medicare,,,2035.34,,,,100% of Medicare,139.24,,,,EAPG Rate,100% of IL Medicaid,139.24,,,,EAPG Rate,100% of IL Medicaid,139.24,,,,EAPG Rate,100% of IL Medicaid,139.24,,,,EAPG Rate,100% of IL Medicaid,139.24,4079.7,
L1005 Tension Scoliosis Orthosis with Pads,L1005,HCPCS,,,,outpatient,,,4564,2738.4,,45.5,,2076.62,percent of total billed charges,,,45.3,,2067.49,percent of total billed charges,,,39,,1779.96,percent of total billed charges,,,,,,,,,80,,3651.2,percent of total billed charges,,,61.4,,2802.3,percent of total billed charges,,,57.4,,2619.74,percent of total billed charges,,,81,,3696.84,percent of total billed charges,,,39,,1779.96,percent of total billed charges,,,57.6,,2628.86,percent of total billed charges,,,85,,3879.4,percent of total billed charges,,,85,,3879.4,percent of total billed charges,,,49,,2236.36,percent of total billed charges,,,90,,4107.6,percent of total billed charges,,,65,,2966.6,percent of total billed charges,,,80,,3651.2,percent of total billed charges,,,55,,2510.2,percent of total billed charges,,,55,,2510.2,percent of total billed charges,,,65,,2966.6,percent of total billed charges,,,78,,3559.92,percent of total billed charges,,,70,,3194.8,percent of total billed charges,,,,,,,,3856.33,,,,100% of Medicare,,3856.33,,,,100% of Medicare,,3856.33,,,,100% of Medicare,,3856.33,,,,100% of Medicare,,3856.33,,,,100% of Medicare,,3856.33,,,,100% of Medicare,,3856.33,,,,100% of Medicare,,3856.33,,,,100% of Medicare,,3856.33,,,,100% of Medicare,,3856.33,,,,100% of Medicare,,3856.33,,,,100% of Medicare,,3856.33,,,,100% of Medicare,,,3856.33,,,,100% of Medicare,145.66,,,,EAPG Rate,100% of IL Medicaid,145.66,,,,EAPG Rate,100% of IL Medicaid,145.66,,,,EAPG Rate,100% of IL Medicaid,145.66,,,,EAPG Rate,100% of IL Medicaid,145.66,4107.6,
"Electronic hook, child, Michigan or equal, switch controlled",L7045,HCPCS,,,,outpatient,,,4575,2745,,45.5,,2081.63,percent of total billed charges,,,45.3,,2072.48,percent of total billed charges,,,39,,1784.25,percent of total billed charges,,,,,,,,,80,,3660,percent of total billed charges,,,61.4,,2809.05,percent of total billed charges,,,57.4,,2626.05,percent of total billed charges,,,81,,3705.75,percent of total billed charges,,,39,,1784.25,percent of total billed charges,,,57.6,,2635.2,percent of total billed charges,,,85,,3888.75,percent of total billed charges,,,85,,3888.75,percent of total billed charges,,,49,,2241.75,percent of total billed charges,,,90,,4117.5,percent of total billed charges,,,65,,2973.75,percent of total billed charges,,,80,,3660,percent of total billed charges,,,55,,2516.25,percent of total billed charges,,,55,,2516.25,percent of total billed charges,,,65,,2973.75,percent of total billed charges,,,78,,3568.5,percent of total billed charges,,,70,,3202.5,percent of total billed charges,,,,,,,,1939.99,,,,100% of Medicare,,1939.99,,,,100% of Medicare,,1939.99,,,,100% of Medicare,,1939.99,,,,100% of Medicare,,1939.99,,,,100% of Medicare,,1939.99,,,,100% of Medicare,,1939.99,,,,100% of Medicare,,1939.99,,,,100% of Medicare,,1939.99,,,,100% of Medicare,,1939.99,,,,100% of Medicare,,1939.99,,,,100% of Medicare,,1939.99,,,,100% of Medicare,,,1939.99,,,,100% of Medicare,147.94,,,,EAPG Rate,100% of IL Medicaid,147.94,,,,EAPG Rate,100% of IL Medicaid,147.94,,,,EAPG Rate,100% of IL Medicaid,147.94,,,,EAPG Rate,100% of IL Medicaid,147.94,4117.5,
"Thoracic-Lumbar-Sacral Orthosis, Inclusive of Initial Orthosis",L1200,HCPCS,,,,outpatient,,,4585,2751,,45.5,,2086.18,percent of total billed charges,,,45.3,,2077.01,percent of total billed charges,,,39,,1788.15,percent of total billed charges,,,,,,,,,80,,3668,percent of total billed charges,,,61.4,,2815.19,percent of total billed charges,,,57.4,,2631.79,percent of total billed charges,,,81,,3713.85,percent of total billed charges,,,39,,1788.15,percent of total billed charges,,,57.6,,2640.96,percent of total billed charges,,,85,,3897.25,percent of total billed charges,,,85,,3897.25,percent of total billed charges,,,49,,2246.65,percent of total billed charges,,,90,,4126.5,percent of total billed charges,,,65,,2980.25,percent of total billed charges,,,80,,3668,percent of total billed charges,,,55,,2521.75,percent of total billed charges,,,55,,2521.75,percent of total billed charges,,,65,,2980.25,percent of total billed charges,,,78,,3576.3,percent of total billed charges,,,70,,3209.5,percent of total billed charges,,,,,,,,2156.12,,,,100% of Medicare,,2156.12,,,,100% of Medicare,,2156.12,,,,100% of Medicare,,2156.12,,,,100% of Medicare,,2156.12,,,,100% of Medicare,,2156.12,,,,100% of Medicare,,2156.12,,,,100% of Medicare,,2156.12,,,,100% of Medicare,,2156.12,,,,100% of Medicare,,2156.12,,,,100% of Medicare,,2156.12,,,,100% of Medicare,,2156.12,,,,100% of Medicare,,,2156.12,,,,100% of Medicare,150.01,,,,EAPG Rate,100% of IL Medicaid,150.01,,,,EAPG Rate,100% of IL Medicaid,150.01,,,,EAPG Rate,100% of IL Medicaid,150.01,,,,EAPG Rate,100% of IL Medicaid,150.01,4126.5,
"Legg Perthes Orthosis, Patten Bottom Type",L1755,HCPCS,,,,outpatient,,,4588,2752.8,,45.5,,2087.54,percent of total billed charges,,,45.3,,2078.36,percent of total billed charges,,,39,,1789.32,percent of total billed charges,,,,,,,,,80,,3670.4,percent of total billed charges,,,61.4,,2817.03,percent of total billed charges,,,57.4,,2633.51,percent of total billed charges,,,81,,3716.28,percent of total billed charges,,,39,,1789.32,percent of total billed charges,,,57.6,,2642.69,percent of total billed charges,,,85,,3899.8,percent of total billed charges,,,85,,3899.8,percent of total billed charges,,,49,,2248.12,percent of total billed charges,,,90,,4129.2,percent of total billed charges,,,65,,2982.2,percent of total billed charges,,,80,,3670.4,percent of total billed charges,,,55,,2523.4,percent of total billed charges,,,55,,2523.4,percent of total billed charges,,,65,,2982.2,percent of total billed charges,,,78,,3578.64,percent of total billed charges,,,70,,3211.6,percent of total billed charges,,,,,,,,2157.3,,,,100% of Medicare,,2157.3,,,,100% of Medicare,,2157.3,,,,100% of Medicare,,2157.3,,,,100% of Medicare,,2157.3,,,,100% of Medicare,,2157.3,,,,100% of Medicare,,2157.3,,,,100% of Medicare,,2157.3,,,,100% of Medicare,,2157.3,,,,100% of Medicare,,2157.3,,,,100% of Medicare,,2157.3,,,,100% of Medicare,,2157.3,,,,100% of Medicare,,,2157.3,,,,100% of Medicare,150.63,,,,EAPG Rate,100% of IL Medicaid,150.63,,,,EAPG Rate,100% of IL Medicaid,150.63,,,,EAPG Rate,100% of IL Medicaid,150.63,,,,EAPG Rate,100% of IL Medicaid,150.63,4129.2,
"Scoliosis Procedures, Post-Op Body Jacket",L1310,HCPCS,,,,outpatient,,,4600,2760,,45.5,,2093,percent of total billed charges,,,45.3,,2083.8,percent of total billed charges,,,39,,1794,percent of total billed charges,,,,,,,,,80,,3680,percent of total billed charges,,,61.4,,2824.4,percent of total billed charges,,,57.4,,2640.4,percent of total billed charges,,,81,,3726,percent of total billed charges,,,39,,1794,percent of total billed charges,,,57.6,,2649.6,percent of total billed charges,,,85,,3910,percent of total billed charges,,,85,,3910,percent of total billed charges,,,49,,2254,percent of total billed charges,,,90,,4140,percent of total billed charges,,,65,,2990,percent of total billed charges,,,80,,3680,percent of total billed charges,,,55,,2530,percent of total billed charges,,,55,,2530,percent of total billed charges,,,65,,2990,percent of total billed charges,,,78,,3588,percent of total billed charges,,,70,,3220,percent of total billed charges,,,,,,,,2162.89,,,,100% of Medicare,,2162.89,,,,100% of Medicare,,2162.89,,,,100% of Medicare,,2162.89,,,,100% of Medicare,,2162.89,,,,100% of Medicare,,2162.89,,,,100% of Medicare,,2162.89,,,,100% of Medicare,,2162.89,,,,100% of Medicare,,2162.89,,,,100% of Medicare,,2162.89,,,,100% of Medicare,,2162.89,,,,100% of Medicare,,2162.89,,,,100% of Medicare,,,2162.89,,,,100% of Medicare,153.12,,,,EAPG Rate,100% of IL Medicaid,153.12,,,,EAPG Rate,100% of IL Medicaid,153.12,,,,EAPG Rate,100% of IL Medicaid,153.12,,,,EAPG Rate,100% of IL Medicaid,153.12,4140,
"L6714 Terminal device, hand, VC, pediatric",L6714,HCPCS,,,,outpatient,,,4662,2797.2,,45.5,,2121.21,percent of total billed charges,,,45.3,,2111.89,percent of total billed charges,,,39,,1818.18,percent of total billed charges,,,,,,,,,80,,3729.6,percent of total billed charges,,,61.4,,2862.47,percent of total billed charges,,,57.4,,2675.99,percent of total billed charges,,,81,,3776.22,percent of total billed charges,,,39,,1818.18,percent of total billed charges,,,57.6,,2685.31,percent of total billed charges,,,85,,3962.7,percent of total billed charges,,,85,,3962.7,percent of total billed charges,,,49,,2284.38,percent of total billed charges,,,90,,4195.8,percent of total billed charges,,,65,,3030.3,percent of total billed charges,,,80,,3729.6,percent of total billed charges,,,55,,2564.1,percent of total billed charges,,,55,,2564.1,percent of total billed charges,,,65,,3030.3,percent of total billed charges,,,78,,3636.36,percent of total billed charges,,,70,,3263.4,percent of total billed charges,,,,,,,,1597.45,,,,100% of Medicare,,1597.45,,,,100% of Medicare,,1597.45,,,,100% of Medicare,,1597.45,,,,100% of Medicare,,1597.45,,,,100% of Medicare,,1597.45,,,,100% of Medicare,,1597.45,,,,100% of Medicare,,1597.45,,,,100% of Medicare,,1597.45,,,,100% of Medicare,,1597.45,,,,100% of Medicare,,1597.45,,,,100% of Medicare,,1597.45,,,,100% of Medicare,,,1597.45,,,,100% of Medicare,165.97,,,,EAPG Rate,100% of IL Medicaid,165.97,,,,EAPG Rate,100% of IL Medicaid,165.97,,,,EAPG Rate,100% of IL Medicaid,165.97,,,,EAPG Rate,100% of IL Medicaid,165.97,4195.8,
"Prep, BK ""PTB"" type socket, non-alignable sys, pylon, no cover, SACH foot, plaster socket",L5510,HCPCS,,,,outpatient,,,4737,2842.2,,45.5,,2155.34,percent of total billed charges,,,45.3,,2145.86,percent of total billed charges,,,39,,1847.43,percent of total billed charges,,,,,,,,,80,,3789.6,percent of total billed charges,,,61.4,,2908.52,percent of total billed charges,,,57.4,,2719.04,percent of total billed charges,,,81,,3836.97,percent of total billed charges,,,39,,1847.43,percent of total billed charges,,,57.6,,2728.51,percent of total billed charges,,,85,,4026.45,percent of total billed charges,,,85,,4026.45,percent of total billed charges,,,49,,2321.13,percent of total billed charges,,,90,,4263.3,percent of total billed charges,,,65,,3079.05,percent of total billed charges,,,80,,3789.6,percent of total billed charges,,,55,,2605.35,percent of total billed charges,,,55,,2605.35,percent of total billed charges,,,65,,3079.05,percent of total billed charges,,,78,,3694.86,percent of total billed charges,,,70,,3315.9,percent of total billed charges,,,,,,,,2125.9,,,,100% of Medicare,,2125.9,,,,100% of Medicare,,2125.9,,,,100% of Medicare,,2125.9,,,,100% of Medicare,,2125.9,,,,100% of Medicare,,2125.9,,,,100% of Medicare,,2125.9,,,,100% of Medicare,,2125.9,,,,100% of Medicare,,2125.9,,,,100% of Medicare,,2125.9,,,,100% of Medicare,,2125.9,,,,100% of Medicare,,2125.9,,,,100% of Medicare,,,2125.9,,,,100% of Medicare,181.51,,,,EAPG Rate,100% of IL Medicaid,181.51,,,,EAPG Rate,100% of IL Medicaid,181.51,,,,EAPG Rate,100% of IL Medicaid,181.51,,,,EAPG Rate,100% of IL Medicaid,181.51,4263.3,
"L3973 SEWHO, Airplane design, Incl Nontorsion JTs/bands/turnbuckles",L3973,HCPCS,,,,outpatient,,,4738,2842.8,,45.5,,2155.79,percent of total billed charges,,,45.3,,2146.31,percent of total billed charges,,,39,,1847.82,percent of total billed charges,,,,,,,,,80,,3790.4,percent of total billed charges,,,61.4,,2909.13,percent of total billed charges,,,57.4,,2719.61,percent of total billed charges,,,81,,3837.78,percent of total billed charges,,,39,,1847.82,percent of total billed charges,,,57.6,,2729.09,percent of total billed charges,,,85,,4027.3,percent of total billed charges,,,85,,4027.3,percent of total billed charges,,,49,,2321.62,percent of total billed charges,,,90,,4264.2,percent of total billed charges,,,65,,3079.7,percent of total billed charges,,,80,,3790.4,percent of total billed charges,,,55,,2605.9,percent of total billed charges,,,55,,2605.9,percent of total billed charges,,,65,,3079.7,percent of total billed charges,,,78,,3695.64,percent of total billed charges,,,70,,3316.6,percent of total billed charges,,,,,,,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,,2175.13,,,,100% of Medicare,181.71,,,,EAPG Rate,100% of IL Medicaid,181.71,,,,EAPG Rate,100% of IL Medicaid,181.71,,,,EAPG Rate,100% of IL Medicaid,181.71,,,,EAPG Rate,100% of IL Medicaid,181.71,4264.2,
"L3978 SEWHFO, Airplane design, Incl Nontorsion JTs/bands/turnbuckles",L3978,HCPCS,,,,outpatient,,,4738,2842.8,,45.5,,2155.79,percent of total billed charges,,,45.3,,2146.31,percent of total billed charges,,,39,,1847.82,percent of total billed charges,,,,,,,,,80,,3790.4,percent of total billed charges,,,61.4,,2909.13,percent of total billed charges,,,57.4,,2719.61,percent of total billed charges,,,81,,3837.78,percent of total billed charges,,,39,,1847.82,percent of total billed charges,,,57.6,,2729.09,percent of total billed charges,,,85,,4027.3,percent of total billed charges,,,85,,4027.3,percent of total billed charges,,,49,,2321.62,percent of total billed charges,,,90,,4264.2,percent of total billed charges,,,65,,3079.7,percent of total billed charges,,,80,,3790.4,percent of total billed charges,,,55,,2605.9,percent of total billed charges,,,55,,2605.9,percent of total billed charges,,,65,,3079.7,percent of total billed charges,,,78,,3695.64,percent of total billed charges,,,70,,3316.6,percent of total billed charges,,,,,,,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,2175.13,,,,100% of Medicare,,,2175.13,,,,100% of Medicare,181.71,,,,EAPG Rate,100% of IL Medicaid,181.71,,,,EAPG Rate,100% of IL Medicaid,181.71,,,,EAPG Rate,100% of IL Medicaid,181.71,,,,EAPG Rate,100% of IL Medicaid,181.71,4264.2,
"Addition to LE, endosys, AK or knee disartic, 4-bar linkage w/ pneumatic swing phase control",L5614,HCPCS,,,,outpatient,,,4762,2857.2,,45.5,,2166.71,percent of total billed charges,,,45.3,,2157.19,percent of total billed charges,,,39,,1857.18,percent of total billed charges,,,,,,,,,80,,3809.6,percent of total billed charges,,,61.4,,2923.87,percent of total billed charges,,,57.4,,2733.39,percent of total billed charges,,,81,,3857.22,percent of total billed charges,,,39,,1857.18,percent of total billed charges,,,57.6,,2742.91,percent of total billed charges,,,85,,4047.7,percent of total billed charges,,,85,,4047.7,percent of total billed charges,,,49,,2333.38,percent of total billed charges,,,90,,4285.8,percent of total billed charges,,,65,,3095.3,percent of total billed charges,,,80,,3809.6,percent of total billed charges,,,55,,2619.1,percent of total billed charges,,,55,,2619.1,percent of total billed charges,,,65,,3095.3,percent of total billed charges,,,78,,3714.36,percent of total billed charges,,,70,,3333.4,percent of total billed charges,,,,,,,,2037.14,,,,100% of Medicare,,2037.14,,,,100% of Medicare,,2037.14,,,,100% of Medicare,,2037.14,,,,100% of Medicare,,2037.14,,,,100% of Medicare,,2037.14,,,,100% of Medicare,,2037.14,,,,100% of Medicare,,2037.14,,,,100% of Medicare,,2037.14,,,,100% of Medicare,,2037.14,,,,100% of Medicare,,2037.14,,,,100% of Medicare,,2037.14,,,,100% of Medicare,,,2037.14,,,,100% of Medicare,186.69,,,,EAPG Rate,100% of IL Medicaid,186.69,,,,EAPG Rate,100% of IL Medicaid,186.69,,,,EAPG Rate,100% of IL Medicaid,186.69,,,,EAPG Rate,100% of IL Medicaid,186.69,4285.8,
"Ankle-Foot Orthosis, Rigid Anterior Tibial Section, Total Carbon Material, Prefabricated",L1932,HCPCS,,,,outpatient,,,4800,2880,,45.5,,2184,percent of total billed charges,,,45.3,,2174.4,percent of total billed charges,,,39,,1872,percent of total billed charges,,,,,,,,,80,,3840,percent of total billed charges,,,61.4,,2947.2,percent of total billed charges,,,57.4,,2755.2,percent of total billed charges,,,81,,3888,percent of total billed charges,,,39,,1872,percent of total billed charges,,,57.6,,2764.8,percent of total billed charges,,,85,,4080,percent of total billed charges,,,85,,4080,percent of total billed charges,,,49,,2352,percent of total billed charges,,,90,,4320,percent of total billed charges,,,65,,3120,percent of total billed charges,,,80,,3840,percent of total billed charges,,,55,,2640,percent of total billed charges,,,55,,2640,percent of total billed charges,,,65,,3120,percent of total billed charges,,,78,,3744,percent of total billed charges,,,70,,3360,percent of total billed charges,,,,,,,,1075.14,,,,100% of Medicare,,1075.14,,,,100% of Medicare,,1075.14,,,,100% of Medicare,,1075.14,,,,100% of Medicare,,1075.14,,,,100% of Medicare,,1075.14,,,,100% of Medicare,,1075.14,,,,100% of Medicare,,1075.14,,,,100% of Medicare,,1075.14,,,,100% of Medicare,,1075.14,,,,100% of Medicare,,1075.14,,,,100% of Medicare,,1075.14,,,,100% of Medicare,,,1075.14,,,,100% of Medicare,194.56,,,,EAPG Rate,100% of IL Medicaid,194.56,,,,EAPG Rate,100% of IL Medicaid,194.56,,,,EAPG Rate,100% of IL Medicaid,194.56,,,,EAPG Rate,100% of IL Medicaid,194.56,4320,
SO AIRPLANE W/WO JOINT CF,L3674,HCPCS,,,,outpatient,,,4816,2889.6,,45.5,,2191.28,percent of total billed charges,,,45.3,,2181.65,percent of total billed charges,,,39,,1878.24,percent of total billed charges,,,,,,,,,80,,3852.8,percent of total billed charges,,,61.4,,2957.02,percent of total billed charges,,,57.4,,2764.38,percent of total billed charges,,,81,,3900.96,percent of total billed charges,,,39,,1878.24,percent of total billed charges,,,57.6,,2774.02,percent of total billed charges,,,85,,4093.6,percent of total billed charges,,,85,,4093.6,percent of total billed charges,,,49,,2359.84,percent of total billed charges,,,90,,4334.4,percent of total billed charges,,,65,,3130.4,percent of total billed charges,,,80,,3852.8,percent of total billed charges,,,55,,2648.8,percent of total billed charges,,,55,,2648.8,percent of total billed charges,,,65,,3130.4,percent of total billed charges,,,78,,3756.48,percent of total billed charges,,,70,,3371.2,percent of total billed charges,,,,,,,,1296.14,,,,100% of Medicare,,1296.14,,,,100% of Medicare,,1296.14,,,,100% of Medicare,,1296.14,,,,100% of Medicare,,1296.14,,,,100% of Medicare,,1296.14,,,,100% of Medicare,,1296.14,,,,100% of Medicare,,1296.14,,,,100% of Medicare,,1296.14,,,,100% of Medicare,,1296.14,,,,100% of Medicare,,1296.14,,,,100% of Medicare,,1296.14,,,,100% of Medicare,,,1296.14,,,,100% of Medicare,197.88,,,,EAPG Rate,100% of IL Medicaid,197.88,,,,EAPG Rate,100% of IL Medicaid,197.88,,,,EAPG Rate,100% of IL Medicaid,197.88,,,,EAPG Rate,100% of IL Medicaid,197.88,4334.4,
"Addit to LE, BK/AK, custom fab socket insert for congen/atyp traum amp, silicone gel, elasto or equa",L5681,HCPCS,,,,outpatient,,,4829,2897.4,,45.5,,2197.2,percent of total billed charges,,,45.3,,2187.54,percent of total billed charges,,,39,,1883.31,percent of total billed charges,,,,,,,,,80,,3863.2,percent of total billed charges,,,61.4,,2965.01,percent of total billed charges,,,57.4,,2771.85,percent of total billed charges,,,81,,3911.49,percent of total billed charges,,,39,,1883.31,percent of total billed charges,,,57.6,,2781.5,percent of total billed charges,,,85,,4104.65,percent of total billed charges,,,85,,4104.65,percent of total billed charges,,,49,,2366.21,percent of total billed charges,,,90,,4346.1,percent of total billed charges,,,65,,3138.85,percent of total billed charges,,,80,,3863.2,percent of total billed charges,,,55,,2655.95,percent of total billed charges,,,55,,2655.95,percent of total billed charges,,,65,,3138.85,percent of total billed charges,,,78,,3766.62,percent of total billed charges,,,70,,3380.3,percent of total billed charges,,,,,,,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,,1587.98,,,,100% of Medicare,200.57,,,,EAPG Rate,100% of IL Medicaid,200.57,,,,EAPG Rate,100% of IL Medicaid,200.57,,,,EAPG Rate,100% of IL Medicaid,200.57,,,,EAPG Rate,100% of IL Medicaid,200.57,4346.1,
"Addition, exo knee-shin sys, single axis, fluid swing",L5724,HCPCS,,,,outpatient,,,4875,2925,,45.5,,2218.13,percent of total billed charges,,,45.3,,2208.38,percent of total billed charges,,,39,,1901.25,percent of total billed charges,,,,,,,,,80,,3900,percent of total billed charges,,,61.4,,2993.25,percent of total billed charges,,,57.4,,2798.25,percent of total billed charges,,,81,,3948.75,percent of total billed charges,,,39,,1901.25,percent of total billed charges,,,57.6,,2808,percent of total billed charges,,,85,,4143.75,percent of total billed charges,,,85,,4143.75,percent of total billed charges,,,49,,2388.75,percent of total billed charges,,,90,,4387.5,percent of total billed charges,,,65,,3168.75,percent of total billed charges,,,80,,3900,percent of total billed charges,,,55,,2681.25,percent of total billed charges,,,55,,2681.25,percent of total billed charges,,,65,,3168.75,percent of total billed charges,,,78,,3802.5,percent of total billed charges,,,70,,3412.5,percent of total billed charges,,,,,,,,2085.56,,,,100% of Medicare,,2085.56,,,,100% of Medicare,,2085.56,,,,100% of Medicare,,2085.56,,,,100% of Medicare,,2085.56,,,,100% of Medicare,,2085.56,,,,100% of Medicare,,2085.56,,,,100% of Medicare,,2085.56,,,,100% of Medicare,,2085.56,,,,100% of Medicare,,2085.56,,,,100% of Medicare,,2085.56,,,,100% of Medicare,,2085.56,,,,100% of Medicare,,,2085.56,,,,100% of Medicare,210.1,,,,EAPG Rate,100% of IL Medicaid,210.1,,,,EAPG Rate,100% of IL Medicaid,210.1,,,,EAPG Rate,100% of IL Medicaid,210.1,,,,EAPG Rate,100% of IL Medicaid,210.1,4387.5,
"Terminal device, hand, voluntary closing",L6709,HCPCS,,,,outpatient,,,4897,2938.2,,45.5,,2228.14,percent of total billed charges,,,45.3,,2218.34,percent of total billed charges,,,39,,1909.83,percent of total billed charges,,,,,,,,,80,,3917.6,percent of total billed charges,,,61.4,,3006.76,percent of total billed charges,,,57.4,,2810.88,percent of total billed charges,,,81,,3966.57,percent of total billed charges,,,39,,1909.83,percent of total billed charges,,,57.6,,2820.67,percent of total billed charges,,,85,,4162.45,percent of total billed charges,,,85,,4162.45,percent of total billed charges,,,49,,2399.53,percent of total billed charges,,,90,,4407.3,percent of total billed charges,,,65,,3183.05,percent of total billed charges,,,80,,3917.6,percent of total billed charges,,,55,,2693.35,percent of total billed charges,,,55,,2693.35,percent of total billed charges,,,65,,3183.05,percent of total billed charges,,,78,,3819.66,percent of total billed charges,,,70,,3427.9,percent of total billed charges,,,,,,,,1678.64,,,,100% of Medicare,,1678.64,,,,100% of Medicare,,1678.64,,,,100% of Medicare,,1678.64,,,,100% of Medicare,,1678.64,,,,100% of Medicare,,1678.64,,,,100% of Medicare,,1678.64,,,,100% of Medicare,,1678.64,,,,100% of Medicare,,1678.64,,,,100% of Medicare,,1678.64,,,,100% of Medicare,,1678.64,,,,100% of Medicare,,1678.64,,,,100% of Medicare,,,1678.64,,,,100% of Medicare,214.66,,,,EAPG Rate,100% of IL Medicaid,214.66,,,,EAPG Rate,100% of IL Medicaid,214.66,,,,EAPG Rate,100% of IL Medicaid,214.66,,,,EAPG Rate,100% of IL Medicaid,214.66,4407.3,
"Cervical Halo Procedure, Incorporated Into Plaster Body Jacket",L0820,HCPCS,,,,outpatient,,,5387,3232.2,,45.5,,2451.09,percent of total billed charges,,,45.3,,2440.31,percent of total billed charges,,,39,,2100.93,percent of total billed charges,,,,,,,,,80,,4309.6,percent of total billed charges,,,61.4,,3307.62,percent of total billed charges,,,57.4,,3092.14,percent of total billed charges,,,81,,4363.47,percent of total billed charges,,,39,,2100.93,percent of total billed charges,,,57.6,,3102.91,percent of total billed charges,,,85,,4578.95,percent of total billed charges,,,85,,4578.95,percent of total billed charges,,,49,,2639.63,percent of total billed charges,,,90,,4848.3,percent of total billed charges,,,65,,3501.55,percent of total billed charges,,,80,,4309.6,percent of total billed charges,,,55,,2962.85,percent of total billed charges,,,55,,2962.85,percent of total billed charges,,,65,,3501.55,percent of total billed charges,,,78,,4201.86,percent of total billed charges,,,70,,3770.9,percent of total billed charges,,,,,,,,2533.35,,,,100% of Medicare,,2533.35,,,,100% of Medicare,,2533.35,,,,100% of Medicare,,2533.35,,,,100% of Medicare,,2533.35,,,,100% of Medicare,,2533.35,,,,100% of Medicare,,2533.35,,,,100% of Medicare,,2533.35,,,,100% of Medicare,,2533.35,,,,100% of Medicare,,2533.35,,,,100% of Medicare,,2533.35,,,,100% of Medicare,,2533.35,,,,100% of Medicare,,,2533.35,,,,100% of Medicare,216.19,,,,EAPG Rate,100% of IL Medicaid,216.19,,,,EAPG Rate,100% of IL Medicaid,216.19,,,,EAPG Rate,100% of IL Medicaid,216.19,,,,EAPG Rate,100% of IL Medicaid,216.19,4848.3,
TLSO FLEX TRNK SJ-SS PRE OTS (L0457),L0457,HCPCS,,,,outpatient,,,4950,2970,,45.5,,2252.25,percent of total billed charges,,,45.3,,2242.35,percent of total billed charges,,,39,,1930.5,percent of total billed charges,,,,,,,,,80,,3960,percent of total billed charges,,,61.4,,3039.3,percent of total billed charges,,,57.4,,2841.3,percent of total billed charges,,,81,,4009.5,percent of total billed charges,,,39,,1930.5,percent of total billed charges,,,57.6,,2851.2,percent of total billed charges,,,85,,4207.5,percent of total billed charges,,,85,,4207.5,percent of total billed charges,,,49,,2425.5,percent of total billed charges,,,90,,4455,percent of total billed charges,,,65,,3217.5,percent of total billed charges,,,80,,3960,percent of total billed charges,,,55,,2722.5,percent of total billed charges,,,55,,2722.5,percent of total billed charges,,,65,,3217.5,percent of total billed charges,,,78,,3861,percent of total billed charges,,,70,,3465,percent of total billed charges,,,,,,,,638.5,,,,100% of Medicare,,638.5,,,,100% of Medicare,,638.5,,,,100% of Medicare,,638.5,,,,100% of Medicare,,638.5,,,,100% of Medicare,,638.5,,,,100% of Medicare,,638.5,,,,100% of Medicare,,638.5,,,,100% of Medicare,,638.5,,,,100% of Medicare,,638.5,,,,100% of Medicare,,638.5,,,,100% of Medicare,,638.5,,,,100% of Medicare,,,638.5,,,,100% of Medicare,225.64,,,,EAPG Rate,100% of IL Medicaid,225.64,,,,EAPG Rate,100% of IL Medicaid,225.64,,,,EAPG Rate,100% of IL Medicaid,225.64,,,,EAPG Rate,100% of IL Medicaid,225.64,4455,
TLSO R FRAM SOFT PRE OTS (L0467),L0467,HCPCS,,,,outpatient,,,4950,2970,,45.5,,2252.25,percent of total billed charges,,,45.3,,2242.35,percent of total billed charges,,,39,,1930.5,percent of total billed charges,,,,,,,,,80,,3960,percent of total billed charges,,,61.4,,3039.3,percent of total billed charges,,,57.4,,2841.3,percent of total billed charges,,,81,,4009.5,percent of total billed charges,,,39,,1930.5,percent of total billed charges,,,57.6,,2851.2,percent of total billed charges,,,85,,4207.5,percent of total billed charges,,,85,,4207.5,percent of total billed charges,,,49,,2425.5,percent of total billed charges,,,90,,4455,percent of total billed charges,,,65,,3217.5,percent of total billed charges,,,80,,3960,percent of total billed charges,,,55,,2722.5,percent of total billed charges,,,55,,2722.5,percent of total billed charges,,,65,,3217.5,percent of total billed charges,,,78,,3861,percent of total billed charges,,,70,,3465,percent of total billed charges,,,,,,,,249.71,,,,100% of Medicare,,249.71,,,,100% of Medicare,,249.71,,,,100% of Medicare,,249.71,,,,100% of Medicare,,249.71,,,,100% of Medicare,,249.71,,,,100% of Medicare,,249.71,,,,100% of Medicare,,249.71,,,,100% of Medicare,,249.71,,,,100% of Medicare,,249.71,,,,100% of Medicare,,249.71,,,,100% of Medicare,,249.71,,,,100% of Medicare,,,249.71,,,,100% of Medicare,225.64,,,,EAPG Rate,100% of IL Medicaid,225.64,,,,EAPG Rate,100% of IL Medicaid,225.64,,,,EAPG Rate,100% of IL Medicaid,225.64,,,,EAPG Rate,100% of IL Medicaid,225.64,4455,
"Addit to LE, BK/AK, custom fab socket insert for other than congen/atyp, silicone gel, elasto or equ",L5683,HCPCS,,,,outpatient,,,4974,2984.4,,45.5,,2263.17,percent of total billed charges,,,45.3,,2253.22,percent of total billed charges,,,39,,1939.86,percent of total billed charges,,,,,,,,,80,,3979.2,percent of total billed charges,,,61.4,,3054.04,percent of total billed charges,,,57.4,,2855.08,percent of total billed charges,,,81,,4028.94,percent of total billed charges,,,39,,1939.86,percent of total billed charges,,,57.6,,2865.02,percent of total billed charges,,,85,,4227.9,percent of total billed charges,,,85,,4227.9,percent of total billed charges,,,49,,2437.26,percent of total billed charges,,,90,,4476.6,percent of total billed charges,,,65,,3233.1,percent of total billed charges,,,80,,3979.2,percent of total billed charges,,,55,,2735.7,percent of total billed charges,,,55,,2735.7,percent of total billed charges,,,65,,3233.1,percent of total billed charges,,,78,,3879.72,percent of total billed charges,,,70,,3481.8,percent of total billed charges,,,,,,,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,,1587.98,,,,100% of Medicare,230.61,,,,EAPG Rate,100% of IL Medicaid,230.61,,,,EAPG Rate,100% of IL Medicaid,230.61,,,,EAPG Rate,100% of IL Medicaid,230.61,,,,EAPG Rate,100% of IL Medicaid,230.61,4476.6,
"Hip Orthosis, Abduction Control, Post-op type",L1686,HCPCS,,,,outpatient,,,5040,3024,,45.5,,2293.2,percent of total billed charges,,,45.3,,2283.12,percent of total billed charges,,,39,,1965.6,percent of total billed charges,,,,,,,,,80,,4032,percent of total billed charges,,,61.4,,3094.56,percent of total billed charges,,,57.4,,2892.96,percent of total billed charges,,,81,,4082.4,percent of total billed charges,,,39,,1965.6,percent of total billed charges,,,57.6,,2903.04,percent of total billed charges,,,85,,4284,percent of total billed charges,,,85,,4284,percent of total billed charges,,,49,,2469.6,percent of total billed charges,,,90,,4536,percent of total billed charges,,,65,,3276,percent of total billed charges,,,80,,4032,percent of total billed charges,,,55,,2772,percent of total billed charges,,,55,,2772,percent of total billed charges,,,65,,3276,percent of total billed charges,,,78,,3931.2,percent of total billed charges,,,70,,3528,percent of total billed charges,,,,,,,,1128.98,,,,100% of Medicare,,1128.98,,,,100% of Medicare,,1128.98,,,,100% of Medicare,,1128.98,,,,100% of Medicare,,1128.98,,,,100% of Medicare,,1128.98,,,,100% of Medicare,,1128.98,,,,100% of Medicare,,1128.98,,,,100% of Medicare,,1128.98,,,,100% of Medicare,,1128.98,,,,100% of Medicare,,1128.98,,,,100% of Medicare,,1128.98,,,,100% of Medicare,,,1128.98,,,,100% of Medicare,244.29,,,,EAPG Rate,100% of IL Medicaid,244.29,,,,EAPG Rate,100% of IL Medicaid,244.29,,,,EAPG Rate,100% of IL Medicaid,244.29,,,,EAPG Rate,100% of IL Medicaid,244.29,4536,
"Wrist-Hand-Finger Orthosis, Dynamic Flexor Hinge, Cable Driven",L3901,HCPCS,,,,outpatient,,,5058,3034.8,,45.5,,2301.39,percent of total billed charges,,,45.3,,2291.27,percent of total billed charges,,,39,,1972.62,percent of total billed charges,,,,,,,,,80,,4046.4,percent of total billed charges,,,61.4,,3105.61,percent of total billed charges,,,57.4,,2903.29,percent of total billed charges,,,81,,4096.98,percent of total billed charges,,,39,,1972.62,percent of total billed charges,,,57.6,,2913.41,percent of total billed charges,,,85,,4299.3,percent of total billed charges,,,85,,4299.3,percent of total billed charges,,,49,,2478.42,percent of total billed charges,,,90,,4552.2,percent of total billed charges,,,65,,3287.7,percent of total billed charges,,,80,,4046.4,percent of total billed charges,,,55,,2781.9,percent of total billed charges,,,55,,2781.9,percent of total billed charges,,,65,,3287.7,percent of total billed charges,,,78,,3945.24,percent of total billed charges,,,70,,3540.6,percent of total billed charges,,,,,,,,2327.97,,,,100% of Medicare,,2327.97,,,,100% of Medicare,,2327.97,,,,100% of Medicare,,2327.97,,,,100% of Medicare,,2327.97,,,,100% of Medicare,,2327.97,,,,100% of Medicare,,2327.97,,,,100% of Medicare,,2327.97,,,,100% of Medicare,,2327.97,,,,100% of Medicare,,2327.97,,,,100% of Medicare,,2327.97,,,,100% of Medicare,,2327.97,,,,100% of Medicare,,,2327.97,,,,100% of Medicare,248.02,,,,EAPG Rate,100% of IL Medicaid,248.02,,,,EAPG Rate,100% of IL Medicaid,248.02,,,,EAPG Rate,100% of IL Medicaid,248.02,,,,EAPG Rate,100% of IL Medicaid,248.02,4552.2,
"Legg Perthes Orthosis, Newington Type",L1710,HCPCS,,,,outpatient,,,5076,3045.6,,45.5,,2309.58,percent of total billed charges,,,45.3,,2299.43,percent of total billed charges,,,39,,1979.64,percent of total billed charges,,,,,,,,,80,,4060.8,percent of total billed charges,,,61.4,,3116.66,percent of total billed charges,,,57.4,,2913.62,percent of total billed charges,,,81,,4111.56,percent of total billed charges,,,39,,1979.64,percent of total billed charges,,,57.6,,2923.78,percent of total billed charges,,,85,,4314.6,percent of total billed charges,,,85,,4314.6,percent of total billed charges,,,49,,2487.24,percent of total billed charges,,,90,,4568.4,percent of total billed charges,,,65,,3299.4,percent of total billed charges,,,80,,4060.8,percent of total billed charges,,,55,,2791.8,percent of total billed charges,,,55,,2791.8,percent of total billed charges,,,65,,3299.4,percent of total billed charges,,,78,,3959.28,percent of total billed charges,,,70,,3553.2,percent of total billed charges,,,,,,,,2387.05,,,,100% of Medicare,,2387.05,,,,100% of Medicare,,2387.05,,,,100% of Medicare,,2387.05,,,,100% of Medicare,,2387.05,,,,100% of Medicare,,2387.05,,,,100% of Medicare,,2387.05,,,,100% of Medicare,,2387.05,,,,100% of Medicare,,2387.05,,,,100% of Medicare,,2387.05,,,,100% of Medicare,,2387.05,,,,100% of Medicare,,2387.05,,,,100% of Medicare,,,2387.05,,,,100% of Medicare,251.75,,,,EAPG Rate,100% of IL Medicaid,251.75,,,,EAPG Rate,100% of IL Medicaid,251.75,,,,EAPG Rate,100% of IL Medicaid,251.75,,,,EAPG Rate,100% of IL Medicaid,251.75,4568.4,
"Cervical-Thoracic-Lumbar-Sacral Orthosis, Ant/Post/Lat Control, Molded to Patient",L0700,HCPCS,,,,outpatient,,,5100,3060,,45.5,,2320.5,percent of total billed charges,,,45.3,,2310.3,percent of total billed charges,,,39,,1989,percent of total billed charges,,,,,,,,,80,,4080,percent of total billed charges,,,61.4,,3131.4,percent of total billed charges,,,57.4,,2927.4,percent of total billed charges,,,81,,4131,percent of total billed charges,,,39,,1989,percent of total billed charges,,,57.6,,2937.6,percent of total billed charges,,,85,,4335,percent of total billed charges,,,85,,4335,percent of total billed charges,,,49,,2499,percent of total billed charges,,,90,,4590,percent of total billed charges,,,65,,3315,percent of total billed charges,,,80,,4080,percent of total billed charges,,,55,,2805,percent of total billed charges,,,55,,2805,percent of total billed charges,,,65,,3315,percent of total billed charges,,,78,,3978,percent of total billed charges,,,70,,3570,percent of total billed charges,,,,,,,,2398.6,,,,100% of Medicare,,2398.6,,,,100% of Medicare,,2398.6,,,,100% of Medicare,,2398.6,,,,100% of Medicare,,2398.6,,,,100% of Medicare,,2398.6,,,,100% of Medicare,,2398.6,,,,100% of Medicare,,2398.6,,,,100% of Medicare,,2398.6,,,,100% of Medicare,,2398.6,,,,100% of Medicare,,2398.6,,,,100% of Medicare,,2398.6,,,,100% of Medicare,,,2398.6,,,,100% of Medicare,256.72,,,,EAPG Rate,100% of IL Medicaid,256.72,,,,EAPG Rate,100% of IL Medicaid,256.72,,,,EAPG Rate,100% of IL Medicaid,256.72,,,,EAPG Rate,100% of IL Medicaid,256.72,4590,
LSO SAG R AN/POS PNL PRE OTS (L0648),L0648,HCPCS,,,,outpatient,,,5112,3067.2,,45.5,,2325.96,percent of total billed charges,,,45.3,,2315.74,percent of total billed charges,,,39,,1993.68,percent of total billed charges,,,,,,,,,80,,4089.6,percent of total billed charges,,,61.4,,3138.77,percent of total billed charges,,,57.4,,2934.29,percent of total billed charges,,,81,,4140.72,percent of total billed charges,,,39,,1993.68,percent of total billed charges,,,57.6,,2944.51,percent of total billed charges,,,85,,4345.2,percent of total billed charges,,,85,,4345.2,percent of total billed charges,,,49,,2504.88,percent of total billed charges,,,90,,4600.8,percent of total billed charges,,,65,,3322.8,percent of total billed charges,,,80,,4089.6,percent of total billed charges,,,55,,2811.6,percent of total billed charges,,,55,,2811.6,percent of total billed charges,,,65,,3322.8,percent of total billed charges,,,78,,3987.36,percent of total billed charges,,,70,,3578.4,percent of total billed charges,,,,,,,,659.19,,,,100% of Medicare,,659.19,,,,100% of Medicare,,659.19,,,,100% of Medicare,,659.19,,,,100% of Medicare,,659.19,,,,100% of Medicare,,659.19,,,,100% of Medicare,,659.19,,,,100% of Medicare,,659.19,,,,100% of Medicare,,659.19,,,,100% of Medicare,,659.19,,,,100% of Medicare,,659.19,,,,100% of Medicare,,659.19,,,,100% of Medicare,,,659.19,,,,100% of Medicare,259.21,,,,EAPG Rate,100% of IL Medicaid,259.21,,,,EAPG Rate,100% of IL Medicaid,259.21,,,,EAPG Rate,100% of IL Medicaid,259.21,,,,EAPG Rate,100% of IL Medicaid,259.21,4600.8,
C-Arm Exam,72295,CPT,,,TC,both,,,1244,746.4,,45.5,,566.02,percent of total billed charges,,,45.3,,563.53,percent of total billed charges,,,51,,634.44,percent of total billed charges,,,,,,,,,80,,995.2,percent of total billed charges,,,61.4,,763.82,percent of total billed charges,,,57.4,,714.06,percent of total billed charges,,,81,,1007.64,percent of total billed charges,,,51.5,,640.66,percent of total billed charges,,,57.6,,716.54,percent of total billed charges,,,85,,1057.4,percent of total billed charges,,,85,,1057.4,percent of total billed charges,,,49,,609.56,percent of total billed charges,,,90,,1119.6,percent of total billed charges,,,65,,808.6,percent of total billed charges,,,80,,995.2,percent of total billed charges,,,55,,684.2,percent of total billed charges,,,55,,684.2,percent of total billed charges,,,65,,808.6,percent of total billed charges,,,78,,970.32,percent of total billed charges,,,70,,870.8,percent of total billed charges,,,,,,,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,,2035.61,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,563.53,2035.61,
Radiological Interpretation for Lumbar Discography (72295),72295,CPT,,,TC,outpatient,,,4635,2781,,45.5,,2108.93,percent of total billed charges,,,45.3,,2099.66,percent of total billed charges,,,51,,2363.85,percent of total billed charges,,,,,,,,,80,,3708,percent of total billed charges,,,61.4,,2845.89,percent of total billed charges,,,57.4,,2660.49,percent of total billed charges,,,81,,3754.35,percent of total billed charges,,,51.5,,2387.03,percent of total billed charges,,,57.6,,2669.76,percent of total billed charges,,,85,,3939.75,percent of total billed charges,,,85,,3939.75,percent of total billed charges,,,49,,2271.15,percent of total billed charges,,,90,,4171.5,percent of total billed charges,,,65,,3012.75,percent of total billed charges,,,80,,3708,percent of total billed charges,,,55,,2549.25,percent of total billed charges,,,55,,2549.25,percent of total billed charges,,,65,,3012.75,percent of total billed charges,,,78,,3615.3,percent of total billed charges,,,70,,3244.5,percent of total billed charges,,,,,,,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,2035.61,,,,100% of Medicare,,,2035.61,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,2035.61,4171.5,
"Cervical-Thoracic-Lumbar-Sacral Orthosis, Milwaukee Type, Incl Initial Orth/Model",L1000,HCPCS,,,,outpatient,,,5193,3115.8,,45.5,,2362.82,percent of total billed charges,,,45.3,,2352.43,percent of total billed charges,,,39,,2025.27,percent of total billed charges,,,,,,,,,80,,4154.4,percent of total billed charges,,,61.4,,3188.5,percent of total billed charges,,,57.4,,2980.78,percent of total billed charges,,,81,,4206.33,percent of total billed charges,,,39,,2025.27,percent of total billed charges,,,57.6,,2991.17,percent of total billed charges,,,85,,4414.05,percent of total billed charges,,,85,,4414.05,percent of total billed charges,,,49,,2544.57,percent of total billed charges,,,90,,4673.7,percent of total billed charges,,,65,,3375.45,percent of total billed charges,,,80,,4154.4,percent of total billed charges,,,55,,2856.15,percent of total billed charges,,,55,,2856.15,percent of total billed charges,,,65,,3375.45,percent of total billed charges,,,78,,4050.54,percent of total billed charges,,,70,,3635.1,percent of total billed charges,,,,,,,,2443.18,,,,100% of Medicare,,2443.18,,,,100% of Medicare,,2443.18,,,,100% of Medicare,,2443.18,,,,100% of Medicare,,2443.18,,,,100% of Medicare,,2443.18,,,,100% of Medicare,,2443.18,,,,100% of Medicare,,2443.18,,,,100% of Medicare,,2443.18,,,,100% of Medicare,,2443.18,,,,100% of Medicare,,2443.18,,,,100% of Medicare,,2443.18,,,,100% of Medicare,,,2443.18,,,,100% of Medicare,275.99,,,,EAPG Rate,100% of IL Medicaid,275.99,,,,EAPG Rate,100% of IL Medicaid,275.99,,,,EAPG Rate,100% of IL Medicaid,275.99,,,,EAPG Rate,100% of IL Medicaid,275.99,4673.7,
"Prep, BK ""PTB"" type socket, non-alignable sys, pylon, no cover, SACH foot, prefab",L5535,HCPCS,,,,outpatient,,,5202,3121.2,,45.5,,2366.91,percent of total billed charges,,,45.3,,2356.51,percent of total billed charges,,,39,,2028.78,percent of total billed charges,,,,,,,,,80,,4161.6,percent of total billed charges,,,61.4,,3194.03,percent of total billed charges,,,57.4,,2985.95,percent of total billed charges,,,81,,4213.62,percent of total billed charges,,,39,,2028.78,percent of total billed charges,,,57.6,,2996.35,percent of total billed charges,,,85,,4421.7,percent of total billed charges,,,85,,4421.7,percent of total billed charges,,,49,,2548.98,percent of total billed charges,,,90,,4681.8,percent of total billed charges,,,65,,3381.3,percent of total billed charges,,,80,,4161.6,percent of total billed charges,,,55,,2861.1,percent of total billed charges,,,55,,2861.1,percent of total billed charges,,,65,,3381.3,percent of total billed charges,,,78,,4057.56,percent of total billed charges,,,70,,3641.4,percent of total billed charges,,,,,,,,2335.24,,,,100% of Medicare,,2335.24,,,,100% of Medicare,,2335.24,,,,100% of Medicare,,2335.24,,,,100% of Medicare,,2335.24,,,,100% of Medicare,,2335.24,,,,100% of Medicare,,2335.24,,,,100% of Medicare,,2335.24,,,,100% of Medicare,,2335.24,,,,100% of Medicare,,2335.24,,,,100% of Medicare,,2335.24,,,,100% of Medicare,,2335.24,,,,100% of Medicare,,,2335.24,,,,100% of Medicare,277.85,,,,EAPG Rate,100% of IL Medicaid,277.85,,,,EAPG Rate,100% of IL Medicaid,277.85,,,,EAPG Rate,100% of IL Medicaid,277.85,,,,EAPG Rate,100% of IL Medicaid,277.85,4681.8,
"Addition to LE, AK, flexible inner socket, external frame",L5651,HCPCS,,,,outpatient,,,5214,3128.4,,45.5,,2372.37,percent of total billed charges,,,45.3,,2361.94,percent of total billed charges,,,39,,2033.46,percent of total billed charges,,,,,,,,,80,,4171.2,percent of total billed charges,,,61.4,,3201.4,percent of total billed charges,,,57.4,,2992.84,percent of total billed charges,,,81,,4223.34,percent of total billed charges,,,39,,2033.46,percent of total billed charges,,,57.6,,3003.26,percent of total billed charges,,,85,,4431.9,percent of total billed charges,,,85,,4431.9,percent of total billed charges,,,49,,2554.86,percent of total billed charges,,,90,,4692.6,percent of total billed charges,,,65,,3389.1,percent of total billed charges,,,80,,4171.2,percent of total billed charges,,,55,,2867.7,percent of total billed charges,,,55,,2867.7,percent of total billed charges,,,65,,3389.1,percent of total billed charges,,,78,,4066.92,percent of total billed charges,,,70,,3649.8,percent of total billed charges,,,,,,,,1716.73,,,,100% of Medicare,,1716.73,,,,100% of Medicare,,1716.73,,,,100% of Medicare,,1716.73,,,,100% of Medicare,,1716.73,,,,100% of Medicare,,1716.73,,,,100% of Medicare,,1716.73,,,,100% of Medicare,,1716.73,,,,100% of Medicare,,1716.73,,,,100% of Medicare,,1716.73,,,,100% of Medicare,,1716.73,,,,100% of Medicare,,1716.73,,,,100% of Medicare,,,1716.73,,,,100% of Medicare,280.34,,,,EAPG Rate,100% of IL Medicaid,280.34,,,,EAPG Rate,100% of IL Medicaid,280.34,,,,EAPG Rate,100% of IL Medicaid,280.34,,,,EAPG Rate,100% of IL Medicaid,280.34,4692.6,
"Custom shaped protective cover, hip disartic",L5707,HCPCS,,,,outpatient,,,5242,3145.2,,45.5,,2385.11,percent of total billed charges,,,45.3,,2374.63,percent of total billed charges,,,39,,2044.38,percent of total billed charges,,,,,,,,,80,,4193.6,percent of total billed charges,,,61.4,,3218.59,percent of total billed charges,,,57.4,,3008.91,percent of total billed charges,,,81,,4246.02,percent of total billed charges,,,39,,2044.38,percent of total billed charges,,,57.6,,3019.39,percent of total billed charges,,,85,,4455.7,percent of total billed charges,,,85,,4455.7,percent of total billed charges,,,49,,2568.58,percent of total billed charges,,,90,,4717.8,percent of total billed charges,,,65,,3407.3,percent of total billed charges,,,80,,4193.6,percent of total billed charges,,,55,,2883.1,percent of total billed charges,,,55,,2883.1,percent of total billed charges,,,65,,3407.3,percent of total billed charges,,,78,,4088.76,percent of total billed charges,,,70,,3669.4,percent of total billed charges,,,,,,,,1813.93,,,,100% of Medicare,,1813.93,,,,100% of Medicare,,1813.93,,,,100% of Medicare,,1813.93,,,,100% of Medicare,,1813.93,,,,100% of Medicare,,1813.93,,,,100% of Medicare,,1813.93,,,,100% of Medicare,,1813.93,,,,100% of Medicare,,1813.93,,,,100% of Medicare,,1813.93,,,,100% of Medicare,,1813.93,,,,100% of Medicare,,1813.93,,,,100% of Medicare,,,1813.93,,,,100% of Medicare,286.14,,,,EAPG Rate,100% of IL Medicaid,286.14,,,,EAPG Rate,100% of IL Medicaid,286.14,,,,EAPG Rate,100% of IL Medicaid,286.14,,,,EAPG Rate,100% of IL Medicaid,286.14,4717.8,
XR Clavicle Left,73000,CPT,,,LT,both,,,570,342,,45.5,,259.35,percent of total billed charges,,,45.3,,258.21,percent of total billed charges,,,51,,290.7,percent of total billed charges,,,,,,,,,80,,456,percent of total billed charges,,,61.4,,349.98,percent of total billed charges,,,57.4,,327.18,percent of total billed charges,,,81,,461.7,percent of total billed charges,,,51.5,,293.55,percent of total billed charges,,365,,,,fee schedule,,,85,,484.5,percent of total billed charges,,,85,,484.5,percent of total billed charges,,,49,,279.3,percent of total billed charges,,,90,,513,percent of total billed charges,,,65,,370.5,percent of total billed charges,,,80,,456,percent of total billed charges,,,55,,313.5,percent of total billed charges,,,55,,313.5,percent of total billed charges,,,65,,370.5,percent of total billed charges,,,78,,444.6,percent of total billed charges,,,70,,399,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,513,
XR Clavicle Right,73000,CPT,,,RT,both,,,570,342,,45.5,,259.35,percent of total billed charges,,,45.3,,258.21,percent of total billed charges,,,51,,290.7,percent of total billed charges,,,,,,,,,80,,456,percent of total billed charges,,,61.4,,349.98,percent of total billed charges,,,57.4,,327.18,percent of total billed charges,,,81,,461.7,percent of total billed charges,,,51.5,,293.55,percent of total billed charges,,365,,,,fee schedule,,,85,,484.5,percent of total billed charges,,,85,,484.5,percent of total billed charges,,,49,,279.3,percent of total billed charges,,,90,,513,percent of total billed charges,,,65,,370.5,percent of total billed charges,,,80,,456,percent of total billed charges,,,55,,313.5,percent of total billed charges,,,55,,313.5,percent of total billed charges,,,65,,370.5,percent of total billed charges,,,78,,444.6,percent of total billed charges,,,70,,399,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,513,
"Elbow Orthosis, Double Upright w/ Forearm/Arm Cuffs, Adjustable Lock",L3740,HCPCS,,,,outpatient,,,5260,3156,,45.5,,2393.3,percent of total billed charges,,,45.3,,2382.78,percent of total billed charges,,,39,,2051.4,percent of total billed charges,,,,,,,,,80,,4208,percent of total billed charges,,,61.4,,3229.64,percent of total billed charges,,,57.4,,3019.24,percent of total billed charges,,,81,,4260.6,percent of total billed charges,,,39,,2051.4,percent of total billed charges,,,57.6,,3029.76,percent of total billed charges,,,85,,4471,percent of total billed charges,,,85,,4471,percent of total billed charges,,,49,,2577.4,percent of total billed charges,,,90,,4734,percent of total billed charges,,,65,,3419,percent of total billed charges,,,80,,4208,percent of total billed charges,,,55,,2893,percent of total billed charges,,,55,,2893,percent of total billed charges,,,65,,3419,percent of total billed charges,,,78,,4102.8,percent of total billed charges,,,70,,3682,percent of total billed charges,,,,,,,,1178.21,,,,100% of Medicare,,1178.21,,,,100% of Medicare,,1178.21,,,,100% of Medicare,,1178.21,,,,100% of Medicare,,1178.21,,,,100% of Medicare,,1178.21,,,,100% of Medicare,,1178.21,,,,100% of Medicare,,1178.21,,,,100% of Medicare,,1178.21,,,,100% of Medicare,,1178.21,,,,100% of Medicare,,1178.21,,,,100% of Medicare,,1178.21,,,,100% of Medicare,,,1178.21,,,,100% of Medicare,289.87,,,,EAPG Rate,100% of IL Medicaid,289.87,,,,EAPG Rate,100% of IL Medicaid,289.87,,,,EAPG Rate,100% of IL Medicaid,289.87,,,,EAPG Rate,100% of IL Medicaid,289.87,4734,
"Hand restoration (incl cast/shade/measure), partial hand, w/ glove, no fingers remain",L6910,HCPCS,,,,outpatient,,,5379,3227.4,,45.5,,2447.45,percent of total billed charges,,,45.3,,2436.69,percent of total billed charges,,,39,,2097.81,percent of total billed charges,,,,,,,,,80,,4303.2,percent of total billed charges,,,61.4,,3302.71,percent of total billed charges,,,57.4,,3087.55,percent of total billed charges,,,81,,4356.99,percent of total billed charges,,,39,,2097.81,percent of total billed charges,,,57.6,,3098.3,percent of total billed charges,,,85,,4572.15,percent of total billed charges,,,85,,4572.15,percent of total billed charges,,,49,,2635.71,percent of total billed charges,,,90,,4841.1,percent of total billed charges,,,65,,3496.35,percent of total billed charges,,,80,,4303.2,percent of total billed charges,,,55,,2958.45,percent of total billed charges,,,55,,2958.45,percent of total billed charges,,,65,,3496.35,percent of total billed charges,,,78,,4195.62,percent of total billed charges,,,70,,3765.3,percent of total billed charges,,,,,,,,2277.86,,,,100% of Medicare,,2277.86,,,,100% of Medicare,,2277.86,,,,100% of Medicare,,2277.86,,,,100% of Medicare,,2277.86,,,,100% of Medicare,,2277.86,,,,100% of Medicare,,2277.86,,,,100% of Medicare,,2277.86,,,,100% of Medicare,,2277.86,,,,100% of Medicare,,2277.86,,,,100% of Medicare,,2277.86,,,,100% of Medicare,,2277.86,,,,100% of Medicare,,,2277.86,,,,100% of Medicare,314.53,,,,EAPG Rate,100% of IL Medicaid,314.53,,,,EAPG Rate,100% of IL Medicaid,314.53,,,,EAPG Rate,100% of IL Medicaid,314.53,,,,EAPG Rate,100% of IL Medicaid,314.53,4841.1,
"Thoracic-Lumbar-Sacral Orthosis, 1-Piece Rigid Shell w/ Liner, Prefabricated",L0488,HCPCS,,,,outpatient,,,5399,3239.4,,45.5,,2456.55,percent of total billed charges,,,45.3,,2445.75,percent of total billed charges,,,39,,2105.61,percent of total billed charges,,,,,,,,,80,,4319.2,percent of total billed charges,,,61.4,,3314.99,percent of total billed charges,,,57.4,,3099.03,percent of total billed charges,,,81,,4373.19,percent of total billed charges,,,39,,2105.61,percent of total billed charges,,,57.6,,3109.82,percent of total billed charges,,,85,,4589.15,percent of total billed charges,,,85,,4589.15,percent of total billed charges,,,49,,2645.51,percent of total billed charges,,,90,,4859.1,percent of total billed charges,,,65,,3509.35,percent of total billed charges,,,80,,4319.2,percent of total billed charges,,,55,,2969.45,percent of total billed charges,,,55,,2969.45,percent of total billed charges,,,65,,3509.35,percent of total billed charges,,,78,,4211.22,percent of total billed charges,,,70,,3779.3,percent of total billed charges,,,,,,,,1209.49,,,,100% of Medicare,,1209.49,,,,100% of Medicare,,1209.49,,,,100% of Medicare,,1209.49,,,,100% of Medicare,,1209.49,,,,100% of Medicare,,1209.49,,,,100% of Medicare,,1209.49,,,,100% of Medicare,,1209.49,,,,100% of Medicare,,1209.49,,,,100% of Medicare,,1209.49,,,,100% of Medicare,,1209.49,,,,100% of Medicare,,1209.49,,,,100% of Medicare,,,1209.49,,,,100% of Medicare,318.67,,,,EAPG Rate,100% of IL Medicaid,318.67,,,,EAPG Rate,100% of IL Medicaid,318.67,,,,EAPG Rate,100% of IL Medicaid,318.67,,,,EAPG Rate,100% of IL Medicaid,318.67,4859.1,
"Partial hand, Robin-Aids, little and/or ring finger remaning (or equal)",L6010,HCPCS,,,,outpatient,,,5434,3260.4,,45.5,,2472.47,percent of total billed charges,,,45.3,,2461.6,percent of total billed charges,,,39,,2119.26,percent of total billed charges,,,,,,,,,80,,4347.2,percent of total billed charges,,,61.4,,3336.48,percent of total billed charges,,,57.4,,3119.12,percent of total billed charges,,,81,,4401.54,percent of total billed charges,,,39,,2119.26,percent of total billed charges,,,57.6,,3129.98,percent of total billed charges,,,85,,4618.9,percent of total billed charges,,,85,,4618.9,percent of total billed charges,,,49,,2662.66,percent of total billed charges,,,90,,4890.6,percent of total billed charges,,,65,,3532.1,percent of total billed charges,,,80,,4347.2,percent of total billed charges,,,55,,2988.7,percent of total billed charges,,,55,,2988.7,percent of total billed charges,,,65,,3532.1,percent of total billed charges,,,78,,4238.52,percent of total billed charges,,,70,,3803.8,percent of total billed charges,,,,,,,,2366.26,,,,100% of Medicare,,2366.26,,,,100% of Medicare,,2366.26,,,,100% of Medicare,,2366.26,,,,100% of Medicare,,2366.26,,,,100% of Medicare,,2366.26,,,,100% of Medicare,,2366.26,,,,100% of Medicare,,2366.26,,,,100% of Medicare,,2366.26,,,,100% of Medicare,,2366.26,,,,100% of Medicare,,2366.26,,,,100% of Medicare,,2366.26,,,,100% of Medicare,,,2366.26,,,,100% of Medicare,325.92,,,,EAPG Rate,100% of IL Medicaid,325.92,,,,EAPG Rate,100% of IL Medicaid,325.92,,,,EAPG Rate,100% of IL Medicaid,325.92,,,,EAPG Rate,100% of IL Medicaid,325.92,4890.6,
"L0640 Lumbar-Sacral Orthosis, sac - T9, Custom Fabricated",L0640,HCPCS,,,,outpatient,,,5462,3277.2,,45.5,,2485.21,percent of total billed charges,,,45.3,,2474.29,percent of total billed charges,,,39,,2130.18,percent of total billed charges,,,,,,,,,80,,4369.6,percent of total billed charges,,,61.4,,3353.67,percent of total billed charges,,,57.4,,3135.19,percent of total billed charges,,,81,,4424.22,percent of total billed charges,,,39,,2130.18,percent of total billed charges,,,57.6,,3146.11,percent of total billed charges,,,85,,4642.7,percent of total billed charges,,,85,,4642.7,percent of total billed charges,,,49,,2676.38,percent of total billed charges,,,90,,4915.8,percent of total billed charges,,,65,,3550.3,percent of total billed charges,,,80,,4369.6,percent of total billed charges,,,55,,3004.1,percent of total billed charges,,,55,,3004.1,percent of total billed charges,,,65,,3550.3,percent of total billed charges,,,78,,4260.36,percent of total billed charges,,,70,,3823.4,percent of total billed charges,,,,,,,,1260.75,,,,100% of Medicare,,1260.75,,,,100% of Medicare,,1260.75,,,,100% of Medicare,,1260.75,,,,100% of Medicare,,1260.75,,,,100% of Medicare,,1260.75,,,,100% of Medicare,,1260.75,,,,100% of Medicare,,1260.75,,,,100% of Medicare,,1260.75,,,,100% of Medicare,,1260.75,,,,100% of Medicare,,1260.75,,,,100% of Medicare,,1260.75,,,,100% of Medicare,,,1260.75,,,,100% of Medicare,331.73,,,,EAPG Rate,100% of IL Medicaid,331.73,,,,EAPG Rate,100% of IL Medicaid,331.73,,,,EAPG Rate,100% of IL Medicaid,331.73,,,,EAPG Rate,100% of IL Medicaid,331.73,4915.8,
"Hand restoration (incl cast/shade/measure), partial hand, w/ glove, multiple fingers remain",L6905,HCPCS,,,,outpatient,,,5466,3279.6,,45.5,,2487.03,percent of total billed charges,,,45.3,,2476.1,percent of total billed charges,,,39,,2131.74,percent of total billed charges,,,,,,,,,80,,4372.8,percent of total billed charges,,,61.4,,3356.12,percent of total billed charges,,,57.4,,3137.48,percent of total billed charges,,,81,,4427.46,percent of total billed charges,,,39,,2131.74,percent of total billed charges,,,57.6,,3148.42,percent of total billed charges,,,85,,4646.1,percent of total billed charges,,,85,,4646.1,percent of total billed charges,,,49,,2678.34,percent of total billed charges,,,90,,4919.4,percent of total billed charges,,,65,,3552.9,percent of total billed charges,,,80,,4372.8,percent of total billed charges,,,55,,3006.3,percent of total billed charges,,,55,,3006.3,percent of total billed charges,,,65,,3552.9,percent of total billed charges,,,78,,4263.48,percent of total billed charges,,,70,,3826.2,percent of total billed charges,,,,,,,,2317.09,,,,100% of Medicare,,2317.09,,,,100% of Medicare,,2317.09,,,,100% of Medicare,,2317.09,,,,100% of Medicare,,2317.09,,,,100% of Medicare,,2317.09,,,,100% of Medicare,,2317.09,,,,100% of Medicare,,2317.09,,,,100% of Medicare,,2317.09,,,,100% of Medicare,,2317.09,,,,100% of Medicare,,2317.09,,,,100% of Medicare,,2317.09,,,,100% of Medicare,,,2317.09,,,,100% of Medicare,332.56,,,,EAPG Rate,100% of IL Medicaid,332.56,,,,EAPG Rate,100% of IL Medicaid,332.56,,,,EAPG Rate,100% of IL Medicaid,332.56,,,,EAPG Rate,100% of IL Medicaid,332.56,4919.4,
"Prep, wrist disartic or BE, direct formed",L6582,HCPCS,,,,outpatient,,,5523,3313.8,,45.5,,2512.97,percent of total billed charges,,,45.3,,2501.92,percent of total billed charges,,,39,,2153.97,percent of total billed charges,,,,,,,,,80,,4418.4,percent of total billed charges,,,61.4,,3391.12,percent of total billed charges,,,57.4,,3170.2,percent of total billed charges,,,81,,4473.63,percent of total billed charges,,,39,,2153.97,percent of total billed charges,,,57.6,,3181.25,percent of total billed charges,,,85,,4694.55,percent of total billed charges,,,85,,4694.55,percent of total billed charges,,,49,,2706.27,percent of total billed charges,,,90,,4970.7,percent of total billed charges,,,65,,3589.95,percent of total billed charges,,,80,,4418.4,percent of total billed charges,,,55,,3037.65,percent of total billed charges,,,55,,3037.65,percent of total billed charges,,,65,,3589.95,percent of total billed charges,,,78,,4307.94,percent of total billed charges,,,70,,3866.1,percent of total billed charges,,,,,,,,2047,,,,100% of Medicare,,2047,,,,100% of Medicare,,2047,,,,100% of Medicare,,2047,,,,100% of Medicare,,2047,,,,100% of Medicare,,2047,,,,100% of Medicare,,2047,,,,100% of Medicare,,2047,,,,100% of Medicare,,2047,,,,100% of Medicare,,2047,,,,100% of Medicare,,2047,,,,100% of Medicare,,2047,,,,100% of Medicare,,,2047,,,,100% of Medicare,344.37,,,,EAPG Rate,100% of IL Medicaid,344.37,,,,EAPG Rate,100% of IL Medicaid,344.37,,,,EAPG Rate,100% of IL Medicaid,344.37,,,,EAPG Rate,100% of IL Medicaid,344.37,4970.7,
"Hand restoration (incl cast/shade/measure), partial hand, w/ glove, thumb or 1 finger remain",L6900,HCPCS,,,,outpatient,,,5526,3315.6,,45.5,,2514.33,percent of total billed charges,,,45.3,,2503.28,percent of total billed charges,,,39,,2155.14,percent of total billed charges,,,,,,,,,80,,4420.8,percent of total billed charges,,,61.4,,3392.96,percent of total billed charges,,,57.4,,3171.92,percent of total billed charges,,,81,,4476.06,percent of total billed charges,,,39,,2155.14,percent of total billed charges,,,57.6,,3182.98,percent of total billed charges,,,85,,4697.1,percent of total billed charges,,,85,,4697.1,percent of total billed charges,,,49,,2707.74,percent of total billed charges,,,90,,4973.4,percent of total billed charges,,,65,,3591.9,percent of total billed charges,,,80,,4420.8,percent of total billed charges,,,55,,3039.3,percent of total billed charges,,,55,,3039.3,percent of total billed charges,,,65,,3591.9,percent of total billed charges,,,78,,4310.28,percent of total billed charges,,,70,,3868.2,percent of total billed charges,,,,,,,,2341.16,,,,100% of Medicare,,2341.16,,,,100% of Medicare,,2341.16,,,,100% of Medicare,,2341.16,,,,100% of Medicare,,2341.16,,,,100% of Medicare,,2341.16,,,,100% of Medicare,,2341.16,,,,100% of Medicare,,2341.16,,,,100% of Medicare,,2341.16,,,,100% of Medicare,,2341.16,,,,100% of Medicare,,2341.16,,,,100% of Medicare,,2341.16,,,,100% of Medicare,,,2341.16,,,,100% of Medicare,344.99,,,,EAPG Rate,100% of IL Medicaid,344.99,,,,EAPG Rate,100% of IL Medicaid,344.99,,,,EAPG Rate,100% of IL Medicaid,344.99,,,,EAPG Rate,100% of IL Medicaid,344.99,4973.4,
"Initial, AK or knee disartic, ischial level socket, non-align sys, pylon, no cover, SACH foot, plast",L5505,HCPCS,,,,outpatient,,,5578,3346.8,,45.5,,2537.99,percent of total billed charges,,,45.3,,2526.83,percent of total billed charges,,,39,,2175.42,percent of total billed charges,,,,,,,,,80,,4462.4,percent of total billed charges,,,61.4,,3424.89,percent of total billed charges,,,57.4,,3201.77,percent of total billed charges,,,81,,4518.18,percent of total billed charges,,,39,,2175.42,percent of total billed charges,,,57.6,,3212.93,percent of total billed charges,,,85,,4741.3,percent of total billed charges,,,85,,4741.3,percent of total billed charges,,,49,,2733.22,percent of total billed charges,,,90,,5020.2,percent of total billed charges,,,65,,3625.7,percent of total billed charges,,,80,,4462.4,percent of total billed charges,,,55,,3067.9,percent of total billed charges,,,55,,3067.9,percent of total billed charges,,,65,,3625.7,percent of total billed charges,,,78,,4350.84,percent of total billed charges,,,70,,3904.6,percent of total billed charges,,,,,,,,2504.29,,,,100% of Medicare,,2504.29,,,,100% of Medicare,,2504.29,,,,100% of Medicare,,2504.29,,,,100% of Medicare,,2504.29,,,,100% of Medicare,,2504.29,,,,100% of Medicare,,2504.29,,,,100% of Medicare,,2504.29,,,,100% of Medicare,,2504.29,,,,100% of Medicare,,2504.29,,,,100% of Medicare,,2504.29,,,,100% of Medicare,,2504.29,,,,100% of Medicare,,,2504.29,,,,100% of Medicare,355.76,,,,EAPG Rate,100% of IL Medicaid,355.76,,,,EAPG Rate,100% of IL Medicaid,355.76,,,,EAPG Rate,100% of IL Medicaid,355.76,,,,EAPG Rate,100% of IL Medicaid,355.76,5020.2,
"Immediate postsurg/early fitting, app of initial rigid drsg incl fit/align/susp and 1 cast change""A",L5420,HCPCS,,,,outpatient,,,5581,3348.6,,45.5,,2539.36,percent of total billed charges,,,45.3,,2528.19,percent of total billed charges,,,39,,2176.59,percent of total billed charges,,,,,,,,,80,,4464.8,percent of total billed charges,,,61.4,,3426.73,percent of total billed charges,,,57.4,,3203.49,percent of total billed charges,,,81,,4520.61,percent of total billed charges,,,39,,2176.59,percent of total billed charges,,,57.6,,3214.66,percent of total billed charges,,,85,,4743.85,percent of total billed charges,,,85,,4743.85,percent of total billed charges,,,49,,2734.69,percent of total billed charges,,,90,,5022.9,percent of total billed charges,,,65,,3627.65,percent of total billed charges,,,80,,4464.8,percent of total billed charges,,,55,,3069.55,percent of total billed charges,,,55,,3069.55,percent of total billed charges,,,65,,3627.65,percent of total billed charges,,,78,,4353.18,percent of total billed charges,,,70,,3906.7,percent of total billed charges,,,,,,,,2432.52,,,,100% of Medicare,,2432.52,,,,100% of Medicare,,2432.52,,,,100% of Medicare,,2432.52,,,,100% of Medicare,,2432.52,,,,100% of Medicare,,2432.52,,,,100% of Medicare,,2432.52,,,,100% of Medicare,,2432.52,,,,100% of Medicare,,2432.52,,,,100% of Medicare,,2432.52,,,,100% of Medicare,,2432.52,,,,100% of Medicare,,2432.52,,,,100% of Medicare,,,2432.52,,,,100% of Medicare,356.38,,,,EAPG Rate,100% of IL Medicaid,356.38,,,,EAPG Rate,100% of IL Medicaid,356.38,,,,EAPG Rate,100% of IL Medicaid,356.38,,,,EAPG Rate,100% of IL Medicaid,356.38,5022.9,
"Addition, endo knee-shin sys, single axis, pneumatic swing",L5830,HCPCS,,,,outpatient,,,5602,3361.2,,45.5,,2548.91,percent of total billed charges,,,45.3,,2537.71,percent of total billed charges,,,39,,2184.78,percent of total billed charges,,,,,,,,,80,,4481.6,percent of total billed charges,,,61.4,,3439.63,percent of total billed charges,,,57.4,,3215.55,percent of total billed charges,,,81,,4537.62,percent of total billed charges,,,39,,2184.78,percent of total billed charges,,,57.6,,3226.75,percent of total billed charges,,,85,,4761.7,percent of total billed charges,,,85,,4761.7,percent of total billed charges,,,49,,2744.98,percent of total billed charges,,,90,,5041.8,percent of total billed charges,,,65,,3641.3,percent of total billed charges,,,80,,4481.6,percent of total billed charges,,,55,,3081.1,percent of total billed charges,,,55,,3081.1,percent of total billed charges,,,65,,3641.3,percent of total billed charges,,,78,,4369.56,percent of total billed charges,,,70,,3921.4,percent of total billed charges,,,,,,,,2398.6,,,,100% of Medicare,,2398.6,,,,100% of Medicare,,2398.6,,,,100% of Medicare,,2398.6,,,,100% of Medicare,,2398.6,,,,100% of Medicare,,2398.6,,,,100% of Medicare,,2398.6,,,,100% of Medicare,,2398.6,,,,100% of Medicare,,2398.6,,,,100% of Medicare,,2398.6,,,,100% of Medicare,,2398.6,,,,100% of Medicare,,2398.6,,,,100% of Medicare,,,2398.6,,,,100% of Medicare,360.73,,,,EAPG Rate,100% of IL Medicaid,360.73,,,,EAPG Rate,100% of IL Medicaid,360.73,,,,EAPG Rate,100% of IL Medicaid,360.73,,,,EAPG Rate,100% of IL Medicaid,360.73,5041.8,
"Cervical-Thoracic-Lumbar-Sacral Orthosis, Ant/Post/Lat Control, Molded to Pt, w/ Interface Mat",L0710,HCPCS,,,,outpatient,,,5606,3363.6,,45.5,,2550.73,percent of total billed charges,,,45.3,,2539.52,percent of total billed charges,,,39,,2186.34,percent of total billed charges,,,,,,,,,80,,4484.8,percent of total billed charges,,,61.4,,3442.08,percent of total billed charges,,,57.4,,3217.84,percent of total billed charges,,,81,,4540.86,percent of total billed charges,,,39,,2186.34,percent of total billed charges,,,57.6,,3229.06,percent of total billed charges,,,85,,4765.1,percent of total billed charges,,,85,,4765.1,percent of total billed charges,,,49,,2746.94,percent of total billed charges,,,90,,5045.4,percent of total billed charges,,,65,,3643.9,percent of total billed charges,,,80,,4484.8,percent of total billed charges,,,55,,3083.3,percent of total billed charges,,,55,,3083.3,percent of total billed charges,,,65,,3643.9,percent of total billed charges,,,78,,4372.68,percent of total billed charges,,,70,,3924.2,percent of total billed charges,,,,,,,,2636.69,,,,100% of Medicare,,2636.69,,,,100% of Medicare,,2636.69,,,,100% of Medicare,,2636.69,,,,100% of Medicare,,2636.69,,,,100% of Medicare,,2636.69,,,,100% of Medicare,,2636.69,,,,100% of Medicare,,2636.69,,,,100% of Medicare,,2636.69,,,,100% of Medicare,,2636.69,,,,100% of Medicare,,2636.69,,,,100% of Medicare,,2636.69,,,,100% of Medicare,,,2636.69,,,,100% of Medicare,361.56,,,,EAPG Rate,100% of IL Medicaid,361.56,,,,EAPG Rate,100% of IL Medicaid,361.56,,,,EAPG Rate,100% of IL Medicaid,361.56,,,,EAPG Rate,100% of IL Medicaid,361.56,5045.4,
"Immediate postsurg/early fitting, app of initial rigid drsg, 1 cast change, shoulder disartic or int",L6384,HCPCS,,,,outpatient,,,5736,3441.6,,45.5,,2609.88,percent of total billed charges,,,45.3,,2598.41,percent of total billed charges,,,39,,2237.04,percent of total billed charges,,,,,,,,,80,,4588.8,percent of total billed charges,,,61.4,,3521.9,percent of total billed charges,,,57.4,,3292.46,percent of total billed charges,,,81,,4646.16,percent of total billed charges,,,39,,2237.04,percent of total billed charges,,,57.6,,3303.94,percent of total billed charges,,,85,,4875.6,percent of total billed charges,,,85,,4875.6,percent of total billed charges,,,49,,2810.64,percent of total billed charges,,,90,,5162.4,percent of total billed charges,,,65,,3728.4,percent of total billed charges,,,80,,4588.8,percent of total billed charges,,,55,,3154.8,percent of total billed charges,,,55,,3154.8,percent of total billed charges,,,65,,3728.4,percent of total billed charges,,,78,,4474.08,percent of total billed charges,,,70,,4015.2,percent of total billed charges,,,,,,,,2574.83,,,,100% of Medicare,,2574.83,,,,100% of Medicare,,2574.83,,,,100% of Medicare,,2574.83,,,,100% of Medicare,,2574.83,,,,100% of Medicare,,2574.83,,,,100% of Medicare,,2574.83,,,,100% of Medicare,,2574.83,,,,100% of Medicare,,2574.83,,,,100% of Medicare,,2574.83,,,,100% of Medicare,,2574.83,,,,100% of Medicare,,2574.83,,,,100% of Medicare,,,2574.83,,,,100% of Medicare,388.5,,,,EAPG Rate,100% of IL Medicaid,388.5,,,,EAPG Rate,100% of IL Medicaid,388.5,,,,EAPG Rate,100% of IL Medicaid,388.5,,,,EAPG Rate,100% of IL Medicaid,388.5,5162.4,
"Partial foot, molded socket, ankle height, with toe filler",L5010,HCPCS,,,,outpatient,,,5752,3451.2,,45.5,,2617.16,percent of total billed charges,,,45.3,,2605.66,percent of total billed charges,,,39,,2243.28,percent of total billed charges,,,,,,,,,80,,4601.6,percent of total billed charges,,,61.4,,3531.73,percent of total billed charges,,,57.4,,3301.65,percent of total billed charges,,,81,,4659.12,percent of total billed charges,,,39,,2243.28,percent of total billed charges,,,57.6,,3313.15,percent of total billed charges,,,85,,4889.2,percent of total billed charges,,,85,,4889.2,percent of total billed charges,,,49,,2818.48,percent of total billed charges,,,90,,5176.8,percent of total billed charges,,,65,,3738.8,percent of total billed charges,,,80,,4601.6,percent of total billed charges,,,55,,3163.6,percent of total billed charges,,,55,,3163.6,percent of total billed charges,,,65,,3738.8,percent of total billed charges,,,78,,4486.56,percent of total billed charges,,,70,,4026.4,percent of total billed charges,,,,,,,,1933.16,,,,100% of Medicare,,1933.16,,,,100% of Medicare,,1933.16,,,,100% of Medicare,,1933.16,,,,100% of Medicare,,1933.16,,,,100% of Medicare,,1933.16,,,,100% of Medicare,,1933.16,,,,100% of Medicare,,1933.16,,,,100% of Medicare,,1933.16,,,,100% of Medicare,,1933.16,,,,100% of Medicare,,1933.16,,,,100% of Medicare,,1933.16,,,,100% of Medicare,,,1933.16,,,,100% of Medicare,391.81,,,,EAPG Rate,100% of IL Medicaid,391.81,,,,EAPG Rate,100% of IL Medicaid,391.81,,,,EAPG Rate,100% of IL Medicaid,391.81,,,,EAPG Rate,100% of IL Medicaid,391.81,5176.8,
"Knee-Ankle-Foot Orthosis, Double Upright, Free Knee/Ankle, Solid Stirrup",L2020,HCPCS,,,,outpatient,,,5755,3453,,45.5,,2618.53,percent of total billed charges,,,45.3,,2607.02,percent of total billed charges,,,39,,2244.45,percent of total billed charges,,,,,,,,,80,,4604,percent of total billed charges,,,61.4,,3533.57,percent of total billed charges,,,57.4,,3303.37,percent of total billed charges,,,81,,4661.55,percent of total billed charges,,,39,,2244.45,percent of total billed charges,,,57.6,,3314.88,percent of total billed charges,,,85,,4891.75,percent of total billed charges,,,85,,4891.75,percent of total billed charges,,,49,,2819.95,percent of total billed charges,,,90,,5179.5,percent of total billed charges,,,65,,3740.75,percent of total billed charges,,,80,,4604,percent of total billed charges,,,55,,3165.25,percent of total billed charges,,,55,,3165.25,percent of total billed charges,,,65,,3740.75,percent of total billed charges,,,78,,4488.9,percent of total billed charges,,,70,,4028.5,percent of total billed charges,,,,,,,,1327.77,,,,100% of Medicare,,1327.77,,,,100% of Medicare,,1327.77,,,,100% of Medicare,,1327.77,,,,100% of Medicare,,1327.77,,,,100% of Medicare,,1327.77,,,,100% of Medicare,,1327.77,,,,100% of Medicare,,1327.77,,,,100% of Medicare,,1327.77,,,,100% of Medicare,,1327.77,,,,100% of Medicare,,1327.77,,,,100% of Medicare,,1327.77,,,,100% of Medicare,,,1327.77,,,,100% of Medicare,392.44,,,,EAPG Rate,100% of IL Medicaid,392.44,,,,EAPG Rate,100% of IL Medicaid,392.44,,,,EAPG Rate,100% of IL Medicaid,392.44,,,,EAPG Rate,100% of IL Medicaid,392.44,5179.5,
"Addition, exo knee-shin sys, single axis, external joints, fluid swing",L5726,HCPCS,,,,outpatient,,,5766,3459.6,,45.5,,2623.53,percent of total billed charges,,,45.3,,2612,percent of total billed charges,,,39,,2248.74,percent of total billed charges,,,,,,,,,80,,4612.8,percent of total billed charges,,,61.4,,3540.32,percent of total billed charges,,,57.4,,3309.68,percent of total billed charges,,,81,,4670.46,percent of total billed charges,,,39,,2248.74,percent of total billed charges,,,57.6,,3321.22,percent of total billed charges,,,85,,4901.1,percent of total billed charges,,,85,,4901.1,percent of total billed charges,,,49,,2825.34,percent of total billed charges,,,90,,5189.4,percent of total billed charges,,,65,,3747.9,percent of total billed charges,,,80,,4612.8,percent of total billed charges,,,55,,3171.3,percent of total billed charges,,,55,,3171.3,percent of total billed charges,,,65,,3747.9,percent of total billed charges,,,78,,4497.48,percent of total billed charges,,,70,,4036.2,percent of total billed charges,,,,,,,,2482.94,,,,100% of Medicare,,2482.94,,,,100% of Medicare,,2482.94,,,,100% of Medicare,,2482.94,,,,100% of Medicare,,2482.94,,,,100% of Medicare,,2482.94,,,,100% of Medicare,,2482.94,,,,100% of Medicare,,2482.94,,,,100% of Medicare,,2482.94,,,,100% of Medicare,,2482.94,,,,100% of Medicare,,2482.94,,,,100% of Medicare,,2482.94,,,,100% of Medicare,,,2482.94,,,,100% of Medicare,394.72,,,,EAPG Rate,100% of IL Medicaid,394.72,,,,EAPG Rate,100% of IL Medicaid,394.72,,,,EAPG Rate,100% of IL Medicaid,394.72,,,,EAPG Rate,100% of IL Medicaid,394.72,5189.4,
"Addition, endo knee-shin sys, single axis, fluid swing",L5824,HCPCS,,,,outpatient,,,5773,3463.8,,45.5,,2626.72,percent of total billed charges,,,45.3,,2615.17,percent of total billed charges,,,39,,2251.47,percent of total billed charges,,,,,,,,,80,,4618.4,percent of total billed charges,,,61.4,,3544.62,percent of total billed charges,,,57.4,,3313.7,percent of total billed charges,,,81,,4676.13,percent of total billed charges,,,39,,2251.47,percent of total billed charges,,,57.6,,3325.25,percent of total billed charges,,,85,,4907.05,percent of total billed charges,,,85,,4907.05,percent of total billed charges,,,49,,2828.77,percent of total billed charges,,,90,,5195.7,percent of total billed charges,,,65,,3752.45,percent of total billed charges,,,80,,4618.4,percent of total billed charges,,,55,,3175.15,percent of total billed charges,,,55,,3175.15,percent of total billed charges,,,65,,3752.45,percent of total billed charges,,,78,,4502.94,percent of total billed charges,,,70,,4041.1,percent of total billed charges,,,,,,,,1998.78,,,,100% of Medicare,,1998.78,,,,100% of Medicare,,1998.78,,,,100% of Medicare,,1998.78,,,,100% of Medicare,,1998.78,,,,100% of Medicare,,1998.78,,,,100% of Medicare,,1998.78,,,,100% of Medicare,,1998.78,,,,100% of Medicare,,1998.78,,,,100% of Medicare,,1998.78,,,,100% of Medicare,,1998.78,,,,100% of Medicare,,1998.78,,,,100% of Medicare,,,1998.78,,,,100% of Medicare,396.17,,,,EAPG Rate,100% of IL Medicaid,396.17,,,,EAPG Rate,100% of IL Medicaid,396.17,,,,EAPG Rate,100% of IL Medicaid,396.17,,,,EAPG Rate,100% of IL Medicaid,396.17,5195.7,
"Terminal Device, Hand, Mechanical, Voluntary Opening, Any Material, Any Size, Pediatric",L6713,HCPCS,,,,outpatient,,,5781,3468.6,,45.5,,2630.36,percent of total billed charges,,,45.3,,2618.79,percent of total billed charges,,,39,,2254.59,percent of total billed charges,,,,,,,,,80,,4624.8,percent of total billed charges,,,61.4,,3549.53,percent of total billed charges,,,57.4,,3318.29,percent of total billed charges,,,81,,4682.61,percent of total billed charges,,,39,,2254.59,percent of total billed charges,,,57.6,,3329.86,percent of total billed charges,,,85,,4913.85,percent of total billed charges,,,85,,4913.85,percent of total billed charges,,,49,,2832.69,percent of total billed charges,,,90,,5202.9,percent of total billed charges,,,65,,3757.65,percent of total billed charges,,,80,,4624.8,percent of total billed charges,,,55,,3179.55,percent of total billed charges,,,55,,3179.55,percent of total billed charges,,,65,,3757.65,percent of total billed charges,,,78,,4509.18,percent of total billed charges,,,70,,4046.7,percent of total billed charges,,,,,,,,1886.02,,,,100% of Medicare,,1886.02,,,,100% of Medicare,,1886.02,,,,100% of Medicare,,1886.02,,,,100% of Medicare,,1886.02,,,,100% of Medicare,,1886.02,,,,100% of Medicare,,1886.02,,,,100% of Medicare,,1886.02,,,,100% of Medicare,,1886.02,,,,100% of Medicare,,1886.02,,,,100% of Medicare,,1886.02,,,,100% of Medicare,,1886.02,,,,100% of Medicare,,,1886.02,,,,100% of Medicare,397.82,,,,EAPG Rate,100% of IL Medicaid,397.82,,,,EAPG Rate,100% of IL Medicaid,397.82,,,,EAPG Rate,100% of IL Medicaid,397.82,,,,EAPG Rate,100% of IL Medicaid,397.82,5202.9,
"Ankle-Foot Orthosis, Plastic, Rigid Anterior Tibial Section, Molded to Patient",L1945,HCPCS,,,,outpatient,,,5861,3516.6,,45.5,,2666.76,percent of total billed charges,,,45.3,,2655.03,percent of total billed charges,,,39,,2285.79,percent of total billed charges,,,,,,,,,80,,4688.8,percent of total billed charges,,,61.4,,3598.65,percent of total billed charges,,,57.4,,3364.21,percent of total billed charges,,,81,,4747.41,percent of total billed charges,,,39,,2285.79,percent of total billed charges,,,57.6,,3375.94,percent of total billed charges,,,85,,4981.85,percent of total billed charges,,,85,,4981.85,percent of total billed charges,,,49,,2871.89,percent of total billed charges,,,90,,5274.9,percent of total billed charges,,,65,,3809.65,percent of total billed charges,,,80,,4688.8,percent of total billed charges,,,55,,3223.55,percent of total billed charges,,,55,,3223.55,percent of total billed charges,,,65,,3809.65,percent of total billed charges,,,78,,4571.58,percent of total billed charges,,,70,,4102.7,percent of total billed charges,,,,,,,,1352.44,,,,100% of Medicare,,1352.44,,,,100% of Medicare,,1352.44,,,,100% of Medicare,,1352.44,,,,100% of Medicare,,1352.44,,,,100% of Medicare,,1352.44,,,26872.93893,100% of Medicare,,1352.44,,,,100% of Medicare,,1352.44,,,,100% of Medicare,,1352.44,,,,100% of Medicare,,1352.44,,,,100% of Medicare,,1352.44,,,,100% of Medicare,,1352.44,,,,100% of Medicare,,,1352.44,,,,100% of Medicare,414.4,,,,EAPG Rate,100% of IL Medicaid,414.4,,,,EAPG Rate,100% of IL Medicaid,414.4,,,,EAPG Rate,100% of IL Medicaid,414.4,,,,EAPG Rate,100% of IL Medicaid,414.4,26872.94,
"Addition to LE, endo sys, AK or knee disartic, 4-bar linkage w/ friction swing phase control",L5611,HCPCS,,,,outpatient,,,5878,3526.8,,45.5,,2674.49,percent of total billed charges,,,45.3,,2662.73,percent of total billed charges,,,39,,2292.42,percent of total billed charges,,,,,,,,,80,,4702.4,percent of total billed charges,,,61.4,,3609.09,percent of total billed charges,,,57.4,,3373.97,percent of total billed charges,,,81,,4761.18,percent of total billed charges,,,39,,2292.42,percent of total billed charges,,,57.6,,3385.73,percent of total billed charges,,,85,,4996.3,percent of total billed charges,,,85,,4996.3,percent of total billed charges,,,49,,2880.22,percent of total billed charges,,,90,,5290.2,percent of total billed charges,,,65,,3820.7,percent of total billed charges,,,80,,4702.4,percent of total billed charges,,,55,,3232.9,percent of total billed charges,,,55,,3232.9,percent of total billed charges,,,65,,3820.7,percent of total billed charges,,,78,,4584.84,percent of total billed charges,,,70,,4114.6,percent of total billed charges,,,,,,,,1933.8,,,,100% of Medicare,,1933.8,,,,100% of Medicare,,1933.8,,,,100% of Medicare,,1933.8,,,,100% of Medicare,,1933.8,,,,100% of Medicare,,1933.8,,,,100% of Medicare,,1933.8,,,,100% of Medicare,,1933.8,,,,100% of Medicare,,1933.8,,,,100% of Medicare,,1933.8,,,,100% of Medicare,,1933.8,,,,100% of Medicare,,1933.8,,,,100% of Medicare,,,1933.8,,,,100% of Medicare,417.92,,,,EAPG Rate,100% of IL Medicaid,417.92,,,,EAPG Rate,100% of IL Medicaid,417.92,,,,EAPG Rate,100% of IL Medicaid,417.92,,,,EAPG Rate,100% of IL Medicaid,417.92,5290.2,
"Hip Orthosis, Abduction Control, Custom Fabricated, Post-op type",L1685,HCPCS,,,,outpatient,,,5981,3588.6,,45.5,,2721.36,percent of total billed charges,,,45.3,,2709.39,percent of total billed charges,,,39,,2332.59,percent of total billed charges,,,,,,,,,80,,4784.8,percent of total billed charges,,,61.4,,3672.33,percent of total billed charges,,,57.4,,3433.09,percent of total billed charges,,,81,,4844.61,percent of total billed charges,,,39,,2332.59,percent of total billed charges,,,57.6,,3445.06,percent of total billed charges,,,85,,5083.85,percent of total billed charges,,,85,,5083.85,percent of total billed charges,,,49,,2930.69,percent of total billed charges,,,90,,5382.9,percent of total billed charges,,,65,,3887.65,percent of total billed charges,,,80,,4784.8,percent of total billed charges,,,55,,3289.55,percent of total billed charges,,,55,,3289.55,percent of total billed charges,,,65,,3887.65,percent of total billed charges,,,78,,4665.18,percent of total billed charges,,,70,,4186.7,percent of total billed charges,,,,,,,,1340.06,,,,100% of Medicare,,1340.06,,,,100% of Medicare,,1340.06,,,,100% of Medicare,,1340.06,,,,100% of Medicare,,1340.06,,,,100% of Medicare,,1340.06,,,,100% of Medicare,,1340.06,,,,100% of Medicare,,1340.06,,,,100% of Medicare,,1340.06,,,,100% of Medicare,,1340.06,,,,100% of Medicare,,1340.06,,,,100% of Medicare,,1340.06,,,,100% of Medicare,,,1340.06,,,,100% of Medicare,439.26,,,,EAPG Rate,100% of IL Medicaid,439.26,,,,EAPG Rate,100% of IL Medicaid,439.26,,,,EAPG Rate,100% of IL Medicaid,439.26,,,,EAPG Rate,100% of IL Medicaid,439.26,5382.9,
"Knee-Ankle-Foot Orthosis, Single Upright, Free Knee/Ankle, Solid Stirrup",L2000,HCPCS,,,,outpatient,,,6019,3611.4,,45.5,,2738.65,percent of total billed charges,,,45.3,,2726.61,percent of total billed charges,,,39,,2347.41,percent of total billed charges,,,,,,,,,80,,4815.2,percent of total billed charges,,,61.4,,3695.67,percent of total billed charges,,,57.4,,3454.91,percent of total billed charges,,,81,,4875.39,percent of total billed charges,,,39,,2347.41,percent of total billed charges,,,57.6,,3466.94,percent of total billed charges,,,85,,5116.15,percent of total billed charges,,,85,,5116.15,percent of total billed charges,,,49,,2949.31,percent of total billed charges,,,90,,5417.1,percent of total billed charges,,,65,,3912.35,percent of total billed charges,,,80,,4815.2,percent of total billed charges,,,55,,3310.45,percent of total billed charges,,,55,,3310.45,percent of total billed charges,,,65,,3912.35,percent of total billed charges,,,78,,4694.82,percent of total billed charges,,,70,,4213.3,percent of total billed charges,,,,,,,,1347.85,,,,100% of Medicare,,1347.85,,,,100% of Medicare,,1347.85,,,,100% of Medicare,,1347.85,,,,100% of Medicare,,1347.85,,,,100% of Medicare,,1347.85,,,,100% of Medicare,,1347.85,,,,100% of Medicare,,1347.85,,,,100% of Medicare,,1347.85,,,,100% of Medicare,,1347.85,,,,100% of Medicare,,1347.85,,,,100% of Medicare,,1347.85,,,,100% of Medicare,,,1347.85,,,,100% of Medicare,447.14,,,,EAPG Rate,100% of IL Medicaid,447.14,,,,EAPG Rate,100% of IL Medicaid,447.14,,,,EAPG Rate,100% of IL Medicaid,447.14,,,,EAPG Rate,100% of IL Medicaid,447.14,5417.1,
"Addition, endo knee-shin sys, single axis, pneumatic swing, friction stance",L5822,HCPCS,,,,outpatient,,,6112,3667.2,,45.5,,2780.96,percent of total billed charges,,,45.3,,2768.74,percent of total billed charges,,,39,,2383.68,percent of total billed charges,,,,,,,,,80,,4889.6,percent of total billed charges,,,61.4,,3752.77,percent of total billed charges,,,57.4,,3508.29,percent of total billed charges,,,81,,4950.72,percent of total billed charges,,,39,,2383.68,percent of total billed charges,,,57.6,,3520.51,percent of total billed charges,,,85,,5195.2,percent of total billed charges,,,85,,5195.2,percent of total billed charges,,,49,,2994.88,percent of total billed charges,,,90,,5500.8,percent of total billed charges,,,65,,3972.8,percent of total billed charges,,,80,,4889.6,percent of total billed charges,,,55,,3361.6,percent of total billed charges,,,55,,3361.6,percent of total billed charges,,,65,,3972.8,percent of total billed charges,,,78,,4767.36,percent of total billed charges,,,70,,4278.4,percent of total billed charges,,,,,,,,2114.46,,,,100% of Medicare,,2114.46,,,,100% of Medicare,,2114.46,,,,100% of Medicare,,2114.46,,,,100% of Medicare,,2114.46,,,,100% of Medicare,,2114.46,,,,100% of Medicare,,2114.46,,,,100% of Medicare,,2114.46,,,,100% of Medicare,,2114.46,,,,100% of Medicare,,2114.46,,,,100% of Medicare,,2114.46,,,,100% of Medicare,,2114.46,,,,100% of Medicare,,,2114.46,,,,100% of Medicare,466.41,,,,EAPG Rate,100% of IL Medicaid,466.41,,,,EAPG Rate,100% of IL Medicaid,466.41,,,,EAPG Rate,100% of IL Medicaid,466.41,,,,EAPG Rate,100% of IL Medicaid,466.41,5500.8,
"Hip Orthosis, Dynamic, Abduction/Pelvic/Adj Hip Control",L1680,HCPCS,,,,outpatient,,,6127,3676.2,,45.5,,2787.79,percent of total billed charges,,,45.3,,2775.53,percent of total billed charges,,,39,,2389.53,percent of total billed charges,,,,,,,,,80,,4901.6,percent of total billed charges,,,61.4,,3761.98,percent of total billed charges,,,57.4,,3516.9,percent of total billed charges,,,81,,4962.87,percent of total billed charges,,,39,,2389.53,percent of total billed charges,,,57.6,,3529.15,percent of total billed charges,,,85,,5207.95,percent of total billed charges,,,85,,5207.95,percent of total billed charges,,,49,,3002.23,percent of total billed charges,,,90,,5514.3,percent of total billed charges,,,65,,3982.55,percent of total billed charges,,,80,,4901.6,percent of total billed charges,,,55,,3369.85,percent of total billed charges,,,55,,3369.85,percent of total billed charges,,,65,,3982.55,percent of total billed charges,,,78,,4779.06,percent of total billed charges,,,70,,4288.9,percent of total billed charges,,,,,,,,1372.66,,,,100% of Medicare,,1372.66,,,,100% of Medicare,,1372.66,,,,100% of Medicare,,1372.66,,,,100% of Medicare,,1372.66,,,,100% of Medicare,,1372.66,,,,100% of Medicare,,1372.66,,,,100% of Medicare,,1372.66,,,,100% of Medicare,,1372.66,,,,100% of Medicare,,1372.66,,,,100% of Medicare,,1372.66,,,,100% of Medicare,,1372.66,,,,100% of Medicare,,,1372.66,,,,100% of Medicare,469.51,,,,EAPG Rate,100% of IL Medicaid,469.51,,,,EAPG Rate,100% of IL Medicaid,469.51,,,,EAPG Rate,100% of IL Medicaid,469.51,,,,EAPG Rate,100% of IL Medicaid,469.51,5514.3,
XR Scapula Left,73010,CPT,,,LT,both,,,526,315.6,,45.5,,239.33,percent of total billed charges,,,45.3,,238.28,percent of total billed charges,,,51,,268.26,percent of total billed charges,,,,,,,,,80,,420.8,percent of total billed charges,,,61.4,,322.96,percent of total billed charges,,,57.4,,301.92,percent of total billed charges,,,81,,426.06,percent of total billed charges,,,51.5,,270.89,percent of total billed charges,,365,,,,fee schedule,,,85,,447.1,percent of total billed charges,,,85,,447.1,percent of total billed charges,,,49,,257.74,percent of total billed charges,,,90,,473.4,percent of total billed charges,,,65,,341.9,percent of total billed charges,,,80,,420.8,percent of total billed charges,,,55,,289.3,percent of total billed charges,,,55,,289.3,percent of total billed charges,,,65,,341.9,percent of total billed charges,,,78,,410.28,percent of total billed charges,,,70,,368.2,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,473.4,
XR Scapula Right,73010,CPT,,,RT,both,,,526,315.6,,45.5,,239.33,percent of total billed charges,,,45.3,,238.28,percent of total billed charges,,,51,,268.26,percent of total billed charges,,,,,,,,,80,,420.8,percent of total billed charges,,,61.4,,322.96,percent of total billed charges,,,57.4,,301.92,percent of total billed charges,,,81,,426.06,percent of total billed charges,,,51.5,,270.89,percent of total billed charges,,365,,,,fee schedule,,,85,,447.1,percent of total billed charges,,,85,,447.1,percent of total billed charges,,,49,,257.74,percent of total billed charges,,,90,,473.4,percent of total billed charges,,,65,,341.9,percent of total billed charges,,,80,,420.8,percent of total billed charges,,,55,,289.3,percent of total billed charges,,,55,,289.3,percent of total billed charges,,,65,,341.9,percent of total billed charges,,,78,,410.28,percent of total billed charges,,,70,,368.2,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,473.4,
XR Shoulder 1 View Left,73020,CPT,,,LT,both,,,264,158.4,,45.5,,120.12,percent of total billed charges,,,45.3,,119.59,percent of total billed charges,,,51,,134.64,percent of total billed charges,,,,,,,,,80,,211.2,percent of total billed charges,,,61.4,,162.1,percent of total billed charges,,,57.4,,151.54,percent of total billed charges,,,81,,213.84,percent of total billed charges,,,51.5,,135.96,percent of total billed charges,,365,,,,fee schedule,,,85,,224.4,percent of total billed charges,,,85,,224.4,percent of total billed charges,,,49,,129.36,percent of total billed charges,,,90,,237.6,percent of total billed charges,,,65,,171.6,percent of total billed charges,,,80,,211.2,percent of total billed charges,,,55,,145.2,percent of total billed charges,,,55,,145.2,percent of total billed charges,,,65,,171.6,percent of total billed charges,,,78,,205.92,percent of total billed charges,,,70,,184.8,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,365,
"Addition, endo knee-shin sys, stance flexion feature, adj",L5845,HCPCS,,,,outpatient,,,6253,3751.8,,45.5,,2845.12,percent of total billed charges,,,45.3,,2832.61,percent of total billed charges,,,39,,2438.67,percent of total billed charges,,,,,,,,,80,,5002.4,percent of total billed charges,,,61.4,,3839.34,percent of total billed charges,,,57.4,,3589.22,percent of total billed charges,,,81,,5064.93,percent of total billed charges,,,39,,2438.67,percent of total billed charges,,,57.6,,3601.73,percent of total billed charges,,,85,,5315.05,percent of total billed charges,,,85,,5315.05,percent of total billed charges,,,49,,3063.97,percent of total billed charges,,,90,,5627.7,percent of total billed charges,,,65,,4064.45,percent of total billed charges,,,80,,5002.4,percent of total billed charges,,,55,,3439.15,percent of total billed charges,,,55,,3439.15,percent of total billed charges,,,65,,4064.45,percent of total billed charges,,,78,,4877.34,percent of total billed charges,,,70,,4377.1,percent of total billed charges,,,,,,,,2163.77,,,,100% of Medicare,,2163.77,,,,100% of Medicare,,2163.77,,,,100% of Medicare,,2163.77,,,,100% of Medicare,,2163.77,,,,100% of Medicare,,2163.77,,,,100% of Medicare,,2163.77,,,,100% of Medicare,,2163.77,,,,100% of Medicare,,2163.77,,,,100% of Medicare,,2163.77,,,,100% of Medicare,,2163.77,,,,100% of Medicare,,2163.77,,,,100% of Medicare,,,2163.77,,,,100% of Medicare,495.62,,,,EAPG Rate,100% of IL Medicaid,495.62,,,,EAPG Rate,100% of IL Medicaid,495.62,,,,EAPG Rate,100% of IL Medicaid,495.62,,,,EAPG Rate,100% of IL Medicaid,495.62,5627.7,
LSO SC R ANT/POS PNL PRE OTS (L0650),L0650,HCPCS,,,,outpatient,,,6262,3757.2,,45.5,,2849.21,percent of total billed charges,,,45.3,,2836.69,percent of total billed charges,,,39,,2442.18,percent of total billed charges,,,,,,,,,80,,5009.6,percent of total billed charges,,,61.4,,3844.87,percent of total billed charges,,,57.4,,3594.39,percent of total billed charges,,,81,,5072.22,percent of total billed charges,,,39,,2442.18,percent of total billed charges,,,57.6,,3606.91,percent of total billed charges,,,85,,5322.7,percent of total billed charges,,,85,,5322.7,percent of total billed charges,,,49,,3068.38,percent of total billed charges,,,90,,5635.8,percent of total billed charges,,,65,,4070.3,percent of total billed charges,,,80,,5009.6,percent of total billed charges,,,55,,3444.1,percent of total billed charges,,,55,,3444.1,percent of total billed charges,,,65,,4070.3,percent of total billed charges,,,78,,4884.36,percent of total billed charges,,,70,,4383.4,percent of total billed charges,,,,,,,,762.72,,,,100% of Medicare,,762.72,,,,100% of Medicare,,762.72,,,,100% of Medicare,,762.72,,,,100% of Medicare,,762.72,,,,100% of Medicare,,762.72,,,,100% of Medicare,,762.72,,,,100% of Medicare,,762.72,,,,100% of Medicare,,762.72,,,,100% of Medicare,,762.72,,,,100% of Medicare,,762.72,,,,100% of Medicare,,762.72,,,,100% of Medicare,,,762.72,,,,100% of Medicare,497.49,,,,EAPG Rate,100% of IL Medicaid,497.49,,,,EAPG Rate,100% of IL Medicaid,497.49,,,,EAPG Rate,100% of IL Medicaid,497.49,,,,EAPG Rate,100% of IL Medicaid,497.49,5635.8,
"Prep, AK or knee disartic, ischial level socket, non-align sys, pylon, no cover, SACH foot, plaster",L5560,HCPCS,,,,outpatient,,,6279,3767.4,,45.5,,2856.95,percent of total billed charges,,,45.3,,2844.39,percent of total billed charges,,,39,,2448.81,percent of total billed charges,,,,,,,,,80,,5023.2,percent of total billed charges,,,61.4,,3855.31,percent of total billed charges,,,57.4,,3604.15,percent of total billed charges,,,81,,5085.99,percent of total billed charges,,,39,,2448.81,percent of total billed charges,,,57.6,,3616.7,percent of total billed charges,,,85,,5337.15,percent of total billed charges,,,85,,5337.15,percent of total billed charges,,,49,,3076.71,percent of total billed charges,,,90,,5651.1,percent of total billed charges,,,65,,4081.35,percent of total billed charges,,,80,,5023.2,percent of total billed charges,,,55,,3453.45,percent of total billed charges,,,55,,3453.45,percent of total billed charges,,,65,,4081.35,percent of total billed charges,,,78,,4897.62,percent of total billed charges,,,70,,4395.3,percent of total billed charges,,,,,,,,2818.25,,,,100% of Medicare,,2818.25,,,,100% of Medicare,,2818.25,,,,100% of Medicare,,2818.25,,,,100% of Medicare,,2818.25,,,,100% of Medicare,,2818.25,,,,100% of Medicare,,2818.25,,,,100% of Medicare,,2818.25,,,,100% of Medicare,,2818.25,,,,100% of Medicare,,2818.25,,,,100% of Medicare,,2818.25,,,,100% of Medicare,,2818.25,,,,100% of Medicare,,,2818.25,,,,100% of Medicare,501.01,,,,EAPG Rate,100% of IL Medicaid,501.01,,,,EAPG Rate,100% of IL Medicaid,501.01,,,,EAPG Rate,100% of IL Medicaid,501.01,,,,EAPG Rate,100% of IL Medicaid,501.01,5651.1,
"Knee Orthosis, Double Upright, Medial/Lateral/Rotational Control, Custom Molded to Patient",L1846,HCPCS,,,,outpatient,,,6295,3777,,45.5,,2864.23,percent of total billed charges,,,45.3,,2851.64,percent of total billed charges,,,39,,2455.05,percent of total billed charges,,,,,,,,,80,,5036,percent of total billed charges,,,61.4,,3865.13,percent of total billed charges,,,57.4,,3613.33,percent of total billed charges,,,81,,5098.95,percent of total billed charges,,,39,,2455.05,percent of total billed charges,,,57.6,,3625.92,percent of total billed charges,,,85,,5350.75,percent of total billed charges,,,85,,5350.75,percent of total billed charges,,,49,,3084.55,percent of total billed charges,,,90,,5665.5,percent of total billed charges,,,65,,4091.75,percent of total billed charges,,,80,,5036,percent of total billed charges,,,55,,3462.25,percent of total billed charges,,,55,,3462.25,percent of total billed charges,,,65,,4091.75,percent of total billed charges,,,78,,4910.1,percent of total billed charges,,,70,,4406.5,percent of total billed charges,,,,,,,,1409.73,,,,100% of Medicare,,1409.73,,,,100% of Medicare,,1409.73,,,,100% of Medicare,,1409.73,,,,100% of Medicare,,1409.73,,,,100% of Medicare,,1409.73,,,,100% of Medicare,,1409.73,,,,100% of Medicare,,1409.73,,,,100% of Medicare,,1409.73,,,,100% of Medicare,,1409.73,,,,100% of Medicare,,1409.73,,,,100% of Medicare,,1409.73,,,,100% of Medicare,,,1409.73,,,,100% of Medicare,504.32,,,,EAPG Rate,100% of IL Medicaid,504.32,,,,EAPG Rate,100% of IL Medicaid,504.32,,,,EAPG Rate,100% of IL Medicaid,504.32,,,,EAPG Rate,100% of IL Medicaid,504.32,5665.5,
"Partial Hand, Robin-Aids, thumb remaining, (or equal)",L6000,HCPCS,,,,outpatient,,,6324,3794.4,,45.5,,2877.42,percent of total billed charges,,,45.3,,2864.77,percent of total billed charges,,,39,,2466.36,percent of total billed charges,,,,,,,,,80,,5059.2,percent of total billed charges,,,61.4,,3882.94,percent of total billed charges,,,57.4,,3629.98,percent of total billed charges,,,81,,5122.44,percent of total billed charges,,,39,,2466.36,percent of total billed charges,,,57.6,,3642.62,percent of total billed charges,,,85,,5375.4,percent of total billed charges,,,85,,5375.4,percent of total billed charges,,,49,,3098.76,percent of total billed charges,,,90,,5691.6,percent of total billed charges,,,65,,4110.6,percent of total billed charges,,,80,,5059.2,percent of total billed charges,,,55,,3478.2,percent of total billed charges,,,55,,3478.2,percent of total billed charges,,,65,,4110.6,percent of total billed charges,,,78,,4932.72,percent of total billed charges,,,70,,4426.8,percent of total billed charges,,,,,,,,2126.34,,,,100% of Medicare,,2126.34,,,,100% of Medicare,,2126.34,,,,100% of Medicare,,2126.34,,,,100% of Medicare,,2126.34,,,,100% of Medicare,,2126.34,,,,100% of Medicare,,2126.34,,,,100% of Medicare,,2126.34,,,,100% of Medicare,,2126.34,,,,100% of Medicare,,2126.34,,,,100% of Medicare,,2126.34,,,,100% of Medicare,,2126.34,,,,100% of Medicare,,,2126.34,,,,100% of Medicare,510.33,,,,EAPG Rate,100% of IL Medicaid,510.33,,,,EAPG Rate,100% of IL Medicaid,510.33,,,,EAPG Rate,100% of IL Medicaid,510.33,,,,EAPG Rate,100% of IL Medicaid,510.33,5691.6,
"Addtion to LE prosthesis, user adj heel height",L5990,HCPCS,,,,outpatient,,,6391,3834.6,,45.5,,2907.91,percent of total billed charges,,,45.3,,2895.12,percent of total billed charges,,,39,,2492.49,percent of total billed charges,,,,,,,,,80,,5112.8,percent of total billed charges,,,61.4,,3924.07,percent of total billed charges,,,57.4,,3668.43,percent of total billed charges,,,81,,5176.71,percent of total billed charges,,,39,,2492.49,percent of total billed charges,,,57.6,,3681.22,percent of total billed charges,,,85,,5432.35,percent of total billed charges,,,85,,5432.35,percent of total billed charges,,,49,,3131.59,percent of total billed charges,,,90,,5751.9,percent of total billed charges,,,65,,4154.15,percent of total billed charges,,,80,,5112.8,percent of total billed charges,,,55,,3515.05,percent of total billed charges,,,55,,3515.05,percent of total billed charges,,,65,,4154.15,percent of total billed charges,,,78,,4984.98,percent of total billed charges,,,70,,4473.7,percent of total billed charges,,,,,,,,2190.07,,,,100% of Medicare,,2190.07,,,,100% of Medicare,,2190.07,,,,100% of Medicare,,2190.07,,,,100% of Medicare,,2190.07,,,,100% of Medicare,,2190.07,,,,100% of Medicare,,2190.07,,,,100% of Medicare,,2190.07,,,,100% of Medicare,,2190.07,,,,100% of Medicare,,2190.07,,,,100% of Medicare,,2190.07,,,,100% of Medicare,,2190.07,,,,100% of Medicare,,,2190.07,,,,100% of Medicare,524.22,,,,EAPG Rate,100% of IL Medicaid,524.22,,,,EAPG Rate,100% of IL Medicaid,524.22,,,,EAPG Rate,100% of IL Medicaid,524.22,,,,EAPG Rate,100% of IL Medicaid,524.22,5751.9,
AFO WALK BOOT TYPE CUS FAB,L4631,HCPCS,,,,outpatient,,,6407,3844.2,,45.5,,2915.19,percent of total billed charges,,,45.3,,2902.37,percent of total billed charges,,,39,,2498.73,percent of total billed charges,,,,,,,,,80,,5125.6,percent of total billed charges,,,61.4,,3933.9,percent of total billed charges,,,57.4,,3677.62,percent of total billed charges,,,81,,5189.67,percent of total billed charges,,,39,,2498.73,percent of total billed charges,,,57.6,,3690.43,percent of total billed charges,,,85,,5445.95,percent of total billed charges,,,85,,5445.95,percent of total billed charges,,,49,,3139.43,percent of total billed charges,,,90,,5766.3,percent of total billed charges,,,65,,4164.55,percent of total billed charges,,,80,,5125.6,percent of total billed charges,,,55,,3523.85,percent of total billed charges,,,55,,3523.85,percent of total billed charges,,,65,,4164.55,percent of total billed charges,,,78,,4997.46,percent of total billed charges,,,70,,4484.9,percent of total billed charges,,,,,,,,1776.15,,,,100% of Medicare,,1776.15,,,,100% of Medicare,,1776.15,,,,100% of Medicare,,1776.15,,,,100% of Medicare,,1776.15,,,,100% of Medicare,,1776.15,,,,100% of Medicare,,1776.15,,,,100% of Medicare,,1776.15,,,,100% of Medicare,,1776.15,,,,100% of Medicare,,1776.15,,,,100% of Medicare,,1776.15,,,,100% of Medicare,,1776.15,,,,100% of Medicare,,,1776.15,,,,100% of Medicare,527.53,,,,EAPG Rate,100% of IL Medicaid,527.53,,,,EAPG Rate,100% of IL Medicaid,527.53,,,,EAPG Rate,100% of IL Medicaid,527.53,,,,EAPG Rate,100% of IL Medicaid,527.53,5766.3,
"Partial hand, Robin-Aids, no fingers remaining (or equal)",L6020,HCPCS,,,,outpatient,,,6438,3862.8,,45.5,,2929.29,percent of total billed charges,,,45.3,,2916.41,percent of total billed charges,,,39,,2510.82,percent of total billed charges,,,,,,,,,80,,5150.4,percent of total billed charges,,,61.4,,3952.93,percent of total billed charges,,,57.4,,3695.41,percent of total billed charges,,,81,,5214.78,percent of total billed charges,,,39,,2510.82,percent of total billed charges,,,57.6,,3708.29,percent of total billed charges,,,85,,5472.3,percent of total billed charges,,,85,,5472.3,percent of total billed charges,,,49,,3154.62,percent of total billed charges,,,90,,5794.2,percent of total billed charges,,,65,,4184.7,percent of total billed charges,,,80,,5150.4,percent of total billed charges,,,55,,3540.9,percent of total billed charges,,,55,,3540.9,percent of total billed charges,,,65,,4184.7,percent of total billed charges,,,78,,5021.64,percent of total billed charges,,,70,,4506.6,percent of total billed charges,,,,,,,,2206.16,,,,100% of Medicare,,2206.16,,,,100% of Medicare,,2206.16,,,,100% of Medicare,,2206.16,,,,100% of Medicare,,2206.16,,,,100% of Medicare,,2206.16,,,,100% of Medicare,,2206.16,,,,100% of Medicare,,2206.16,,,,100% of Medicare,,2206.16,,,,100% of Medicare,,2206.16,,,,100% of Medicare,,2206.16,,,,100% of Medicare,,2206.16,,,,100% of Medicare,,,2206.16,,,,100% of Medicare,533.95,,,,EAPG Rate,100% of IL Medicaid,533.95,,,,EAPG Rate,100% of IL Medicaid,533.95,,,,EAPG Rate,100% of IL Medicaid,533.95,,,,EAPG Rate,100% of IL Medicaid,533.95,5794.2,
LSO SAG-CO SHELL PNL PRE OTS (L0651),L0651,HCPCS,,,,outpatient,,,6450,3870,,45.5,,2934.75,percent of total billed charges,,,45.3,,2921.85,percent of total billed charges,,,39,,2515.5,percent of total billed charges,,,,,,,,,80,,5160,percent of total billed charges,,,61.4,,3960.3,percent of total billed charges,,,57.4,,3702.3,percent of total billed charges,,,81,,5224.5,percent of total billed charges,,,39,,2515.5,percent of total billed charges,,,57.6,,3715.2,percent of total billed charges,,,85,,5482.5,percent of total billed charges,,,85,,5482.5,percent of total billed charges,,,49,,3160.5,percent of total billed charges,,,90,,5805,percent of total billed charges,,,65,,4192.5,percent of total billed charges,,,80,,5160,percent of total billed charges,,,55,,3547.5,percent of total billed charges,,,55,,3547.5,percent of total billed charges,,,65,,4192.5,percent of total billed charges,,,78,,5031,percent of total billed charges,,,70,,4515,percent of total billed charges,,,,,,,,762.72,,,,100% of Medicare,,762.72,,,,100% of Medicare,,762.72,,,,100% of Medicare,,762.72,,,,100% of Medicare,,762.72,,,,100% of Medicare,,762.72,,,,100% of Medicare,,762.72,,,,100% of Medicare,,762.72,,,,100% of Medicare,,762.72,,,,100% of Medicare,,762.72,,,,100% of Medicare,,762.72,,,,100% of Medicare,,762.72,,,,100% of Medicare,,,762.72,,,,100% of Medicare,536.44,,,,EAPG Rate,100% of IL Medicaid,536.44,,,,EAPG Rate,100% of IL Medicaid,536.44,,,,EAPG Rate,100% of IL Medicaid,536.44,,,,EAPG Rate,100% of IL Medicaid,536.44,5805,
"L5703 Ankle, symes, molded to patient model w/o solid ankle cushion heel foot, replacement only",L5703,HCPCS,,,,outpatient,,,6505,3903,,45.5,,2959.78,percent of total billed charges,,,45.3,,2946.77,percent of total billed charges,,,39,,2536.95,percent of total billed charges,,,,,,,,,80,,5204,percent of total billed charges,,,61.4,,3994.07,percent of total billed charges,,,57.4,,3733.87,percent of total billed charges,,,81,,5269.05,percent of total billed charges,,,39,,2536.95,percent of total billed charges,,,57.6,,3746.88,percent of total billed charges,,,85,,5529.25,percent of total billed charges,,,85,,5529.25,percent of total billed charges,,,49,,3187.45,percent of total billed charges,,,90,,5854.5,percent of total billed charges,,,65,,4228.25,percent of total billed charges,,,80,,5204,percent of total billed charges,,,55,,3577.75,percent of total billed charges,,,55,,3577.75,percent of total billed charges,,,65,,4228.25,percent of total billed charges,,,78,,5073.9,percent of total billed charges,,,70,,4553.5,percent of total billed charges,,,,,,,,3045.61,,,,100% of Medicare,,3045.61,,,,100% of Medicare,,3045.61,,,,100% of Medicare,,3045.61,,,,100% of Medicare,,3045.61,,,,100% of Medicare,,3045.61,,,,100% of Medicare,,3045.61,,,,100% of Medicare,,3045.61,,,,100% of Medicare,,3045.61,,,,100% of Medicare,,3045.61,,,,100% of Medicare,,3045.61,,,,100% of Medicare,,3045.61,,,,100% of Medicare,,,3045.61,,,,100% of Medicare,547.84,,,,EAPG Rate,100% of IL Medicaid,547.84,,,,EAPG Rate,100% of IL Medicaid,547.84,,,,EAPG Rate,100% of IL Medicaid,547.84,,,,EAPG Rate,100% of IL Medicaid,547.84,5854.5,
HOOK/HAND HVY DTY VOL OPEN,L6721,HCPCS,,,,outpatient,,,6511,3906.6,,45.5,,2962.51,percent of total billed charges,,,45.3,,2949.48,percent of total billed charges,,,39,,2539.29,percent of total billed charges,,,,,,,,,80,,5208.8,percent of total billed charges,,,61.4,,3997.75,percent of total billed charges,,,57.4,,3737.31,percent of total billed charges,,,81,,5273.91,percent of total billed charges,,,39,,2539.29,percent of total billed charges,,,57.6,,3750.34,percent of total billed charges,,,85,,5534.35,percent of total billed charges,,,85,,5534.35,percent of total billed charges,,,49,,3190.39,percent of total billed charges,,,90,,5859.9,percent of total billed charges,,,65,,4232.15,percent of total billed charges,,,80,,5208.8,percent of total billed charges,,,55,,3581.05,percent of total billed charges,,,55,,3581.05,percent of total billed charges,,,65,,4232.15,percent of total billed charges,,,78,,5078.58,percent of total billed charges,,,70,,4557.7,percent of total billed charges,,,,,,,,2839.36,,,,100% of Medicare,,2839.36,,,,100% of Medicare,,2839.36,,,,100% of Medicare,,2839.36,,,,100% of Medicare,,2839.36,,,,100% of Medicare,,2839.36,,,,100% of Medicare,,2839.36,,,,100% of Medicare,,2839.36,,,,100% of Medicare,,2839.36,,,,100% of Medicare,,2839.36,,,,100% of Medicare,,2839.36,,,,100% of Medicare,,2839.36,,,,100% of Medicare,,,2839.36,,,,100% of Medicare,549.08,,,,EAPG Rate,100% of IL Medicaid,549.08,,,,EAPG Rate,100% of IL Medicaid,549.08,,,,EAPG Rate,100% of IL Medicaid,549.08,,,,EAPG Rate,100% of IL Medicaid,549.08,5859.9,
"Intrascapular thoracic, passive restoration (shoulder cap only)",L6370,HCPCS,,,,outpatient,,,6652,3991.2,,45.5,,3026.66,percent of total billed charges,,,45.3,,3013.36,percent of total billed charges,,,39,,2594.28,percent of total billed charges,,,,,,,,,80,,5321.6,percent of total billed charges,,,61.4,,4084.33,percent of total billed charges,,,57.4,,3818.25,percent of total billed charges,,,81,,5388.12,percent of total billed charges,,,39,,2594.28,percent of total billed charges,,,57.6,,3831.55,percent of total billed charges,,,85,,5654.2,percent of total billed charges,,,85,,5654.2,percent of total billed charges,,,49,,3259.48,percent of total billed charges,,,90,,5986.8,percent of total billed charges,,,65,,4323.8,percent of total billed charges,,,80,,5321.6,percent of total billed charges,,,55,,3658.6,percent of total billed charges,,,55,,3658.6,percent of total billed charges,,,65,,4323.8,percent of total billed charges,,,78,,5188.56,percent of total billed charges,,,70,,4656.4,percent of total billed charges,,,,,,,,2956.1,,,,100% of Medicare,,2956.1,,,,100% of Medicare,,2956.1,,,,100% of Medicare,,2956.1,,,,100% of Medicare,,2956.1,,,,100% of Medicare,,2956.1,,,,100% of Medicare,,2956.1,,,,100% of Medicare,,2956.1,,,,100% of Medicare,,2956.1,,,,100% of Medicare,,2956.1,,,,100% of Medicare,,2956.1,,,,100% of Medicare,,2956.1,,,,100% of Medicare,,,2956.1,,,,100% of Medicare,578.29,,,,EAPG Rate,100% of IL Medicaid,578.29,,,,EAPG Rate,100% of IL Medicaid,578.29,,,,EAPG Rate,100% of IL Medicaid,578.29,,,,EAPG Rate,100% of IL Medicaid,578.29,5986.8,
"Knee Orthosis, Supracondylar Model, Molded to Patient",L1860,HCPCS,,,,outpatient,,,6706,4023.6,,45.5,,3051.23,percent of total billed charges,,,45.3,,3037.82,percent of total billed charges,,,39,,2615.34,percent of total billed charges,,,,,,,,,80,,5364.8,percent of total billed charges,,,61.4,,4117.48,percent of total billed charges,,,57.4,,3849.24,percent of total billed charges,,,81,,5431.86,percent of total billed charges,,,39,,2615.34,percent of total billed charges,,,57.6,,3862.66,percent of total billed charges,,,85,,5700.1,percent of total billed charges,,,85,,5700.1,percent of total billed charges,,,49,,3285.94,percent of total billed charges,,,90,,6035.4,percent of total billed charges,,,65,,4358.9,percent of total billed charges,,,80,,5364.8,percent of total billed charges,,,55,,3688.3,percent of total billed charges,,,55,,3688.3,percent of total billed charges,,,65,,4358.9,percent of total billed charges,,,78,,5230.68,percent of total billed charges,,,70,,4694.2,percent of total billed charges,,,,,,,,1502.44,,,,100% of Medicare,,1502.44,,,,100% of Medicare,,1502.44,,,,100% of Medicare,,1502.44,,,,100% of Medicare,,1502.44,,,,100% of Medicare,,1502.44,,,,100% of Medicare,,1502.44,,,,100% of Medicare,,1502.44,,,,100% of Medicare,,1502.44,,,,100% of Medicare,,1502.44,,,,100% of Medicare,,1502.44,,,,100% of Medicare,,1502.44,,,,100% of Medicare,,,1502.44,,,,100% of Medicare,589.48,,,,EAPG Rate,100% of IL Medicaid,589.48,,,,EAPG Rate,100% of IL Medicaid,589.48,,,,EAPG Rate,100% of IL Medicaid,589.48,,,,EAPG Rate,100% of IL Medicaid,589.48,6035.4,
"Addition, exo knee-shin sys, single axis, fluid swing and stance",L5728,HCPCS,,,,outpatient,,,6799,4079.4,,45.5,,3093.55,percent of total billed charges,,,45.3,,3079.95,percent of total billed charges,,,39,,2651.61,percent of total billed charges,,,,,,,,,80,,5439.2,percent of total billed charges,,,61.4,,4174.59,percent of total billed charges,,,57.4,,3902.63,percent of total billed charges,,,81,,5507.19,percent of total billed charges,,,39,,2651.61,percent of total billed charges,,,57.6,,3916.22,percent of total billed charges,,,85,,5779.15,percent of total billed charges,,,85,,5779.15,percent of total billed charges,,,49,,3331.51,percent of total billed charges,,,90,,6119.1,percent of total billed charges,,,65,,4419.35,percent of total billed charges,,,80,,5439.2,percent of total billed charges,,,55,,3739.45,percent of total billed charges,,,55,,3739.45,percent of total billed charges,,,65,,4419.35,percent of total billed charges,,,78,,5303.22,percent of total billed charges,,,70,,4759.3,percent of total billed charges,,,,,,,,2909.74,,,,100% of Medicare,,2909.74,,,,100% of Medicare,,2909.74,,,,100% of Medicare,,2909.74,,,,100% of Medicare,,2909.74,,,,100% of Medicare,,2909.74,,,,100% of Medicare,,2909.74,,,,100% of Medicare,,2909.74,,,,100% of Medicare,,2909.74,,,,100% of Medicare,,2909.74,,,,100% of Medicare,,2909.74,,,,100% of Medicare,,2909.74,,,,100% of Medicare,,,2909.74,,,,100% of Medicare,608.75,,,,EAPG Rate,100% of IL Medicaid,608.75,,,,EAPG Rate,100% of IL Medicaid,608.75,,,,EAPG Rate,100% of IL Medicaid,608.75,,,,EAPG Rate,100% of IL Medicaid,608.75,6119.1,
"Cervical Halo Procedure, Incorporated Into Jacket Vest",L0810,HCPCS,,,,outpatient,,,6848,4108.8,,45.5,,3115.84,percent of total billed charges,,,45.3,,3102.14,percent of total billed charges,,,39,,2670.72,percent of total billed charges,,,,,,,,,80,,5478.4,percent of total billed charges,,,61.4,,4204.67,percent of total billed charges,,,57.4,,3930.75,percent of total billed charges,,,81,,5546.88,percent of total billed charges,,,39,,2670.72,percent of total billed charges,,,57.6,,3944.45,percent of total billed charges,,,85,,5820.8,percent of total billed charges,,,85,,5820.8,percent of total billed charges,,,49,,3355.52,percent of total billed charges,,,90,,6163.2,percent of total billed charges,,,65,,4451.2,percent of total billed charges,,,80,,5478.4,percent of total billed charges,,,55,,3766.4,percent of total billed charges,,,55,,3766.4,percent of total billed charges,,,65,,4451.2,percent of total billed charges,,,78,,5341.44,percent of total billed charges,,,70,,4793.6,percent of total billed charges,,,,,,,,3220.5,,,,100% of Medicare,,3220.5,,,,100% of Medicare,,3220.5,,,,100% of Medicare,,3220.5,,,,100% of Medicare,,3220.5,,,,100% of Medicare,,3220.5,,,,100% of Medicare,,3220.5,,,,100% of Medicare,,3220.5,,,,100% of Medicare,,3220.5,,,,100% of Medicare,,3220.5,,,,100% of Medicare,,3220.5,,,,100% of Medicare,,3220.5,,,,100% of Medicare,,,3220.5,,,,100% of Medicare,618.91,,,,EAPG Rate,100% of IL Medicaid,618.91,,,,EAPG Rate,100% of IL Medicaid,618.91,,,,EAPG Rate,100% of IL Medicaid,618.91,,,,EAPG Rate,100% of IL Medicaid,618.91,6163.2,
"Prep, elbow disartic or AE, plastic molded to patient model",L6584,HCPCS,,,,outpatient,,,6867,4120.2,,45.5,,3124.49,percent of total billed charges,,,45.3,,3110.75,percent of total billed charges,,,39,,2678.13,percent of total billed charges,,,,,,,,,80,,5493.6,percent of total billed charges,,,61.4,,4216.34,percent of total billed charges,,,57.4,,3941.66,percent of total billed charges,,,81,,5562.27,percent of total billed charges,,,39,,2678.13,percent of total billed charges,,,57.6,,3955.39,percent of total billed charges,,,85,,5836.95,percent of total billed charges,,,85,,5836.95,percent of total billed charges,,,49,,3364.83,percent of total billed charges,,,90,,6180.3,percent of total billed charges,,,65,,4463.55,percent of total billed charges,,,80,,5493.6,percent of total billed charges,,,55,,3776.85,percent of total billed charges,,,55,,3776.85,percent of total billed charges,,,65,,4463.55,percent of total billed charges,,,78,,5356.26,percent of total billed charges,,,70,,4806.9,percent of total billed charges,,,,,,,,3031.05,,,,100% of Medicare,,3031.05,,,,100% of Medicare,,3031.05,,,,100% of Medicare,,3031.05,,,,100% of Medicare,,3031.05,,,,100% of Medicare,,3031.05,,,,100% of Medicare,,3031.05,,,,100% of Medicare,,3031.05,,,,100% of Medicare,,3031.05,,,,100% of Medicare,,3031.05,,,,100% of Medicare,,3031.05,,,,100% of Medicare,,3031.05,,,,100% of Medicare,,,3031.05,,,,100% of Medicare,622.84,,,,EAPG Rate,100% of IL Medicaid,622.84,,,,EAPG Rate,100% of IL Medicaid,622.84,,,,EAPG Rate,100% of IL Medicaid,622.84,,,,EAPG Rate,100% of IL Medicaid,622.84,6180.3,
"Prep, elbow disartic or AE, direct formed",L6586,HCPCS,,,,outpatient,,,6867,4120.2,,45.5,,3124.49,percent of total billed charges,,,45.3,,3110.75,percent of total billed charges,,,39,,2678.13,percent of total billed charges,,,,,,,,,80,,5493.6,percent of total billed charges,,,61.4,,4216.34,percent of total billed charges,,,57.4,,3941.66,percent of total billed charges,,,81,,5562.27,percent of total billed charges,,,39,,2678.13,percent of total billed charges,,,57.6,,3955.39,percent of total billed charges,,,85,,5836.95,percent of total billed charges,,,85,,5836.95,percent of total billed charges,,,49,,3364.83,percent of total billed charges,,,90,,6180.3,percent of total billed charges,,,65,,4463.55,percent of total billed charges,,,80,,5493.6,percent of total billed charges,,,55,,3776.85,percent of total billed charges,,,55,,3776.85,percent of total billed charges,,,65,,4463.55,percent of total billed charges,,,78,,5356.26,percent of total billed charges,,,70,,4806.9,percent of total billed charges,,,,,,,,2700.85,,,,100% of Medicare,,2700.85,,,,100% of Medicare,,2700.85,,,,100% of Medicare,,2700.85,,,,100% of Medicare,,2700.85,,,,100% of Medicare,,2700.85,,,,100% of Medicare,,2700.85,,,,100% of Medicare,,2700.85,,,,100% of Medicare,,2700.85,,,,100% of Medicare,,2700.85,,,,100% of Medicare,,2700.85,,,,100% of Medicare,,2700.85,,,,100% of Medicare,,,2700.85,,,,100% of Medicare,622.84,,,,EAPG Rate,100% of IL Medicaid,622.84,,,,EAPG Rate,100% of IL Medicaid,622.84,,,,EAPG Rate,100% of IL Medicaid,622.84,,,,EAPG Rate,100% of IL Medicaid,622.84,6180.3,
"Addition to LE, hip disartic, flexible inner socket, external frame",L5643,HCPCS,,,,outpatient,,,6986,4191.6,,45.5,,3178.63,percent of total billed charges,,,45.3,,3164.66,percent of total billed charges,,,39,,2724.54,percent of total billed charges,,,,,,,,,80,,5588.8,percent of total billed charges,,,61.4,,4289.4,percent of total billed charges,,,57.4,,4009.96,percent of total billed charges,,,81,,5658.66,percent of total billed charges,,,39,,2724.54,percent of total billed charges,,,57.6,,4023.94,percent of total billed charges,,,85,,5938.1,percent of total billed charges,,,85,,5938.1,percent of total billed charges,,,49,,3423.14,percent of total billed charges,,,90,,6287.4,percent of total billed charges,,,65,,4540.9,percent of total billed charges,,,80,,5588.8,percent of total billed charges,,,55,,3842.3,percent of total billed charges,,,55,,3842.3,percent of total billed charges,,,65,,4540.9,percent of total billed charges,,,78,,5449.08,percent of total billed charges,,,70,,4890.2,percent of total billed charges,,,,,,,,2418.36,,,,100% of Medicare,,2418.36,,,,100% of Medicare,,2418.36,,,,100% of Medicare,,2418.36,,,,100% of Medicare,,2418.36,,,,100% of Medicare,,2418.36,,,,100% of Medicare,,2418.36,,,,100% of Medicare,,2418.36,,,,100% of Medicare,,2418.36,,,,100% of Medicare,,2418.36,,,,100% of Medicare,,2418.36,,,,100% of Medicare,,2418.36,,,,100% of Medicare,,,2418.36,,,,100% of Medicare,647.5,,,,EAPG Rate,100% of IL Medicaid,647.5,,,,EAPG Rate,100% of IL Medicaid,647.5,,,,EAPG Rate,100% of IL Medicaid,647.5,,,,EAPG Rate,100% of IL Medicaid,647.5,6287.4,
"L6884 Replacement socket,above elbow/elbow disarticulation,molded to patient model,for use with or w",L6884,HCPCS,,,,outpatient,,,7009,4205.4,,45.5,,3189.1,percent of total billed charges,,,45.3,,3175.08,percent of total billed charges,,,39,,2733.51,percent of total billed charges,,,,,,,,,80,,5607.2,percent of total billed charges,,,61.4,,4303.53,percent of total billed charges,,,57.4,,4023.17,percent of total billed charges,,,81,,5677.29,percent of total billed charges,,,39,,2733.51,percent of total billed charges,,,57.6,,4037.18,percent of total billed charges,,,85,,5957.65,percent of total billed charges,,,85,,5957.65,percent of total billed charges,,,49,,3434.41,percent of total billed charges,,,90,,6308.1,percent of total billed charges,,,65,,4555.85,percent of total billed charges,,,80,,5607.2,percent of total billed charges,,,55,,3854.95,percent of total billed charges,,,55,,3854.95,percent of total billed charges,,,65,,4555.85,percent of total billed charges,,,78,,5467.02,percent of total billed charges,,,70,,4906.3,percent of total billed charges,,,,,,,,3281.15,,,,100% of Medicare,,3281.15,,,,100% of Medicare,,3281.15,,,,100% of Medicare,,3281.15,,,,100% of Medicare,,3281.15,,,,100% of Medicare,,3281.15,,,,100% of Medicare,,3281.15,,,,100% of Medicare,,3281.15,,,,100% of Medicare,,3281.15,,,,100% of Medicare,,3281.15,,,,100% of Medicare,,3281.15,,,,100% of Medicare,,3281.15,,,,100% of Medicare,,,3281.15,,,,100% of Medicare,652.26,,,,EAPG Rate,100% of IL Medicaid,652.26,,,,EAPG Rate,100% of IL Medicaid,652.26,,,,EAPG Rate,100% of IL Medicaid,652.26,,,,EAPG Rate,100% of IL Medicaid,652.26,6308.1,
"Addition to LE, endo sys, AK, hydracadence system",L5610,HCPCS,,,,outpatient,,,7046,4227.6,,45.5,,3205.93,percent of total billed charges,,,45.3,,3191.84,percent of total billed charges,,,39,,2747.94,percent of total billed charges,,,,,,,,,80,,5636.8,percent of total billed charges,,,61.4,,4326.24,percent of total billed charges,,,57.4,,4044.4,percent of total billed charges,,,81,,5707.26,percent of total billed charges,,,39,,2747.94,percent of total billed charges,,,57.6,,4058.5,percent of total billed charges,,,85,,5989.1,percent of total billed charges,,,85,,5989.1,percent of total billed charges,,,49,,3452.54,percent of total billed charges,,,90,,6341.4,percent of total billed charges,,,65,,4579.9,percent of total billed charges,,,80,,5636.8,percent of total billed charges,,,55,,3875.3,percent of total billed charges,,,55,,3875.3,percent of total billed charges,,,65,,4579.9,percent of total billed charges,,,78,,5495.88,percent of total billed charges,,,70,,4932.2,percent of total billed charges,,,,,,,,3036.2,,,,100% of Medicare,,3036.2,,,,100% of Medicare,,3036.2,,,,100% of Medicare,,3036.2,,,,100% of Medicare,,3036.2,,,,100% of Medicare,,3036.2,,,,100% of Medicare,,3036.2,,,,100% of Medicare,,3036.2,,,,100% of Medicare,,3036.2,,,,100% of Medicare,,3036.2,,,,100% of Medicare,,3036.2,,,,100% of Medicare,,3036.2,,,,100% of Medicare,,,3036.2,,,,100% of Medicare,659.93,,,,EAPG Rate,100% of IL Medicaid,659.93,,,,EAPG Rate,100% of IL Medicaid,659.93,,,,EAPG Rate,100% of IL Medicaid,659.93,,,,EAPG Rate,100% of IL Medicaid,659.93,6341.4,
"Prep, wrist disartic or BE, plastic molded to patient model",L6580,HCPCS,,,,outpatient,,,7113,4267.8,,45.5,,3236.42,percent of total billed charges,,,45.3,,3222.19,percent of total billed charges,,,39,,2774.07,percent of total billed charges,,,,,,,,,80,,5690.4,percent of total billed charges,,,61.4,,4367.38,percent of total billed charges,,,57.4,,4082.86,percent of total billed charges,,,81,,5761.53,percent of total billed charges,,,39,,2774.07,percent of total billed charges,,,57.6,,4097.09,percent of total billed charges,,,85,,6046.05,percent of total billed charges,,,85,,6046.05,percent of total billed charges,,,49,,3485.37,percent of total billed charges,,,90,,6401.7,percent of total billed charges,,,65,,4623.45,percent of total billed charges,,,80,,5690.4,percent of total billed charges,,,55,,3912.15,percent of total billed charges,,,55,,3912.15,percent of total billed charges,,,65,,4623.45,percent of total billed charges,,,78,,5548.14,percent of total billed charges,,,70,,4979.1,percent of total billed charges,,,,,,,,2437.29,,,,100% of Medicare,,2437.29,,,,100% of Medicare,,2437.29,,,,100% of Medicare,,2437.29,,,,100% of Medicare,,2437.29,,,,100% of Medicare,,2437.29,,,,100% of Medicare,,2437.29,,,,100% of Medicare,,2437.29,,,,100% of Medicare,,2437.29,,,,100% of Medicare,,2437.29,,,,100% of Medicare,,2437.29,,,,100% of Medicare,,2437.29,,,,100% of Medicare,,,2437.29,,,,100% of Medicare,673.81,,,,EAPG Rate,100% of IL Medicaid,673.81,,,,EAPG Rate,100% of IL Medicaid,673.81,,,,EAPG Rate,100% of IL Medicaid,673.81,,,,EAPG Rate,100% of IL Medicaid,673.81,6401.7,
HOOK/HAND HVY DTY VOL CLOS,L6722,HCPCS,,,,outpatient,,,7290,4374,,45.5,,3316.95,percent of total billed charges,,,45.3,,3302.37,percent of total billed charges,,,39,,2843.1,percent of total billed charges,,,,,,,,,80,,5832,percent of total billed charges,,,61.4,,4476.06,percent of total billed charges,,,57.4,,4184.46,percent of total billed charges,,,81,,5904.9,percent of total billed charges,,,39,,2843.1,percent of total billed charges,,,57.6,,4199.04,percent of total billed charges,,,85,,6196.5,percent of total billed charges,,,85,,6196.5,percent of total billed charges,,,49,,3572.1,percent of total billed charges,,,90,,6561,percent of total billed charges,,,65,,4738.5,percent of total billed charges,,,80,,5832,percent of total billed charges,,,55,,4009.5,percent of total billed charges,,,55,,4009.5,percent of total billed charges,,,65,,4738.5,percent of total billed charges,,,78,,5686.2,percent of total billed charges,,,70,,5103,percent of total billed charges,,,,,,,,2447.69,,,,100% of Medicare,,2447.69,,,,100% of Medicare,,2447.69,,,,100% of Medicare,,2447.69,,,,100% of Medicare,,2447.69,,,,100% of Medicare,,2447.69,,,,100% of Medicare,,2447.69,,,,100% of Medicare,,2447.69,,,,100% of Medicare,,2447.69,,,,100% of Medicare,,2447.69,,,,100% of Medicare,,2447.69,,,,100% of Medicare,,2447.69,,,,100% of Medicare,,,2447.69,,,,100% of Medicare,693.7,,,,EAPG Rate,100% of IL Medicaid,693.7,,,,EAPG Rate,100% of IL Medicaid,693.7,,,,EAPG Rate,100% of IL Medicaid,693.7,,,,EAPG Rate,100% of IL Medicaid,693.7,6561,
"Prep, BK ""PTB"" type socket, non-alignable sys, pylon, no cover, SACH foot, lam socket, molded to p",L5540,HCPCS,,,,outpatient,,,7215,4329,,45.5,,3282.83,percent of total billed charges,,,45.3,,3268.4,percent of total billed charges,,,39,,2813.85,percent of total billed charges,,,,,,,,,80,,5772,percent of total billed charges,,,61.4,,4430.01,percent of total billed charges,,,57.4,,4141.41,percent of total billed charges,,,81,,5844.15,percent of total billed charges,,,39,,2813.85,percent of total billed charges,,,57.6,,4155.84,percent of total billed charges,,,85,,6132.75,percent of total billed charges,,,85,,6132.75,percent of total billed charges,,,49,,3535.35,percent of total billed charges,,,90,,6493.5,percent of total billed charges,,,65,,4689.75,percent of total billed charges,,,80,,5772,percent of total billed charges,,,55,,3968.25,percent of total billed charges,,,55,,3968.25,percent of total billed charges,,,65,,4689.75,percent of total billed charges,,,78,,5627.7,percent of total billed charges,,,70,,5050.5,percent of total billed charges,,,,,,,,2473.35,,,,100% of Medicare,,2473.35,,,,100% of Medicare,,2473.35,,,,100% of Medicare,,2473.35,,,,100% of Medicare,,2473.35,,,,100% of Medicare,,2473.35,,,,100% of Medicare,,2473.35,,,,100% of Medicare,,2473.35,,,,100% of Medicare,,2473.35,,,,100% of Medicare,,2473.35,,,,100% of Medicare,,2473.35,,,,100% of Medicare,,2473.35,,,,100% of Medicare,,,2473.35,,,,100% of Medicare,694.95,,,,EAPG Rate,100% of IL Medicaid,694.95,,,,EAPG Rate,100% of IL Medicaid,694.95,,,,EAPG Rate,100% of IL Medicaid,694.95,,,,EAPG Rate,100% of IL Medicaid,694.95,6493.5,
"Prep, BK ""PTB"" type socket, non-align sys, pylon, no cover, SACH foot, thermoplastic or equal, mol",L5530,HCPCS,,,,outpatient,,,7237,4342.2,,45.5,,3292.84,percent of total billed charges,,,45.3,,3278.36,percent of total billed charges,,,39,,2822.43,percent of total billed charges,,,,,,,,,80,,5789.6,percent of total billed charges,,,61.4,,4443.52,percent of total billed charges,,,57.4,,4154.04,percent of total billed charges,,,81,,5861.97,percent of total billed charges,,,39,,2822.43,percent of total billed charges,,,57.6,,4168.51,percent of total billed charges,,,85,,6151.45,percent of total billed charges,,,85,,6151.45,percent of total billed charges,,,49,,3546.13,percent of total billed charges,,,90,,6513.3,percent of total billed charges,,,65,,4704.05,percent of total billed charges,,,80,,5789.6,percent of total billed charges,,,55,,3980.35,percent of total billed charges,,,55,,3980.35,percent of total billed charges,,,65,,4704.05,percent of total billed charges,,,78,,5644.86,percent of total billed charges,,,70,,5065.9,percent of total billed charges,,,,,,,,2505.05,,,,100% of Medicare,,2505.05,,,,100% of Medicare,,2505.05,,,,100% of Medicare,,2505.05,,,,100% of Medicare,,2505.05,,,,100% of Medicare,,2505.05,,,,100% of Medicare,,2505.05,,,,100% of Medicare,,2505.05,,,,100% of Medicare,,2505.05,,,,100% of Medicare,,2505.05,,,,100% of Medicare,,2505.05,,,,100% of Medicare,,2505.05,,,,100% of Medicare,,,2505.05,,,,100% of Medicare,699.51,,,,EAPG Rate,100% of IL Medicaid,699.51,,,,EAPG Rate,100% of IL Medicaid,699.51,,,,EAPG Rate,100% of IL Medicaid,699.51,,,,EAPG Rate,100% of IL Medicaid,699.51,6513.3,
"Shoulder disartic, passive restoration (shoulder cap only)",L6320,HCPCS,,,,outpatient,,,7386,4431.6,,45.5,,3360.63,percent of total billed charges,,,45.3,,3345.86,percent of total billed charges,,,39,,2880.54,percent of total billed charges,,,,,,,,,80,,5908.8,percent of total billed charges,,,61.4,,4535,percent of total billed charges,,,57.4,,4239.56,percent of total billed charges,,,81,,5982.66,percent of total billed charges,,,39,,2880.54,percent of total billed charges,,,57.6,,4254.34,percent of total billed charges,,,85,,6278.1,percent of total billed charges,,,85,,6278.1,percent of total billed charges,,,49,,3619.14,percent of total billed charges,,,90,,6647.4,percent of total billed charges,,,65,,4800.9,percent of total billed charges,,,80,,5908.8,percent of total billed charges,,,55,,4062.3,percent of total billed charges,,,55,,4062.3,percent of total billed charges,,,65,,4800.9,percent of total billed charges,,,78,,5761.08,percent of total billed charges,,,70,,5170.2,percent of total billed charges,,,,,,,,2530.97,,,,100% of Medicare,,2530.97,,,,100% of Medicare,,2530.97,,,,100% of Medicare,,2530.97,,,,100% of Medicare,,2530.97,,,,100% of Medicare,,2530.97,,,,100% of Medicare,,2530.97,,,,100% of Medicare,,2530.97,,,,100% of Medicare,,2530.97,,,,100% of Medicare,,2530.97,,,,100% of Medicare,,2530.97,,,,100% of Medicare,,2530.97,,,,100% of Medicare,,,2530.97,,,,100% of Medicare,730.38,,,,EAPG Rate,100% of IL Medicaid,730.38,,,,EAPG Rate,100% of IL Medicaid,730.38,,,,EAPG Rate,100% of IL Medicaid,730.38,,,,EAPG Rate,100% of IL Medicaid,730.38,6647.4,
"Cranial Cervical Orthosis, Congenital Torticolous Type, w/out Interface",L0112,HCPCS,,,,outpatient,,,7526,4515.6,,45.5,,3424.33,percent of total billed charges,,,45.3,,3409.28,percent of total billed charges,,,39,,2935.14,percent of total billed charges,,,,,,,,,80,,6020.8,percent of total billed charges,,,61.4,,4620.96,percent of total billed charges,,,57.4,,4319.92,percent of total billed charges,,,81,,6096.06,percent of total billed charges,,,39,,2935.14,percent of total billed charges,,,57.6,,4334.98,percent of total billed charges,,,85,,6397.1,percent of total billed charges,,,85,,6397.1,percent of total billed charges,,,49,,3687.74,percent of total billed charges,,,90,,6773.4,percent of total billed charges,,,65,,4891.9,percent of total billed charges,,,80,,6020.8,percent of total billed charges,,,55,,4139.3,percent of total billed charges,,,55,,4139.3,percent of total billed charges,,,65,,4891.9,percent of total billed charges,,,78,,5870.28,percent of total billed charges,,,70,,5268.2,percent of total billed charges,,,,,,,,1686.33,,,,100% of Medicare,,1686.33,,,,100% of Medicare,,1686.33,,,,100% of Medicare,,1686.33,,,,100% of Medicare,,1686.33,,,,100% of Medicare,,1686.33,,,,100% of Medicare,,1686.33,,,,100% of Medicare,,1686.33,,,,100% of Medicare,,1686.33,,,,100% of Medicare,,1686.33,,,,100% of Medicare,,1686.33,,,,100% of Medicare,,1686.33,,,,100% of Medicare,,,1686.33,,,,100% of Medicare,738.67,,,,EAPG Rate,100% of IL Medicaid,738.67,,,,EAPG Rate,100% of IL Medicaid,738.67,,,,EAPG Rate,100% of IL Medicaid,738.67,,,,EAPG Rate,100% of IL Medicaid,738.67,6773.4,
"All LE prosthesis, combination vertical shock and multiaxial rotation/torsional force",L5988,HCPCS,,,,outpatient,,,7545,4527,,45.5,,3432.98,percent of total billed charges,,,45.3,,3417.89,percent of total billed charges,,,39,,2942.55,percent of total billed charges,,,,,,,,,80,,6036,percent of total billed charges,,,61.4,,4632.63,percent of total billed charges,,,57.4,,4330.83,percent of total billed charges,,,81,,6111.45,percent of total billed charges,,,39,,2942.55,percent of total billed charges,,,57.6,,4345.92,percent of total billed charges,,,85,,6413.25,percent of total billed charges,,,85,,6413.25,percent of total billed charges,,,49,,3697.05,percent of total billed charges,,,90,,6790.5,percent of total billed charges,,,65,,4904.25,percent of total billed charges,,,80,,6036,percent of total billed charges,,,55,,4149.75,percent of total billed charges,,,55,,4149.75,percent of total billed charges,,,65,,4904.25,percent of total billed charges,,,78,,5885.1,percent of total billed charges,,,70,,5281.5,percent of total billed charges,,,,,,,,2411.64,,,,100% of Medicare,,2411.64,,,,100% of Medicare,,2411.64,,,,100% of Medicare,,2411.64,,,,100% of Medicare,,2411.64,,,,100% of Medicare,,2411.64,,,,100% of Medicare,,2411.64,,,,100% of Medicare,,2411.64,,,,100% of Medicare,,2411.64,,,,100% of Medicare,,2411.64,,,,100% of Medicare,,2411.64,,,,100% of Medicare,,2411.64,,,,100% of Medicare,,,2411.64,,,,100% of Medicare,763.32,,,,EAPG Rate,100% of IL Medicaid,763.32,,,,EAPG Rate,100% of IL Medicaid,763.32,,,,EAPG Rate,100% of IL Medicaid,763.32,,,,EAPG Rate,100% of IL Medicaid,763.32,6790.5,
"Thoracic-Lumbar-Sacral Orthosis, Triplaner Control, 1-Piece Rigid Plastic Shell w/o Liner",L0480,HCPCS,,,,outpatient,,,8125,4875,,45.5,,3696.88,percent of total billed charges,,,45.3,,3680.63,percent of total billed charges,,,39,,3168.75,percent of total billed charges,,,,,,,,,80,,6500,percent of total billed charges,,,61.4,,4988.75,percent of total billed charges,,,57.4,,4663.75,percent of total billed charges,,,81,,6581.25,percent of total billed charges,,,39,,3168.75,percent of total billed charges,,,57.6,,4680,percent of total billed charges,,,85,,6906.25,percent of total billed charges,,,85,,6906.25,percent of total billed charges,,,49,,3981.25,percent of total billed charges,,,90,,7312.5,percent of total billed charges,,,65,,5281.25,percent of total billed charges,,,80,,6500,percent of total billed charges,,,55,,4468.75,percent of total billed charges,,,55,,4468.75,percent of total billed charges,,,65,,5281.25,percent of total billed charges,,,78,,6337.5,percent of total billed charges,,,70,,5687.5,percent of total billed charges,,,,,,,,1819.89,,,,100% of Medicare,,1819.89,,,,100% of Medicare,,1819.89,,,,100% of Medicare,,1819.89,,,,100% of Medicare,,1819.89,,,,100% of Medicare,,1819.89,,,,100% of Medicare,,1819.89,,,,100% of Medicare,,1819.89,,,,100% of Medicare,,1819.89,,,,100% of Medicare,,1819.89,,,,100% of Medicare,,1819.89,,,,100% of Medicare,,1819.89,,,,100% of Medicare,,,1819.89,,,,100% of Medicare,883.5,,,,EAPG Rate,100% of IL Medicaid,883.5,,,,EAPG Rate,100% of IL Medicaid,883.5,,,,EAPG Rate,100% of IL Medicaid,883.5,,,,EAPG Rate,100% of IL Medicaid,883.5,7312.5,
"Lower Extremity Addition, Pelvic Control, Reciprocating Hip Joint/Cable, Metal Frame",L2628,HCPCS,,,,outpatient,,,8180,4908,,45.5,,3721.9,percent of total billed charges,,,45.3,,3705.54,percent of total billed charges,,,39,,3190.2,percent of total billed charges,,,,,,,,,80,,6544,percent of total billed charges,,,61.4,,5022.52,percent of total billed charges,,,57.4,,4695.32,percent of total billed charges,,,81,,6625.8,percent of total billed charges,,,39,,3190.2,percent of total billed charges,,,57.6,,4711.68,percent of total billed charges,,,85,,6953,percent of total billed charges,,,85,,6953,percent of total billed charges,,,49,,4008.2,percent of total billed charges,,,90,,7362,percent of total billed charges,,,65,,5317,percent of total billed charges,,,80,,6544,percent of total billed charges,,,55,,4499,percent of total billed charges,,,55,,4499,percent of total billed charges,,,65,,5317,percent of total billed charges,,,78,,6380.4,percent of total billed charges,,,70,,5726,percent of total billed charges,,,,,,,,1887.48,,,,100% of Medicare,,1887.48,,,,100% of Medicare,,1887.48,,,,100% of Medicare,,1887.48,,,,100% of Medicare,,1887.48,,,,100% of Medicare,,1887.48,,,,100% of Medicare,,1887.48,,,,100% of Medicare,,1887.48,,,,100% of Medicare,,1887.48,,,,100% of Medicare,,1887.48,,,,100% of Medicare,,1887.48,,,,100% of Medicare,,1887.48,,,,100% of Medicare,,,1887.48,,,,100% of Medicare,894.9,,,,EAPG Rate,100% of IL Medicaid,894.9,,,,EAPG Rate,100% of IL Medicaid,894.9,,,,EAPG Rate,100% of IL Medicaid,894.9,,,,EAPG Rate,100% of IL Medicaid,894.9,7362,
"Knee Orthosis, Single Upright, Thigh/Calf Adjustable, Custom Fabricated",L1844,HCPCS,,,,outpatient,,,8193,4915.8,,45.5,,3727.82,percent of total billed charges,,,45.3,,3711.43,percent of total billed charges,,,39,,3195.27,percent of total billed charges,,,,,,,,,80,,6554.4,percent of total billed charges,,,61.4,,5030.5,percent of total billed charges,,,57.4,,4702.78,percent of total billed charges,,,81,,6636.33,percent of total billed charges,,,39,,3195.27,percent of total billed charges,,,57.6,,4719.17,percent of total billed charges,,,85,,6964.05,percent of total billed charges,,,85,,6964.05,percent of total billed charges,,,49,,4014.57,percent of total billed charges,,,90,,7373.7,percent of total billed charges,,,65,,5325.45,percent of total billed charges,,,80,,6554.4,percent of total billed charges,,,55,,4506.15,percent of total billed charges,,,55,,4506.15,percent of total billed charges,,,65,,5325.45,percent of total billed charges,,,78,,6390.54,percent of total billed charges,,,70,,5735.1,percent of total billed charges,,,,,,,,1834.81,,,,100% of Medicare,,1834.81,,,,100% of Medicare,,1834.81,,,,100% of Medicare,,1834.81,,,,100% of Medicare,,1834.81,,,,100% of Medicare,,1834.81,,,,100% of Medicare,,1834.81,,,,100% of Medicare,,1834.81,,,,100% of Medicare,,1834.81,,,,100% of Medicare,,1834.81,,,,100% of Medicare,,1834.81,,,,100% of Medicare,,1834.81,,,,100% of Medicare,,,1834.81,,,,100% of Medicare,897.59,,,,EAPG Rate,100% of IL Medicaid,897.59,,,,EAPG Rate,100% of IL Medicaid,897.59,,,,EAPG Rate,100% of IL Medicaid,897.59,,,,EAPG Rate,100% of IL Medicaid,897.59,7373.7,
"L6621 Upper extremity additions,flexion/extension wrist with or without friction, for use with exter",L6621,HCPCS,,,,outpatient,,,8216,4929.6,,45.5,,3738.28,percent of total billed charges,,,45.3,,3721.85,percent of total billed charges,,,39,,3204.24,percent of total billed charges,,,,,,,,,80,,6572.8,percent of total billed charges,,,61.4,,5044.62,percent of total billed charges,,,57.4,,4715.98,percent of total billed charges,,,81,,6654.96,percent of total billed charges,,,39,,3204.24,percent of total billed charges,,,57.6,,4732.42,percent of total billed charges,,,85,,6983.6,percent of total billed charges,,,85,,6983.6,percent of total billed charges,,,49,,4025.84,percent of total billed charges,,,90,,7394.4,percent of total billed charges,,,65,,5340.4,percent of total billed charges,,,80,,6572.8,percent of total billed charges,,,55,,4518.8,percent of total billed charges,,,55,,4518.8,percent of total billed charges,,,65,,5340.4,percent of total billed charges,,,78,,6408.48,percent of total billed charges,,,70,,5751.2,percent of total billed charges,,,,,,,,2761.27,,,,100% of Medicare,,2761.27,,,,100% of Medicare,,2761.27,,,,100% of Medicare,,2761.27,,,,100% of Medicare,,2761.27,,,,100% of Medicare,,2761.27,,,,100% of Medicare,,2761.27,,,,100% of Medicare,,2761.27,,,,100% of Medicare,,2761.27,,,,100% of Medicare,,2761.27,,,,100% of Medicare,,2761.27,,,,100% of Medicare,,2761.27,,,,100% of Medicare,,,2761.27,,,,100% of Medicare,902.36,,,,EAPG Rate,100% of IL Medicaid,902.36,,,,EAPG Rate,100% of IL Medicaid,902.36,,,,EAPG Rate,100% of IL Medicaid,902.36,,,,EAPG Rate,100% of IL Medicaid,902.36,7394.4,
"Cervical Halo Procedure, Incorporated Into Milwaukee Type",L0830,HCPCS,,,,outpatient,,,8241,4944.6,,45.5,,3749.66,percent of total billed charges,,,45.3,,3733.17,percent of total billed charges,,,39,,3213.99,percent of total billed charges,,,,,,,,,80,,6592.8,percent of total billed charges,,,61.4,,5059.97,percent of total billed charges,,,57.4,,4730.33,percent of total billed charges,,,81,,6675.21,percent of total billed charges,,,39,,3213.99,percent of total billed charges,,,57.6,,4746.82,percent of total billed charges,,,85,,7004.85,percent of total billed charges,,,85,,7004.85,percent of total billed charges,,,49,,4038.09,percent of total billed charges,,,90,,7416.9,percent of total billed charges,,,65,,5356.65,percent of total billed charges,,,80,,6592.8,percent of total billed charges,,,55,,4532.55,percent of total billed charges,,,55,,4532.55,percent of total billed charges,,,65,,5356.65,percent of total billed charges,,,78,,6427.98,percent of total billed charges,,,70,,5768.7,percent of total billed charges,,,,,,,,3876.39,,,,100% of Medicare,,3876.39,,,,100% of Medicare,,3876.39,,,,100% of Medicare,,3876.39,,,,100% of Medicare,,3876.39,,,,100% of Medicare,,3876.39,,,,100% of Medicare,,3876.39,,,,100% of Medicare,,3876.39,,,,100% of Medicare,,3876.39,,,,100% of Medicare,,3876.39,,,,100% of Medicare,,3876.39,,,,100% of Medicare,,3876.39,,,,100% of Medicare,,,3876.39,,,,100% of Medicare,907.54,,,,EAPG Rate,100% of IL Medicaid,907.54,,,,EAPG Rate,100% of IL Medicaid,907.54,,,,EAPG Rate,100% of IL Medicaid,907.54,,,,EAPG Rate,100% of IL Medicaid,907.54,7416.9,
66794-0155-02 - baclofen 0.5 mg/mL Soln,J0475,HCPCS,66794-0155-02,NDC,,both,20,ML,734.55,440.73,,45.5,,334.22,percent of total billed charges,,,45.3,,332.75,percent of total billed charges,,,51,,374.62,percent of total billed charges,,,,,,,,,80,,587.64,percent of total billed charges,,,61.4,,451.01,percent of total billed charges,,,57.4,,421.63,percent of total billed charges,,,81,,594.99,percent of total billed charges,,,51.5,,378.29,percent of total billed charges,,,57.6,,423.1,percent of total billed charges,,,85,,624.37,percent of total billed charges,,,85,,624.37,percent of total billed charges,,,49,,359.93,percent of total billed charges,,,90,,661.1,percent of total billed charges,,,65,,477.46,percent of total billed charges,,,80,,587.64,percent of total billed charges,,,55,,404,percent of total billed charges,,,55,,404,percent of total billed charges,,,65,,477.46,percent of total billed charges,,,78,,572.95,percent of total billed charges,,,70,,514.19,percent of total billed charges,,,,,,,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,,181.99,,,,100% of Medicare,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,181.99,920.53,
70257-0560-01 - baclofen 0.5 mg/mL Soln,J0475,HCPCS,70257-0560-01,NDC,,both,20,ML,734.55,440.73,,45.5,,334.22,percent of total billed charges,,,45.3,,332.75,percent of total billed charges,,,51,,374.62,percent of total billed charges,,,,,,,,,80,,587.64,percent of total billed charges,,,61.4,,451.01,percent of total billed charges,,,57.4,,421.63,percent of total billed charges,,,81,,594.99,percent of total billed charges,,,51.5,,378.29,percent of total billed charges,,,57.6,,423.1,percent of total billed charges,,,85,,624.37,percent of total billed charges,,,85,,624.37,percent of total billed charges,,,49,,359.93,percent of total billed charges,,,90,,661.1,percent of total billed charges,,,65,,477.46,percent of total billed charges,,,80,,587.64,percent of total billed charges,,,55,,404,percent of total billed charges,,,55,,404,percent of total billed charges,,,65,,477.46,percent of total billed charges,,,78,,572.95,percent of total billed charges,,,70,,514.19,percent of total billed charges,,,,,,,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,,181.99,,,,100% of Medicare,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,181.99,920.53,
70257-0560-02 - baclofen 0.5 mg/mL Soln,J0475,HCPCS,70257-0560-02,NDC,,both,40,ML,734.55,440.73,,45.5,,334.22,percent of total billed charges,,,45.3,,332.75,percent of total billed charges,,,51,,374.62,percent of total billed charges,,,,,,,,,80,,587.64,percent of total billed charges,,,61.4,,451.01,percent of total billed charges,,,57.4,,421.63,percent of total billed charges,,,81,,594.99,percent of total billed charges,,,51.5,,378.29,percent of total billed charges,,,57.6,,423.1,percent of total billed charges,,,85,,624.37,percent of total billed charges,,,85,,624.37,percent of total billed charges,,,49,,359.93,percent of total billed charges,,,90,,661.1,percent of total billed charges,,,65,,477.46,percent of total billed charges,,,80,,587.64,percent of total billed charges,,,55,,404,percent of total billed charges,,,55,,404,percent of total billed charges,,,65,,477.46,percent of total billed charges,,,78,,572.95,percent of total billed charges,,,70,,514.19,percent of total billed charges,,,,,,,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,,181.99,,,,100% of Medicare,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,181.99,920.53,
45945-0156-02 - baclofen IT (MIDDLE) 1 mg/mL Soln,J0475,HCPCS,45945-0156-02,NDC,,both,20,ML,1336.45,801.87,,45.5,,608.08,percent of total billed charges,,,45.3,,605.41,percent of total billed charges,,,51,,681.59,percent of total billed charges,,,,,,,,,80,,1069.16,percent of total billed charges,,,61.4,,820.58,percent of total billed charges,,,57.4,,767.12,percent of total billed charges,,,81,,1082.52,percent of total billed charges,,,51.5,,688.27,percent of total billed charges,,,57.6,,769.8,percent of total billed charges,,,85,,1135.98,percent of total billed charges,,,85,,1135.98,percent of total billed charges,,,49,,654.86,percent of total billed charges,,,90,,1202.81,percent of total billed charges,,,65,,868.69,percent of total billed charges,,,80,,1069.16,percent of total billed charges,,,55,,735.05,percent of total billed charges,,,55,,735.05,percent of total billed charges,,,65,,868.69,percent of total billed charges,,,78,,1042.43,percent of total billed charges,,,70,,935.52,percent of total billed charges,,,,,,,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,,181.99,,,,100% of Medicare,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,181.99,1202.81,
66794-0156-02 - baclofen 1 mg/mL Soln,J0475,HCPCS,66794-0156-02,NDC,,both,20,ML,1468.55,881.13,,45.5,,668.19,percent of total billed charges,,,45.3,,665.25,percent of total billed charges,,,51,,748.96,percent of total billed charges,,,,,,,,,80,,1174.84,percent of total billed charges,,,61.4,,901.69,percent of total billed charges,,,57.4,,842.95,percent of total billed charges,,,81,,1189.53,percent of total billed charges,,,51.5,,756.3,percent of total billed charges,,,57.6,,845.88,percent of total billed charges,,,85,,1248.27,percent of total billed charges,,,85,,1248.27,percent of total billed charges,,,49,,719.59,percent of total billed charges,,,90,,1321.7,percent of total billed charges,,,65,,954.56,percent of total billed charges,,,80,,1174.84,percent of total billed charges,,,55,,807.7,percent of total billed charges,,,55,,807.7,percent of total billed charges,,,65,,954.56,percent of total billed charges,,,78,,1145.47,percent of total billed charges,,,70,,1027.99,percent of total billed charges,,,,,,,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,,181.99,,,,100% of Medicare,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,181.99,1321.7,
70257-0561-02 - baclofen 2 mg/mL Soln,J0475,HCPCS,70257-0561-02,NDC,,both,20,ML,1468.8,881.28,,45.5,,668.3,percent of total billed charges,,,45.3,,665.37,percent of total billed charges,,,51,,749.09,percent of total billed charges,,,,,,,,,80,,1175.04,percent of total billed charges,,,61.4,,901.84,percent of total billed charges,,,57.4,,843.09,percent of total billed charges,,,81,,1189.73,percent of total billed charges,,,51.5,,756.43,percent of total billed charges,,,57.6,,846.03,percent of total billed charges,,,85,,1248.48,percent of total billed charges,,,85,,1248.48,percent of total billed charges,,,49,,719.71,percent of total billed charges,,,90,,1321.92,percent of total billed charges,,,65,,954.72,percent of total billed charges,,,80,,1175.04,percent of total billed charges,,,55,,807.84,percent of total billed charges,,,55,,807.84,percent of total billed charges,,,65,,954.72,percent of total billed charges,,,78,,1145.66,percent of total billed charges,,,70,,1028.16,percent of total billed charges,,,,,,,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,,181.99,,,,100% of Medicare,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,181.99,1321.92,
45945-0157-02 - baclofen 2 mg/mL Soln,J0475,HCPCS,45945-0157-02,NDC,,both,20,ML,2672.9,1603.74,,45.5,,1216.17,percent of total billed charges,,,45.3,,1210.82,percent of total billed charges,,,51,,1363.18,percent of total billed charges,,,,,,,,,80,,2138.32,percent of total billed charges,,,61.4,,1641.16,percent of total billed charges,,,57.4,,1534.24,percent of total billed charges,,,81,,2165.05,percent of total billed charges,,,51.5,,1376.54,percent of total billed charges,,,57.6,,1539.59,percent of total billed charges,,,85,,2271.97,percent of total billed charges,,,85,,2271.97,percent of total billed charges,,,49,,1309.72,percent of total billed charges,,,90,,2405.61,percent of total billed charges,,,65,,1737.39,percent of total billed charges,,,80,,2138.32,percent of total billed charges,,,55,,1470.1,percent of total billed charges,,,55,,1470.1,percent of total billed charges,,,65,,1737.39,percent of total billed charges,,,78,,2084.86,percent of total billed charges,,,70,,1871.03,percent of total billed charges,,,,,,,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,,181.99,,,,100% of Medicare,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,181.99,2405.61,
66794-0157-02 - baclofen 2 mg/mL Soln,J0475,HCPCS,66794-0157-02,NDC,,both,20,ML,2937.6,1762.56,,45.5,,1336.61,percent of total billed charges,,,45.3,,1330.73,percent of total billed charges,,,51,,1498.18,percent of total billed charges,,,,,,,,,80,,2350.08,percent of total billed charges,,,61.4,,1803.69,percent of total billed charges,,,57.4,,1686.18,percent of total billed charges,,,81,,2379.46,percent of total billed charges,,,51.5,,1512.86,percent of total billed charges,,,57.6,,1692.06,percent of total billed charges,,,85,,2496.96,percent of total billed charges,,,85,,2496.96,percent of total billed charges,,,49,,1439.42,percent of total billed charges,,,90,,2643.84,percent of total billed charges,,,65,,1909.44,percent of total billed charges,,,80,,2350.08,percent of total billed charges,,,55,,1615.68,percent of total billed charges,,,55,,1615.68,percent of total billed charges,,,65,,1909.44,percent of total billed charges,,,78,,2291.33,percent of total billed charges,,,70,,2056.32,percent of total billed charges,,,,,,,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,,181.99,,,,100% of Medicare,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,181.99,2643.84,
70257-0563-01 - baclofen 2 mg/mL Soln,J0475,HCPCS,70257-0563-01,NDC,,both,20,ML,2937.6,1762.56,,45.5,,1336.61,percent of total billed charges,,,45.3,,1330.73,percent of total billed charges,,,51,,1498.18,percent of total billed charges,,,,,,,,,80,,2350.08,percent of total billed charges,,,61.4,,1803.69,percent of total billed charges,,,57.4,,1686.18,percent of total billed charges,,,81,,2379.46,percent of total billed charges,,,51.5,,1512.86,percent of total billed charges,,,57.6,,1692.06,percent of total billed charges,,,85,,2496.96,percent of total billed charges,,,85,,2496.96,percent of total billed charges,,,49,,1439.42,percent of total billed charges,,,90,,2643.84,percent of total billed charges,,,65,,1909.44,percent of total billed charges,,,80,,2350.08,percent of total billed charges,,,55,,1615.68,percent of total billed charges,,,55,,1615.68,percent of total billed charges,,,65,,1909.44,percent of total billed charges,,,78,,2291.33,percent of total billed charges,,,70,,2056.32,percent of total billed charges,,,,,,,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,,181.99,,,,100% of Medicare,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,181.99,2643.84,
70257-0563-02 - baclofen 2 mg/mL Soln,J0475,HCPCS,70257-0563-02,NDC,,both,40,ML,2937.6,1762.56,,45.5,,1336.61,percent of total billed charges,,,45.3,,1330.73,percent of total billed charges,,,51,,1498.18,percent of total billed charges,,,,,,,,,80,,2350.08,percent of total billed charges,,,61.4,,1803.69,percent of total billed charges,,,57.4,,1686.18,percent of total billed charges,,,81,,2379.46,percent of total billed charges,,,51.5,,1512.86,percent of total billed charges,,,57.6,,1692.06,percent of total billed charges,,,85,,2496.96,percent of total billed charges,,,85,,2496.96,percent of total billed charges,,,49,,1439.42,percent of total billed charges,,,90,,2643.84,percent of total billed charges,,,65,,1909.44,percent of total billed charges,,,80,,2350.08,percent of total billed charges,,,55,,1615.68,percent of total billed charges,,,55,,1615.68,percent of total billed charges,,,65,,1909.44,percent of total billed charges,,,78,,2291.33,percent of total billed charges,,,70,,2056.32,percent of total billed charges,,,,,,,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,181.99,,,,100% of Medicare,,,181.99,,,,100% of Medicare,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,181.99,2643.84,
00023-1145-01 - botulinum toxin type A 100 units REC I,J0585,HCPCS,00023-1145-01,NDC,,both,1,UN,2473.75,1484.25,,45.5,,1125.56,percent of total billed charges,,,45.3,,1120.61,percent of total billed charges,,,51,,1261.61,percent of total billed charges,,,,,,,,,80,,1979,percent of total billed charges,,,61.4,,1518.88,percent of total billed charges,,,57.4,,1419.93,percent of total billed charges,,,81,,2003.74,percent of total billed charges,,,51.5,,1273.98,percent of total billed charges,,,57.6,,1424.88,percent of total billed charges,,,85,,2102.69,percent of total billed charges,,,85,,2102.69,percent of total billed charges,,,49,,1212.14,percent of total billed charges,,,90,,2226.38,percent of total billed charges,,,65,,1607.94,percent of total billed charges,,,80,,1979,percent of total billed charges,,,55,,1360.56,percent of total billed charges,,,55,,1360.56,percent of total billed charges,,,65,,1607.94,percent of total billed charges,,,78,,1929.53,percent of total billed charges,,,70,,1731.63,percent of total billed charges,,,,,,,,6.68,,,,100% of Medicare,,6.68,,,,100% of Medicare,,6.68,,,,100% of Medicare,,6.68,,,,100% of Medicare,,6.68,,,,100% of Medicare,,6.68,,,,100% of Medicare,,6.68,,,,100% of Medicare,,6.68,,,,100% of Medicare,,6.68,,,,100% of Medicare,,6.68,,,,100% of Medicare,,6.68,,,,100% of Medicare,,6.68,,,,100% of Medicare,,,6.68,,,,100% of Medicare,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,6.68,2226.38,
58281-0562-01 - baclofen 0.05 mg/mL Soln,J0476,HCPCS,58281-0562-01,NDC,,both,1,ML,226.9,136.14,,45.5,,103.24,percent of total billed charges,,,45.3,,102.79,percent of total billed charges,,,51,,115.72,percent of total billed charges,,,,,,,,,80,,181.52,percent of total billed charges,,,61.4,,139.32,percent of total billed charges,,,57.4,,130.24,percent of total billed charges,,,81,,183.79,percent of total billed charges,,,51.5,,116.85,percent of total billed charges,,,57.6,,130.69,percent of total billed charges,,,85,,192.87,percent of total billed charges,,,85,,192.87,percent of total billed charges,,,49,,111.18,percent of total billed charges,,,90,,204.21,percent of total billed charges,,,65,,147.49,percent of total billed charges,,,80,,181.52,percent of total billed charges,,,55,,124.8,percent of total billed charges,,,55,,124.8,percent of total billed charges,,,65,,147.49,percent of total billed charges,,,78,,176.98,percent of total billed charges,,,70,,158.83,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,920.53,,,,EAPG rate,100% of IL Medicaid,102.79,920.53,
XR Transthoracic Shoulder Left,73020,CPT,,,LT,both,,,264,158.4,,45.5,,120.12,percent of total billed charges,,,45.3,,119.59,percent of total billed charges,,,51,,134.64,percent of total billed charges,,,,,,,,,80,,211.2,percent of total billed charges,,,61.4,,162.1,percent of total billed charges,,,57.4,,151.54,percent of total billed charges,,,81,,213.84,percent of total billed charges,,,51.5,,135.96,percent of total billed charges,,365,,,,fee schedule,,,85,,224.4,percent of total billed charges,,,85,,224.4,percent of total billed charges,,,49,,129.36,percent of total billed charges,,,90,,237.6,percent of total billed charges,,,65,,171.6,percent of total billed charges,,,80,,211.2,percent of total billed charges,,,55,,145.2,percent of total billed charges,,,55,,145.2,percent of total billed charges,,,65,,171.6,percent of total billed charges,,,78,,205.92,percent of total billed charges,,,70,,184.8,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,365,
"Prep, shoulder disartic or interscapular thoracic, single wall plastic socket, shoulder jot, locki e",L6590,HCPCS,,,,outpatient,,,8438,5062.8,,45.5,,3839.29,percent of total billed charges,,,45.3,,3822.41,percent of total billed charges,,,39,,3290.82,percent of total billed charges,,,,,,,,,80,,6750.4,percent of total billed charges,,,61.4,,5180.93,percent of total billed charges,,,57.4,,4843.41,percent of total billed charges,,,81,,6834.78,percent of total billed charges,,,39,,3290.82,percent of total billed charges,,,57.6,,4860.29,percent of total billed charges,,,85,,7172.3,percent of total billed charges,,,85,,7172.3,percent of total billed charges,,,49,,4134.62,percent of total billed charges,,,90,,7594.2,percent of total billed charges,,,65,,5484.7,percent of total billed charges,,,80,,6750.4,percent of total billed charges,,,55,,4640.9,percent of total billed charges,,,55,,4640.9,percent of total billed charges,,,65,,5484.7,percent of total billed charges,,,78,,6581.64,percent of total billed charges,,,70,,5906.6,percent of total billed charges,,,,,,,,3748.87,,,,100% of Medicare,,3748.87,,,,100% of Medicare,,3748.87,,,,100% of Medicare,,3748.87,,,,100% of Medicare,,3748.87,,,,100% of Medicare,,3748.87,,,,100% of Medicare,,3748.87,,,,100% of Medicare,,3748.87,,,,100% of Medicare,,3748.87,,,,100% of Medicare,,3748.87,,,,100% of Medicare,,3748.87,,,,100% of Medicare,,3748.87,,,,100% of Medicare,,,3748.87,,,,100% of Medicare,948.35,,,,EAPG Rate,100% of IL Medicaid,948.35,,,,EAPG Rate,100% of IL Medicaid,948.35,,,,EAPG Rate,100% of IL Medicaid,948.35,,,,EAPG Rate,100% of IL Medicaid,948.35,7594.2,
"Above knee, short prosthesis, no knee joint (""stubbies""), with articulated ankle/foot, dynamically",L5220,HCPCS,,,,outpatient,,,8614,5168.4,,45.5,,3919.37,percent of total billed charges,,,45.3,,3902.14,percent of total billed charges,,,39,,3359.46,percent of total billed charges,,,,,,,,,80,,6891.2,percent of total billed charges,,,61.4,,5289,percent of total billed charges,,,57.4,,4944.44,percent of total billed charges,,,81,,6977.34,percent of total billed charges,,,39,,3359.46,percent of total billed charges,,,57.6,,4961.66,percent of total billed charges,,,85,,7321.9,percent of total billed charges,,,85,,7321.9,percent of total billed charges,,,49,,4220.86,percent of total billed charges,,,90,,7752.6,percent of total billed charges,,,65,,5599.1,percent of total billed charges,,,80,,6891.2,percent of total billed charges,,,55,,4737.7,percent of total billed charges,,,55,,4737.7,percent of total billed charges,,,65,,5599.1,percent of total billed charges,,,78,,6718.92,percent of total billed charges,,,70,,6029.8,percent of total billed charges,,,,,,,,3838.15,,,,100% of Medicare,,3838.15,,,,100% of Medicare,,3838.15,,,,100% of Medicare,,3838.15,,,,100% of Medicare,,3838.15,,,,100% of Medicare,,3838.15,,,,100% of Medicare,,3838.15,,,,100% of Medicare,,3838.15,,,,100% of Medicare,,3838.15,,,,100% of Medicare,,3838.15,,,,100% of Medicare,,3838.15,,,,100% of Medicare,,3838.15,,,,100% of Medicare,,,3838.15,,,,100% of Medicare,984.82,,,,EAPG Rate,100% of IL Medicaid,984.82,,,,EAPG Rate,100% of IL Medicaid,984.82,,,,EAPG Rate,100% of IL Medicaid,984.82,,,,EAPG Rate,100% of IL Medicaid,984.82,7752.6,
"Knee-Ankle-Foot Orthosis, Single Upright, Full Plastic, Free Knee, Molded to Patient",L2037,HCPCS,,,,outpatient,,,8660,5196,,45.5,,3940.3,percent of total billed charges,,,45.3,,3922.98,percent of total billed charges,,,39,,3377.4,percent of total billed charges,,,,,,,,,80,,6928,percent of total billed charges,,,61.4,,5317.24,percent of total billed charges,,,57.4,,4970.84,percent of total billed charges,,,81,,7014.6,percent of total billed charges,,,39,,3377.4,percent of total billed charges,,,57.6,,4988.16,percent of total billed charges,,,85,,7361,percent of total billed charges,,,85,,7361,percent of total billed charges,,,49,,4243.4,percent of total billed charges,,,90,,7794,percent of total billed charges,,,65,,5629,percent of total billed charges,,,80,,6928,percent of total billed charges,,,55,,4763,percent of total billed charges,,,55,,4763,percent of total billed charges,,,65,,5629,percent of total billed charges,,,78,,6754.8,percent of total billed charges,,,70,,6062,percent of total billed charges,,,,,,,,1998.06,,,,100% of Medicare,,1998.06,,,,100% of Medicare,,1998.06,,,,100% of Medicare,,1998.06,,,,100% of Medicare,,1998.06,,,,100% of Medicare,,1998.06,,,,100% of Medicare,,1998.06,,,,100% of Medicare,,1998.06,,,,100% of Medicare,,1998.06,,,,100% of Medicare,,1998.06,,,,100% of Medicare,,1998.06,,,,100% of Medicare,,1998.06,,,,100% of Medicare,,,1998.06,,,,100% of Medicare,994.35,,,,EAPG Rate,100% of IL Medicaid,994.35,,,,EAPG Rate,100% of IL Medicaid,994.35,,,,EAPG Rate,100% of IL Medicaid,994.35,,,,EAPG Rate,100% of IL Medicaid,994.35,7794,
"Prehensile actuator, Hosmer or equal, switch controlled",L7040,HCPCS,,,,outpatient,,,8667,5200.2,,45.5,,3943.49,percent of total billed charges,,,45.3,,3926.15,percent of total billed charges,,,39,,3380.13,percent of total billed charges,,,,,,,,,80,,6933.6,percent of total billed charges,,,61.4,,5321.54,percent of total billed charges,,,57.4,,4974.86,percent of total billed charges,,,81,,7020.27,percent of total billed charges,,,39,,3380.13,percent of total billed charges,,,57.6,,4992.19,percent of total billed charges,,,85,,7366.95,percent of total billed charges,,,85,,7366.95,percent of total billed charges,,,49,,4246.83,percent of total billed charges,,,90,,7800.3,percent of total billed charges,,,65,,5633.55,percent of total billed charges,,,80,,6933.6,percent of total billed charges,,,55,,4766.85,percent of total billed charges,,,55,,4766.85,percent of total billed charges,,,65,,5633.55,percent of total billed charges,,,78,,6760.26,percent of total billed charges,,,70,,6066.9,percent of total billed charges,,,,,,,,3671.91,,,,100% of Medicare,,3671.91,,,,100% of Medicare,,3671.91,,,,100% of Medicare,,3671.91,,,,100% of Medicare,,3671.91,,,,100% of Medicare,,3671.91,,,,100% of Medicare,,3671.91,,,,100% of Medicare,,3671.91,,,,100% of Medicare,,3671.91,,,,100% of Medicare,,3671.91,,,,100% of Medicare,,3671.91,,,,100% of Medicare,,3671.91,,,,100% of Medicare,,,3671.91,,,,100% of Medicare,995.8,,,,EAPG Rate,100% of IL Medicaid,995.8,,,,EAPG Rate,100% of IL Medicaid,995.8,,,,EAPG Rate,100% of IL Medicaid,995.8,,,,EAPG Rate,100% of IL Medicaid,995.8,7800.3,
"L6130 BE, molded socket (Muenster or Northwestern suspension types)",L6130,HCPCS,,,,outpatient,,,8680,5208,,45.5,,3949.4,percent of total billed charges,,,45.3,,3932.04,percent of total billed charges,,,39,,3385.2,percent of total billed charges,,,,,,,,,80,,6944,percent of total billed charges,,,61.4,,5329.52,percent of total billed charges,,,57.4,,4982.32,percent of total billed charges,,,81,,7030.8,percent of total billed charges,,,39,,3385.2,percent of total billed charges,,,57.6,,4999.68,percent of total billed charges,,,85,,7378,percent of total billed charges,,,85,,7378,percent of total billed charges,,,49,,4253.2,percent of total billed charges,,,90,,7812,percent of total billed charges,,,65,,5642,percent of total billed charges,,,80,,6944,percent of total billed charges,,,55,,4774,percent of total billed charges,,,55,,4774,percent of total billed charges,,,65,,5642,percent of total billed charges,,,78,,6770.4,percent of total billed charges,,,70,,6076,percent of total billed charges,,,,,,,,3833.45,,,,100% of Medicare,,3833.45,,,,100% of Medicare,,3833.45,,,,100% of Medicare,,3833.45,,,,100% of Medicare,,3833.45,,,,100% of Medicare,,3833.45,,,,100% of Medicare,,3833.45,,,,100% of Medicare,,3833.45,,,,100% of Medicare,,3833.45,,,,100% of Medicare,,3833.45,,,,100% of Medicare,,3833.45,,,,100% of Medicare,,3833.45,,,,100% of Medicare,,,3833.45,,,,100% of Medicare,998.5,,,,EAPG Rate,100% of IL Medicaid,998.5,,,,EAPG Rate,100% of IL Medicaid,998.5,,,,EAPG Rate,100% of IL Medicaid,998.5,,,,EAPG Rate,100% of IL Medicaid,998.5,7812,
"Addition, endo knee-shin sys, single axis, hydraulic swing, w/ mini high activity frame",L5826,HCPCS,,,,outpatient,,,8810,5286,,45.5,,4008.55,percent of total billed charges,,,45.3,,3990.93,percent of total billed charges,,,39,,3435.9,percent of total billed charges,,,,,,,,,80,,7048,percent of total billed charges,,,61.4,,5409.34,percent of total billed charges,,,57.4,,5056.94,percent of total billed charges,,,81,,7136.1,percent of total billed charges,,,39,,3435.9,percent of total billed charges,,,57.6,,5074.56,percent of total billed charges,,,85,,7488.5,percent of total billed charges,,,85,,7488.5,percent of total billed charges,,,49,,4316.9,percent of total billed charges,,,90,,7929,percent of total billed charges,,,65,,5726.5,percent of total billed charges,,,80,,7048,percent of total billed charges,,,55,,4845.5,percent of total billed charges,,,55,,4845.5,percent of total billed charges,,,65,,5726.5,percent of total billed charges,,,78,,6871.8,percent of total billed charges,,,70,,6167,percent of total billed charges,,,,,,,,3770.02,,,,100% of Medicare,,3770.02,,,,100% of Medicare,,3770.02,,,,100% of Medicare,,3770.02,,,,100% of Medicare,,3770.02,,,,100% of Medicare,,3770.02,,,,100% of Medicare,,3770.02,,,,100% of Medicare,,3770.02,,,,100% of Medicare,,3770.02,,,,100% of Medicare,,3770.02,,,,100% of Medicare,,3770.02,,,,100% of Medicare,,3770.02,,,,100% of Medicare,,,3770.02,,,,100% of Medicare,1025.43,,,,EAPG Rate,100% of IL Medicaid,1025.43,,,,EAPG Rate,100% of IL Medicaid,1025.43,,,,EAPG Rate,100% of IL Medicaid,1025.43,,,,EAPG Rate,100% of IL Medicaid,1025.43,7929,
"Partial foot, molded socket, tibial tubercle height, with toe filler",L5020,HCPCS,,,,outpatient,,,8833,5299.8,,45.5,,4019.02,percent of total billed charges,,,45.3,,4001.35,percent of total billed charges,,,39,,3444.87,percent of total billed charges,,,,,,,,,80,,7066.4,percent of total billed charges,,,61.4,,5423.46,percent of total billed charges,,,57.4,,5070.14,percent of total billed charges,,,81,,7154.73,percent of total billed charges,,,39,,3444.87,percent of total billed charges,,,57.6,,5087.81,percent of total billed charges,,,85,,7508.05,percent of total billed charges,,,85,,7508.05,percent of total billed charges,,,49,,4328.17,percent of total billed charges,,,90,,7949.7,percent of total billed charges,,,65,,5741.45,percent of total billed charges,,,80,,7066.4,percent of total billed charges,,,55,,4858.15,percent of total billed charges,,,55,,4858.15,percent of total billed charges,,,65,,5741.45,percent of total billed charges,,,78,,6889.74,percent of total billed charges,,,70,,6183.1,percent of total billed charges,,,,,,,,3028.63,,,,100% of Medicare,,3028.63,,,,100% of Medicare,,3028.63,,,,100% of Medicare,,3028.63,,,,100% of Medicare,,3028.63,,,,100% of Medicare,,3028.63,,,,100% of Medicare,,3028.63,,,,100% of Medicare,,3028.63,,,,100% of Medicare,,3028.63,,,,100% of Medicare,,3028.63,,,,100% of Medicare,,3028.63,,,,100% of Medicare,,3028.63,,,,100% of Medicare,,,3028.63,,,,100% of Medicare,1030.2,,,,EAPG Rate,100% of IL Medicaid,1030.2,,,,EAPG Rate,100% of IL Medicaid,1030.2,,,,EAPG Rate,100% of IL Medicaid,1030.2,,,,EAPG Rate,100% of IL Medicaid,1030.2,7949.7,
"Wrist disartic, molded socket, flexible elbow hinges, triceps pad",L6050,HCPCS,,,,outpatient,,,8834,5300.4,,45.5,,4019.47,percent of total billed charges,,,45.3,,4001.8,percent of total billed charges,,,39,,3445.26,percent of total billed charges,,,,,,,,,80,,7067.2,percent of total billed charges,,,61.4,,5424.08,percent of total billed charges,,,57.4,,5070.72,percent of total billed charges,,,81,,7155.54,percent of total billed charges,,,39,,3445.26,percent of total billed charges,,,57.6,,5088.38,percent of total billed charges,,,85,,7508.9,percent of total billed charges,,,85,,7508.9,percent of total billed charges,,,49,,4328.66,percent of total billed charges,,,90,,7950.6,percent of total billed charges,,,65,,5742.1,percent of total billed charges,,,80,,7067.2,percent of total billed charges,,,55,,4858.7,percent of total billed charges,,,55,,4858.7,percent of total billed charges,,,65,,5742.1,percent of total billed charges,,,78,,6890.52,percent of total billed charges,,,70,,6183.8,percent of total billed charges,,,,,,,,3000.82,,,,100% of Medicare,,3000.82,,,,100% of Medicare,,3000.82,,,,100% of Medicare,,3000.82,,,,100% of Medicare,,3000.82,,,,100% of Medicare,,3000.82,,,,100% of Medicare,,3000.82,,,,100% of Medicare,,3000.82,,,,100% of Medicare,,3000.82,,,,100% of Medicare,,3000.82,,,,100% of Medicare,,3000.82,,,,100% of Medicare,,3000.82,,,,100% of Medicare,,,3000.82,,,,100% of Medicare,1030.4,,,,EAPG Rate,100% of IL Medicaid,1030.4,,,,EAPG Rate,100% of IL Medicaid,1030.4,,,,EAPG Rate,100% of IL Medicaid,1030.4,,,,EAPG Rate,100% of IL Medicaid,1030.4,7950.6,
"BE, molded socket, flexible elbow hinges, triceps pad",L6100,HCPCS,,,,outpatient,,,8855,5313,,45.5,,4029.03,percent of total billed charges,,,45.3,,4011.32,percent of total billed charges,,,39,,3453.45,percent of total billed charges,,,,,,,,,80,,7084,percent of total billed charges,,,61.4,,5436.97,percent of total billed charges,,,57.4,,5082.77,percent of total billed charges,,,81,,7172.55,percent of total billed charges,,,39,,3453.45,percent of total billed charges,,,57.6,,5100.48,percent of total billed charges,,,85,,7526.75,percent of total billed charges,,,85,,7526.75,percent of total billed charges,,,49,,4338.95,percent of total billed charges,,,90,,7969.5,percent of total billed charges,,,65,,5755.75,percent of total billed charges,,,80,,7084,percent of total billed charges,,,55,,4870.25,percent of total billed charges,,,55,,4870.25,percent of total billed charges,,,65,,5755.75,percent of total billed charges,,,78,,6906.9,percent of total billed charges,,,70,,6198.5,percent of total billed charges,,,,,,,,3036.73,,,,100% of Medicare,,3036.73,,,,100% of Medicare,,3036.73,,,,100% of Medicare,,3036.73,,,,100% of Medicare,,3036.73,,,,100% of Medicare,,3036.73,,,21193.53846,100% of Medicare,,3036.73,,,,100% of Medicare,,3036.73,,,,100% of Medicare,,3036.73,,,,100% of Medicare,,3036.73,,,,100% of Medicare,,3036.73,,,,100% of Medicare,,3036.73,,,,100% of Medicare,,,3036.73,,,,100% of Medicare,1034.76,,,,EAPG Rate,100% of IL Medicaid,1034.76,,,,EAPG Rate,100% of IL Medicaid,1034.76,,,,EAPG Rate,100% of IL Medicaid,1034.76,,,,EAPG Rate,100% of IL Medicaid,1034.76,21193.54,
"Prep, AK or knee disartic, ischial level socket, non-align sys, pylon, no cover, SACH foot, prefab a",L5585,HCPCS,,,,outpatient,,,8859,5315.4,,45.5,,4030.85,percent of total billed charges,,,45.3,,4013.13,percent of total billed charges,,,39,,3455.01,percent of total billed charges,,,,,,,,,80,,7087.2,percent of total billed charges,,,61.4,,5439.43,percent of total billed charges,,,57.4,,5085.07,percent of total billed charges,,,81,,7175.79,percent of total billed charges,,,39,,3455.01,percent of total billed charges,,,57.6,,5102.78,percent of total billed charges,,,85,,7530.15,percent of total billed charges,,,85,,7530.15,percent of total billed charges,,,49,,4340.91,percent of total billed charges,,,90,,7973.1,percent of total billed charges,,,65,,5758.35,percent of total billed charges,,,80,,7087.2,percent of total billed charges,,,55,,4872.45,percent of total billed charges,,,55,,4872.45,percent of total billed charges,,,65,,5758.35,percent of total billed charges,,,78,,6910.02,percent of total billed charges,,,70,,6201.3,percent of total billed charges,,,,,,,,3975.58,,,,100% of Medicare,,3975.58,,,,100% of Medicare,,3975.58,,,,100% of Medicare,,3975.58,,,,100% of Medicare,,3975.58,,,,100% of Medicare,,3975.58,,,,100% of Medicare,,3975.58,,,,100% of Medicare,,3975.58,,,,100% of Medicare,,3975.58,,,,100% of Medicare,,3975.58,,,,100% of Medicare,,3975.58,,,,100% of Medicare,,3975.58,,,,100% of Medicare,,,3975.58,,,,100% of Medicare,1035.58,,,,EAPG Rate,100% of IL Medicaid,1035.58,,,,EAPG Rate,100% of IL Medicaid,1035.58,,,,EAPG Rate,100% of IL Medicaid,1035.58,,,,EAPG Rate,100% of IL Medicaid,1035.58,7973.1,
"Elbow disartic, molded socket, outside locking hinges, forearm",L6200,HCPCS,,,,outpatient,,,8859,5315.4,,45.5,,4030.85,percent of total billed charges,,,45.3,,4013.13,percent of total billed charges,,,39,,3455.01,percent of total billed charges,,,,,,,,,80,,7087.2,percent of total billed charges,,,61.4,,5439.43,percent of total billed charges,,,57.4,,5085.07,percent of total billed charges,,,81,,7175.79,percent of total billed charges,,,39,,3455.01,percent of total billed charges,,,57.6,,5102.78,percent of total billed charges,,,85,,7530.15,percent of total billed charges,,,85,,7530.15,percent of total billed charges,,,49,,4340.91,percent of total billed charges,,,90,,7973.1,percent of total billed charges,,,65,,5758.35,percent of total billed charges,,,80,,7087.2,percent of total billed charges,,,55,,4872.45,percent of total billed charges,,,55,,4872.45,percent of total billed charges,,,65,,5758.35,percent of total billed charges,,,78,,6910.02,percent of total billed charges,,,70,,6201.3,percent of total billed charges,,,,,,,,3948.9,,,,100% of Medicare,,3948.9,,,,100% of Medicare,,3948.9,,,,100% of Medicare,,3948.9,,,,100% of Medicare,,3948.9,,,,100% of Medicare,,3948.9,,,,100% of Medicare,,3948.9,,,,100% of Medicare,,3948.9,,,,100% of Medicare,,3948.9,,,,100% of Medicare,,3948.9,,,,100% of Medicare,,3948.9,,,,100% of Medicare,,3948.9,,,,100% of Medicare,,,3948.9,,,,100% of Medicare,1035.58,,,,EAPG Rate,100% of IL Medicaid,1035.58,,,,EAPG Rate,100% of IL Medicaid,1035.58,,,,EAPG Rate,100% of IL Medicaid,1035.58,,,,EAPG Rate,100% of IL Medicaid,1035.58,7973.1,
"UE addition, electric lock feature, w/ manually powered elbow",L6638,HCPCS,,,,outpatient,,,8896,5337.6,,45.5,,4047.68,percent of total billed charges,,,45.3,,4029.89,percent of total billed charges,,,39,,3469.44,percent of total billed charges,,,,,,,,,80,,7116.8,percent of total billed charges,,,61.4,,5462.14,percent of total billed charges,,,57.4,,5106.3,percent of total billed charges,,,81,,7205.76,percent of total billed charges,,,39,,3469.44,percent of total billed charges,,,57.6,,5124.1,percent of total billed charges,,,85,,7561.6,percent of total billed charges,,,85,,7561.6,percent of total billed charges,,,49,,4359.04,percent of total billed charges,,,90,,8006.4,percent of total billed charges,,,65,,5782.4,percent of total billed charges,,,80,,7116.8,percent of total billed charges,,,55,,4892.8,percent of total billed charges,,,55,,4892.8,percent of total billed charges,,,65,,5782.4,percent of total billed charges,,,78,,6938.88,percent of total billed charges,,,70,,6227.2,percent of total billed charges,,,,,,,,3018.93,,,,100% of Medicare,,3018.93,,,,100% of Medicare,,3018.93,,,,100% of Medicare,,3018.93,,,,100% of Medicare,,3018.93,,,,100% of Medicare,,3018.93,,,,100% of Medicare,,3018.93,,,,100% of Medicare,,3018.93,,,,100% of Medicare,,3018.93,,,,100% of Medicare,,3018.93,,,,100% of Medicare,,3018.93,,,,100% of Medicare,,3018.93,,,,100% of Medicare,,,3018.93,,,,100% of Medicare,1043.25,,,,EAPG Rate,100% of IL Medicaid,1043.25,,,,EAPG Rate,100% of IL Medicaid,1043.25,,,,EAPG Rate,100% of IL Medicaid,1043.25,,,,EAPG Rate,100% of IL Medicaid,1043.25,8006.4,
"Addition to LE, endo sys, AK or knee disartic, 4-bar linkage w/ hydraulic swing phase control",L5613,HCPCS,,,,outpatient,,,8932,5359.2,,45.5,,4064.06,percent of total billed charges,,,45.3,,4046.2,percent of total billed charges,,,39,,3483.48,percent of total billed charges,,,,,,,,,80,,7145.6,percent of total billed charges,,,61.4,,5484.25,percent of total billed charges,,,57.4,,5126.97,percent of total billed charges,,,81,,7234.92,percent of total billed charges,,,39,,3483.48,percent of total billed charges,,,57.6,,5144.83,percent of total billed charges,,,85,,7592.2,percent of total billed charges,,,85,,7592.2,percent of total billed charges,,,49,,4376.68,percent of total billed charges,,,90,,8038.8,percent of total billed charges,,,65,,5805.8,percent of total billed charges,,,80,,7145.6,percent of total billed charges,,,55,,4912.6,percent of total billed charges,,,55,,4912.6,percent of total billed charges,,,65,,5805.8,percent of total billed charges,,,78,,6966.96,percent of total billed charges,,,70,,6252.4,percent of total billed charges,,,,,,,,2941.43,,,,100% of Medicare,,2941.43,,,,100% of Medicare,,2941.43,,,,100% of Medicare,,2941.43,,,,100% of Medicare,,2941.43,,,,100% of Medicare,,2941.43,,,,100% of Medicare,,2941.43,,,,100% of Medicare,,2941.43,,,,100% of Medicare,,2941.43,,,,100% of Medicare,,2941.43,,,,100% of Medicare,,2941.43,,,,100% of Medicare,,2941.43,,,,100% of Medicare,,,2941.43,,,,100% of Medicare,1050.71,,,,EAPG Rate,100% of IL Medicaid,1050.71,,,,EAPG Rate,100% of IL Medicaid,1050.71,,,,EAPG Rate,100% of IL Medicaid,1050.71,,,,EAPG Rate,100% of IL Medicaid,1050.71,8038.8,
"Addition to LE, ischial containment/narrow M-L socket",L5649,HCPCS,,,,outpatient,,,8988,5392.8,,45.5,,4089.54,percent of total billed charges,,,45.3,,4071.56,percent of total billed charges,,,39,,3505.32,percent of total billed charges,,,,,,,,,80,,7190.4,percent of total billed charges,,,61.4,,5518.63,percent of total billed charges,,,57.4,,5159.11,percent of total billed charges,,,81,,7280.28,percent of total billed charges,,,39,,3505.32,percent of total billed charges,,,57.6,,5177.09,percent of total billed charges,,,85,,7639.8,percent of total billed charges,,,85,,7639.8,percent of total billed charges,,,49,,4404.12,percent of total billed charges,,,90,,8089.2,percent of total billed charges,,,65,,5842.2,percent of total billed charges,,,80,,7190.4,percent of total billed charges,,,55,,4943.4,percent of total billed charges,,,55,,4943.4,percent of total billed charges,,,65,,5842.2,percent of total billed charges,,,78,,7010.64,percent of total billed charges,,,70,,6291.6,percent of total billed charges,,,,,,,,2958.96,,,,100% of Medicare,,2958.96,,,,100% of Medicare,,2958.96,,,,100% of Medicare,,2958.96,,,,100% of Medicare,,2958.96,,,,100% of Medicare,,2958.96,,,,100% of Medicare,,2958.96,,,,100% of Medicare,,2958.96,,,,100% of Medicare,,2958.96,,,,100% of Medicare,,2958.96,,,,100% of Medicare,,2958.96,,,,100% of Medicare,,2958.96,,,,100% of Medicare,,,2958.96,,,,100% of Medicare,1062.31,,,,EAPG Rate,100% of IL Medicaid,1062.31,,,,EAPG Rate,100% of IL Medicaid,1062.31,,,,EAPG Rate,100% of IL Medicaid,1062.31,,,,EAPG Rate,100% of IL Medicaid,1062.31,8089.2,
"Thoracic-Lumbar-Sacral Orthosis, Triplaner Control, 1-Piece Rigid Shell w/o Liner, Custom Fabricated",L0482,HCPCS,,,,outpatient,,,9074,5444.4,,45.5,,4128.67,percent of total billed charges,,,45.3,,4110.52,percent of total billed charges,,,39,,3538.86,percent of total billed charges,,,,,,,,,80,,7259.2,percent of total billed charges,,,61.4,,5571.44,percent of total billed charges,,,57.4,,5208.48,percent of total billed charges,,,81,,7349.94,percent of total billed charges,,,39,,3538.86,percent of total billed charges,,,57.6,,5226.62,percent of total billed charges,,,85,,7712.9,percent of total billed charges,,,85,,7712.9,percent of total billed charges,,,49,,4446.26,percent of total billed charges,,,90,,8166.6,percent of total billed charges,,,65,,5898.1,percent of total billed charges,,,80,,7259.2,percent of total billed charges,,,55,,4990.7,percent of total billed charges,,,55,,4990.7,percent of total billed charges,,,65,,5898.1,percent of total billed charges,,,78,,7077.72,percent of total billed charges,,,70,,6351.8,percent of total billed charges,,,,,,,,2032.83,,,,100% of Medicare,,2032.83,,,,100% of Medicare,,2032.83,,,,100% of Medicare,,2032.83,,,,100% of Medicare,,2032.83,,,,100% of Medicare,,2032.83,,,,100% of Medicare,,2032.83,,,,100% of Medicare,,2032.83,,,,100% of Medicare,,2032.83,,,,100% of Medicare,,2032.83,,,,100% of Medicare,,2032.83,,,,100% of Medicare,,2032.83,,,,100% of Medicare,,,2032.83,,,,100% of Medicare,1080.13,,,,EAPG Rate,100% of IL Medicaid,1080.13,,,,EAPG Rate,100% of IL Medicaid,1080.13,,,,EAPG Rate,100% of IL Medicaid,1080.13,,,,EAPG Rate,100% of IL Medicaid,1080.13,8166.6,
"Ankle, Symes, metal frame, molded leather socket, articulated ankle/foot",L5060,HCPCS,,,,outpatient,,,9084,5450.4,,45.5,,4133.22,percent of total billed charges,,,45.3,,4115.05,percent of total billed charges,,,39,,3542.76,percent of total billed charges,,,,,,,,,80,,7267.2,percent of total billed charges,,,61.4,,5577.58,percent of total billed charges,,,57.4,,5214.22,percent of total billed charges,,,81,,7358.04,percent of total billed charges,,,39,,3542.76,percent of total billed charges,,,57.6,,5232.38,percent of total billed charges,,,85,,7721.4,percent of total billed charges,,,85,,7721.4,percent of total billed charges,,,49,,4451.16,percent of total billed charges,,,90,,8175.6,percent of total billed charges,,,65,,5904.6,percent of total billed charges,,,80,,7267.2,percent of total billed charges,,,55,,4996.2,percent of total billed charges,,,55,,4996.2,percent of total billed charges,,,65,,5904.6,percent of total billed charges,,,78,,7085.52,percent of total billed charges,,,70,,6358.8,percent of total billed charges,,,,,,,,4077.61,,,,100% of Medicare,,4077.61,,,,100% of Medicare,,4077.61,,,,100% of Medicare,,4077.61,,,,100% of Medicare,,4077.61,,,,100% of Medicare,,4077.61,,,33491.23857,100% of Medicare,,4077.61,,,,100% of Medicare,,4077.61,,,,100% of Medicare,,4077.61,,,,100% of Medicare,,4077.61,,,,100% of Medicare,,4077.61,,,,100% of Medicare,,4077.61,,,,100% of Medicare,,,4077.61,,,,100% of Medicare,1082.2,,,,EAPG Rate,100% of IL Medicaid,1082.2,,,,EAPG Rate,100% of IL Medicaid,1082.2,,,,EAPG Rate,100% of IL Medicaid,1082.2,,,,EAPG Rate,100% of IL Medicaid,1082.2,33491.24,
"All LE prostheses, multi-axial ankle/foot, dynamic response",L5979,HCPCS,,,,outpatient,,,9145,5487,,45.5,,4160.98,percent of total billed charges,,,45.3,,4142.69,percent of total billed charges,,,39,,3566.55,percent of total billed charges,,,,,,,,,80,,7316,percent of total billed charges,,,61.4,,5615.03,percent of total billed charges,,,57.4,,5249.23,percent of total billed charges,,,81,,7407.45,percent of total billed charges,,,39,,3566.55,percent of total billed charges,,,57.6,,5267.52,percent of total billed charges,,,85,,7773.25,percent of total billed charges,,,85,,7773.25,percent of total billed charges,,,49,,4481.05,percent of total billed charges,,,90,,8230.5,percent of total billed charges,,,65,,5944.25,percent of total billed charges,,,80,,7316,percent of total billed charges,,,55,,5029.75,percent of total billed charges,,,55,,5029.75,percent of total billed charges,,,65,,5944.25,percent of total billed charges,,,78,,7133.1,percent of total billed charges,,,70,,6401.5,percent of total billed charges,,,,,,,,3009.91,,,,100% of Medicare,,3009.91,,,,100% of Medicare,,3009.91,,,,100% of Medicare,,3009.91,,,,100% of Medicare,,3009.91,,,,100% of Medicare,,3009.91,,,,100% of Medicare,,3009.91,,,,100% of Medicare,,3009.91,,,,100% of Medicare,,3009.91,,,,100% of Medicare,,3009.91,,,,100% of Medicare,,3009.91,,,,100% of Medicare,,3009.91,,,,100% of Medicare,,,3009.91,,,,100% of Medicare,1094.84,,,,EAPG Rate,100% of IL Medicaid,1094.84,,,,EAPG Rate,100% of IL Medicaid,1094.84,,,,EAPG Rate,100% of IL Medicaid,1094.84,,,,EAPG Rate,100% of IL Medicaid,1094.84,8230.5,
"Below knee, molded socket, shin, SACH foot, endoskeletal system",L5301,HCPCS,,,,outpatient,,,9344,5606.4,,45.5,,4251.52,percent of total billed charges,,,45.3,,4232.83,percent of total billed charges,,,39,,3644.16,percent of total billed charges,,,,,,,,,80,,7475.2,percent of total billed charges,,,61.4,,5737.22,percent of total billed charges,,,57.4,,5363.46,percent of total billed charges,,,81,,7568.64,percent of total billed charges,,,39,,3644.16,percent of total billed charges,,,57.6,,5382.14,percent of total billed charges,,,85,,7942.4,percent of total billed charges,,,85,,7942.4,percent of total billed charges,,,49,,4578.56,percent of total billed charges,,,90,,8409.6,percent of total billed charges,,,65,,6073.6,percent of total billed charges,,,80,,7475.2,percent of total billed charges,,,55,,5139.2,percent of total billed charges,,,55,,5139.2,percent of total billed charges,,,65,,6073.6,percent of total billed charges,,,78,,7288.32,percent of total billed charges,,,70,,6540.8,percent of total billed charges,,,,,,,,3234.32,,,,100% of Medicare,,3234.32,,,,100% of Medicare,,3234.32,,,,100% of Medicare,,3234.32,,,,100% of Medicare,,3234.32,,,,100% of Medicare,,3234.32,,,26528.66,100% of Medicare,,3234.32,,,,100% of Medicare,,3234.32,,,,100% of Medicare,,3234.32,,,,100% of Medicare,,3234.32,,,,100% of Medicare,,3234.32,,,,100% of Medicare,,3234.32,,,,100% of Medicare,,,3234.32,,,,100% of Medicare,1136.08,,,,EAPG Rate,100% of IL Medicaid,1136.08,,,,EAPG Rate,100% of IL Medicaid,1136.08,,,,EAPG Rate,100% of IL Medicaid,1136.08,,,,EAPG Rate,100% of IL Medicaid,1136.08,26528.66,
"BE, molded socket (Muenster or Northwestern suspension types)",L6110,HCPCS,,,,outpatient,,,9370,5622,,45.5,,4263.35,percent of total billed charges,,,45.3,,4244.61,percent of total billed charges,,,39,,3654.3,percent of total billed charges,,,,,,,,,80,,7496,percent of total billed charges,,,61.4,,5753.18,percent of total billed charges,,,57.4,,5378.38,percent of total billed charges,,,81,,7589.7,percent of total billed charges,,,39,,3654.3,percent of total billed charges,,,57.6,,5397.12,percent of total billed charges,,,85,,7964.5,percent of total billed charges,,,85,,7964.5,percent of total billed charges,,,49,,4591.3,percent of total billed charges,,,90,,8433,percent of total billed charges,,,65,,6090.5,percent of total billed charges,,,80,,7496,percent of total billed charges,,,55,,5153.5,percent of total billed charges,,,55,,5153.5,percent of total billed charges,,,65,,6090.5,percent of total billed charges,,,78,,7308.6,percent of total billed charges,,,70,,6559,percent of total billed charges,,,,,,,,3212.66,,,,100% of Medicare,,3212.66,,,,100% of Medicare,,3212.66,,,,100% of Medicare,,3212.66,,,,100% of Medicare,,3212.66,,,,100% of Medicare,,3212.66,,,18578.185,100% of Medicare,,3212.66,,,,100% of Medicare,,3212.66,,,,100% of Medicare,,3212.66,,,,100% of Medicare,,3212.66,,,,100% of Medicare,,3212.66,,,,100% of Medicare,,3212.66,,,,100% of Medicare,,,3212.66,,,,100% of Medicare,1141.46,,,,EAPG Rate,100% of IL Medicaid,1141.46,,,,EAPG Rate,100% of IL Medicaid,1141.46,,,,EAPG Rate,100% of IL Medicaid,1141.46,,,,EAPG Rate,100% of IL Medicaid,1141.46,18578.19,
"BE, molded socket (Muenster or Northwestern suspension types)",L6120,HCPCS,,,,outpatient,,,9370,5622,,45.5,,4263.35,percent of total billed charges,,,45.3,,4244.61,percent of total billed charges,,,39,,3654.3,percent of total billed charges,,,,,,,,,80,,7496,percent of total billed charges,,,61.4,,5753.18,percent of total billed charges,,,57.4,,5378.38,percent of total billed charges,,,81,,7589.7,percent of total billed charges,,,39,,3654.3,percent of total billed charges,,,57.6,,5397.12,percent of total billed charges,,,85,,7964.5,percent of total billed charges,,,85,,7964.5,percent of total billed charges,,,49,,4591.3,percent of total billed charges,,,90,,8433,percent of total billed charges,,,65,,6090.5,percent of total billed charges,,,80,,7496,percent of total billed charges,,,55,,5153.5,percent of total billed charges,,,55,,5153.5,percent of total billed charges,,,65,,6090.5,percent of total billed charges,,,78,,7308.6,percent of total billed charges,,,70,,6559,percent of total billed charges,,,,,,,,3633.53,,,,100% of Medicare,,3633.53,,,,100% of Medicare,,3633.53,,,,100% of Medicare,,3633.53,,,,100% of Medicare,,3633.53,,,,100% of Medicare,,3633.53,,,28694.62,100% of Medicare,,3633.53,,,,100% of Medicare,,3633.53,,,,100% of Medicare,,3633.53,,,,100% of Medicare,,3633.53,,,,100% of Medicare,,3633.53,,,,100% of Medicare,,3633.53,,,,100% of Medicare,,,3633.53,,,,100% of Medicare,1141.46,,,,EAPG Rate,100% of IL Medicaid,1141.46,,,,EAPG Rate,100% of IL Medicaid,1141.46,,,,EAPG Rate,100% of IL Medicaid,1141.46,,,,EAPG Rate,100% of IL Medicaid,1141.46,28694.62,
"Below knee, molded socket shin, SACH foot (EXO)",L5100,HCPCS,,,,outpatient,,,9603,5761.8,,45.5,,4369.37,percent of total billed charges,,,45.3,,4350.16,percent of total billed charges,,,39,,3745.17,percent of total billed charges,,,,,,,,,80,,7682.4,percent of total billed charges,,,61.4,,5896.24,percent of total billed charges,,,57.4,,5512.12,percent of total billed charges,,,81,,7778.43,percent of total billed charges,,,39,,3745.17,percent of total billed charges,,,57.6,,5531.33,percent of total billed charges,,,85,,8162.55,percent of total billed charges,,,85,,8162.55,percent of total billed charges,,,49,,4705.47,percent of total billed charges,,,90,,8642.7,percent of total billed charges,,,65,,6241.95,percent of total billed charges,,,80,,7682.4,percent of total billed charges,,,55,,5281.65,percent of total billed charges,,,55,,5281.65,percent of total billed charges,,,65,,6241.95,percent of total billed charges,,,78,,7490.34,percent of total billed charges,,,70,,6722.1,percent of total billed charges,,,,,,,,3293.69,,,,100% of Medicare,,3293.69,,,,100% of Medicare,,3293.69,,,,100% of Medicare,,3293.69,,,,100% of Medicare,,3293.69,,,,100% of Medicare,,3293.69,,,44431.906,100% of Medicare,,3293.69,,,,100% of Medicare,,3293.69,,,,100% of Medicare,,3293.69,,,,100% of Medicare,,3293.69,,,,100% of Medicare,,3293.69,,,,100% of Medicare,,3293.69,,,,100% of Medicare,,,3293.69,,,,100% of Medicare,1189.74,,,,EAPG Rate,100% of IL Medicaid,1189.74,,,,EAPG Rate,100% of IL Medicaid,1189.74,,,,EAPG Rate,100% of IL Medicaid,1189.74,,,,EAPG Rate,100% of IL Medicaid,1189.74,44431.91,
"BE, molded socket, endo sys, incl soft prosthetic tissue shaping",L6400,HCPCS,,,,outpatient,,,9678,5806.8,,45.5,,4403.49,percent of total billed charges,,,45.3,,4384.13,percent of total billed charges,,,39,,3774.42,percent of total billed charges,,,,,,,,,80,,7742.4,percent of total billed charges,,,61.4,,5942.29,percent of total billed charges,,,57.4,,5555.17,percent of total billed charges,,,81,,7839.18,percent of total billed charges,,,39,,3774.42,percent of total billed charges,,,57.6,,5574.53,percent of total billed charges,,,85,,8226.3,percent of total billed charges,,,85,,8226.3,percent of total billed charges,,,49,,4742.22,percent of total billed charges,,,90,,8710.2,percent of total billed charges,,,65,,6290.7,percent of total billed charges,,,80,,7742.4,percent of total billed charges,,,55,,5322.9,percent of total billed charges,,,55,,5322.9,percent of total billed charges,,,65,,6290.7,percent of total billed charges,,,78,,7548.84,percent of total billed charges,,,70,,6774.6,percent of total billed charges,,,,,,,,3284.97,,,,100% of Medicare,,3284.97,,,,100% of Medicare,,3284.97,,,,100% of Medicare,,3284.97,,,,100% of Medicare,,3284.97,,,,100% of Medicare,,3284.97,,,36708.25375,100% of Medicare,,3284.97,,,,100% of Medicare,,3284.97,,,,100% of Medicare,,3284.97,,,,100% of Medicare,,3284.97,,,,100% of Medicare,,3284.97,,,,100% of Medicare,,3284.97,,,,100% of Medicare,,,3284.97,,,,100% of Medicare,1205.28,,,,EAPG Rate,100% of IL Medicaid,1205.28,,,,EAPG Rate,100% of IL Medicaid,1205.28,,,,EAPG Rate,100% of IL Medicaid,1205.28,,,,EAPG Rate,100% of IL Medicaid,1205.28,36708.25,
"Elbow disartic, molded socket, endo sys, incl soft prosthetic tissue shaping",L6450,HCPCS,,,,outpatient,,,9729,5837.4,,45.5,,4426.7,percent of total billed charges,,,45.3,,4407.24,percent of total billed charges,,,39,,3794.31,percent of total billed charges,,,,,,,,,80,,7783.2,percent of total billed charges,,,61.4,,5973.61,percent of total billed charges,,,57.4,,5584.45,percent of total billed charges,,,81,,7880.49,percent of total billed charges,,,39,,3794.31,percent of total billed charges,,,57.6,,5603.9,percent of total billed charges,,,85,,8269.65,percent of total billed charges,,,85,,8269.65,percent of total billed charges,,,49,,4767.21,percent of total billed charges,,,90,,8756.1,percent of total billed charges,,,65,,6323.85,percent of total billed charges,,,80,,7783.2,percent of total billed charges,,,55,,5350.95,percent of total billed charges,,,55,,5350.95,percent of total billed charges,,,65,,6323.85,percent of total billed charges,,,78,,7588.62,percent of total billed charges,,,70,,6810.3,percent of total billed charges,,,,,,,,4293.29,,,,100% of Medicare,,4293.29,,,,100% of Medicare,,4293.29,,,,100% of Medicare,,4293.29,,,,100% of Medicare,,4293.29,,,,100% of Medicare,,4293.29,,,,100% of Medicare,,4293.29,,,,100% of Medicare,,4293.29,,,,100% of Medicare,,4293.29,,,,100% of Medicare,,4293.29,,,,100% of Medicare,,4293.29,,,,100% of Medicare,,4293.29,,,,100% of Medicare,,,4293.29,,,,100% of Medicare,1215.85,,,,EAPG Rate,100% of IL Medicaid,1215.85,,,,EAPG Rate,100% of IL Medicaid,1215.85,,,,EAPG Rate,100% of IL Medicaid,1215.85,,,,EAPG Rate,100% of IL Medicaid,1215.85,8756.1,
"All LE prosthesis, ankle, multiaxial shock absorbing system",L5968,HCPCS,,,,outpatient,,,10251,6150.6,,45.5,,4664.21,percent of total billed charges,,,45.3,,4643.7,percent of total billed charges,,,39,,3997.89,percent of total billed charges,,,,,,,,,80,,8200.8,percent of total billed charges,,,61.4,,6294.11,percent of total billed charges,,,57.4,,5884.07,percent of total billed charges,,,81,,8303.31,percent of total billed charges,,,39,,3997.89,percent of total billed charges,,,57.6,,5904.58,percent of total billed charges,,,85,,8713.35,percent of total billed charges,,,85,,8713.35,percent of total billed charges,,,49,,5022.99,percent of total billed charges,,,90,,9225.9,percent of total billed charges,,,65,,6663.15,percent of total billed charges,,,80,,8200.8,percent of total billed charges,,,55,,5638.05,percent of total billed charges,,,55,,5638.05,percent of total billed charges,,,65,,6663.15,percent of total billed charges,,,78,,7995.78,percent of total billed charges,,,70,,7175.7,percent of total billed charges,,,,,,,,4386.88,,,,100% of Medicare,,4386.88,,,,100% of Medicare,,4386.88,,,,100% of Medicare,,4386.88,,,,100% of Medicare,,4386.88,,,,100% of Medicare,,4386.88,,,,100% of Medicare,,4386.88,,,,100% of Medicare,,4386.88,,,,100% of Medicare,,4386.88,,,,100% of Medicare,,4386.88,,,,100% of Medicare,,4386.88,,,,100% of Medicare,,4386.88,,,,100% of Medicare,,,4386.88,,,,100% of Medicare,1217.4,,,,EAPG Rate,100% of IL Medicaid,1217.4,,,,EAPG Rate,100% of IL Medicaid,1217.4,,,,EAPG Rate,100% of IL Medicaid,1217.4,,,,EAPG Rate,100% of IL Medicaid,1217.4,9225.9,
"Prep, shoulder disartic or interscapular thoracic, single wall plastic socket, shoulder jt, lock elb",L6588,HCPCS,,,,outpatient,,,9747,5848.2,,45.5,,4434.89,percent of total billed charges,,,45.3,,4415.39,percent of total billed charges,,,39,,3801.33,percent of total billed charges,,,,,,,,,80,,7797.6,percent of total billed charges,,,61.4,,5984.66,percent of total billed charges,,,57.4,,5594.78,percent of total billed charges,,,81,,7895.07,percent of total billed charges,,,39,,3801.33,percent of total billed charges,,,57.6,,5614.27,percent of total billed charges,,,85,,8284.95,percent of total billed charges,,,85,,8284.95,percent of total billed charges,,,49,,4776.03,percent of total billed charges,,,90,,8772.3,percent of total billed charges,,,65,,6335.55,percent of total billed charges,,,80,,7797.6,percent of total billed charges,,,55,,5360.85,percent of total billed charges,,,55,,5360.85,percent of total billed charges,,,65,,6335.55,percent of total billed charges,,,78,,7602.66,percent of total billed charges,,,70,,6822.9,percent of total billed charges,,,,,,,,4301.46,,,,100% of Medicare,,4301.46,,,,100% of Medicare,,4301.46,,,,100% of Medicare,,4301.46,,,,100% of Medicare,,4301.46,,,,100% of Medicare,,4301.46,,,,100% of Medicare,,4301.46,,,,100% of Medicare,,4301.46,,,,100% of Medicare,,4301.46,,,,100% of Medicare,,4301.46,,,,100% of Medicare,,4301.46,,,,100% of Medicare,,4301.46,,,,100% of Medicare,,,4301.46,,,,100% of Medicare,1219.58,,,,EAPG Rate,100% of IL Medicaid,1219.58,,,,EAPG Rate,100% of IL Medicaid,1219.58,,,,EAPG Rate,100% of IL Medicaid,1219.58,,,,EAPG Rate,100% of IL Medicaid,1219.58,8772.3,
"Thoracic-Lumbar-Sacral Orthosis, 2-Piece Rigid Shell w/o Liner, Custom Fabricated",L0484,HCPCS,,,,outpatient,,,9801,5880.6,,45.5,,4459.46,percent of total billed charges,,,45.3,,4439.85,percent of total billed charges,,,39,,3822.39,percent of total billed charges,,,,,,,,,80,,7840.8,percent of total billed charges,,,61.4,,6017.81,percent of total billed charges,,,57.4,,5625.77,percent of total billed charges,,,81,,7938.81,percent of total billed charges,,,39,,3822.39,percent of total billed charges,,,57.6,,5645.38,percent of total billed charges,,,85,,8330.85,percent of total billed charges,,,85,,8330.85,percent of total billed charges,,,49,,4802.49,percent of total billed charges,,,90,,8820.9,percent of total billed charges,,,65,,6370.65,percent of total billed charges,,,80,,7840.8,percent of total billed charges,,,55,,5390.55,percent of total billed charges,,,55,,5390.55,percent of total billed charges,,,65,,6370.65,percent of total billed charges,,,78,,7644.78,percent of total billed charges,,,70,,6860.7,percent of total billed charges,,,,,,,,2195.36,,,,100% of Medicare,,2195.36,,,,100% of Medicare,,2195.36,,,,100% of Medicare,,2195.36,,,,100% of Medicare,,2195.36,,,,100% of Medicare,,2195.36,,,,100% of Medicare,,2195.36,,,,100% of Medicare,,2195.36,,,,100% of Medicare,,2195.36,,,,100% of Medicare,,2195.36,,,,100% of Medicare,,2195.36,,,,100% of Medicare,,2195.36,,,,100% of Medicare,,,2195.36,,,,100% of Medicare,1230.77,,,,EAPG Rate,100% of IL Medicaid,1230.77,,,,EAPG Rate,100% of IL Medicaid,1230.77,,,,EAPG Rate,100% of IL Medicaid,1230.77,,,,EAPG Rate,100% of IL Medicaid,1230.77,8820.9,
"L5580 Prep, AK or knee disartic, ischial level socket, non-align sys, pylon, no cover, SACH foot, th",L5580,HCPCS,,,,outpatient,,,9898,5938.8,,45.5,,4503.59,percent of total billed charges,,,45.3,,4483.79,percent of total billed charges,,,39,,3860.22,percent of total billed charges,,,,,,,,,80,,7918.4,percent of total billed charges,,,61.4,,6077.37,percent of total billed charges,,,57.4,,5681.45,percent of total billed charges,,,81,,8017.38,percent of total billed charges,,,39,,3860.22,percent of total billed charges,,,57.6,,5701.25,percent of total billed charges,,,85,,8413.3,percent of total billed charges,,,85,,8413.3,percent of total billed charges,,,49,,4850.02,percent of total billed charges,,,90,,8908.2,percent of total billed charges,,,65,,6433.7,percent of total billed charges,,,80,,7918.4,percent of total billed charges,,,55,,5443.9,percent of total billed charges,,,55,,5443.9,percent of total billed charges,,,65,,6433.7,percent of total billed charges,,,78,,7720.44,percent of total billed charges,,,70,,6928.6,percent of total billed charges,,,,,,,,3394.81,,,,100% of Medicare,,3394.81,,,,100% of Medicare,,3394.81,,,,100% of Medicare,,3394.81,,,,100% of Medicare,,3394.81,,,,100% of Medicare,,3394.81,,,,100% of Medicare,,3394.81,,,,100% of Medicare,,3394.81,,,,100% of Medicare,,3394.81,,,,100% of Medicare,,3394.81,,,,100% of Medicare,,3394.81,,,,100% of Medicare,,3394.81,,,,100% of Medicare,,,3394.81,,,,100% of Medicare,1250.87,,,,EAPG Rate,100% of IL Medicaid,1250.87,,,,EAPG Rate,100% of IL Medicaid,1250.87,,,,EAPG Rate,100% of IL Medicaid,1250.87,,,,EAPG Rate,100% of IL Medicaid,1250.87,8908.2,
"Ankle, Symes, molded socket, SACH foot",L5050,HCPCS,,,,outpatient,,,9938,5962.8,,45.5,,4521.79,percent of total billed charges,,,45.3,,4501.91,percent of total billed charges,,,39,,3875.82,percent of total billed charges,,,,,,,,,80,,7950.4,percent of total billed charges,,,61.4,,6101.93,percent of total billed charges,,,57.4,,5704.41,percent of total billed charges,,,81,,8049.78,percent of total billed charges,,,39,,3875.82,percent of total billed charges,,,57.6,,5724.29,percent of total billed charges,,,85,,8447.3,percent of total billed charges,,,85,,8447.3,percent of total billed charges,,,49,,4869.62,percent of total billed charges,,,90,,8944.2,percent of total billed charges,,,65,,6459.7,percent of total billed charges,,,80,,7950.4,percent of total billed charges,,,55,,5465.9,percent of total billed charges,,,55,,5465.9,percent of total billed charges,,,65,,6459.7,percent of total billed charges,,,78,,7751.64,percent of total billed charges,,,70,,6956.6,percent of total billed charges,,,,,,,,3307.84,,,,100% of Medicare,,3307.84,,,,100% of Medicare,,3307.84,,,,100% of Medicare,,3307.84,,,,100% of Medicare,,3307.84,,,,100% of Medicare,,3307.84,,,51651.10778,100% of Medicare,,3307.84,,,,100% of Medicare,,3307.84,,,,100% of Medicare,,3307.84,,,,100% of Medicare,,3307.84,,,,100% of Medicare,,3307.84,,,,100% of Medicare,,3307.84,,,,100% of Medicare,,,3307.84,,,,100% of Medicare,1259.15,,,,EAPG Rate,100% of IL Medicaid,1259.15,,,,EAPG Rate,100% of IL Medicaid,1259.15,,,,EAPG Rate,100% of IL Medicaid,1259.15,,,,EAPG Rate,100% of IL Medicaid,1259.15,51651.11,
"Term Device, Multi Art Digit",L6715,HCPCS,,,,outpatient,,,9950,5970,,45.5,,4527.25,percent of total billed charges,,,45.3,,4507.35,percent of total billed charges,,,39,,3880.5,percent of total billed charges,,,,,,,,,80,,7960,percent of total billed charges,,,61.4,,6109.3,percent of total billed charges,,,57.4,,5711.3,percent of total billed charges,,,81,,8059.5,percent of total billed charges,,,39,,3880.5,percent of total billed charges,,,57.6,,5731.2,percent of total billed charges,,,85,,8457.5,percent of total billed charges,,,85,,8457.5,percent of total billed charges,,,49,,4875.5,percent of total billed charges,,,90,,8955,percent of total billed charges,,,65,,6467.5,percent of total billed charges,,,80,,7960,percent of total billed charges,,,55,,5472.5,percent of total billed charges,,,55,,5472.5,percent of total billed charges,,,65,,6467.5,percent of total billed charges,,,78,,7761,percent of total billed charges,,,70,,6965,percent of total billed charges,,,,,,,,3811.37,,,,100% of Medicare,,3811.37,,,,100% of Medicare,,3811.37,,,,100% of Medicare,,3811.37,,,,100% of Medicare,,3811.37,,,,100% of Medicare,,3811.37,,,,100% of Medicare,,3811.37,,,,100% of Medicare,,3811.37,,,,100% of Medicare,,3811.37,,,,100% of Medicare,,3811.37,,,,100% of Medicare,,3811.37,,,,100% of Medicare,,3811.37,,,,100% of Medicare,,,3811.37,,,,100% of Medicare,1261.64,,,,EAPG Rate,100% of IL Medicaid,1261.64,,,,EAPG Rate,100% of IL Medicaid,1261.64,,,,EAPG Rate,100% of IL Medicaid,1261.64,,,,EAPG Rate,100% of IL Medicaid,1261.64,8955,
"Knee-Ankle-Foot Orthosis, Double Upright, Free Knee, Molded to Patient",L2036,HCPCS,,,,outpatient,,,9971,5982.6,,45.5,,4536.81,percent of total billed charges,,,45.3,,4516.86,percent of total billed charges,,,39,,3888.69,percent of total billed charges,,,,,,,,,80,,7976.8,percent of total billed charges,,,61.4,,6122.19,percent of total billed charges,,,57.4,,5723.35,percent of total billed charges,,,81,,8076.51,percent of total billed charges,,,39,,3888.69,percent of total billed charges,,,57.6,,5743.3,percent of total billed charges,,,85,,8475.35,percent of total billed charges,,,85,,8475.35,percent of total billed charges,,,49,,4885.79,percent of total billed charges,,,90,,8973.9,percent of total billed charges,,,65,,6481.15,percent of total billed charges,,,80,,7976.8,percent of total billed charges,,,55,,5484.05,percent of total billed charges,,,55,,5484.05,percent of total billed charges,,,65,,6481.15,percent of total billed charges,,,78,,7777.38,percent of total billed charges,,,70,,6979.7,percent of total billed charges,,,,,,,,2233.75,,,,100% of Medicare,,2233.75,,,,100% of Medicare,,2233.75,,,,100% of Medicare,,2233.75,,,,100% of Medicare,,2233.75,,,,100% of Medicare,,2233.75,,,,100% of Medicare,,2233.75,,,,100% of Medicare,,2233.75,,,,100% of Medicare,,2233.75,,,,100% of Medicare,,2233.75,,,,100% of Medicare,,2233.75,,,,100% of Medicare,,2233.75,,,,100% of Medicare,,,2233.75,,,,100% of Medicare,1265.99,,,,EAPG Rate,100% of IL Medicaid,1265.99,,,,EAPG Rate,100% of IL Medicaid,1265.99,,,,EAPG Rate,100% of IL Medicaid,1265.99,,,,EAPG Rate,100% of IL Medicaid,1265.99,8973.9,
"Above knee, short prosthesis, no knee joint (""stubbies""), with foot blocks, no ankle joints, each",L5210,HCPCS,,,,outpatient,,,10065,6039,,45.5,,4579.58,percent of total billed charges,,,45.3,,4559.45,percent of total billed charges,,,39,,3925.35,percent of total billed charges,,,,,,,,,80,,8052,percent of total billed charges,,,61.4,,6179.91,percent of total billed charges,,,57.4,,5777.31,percent of total billed charges,,,81,,8152.65,percent of total billed charges,,,39,,3925.35,percent of total billed charges,,,57.6,,5797.44,percent of total billed charges,,,85,,8555.25,percent of total billed charges,,,85,,8555.25,percent of total billed charges,,,49,,4931.85,percent of total billed charges,,,90,,9058.5,percent of total billed charges,,,65,,6542.25,percent of total billed charges,,,80,,8052,percent of total billed charges,,,55,,5535.75,percent of total billed charges,,,55,,5535.75,percent of total billed charges,,,65,,6542.25,percent of total billed charges,,,78,,7850.7,percent of total billed charges,,,70,,7045.5,percent of total billed charges,,,,,,,,3484.26,,,,100% of Medicare,,3484.26,,,,100% of Medicare,,3484.26,,,,100% of Medicare,,3484.26,,,,100% of Medicare,,3484.26,,,,100% of Medicare,,3484.26,,,,100% of Medicare,,3484.26,,,,100% of Medicare,,3484.26,,,,100% of Medicare,,3484.26,,,,100% of Medicare,,3484.26,,,,100% of Medicare,,3484.26,,,,100% of Medicare,,3484.26,,,,100% of Medicare,,,3484.26,,,,100% of Medicare,1285.47,,,,EAPG Rate,100% of IL Medicaid,1285.47,,,,EAPG Rate,100% of IL Medicaid,1285.47,,,,EAPG Rate,100% of IL Medicaid,1285.47,,,,EAPG Rate,100% of IL Medicaid,1285.47,9058.5,
Hip orthosis bilat hip abduction adjust flexion ext,L1681,HCPCS,,,,outpatient,,,10080,6048,,45.5,,4586.4,percent of total billed charges,,,45.3,,4566.24,percent of total billed charges,,,51,,5140.8,percent of total billed charges,,,,,,,,,80,,8064,percent of total billed charges,,,61.4,,6189.12,percent of total billed charges,,,57.4,,5785.92,percent of total billed charges,,,81,,8164.8,percent of total billed charges,,,51.5,,5191.2,percent of total billed charges,,,57.6,,5806.08,percent of total billed charges,,,85,,8568,percent of total billed charges,,,85,,8568,percent of total billed charges,,,49,,4939.2,percent of total billed charges,,,90,,9072,percent of total billed charges,,,65,,6552,percent of total billed charges,,,80,,8064,percent of total billed charges,,,55,,5544,percent of total billed charges,,,55,,5544,percent of total billed charges,,,65,,6552,percent of total billed charges,,,78,,7862.4,percent of total billed charges,,,70,,7056,percent of total billed charges,,,,,,,,2257.96,,,,100% of Medicare,,2257.96,,,,100% of Medicare,,2257.96,,,,100% of Medicare,,2257.96,,,,100% of Medicare,,2257.96,,,,100% of Medicare,,2257.96,,,,100% of Medicare,,2257.96,,,,100% of Medicare,,2257.96,,,,100% of Medicare,,2257.96,,,,100% of Medicare,,2257.96,,,,100% of Medicare,,2257.96,,,,100% of Medicare,,2257.96,,,,100% of Medicare,,2205.04,2257.96,,,,100% of Medicare,1288.58,,,,EAPG Rate,100% of IL Medicaid,1288.58,,,,EAPG Rate,100% of IL Medicaid,1288.58,,,,EAPG Rate,100% of IL Medicaid,1288.58,,,,EAPG Rate,100% of IL Medicaid,1288.58,9072,
"Hip Orthosis, Adduction Control",L1690,HCPCS,,,,outpatient,,,10099,6059.4,,45.5,,4595.05,percent of total billed charges,,,45.3,,4574.85,percent of total billed charges,,,39,,3938.61,percent of total billed charges,,,,,,,,,80,,8079.2,percent of total billed charges,,,61.4,,6200.79,percent of total billed charges,,,57.4,,5796.83,percent of total billed charges,,,81,,8180.19,percent of total billed charges,,,39,,3938.61,percent of total billed charges,,,57.6,,5817.02,percent of total billed charges,,,85,,8584.15,percent of total billed charges,,,85,,8584.15,percent of total billed charges,,,49,,4948.51,percent of total billed charges,,,90,,9089.1,percent of total billed charges,,,65,,6564.35,percent of total billed charges,,,80,,8079.2,percent of total billed charges,,,55,,5554.45,percent of total billed charges,,,55,,5554.45,percent of total billed charges,,,65,,6564.35,percent of total billed charges,,,78,,7877.22,percent of total billed charges,,,70,,7069.3,percent of total billed charges,,,,,,,,2329.91,,,,100% of Medicare,,2329.91,,,,100% of Medicare,,2329.91,,,,100% of Medicare,,2329.91,,,,100% of Medicare,,2329.91,,,,100% of Medicare,,2329.91,,,,100% of Medicare,,2329.91,,,,100% of Medicare,,2329.91,,,,100% of Medicare,,2329.91,,,,100% of Medicare,,2329.91,,,,100% of Medicare,,2329.91,,,,100% of Medicare,,2329.91,,,,100% of Medicare,,,2329.91,,,,100% of Medicare,1292.51,,,,EAPG Rate,100% of IL Medicaid,1292.51,,,,EAPG Rate,100% of IL Medicaid,1292.51,,,,EAPG Rate,100% of IL Medicaid,1292.51,,,,EAPG Rate,100% of IL Medicaid,1292.51,9089.1,
"Prep, AK or knee disartic, ischial level socket, non-align sys, pylon, no cover, SACH foot, lam sock",L5590,HCPCS,,,,outpatient,,,10226,6135.6,,45.5,,4652.83,percent of total billed charges,,,45.3,,4632.38,percent of total billed charges,,,39,,3988.14,percent of total billed charges,,,,,,,,,80,,8180.8,percent of total billed charges,,,61.4,,6278.76,percent of total billed charges,,,57.4,,5869.72,percent of total billed charges,,,81,,8283.06,percent of total billed charges,,,39,,3988.14,percent of total billed charges,,,57.6,,5890.18,percent of total billed charges,,,85,,8692.1,percent of total billed charges,,,85,,8692.1,percent of total billed charges,,,49,,5010.74,percent of total billed charges,,,90,,9203.4,percent of total billed charges,,,65,,6646.9,percent of total billed charges,,,80,,8180.8,percent of total billed charges,,,55,,5624.3,percent of total billed charges,,,55,,5624.3,percent of total billed charges,,,65,,6646.9,percent of total billed charges,,,78,,7976.28,percent of total billed charges,,,70,,7158.2,percent of total billed charges,,,,,,,,3539.42,,,,100% of Medicare,,3539.42,,,,100% of Medicare,,3539.42,,,,100% of Medicare,,3539.42,,,,100% of Medicare,,3539.42,,,,100% of Medicare,,3539.42,,,,100% of Medicare,,3539.42,,,,100% of Medicare,,3539.42,,,,100% of Medicare,,3539.42,,,,100% of Medicare,,3539.42,,,,100% of Medicare,,3539.42,,,,100% of Medicare,,3539.42,,,,100% of Medicare,,,3539.42,,,,100% of Medicare,1318.83,,,,EAPG Rate,100% of IL Medicaid,1318.83,,,,EAPG Rate,100% of IL Medicaid,1318.83,,,,EAPG Rate,100% of IL Medicaid,1318.83,,,,EAPG Rate,100% of IL Medicaid,1318.83,9203.4,
"Addition, endo knee-shin sys, single axis, fluid swing and stance",L5828,HCPCS,,,,outpatient,,,10279,6167.4,,45.5,,4676.95,percent of total billed charges,,,45.3,,4656.39,percent of total billed charges,,,39,,4008.81,percent of total billed charges,,,,,,,,,80,,8223.2,percent of total billed charges,,,61.4,,6311.31,percent of total billed charges,,,57.4,,5900.15,percent of total billed charges,,,81,,8325.99,percent of total billed charges,,,39,,4008.81,percent of total billed charges,,,57.6,,5920.7,percent of total billed charges,,,85,,8737.15,percent of total billed charges,,,85,,8737.15,percent of total billed charges,,,49,,5036.71,percent of total billed charges,,,90,,9251.1,percent of total billed charges,,,65,,6681.35,percent of total billed charges,,,80,,8223.2,percent of total billed charges,,,55,,5653.45,percent of total billed charges,,,55,,5653.45,percent of total billed charges,,,65,,6681.35,percent of total billed charges,,,78,,8017.62,percent of total billed charges,,,70,,7195.3,percent of total billed charges,,,,,,,,3557.34,,,,100% of Medicare,,3557.34,,,,100% of Medicare,,3557.34,,,,100% of Medicare,,3557.34,,,,100% of Medicare,,3557.34,,,,100% of Medicare,,3557.34,,,,100% of Medicare,,3557.34,,,,100% of Medicare,,3557.34,,,,100% of Medicare,,3557.34,,,,100% of Medicare,,3557.34,,,,100% of Medicare,,3557.34,,,,100% of Medicare,,3557.34,,,,100% of Medicare,,,3557.34,,,,100% of Medicare,1329.81,,,,EAPG Rate,100% of IL Medicaid,1329.81,,,,EAPG Rate,100% of IL Medicaid,1329.81,,,,EAPG Rate,100% of IL Medicaid,1329.81,,,,EAPG Rate,100% of IL Medicaid,1329.81,9251.1,
"L6883 Replacement socket,below elbow/wrist disarticulation,molded to patient model,for use with or w",L6883,HCPCS,,,,outpatient,,,10393,6235.8,,45.5,,4728.82,percent of total billed charges,,,45.3,,4708.03,percent of total billed charges,,,39,,4053.27,percent of total billed charges,,,,,,,,,80,,8314.4,percent of total billed charges,,,61.4,,6381.3,percent of total billed charges,,,57.4,,5965.58,percent of total billed charges,,,81,,8418.33,percent of total billed charges,,,39,,4053.27,percent of total billed charges,,,57.6,,5986.37,percent of total billed charges,,,85,,8834.05,percent of total billed charges,,,85,,8834.05,percent of total billed charges,,,49,,5092.57,percent of total billed charges,,,90,,9353.7,percent of total billed charges,,,65,,6755.45,percent of total billed charges,,,80,,8314.4,percent of total billed charges,,,55,,5716.15,percent of total billed charges,,,55,,5716.15,percent of total billed charges,,,65,,6755.45,percent of total billed charges,,,78,,8106.54,percent of total billed charges,,,70,,7275.1,percent of total billed charges,,,,,,,,2398.11,,,,100% of Medicare,,2398.11,,,,100% of Medicare,,2398.11,,,,100% of Medicare,,2398.11,,,,100% of Medicare,,2398.11,,,,100% of Medicare,,2398.11,,,,100% of Medicare,,2398.11,,,,100% of Medicare,,2398.11,,,,100% of Medicare,,2398.11,,,,100% of Medicare,,2398.11,,,,100% of Medicare,,2398.11,,,,100% of Medicare,,2398.11,,,,100% of Medicare,,,2398.11,,,,100% of Medicare,1353.43,,,,EAPG Rate,100% of IL Medicaid,1353.43,,,,EAPG Rate,100% of IL Medicaid,1353.43,,,,EAPG Rate,100% of IL Medicaid,1353.43,,,,EAPG Rate,100% of IL Medicaid,1353.43,9353.7,
"Wrist-Hand-Finger Orthosis, Electric, External Power",L3904,HCPCS,,,,outpatient,,,10496,6297.6,,45.5,,4775.68,percent of total billed charges,,,45.3,,4754.69,percent of total billed charges,,,39,,4093.44,percent of total billed charges,,,,,,,,,80,,8396.8,percent of total billed charges,,,61.4,,6444.54,percent of total billed charges,,,57.4,,6024.7,percent of total billed charges,,,81,,8501.76,percent of total billed charges,,,39,,4093.44,percent of total billed charges,,,57.6,,6045.7,percent of total billed charges,,,85,,8921.6,percent of total billed charges,,,85,,8921.6,percent of total billed charges,,,49,,5143.04,percent of total billed charges,,,90,,9446.4,percent of total billed charges,,,65,,6822.4,percent of total billed charges,,,80,,8396.8,percent of total billed charges,,,55,,5772.8,percent of total billed charges,,,55,,5772.8,percent of total billed charges,,,65,,6822.4,percent of total billed charges,,,78,,8186.88,percent of total billed charges,,,70,,7347.2,percent of total billed charges,,,,,,,,3701.21,,,,100% of Medicare,,3701.21,,,,100% of Medicare,,3701.21,,,,100% of Medicare,,3701.21,,,,100% of Medicare,,3701.21,,,,100% of Medicare,,3701.21,,,,100% of Medicare,,3701.21,,,,100% of Medicare,,3701.21,,,,100% of Medicare,,3701.21,,,,100% of Medicare,,3701.21,,,,100% of Medicare,,3701.21,,,,100% of Medicare,,3701.21,,,,100% of Medicare,,,3701.21,,,,100% of Medicare,1374.77,,,,EAPG Rate,100% of IL Medicaid,1374.77,,,,EAPG Rate,100% of IL Medicaid,1374.77,,,,EAPG Rate,100% of IL Medicaid,1374.77,,,,EAPG Rate,100% of IL Medicaid,1374.77,9446.4,
"L2034 Knee-Ankle-Foot Orthosis, Full Plastic, Single Upright, w/ or w/out Free Motion Ankle, Custom",L2034,HCPCS,,,,outpatient,,,10607,6364.2,,45.5,,4826.19,percent of total billed charges,,,45.3,,4804.97,percent of total billed charges,,,39,,4136.73,percent of total billed charges,,,,,,,,,80,,8485.6,percent of total billed charges,,,61.4,,6512.7,percent of total billed charges,,,57.4,,6088.42,percent of total billed charges,,,81,,8591.67,percent of total billed charges,,,39,,4136.73,percent of total billed charges,,,57.6,,6109.63,percent of total billed charges,,,85,,9015.95,percent of total billed charges,,,85,,9015.95,percent of total billed charges,,,49,,5197.43,percent of total billed charges,,,90,,9546.3,percent of total billed charges,,,65,,6894.55,percent of total billed charges,,,80,,8485.6,percent of total billed charges,,,55,,5833.85,percent of total billed charges,,,55,,5833.85,percent of total billed charges,,,65,,6894.55,percent of total billed charges,,,78,,8273.46,percent of total billed charges,,,70,,7424.9,percent of total billed charges,,,,,,,,2447.64,,,,100% of Medicare,,2447.64,,,,100% of Medicare,,2447.64,,,,100% of Medicare,,2447.64,,,,100% of Medicare,,2447.64,,,,100% of Medicare,,2447.64,,,,100% of Medicare,,2447.64,,,,100% of Medicare,,2447.64,,,,100% of Medicare,,2447.64,,,,100% of Medicare,,2447.64,,,,100% of Medicare,,2447.64,,,,100% of Medicare,,2447.64,,,,100% of Medicare,,,2447.64,,,,100% of Medicare,1397.77,,,,EAPG Rate,100% of IL Medicaid,1397.77,,,,EAPG Rate,100% of IL Medicaid,1397.77,,,,EAPG Rate,100% of IL Medicaid,1397.77,,,,EAPG Rate,100% of IL Medicaid,1397.77,9546.3,
"UE addition, external locking elbow, forearm counterbalance",L6693,HCPCS,,,,outpatient,,,10616,6369.6,,45.5,,4830.28,percent of total billed charges,,,45.3,,4809.05,percent of total billed charges,,,39,,4140.24,percent of total billed charges,,,,,,,,,80,,8492.8,percent of total billed charges,,,61.4,,6518.22,percent of total billed charges,,,57.4,,6093.58,percent of total billed charges,,,81,,8598.96,percent of total billed charges,,,39,,4140.24,percent of total billed charges,,,57.6,,6114.82,percent of total billed charges,,,85,,9023.6,percent of total billed charges,,,85,,9023.6,percent of total billed charges,,,49,,5201.84,percent of total billed charges,,,90,,9554.4,percent of total billed charges,,,65,,6900.4,percent of total billed charges,,,80,,8492.8,percent of total billed charges,,,55,,5838.8,percent of total billed charges,,,55,,5838.8,percent of total billed charges,,,65,,6900.4,percent of total billed charges,,,78,,8280.48,percent of total billed charges,,,70,,7431.2,percent of total billed charges,,,,,,,,3427.3,,,,100% of Medicare,,3427.3,,,,100% of Medicare,,3427.3,,,,100% of Medicare,,3427.3,,,,100% of Medicare,,3427.3,,,,100% of Medicare,,3427.3,,,,100% of Medicare,,3427.3,,,,100% of Medicare,,3427.3,,,,100% of Medicare,,3427.3,,,,100% of Medicare,,3427.3,,,,100% of Medicare,,3427.3,,,,100% of Medicare,,3427.3,,,,100% of Medicare,,,3427.3,,,,100% of Medicare,1399.64,,,,EAPG Rate,100% of IL Medicaid,1399.64,,,,EAPG Rate,100% of IL Medicaid,1399.64,,,,EAPG Rate,100% of IL Medicaid,1399.64,,,,EAPG Rate,100% of IL Medicaid,1399.64,9554.4,
"Microproc control feature, addtion to upper-limb prosthetic terminal device",L6882,HCPCS,,,,outpatient,,,10816,6489.6,,45.5,,4921.28,percent of total billed charges,,,45.3,,4899.65,percent of total billed charges,,,39,,4218.24,percent of total billed charges,,,,,,,,,80,,8652.8,percent of total billed charges,,,61.4,,6641.02,percent of total billed charges,,,57.4,,6208.38,percent of total billed charges,,,81,,8760.96,percent of total billed charges,,,39,,4218.24,percent of total billed charges,,,57.6,,6230.02,percent of total billed charges,,,85,,9193.6,percent of total billed charges,,,85,,9193.6,percent of total billed charges,,,49,,5299.84,percent of total billed charges,,,90,,9734.4,percent of total billed charges,,,65,,7030.4,percent of total billed charges,,,80,,8652.8,percent of total billed charges,,,55,,5948.8,percent of total billed charges,,,55,,5948.8,percent of total billed charges,,,65,,7030.4,percent of total billed charges,,,78,,8436.48,percent of total billed charges,,,70,,7571.2,percent of total billed charges,,,,,,,,3743.74,,,,100% of Medicare,,3743.74,,,,100% of Medicare,,3743.74,,,,100% of Medicare,,3743.74,,,,100% of Medicare,,3743.74,,,,100% of Medicare,,3743.74,,,,100% of Medicare,,3743.74,,,,100% of Medicare,,3743.74,,,,100% of Medicare,,3743.74,,,,100% of Medicare,,3743.74,,,,100% of Medicare,,3743.74,,,,100% of Medicare,,3743.74,,,,100% of Medicare,,,3743.74,,,,100% of Medicare,1441.08,,,,EAPG Rate,100% of IL Medicaid,1441.08,,,,EAPG Rate,100% of IL Medicaid,1441.08,,,,EAPG Rate,100% of IL Medicaid,1441.08,,,,EAPG Rate,100% of IL Medicaid,1441.08,9734.4,
"Upper Extremity addition, flexion/extension and rotation wrist unit",L6624,HCPCS,,,,outpatient,,,10835,6501,,45.5,,4929.93,percent of total billed charges,,,45.3,,4908.26,percent of total billed charges,,,39,,4225.65,percent of total billed charges,,,,,,,,,80,,8668,percent of total billed charges,,,61.4,,6652.69,percent of total billed charges,,,57.4,,6219.29,percent of total billed charges,,,81,,8776.35,percent of total billed charges,,,39,,4225.65,percent of total billed charges,,,57.6,,6240.96,percent of total billed charges,,,85,,9209.75,percent of total billed charges,,,85,,9209.75,percent of total billed charges,,,49,,5309.15,percent of total billed charges,,,90,,9751.5,percent of total billed charges,,,65,,7042.75,percent of total billed charges,,,80,,8668,percent of total billed charges,,,55,,5959.25,percent of total billed charges,,,55,,5959.25,percent of total billed charges,,,65,,7042.75,percent of total billed charges,,,78,,8451.3,percent of total billed charges,,,70,,7584.5,percent of total billed charges,,,,,,,,4546.46,,,,100% of Medicare,,4546.46,,,,100% of Medicare,,4546.46,,,,100% of Medicare,,4546.46,,,,100% of Medicare,,4546.46,,,,100% of Medicare,,4546.46,,,,100% of Medicare,,4546.46,,,,100% of Medicare,,4546.46,,,,100% of Medicare,,4546.46,,,,100% of Medicare,,4546.46,,,,100% of Medicare,,4546.46,,,,100% of Medicare,,4546.46,,,,100% of Medicare,,,4546.46,,,,100% of Medicare,1445.01,,,,EAPG Rate,100% of IL Medicaid,1445.01,,,,EAPG Rate,100% of IL Medicaid,1445.01,,,,EAPG Rate,100% of IL Medicaid,1445.01,,,,EAPG Rate,100% of IL Medicaid,1445.01,9751.5,
"L6885 Replacement socket,shoulder disarticulation/intrascapular thoracic,molded to patient model,for",L6885,HCPCS,,,,outpatient,,,10890,6534,,45.5,,4954.95,percent of total billed charges,,,45.3,,4933.17,percent of total billed charges,,,39,,4247.1,percent of total billed charges,,,,,,,,,80,,8712,percent of total billed charges,,,61.4,,6686.46,percent of total billed charges,,,57.4,,6250.86,percent of total billed charges,,,81,,8820.9,percent of total billed charges,,,39,,4247.1,percent of total billed charges,,,57.6,,6272.64,percent of total billed charges,,,85,,9256.5,percent of total billed charges,,,85,,9256.5,percent of total billed charges,,,49,,5336.1,percent of total billed charges,,,90,,9801,percent of total billed charges,,,65,,7078.5,percent of total billed charges,,,80,,8712,percent of total billed charges,,,55,,5989.5,percent of total billed charges,,,55,,5989.5,percent of total billed charges,,,65,,7078.5,percent of total billed charges,,,78,,8494.2,percent of total billed charges,,,70,,7623,percent of total billed charges,,,,,,,,5097.31,,,,100% of Medicare,,5097.31,,,,100% of Medicare,,5097.31,,,,100% of Medicare,,5097.31,,,,100% of Medicare,,5097.31,,,,100% of Medicare,,5097.31,,,,100% of Medicare,,5097.31,,,,100% of Medicare,,5097.31,,,,100% of Medicare,,5097.31,,,,100% of Medicare,,5097.31,,,,100% of Medicare,,5097.31,,,,100% of Medicare,,5097.31,,,,100% of Medicare,,,5097.31,,,,100% of Medicare,1456.41,,,,EAPG Rate,100% of IL Medicaid,1456.41,,,,EAPG Rate,100% of IL Medicaid,1456.41,,,,EAPG Rate,100% of IL Medicaid,1456.41,,,,EAPG Rate,100% of IL Medicaid,1456.41,9801,
"Shoulder disartic, passive restoration (complete prosthesis)",L6310,HCPCS,,,,outpatient,,,10928,6556.8,,45.5,,4972.24,percent of total billed charges,,,45.3,,4950.38,percent of total billed charges,,,39,,4261.92,percent of total billed charges,,,,,,,,,80,,8742.4,percent of total billed charges,,,61.4,,6709.79,percent of total billed charges,,,57.4,,6272.67,percent of total billed charges,,,81,,8851.68,percent of total billed charges,,,39,,4261.92,percent of total billed charges,,,57.6,,6294.53,percent of total billed charges,,,85,,9288.8,percent of total billed charges,,,85,,9288.8,percent of total billed charges,,,49,,5354.72,percent of total billed charges,,,90,,9835.2,percent of total billed charges,,,65,,7103.2,percent of total billed charges,,,80,,8742.4,percent of total billed charges,,,55,,6010.4,percent of total billed charges,,,55,,6010.4,percent of total billed charges,,,65,,7103.2,percent of total billed charges,,,78,,8523.84,percent of total billed charges,,,70,,7649.6,percent of total billed charges,,,,,,,,4856.35,,,,100% of Medicare,,4856.35,,,,100% of Medicare,,4856.35,,,,100% of Medicare,,4856.35,,,,100% of Medicare,,4856.35,,,,100% of Medicare,,4856.35,,,,100% of Medicare,,4856.35,,,,100% of Medicare,,4856.35,,,,100% of Medicare,,4856.35,,,,100% of Medicare,,4856.35,,,,100% of Medicare,,4856.35,,,,100% of Medicare,,4856.35,,,,100% of Medicare,,,4856.35,,,,100% of Medicare,1464.28,,,,EAPG Rate,100% of IL Medicaid,1464.28,,,,EAPG Rate,100% of IL Medicaid,1464.28,,,,EAPG Rate,100% of IL Medicaid,1464.28,,,,EAPG Rate,100% of IL Medicaid,1464.28,9835.2,
"Thoracic-Lumbar-Sacral Orthosis, 2-Piece Rigid Shell w/ Liner, Custom Fabricated",L0486,HCPCS,,,,outpatient,,,11009,6605.4,,45.5,,5009.1,percent of total billed charges,,,45.3,,4987.08,percent of total billed charges,,,39,,4293.51,percent of total billed charges,,,,,,,,,80,,8807.2,percent of total billed charges,,,61.4,,6759.53,percent of total billed charges,,,57.4,,6319.17,percent of total billed charges,,,81,,8917.29,percent of total billed charges,,,39,,4293.51,percent of total billed charges,,,57.6,,6341.18,percent of total billed charges,,,85,,9357.65,percent of total billed charges,,,85,,9357.65,percent of total billed charges,,,49,,5394.41,percent of total billed charges,,,90,,9908.1,percent of total billed charges,,,65,,7155.85,percent of total billed charges,,,80,,8807.2,percent of total billed charges,,,55,,6054.95,percent of total billed charges,,,55,,6054.95,percent of total billed charges,,,65,,7155.85,percent of total billed charges,,,78,,8587.02,percent of total billed charges,,,70,,7706.3,percent of total billed charges,,,,,,,,2465.48,,,,100% of Medicare,,2465.48,,,,100% of Medicare,,2465.48,,,,100% of Medicare,,2465.48,,,,100% of Medicare,,2465.48,,,,100% of Medicare,,2465.48,,,,100% of Medicare,,2465.48,,,,100% of Medicare,,2465.48,,,,100% of Medicare,,2465.48,,,,100% of Medicare,,2465.48,,,,100% of Medicare,,2465.48,,,,100% of Medicare,,2465.48,,,,100% of Medicare,,,2465.48,,,,100% of Medicare,1481.06,,,,EAPG Rate,100% of IL Medicaid,1481.06,,,,EAPG Rate,100% of IL Medicaid,1481.06,,,,EAPG Rate,100% of IL Medicaid,1481.06,,,,EAPG Rate,100% of IL Medicaid,1481.06,9908.1,
"Lower Extremity Addition, Pelvic Control, Reciprocating Hip Joint/Cable",L2627,HCPCS,,,,outpatient,,,11159,6695.4,,45.5,,5077.35,percent of total billed charges,,,45.3,,5055.03,percent of total billed charges,,,39,,4352.01,percent of total billed charges,,,,,,,,,80,,8927.2,percent of total billed charges,,,61.4,,6851.63,percent of total billed charges,,,57.4,,6405.27,percent of total billed charges,,,81,,9038.79,percent of total billed charges,,,39,,4352.01,percent of total billed charges,,,57.6,,6427.58,percent of total billed charges,,,85,,9485.15,percent of total billed charges,,,85,,9485.15,percent of total billed charges,,,49,,5467.91,percent of total billed charges,,,90,,10043.1,percent of total billed charges,,,65,,7253.35,percent of total billed charges,,,80,,8927.2,percent of total billed charges,,,55,,6137.45,percent of total billed charges,,,55,,6137.45,percent of total billed charges,,,65,,7253.35,percent of total billed charges,,,78,,8704.02,percent of total billed charges,,,70,,7811.3,percent of total billed charges,,,,,,,,2575.08,,,,100% of Medicare,,2575.08,,,,100% of Medicare,,2575.08,,,,100% of Medicare,,2575.08,,,,100% of Medicare,,2575.08,,,,100% of Medicare,,2575.08,,,,100% of Medicare,,2575.08,,,,100% of Medicare,,2575.08,,,,100% of Medicare,,2575.08,,,,100% of Medicare,,2575.08,,,,100% of Medicare,,2575.08,,,,100% of Medicare,,2575.08,,,,100% of Medicare,,,2575.08,,,,100% of Medicare,1512.14,,,,EAPG rate,100% of IL Medicaid,1512.14,,,,EAPG rate,100% of IL Medicaid,1512.14,,,,EAPG rate,100% of IL Medicaid,1512.14,,,,EAPG rate,100% of IL Medicaid,1512.14,10043.1,
"Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad",L6055,HCPCS,,,,outpatient,,,11170,6702,,45.5,,5082.35,percent of total billed charges,,,45.3,,5060.01,percent of total billed charges,,,39,,4356.3,percent of total billed charges,,,,,,,,,80,,8936,percent of total billed charges,,,61.4,,6858.38,percent of total billed charges,,,57.4,,6411.58,percent of total billed charges,,,81,,9047.7,percent of total billed charges,,,39,,4356.3,percent of total billed charges,,,57.6,,6433.92,percent of total billed charges,,,85,,9494.5,percent of total billed charges,,,85,,9494.5,percent of total billed charges,,,49,,5473.3,percent of total billed charges,,,90,,10053,percent of total billed charges,,,65,,7260.5,percent of total billed charges,,,80,,8936,percent of total billed charges,,,55,,6143.5,percent of total billed charges,,,55,,6143.5,percent of total billed charges,,,65,,7260.5,percent of total billed charges,,,78,,8712.6,percent of total billed charges,,,70,,7819,percent of total billed charges,,,,,,,,3827.72,,,,100% of Medicare,,3827.72,,,,100% of Medicare,,3827.72,,,,100% of Medicare,,3827.72,,,,100% of Medicare,,3827.72,,,,100% of Medicare,,3827.72,,,,100% of Medicare,,3827.72,,,,100% of Medicare,,3827.72,,,,100% of Medicare,,3827.72,,,,100% of Medicare,,3827.72,,,,100% of Medicare,,3827.72,,,,100% of Medicare,,3827.72,,,,100% of Medicare,,,3827.72,,,,100% of Medicare,1514.42,,,,EAPG rate,100% of IL Medicaid,1514.42,,,,EAPG rate,100% of IL Medicaid,1514.42,,,,EAPG rate,100% of IL Medicaid,1514.42,,,,EAPG rate,100% of IL Medicaid,1514.42,10053,
"Replacement, socket, BK, molded to patient model",L5700,HCPCS,,,,outpatient,,,11249,6749.4,,45.5,,5118.3,percent of total billed charges,,,45.3,,5095.8,percent of total billed charges,,,39,,4387.11,percent of total billed charges,,,,,,,,,80,,8999.2,percent of total billed charges,,,61.4,,6906.89,percent of total billed charges,,,57.4,,6456.93,percent of total billed charges,,,81,,9111.69,percent of total billed charges,,,39,,4387.11,percent of total billed charges,,,57.6,,6479.42,percent of total billed charges,,,85,,9561.65,percent of total billed charges,,,85,,9561.65,percent of total billed charges,,,49,,5512.01,percent of total billed charges,,,90,,10124.1,percent of total billed charges,,,65,,7311.85,percent of total billed charges,,,80,,8999.2,percent of total billed charges,,,55,,6186.95,percent of total billed charges,,,55,,6186.95,percent of total billed charges,,,65,,7311.85,percent of total billed charges,,,78,,8774.22,percent of total billed charges,,,70,,7874.3,percent of total billed charges,,,,,,,,3702.93,,,,100% of Medicare,,3702.93,,,,100% of Medicare,,3702.93,,,,100% of Medicare,,3702.93,,,,100% of Medicare,,3702.93,,,,100% of Medicare,,3702.93,,,,100% of Medicare,,3702.93,,,,100% of Medicare,,3702.93,,,,100% of Medicare,,3702.93,,,,100% of Medicare,,3702.93,,,,100% of Medicare,,3702.93,,,,100% of Medicare,,3702.93,,,,100% of Medicare,,,3702.93,,,,100% of Medicare,1530.79,,,,EAPG rate,100% of IL Medicaid,1530.79,,,,EAPG rate,100% of IL Medicaid,1530.79,,,,EAPG rate,100% of IL Medicaid,1530.79,,,,EAPG rate,100% of IL Medicaid,1530.79,10124.1,
"AE, molded double wall socket, internal locking elbow, forearm",L6250,HCPCS,,,,outpatient,,,11329,6797.4,,45.5,,5154.7,percent of total billed charges,,,45.3,,5132.04,percent of total billed charges,,,39,,4418.31,percent of total billed charges,,,,,,,,,80,,9063.2,percent of total billed charges,,,61.4,,6956.01,percent of total billed charges,,,57.4,,6502.85,percent of total billed charges,,,81,,9176.49,percent of total billed charges,,,39,,4418.31,percent of total billed charges,,,57.6,,6525.5,percent of total billed charges,,,85,,9629.65,percent of total billed charges,,,85,,9629.65,percent of total billed charges,,,49,,5551.21,percent of total billed charges,,,90,,10196.1,percent of total billed charges,,,65,,7363.85,percent of total billed charges,,,80,,9063.2,percent of total billed charges,,,55,,6230.95,percent of total billed charges,,,55,,6230.95,percent of total billed charges,,,65,,7363.85,percent of total billed charges,,,78,,8836.62,percent of total billed charges,,,70,,7930.3,percent of total billed charges,,,,,,,,3885.03,,,,100% of Medicare,,3885.03,,,,100% of Medicare,,3885.03,,,,100% of Medicare,,3885.03,,,,100% of Medicare,,3885.03,,,,100% of Medicare,,3885.03,,,,100% of Medicare,,3885.03,,,,100% of Medicare,,3885.03,,,,100% of Medicare,,3885.03,,,,100% of Medicare,,3885.03,,,,100% of Medicare,,3885.03,,,,100% of Medicare,,3885.03,,,,100% of Medicare,,,3885.03,,,,100% of Medicare,1547.37,,,,EAPG rate,100% of IL Medicaid,1547.37,,,,EAPG rate,100% of IL Medicaid,1547.37,,,,EAPG rate,100% of IL Medicaid,1547.37,,,,EAPG rate,100% of IL Medicaid,1547.37,10196.1,
"UE addition, shoulder jt, multipositional lock, flexion, adj abd fric control, w/ body power or ext",L6646,HCPCS,,,,outpatient,,,11332,6799.2,,45.5,,5156.06,percent of total billed charges,,,45.3,,5133.4,percent of total billed charges,,,39,,4419.48,percent of total billed charges,,,,,,,,,80,,9065.6,percent of total billed charges,,,61.4,,6957.85,percent of total billed charges,,,57.4,,6504.57,percent of total billed charges,,,81,,9178.92,percent of total billed charges,,,39,,4419.48,percent of total billed charges,,,57.6,,6527.23,percent of total billed charges,,,85,,9632.2,percent of total billed charges,,,85,,9632.2,percent of total billed charges,,,49,,5552.68,percent of total billed charges,,,90,,10198.8,percent of total billed charges,,,65,,7365.8,percent of total billed charges,,,80,,9065.6,percent of total billed charges,,,55,,6232.6,percent of total billed charges,,,55,,6232.6,percent of total billed charges,,,65,,7365.8,percent of total billed charges,,,78,,8838.96,percent of total billed charges,,,70,,7932.4,percent of total billed charges,,,,,,,,3807.55,,,,100% of Medicare,,3807.55,,,,100% of Medicare,,3807.55,,,,100% of Medicare,,3807.55,,,,100% of Medicare,,3807.55,,,,100% of Medicare,,3807.55,,,,100% of Medicare,,3807.55,,,,100% of Medicare,,3807.55,,,,100% of Medicare,,3807.55,,,,100% of Medicare,,3807.55,,,,100% of Medicare,,3807.55,,,,100% of Medicare,,3807.55,,,,100% of Medicare,,,3807.55,,,,100% of Medicare,1547.99,,,,EAPG Rate,100% of IL Medicaid,1547.99,,,,EAPG Rate,100% of IL Medicaid,1547.99,,,,EAPG Rate,100% of IL Medicaid,1547.99,,,,EAPG Rate,100% of IL Medicaid,1547.99,10198.8,
"Interscapular thoracic, passive restoration (complete prosthesis)",L6360,HCPCS,,,,outpatient,,,11473,6883.8,,45.5,,5220.22,percent of total billed charges,,,45.3,,5197.27,percent of total billed charges,,,39,,4474.47,percent of total billed charges,,,,,,,,,80,,9178.4,percent of total billed charges,,,61.4,,7044.42,percent of total billed charges,,,57.4,,6585.5,percent of total billed charges,,,81,,9293.13,percent of total billed charges,,,39,,4474.47,percent of total billed charges,,,57.6,,6608.45,percent of total billed charges,,,85,,9752.05,percent of total billed charges,,,85,,9752.05,percent of total billed charges,,,49,,5621.77,percent of total billed charges,,,90,,10325.7,percent of total billed charges,,,65,,7457.45,percent of total billed charges,,,80,,9178.4,percent of total billed charges,,,55,,6310.15,percent of total billed charges,,,55,,6310.15,percent of total billed charges,,,65,,7457.45,percent of total billed charges,,,78,,8948.94,percent of total billed charges,,,70,,8031.1,percent of total billed charges,,,,,,,,5097.31,,,,100% of Medicare,,5097.31,,,,100% of Medicare,,5097.31,,,,100% of Medicare,,5097.31,,,,100% of Medicare,,5097.31,,,,100% of Medicare,,5097.31,,,,100% of Medicare,,5097.31,,,,100% of Medicare,,5097.31,,,,100% of Medicare,,5097.31,,,,100% of Medicare,,5097.31,,,,100% of Medicare,,5097.31,,,,100% of Medicare,,5097.31,,,,100% of Medicare,,,5097.31,,,,100% of Medicare,1577.21,,,,EAPG rate,100% of IL Medicaid,1577.21,,,,EAPG rate,100% of IL Medicaid,1577.21,,,,EAPG rate,100% of IL Medicaid,1577.21,,,,EAPG rate,100% of IL Medicaid,1577.21,10325.7,
"UE addition, shoulder lock mechanism, external powered actuator",L6648,HCPCS,,,,outpatient,,,11571,6942.6,,45.5,,5264.81,percent of total billed charges,,,45.3,,5241.66,percent of total billed charges,,,39,,4512.69,percent of total billed charges,,,,,,,,,80,,9256.8,percent of total billed charges,,,61.4,,7104.59,percent of total billed charges,,,57.4,,6641.75,percent of total billed charges,,,81,,9372.51,percent of total billed charges,,,39,,4512.69,percent of total billed charges,,,57.6,,6664.9,percent of total billed charges,,,85,,9835.35,percent of total billed charges,,,85,,9835.35,percent of total billed charges,,,49,,5669.79,percent of total billed charges,,,90,,10413.9,percent of total billed charges,,,65,,7521.15,percent of total billed charges,,,80,,9256.8,percent of total billed charges,,,55,,6364.05,percent of total billed charges,,,55,,6364.05,percent of total billed charges,,,65,,7521.15,percent of total billed charges,,,78,,9025.38,percent of total billed charges,,,70,,8099.7,percent of total billed charges,,,,,,,,3926.95,,,,100% of Medicare,,3926.95,,,,100% of Medicare,,3926.95,,,,100% of Medicare,,3926.95,,,,100% of Medicare,,3926.95,,,,100% of Medicare,,3926.95,,,,100% of Medicare,,3926.95,,,,100% of Medicare,,3926.95,,,,100% of Medicare,,3926.95,,,,100% of Medicare,,3926.95,,,,100% of Medicare,,3926.95,,,,100% of Medicare,,3926.95,,,,100% of Medicare,,,3926.95,,,,100% of Medicare,1597.51,,,,EAPG rate,100% of IL Medicaid,1597.51,,,,EAPG rate,100% of IL Medicaid,1597.51,,,,EAPG rate,100% of IL Medicaid,1597.51,,,,EAPG rate,100% of IL Medicaid,1597.51,10413.9,
"Addition, endo sys, high activity knee control frame",L5930,HCPCS,,,,outpatient,,,11742,7045.2,,45.5,,5342.61,percent of total billed charges,,,45.3,,5319.13,percent of total billed charges,,,39,,4579.38,percent of total billed charges,,,,,,,,,80,,9393.6,percent of total billed charges,,,61.4,,7209.59,percent of total billed charges,,,57.4,,6739.91,percent of total billed charges,,,81,,9511.02,percent of total billed charges,,,39,,4579.38,percent of total billed charges,,,57.6,,6763.39,percent of total billed charges,,,85,,9980.7,percent of total billed charges,,,85,,9980.7,percent of total billed charges,,,49,,5753.58,percent of total billed charges,,,90,,10567.8,percent of total billed charges,,,65,,7632.3,percent of total billed charges,,,80,,9393.6,percent of total billed charges,,,55,,6458.1,percent of total billed charges,,,55,,6458.1,percent of total billed charges,,,65,,7632.3,percent of total billed charges,,,78,,9158.76,percent of total billed charges,,,70,,8219.4,percent of total billed charges,,,,,,,,4063.39,,,,100% of Medicare,,4063.39,,,,100% of Medicare,,4063.39,,,,100% of Medicare,,4063.39,,,,100% of Medicare,,4063.39,,,,100% of Medicare,,4063.39,,,,100% of Medicare,,4063.39,,,,100% of Medicare,,4063.39,,,,100% of Medicare,,4063.39,,,,100% of Medicare,,4063.39,,,,100% of Medicare,,4063.39,,,,100% of Medicare,,4063.39,,,,100% of Medicare,,,4063.39,,,,100% of Medicare,1632.94,,,,EAPG rate,100% of IL Medicaid,1632.94,,,,EAPG rate,100% of IL Medicaid,1632.94,,,,EAPG rate,100% of IL Medicaid,1632.94,,,,EAPG rate,100% of IL Medicaid,1632.94,10567.8,
"Elbow disartic, molded socket with expandable interface, outside locking hinges, forearm",L6205,HCPCS,,,,outpatient,,,12262,7357.2,,45.5,,5579.21,percent of total billed charges,,,45.3,,5554.69,percent of total billed charges,,,39,,4782.18,percent of total billed charges,,,,,,,,,80,,9809.6,percent of total billed charges,,,61.4,,7528.87,percent of total billed charges,,,57.4,,7038.39,percent of total billed charges,,,81,,9932.22,percent of total billed charges,,,39,,4782.18,percent of total billed charges,,,57.6,,7062.91,percent of total billed charges,,,85,,10422.7,percent of total billed charges,,,85,,10422.7,percent of total billed charges,,,49,,6008.38,percent of total billed charges,,,90,,11035.8,percent of total billed charges,,,65,,7970.3,percent of total billed charges,,,80,,9809.6,percent of total billed charges,,,55,,6744.1,percent of total billed charges,,,55,,6744.1,percent of total billed charges,,,65,,7970.3,percent of total billed charges,,,78,,9564.36,percent of total billed charges,,,70,,8583.4,percent of total billed charges,,,,,,,,5447.43,,,,100% of Medicare,,5447.43,,,,100% of Medicare,,5447.43,,,,100% of Medicare,,5447.43,,,,100% of Medicare,,5447.43,,,,100% of Medicare,,5447.43,,,,100% of Medicare,,5447.43,,,,100% of Medicare,,5447.43,,,,100% of Medicare,,5447.43,,,,100% of Medicare,,5447.43,,,,100% of Medicare,,5447.43,,,,100% of Medicare,,5447.43,,,,100% of Medicare,,,5447.43,,,,100% of Medicare,1740.69,,,,EAPG rate,100% of IL Medicaid,1740.69,,,,EAPG rate,100% of IL Medicaid,1740.69,,,,EAPG rate,100% of IL Medicaid,1740.69,,,,EAPG rate,100% of IL Medicaid,1740.69,11035.8,
"AE, molded socket, endo sys, incl soft prosthetic tissue shaping",L6500,HCPCS,,,,outpatient,,,12302,7381.2,,45.5,,5597.41,percent of total billed charges,,,45.3,,5572.81,percent of total billed charges,,,39,,4797.78,percent of total billed charges,,,,,,,,,80,,9841.6,percent of total billed charges,,,61.4,,7553.43,percent of total billed charges,,,57.4,,7061.35,percent of total billed charges,,,81,,9964.62,percent of total billed charges,,,39,,4797.78,percent of total billed charges,,,57.6,,7085.95,percent of total billed charges,,,85,,10456.7,percent of total billed charges,,,85,,10456.7,percent of total billed charges,,,49,,6027.98,percent of total billed charges,,,90,,11071.8,percent of total billed charges,,,65,,7996.3,percent of total billed charges,,,80,,9841.6,percent of total billed charges,,,55,,6766.1,percent of total billed charges,,,55,,6766.1,percent of total billed charges,,,65,,7996.3,percent of total billed charges,,,78,,9595.56,percent of total billed charges,,,70,,8611.4,percent of total billed charges,,,,,,,,4215.93,,,,100% of Medicare,,4215.93,,,,100% of Medicare,,4215.93,,,,100% of Medicare,,4215.93,,,,100% of Medicare,,4215.93,,,,100% of Medicare,,4215.93,,,,100% of Medicare,,4215.93,,,,100% of Medicare,,4215.93,,,,100% of Medicare,,4215.93,,,,100% of Medicare,,4215.93,,,,100% of Medicare,,4215.93,,,,100% of Medicare,,4215.93,,,,100% of Medicare,,,4215.93,,,,100% of Medicare,1748.97,,,,EAPG rate,100% of IL Medicaid,1748.97,,,,EAPG rate,100% of IL Medicaid,1748.97,,,,EAPG rate,100% of IL Medicaid,1748.97,,,,EAPG rate,100% of IL Medicaid,1748.97,11071.8,
"Above knee, molded socket, open end, SACH foot, endoskeletal system, single axis knee",L5321,HCPCS,,,,outpatient,,,12464,7478.4,,45.5,,5671.12,percent of total billed charges,,,45.3,,5646.19,percent of total billed charges,,,39,,4860.96,percent of total billed charges,,,,,,,,,80,,9971.2,percent of total billed charges,,,61.4,,7652.9,percent of total billed charges,,,57.4,,7154.34,percent of total billed charges,,,81,,10095.84,percent of total billed charges,,,39,,4860.96,percent of total billed charges,,,57.6,,7179.26,percent of total billed charges,,,85,,10594.4,percent of total billed charges,,,85,,10594.4,percent of total billed charges,,,49,,6107.36,percent of total billed charges,,,90,,11217.6,percent of total billed charges,,,65,,8101.6,percent of total billed charges,,,80,,9971.2,percent of total billed charges,,,55,,6855.2,percent of total billed charges,,,55,,6855.2,percent of total billed charges,,,65,,8101.6,percent of total billed charges,,,78,,9721.92,percent of total billed charges,,,70,,8724.8,percent of total billed charges,,,,,,,,4312.87,,,,100% of Medicare,,4312.87,,,,100% of Medicare,,4312.87,,,,100% of Medicare,,4312.87,,,,100% of Medicare,,4312.87,,,,100% of Medicare,,4312.87,,,,100% of Medicare,,4312.87,,,,100% of Medicare,,4312.87,,,,100% of Medicare,,4312.87,,,,100% of Medicare,,4312.87,,,,100% of Medicare,,4312.87,,,,100% of Medicare,,4312.87,,,,100% of Medicare,,,4312.87,,,,100% of Medicare,1782.54,,,,EAPG rate,100% of IL Medicaid,1782.54,,,,EAPG rate,100% of IL Medicaid,1782.54,,,,EAPG rate,100% of IL Medicaid,1782.54,,,,EAPG rate,100% of IL Medicaid,1782.54,11217.6,
"All LE prostheses, Flex-Walk system or equal",L5981,HCPCS,,,,outpatient,,,12513,7507.8,,45.5,,5693.42,percent of total billed charges,,,45.3,,5668.39,percent of total billed charges,,,39,,4880.07,percent of total billed charges,,,,,,,,,80,,10010.4,percent of total billed charges,,,61.4,,7682.98,percent of total billed charges,,,57.4,,7182.46,percent of total billed charges,,,81,,10135.53,percent of total billed charges,,,39,,4880.07,percent of total billed charges,,,57.6,,7207.49,percent of total billed charges,,,85,,10636.05,percent of total billed charges,,,85,,10636.05,percent of total billed charges,,,49,,6131.37,percent of total billed charges,,,90,,11261.7,percent of total billed charges,,,65,,8133.45,percent of total billed charges,,,80,,10010.4,percent of total billed charges,,,55,,6882.15,percent of total billed charges,,,55,,6882.15,percent of total billed charges,,,65,,8133.45,percent of total billed charges,,,78,,9760.14,percent of total billed charges,,,70,,8759.1,percent of total billed charges,,,,,,,,4119.22,,,,100% of Medicare,,4119.22,,,,100% of Medicare,,4119.22,,,,100% of Medicare,,4119.22,,,,100% of Medicare,,4119.22,,,,100% of Medicare,,4119.22,,,,100% of Medicare,,4119.22,,,,100% of Medicare,,4119.22,,,,100% of Medicare,,4119.22,,,,100% of Medicare,,4119.22,,,,100% of Medicare,,4119.22,,,,100% of Medicare,,4119.22,,,,100% of Medicare,,,4119.22,,,,100% of Medicare,1792.69,,,,EAPG rate,100% of IL Medicaid,1792.69,,,,EAPG rate,100% of IL Medicaid,1792.69,,,,EAPG rate,100% of IL Medicaid,1792.69,,,,EAPG rate,100% of IL Medicaid,1792.69,11261.7,
"Shoulder disartic, molded socket, endo sys, incl soft prosthetic tissue shaping",L6550,HCPCS,,,,outpatient,,,12601,7560.6,,45.5,,5733.46,percent of total billed charges,,,45.3,,5708.25,percent of total billed charges,,,39,,4914.39,percent of total billed charges,,,,,,,,,80,,10080.8,percent of total billed charges,,,61.4,,7737.01,percent of total billed charges,,,57.4,,7232.97,percent of total billed charges,,,81,,10206.81,percent of total billed charges,,,39,,4914.39,percent of total billed charges,,,57.6,,7258.18,percent of total billed charges,,,85,,10710.85,percent of total billed charges,,,85,,10710.85,percent of total billed charges,,,49,,6174.49,percent of total billed charges,,,90,,11340.9,percent of total billed charges,,,65,,8190.65,percent of total billed charges,,,80,,10080.8,percent of total billed charges,,,55,,6930.55,percent of total billed charges,,,55,,6930.55,percent of total billed charges,,,65,,8190.65,percent of total billed charges,,,78,,9828.78,percent of total billed charges,,,70,,8820.7,percent of total billed charges,,,,,,,,5460.5,,,,100% of Medicare,,5460.5,,,,100% of Medicare,,5460.5,,,,100% of Medicare,,5460.5,,,,100% of Medicare,,5460.5,,,,100% of Medicare,,5460.5,,,,100% of Medicare,,5460.5,,,,100% of Medicare,,5460.5,,,,100% of Medicare,,5460.5,,,,100% of Medicare,,5460.5,,,,100% of Medicare,,5460.5,,,,100% of Medicare,,5460.5,,,,100% of Medicare,,,5460.5,,,,100% of Medicare,1810.93,,,,EAPG rate,100% of IL Medicaid,1810.93,,,,EAPG rate,100% of IL Medicaid,1810.93,,,,EAPG rate,100% of IL Medicaid,1810.93,,,,EAPG rate,100% of IL Medicaid,1810.93,11340.9,
"Knee disarticulation, molded socket, bent knee configuration, external knee joints, shin, SACH foot",L5160,HCPCS,,,,outpatient,,,12638,7582.8,,45.5,,5750.29,percent of total billed charges,,,45.3,,5725.01,percent of total billed charges,,,39,,4928.82,percent of total billed charges,,,,,,,,,80,,10110.4,percent of total billed charges,,,61.4,,7759.73,percent of total billed charges,,,57.4,,7254.21,percent of total billed charges,,,81,,10236.78,percent of total billed charges,,,39,,4928.82,percent of total billed charges,,,57.6,,7279.49,percent of total billed charges,,,85,,10742.3,percent of total billed charges,,,85,,10742.3,percent of total billed charges,,,49,,6192.62,percent of total billed charges,,,90,,11374.2,percent of total billed charges,,,65,,8214.7,percent of total billed charges,,,80,,10110.4,percent of total billed charges,,,55,,6950.9,percent of total billed charges,,,55,,6950.9,percent of total billed charges,,,65,,8214.7,percent of total billed charges,,,78,,9857.64,percent of total billed charges,,,70,,8846.6,percent of total billed charges,,,,,,,,5673.77,,,,100% of Medicare,,5673.77,,,,100% of Medicare,,5673.77,,,,100% of Medicare,,5673.77,,,,100% of Medicare,,5673.77,,,,100% of Medicare,,5673.77,,,,100% of Medicare,,5673.77,,,,100% of Medicare,,5673.77,,,,100% of Medicare,,5673.77,,,,100% of Medicare,,5673.77,,,,100% of Medicare,,5673.77,,,,100% of Medicare,,5673.77,,,,100% of Medicare,,,5673.77,,,,100% of Medicare,1818.59,,,,EAPG rate,100% of IL Medicaid,1818.59,,,,EAPG rate,100% of IL Medicaid,1818.59,,,,EAPG rate,100% of IL Medicaid,1818.59,,,,EAPG rate,100% of IL Medicaid,1818.59,11374.2,
"Electric hand, switch or myo, adult",L7007,HCPCS,,,,outpatient,,,13453,8071.8,,45.5,,6121.12,percent of total billed charges,,,45.3,,6094.21,percent of total billed charges,,,39,,5246.67,percent of total billed charges,,,,,,,,,80,,10762.4,percent of total billed charges,,,61.4,,8260.14,percent of total billed charges,,,57.4,,7722.02,percent of total billed charges,,,81,,10896.93,percent of total billed charges,,,39,,5246.67,percent of total billed charges,,,57.6,,7748.93,percent of total billed charges,,,85,,11435.05,percent of total billed charges,,,85,,11435.05,percent of total billed charges,,,49,,6591.97,percent of total billed charges,,,90,,12107.7,percent of total billed charges,,,65,,8744.45,percent of total billed charges,,,80,,10762.4,percent of total billed charges,,,55,,7399.15,percent of total billed charges,,,55,,7399.15,percent of total billed charges,,,65,,8744.45,percent of total billed charges,,,78,,10493.34,percent of total billed charges,,,70,,9417.1,percent of total billed charges,,,,,,,,4409.36,,,,100% of Medicare,,4409.36,,,,100% of Medicare,,4409.36,,,,100% of Medicare,,4409.36,,,,100% of Medicare,,4409.36,,,,100% of Medicare,,4409.36,,,,100% of Medicare,,4409.36,,,,100% of Medicare,,4409.36,,,,100% of Medicare,,4409.36,,,,100% of Medicare,,4409.36,,,,100% of Medicare,,4409.36,,,,100% of Medicare,,4409.36,,,,100% of Medicare,,,4409.36,,,,100% of Medicare,1821.38,,,,EAPG rate,100% of IL Medicaid,1821.38,,,,EAPG rate,100% of IL Medicaid,1821.38,,,,EAPG rate,100% of IL Medicaid,1821.38,,,,EAPG rate,100% of IL Medicaid,1821.38,12107.7,
"Above knee, molded socket, single axis constant friction knee, shin, SACH foot (EXO)",L5200,HCPCS,,,,outpatient,,,12678,7606.8,,45.5,,5768.49,percent of total billed charges,,,45.3,,5743.13,percent of total billed charges,,,39,,4944.42,percent of total billed charges,,,,,,,,,80,,10142.4,percent of total billed charges,,,61.4,,7784.29,percent of total billed charges,,,57.4,,7277.17,percent of total billed charges,,,81,,10269.18,percent of total billed charges,,,39,,4944.42,percent of total billed charges,,,57.6,,7302.53,percent of total billed charges,,,85,,10776.3,percent of total billed charges,,,85,,10776.3,percent of total billed charges,,,49,,6212.22,percent of total billed charges,,,90,,11410.2,percent of total billed charges,,,65,,8240.7,percent of total billed charges,,,80,,10142.4,percent of total billed charges,,,55,,6972.9,percent of total billed charges,,,55,,6972.9,percent of total billed charges,,,65,,8240.7,percent of total billed charges,,,78,,9888.84,percent of total billed charges,,,70,,8874.6,percent of total billed charges,,,,,,,,4388.25,,,,100% of Medicare,,4388.25,,,,100% of Medicare,,4388.25,,,,100% of Medicare,,4388.25,,,,100% of Medicare,,4388.25,,,,100% of Medicare,,4388.25,,,,100% of Medicare,,4388.25,,,,100% of Medicare,,4388.25,,,,100% of Medicare,,4388.25,,,,100% of Medicare,,4388.25,,,,100% of Medicare,,4388.25,,,,100% of Medicare,,4388.25,,,,100% of Medicare,,,4388.25,,,,100% of Medicare,1826.88,,,,EAPG rate,100% of IL Medicaid,1826.88,,,,EAPG rate,100% of IL Medicaid,1826.88,,,,EAPG rate,100% of IL Medicaid,1826.88,,,,EAPG rate,100% of IL Medicaid,1826.88,11410.2,
"Replacement, socket, AK/knee disartic, incl attachment plate, molded to",L5701,HCPCS,,,,outpatient,,,13272,7963.2,,45.5,,6038.76,percent of total billed charges,,,45.3,,6012.22,percent of total billed charges,,,39,,5176.08,percent of total billed charges,,,,,,,,,80,,10617.6,percent of total billed charges,,,61.4,,8149.01,percent of total billed charges,,,57.4,,7618.13,percent of total billed charges,,,81,,10750.32,percent of total billed charges,,,39,,5176.08,percent of total billed charges,,,57.6,,7644.67,percent of total billed charges,,,85,,11281.2,percent of total billed charges,,,85,,11281.2,percent of total billed charges,,,49,,6503.28,percent of total billed charges,,,90,,11944.8,percent of total billed charges,,,65,,8626.8,percent of total billed charges,,,80,,10617.6,percent of total billed charges,,,55,,7299.6,percent of total billed charges,,,55,,7299.6,percent of total billed charges,,,65,,8626.8,percent of total billed charges,,,78,,10352.16,percent of total billed charges,,,70,,9290.4,percent of total billed charges,,,,,,,,4593.82,,,,100% of Medicare,,4593.82,,,,100% of Medicare,,4593.82,,,,100% of Medicare,,4593.82,,,,100% of Medicare,,4593.82,,,,100% of Medicare,,4593.82,,,,100% of Medicare,,4593.82,,,,100% of Medicare,,4593.82,,,,100% of Medicare,,4593.82,,,,100% of Medicare,,4593.82,,,,100% of Medicare,,4593.82,,,,100% of Medicare,,4593.82,,,,100% of Medicare,,,4593.82,,,,100% of Medicare,1949.96,,,,EAPG rate,100% of IL Medicaid,1949.96,,,,EAPG rate,100% of IL Medicaid,1949.96,,,,EAPG rate,100% of IL Medicaid,1949.96,,,,EAPG rate,100% of IL Medicaid,1949.96,11944.8,
Electronic Wrist Rotator Any,L7259,HCPCS,,,,outpatient,,,13302,7981.2,,45.5,,6052.41,percent of total billed charges,,,45.3,,6025.81,percent of total billed charges,,,39,,5187.78,percent of total billed charges,,,,,,,,,80,,10641.6,percent of total billed charges,,,61.4,,8167.43,percent of total billed charges,,,57.4,,7635.35,percent of total billed charges,,,81,,10774.62,percent of total billed charges,,,39,,5187.78,percent of total billed charges,,,57.6,,7661.95,percent of total billed charges,,,85,,11306.7,percent of total billed charges,,,85,,11306.7,percent of total billed charges,,,49,,6517.98,percent of total billed charges,,,90,,11971.8,percent of total billed charges,,,65,,8646.3,percent of total billed charges,,,80,,10641.6,percent of total billed charges,,,55,,7316.1,percent of total billed charges,,,55,,7316.1,percent of total billed charges,,,65,,8646.3,percent of total billed charges,,,78,,10375.56,percent of total billed charges,,,70,,9311.4,percent of total billed charges,,,,,,,,4947.46,,,,100% of Medicare,,4947.46,,,,100% of Medicare,,4947.46,,,,100% of Medicare,,4947.46,,,,100% of Medicare,,4947.46,,,,100% of Medicare,,4947.46,,,,100% of Medicare,,4947.46,,,,100% of Medicare,,4947.46,,,,100% of Medicare,,4947.46,,,,100% of Medicare,,4947.46,,,,100% of Medicare,,4947.46,,,,100% of Medicare,,4947.46,,,,100% of Medicare,,,4947.46,,,,100% of Medicare,1956.17,,,,EAPG rate,100% of IL Medicaid,1956.17,,,,EAPG rate,100% of IL Medicaid,1956.17,,,,EAPG rate,100% of IL Medicaid,1956.17,,,,EAPG rate,100% of IL Medicaid,1956.17,11971.8,
"Interscapular thoracic, molded socket, shoulder bulkhead, humeral sect, internal lock elbow, forearm",L6350,HCPCS,,,,outpatient,,,13408,8044.8,,45.5,,6100.64,percent of total billed charges,,,45.3,,6073.82,percent of total billed charges,,,39,,5229.12,percent of total billed charges,,,,,,,,,80,,10726.4,percent of total billed charges,,,61.4,,8232.51,percent of total billed charges,,,57.4,,7696.19,percent of total billed charges,,,81,,10860.48,percent of total billed charges,,,39,,5229.12,percent of total billed charges,,,57.6,,7723.01,percent of total billed charges,,,85,,11396.8,percent of total billed charges,,,85,,11396.8,percent of total billed charges,,,49,,6569.92,percent of total billed charges,,,90,,12067.2,percent of total billed charges,,,65,,8715.2,percent of total billed charges,,,80,,10726.4,percent of total billed charges,,,55,,7374.4,percent of total billed charges,,,55,,7374.4,percent of total billed charges,,,65,,8715.2,percent of total billed charges,,,78,,10458.24,percent of total billed charges,,,70,,9385.6,percent of total billed charges,,,,,,,,5871.29,,,,100% of Medicare,,5871.29,,,,100% of Medicare,,5871.29,,,,100% of Medicare,,5871.29,,,,100% of Medicare,,5871.29,,,,100% of Medicare,,5871.29,,,,100% of Medicare,,5871.29,,,,100% of Medicare,,5871.29,,,,100% of Medicare,,5871.29,,,,100% of Medicare,,5871.29,,,,100% of Medicare,,5871.29,,,,100% of Medicare,,5871.29,,,,100% of Medicare,,,5871.29,,,,100% of Medicare,1978.14,,,,EAPG rate,100% of IL Medicaid,1978.14,,,,EAPG rate,100% of IL Medicaid,1978.14,,,,EAPG rate,100% of IL Medicaid,1978.14,,,,EAPG rate,100% of IL Medicaid,1978.14,12067.2,
"Below knee, plastic socket, joints and thigh lacer, SACH foot",L5105,HCPCS,,,,outpatient,,,13428,8056.8,,45.5,,6109.74,percent of total billed charges,,,45.3,,6082.88,percent of total billed charges,,,39,,5236.92,percent of total billed charges,,,,,,,,,80,,10742.4,percent of total billed charges,,,61.4,,8244.79,percent of total billed charges,,,57.4,,7707.67,percent of total billed charges,,,81,,10876.68,percent of total billed charges,,,39,,5236.92,percent of total billed charges,,,57.6,,7734.53,percent of total billed charges,,,85,,11413.8,percent of total billed charges,,,85,,11413.8,percent of total billed charges,,,49,,6579.72,percent of total billed charges,,,90,,12085.2,percent of total billed charges,,,65,,8728.2,percent of total billed charges,,,80,,10742.4,percent of total billed charges,,,55,,7385.4,percent of total billed charges,,,55,,7385.4,percent of total billed charges,,,65,,8728.2,percent of total billed charges,,,78,,10473.84,percent of total billed charges,,,70,,9399.6,percent of total billed charges,,,,,,,,4648.11,,,,100% of Medicare,,4648.11,,,,100% of Medicare,,4648.11,,,,100% of Medicare,,4648.11,,,,100% of Medicare,,4648.11,,,,100% of Medicare,,4648.11,,,,100% of Medicare,,4648.11,,,,100% of Medicare,,4648.11,,,,100% of Medicare,,4648.11,,,,100% of Medicare,,4648.11,,,,100% of Medicare,,4648.11,,,,100% of Medicare,,4648.11,,,,100% of Medicare,,,4648.11,,,,100% of Medicare,1982.28,,,,EAPG rate,100% of IL Medicaid,1982.28,,,,EAPG rate,100% of IL Medicaid,1982.28,,,,EAPG rate,100% of IL Medicaid,1982.28,,,,EAPG rate,100% of IL Medicaid,1982.28,12085.2,
"Electric hook, switch or myo, adult",L7009,HCPCS,,,,outpatient,,,13163,7897.8,,45.5,,5989.17,percent of total billed charges,,,45.3,,5962.84,percent of total billed charges,,,39,,5133.57,percent of total billed charges,,,,,,,,,80,,10530.4,percent of total billed charges,,,61.4,,8082.08,percent of total billed charges,,,57.4,,7555.56,percent of total billed charges,,,81,,10662.03,percent of total billed charges,,,39,,5133.57,percent of total billed charges,,,57.6,,7581.89,percent of total billed charges,,,85,,11188.55,percent of total billed charges,,,85,,11188.55,percent of total billed charges,,,49,,6449.87,percent of total billed charges,,,90,,11846.7,percent of total billed charges,,,65,,8555.95,percent of total billed charges,,,80,,10530.4,percent of total billed charges,,,55,,7239.65,percent of total billed charges,,,55,,7239.65,percent of total billed charges,,,65,,8555.95,percent of total billed charges,,,78,,10267.14,percent of total billed charges,,,70,,9214.1,percent of total billed charges,,,,,,,,4511.3,,,,100% of Medicare,,4511.3,,,,100% of Medicare,,4511.3,,,,100% of Medicare,,4511.3,,,,100% of Medicare,,4511.3,,,,100% of Medicare,,4511.3,,,,100% of Medicare,,4511.3,,,,100% of Medicare,,4511.3,,,,100% of Medicare,,4511.3,,,,100% of Medicare,,4511.3,,,,100% of Medicare,,4511.3,,,,100% of Medicare,,4511.3,,,,100% of Medicare,,,4511.3,,,,100% of Medicare,1987.46,,,,EAPG rate,100% of IL Medicaid,1987.46,,,,EAPG rate,100% of IL Medicaid,1987.46,,,,EAPG rate,100% of IL Medicaid,1987.46,,,,EAPG rate,100% of IL Medicaid,1987.46,11846.7,
"Replacement, socket, hip disartic, incl hip joint, molded to",L5702,HCPCS,,,,outpatient,,,13527,8116.2,,45.5,,6154.79,percent of total billed charges,,,45.3,,6127.73,percent of total billed charges,,,39,,5275.53,percent of total billed charges,,,,,,,,,80,,10821.6,percent of total billed charges,,,61.4,,8305.58,percent of total billed charges,,,57.4,,7764.5,percent of total billed charges,,,81,,10956.87,percent of total billed charges,,,39,,5275.53,percent of total billed charges,,,57.6,,7791.55,percent of total billed charges,,,85,,11497.95,percent of total billed charges,,,85,,11497.95,percent of total billed charges,,,49,,6628.23,percent of total billed charges,,,90,,12174.3,percent of total billed charges,,,65,,8792.55,percent of total billed charges,,,80,,10821.6,percent of total billed charges,,,55,,7439.85,percent of total billed charges,,,55,,7439.85,percent of total billed charges,,,65,,8792.55,percent of total billed charges,,,78,,10551.06,percent of total billed charges,,,70,,9468.9,percent of total billed charges,,,,,,,,5789.81,,,,100% of Medicare,,5789.81,,,,100% of Medicare,,5789.81,,,,100% of Medicare,,5789.81,,,,100% of Medicare,,5789.81,,,,100% of Medicare,,5789.81,,,,100% of Medicare,,5789.81,,,,100% of Medicare,,5789.81,,,,100% of Medicare,,5789.81,,,,100% of Medicare,,5789.81,,,,100% of Medicare,,5789.81,,,,100% of Medicare,,5789.81,,,,100% of Medicare,,,5789.81,,,,100% of Medicare,2002.79,,,,EAPG rate,100% of IL Medicaid,2002.79,,,,EAPG rate,100% of IL Medicaid,2002.79,,,,EAPG rate,100% of IL Medicaid,2002.79,,,,EAPG rate,100% of IL Medicaid,2002.79,12174.3,
"Knee disartic (or through knee), molded socket, external knee joints, shin, SACH foot (EXO)",L5150,HCPCS,,,,outpatient,,,13598,8158.8,,45.5,,6187.09,percent of total billed charges,,,45.3,,6159.89,percent of total billed charges,,,39,,5303.22,percent of total billed charges,,,,,,,,,80,,10878.4,percent of total billed charges,,,61.4,,8349.17,percent of total billed charges,,,57.4,,7805.25,percent of total billed charges,,,81,,11014.38,percent of total billed charges,,,39,,5303.22,percent of total billed charges,,,57.6,,7832.45,percent of total billed charges,,,85,,11558.3,percent of total billed charges,,,85,,11558.3,percent of total billed charges,,,49,,6663.02,percent of total billed charges,,,90,,12238.2,percent of total billed charges,,,65,,8838.7,percent of total billed charges,,,80,,10878.4,percent of total billed charges,,,55,,7478.9,percent of total billed charges,,,55,,7478.9,percent of total billed charges,,,65,,8838.7,percent of total billed charges,,,78,,10606.44,percent of total billed charges,,,70,,9518.6,percent of total billed charges,,,,,,,,5167.59,,,,100% of Medicare,,5167.59,,,,100% of Medicare,,5167.59,,,,100% of Medicare,,5167.59,,,,100% of Medicare,,5167.59,,,,100% of Medicare,,5167.59,,,,100% of Medicare,,5167.59,,,,100% of Medicare,,5167.59,,,,100% of Medicare,,5167.59,,,,100% of Medicare,,5167.59,,,,100% of Medicare,,5167.59,,,,100% of Medicare,,5167.59,,,,100% of Medicare,,,5167.59,,,,100% of Medicare,2017.51,,,,EAPG rate,100% of IL Medicaid,2017.51,,,,EAPG rate,100% of IL Medicaid,2017.51,,,,EAPG rate,100% of IL Medicaid,2017.51,,,,EAPG rate,100% of IL Medicaid,2017.51,12238.2,
"Addition, endo knee-shin sys, 4-bar linkage or multiaxial pneumatic swing",L5840,HCPCS,,,,outpatient,,,13602,8161.2,,45.5,,6188.91,percent of total billed charges,,,45.3,,6161.71,percent of total billed charges,,,39,,5304.78,percent of total billed charges,,,,,,,,,80,,10881.6,percent of total billed charges,,,61.4,,8351.63,percent of total billed charges,,,57.4,,7807.55,percent of total billed charges,,,81,,11017.62,percent of total billed charges,,,39,,5304.78,percent of total billed charges,,,57.6,,7834.75,percent of total billed charges,,,85,,11561.7,percent of total billed charges,,,85,,11561.7,percent of total billed charges,,,49,,6664.98,percent of total billed charges,,,90,,12241.8,percent of total billed charges,,,65,,8841.3,percent of total billed charges,,,80,,10881.6,percent of total billed charges,,,55,,7481.1,percent of total billed charges,,,55,,7481.1,percent of total billed charges,,,65,,8841.3,percent of total billed charges,,,78,,10609.56,percent of total billed charges,,,70,,9521.4,percent of total billed charges,,,,,,,,4707.8,,,,100% of Medicare,,4707.8,,,,100% of Medicare,,4707.8,,,,100% of Medicare,,4707.8,,,,100% of Medicare,,4707.8,,,,100% of Medicare,,4707.8,,,,100% of Medicare,,4707.8,,,,100% of Medicare,,4707.8,,,,100% of Medicare,,4707.8,,,,100% of Medicare,,4707.8,,,,100% of Medicare,,4707.8,,,,100% of Medicare,,4707.8,,,,100% of Medicare,,,4707.8,,,,100% of Medicare,2018.33,,,,EAPG rate,100% of IL Medicaid,2018.33,,,,EAPG rate,100% of IL Medicaid,2018.33,,,,EAPG rate,100% of IL Medicaid,2018.33,,,,EAPG rate,100% of IL Medicaid,2018.33,12241.8,
"KNEE DISART, SACH FT, ENDO (L5312)",L5312,HCPCS,,,,outpatient,,,13631,8178.6,,45.5,,6202.11,percent of total billed charges,,,45.3,,6174.84,percent of total billed charges,,,39,,5316.09,percent of total billed charges,,,,,,,,,80,,10904.8,percent of total billed charges,,,61.4,,8369.43,percent of total billed charges,,,57.4,,7824.19,percent of total billed charges,,,81,,11041.11,percent of total billed charges,,,39,,5316.09,percent of total billed charges,,,57.6,,7851.46,percent of total billed charges,,,85,,11586.35,percent of total billed charges,,,85,,11586.35,percent of total billed charges,,,49,,6679.19,percent of total billed charges,,,90,,12267.9,percent of total billed charges,,,65,,8860.15,percent of total billed charges,,,80,,10904.8,percent of total billed charges,,,55,,7497.05,percent of total billed charges,,,55,,7497.05,percent of total billed charges,,,65,,8860.15,percent of total billed charges,,,78,,10632.18,percent of total billed charges,,,70,,9541.7,percent of total billed charges,,,,,,,,5095.91,,,,100% of Medicare,,5095.91,,,,100% of Medicare,,5095.91,,,,100% of Medicare,,5095.91,,,,100% of Medicare,,5095.91,,,,100% of Medicare,,5095.91,,,,100% of Medicare,,5095.91,,,,100% of Medicare,,5095.91,,,,100% of Medicare,,5095.91,,,,100% of Medicare,,5095.91,,,,100% of Medicare,,5095.91,,,,100% of Medicare,,5095.91,,,,100% of Medicare,,,5095.91,,,,100% of Medicare,2024.34,,,,EAPG rate,100% of IL Medicaid,2024.34,,,,EAPG rate,100% of IL Medicaid,2024.34,,,,EAPG rate,100% of IL Medicaid,2024.34,,,,EAPG rate,100% of IL Medicaid,2024.34,12267.9,
"L6570 Shoulder disartic, molded socket, endo sys, incl soft prosthetic tissue shaping",L6570,HCPCS,,,,outpatient,,,13809,8285.4,,45.5,,6283.1,percent of total billed charges,,,45.3,,6255.48,percent of total billed charges,,,39,,5385.51,percent of total billed charges,,,,,,,,,80,,11047.2,percent of total billed charges,,,61.4,,8478.73,percent of total billed charges,,,57.4,,7926.37,percent of total billed charges,,,81,,11185.29,percent of total billed charges,,,39,,5385.51,percent of total billed charges,,,57.6,,7953.98,percent of total billed charges,,,85,,11737.65,percent of total billed charges,,,85,,11737.65,percent of total billed charges,,,49,,6766.41,percent of total billed charges,,,90,,12428.1,percent of total billed charges,,,65,,8975.85,percent of total billed charges,,,80,,11047.2,percent of total billed charges,,,55,,7594.95,percent of total billed charges,,,55,,7594.95,percent of total billed charges,,,65,,8975.85,percent of total billed charges,,,78,,10771.02,percent of total billed charges,,,70,,9666.3,percent of total billed charges,,,,,,,,6095.93,,,,100% of Medicare,,6095.93,,,,100% of Medicare,,6095.93,,,,100% of Medicare,,6095.93,,,,100% of Medicare,,6095.93,,,,100% of Medicare,,6095.93,,,,100% of Medicare,,6095.93,,,,100% of Medicare,,6095.93,,,,100% of Medicare,,6095.93,,,,100% of Medicare,,6095.93,,,,100% of Medicare,,6095.93,,,,100% of Medicare,,6095.93,,,,100% of Medicare,,,6095.93,,,,100% of Medicare,2061.22,,,,EAPG rate,100% of IL Medicaid,2061.22,,,,EAPG rate,100% of IL Medicaid,2061.22,,,,EAPG rate,100% of IL Medicaid,2061.22,,,,EAPG rate,100% of IL Medicaid,2061.22,12428.1,
"All LE prostheses, Flex-Foot system",L5980,HCPCS,,,,outpatient,,,13928,8356.8,,45.5,,6337.24,percent of total billed charges,,,45.3,,6309.38,percent of total billed charges,,,39,,5431.92,percent of total billed charges,,,,,,,,,80,,11142.4,percent of total billed charges,,,61.4,,8551.79,percent of total billed charges,,,57.4,,7994.67,percent of total billed charges,,,81,,11281.68,percent of total billed charges,,,39,,5431.92,percent of total billed charges,,,57.6,,8022.53,percent of total billed charges,,,85,,11838.8,percent of total billed charges,,,85,,11838.8,percent of total billed charges,,,49,,6824.72,percent of total billed charges,,,90,,12535.2,percent of total billed charges,,,65,,9053.2,percent of total billed charges,,,80,,11142.4,percent of total billed charges,,,55,,7660.4,percent of total billed charges,,,55,,7660.4,percent of total billed charges,,,65,,9053.2,percent of total billed charges,,,78,,10863.84,percent of total billed charges,,,70,,9749.6,percent of total billed charges,,,,,,,,4585.87,,,,100% of Medicare,,4585.87,,,,100% of Medicare,,4585.87,,,,100% of Medicare,,4585.87,,,,100% of Medicare,,4585.87,,,,100% of Medicare,,4585.87,,,,100% of Medicare,,4585.87,,,,100% of Medicare,,4585.87,,,,100% of Medicare,,4585.87,,,,100% of Medicare,,4585.87,,,,100% of Medicare,,4585.87,,,,100% of Medicare,,4585.87,,,,100% of Medicare,,,4585.87,,,,100% of Medicare,2085.88,,,,EAPG rate,100% of IL Medicaid,2085.88,,,,EAPG rate,100% of IL Medicaid,2085.88,,,,EAPG rate,100% of IL Medicaid,2085.88,,,,EAPG rate,100% of IL Medicaid,2085.88,12535.2,
"Addition, endo knee-shin sys, polycentric, hydraulic swing, mechanical stance phase lock",L5814,HCPCS,,,,outpatient,,,14031,8418.6,,45.5,,6384.11,percent of total billed charges,,,45.3,,6356.04,percent of total billed charges,,,39,,5472.09,percent of total billed charges,,,,,,,,,80,,11224.8,percent of total billed charges,,,61.4,,8615.03,percent of total billed charges,,,57.4,,8053.79,percent of total billed charges,,,81,,11365.11,percent of total billed charges,,,39,,5472.09,percent of total billed charges,,,57.6,,8081.86,percent of total billed charges,,,85,,11926.35,percent of total billed charges,,,85,,11926.35,percent of total billed charges,,,49,,6875.19,percent of total billed charges,,,90,,12627.9,percent of total billed charges,,,65,,9120.15,percent of total billed charges,,,80,,11224.8,percent of total billed charges,,,55,,7717.05,percent of total billed charges,,,55,,7717.05,percent of total billed charges,,,65,,9120.15,percent of total billed charges,,,78,,10944.18,percent of total billed charges,,,70,,9821.7,percent of total billed charges,,,,,,,,4483.45,,,,100% of Medicare,,4483.45,,,,100% of Medicare,,4483.45,,,,100% of Medicare,,4483.45,,,,100% of Medicare,,4483.45,,,,100% of Medicare,,4483.45,,,,100% of Medicare,,4483.45,,,,100% of Medicare,,4483.45,,,,100% of Medicare,,4483.45,,,,100% of Medicare,,4483.45,,,,100% of Medicare,,4483.45,,,,100% of Medicare,,4483.45,,,,100% of Medicare,,,4483.45,,,,100% of Medicare,2107.22,,,,EAPG rate,100% of IL Medicaid,2107.22,,,,EAPG rate,100% of IL Medicaid,2107.22,,,,EAPG rate,100% of IL Medicaid,2107.22,,,,EAPG rate,100% of IL Medicaid,2107.22,12627.9,
PART HAND MYO EXCLU TERM DEV (L6026),L6026,HCPCS,,,,outpatient,,,14282,8569.2,,45.5,,6498.31,percent of total billed charges,,,45.3,,6469.75,percent of total billed charges,,,39,,5569.98,percent of total billed charges,,,,,,,,,80,,11425.6,percent of total billed charges,,,61.4,,8769.15,percent of total billed charges,,,57.4,,8197.87,percent of total billed charges,,,81,,11568.42,percent of total billed charges,,,39,,5569.98,percent of total billed charges,,,57.6,,8226.43,percent of total billed charges,,,85,,12139.7,percent of total billed charges,,,85,,12139.7,percent of total billed charges,,,49,,6998.18,percent of total billed charges,,,90,,12853.8,percent of total billed charges,,,65,,9283.3,percent of total billed charges,,,80,,11425.6,percent of total billed charges,,,55,,7855.1,percent of total billed charges,,,55,,7855.1,percent of total billed charges,,,65,,9283.3,percent of total billed charges,,,78,,11139.96,percent of total billed charges,,,70,,9997.4,percent of total billed charges,,,,,,,,5251.23,,,,100% of Medicare,,5251.23,,,,100% of Medicare,,5251.23,,,,100% of Medicare,,5251.23,,,,100% of Medicare,,5251.23,,,,100% of Medicare,,5251.23,,,,100% of Medicare,,5251.23,,,,100% of Medicare,,5251.23,,,,100% of Medicare,,5251.23,,,,100% of Medicare,,5251.23,,,,100% of Medicare,,5251.23,,,,100% of Medicare,,5251.23,,,,100% of Medicare,,,5251.23,,,,100% of Medicare,2159.23,,,,EAPG rate,100% of IL Medicaid,2159.23,,,,EAPG rate,100% of IL Medicaid,2159.23,,,,EAPG rate,100% of IL Medicaid,2159.23,,,,EAPG rate,100% of IL Medicaid,2159.23,12853.8,
"Addition, vacuum pump, residual limb volume management and moisture evac sys",L5781,HCPCS,,,,outpatient,,,14671,8802.6,,45.5,,6675.31,percent of total billed charges,,,45.3,,6645.96,percent of total billed charges,,,39,,5721.69,percent of total billed charges,,,,,,,,,80,,11736.8,percent of total billed charges,,,61.4,,9007.99,percent of total billed charges,,,57.4,,8421.15,percent of total billed charges,,,81,,11883.51,percent of total billed charges,,,39,,5721.69,percent of total billed charges,,,57.6,,8450.5,percent of total billed charges,,,85,,12470.35,percent of total billed charges,,,85,,12470.35,percent of total billed charges,,,49,,7188.79,percent of total billed charges,,,90,,13203.9,percent of total billed charges,,,65,,9536.15,percent of total billed charges,,,80,,11736.8,percent of total billed charges,,,55,,8069.05,percent of total billed charges,,,55,,8069.05,percent of total billed charges,,,65,,9536.15,percent of total billed charges,,,78,,11443.38,percent of total billed charges,,,70,,10269.7,percent of total billed charges,,,,,,,,4830.29,,,,100% of Medicare,,4830.29,,,,100% of Medicare,,4830.29,,,,100% of Medicare,,4830.29,,,,100% of Medicare,,4830.29,,,,100% of Medicare,,4830.29,,,,100% of Medicare,,4830.29,,,,100% of Medicare,,4830.29,,,,100% of Medicare,,4830.29,,,,100% of Medicare,,4830.29,,,,100% of Medicare,,4830.29,,,,100% of Medicare,,4830.29,,,,100% of Medicare,,,4830.29,,,,100% of Medicare,2239.83,,,,EAPG rate,100% of IL Medicaid,2239.83,,,,EAPG rate,100% of IL Medicaid,2239.83,,,,EAPG rate,100% of IL Medicaid,2239.83,,,,EAPG rate,100% of IL Medicaid,2239.83,13203.9,
"Addition, vacuum pump, residual limb volume management and moisture evac system, heavy duty",L5782,HCPCS,,,,outpatient,,,14710,8826,,45.5,,6693.05,percent of total billed charges,,,45.3,,6663.63,percent of total billed charges,,,39,,5736.9,percent of total billed charges,,,,,,,,,80,,11768,percent of total billed charges,,,61.4,,9031.94,percent of total billed charges,,,57.4,,8443.54,percent of total billed charges,,,81,,11915.1,percent of total billed charges,,,39,,5736.9,percent of total billed charges,,,57.6,,8472.96,percent of total billed charges,,,85,,12503.5,percent of total billed charges,,,85,,12503.5,percent of total billed charges,,,49,,7207.9,percent of total billed charges,,,90,,13239,percent of total billed charges,,,65,,9561.5,percent of total billed charges,,,80,,11768,percent of total billed charges,,,55,,8090.5,percent of total billed charges,,,55,,8090.5,percent of total billed charges,,,65,,9561.5,percent of total billed charges,,,78,,11473.8,percent of total billed charges,,,70,,10297,percent of total billed charges,,,,,,,,5092.22,,,,100% of Medicare,,5092.22,,,,100% of Medicare,,5092.22,,,,100% of Medicare,,5092.22,,,,100% of Medicare,,5092.22,,,,100% of Medicare,,5092.22,,,,100% of Medicare,,5092.22,,,,100% of Medicare,,5092.22,,,,100% of Medicare,,5092.22,,,,100% of Medicare,,5092.22,,,,100% of Medicare,,5092.22,,,,100% of Medicare,,5092.22,,,,100% of Medicare,,,5092.22,,,,100% of Medicare,2247.91,,,,EAPG rate,100% of IL Medicaid,2247.91,,,,EAPG rate,100% of IL Medicaid,2247.91,,,,EAPG rate,100% of IL Medicaid,2247.91,,,,EAPG rate,100% of IL Medicaid,2247.91,13239,
"Hip disartic, Canadian type; molded socket, hip jt, single axis constant friction knee, shin, SACH f",L5250,HCPCS,,,,outpatient,,,15039,9023.4,,45.5,,6842.75,percent of total billed charges,,,45.3,,6812.67,percent of total billed charges,,,39,,5865.21,percent of total billed charges,,,,,,,,,80,,12031.2,percent of total billed charges,,,61.4,,9233.95,percent of total billed charges,,,57.4,,8632.39,percent of total billed charges,,,81,,12181.59,percent of total billed charges,,,39,,5865.21,percent of total billed charges,,,57.6,,8662.46,percent of total billed charges,,,85,,12783.15,percent of total billed charges,,,85,,12783.15,percent of total billed charges,,,49,,7369.11,percent of total billed charges,,,90,,13535.1,percent of total billed charges,,,65,,9775.35,percent of total billed charges,,,80,,12031.2,percent of total billed charges,,,55,,8271.45,percent of total billed charges,,,55,,8271.45,percent of total billed charges,,,65,,9775.35,percent of total billed charges,,,78,,11730.42,percent of total billed charges,,,70,,10527.3,percent of total billed charges,,,,,,,,6749.81,,,,100% of Medicare,,6749.81,,,,100% of Medicare,,6749.81,,,,100% of Medicare,,6749.81,,,,100% of Medicare,,6749.81,,,,100% of Medicare,,6749.81,,,,100% of Medicare,,6749.81,,,,100% of Medicare,,6749.81,,,,100% of Medicare,,6749.81,,,,100% of Medicare,,6749.81,,,,100% of Medicare,,6749.81,,,,100% of Medicare,,6749.81,,,,100% of Medicare,,,6749.81,,,,100% of Medicare,2316.08,,,,EAPG rate,100% of IL Medicaid,2316.08,,,,EAPG rate,100% of IL Medicaid,2316.08,,,,EAPG rate,100% of IL Medicaid,2316.08,,,,EAPG rate,100% of IL Medicaid,2316.08,13535.1,
"Hemipel, Canadian type; molded socket, endo system, hip jt, single axis knee, SACH foot",L5341,HCPCS,,,,outpatient,,,15062,9037.2,,45.5,,6853.21,percent of total billed charges,,,45.3,,6823.09,percent of total billed charges,,,39,,5874.18,percent of total billed charges,,,,,,,,,80,,12049.6,percent of total billed charges,,,61.4,,9248.07,percent of total billed charges,,,57.4,,8645.59,percent of total billed charges,,,81,,12200.22,percent of total billed charges,,,39,,5874.18,percent of total billed charges,,,57.6,,8675.71,percent of total billed charges,,,85,,12802.7,percent of total billed charges,,,85,,12802.7,percent of total billed charges,,,49,,7380.38,percent of total billed charges,,,90,,13555.8,percent of total billed charges,,,65,,9790.3,percent of total billed charges,,,80,,12049.6,percent of total billed charges,,,55,,8284.1,percent of total billed charges,,,55,,8284.1,percent of total billed charges,,,65,,9790.3,percent of total billed charges,,,78,,11748.36,percent of total billed charges,,,70,,10543.4,percent of total billed charges,,,,,,,,6714.65,,,,100% of Medicare,,6714.65,,,,100% of Medicare,,6714.65,,,,100% of Medicare,,6714.65,,,,100% of Medicare,,6714.65,,,,100% of Medicare,,6714.65,,,,100% of Medicare,,6714.65,,,,100% of Medicare,,6714.65,,,,100% of Medicare,,6714.65,,,,100% of Medicare,,6714.65,,,,100% of Medicare,,6714.65,,,,100% of Medicare,,6714.65,,,,100% of Medicare,,,6714.65,,,,100% of Medicare,2320.85,,,,EAPG rate,100% of IL Medicaid,2320.85,,,,EAPG rate,100% of IL Medicaid,2320.85,,,,EAPG rate,100% of IL Medicaid,2320.85,,,,EAPG rate,100% of IL Medicaid,2320.85,13555.8,
"Automatic grasp feature, addition to upper-limb prosthetic terminal device",L6881,HCPCS,,,,outpatient,,,15441,9264.6,,45.5,,7025.66,percent of total billed charges,,,45.3,,6994.77,percent of total billed charges,,,39,,6021.99,percent of total billed charges,,,,,,,,,80,,12352.8,percent of total billed charges,,,61.4,,9480.77,percent of total billed charges,,,57.4,,8863.13,percent of total billed charges,,,81,,12507.21,percent of total billed charges,,,39,,6021.99,percent of total billed charges,,,57.6,,8894.02,percent of total billed charges,,,85,,13124.85,percent of total billed charges,,,85,,13124.85,percent of total billed charges,,,49,,7566.09,percent of total billed charges,,,90,,13896.9,percent of total billed charges,,,65,,10036.65,percent of total billed charges,,,80,,12352.8,percent of total billed charges,,,55,,8492.55,percent of total billed charges,,,55,,8492.55,percent of total billed charges,,,65,,10036.65,percent of total billed charges,,,78,,12043.98,percent of total billed charges,,,70,,10808.7,percent of total billed charges,,,,,,,,4935.41,,,,100% of Medicare,,4935.41,,,,100% of Medicare,,4935.41,,,,100% of Medicare,,4935.41,,,,100% of Medicare,,4935.41,,,,100% of Medicare,,4935.41,,,17975.31,100% of Medicare,,4935.41,,,,100% of Medicare,,4935.41,,,,100% of Medicare,,4935.41,,,,100% of Medicare,,4935.41,,,,100% of Medicare,,4935.41,,,,100% of Medicare,,4935.41,,,,100% of Medicare,,,4935.41,,,,100% of Medicare,2399.38,,,,EAPG rate,100% of IL Medicaid,2399.38,,,,EAPG rate,100% of IL Medicaid,2399.38,,,,EAPG rate,100% of IL Medicaid,2399.38,,,,EAPG rate,100% of IL Medicaid,2399.38,17975.31,
"L7499 - UE prosthesis, not otherwise specified",L7499,HCPCS,,,,both,,,15526.97,9316.18,,45.5,,7064.77,percent of total billed charges,,,45.3,,7033.72,percent of total billed charges,,,39,,6055.52,percent of total billed charges,,,,,,,,,80,,12421.58,percent of total billed charges,,,61.4,,9533.56,percent of total billed charges,,,57.4,,8912.48,percent of total billed charges,,,81,,12576.85,percent of total billed charges,,,51.5,,7996.39,percent of total billed charges,,,57.6,,8943.53,percent of total billed charges,,,85,,13197.92,percent of total billed charges,,,85,,13197.92,percent of total billed charges,,,49,,7608.22,percent of total billed charges,,,90,,13974.27,percent of total billed charges,,,65,,10092.53,percent of total billed charges,,,80,,12421.58,percent of total billed charges,,,55,,8539.83,percent of total billed charges,,,55,,8539.83,percent of total billed charges,,,65,,10092.53,percent of total billed charges,,,78,,12111.04,percent of total billed charges,,,70,,10868.88,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,2417.91,,,,EAPG rate,100% of IL Medicaid,2417.91,,,,EAPG rate,100% of IL Medicaid,2417.91,,,,EAPG rate,100% of IL Medicaid,2417.91,,,,EAPG rate,100% of IL Medicaid,2417.91,13974.27,
"Shoulder disartic, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forear",L6300,HCPCS,,,,outpatient,,,15638,9382.8,,45.5,,7115.29,percent of total billed charges,,,45.3,,7084.01,percent of total billed charges,,,39,,6098.82,percent of total billed charges,,,,,,,,,80,,12510.4,percent of total billed charges,,,61.4,,9601.73,percent of total billed charges,,,57.4,,8976.21,percent of total billed charges,,,81,,12666.78,percent of total billed charges,,,39,,6098.82,percent of total billed charges,,,57.6,,9007.49,percent of total billed charges,,,85,,13292.3,percent of total billed charges,,,85,,13292.3,percent of total billed charges,,,49,,7662.62,percent of total billed charges,,,90,,14074.2,percent of total billed charges,,,65,,10164.7,percent of total billed charges,,,80,,12510.4,percent of total billed charges,,,55,,8600.9,percent of total billed charges,,,55,,8600.9,percent of total billed charges,,,65,,10164.7,percent of total billed charges,,,78,,12197.64,percent of total billed charges,,,70,,10946.6,percent of total billed charges,,,,,,,,5358.53,,,,100% of Medicare,,5358.53,,,,100% of Medicare,,5358.53,,,,100% of Medicare,,5358.53,,,,100% of Medicare,,5358.53,,,,100% of Medicare,,5358.53,,,,100% of Medicare,,5358.53,,,,100% of Medicare,,5358.53,,,,100% of Medicare,,5358.53,,,,100% of Medicare,,5358.53,,,,100% of Medicare,,5358.53,,,,100% of Medicare,,5358.53,,,,100% of Medicare,,,5358.53,,,,100% of Medicare,2440.19,,,,EAPG rate,100% of IL Medicaid,2440.19,,,,EAPG rate,100% of IL Medicaid,2440.19,,,,EAPG rate,100% of IL Medicaid,2440.19,,,,EAPG rate,100% of IL Medicaid,2440.19,14074.2,
"Prep, hip disartic - hemipel, pylon, no cover, SACH foot, thermoplastic or equal, molded to",L5595,HCPCS,,,,outpatient,,,15984,9590.4,,45.5,,7272.72,percent of total billed charges,,,45.3,,7240.75,percent of total billed charges,,,39,,6233.76,percent of total billed charges,,,,,,,,,80,,12787.2,percent of total billed charges,,,61.4,,9814.18,percent of total billed charges,,,57.4,,9174.82,percent of total billed charges,,,81,,12947.04,percent of total billed charges,,,39,,6233.76,percent of total billed charges,,,57.6,,9206.78,percent of total billed charges,,,85,,13586.4,percent of total billed charges,,,85,,13586.4,percent of total billed charges,,,49,,7832.16,percent of total billed charges,,,90,,14385.6,percent of total billed charges,,,65,,10389.6,percent of total billed charges,,,80,,12787.2,percent of total billed charges,,,55,,8791.2,percent of total billed charges,,,55,,8791.2,percent of total billed charges,,,65,,10389.6,percent of total billed charges,,,78,,12467.52,percent of total billed charges,,,70,,11188.8,percent of total billed charges,,,,,,,,5531.2,,,,100% of Medicare,,5531.2,,,,100% of Medicare,,5531.2,,,,100% of Medicare,,5531.2,,,,100% of Medicare,,5531.2,,,,100% of Medicare,,5531.2,,,,100% of Medicare,,5531.2,,,,100% of Medicare,,5531.2,,,,100% of Medicare,,5531.2,,,,100% of Medicare,,5531.2,,,,100% of Medicare,,5531.2,,,,100% of Medicare,,5531.2,,,,100% of Medicare,,,5531.2,,,,100% of Medicare,2511.88,,,,EAPG rate,100% of IL Medicaid,2511.88,,,,EAPG rate,100% of IL Medicaid,2511.88,,,,EAPG rate,100% of IL Medicaid,2511.88,,,,EAPG rate,100% of IL Medicaid,2511.88,14385.6,
"Hemipelvectomy, Canadian type; molded socket, hip jt, single axis constant friction knee, shin, SACH",L5280,HCPCS,,,,outpatient,,,16292,9775.2,,45.5,,7412.86,percent of total billed charges,,,45.3,,7380.28,percent of total billed charges,,,39,,6353.88,percent of total billed charges,,,,,,,,,80,,13033.6,percent of total billed charges,,,61.4,,10003.29,percent of total billed charges,,,57.4,,9351.61,percent of total billed charges,,,81,,13196.52,percent of total billed charges,,,39,,6353.88,percent of total billed charges,,,57.6,,9384.19,percent of total billed charges,,,85,,13848.2,percent of total billed charges,,,85,,13848.2,percent of total billed charges,,,49,,7983.08,percent of total billed charges,,,90,,14662.8,percent of total billed charges,,,65,,10589.8,percent of total billed charges,,,80,,13033.6,percent of total billed charges,,,55,,8960.6,percent of total billed charges,,,55,,8960.6,percent of total billed charges,,,65,,10589.8,percent of total billed charges,,,78,,12707.76,percent of total billed charges,,,70,,11404.4,percent of total billed charges,,,,,,,,7310.32,,,,100% of Medicare,,7310.32,,,,100% of Medicare,,7310.32,,,,100% of Medicare,,7310.32,,,,100% of Medicare,,7310.32,,,,100% of Medicare,,7310.32,,,,100% of Medicare,,7310.32,,,,100% of Medicare,,7310.32,,,,100% of Medicare,,7310.32,,,,100% of Medicare,,7310.32,,,,100% of Medicare,,7310.32,,,,100% of Medicare,,7310.32,,,,100% of Medicare,,,7310.32,,,,100% of Medicare,2575.7,,,,EAPG rate,100% of IL Medicaid,2575.7,,,,EAPG rate,100% of IL Medicaid,2575.7,,,,EAPG rate,100% of IL Medicaid,2575.7,,,,EAPG rate,100% of IL Medicaid,2575.7,14662.8,
"Above knee, for proximal femoral focal deficiency, constant friction knee, shin, SACH foot",L5230,HCPCS,,,,outpatient,,,16628,9976.8,,45.5,,7565.74,percent of total billed charges,,,45.3,,7532.48,percent of total billed charges,,,39,,6484.92,percent of total billed charges,,,,,,,,,80,,13302.4,percent of total billed charges,,,61.4,,10209.59,percent of total billed charges,,,57.4,,9544.47,percent of total billed charges,,,81,,13468.68,percent of total billed charges,,,39,,6484.92,percent of total billed charges,,,57.6,,9577.73,percent of total billed charges,,,85,,14133.8,percent of total billed charges,,,85,,14133.8,percent of total billed charges,,,49,,8147.72,percent of total billed charges,,,90,,14965.2,percent of total billed charges,,,65,,10808.2,percent of total billed charges,,,80,,13302.4,percent of total billed charges,,,55,,9145.4,percent of total billed charges,,,55,,9145.4,percent of total billed charges,,,65,,10808.2,percent of total billed charges,,,78,,12969.84,percent of total billed charges,,,70,,11639.6,percent of total billed charges,,,,,,,,5756.63,,,,100% of Medicare,,5756.63,,,,100% of Medicare,,5756.63,,,,100% of Medicare,,5756.63,,,,100% of Medicare,,5756.63,,,,100% of Medicare,,5756.63,,,,100% of Medicare,,5756.63,,,,100% of Medicare,,5756.63,,,,100% of Medicare,,5756.63,,,,100% of Medicare,,5756.63,,,,100% of Medicare,,5756.63,,,,100% of Medicare,,5756.63,,,,100% of Medicare,,,5756.63,,,,100% of Medicare,2645.32,,,,EAPG rate,100% of IL Medicaid,2645.32,,,,EAPG rate,100% of IL Medicaid,2645.32,,,,EAPG rate,100% of IL Medicaid,2645.32,,,,EAPG rate,100% of IL Medicaid,2645.32,14965.2,
"Hip disartic, tilt table type; molded socket, locking hip jt, single axis constant friction knee, sh",L5270,HCPCS,,,,outpatient,,,16755,10053,,45.5,,7623.53,percent of total billed charges,,,45.3,,7590.02,percent of total billed charges,,,39,,6534.45,percent of total billed charges,,,,,,,,,80,,13404,percent of total billed charges,,,61.4,,10287.57,percent of total billed charges,,,57.4,,9617.37,percent of total billed charges,,,81,,13571.55,percent of total billed charges,,,39,,6534.45,percent of total billed charges,,,57.6,,9650.88,percent of total billed charges,,,85,,14241.75,percent of total billed charges,,,85,,14241.75,percent of total billed charges,,,49,,8209.95,percent of total billed charges,,,90,,15079.5,percent of total billed charges,,,65,,10890.75,percent of total billed charges,,,80,,13404,percent of total billed charges,,,55,,9215.25,percent of total billed charges,,,55,,9215.25,percent of total billed charges,,,65,,10890.75,percent of total billed charges,,,78,,13068.9,percent of total billed charges,,,70,,11728.5,percent of total billed charges,,,,,,,,7520.6,,,,100% of Medicare,,7520.6,,,,100% of Medicare,,7520.6,,,,100% of Medicare,,7520.6,,,,100% of Medicare,,7520.6,,,,100% of Medicare,,7520.6,,,,100% of Medicare,,7520.6,,,,100% of Medicare,,7520.6,,,,100% of Medicare,,7520.6,,,,100% of Medicare,,7520.6,,,,100% of Medicare,,7520.6,,,,100% of Medicare,,7520.6,,,,100% of Medicare,,,7520.6,,,,100% of Medicare,2671.64,,,,EAPG rate,100% of IL Medicaid,2671.64,,,,EAPG rate,100% of IL Medicaid,2671.64,,,,EAPG rate,100% of IL Medicaid,2671.64,,,,EAPG rate,100% of IL Medicaid,2671.64,15079.5,
"Electronic elbow, Hosmer or equal, switch controlled",L7170,HCPCS,,,,outpatient,,,17305,10383,,45.5,,7873.78,percent of total billed charges,,,45.3,,7839.17,percent of total billed charges,,,39,,6748.95,percent of total billed charges,,,,,,,,,80,,13844,percent of total billed charges,,,61.4,,10625.27,percent of total billed charges,,,57.4,,9933.07,percent of total billed charges,,,81,,14017.05,percent of total billed charges,,,39,,6748.95,percent of total billed charges,,,57.6,,9967.68,percent of total billed charges,,,85,,14709.25,percent of total billed charges,,,85,,14709.25,percent of total billed charges,,,49,,8479.45,percent of total billed charges,,,90,,15574.5,percent of total billed charges,,,65,,11248.25,percent of total billed charges,,,80,,13844,percent of total billed charges,,,55,,9517.75,percent of total billed charges,,,55,,9517.75,percent of total billed charges,,,65,,11248.25,percent of total billed charges,,,78,,13497.9,percent of total billed charges,,,70,,12113.5,percent of total billed charges,,,,,,,,7261.64,,,,100% of Medicare,,7261.64,,,,100% of Medicare,,7261.64,,,,100% of Medicare,,7261.64,,,,100% of Medicare,,7261.64,,,,100% of Medicare,,7261.64,,,,100% of Medicare,,7261.64,,,,100% of Medicare,,7261.64,,,,100% of Medicare,,7261.64,,,,100% of Medicare,,7261.64,,,,100% of Medicare,,7261.64,,,,100% of Medicare,,7261.64,,,,100% of Medicare,,,7261.64,,,,100% of Medicare,2785.6,,,,EAPG rate,100% of IL Medicaid,2785.6,,,,EAPG rate,100% of IL Medicaid,2785.6,,,,EAPG rate,100% of IL Medicaid,2785.6,,,,EAPG rate,100% of IL Medicaid,2785.6,15574.5,
AK 4 BAR FLUID SWING/STANCE,L5615,HCPCS,,,,outpatient,,,17842,10705.2,,45.5,,8118.11,percent of total billed charges,,,45.3,,8082.43,percent of total billed charges,,,39,,6958.38,percent of total billed charges,,,,,,,,,80,,14273.6,percent of total billed charges,,,61.4,,10954.99,percent of total billed charges,,,57.4,,10241.31,percent of total billed charges,,,81,,14452.02,percent of total billed charges,,,39,,6958.38,percent of total billed charges,,,57.6,,10276.99,percent of total billed charges,,,85,,15165.7,percent of total billed charges,,,85,,15165.7,percent of total billed charges,,,49,,8742.58,percent of total billed charges,,,90,,16057.8,percent of total billed charges,,,65,,11597.3,percent of total billed charges,,,80,,14273.6,percent of total billed charges,,,55,,9813.1,percent of total billed charges,,,55,,9813.1,percent of total billed charges,,,65,,11597.3,percent of total billed charges,,,78,,13916.76,percent of total billed charges,,,70,,12489.4,percent of total billed charges,,,,,,,,6792.14,,,,100% of Medicare,,6792.14,,,,100% of Medicare,,6792.14,,,,100% of Medicare,,6792.14,,,,100% of Medicare,,6792.14,,,,100% of Medicare,,6792.14,,,,100% of Medicare,,6792.14,,,,100% of Medicare,,6792.14,,,,100% of Medicare,,6792.14,,,,100% of Medicare,,6792.14,,,,100% of Medicare,,6792.14,,,,100% of Medicare,,6792.14,,,,100% of Medicare,,,6792.14,,,,100% of Medicare,2896.86,,,,EAPG rate,100% of IL Medicaid,2896.86,,,,EAPG rate,100% of IL Medicaid,2896.86,,,,EAPG rate,100% of IL Medicaid,2896.86,,,,EAPG rate,100% of IL Medicaid,2896.86,16057.8,
"Prep, hip disartic or hemipel, pylon, no cover, SACH foot, lam socket, molded to",L5600,HCPCS,,,,outpatient,,,18188,10912.8,,45.5,,8275.54,percent of total billed charges,,,45.3,,8239.16,percent of total billed charges,,,39,,7093.32,percent of total billed charges,,,,,,,,,80,,14550.4,percent of total billed charges,,,61.4,,11167.43,percent of total billed charges,,,57.4,,10439.91,percent of total billed charges,,,81,,14732.28,percent of total billed charges,,,39,,7093.32,percent of total billed charges,,,57.6,,10476.29,percent of total billed charges,,,85,,15459.8,percent of total billed charges,,,85,,15459.8,percent of total billed charges,,,49,,8912.12,percent of total billed charges,,,90,,16369.2,percent of total billed charges,,,65,,11822.2,percent of total billed charges,,,80,,14550.4,percent of total billed charges,,,55,,10003.4,percent of total billed charges,,,55,,10003.4,percent of total billed charges,,,65,,11822.2,percent of total billed charges,,,78,,14186.64,percent of total billed charges,,,70,,12731.6,percent of total billed charges,,,,,,,,6295.32,,,,100% of Medicare,,6295.32,,,,100% of Medicare,,6295.32,,,,100% of Medicare,,6295.32,,,,100% of Medicare,,6295.32,,,,100% of Medicare,,6295.32,,,,100% of Medicare,,6295.32,,,,100% of Medicare,,6295.32,,,,100% of Medicare,,6295.32,,,,100% of Medicare,,6295.32,,,,100% of Medicare,,6295.32,,,,100% of Medicare,,6295.32,,,,100% of Medicare,,,6295.32,,,,100% of Medicare,2968.55,,,,EAPG rate,100% of IL Medicaid,2968.55,,,,EAPG rate,100% of IL Medicaid,2968.55,,,,EAPG rate,100% of IL Medicaid,2968.55,,,,EAPG rate,100% of IL Medicaid,2968.55,16369.2,
"Electronic elbow, adolescent, Variety Village or equal, switch controlled",L7185,HCPCS,,,,outpatient,,,18197,10918.2,,45.5,,8279.64,percent of total billed charges,,,45.3,,8243.24,percent of total billed charges,,,39,,7096.83,percent of total billed charges,,,,,,,,,80,,14557.6,percent of total billed charges,,,61.4,,11172.96,percent of total billed charges,,,57.4,,10445.08,percent of total billed charges,,,81,,14739.57,percent of total billed charges,,,39,,7096.83,percent of total billed charges,,,57.6,,10481.47,percent of total billed charges,,,85,,15467.45,percent of total billed charges,,,85,,15467.45,percent of total billed charges,,,49,,8916.53,percent of total billed charges,,,90,,16377.3,percent of total billed charges,,,65,,11828.05,percent of total billed charges,,,80,,14557.6,percent of total billed charges,,,55,,10008.35,percent of total billed charges,,,55,,10008.35,percent of total billed charges,,,65,,11828.05,percent of total billed charges,,,78,,14193.66,percent of total billed charges,,,70,,12737.9,percent of total billed charges,,,,,,,,7634.35,,,,100% of Medicare,,7634.35,,,,100% of Medicare,,7634.35,,,,100% of Medicare,,7634.35,,,,100% of Medicare,,7634.35,,,,100% of Medicare,,7634.35,,,,100% of Medicare,,7634.35,,,,100% of Medicare,,7634.35,,,,100% of Medicare,,7634.35,,,,100% of Medicare,,7634.35,,,,100% of Medicare,,7634.35,,,,100% of Medicare,,7634.35,,,,100% of Medicare,,,7634.35,,,,100% of Medicare,2970.42,,,,EAPG rate,100% of IL Medicaid,2970.42,,,,EAPG rate,100% of IL Medicaid,2970.42,,,,EAPG rate,100% of IL Medicaid,2970.42,,,,EAPG rate,100% of IL Medicaid,2970.42,16377.3,
"Hip disart, Canadian type; molded socket, endo system, hip jt, single axis knee, SACH foot",L5331,HCPCS,,,,outpatient,,,18251,10950.6,,45.5,,8304.21,percent of total billed charges,,,45.3,,8267.7,percent of total billed charges,,,39,,7117.89,percent of total billed charges,,,,,,,,,80,,14600.8,percent of total billed charges,,,61.4,,11206.11,percent of total billed charges,,,57.4,,10476.07,percent of total billed charges,,,81,,14783.31,percent of total billed charges,,,39,,7117.89,percent of total billed charges,,,57.6,,10512.58,percent of total billed charges,,,85,,15513.35,percent of total billed charges,,,85,,15513.35,percent of total billed charges,,,49,,8942.99,percent of total billed charges,,,90,,16425.9,percent of total billed charges,,,65,,11863.15,percent of total billed charges,,,80,,14600.8,percent of total billed charges,,,55,,10038.05,percent of total billed charges,,,55,,10038.05,percent of total billed charges,,,65,,11863.15,percent of total billed charges,,,78,,14235.78,percent of total billed charges,,,70,,12775.7,percent of total billed charges,,,,,,,,6316.78,,,,100% of Medicare,,6316.78,,,,100% of Medicare,,6316.78,,,,100% of Medicare,,6316.78,,,,100% of Medicare,,6316.78,,,,100% of Medicare,,6316.78,,,,100% of Medicare,,6316.78,,,,100% of Medicare,,6316.78,,,,100% of Medicare,,6316.78,,,,100% of Medicare,,6316.78,,,,100% of Medicare,,6316.78,,,,100% of Medicare,,6316.78,,,,100% of Medicare,,,6316.78,,,,100% of Medicare,2981.61,,,,EAPG rate,100% of IL Medicaid,2981.61,,,,EAPG rate,100% of IL Medicaid,2981.61,,,,EAPG rate,100% of IL Medicaid,2981.61,,,,EAPG rate,100% of IL Medicaid,2981.61,16425.9,
"Electric hand, switch or myo, pediatric",L7008,HCPCS,,,,outpatient,,,19754,11852.4,,45.5,,8988.07,percent of total billed charges,,,45.3,,8948.56,percent of total billed charges,,,39,,7704.06,percent of total billed charges,,,,,,,,,80,,15803.2,percent of total billed charges,,,61.4,,12128.96,percent of total billed charges,,,57.4,,11338.8,percent of total billed charges,,,81,,16000.74,percent of total billed charges,,,39,,7704.06,percent of total billed charges,,,57.6,,11378.3,percent of total billed charges,,,85,,16790.9,percent of total billed charges,,,85,,16790.9,percent of total billed charges,,,49,,9679.46,percent of total billed charges,,,90,,17778.6,percent of total billed charges,,,65,,12840.1,percent of total billed charges,,,80,,15803.2,percent of total billed charges,,,55,,10864.7,percent of total billed charges,,,55,,10864.7,percent of total billed charges,,,65,,12840.1,percent of total billed charges,,,78,,15408.12,percent of total billed charges,,,70,,13827.8,percent of total billed charges,,,,,,,,6837.6,,,,100% of Medicare,,6837.6,,,,100% of Medicare,,6837.6,,,,100% of Medicare,,6837.6,,,,100% of Medicare,,6837.6,,,,100% of Medicare,,6837.6,,,,100% of Medicare,,6837.6,,,,100% of Medicare,,6837.6,,,,100% of Medicare,,6837.6,,,,100% of Medicare,,6837.6,,,,100% of Medicare,,6837.6,,,,100% of Medicare,,6837.6,,,,100% of Medicare,,,6837.6,,,,100% of Medicare,3293.03,,,,EAPG rate,100% of IL Medicaid,3293.03,,,,EAPG rate,100% of IL Medicaid,3293.03,,,,EAPG rate,100% of IL Medicaid,3293.03,,,,EAPG rate,100% of IL Medicaid,3293.03,17778.6,
"Knee-Ankle-Foot Orthosis, Single or Double Upright, Any Material, Incl Ankle Jt",L2005,HCPCS,,,,outpatient,,,22038,13222.8,,45.5,,10027.29,percent of total billed charges,,,45.3,,9983.21,percent of total billed charges,,,39,,8594.82,percent of total billed charges,,,,,,,,,80,,17630.4,percent of total billed charges,,,61.4,,13531.33,percent of total billed charges,,,57.4,,12649.81,percent of total billed charges,,,81,,17850.78,percent of total billed charges,,,39,,8594.82,percent of total billed charges,,,57.6,,12693.89,percent of total billed charges,,,85,,18732.3,percent of total billed charges,,,85,,18732.3,percent of total billed charges,,,49,,10798.62,percent of total billed charges,,,90,,19834.2,percent of total billed charges,,,65,,14324.7,percent of total billed charges,,,80,,17630.4,percent of total billed charges,,,55,,12120.9,percent of total billed charges,,,55,,12120.9,percent of total billed charges,,,65,,14324.7,percent of total billed charges,,,78,,17189.64,percent of total billed charges,,,70,,15426.6,percent of total billed charges,,,,,,,,4937.19,,,,100% of Medicare,,4937.19,,,,100% of Medicare,,4937.19,,,,100% of Medicare,,4937.19,,,,100% of Medicare,,4937.19,,,,100% of Medicare,,4937.19,,,,100% of Medicare,,4937.19,,,,100% of Medicare,,4937.19,,,,100% of Medicare,,4937.19,,,,100% of Medicare,,4937.19,,,,100% of Medicare,,4937.19,,,,100% of Medicare,,4937.19,,,,100% of Medicare,,,4937.19,,,,100% of Medicare,3766.27,,,,EAPG rate,100% of IL Medicaid,3766.27,,,,EAPG rate,100% of IL Medicaid,3766.27,,,,EAPG rate,100% of IL Medicaid,3766.27,,,,EAPG rate,100% of IL Medicaid,3766.27,19834.2,
"be, ext power, self-susp inner socket, remov shell, Otto Bock or equal switch, cables, 2 batteries/1",L6930,HCPCS,,,,outpatient,,,22986,13791.6,,45.5,,10458.63,percent of total billed charges,,,45.3,,10412.66,percent of total billed charges,,,39,,8964.54,percent of total billed charges,,,,,,,,,80,,18388.8,percent of total billed charges,,,61.4,,14113.4,percent of total billed charges,,,57.4,,13193.96,percent of total billed charges,,,81,,18618.66,percent of total billed charges,,,39,,8964.54,percent of total billed charges,,,57.6,,13239.94,percent of total billed charges,,,85,,19538.1,percent of total billed charges,,,85,,19538.1,percent of total billed charges,,,49,,11263.14,percent of total billed charges,,,90,,20687.4,percent of total billed charges,,,65,,14940.9,percent of total billed charges,,,80,,18388.8,percent of total billed charges,,,55,,12642.3,percent of total billed charges,,,55,,12642.3,percent of total billed charges,,,65,,14940.9,percent of total billed charges,,,78,,17929.08,percent of total billed charges,,,70,,16090.2,percent of total billed charges,,,,,,,,9740,,,,100% of Medicare,,9740,,,,100% of Medicare,,9740,,,,100% of Medicare,,9740,,,,100% of Medicare,,9740,,,,100% of Medicare,,9740,,,24398.75375,100% of Medicare,,9740,,,,100% of Medicare,,9740,,,,100% of Medicare,,9740,,,,100% of Medicare,,9740,,,,100% of Medicare,,9740,,,,100% of Medicare,,9740,,,,100% of Medicare,,,9740,,,,100% of Medicare,3962.7,,,,EAPG rate,100% of IL Medicaid,3962.7,,,,EAPG rate,100% of IL Medicaid,3962.7,,,,EAPG rate,100% of IL Medicaid,3962.7,,,,EAPG rate,100% of IL Medicaid,3962.7,24398.75,
ENDO POLY HIP PNEU/HYD/ROT,L5961,HCPCS,,,,outpatient,,,23833,14299.8,,45.5,,10844.02,percent of total billed charges,,,45.3,,10796.35,percent of total billed charges,,,39,,9294.87,percent of total billed charges,,,,,,,,,80,,19066.4,percent of total billed charges,,,61.4,,14633.46,percent of total billed charges,,,57.4,,13680.14,percent of total billed charges,,,81,,19304.73,percent of total billed charges,,,39,,9294.87,percent of total billed charges,,,57.6,,13727.81,percent of total billed charges,,,85,,20258.05,percent of total billed charges,,,85,,20258.05,percent of total billed charges,,,49,,11678.17,percent of total billed charges,,,90,,21449.7,percent of total billed charges,,,65,,15491.45,percent of total billed charges,,,80,,19066.4,percent of total billed charges,,,55,,13108.15,percent of total billed charges,,,55,,13108.15,percent of total billed charges,,,65,,15491.45,percent of total billed charges,,,78,,18589.74,percent of total billed charges,,,70,,16683.1,percent of total billed charges,,,,,,,,5762.36,,,,100% of Medicare,,5762.36,,,,100% of Medicare,,5762.36,,,,100% of Medicare,,5762.36,,,,100% of Medicare,,5762.36,,,,100% of Medicare,,5762.36,,,,100% of Medicare,,5762.36,,,,100% of Medicare,,5762.36,,,,100% of Medicare,,5762.36,,,,100% of Medicare,,5762.36,,,,100% of Medicare,,5762.36,,,,100% of Medicare,,5762.36,,,,100% of Medicare,,,5762.36,,,,100% of Medicare,4138.2,,,,EAPG rate,100% of IL Medicaid,4138.2,,,,EAPG rate,100% of IL Medicaid,4138.2,,,,EAPG rate,100% of IL Medicaid,4138.2,,,,EAPG rate,100% of IL Medicaid,4138.2,21449.7,
"Wrist disartic, ext power, self-susp inner socket, remov shell, Otto Bock or equal switch, cables, 2",L6920,HCPCS,,,,outpatient,,,23864,14318.4,,45.5,,10858.12,percent of total billed charges,,,45.3,,10810.39,percent of total billed charges,,,39,,9306.96,percent of total billed charges,,,,,,,,,80,,19091.2,percent of total billed charges,,,61.4,,14652.5,percent of total billed charges,,,57.4,,13697.94,percent of total billed charges,,,81,,19329.84,percent of total billed charges,,,39,,9306.96,percent of total billed charges,,,57.6,,13745.66,percent of total billed charges,,,85,,20284.4,percent of total billed charges,,,85,,20284.4,percent of total billed charges,,,49,,11693.36,percent of total billed charges,,,90,,21477.6,percent of total billed charges,,,65,,15511.6,percent of total billed charges,,,80,,19091.2,percent of total billed charges,,,55,,13125.2,percent of total billed charges,,,55,,13125.2,percent of total billed charges,,,65,,15511.6,percent of total billed charges,,,78,,18613.92,percent of total billed charges,,,70,,16704.8,percent of total billed charges,,,,,,,,10112.75,,,,100% of Medicare,,10112.75,,,,100% of Medicare,,10112.75,,,,100% of Medicare,,10112.75,,,,100% of Medicare,,10112.75,,,,100% of Medicare,,10112.75,,,,100% of Medicare,,10112.75,,,,100% of Medicare,,10112.75,,,,100% of Medicare,,10112.75,,,,100% of Medicare,,10112.75,,,,100% of Medicare,,10112.75,,,,100% of Medicare,,10112.75,,,,100% of Medicare,,,10112.75,,,,100% of Medicare,4144.62,,,,EAPG rate,100% of IL Medicaid,4144.62,,,,EAPG rate,100% of IL Medicaid,4144.62,,,,EAPG rate,100% of IL Medicaid,4144.62,,,,EAPG rate,100% of IL Medicaid,4144.62,21477.6,
"Addition to LE pros, endo knee-shin sys, microproc-control feature, swing only, incl elec sensor(s),",L5857,HCPCS,,,,outpatient,,,24025,14415,,45.5,,10931.38,percent of total billed charges,,,45.3,,10883.33,percent of total billed charges,,,39,,9369.75,percent of total billed charges,,,,,,,,,80,,19220,percent of total billed charges,,,61.4,,14751.35,percent of total billed charges,,,57.4,,13790.35,percent of total billed charges,,,81,,19460.25,percent of total billed charges,,,39,,9369.75,percent of total billed charges,,,57.6,,13838.4,percent of total billed charges,,,85,,20421.25,percent of total billed charges,,,85,,20421.25,percent of total billed charges,,,49,,11772.25,percent of total billed charges,,,90,,21622.5,percent of total billed charges,,,65,,15616.25,percent of total billed charges,,,80,,19220,percent of total billed charges,,,55,,13213.75,percent of total billed charges,,,55,,13213.75,percent of total billed charges,,,65,,15616.25,percent of total billed charges,,,78,,18739.5,percent of total billed charges,,,70,,16817.5,percent of total billed charges,,,,,,,,10283.25,,,,100% of Medicare,,10283.25,,,,100% of Medicare,,10283.25,,,,100% of Medicare,,10283.25,,,,100% of Medicare,,10283.25,,,,100% of Medicare,,10283.25,,,,100% of Medicare,,10283.25,,,,100% of Medicare,,10283.25,,,,100% of Medicare,,10283.25,,,,100% of Medicare,,10283.25,,,,100% of Medicare,,10283.25,,,,100% of Medicare,,10283.25,,,,100% of Medicare,,,10283.25,,,,100% of Medicare,4177.98,,,,EAPG rate,100% of IL Medicaid,4177.98,,,,EAPG rate,100% of IL Medicaid,4177.98,,,,EAPG rate,100% of IL Medicaid,4177.98,,,,EAPG rate,100% of IL Medicaid,4177.98,21622.5,
"Electronic elbow, adolescent, Variety Village or equal, myoelectronically controlled",L7190,HCPCS,,,,outpatient,,,24140,14484,,45.5,,10983.7,percent of total billed charges,,,45.3,,10935.42,percent of total billed charges,,,39,,9414.6,percent of total billed charges,,,,,,,,,80,,19312,percent of total billed charges,,,61.4,,14821.96,percent of total billed charges,,,57.4,,13856.36,percent of total billed charges,,,81,,19553.4,percent of total billed charges,,,39,,9414.6,percent of total billed charges,,,57.6,,13904.64,percent of total billed charges,,,85,,20519,percent of total billed charges,,,85,,20519,percent of total billed charges,,,49,,11828.6,percent of total billed charges,,,90,,21726,percent of total billed charges,,,65,,15691,percent of total billed charges,,,80,,19312,percent of total billed charges,,,55,,13277,percent of total billed charges,,,55,,13277,percent of total billed charges,,,65,,15691,percent of total billed charges,,,78,,18829.2,percent of total billed charges,,,70,,16898,percent of total billed charges,,,,,,,,10130.05,,,,100% of Medicare,,10130.05,,,,100% of Medicare,,10130.05,,,,100% of Medicare,,10130.05,,,,100% of Medicare,,10130.05,,,,100% of Medicare,,10130.05,,,,100% of Medicare,,10130.05,,,,100% of Medicare,,10130.05,,,,100% of Medicare,,10130.05,,,,100% of Medicare,,10130.05,,,,100% of Medicare,,10130.05,,,,100% of Medicare,,10130.05,,,,100% of Medicare,,,10130.05,,,,100% of Medicare,4201.81,,,,EAPG rate,100% of IL Medicaid,4201.81,,,,EAPG rate,100% of IL Medicaid,4201.81,,,,EAPG rate,100% of IL Medicaid,4201.81,,,,EAPG rate,100% of IL Medicaid,4201.81,21726,
"Wrist disartic, ext power, self-susp inner socket, remov shell, Otto Bock or equal electrodes, cable",L6925,HCPCS,,,,outpatient,,,25491,15294.6,,45.5,,11598.41,percent of total billed charges,,,45.3,,11547.42,percent of total billed charges,,,39,,9941.49,percent of total billed charges,,,,,,,,,80,,20392.8,percent of total billed charges,,,61.4,,15651.47,percent of total billed charges,,,57.4,,14631.83,percent of total billed charges,,,81,,20647.71,percent of total billed charges,,,39,,9941.49,percent of total billed charges,,,57.6,,14682.82,percent of total billed charges,,,85,,21667.35,percent of total billed charges,,,85,,21667.35,percent of total billed charges,,,49,,12490.59,percent of total billed charges,,,90,,22941.9,percent of total billed charges,,,65,,16569.15,percent of total billed charges,,,80,,20392.8,percent of total billed charges,,,55,,14020.05,percent of total billed charges,,,55,,14020.05,percent of total billed charges,,,65,,16569.15,percent of total billed charges,,,78,,19882.98,percent of total billed charges,,,70,,17843.7,percent of total billed charges,,,,,,,,10803.79,,,,100% of Medicare,,10803.79,,,999999999,100% of Medicare,,10803.79,,,999999999,100% of Medicare,,10803.79,,,999999999,100% of Medicare,,10803.79,,,999999999,100% of Medicare,,10803.79,,,999999999,100% of Medicare,,10803.79,,,999999999,100% of Medicare,,10803.79,,,999999999,100% of Medicare,,10803.79,,,999999999,100% of Medicare,,10803.79,,,999999999,100% of Medicare,,10803.79,,,999999999,100% of Medicare,,10803.79,,,999999999,100% of Medicare,,,10803.79,,,999999999,100% of Medicare,4481.74,,,,EAPG rate,100% of IL Medicaid,4481.74,,,,EAPG rate,100% of IL Medicaid,4481.74,,,,EAPG rate,100% of IL Medicaid,4481.74,,,,EAPG rate,100% of IL Medicaid,4481.74,999999999,
"All LE prosthesis, shank foot system with vertical loading pylon",L5987,HCPCS,,,,outpatient,,,27167,16300.2,,45.5,,12360.99,percent of total billed charges,,,45.3,,12306.65,percent of total billed charges,,,39,,10595.13,percent of total billed charges,,,,,,,,,80,,21733.6,percent of total billed charges,,,61.4,,16680.54,percent of total billed charges,,,57.4,,15593.86,percent of total billed charges,,,81,,22005.27,percent of total billed charges,,,39,,10595.13,percent of total billed charges,,,57.6,,15648.19,percent of total billed charges,,,85,,23091.95,percent of total billed charges,,,85,,23091.95,percent of total billed charges,,,49,,13311.83,percent of total billed charges,,,90,,24450.3,percent of total billed charges,,,65,,17658.55,percent of total billed charges,,,80,,21733.6,percent of total billed charges,,,55,,14941.85,percent of total billed charges,,,55,,14941.85,percent of total billed charges,,,65,,17658.55,percent of total billed charges,,,78,,21190.26,percent of total billed charges,,,70,,19016.9,percent of total billed charges,,,,,,,,8684.41,,,,100% of Medicare,,8684.41,,,999999999,100% of Medicare,,8684.41,,,999999999,100% of Medicare,,8684.41,,,999999999,100% of Medicare,,8684.41,,,999999999,100% of Medicare,,8684.41,,,999999999,100% of Medicare,,8684.41,,,999999999,100% of Medicare,,8684.41,,,999999999,100% of Medicare,,8684.41,,,999999999,100% of Medicare,,8684.41,,,999999999,100% of Medicare,,8684.41,,,999999999,100% of Medicare,,8684.41,,,999999999,100% of Medicare,,,8684.41,,,999999999,100% of Medicare,4829,,,,EAPG rate,100% of IL Medicaid,4829,,,,EAPG rate,100% of IL Medicaid,4829,,,,EAPG rate,100% of IL Medicaid,4829,,,,EAPG rate,100% of IL Medicaid,4829,999999999,
"Elbow disartic, external power, switch control",L6940,HCPCS,,,,outpatient,,,29680,17808,,45.5,,13504.4,percent of total billed charges,,,45.3,,13445.04,percent of total billed charges,,,39,,11575.2,percent of total billed charges,,,,,,,,,80,,23744,percent of total billed charges,,,61.4,,18223.52,percent of total billed charges,,,57.4,,17036.32,percent of total billed charges,,,81,,24040.8,percent of total billed charges,,,39,,11575.2,percent of total billed charges,,,57.6,,17095.68,percent of total billed charges,,,85,,25228,percent of total billed charges,,,85,,25228,percent of total billed charges,,,49,,14543.2,percent of total billed charges,,,90,,26712,percent of total billed charges,,,65,,19292,percent of total billed charges,,,80,,23744,percent of total billed charges,,,55,,16324,percent of total billed charges,,,55,,16324,percent of total billed charges,,,65,,19292,percent of total billed charges,,,78,,23150.4,percent of total billed charges,,,70,,20776,percent of total billed charges,,,,,,,,12577.53,,,,100% of Medicare,,12577.53,,,999999999,100% of Medicare,,12577.53,,,999999999,100% of Medicare,,12577.53,,,999999999,100% of Medicare,,12577.53,,,999999999,100% of Medicare,,12577.53,,,999999999,100% of Medicare,,12577.53,,,999999999,100% of Medicare,,12577.53,,,999999999,100% of Medicare,,12577.53,,,999999999,100% of Medicare,,12577.53,,,999999999,100% of Medicare,,12577.53,,,999999999,100% of Medicare,,12577.53,,,999999999,100% of Medicare,,,12577.53,,,999999999,100% of Medicare,5349.7,,,,EAPG rate,100% of IL Medicaid,5349.7,,,,EAPG rate,100% of IL Medicaid,5349.7,,,,EAPG rate,100% of IL Medicaid,5349.7,,,,EAPG rate,100% of IL Medicaid,5349.7,999999999,
"BE, ext power, self-susp inner socket, remov shell, Otto Bock or equal electrodes, cables, 2 batteri",L6935,HCPCS,,,,outpatient,,,32000,19200,,45.5,,14560,percent of total billed charges,,,45.3,,14496,percent of total billed charges,,,39,,12480,percent of total billed charges,,,,,,,,,80,,25600,percent of total billed charges,,,61.4,,19648,percent of total billed charges,,,57.4,,18368,percent of total billed charges,,,81,,25920,percent of total billed charges,,,39,,12480,percent of total billed charges,,,57.6,,18432,percent of total billed charges,,,85,,27200,percent of total billed charges,,,85,,27200,percent of total billed charges,,,49,,15680,percent of total billed charges,,,90,,28800,percent of total billed charges,,,65,,20800,percent of total billed charges,,,80,,25600,percent of total billed charges,,,55,,17600,percent of total billed charges,,,55,,17600,percent of total billed charges,,,65,,20800,percent of total billed charges,,,78,,24960,percent of total billed charges,,,70,,22400,percent of total billed charges,,,,,,,,10753.02,,,,100% of Medicare,,10753.02,,,999999999,100% of Medicare,,10753.02,,,999999999,100% of Medicare,,10753.02,,,999999999,100% of Medicare,,10753.02,,,999999999,100% of Medicare,,10753.02,,,999999999,100% of Medicare,,10753.02,,,999999999,100% of Medicare,,10753.02,,,999999999,100% of Medicare,,10753.02,,,999999999,100% of Medicare,,10753.02,,,999999999,100% of Medicare,,10753.02,,,999999999,100% of Medicare,,10753.02,,,999999999,100% of Medicare,,,10753.02,,,999999999,100% of Medicare,5830.4,,,,EAPG rate,100% of IL Medicaid,5830.4,,,,EAPG rate,100% of IL Medicaid,5830.4,,,,EAPG rate,100% of IL Medicaid,5830.4,,,,EAPG rate,100% of IL Medicaid,5830.4,999999999,
"Electronic elbow, child, Variety Village or equal, myoelectronically controlled",L7191,HCPCS,,,,outpatient,,,32173,19303.8,,45.5,,14638.72,percent of total billed charges,,,45.3,,14574.37,percent of total billed charges,,,39,,12547.47,percent of total billed charges,,,,,,,,,80,,25738.4,percent of total billed charges,,,61.4,,19754.22,percent of total billed charges,,,57.4,,18467.3,percent of total billed charges,,,81,,26060.13,percent of total billed charges,,,39,,12547.47,percent of total billed charges,,,57.6,,18531.65,percent of total billed charges,,,85,,27347.05,percent of total billed charges,,,85,,27347.05,percent of total billed charges,,,49,,15764.77,percent of total billed charges,,,90,,28955.7,percent of total billed charges,,,65,,20912.45,percent of total billed charges,,,80,,25738.4,percent of total billed charges,,,55,,17695.15,percent of total billed charges,,,55,,17695.15,percent of total billed charges,,,65,,20912.45,percent of total billed charges,,,78,,25094.94,percent of total billed charges,,,70,,22521.1,percent of total billed charges,,,,,,,,13499.77,,,,100% of Medicare,,13499.77,,,999999999,100% of Medicare,,13499.77,,,999999999,100% of Medicare,,13499.77,,,999999999,100% of Medicare,,13499.77,,,999999999,100% of Medicare,,13499.77,,,999999999,100% of Medicare,,13499.77,,,999999999,100% of Medicare,,13499.77,,,999999999,100% of Medicare,,13499.77,,,999999999,100% of Medicare,,13499.77,,,999999999,100% of Medicare,,13499.77,,,999999999,100% of Medicare,,13499.77,,,999999999,100% of Medicare,,,13499.77,,,999999999,100% of Medicare,5866.25,,,,EAPG rate,100% of IL Medicaid,5866.25,,,,EAPG rate,100% of IL Medicaid,5866.25,,,,EAPG rate,100% of IL Medicaid,5866.25,,,,EAPG rate,100% of IL Medicaid,5866.25,999999999,
"Elbow disartic, external power, myo control",L6945,HCPCS,,,,outpatient,,,33113,19867.8,,45.5,,15066.42,percent of total billed charges,,,45.3,,15000.19,percent of total billed charges,,,39,,12914.07,percent of total billed charges,,,,,,,,,80,,26490.4,percent of total billed charges,,,61.4,,20331.38,percent of total billed charges,,,57.4,,19006.86,percent of total billed charges,,,81,,26821.53,percent of total billed charges,,,39,,12914.07,percent of total billed charges,,,57.6,,19073.09,percent of total billed charges,,,85,,28146.05,percent of total billed charges,,,85,,28146.05,percent of total billed charges,,,49,,16225.37,percent of total billed charges,,,90,,29801.7,percent of total billed charges,,,65,,21523.45,percent of total billed charges,,,80,,26490.4,percent of total billed charges,,,55,,18212.15,percent of total billed charges,,,55,,18212.15,percent of total billed charges,,,65,,21523.45,percent of total billed charges,,,78,,25828.14,percent of total billed charges,,,70,,23179.1,percent of total billed charges,,,,,,,,14031.86,,,,100% of Medicare,,14031.86,,,16266.73,100% of Medicare,,14031.86,,,16266.73,100% of Medicare,,14031.86,,,16266.73,100% of Medicare,,14031.86,,,16266.73,100% of Medicare,,14031.86,,,16266.73,100% of Medicare,,14031.86,,,16266.73,100% of Medicare,,14031.86,,,16266.73,100% of Medicare,,14031.86,,,16266.73,100% of Medicare,,14031.86,,,16266.73,100% of Medicare,,14031.86,,,16266.73,100% of Medicare,,14031.86,,,16266.73,100% of Medicare,,,14031.86,,,16266.73,100% of Medicare,6061.01,,,,EAPG rate,100% of IL Medicaid,6061.01,,,,EAPG rate,100% of IL Medicaid,6061.01,,,,EAPG rate,100% of IL Medicaid,6061.01,,,,EAPG rate,100% of IL Medicaid,6061.01,29801.7,
Addition LE ext osseointegrated connector,L5991,HCPCS,,,,outpatient,,,33736,20241.6,,45.5,,15349.88,percent of total billed charges,,,45.3,,15282.41,percent of total billed charges,,,39,,13157.04,percent of total billed charges,,,,,,,,,80,,26988.8,percent of total billed charges,,,61.4,,20713.9,percent of total billed charges,,,57.4,,19364.46,percent of total billed charges,,,81,,27326.16,percent of total billed charges,,,39,,13157.04,percent of total billed charges,,,57.6,,19431.94,percent of total billed charges,,,85,,28675.6,percent of total billed charges,,,85,,28675.6,percent of total billed charges,,,49,,16530.64,percent of total billed charges,,,90,,30362.4,percent of total billed charges,,,65,,21928.4,percent of total billed charges,,,80,,26988.8,percent of total billed charges,,,55,,18554.8,percent of total billed charges,,,55,,18554.8,percent of total billed charges,,,65,,21928.4,percent of total billed charges,,,78,,26314.08,percent of total billed charges,,,70,,23615.2,percent of total billed charges,,,,,,,,11524.55,,,,100% of Medicare,,11524.55,,,16427.8,100% of Medicare,,11524.55,,,16427.8,100% of Medicare,,11524.55,,,16427.8,100% of Medicare,,11524.55,,,16427.8,100% of Medicare,,11524.55,,,16427.8,100% of Medicare,,11524.55,,,16427.8,100% of Medicare,,11524.55,,,16427.8,100% of Medicare,,11524.55,,,16427.8,100% of Medicare,,11524.55,,,16427.8,100% of Medicare,,11524.55,,,16427.8,100% of Medicare,,11524.55,,,16427.8,100% of Medicare,,,11524.55,,,16427.8,100% of Medicare,6190.1,,,,EAPG rate,100% of IL Medicaid,6190.1,,,,EAPG rate,100% of IL Medicaid,6190.1,,,,EAPG rate,100% of IL Medicaid,6190.1,,,,EAPG rate,100% of IL Medicaid,6190.1,30362.4,
"Above Elbow, external power, myo control",L6955,HCPCS,,,,outpatient,,,34355,20613,,45.5,,15631.53,percent of total billed charges,,,45.3,,15562.82,percent of total billed charges,,,39,,13398.45,percent of total billed charges,,,,,,,,,80,,27484,percent of total billed charges,,,61.4,,21093.97,percent of total billed charges,,,57.4,,19719.77,percent of total billed charges,,,81,,27827.55,percent of total billed charges,,,39,,13398.45,percent of total billed charges,,,57.6,,19788.48,percent of total billed charges,,,85,,29201.75,percent of total billed charges,,,85,,29201.75,percent of total billed charges,,,49,,16833.95,percent of total billed charges,,,90,,30919.5,percent of total billed charges,,,65,,22330.75,percent of total billed charges,,,80,,27484,percent of total billed charges,,,55,,18895.25,percent of total billed charges,,,55,,18895.25,percent of total billed charges,,,65,,22330.75,percent of total billed charges,,,78,,26796.9,percent of total billed charges,,,70,,24048.5,percent of total billed charges,,,,,,,,14558.92,,,,100% of Medicare,,14558.92,,,999999999,100% of Medicare,,14558.92,,,999999999,100% of Medicare,,14558.92,,,999999999,100% of Medicare,,14558.92,,,999999999,100% of Medicare,,14558.92,,,999999999,100% of Medicare,,14558.92,,,999999999,100% of Medicare,,14558.92,,,999999999,100% of Medicare,,14558.92,,,999999999,100% of Medicare,,14558.92,,,999999999,100% of Medicare,,14558.92,,,999999999,100% of Medicare,,14558.92,,,999999999,100% of Medicare,,,14558.92,,,999999999,100% of Medicare,6318.36,,,,EAPG rate,100% of IL Medicaid,6318.36,,,,EAPG rate,100% of IL Medicaid,6318.36,,,,EAPG rate,100% of IL Medicaid,6318.36,,,,EAPG rate,100% of IL Medicaid,6318.36,999999999,
"Above Elbow, external power, switch control",L6950,HCPCS,,,,outpatient,,,36637,21982.2,,45.5,,16669.84,percent of total billed charges,,,45.3,,16596.56,percent of total billed charges,,,39,,14288.43,percent of total billed charges,,,,,,,,,80,,29309.6,percent of total billed charges,,,61.4,,22495.12,percent of total billed charges,,,57.4,,21029.64,percent of total billed charges,,,81,,29675.97,percent of total billed charges,,,39,,14288.43,percent of total billed charges,,,57.6,,21102.91,percent of total billed charges,,,85,,31141.45,percent of total billed charges,,,85,,31141.45,percent of total billed charges,,,49,,17952.13,percent of total billed charges,,,90,,32973.3,percent of total billed charges,,,65,,23814.05,percent of total billed charges,,,80,,29309.6,percent of total billed charges,,,55,,20150.35,percent of total billed charges,,,55,,20150.35,percent of total billed charges,,,65,,23814.05,percent of total billed charges,,,78,,28576.86,percent of total billed charges,,,70,,25645.9,percent of total billed charges,,,,,,,,12554.2,,,,100% of Medicare,,12554.2,,,16624.86,100% of Medicare,,12554.2,,,16624.86,100% of Medicare,,12554.2,,,16624.86,100% of Medicare,,12554.2,,,16624.86,100% of Medicare,,12554.2,,,16624.86,100% of Medicare,,12554.2,,,16624.86,100% of Medicare,,12554.2,,,16624.86,100% of Medicare,,12554.2,,,16624.86,100% of Medicare,,12554.2,,,16624.86,100% of Medicare,,12554.2,,,16624.86,100% of Medicare,,12554.2,,,16624.86,100% of Medicare,,,12554.2,,,16624.86,100% of Medicare,6791.19,,,,EAPG rate,100% of IL Medicaid,6791.19,,,,EAPG rate,100% of IL Medicaid,6791.19,,,,EAPG rate,100% of IL Medicaid,6791.19,,,,EAPG rate,100% of IL Medicaid,6791.19,32973.3,
"Electronic elbow, child, Variety Village or equal, switch controlled",L7186,HCPCS,,,,outpatient,,,37825,22695,,45.5,,17210.38,percent of total billed charges,,,45.3,,17134.73,percent of total billed charges,,,39,,14751.75,percent of total billed charges,,,,,,,,,80,,30260,percent of total billed charges,,,61.4,,23224.55,percent of total billed charges,,,57.4,,21711.55,percent of total billed charges,,,81,,30638.25,percent of total billed charges,,,39,,14751.75,percent of total billed charges,,,57.6,,21787.2,percent of total billed charges,,,85,,32151.25,percent of total billed charges,,,85,,32151.25,percent of total billed charges,,,49,,18534.25,percent of total billed charges,,,90,,34042.5,percent of total billed charges,,,65,,24586.25,percent of total billed charges,,,80,,30260,percent of total billed charges,,,55,,20803.75,percent of total billed charges,,,55,,20803.75,percent of total billed charges,,,65,,24586.25,percent of total billed charges,,,78,,29503.5,percent of total billed charges,,,70,,26477.5,percent of total billed charges,,,,,,,,12834.42,,,,100% of Medicare,,12834.42,,,19265.97,100% of Medicare,,12834.42,,,19265.97,100% of Medicare,,12834.42,,,19265.97,100% of Medicare,,12834.42,,,19265.97,100% of Medicare,,12834.42,,,19265.97,100% of Medicare,,12834.42,,,19265.97,100% of Medicare,,12834.42,,,19265.97,100% of Medicare,,12834.42,,,19265.97,100% of Medicare,,12834.42,,,19265.97,100% of Medicare,,12834.42,,,19265.97,100% of Medicare,,12834.42,,,19265.97,100% of Medicare,,,12834.42,,,19265.97,100% of Medicare,7037.34,,,,EAPG rate,100% of IL Medicaid,7037.34,,,,EAPG rate,100% of IL Medicaid,7037.34,,,,EAPG rate,100% of IL Medicaid,7037.34,,,,EAPG rate,100% of IL Medicaid,7037.34,34042.5,
"Addition to LE pros, endo knee-shin sys, powered & prog flex/ext assist control, incl any type motor",L5859,HCPCS,,,,outpatient,,,42108,25264.8,,45.5,,19159.14,percent of total billed charges,,,45.3,,19074.92,percent of total billed charges,,,39,,16422.12,percent of total billed charges,,,,,,,,,80,,33686.4,percent of total billed charges,,,61.4,,25854.31,percent of total billed charges,,,57.4,,24169.99,percent of total billed charges,,,81,,34107.48,percent of total billed charges,,,39,,16422.12,percent of total billed charges,,,57.6,,24254.21,percent of total billed charges,,,85,,35791.8,percent of total billed charges,,,85,,35791.8,percent of total billed charges,,,49,,20632.92,percent of total billed charges,,,90,,37897.2,percent of total billed charges,,,65,,27370.2,percent of total billed charges,,,80,,33686.4,percent of total billed charges,,,55,,23159.4,percent of total billed charges,,,55,,23159.4,percent of total billed charges,,,65,,27370.2,percent of total billed charges,,,78,,32844.24,percent of total billed charges,,,70,,29475.6,percent of total billed charges,,,,,,,,17515.82,,,,100% of Medicare,,17515.82,,,999999999,100% of Medicare,,17515.82,,,999999999,100% of Medicare,,17515.82,,,999999999,100% of Medicare,,17515.82,,,999999999,100% of Medicare,,17515.82,,,999999999,100% of Medicare,,17515.82,,,999999999,100% of Medicare,,17515.82,,,999999999,100% of Medicare,,17515.82,,,999999999,100% of Medicare,,17515.82,,,999999999,100% of Medicare,,17515.82,,,999999999,100% of Medicare,,17515.82,,,999999999,100% of Medicare,,,17515.82,,,999999999,100% of Medicare,7924.78,,,,EAPG rate,100% of IL Medicaid,7924.78,,,,EAPG rate,100% of IL Medicaid,7924.78,,,,EAPG rate,100% of IL Medicaid,7924.78,,,,EAPG rate,100% of IL Medicaid,7924.78,999999999,
"Shoulder disarticulation, external power, switch control",L6960,HCPCS,,,,outpatient,,,44247,26548.2,,45.5,,20132.39,percent of total billed charges,,,45.3,,20043.89,percent of total billed charges,,,39,,17256.33,percent of total billed charges,,,,,,,,,80,,35397.6,percent of total billed charges,,,61.4,,27167.66,percent of total billed charges,,,57.4,,25397.78,percent of total billed charges,,,81,,35840.07,percent of total billed charges,,,39,,17256.33,percent of total billed charges,,,57.6,,25486.27,percent of total billed charges,,,85,,37609.95,percent of total billed charges,,,85,,37609.95,percent of total billed charges,,,49,,21681.03,percent of total billed charges,,,90,,39822.3,percent of total billed charges,,,65,,28760.55,percent of total billed charges,,,80,,35397.6,percent of total billed charges,,,55,,24335.85,percent of total billed charges,,,55,,24335.85,percent of total billed charges,,,65,,28760.55,percent of total billed charges,,,78,,34512.66,percent of total billed charges,,,70,,30972.9,percent of total billed charges,,,,,,,,15315.43,,,,100% of Medicare,,15315.43,,,18966.15,100% of Medicare,,15315.43,,,18966.15,100% of Medicare,,15315.43,,,18966.15,100% of Medicare,,15315.43,,,18966.15,100% of Medicare,,15315.43,,,18966.15,100% of Medicare,,15315.43,,,18966.15,100% of Medicare,,15315.43,,,18966.15,100% of Medicare,,15315.43,,,18966.15,100% of Medicare,,15315.43,,,18966.15,100% of Medicare,,15315.43,,,18966.15,100% of Medicare,,15315.43,,,18966.15,100% of Medicare,,,15315.43,,,18966.15,100% of Medicare,8367.98,,,,EAPG rate,100% of IL Medicaid,8367.98,,,,EAPG rate,100% of IL Medicaid,8367.98,,,,EAPG rate,100% of IL Medicaid,8367.98,,,,EAPG rate,100% of IL Medicaid,8367.98,39822.3,
"Intrerscapular-thoracic, ext power, molded inner socket, remov shell, shoulder bulkhead, humeral sec",L6970,HCPCS,,,,outpatient,,,45824,27494.4,,45.5,,20849.92,percent of total billed charges,,,45.3,,20758.27,percent of total billed charges,,,39,,17871.36,percent of total billed charges,,,,,,,,,80,,36659.2,percent of total billed charges,,,61.4,,28135.94,percent of total billed charges,,,57.4,,26302.98,percent of total billed charges,,,81,,37117.44,percent of total billed charges,,,39,,17871.36,percent of total billed charges,,,57.6,,26394.62,percent of total billed charges,,,85,,38950.4,percent of total billed charges,,,85,,38950.4,percent of total billed charges,,,49,,22453.76,percent of total billed charges,,,90,,41241.6,percent of total billed charges,,,65,,29785.6,percent of total billed charges,,,80,,36659.2,percent of total billed charges,,,55,,25203.2,percent of total billed charges,,,55,,25203.2,percent of total billed charges,,,65,,29785.6,percent of total billed charges,,,78,,35742.72,percent of total billed charges,,,70,,32076.8,percent of total billed charges,,,,,,,,19420.61,,,,100% of Medicare,,19420.61,,,999999999,100% of Medicare,,19420.61,,,999999999,100% of Medicare,,19420.61,,,999999999,100% of Medicare,,19420.61,,,999999999,100% of Medicare,,19420.61,,,999999999,100% of Medicare,,19420.61,,,999999999,100% of Medicare,,19420.61,,,999999999,100% of Medicare,,19420.61,,,999999999,100% of Medicare,,19420.61,,,999999999,100% of Medicare,,19420.61,,,999999999,100% of Medicare,,19420.61,,,999999999,100% of Medicare,,,19420.61,,,999999999,100% of Medicare,8694.73,,,,EAPG rate,100% of IL Medicaid,8694.73,,,,EAPG rate,100% of IL Medicaid,8694.73,,,,EAPG rate,100% of IL Medicaid,8694.73,,,,EAPG rate,100% of IL Medicaid,8694.73,999999999,
AK/FT POWER ASST INCL MOTORS (L5969),L5969,HCPCS,,,,outpatient,,,47322,28393.2,,45.5,,21531.51,percent of total billed charges,,,45.3,,21436.87,percent of total billed charges,,,39,,18455.58,percent of total billed charges,,,,,,,,,80,,37857.6,percent of total billed charges,,,61.4,,29055.71,percent of total billed charges,,,57.4,,27162.83,percent of total billed charges,,,81,,38330.82,percent of total billed charges,,,39,,18455.58,percent of total billed charges,,,57.6,,27257.47,percent of total billed charges,,,85,,40223.7,percent of total billed charges,,,85,,40223.7,percent of total billed charges,,,49,,23187.78,percent of total billed charges,,,90,,42589.8,percent of total billed charges,,,65,,30759.3,percent of total billed charges,,,80,,37857.6,percent of total billed charges,,,55,,26027.1,percent of total billed charges,,,55,,26027.1,percent of total billed charges,,,65,,30759.3,percent of total billed charges,,,78,,36911.16,percent of total billed charges,,,70,,33125.4,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,9005.12,,,,EAPG rate,100% of IL Medicaid,9005.12,,,,EAPG rate,100% of IL Medicaid,9005.12,,,,EAPG rate,100% of IL Medicaid,9005.12,,,,EAPG rate,100% of IL Medicaid,9005.12,999999999,
"L5858 Add to LE pros, endo knee-shin sys, microproc stance only",L5858,HCPCS,,,,outpatient,,,50324,30194.4,,45.5,,22897.42,percent of total billed charges,,,45.3,,22796.77,percent of total billed charges,,,39,,19626.36,percent of total billed charges,,,,,,,,,80,,40259.2,percent of total billed charges,,,61.4,,30898.94,percent of total billed charges,,,57.4,,28885.98,percent of total billed charges,,,81,,40762.44,percent of total billed charges,,,39,,19626.36,percent of total billed charges,,,57.6,,28986.62,percent of total billed charges,,,85,,42775.4,percent of total billed charges,,,85,,42775.4,percent of total billed charges,,,49,,24658.76,percent of total billed charges,,,90,,45291.6,percent of total billed charges,,,65,,32710.6,percent of total billed charges,,,80,,40259.2,percent of total billed charges,,,55,,27678.2,percent of total billed charges,,,55,,27678.2,percent of total billed charges,,,65,,32710.6,percent of total billed charges,,,78,,39252.72,percent of total billed charges,,,70,,35226.8,percent of total billed charges,,,,,,,,22436.32,,,,100% of Medicare,,22436.32,,,999999999,100% of Medicare,,22436.32,,,999999999,100% of Medicare,,22436.32,,,999999999,100% of Medicare,,22436.32,,,999999999,100% of Medicare,,22436.32,,,999999999,100% of Medicare,,22436.32,,,999999999,100% of Medicare,,22436.32,,,999999999,100% of Medicare,,22436.32,,,999999999,100% of Medicare,,22436.32,,,999999999,100% of Medicare,,22436.32,,,999999999,100% of Medicare,,22436.32,,,999999999,100% of Medicare,,,22436.32,,,999999999,100% of Medicare,9627.13,,,,EAPG rate,100% of IL Medicaid,9627.13,,,,EAPG rate,100% of IL Medicaid,9627.13,,,,EAPG rate,100% of IL Medicaid,9627.13,,,,EAPG rate,100% of IL Medicaid,9627.13,999999999,
"Interscapular-thoracic, ext power, molded inner socket, remov shell, shoulder bulkhead, humeral sect",L6975,HCPCS,,,,outpatient,,,50514,30308.4,,45.5,,22983.87,percent of total billed charges,,,45.3,,22882.84,percent of total billed charges,,,39,,19700.46,percent of total billed charges,,,,,,,,,80,,40411.2,percent of total billed charges,,,61.4,,31015.6,percent of total billed charges,,,57.4,,28995.04,percent of total billed charges,,,81,,40916.34,percent of total billed charges,,,39,,19700.46,percent of total billed charges,,,57.6,,29096.06,percent of total billed charges,,,85,,42936.9,percent of total billed charges,,,85,,42936.9,percent of total billed charges,,,49,,24751.86,percent of total billed charges,,,90,,45462.6,percent of total billed charges,,,65,,32834.1,percent of total billed charges,,,80,,40411.2,percent of total billed charges,,,55,,27782.7,percent of total billed charges,,,55,,27782.7,percent of total billed charges,,,65,,32834.1,percent of total billed charges,,,78,,39400.92,percent of total billed charges,,,70,,35359.8,percent of total billed charges,,,,,,,,21406.09,,,,100% of Medicare,,21406.09,,,999999999,100% of Medicare,,21406.09,,,999999999,100% of Medicare,,21406.09,,,999999999,100% of Medicare,,21406.09,,,999999999,100% of Medicare,,21406.09,,,999999999,100% of Medicare,,21406.09,,,999999999,100% of Medicare,,21406.09,,,999999999,100% of Medicare,,21406.09,,,999999999,100% of Medicare,,21406.09,,,999999999,100% of Medicare,,21406.09,,,999999999,100% of Medicare,,21406.09,,,999999999,100% of Medicare,,,21406.09,,,999999999,100% of Medicare,9666.5,,,,EAPG rate,100% of IL Medicaid,9666.5,,,,EAPG rate,100% of IL Medicaid,9666.5,,,,EAPG rate,100% of IL Medicaid,9666.5,,,,EAPG rate,100% of IL Medicaid,9666.5,999999999,
ANK-FOOT SYS DORS-PLANT FLEX,L5973,HCPCS,,,,outpatient,,,51263,30757.8,,45.5,,23324.67,percent of total billed charges,,,45.3,,23222.14,percent of total billed charges,,,39,,19992.57,percent of total billed charges,,,,,,,,,80,,41010.4,percent of total billed charges,,,61.4,,31475.48,percent of total billed charges,,,57.4,,29424.96,percent of total billed charges,,,81,,41523.03,percent of total billed charges,,,39,,19992.57,percent of total billed charges,,,57.6,,29527.49,percent of total billed charges,,,85,,43573.55,percent of total billed charges,,,85,,43573.55,percent of total billed charges,,,49,,25118.87,percent of total billed charges,,,90,,46136.7,percent of total billed charges,,,65,,33320.95,percent of total billed charges,,,80,,41010.4,percent of total billed charges,,,55,,28194.65,percent of total billed charges,,,55,,28194.65,percent of total billed charges,,,65,,33320.95,percent of total billed charges,,,78,,39985.14,percent of total billed charges,,,70,,35884.1,percent of total billed charges,,,,,,,,21313.25,,,,100% of Medicare,,21313.25,,,20648.95,100% of Medicare,,21313.25,,,20648.95,100% of Medicare,,21313.25,,,20648.95,100% of Medicare,,21313.25,,,20648.95,100% of Medicare,,21313.25,,,20648.95,100% of Medicare,,21313.25,,,20648.95,100% of Medicare,,21313.25,,,20648.95,100% of Medicare,,21313.25,,,20648.95,100% of Medicare,,21313.25,,,20648.95,100% of Medicare,,21313.25,,,20648.95,100% of Medicare,,21313.25,,,20648.95,100% of Medicare,,,21313.25,,,20648.95,100% of Medicare,9821.69,,,,EAPG rate,100% of IL Medicaid,9821.69,,,,EAPG rate,100% of IL Medicaid,9821.69,,,,EAPG rate,100% of IL Medicaid,9821.69,,,,EAPG rate,100% of IL Medicaid,9821.69,46136.7,
"Shoulder disarticulation, external power, myo control",L6965,HCPCS,,,,outpatient,,,52941,31764.6,,45.5,,24088.16,percent of total billed charges,,,45.3,,23982.27,percent of total billed charges,,,39,,20646.99,percent of total billed charges,,,,,,,,,80,,42352.8,percent of total billed charges,,,61.4,,32505.77,percent of total billed charges,,,57.4,,30388.13,percent of total billed charges,,,81,,42882.21,percent of total billed charges,,,39,,20646.99,percent of total billed charges,,,57.6,,30494.02,percent of total billed charges,,,85,,44999.85,percent of total billed charges,,,85,,44999.85,percent of total billed charges,,,49,,25941.09,percent of total billed charges,,,90,,47646.9,percent of total billed charges,,,65,,34411.65,percent of total billed charges,,,80,,42352.8,percent of total billed charges,,,55,,29117.55,percent of total billed charges,,,55,,29117.55,percent of total billed charges,,,65,,34411.65,percent of total billed charges,,,78,,41293.98,percent of total billed charges,,,70,,37058.7,percent of total billed charges,,,,,,,,18143.5,,,,100% of Medicare,,18143.5,,,999999999,100% of Medicare,,18143.5,,,999999999,100% of Medicare,,18143.5,,,999999999,100% of Medicare,,18143.5,,,999999999,100% of Medicare,,18143.5,,,999999999,100% of Medicare,,18143.5,,,999999999,100% of Medicare,,18143.5,,,999999999,100% of Medicare,,18143.5,,,999999999,100% of Medicare,,18143.5,,,999999999,100% of Medicare,,18143.5,,,999999999,100% of Medicare,,18143.5,,,999999999,100% of Medicare,,,18143.5,,,999999999,100% of Medicare,10169.38,,,,EAPG rate,100% of IL Medicaid,10169.38,,,,EAPG rate,100% of IL Medicaid,10169.38,,,,EAPG rate,100% of IL Medicaid,10169.38,,,,EAPG rate,100% of IL Medicaid,10169.38,999999999,
"Powered UE Orthosis, Elbow Wrist Hand, Custom",L8701,HCPCS,,,,outpatient,,,54097,32458.2,,45.5,,24614.14,percent of total billed charges,,,45.3,,24505.94,percent of total billed charges,,,39,,21097.83,percent of total billed charges,,,,,,,,,80,,43277.6,percent of total billed charges,,,61.4,,33215.56,percent of total billed charges,,,57.4,,31051.68,percent of total billed charges,,,81,,43818.57,percent of total billed charges,,,39,,21097.83,percent of total billed charges,,,57.6,,31159.87,percent of total billed charges,,,85,,45982.45,percent of total billed charges,,,85,,45982.45,percent of total billed charges,,,49,,26507.53,percent of total billed charges,,,90,,48687.3,percent of total billed charges,,,65,,35163.05,percent of total billed charges,,,80,,43277.6,percent of total billed charges,,,55,,29753.35,percent of total billed charges,,,55,,29753.35,percent of total billed charges,,,65,,35163.05,percent of total billed charges,,,78,,42195.66,percent of total billed charges,,,70,,37867.9,percent of total billed charges,,,,,,,,34284.44,,,,100% of Medicare,,34284.44,,,24486.79,100% of Medicare,,34284.44,,,24486.79,100% of Medicare,,34284.44,,,24486.79,100% of Medicare,,34284.44,,,24486.79,100% of Medicare,,34284.44,,,24486.79,100% of Medicare,,34284.44,,,24486.79,100% of Medicare,,34284.44,,,24486.79,100% of Medicare,,34284.44,,,24486.79,100% of Medicare,,34284.44,,,24486.79,100% of Medicare,,34284.44,,,24486.79,100% of Medicare,,34284.44,,,24486.79,100% of Medicare,,,34284.44,,,24486.79,100% of Medicare,10408.9,,,,EAPG rate,100% of IL Medicaid,10408.9,,,,EAPG rate,100% of IL Medicaid,10408.9,,,,EAPG rate,100% of IL Medicaid,10408.9,,,,EAPG rate,100% of IL Medicaid,10408.9,48687.3,
"Addition to LE pros, endo knee-shin sys, microproc-control feature, swing and stance, incl elec sens",L5856,HCPCS,,,,outpatient,,,83725,50235,,45.5,,38094.88,percent of total billed charges,,,45.3,,37927.43,percent of total billed charges,,,39,,32652.75,percent of total billed charges,,,,,,,,,80,,66980,percent of total billed charges,,,61.4,,51407.15,percent of total billed charges,,,57.4,,48058.15,percent of total billed charges,,,81,,67817.25,percent of total billed charges,,,39,,32652.75,percent of total billed charges,,,57.6,,48225.6,percent of total billed charges,,,85,,71166.25,percent of total billed charges,,,85,,71166.25,percent of total billed charges,,,49,,41025.25,percent of total billed charges,,,90,,75352.5,percent of total billed charges,,,65,,54421.25,percent of total billed charges,,,80,,66980,percent of total billed charges,,,55,,46048.75,percent of total billed charges,,,55,,46048.75,percent of total billed charges,,,65,,54421.25,percent of total billed charges,,,78,,65305.5,percent of total billed charges,,,70,,58607.5,percent of total billed charges,,,,,,,,28980.18,,,,100% of Medicare,,28980.18,,,23774.35,100% of Medicare,,28980.18,,,23774.35,100% of Medicare,,28980.18,,,23774.35,100% of Medicare,,28980.18,,,23774.35,100% of Medicare,,28980.18,,,23774.35,100% of Medicare,,28980.18,,,23774.35,100% of Medicare,,28980.18,,,23774.35,100% of Medicare,,28980.18,,,23774.35,100% of Medicare,,28980.18,,,23774.35,100% of Medicare,,28980.18,,,23774.35,100% of Medicare,,28980.18,,,23774.35,100% of Medicare,,,28980.18,,,23774.35,100% of Medicare,16547.82,,,,EAPG rate,100% of IL Medicaid,16547.82,,,,EAPG rate,100% of IL Medicaid,16547.82,,,,EAPG rate,100% of IL Medicaid,16547.82,,,,EAPG rate,100% of IL Medicaid,16547.82,75352.5,
L6880 ELEC HAND IND ART DIGITS,L6880,HCPCS,,,,outpatient,,,84424,50654.4,,45.5,,38412.92,percent of total billed charges,,,45.3,,38244.07,percent of total billed charges,,,39,,32925.36,percent of total billed charges,,,,,,,,,80,,67539.2,percent of total billed charges,,,61.4,,51836.34,percent of total billed charges,,,57.4,,48459.38,percent of total billed charges,,,81,,68383.44,percent of total billed charges,,,39,,32925.36,percent of total billed charges,,,57.6,,48628.22,percent of total billed charges,,,85,,71760.4,percent of total billed charges,,,85,,71760.4,percent of total billed charges,,,49,,41367.76,percent of total billed charges,,,90,,75981.6,percent of total billed charges,,,65,,54875.6,percent of total billed charges,,,80,,67539.2,percent of total billed charges,,,55,,46433.2,percent of total billed charges,,,55,,46433.2,percent of total billed charges,,,65,,54875.6,percent of total billed charges,,,78,,65850.72,percent of total billed charges,,,70,,59096.8,percent of total billed charges,,,,,,,,28843.34,,,,100% of Medicare,,28843.34,,,31243.46,100% of Medicare,,28843.34,,,31243.46,100% of Medicare,,28843.34,,,31243.46,100% of Medicare,,28843.34,,,31243.46,100% of Medicare,,28843.34,,,31243.46,100% of Medicare,,28843.34,,,31243.46,100% of Medicare,,28843.34,,,31243.46,100% of Medicare,,28843.34,,,31243.46,100% of Medicare,,28843.34,,,31243.46,100% of Medicare,,28843.34,,,31243.46,100% of Medicare,,28843.34,,,31243.46,100% of Medicare,,,28843.34,,,31243.46,100% of Medicare,16692.65,,,,EAPG rate,100% of IL Medicaid,16692.65,,,,EAPG rate,100% of IL Medicaid,16692.65,,,,EAPG rate,100% of IL Medicaid,16692.65,,,,EAPG rate,100% of IL Medicaid,16692.65,75981.6,
"Powered UE Orthosis, Elbow Wrist Hand Finger, Custom",L8702,HCPCS,,,,outpatient,,,103077,61846.2,,45.5,,46900.04,percent of total billed charges,,,45.3,,46693.88,percent of total billed charges,,,39,,40200.03,percent of total billed charges,,,,,,,,,80,,82461.6,percent of total billed charges,,,61.4,,63289.28,percent of total billed charges,,,57.4,,59166.2,percent of total billed charges,,,81,,83492.37,percent of total billed charges,,,39,,40200.03,percent of total billed charges,,,57.6,,59372.35,percent of total billed charges,,,85,,87615.45,percent of total billed charges,,,85,,87615.45,percent of total billed charges,,,49,,50507.73,percent of total billed charges,,,90,,92769.3,percent of total billed charges,,,65,,67000.05,percent of total billed charges,,,80,,82461.6,percent of total billed charges,,,55,,56692.35,percent of total billed charges,,,55,,56692.35,percent of total billed charges,,,65,,67000.05,percent of total billed charges,,,78,,80400.06,percent of total billed charges,,,70,,72153.9,percent of total billed charges,,,,,,,,67452.66,,,,100% of Medicare,,67452.66,,,999999999,100% of Medicare,,67452.66,,,999999999,100% of Medicare,,67452.66,,,999999999,100% of Medicare,,67452.66,,,999999999,100% of Medicare,,67452.66,,,999999999,100% of Medicare,,67452.66,,,999999999,100% of Medicare,,67452.66,,,999999999,100% of Medicare,,67452.66,,,999999999,100% of Medicare,,67452.66,,,999999999,100% of Medicare,,67452.66,,,999999999,100% of Medicare,,67452.66,,,999999999,100% of Medicare,,,67452.66,,,999999999,100% of Medicare,20557.55,,,,EAPG rate,100% of IL Medicaid,20557.55,,,,EAPG rate,100% of IL Medicaid,20557.55,,,,EAPG rate,100% of IL Medicaid,20557.55,,,,EAPG rate,100% of IL Medicaid,20557.55,999999999,
"L2006 KAFO, Microprocessor Swing and/or Stance",L2006,HCPCS,,,,outpatient,,,104334,62600.4,,45.5,,47471.97,percent of total billed charges,,,45.3,,47263.3,percent of total billed charges,,,39,,40690.26,percent of total billed charges,,,,,,,,,80,,83467.2,percent of total billed charges,,,61.4,,64061.08,percent of total billed charges,,,57.4,,59887.72,percent of total billed charges,,,81,,84510.54,percent of total billed charges,,,39,,40690.26,percent of total billed charges,,,57.6,,60096.38,percent of total billed charges,,,85,,88683.9,percent of total billed charges,,,85,,88683.9,percent of total billed charges,,,49,,51123.66,percent of total billed charges,,,90,,93900.6,percent of total billed charges,,,65,,67817.1,percent of total billed charges,,,80,,83467.2,percent of total billed charges,,,55,,57383.7,percent of total billed charges,,,55,,57383.7,percent of total billed charges,,,65,,67817.1,percent of total billed charges,,,78,,81380.52,percent of total billed charges,,,70,,73033.8,percent of total billed charges,,,,,,,,38762.63,,,,100% of Medicare,,38762.63,,,999999999,100% of Medicare,,38762.63,,,999999999,100% of Medicare,,38762.63,,,999999999,100% of Medicare,,38762.63,,,999999999,100% of Medicare,,38762.63,,,999999999,100% of Medicare,,38762.63,,,999999999,100% of Medicare,,38762.63,,,999999999,100% of Medicare,,38762.63,,,999999999,100% of Medicare,,38762.63,,,999999999,100% of Medicare,,38762.63,,,999999999,100% of Medicare,,38762.63,,,999999999,100% of Medicare,,,38762.63,,,999999999,100% of Medicare,20818,,,,EAPG rate,100% of IL Medicaid,20818,,,,EAPG rate,100% of IL Medicaid,20818,,,,EAPG rate,100% of IL Medicaid,20818,,,,EAPG rate,100% of IL Medicaid,20818,999999999,
"Electronic elbow, microproc sequential control of elbow and terminal device",L7180,HCPCS,,,,outpatient,,,111961,67176.6,,45.5,,50942.26,percent of total billed charges,,,45.3,,50718.33,percent of total billed charges,,,39,,43664.79,percent of total billed charges,,,,,,,,,80,,89568.8,percent of total billed charges,,,61.4,,68744.05,percent of total billed charges,,,57.4,,64265.61,percent of total billed charges,,,81,,90688.41,percent of total billed charges,,,39,,43664.79,percent of total billed charges,,,57.6,,64489.54,percent of total billed charges,,,85,,95166.85,percent of total billed charges,,,85,,95166.85,percent of total billed charges,,,49,,54860.89,percent of total billed charges,,,90,,100764.9,percent of total billed charges,,,65,,72774.65,percent of total billed charges,,,80,,89568.8,percent of total billed charges,,,55,,61578.55,percent of total billed charges,,,55,,61578.55,percent of total billed charges,,,65,,72774.65,percent of total billed charges,,,78,,87329.58,percent of total billed charges,,,70,,78372.7,percent of total billed charges,,,,,,,,46980.38,,,,100% of Medicare,,46980.38,,,35182.88,100% of Medicare,,46980.38,,,35182.88,100% of Medicare,,46980.38,,,35182.88,100% of Medicare,,46980.38,,,35182.88,100% of Medicare,,46980.38,,,35182.88,100% of Medicare,,46980.38,,,35182.88,100% of Medicare,,46980.38,,,35182.88,100% of Medicare,,46980.38,,,35182.88,100% of Medicare,,46980.38,,,35182.88,100% of Medicare,,46980.38,,,35182.88,100% of Medicare,,46980.38,,,35182.88,100% of Medicare,,,46980.38,,,35182.88,100% of Medicare,22398.32,,,,EAPG rate,100% of IL Medicaid,22398.32,,,,EAPG rate,100% of IL Medicaid,22398.32,,,,EAPG rate,100% of IL Medicaid,22398.32,,,,EAPG rate,100% of IL Medicaid,22398.32,100764.9,
"Electronic elbow, microproc simultaneous control of elbow and terminal device",L7181,HCPCS,,,,outpatient,,,123642,74185.2,,45.5,,56257.11,percent of total billed charges,,,45.3,,56009.83,percent of total billed charges,,,39,,48220.38,percent of total billed charges,,,,,,,,,80,,98913.6,percent of total billed charges,,,61.4,,75916.19,percent of total billed charges,,,57.4,,70970.51,percent of total billed charges,,,81,,100150.02,percent of total billed charges,,,39,,48220.38,percent of total billed charges,,,57.6,,71217.79,percent of total billed charges,,,85,,105095.7,percent of total billed charges,,,85,,105095.7,percent of total billed charges,,,49,,60584.58,percent of total billed charges,,,90,,111277.8,percent of total billed charges,,,65,,80367.3,percent of total billed charges,,,80,,98913.6,percent of total billed charges,,,55,,68003.1,percent of total billed charges,,,55,,68003.1,percent of total billed charges,,,65,,80367.3,percent of total billed charges,,,78,,96440.76,percent of total billed charges,,,70,,86549.4,percent of total billed charges,,,,,,,,48370.76,,,,100% of Medicare,,48370.76,,,999999999,100% of Medicare,,48370.76,,,999999999,100% of Medicare,,48370.76,,,999999999,100% of Medicare,,48370.76,,,999999999,100% of Medicare,,48370.76,,,999999999,100% of Medicare,,48370.76,,,999999999,100% of Medicare,,48370.76,,,999999999,100% of Medicare,,48370.76,,,999999999,100% of Medicare,,48370.76,,,999999999,100% of Medicare,,48370.76,,,999999999,100% of Medicare,,48370.76,,,999999999,100% of Medicare,,,48370.76,,,999999999,100% of Medicare,24818.62,,,,EAPG rate,100% of IL Medicaid,24818.62,,,,EAPG rate,100% of IL Medicaid,24818.62,,,,EAPG rate,100% of IL Medicaid,24818.62,,,,EAPG rate,100% of IL Medicaid,24818.62,999999999,
XR Shoulder 1 View Right,73020,CPT,,,RT,both,,,264,158.4,,45.5,,120.12,percent of total billed charges,,,45.3,,119.59,percent of total billed charges,,,51,,134.64,percent of total billed charges,,,,,,,,,80,,211.2,percent of total billed charges,,,61.4,,162.1,percent of total billed charges,,,57.4,,151.54,percent of total billed charges,,,81,,213.84,percent of total billed charges,,,51.5,,135.96,percent of total billed charges,,365,,,,fee schedule,,,85,,224.4,percent of total billed charges,,,85,,224.4,percent of total billed charges,,,49,,129.36,percent of total billed charges,,,90,,237.6,percent of total billed charges,,,65,,171.6,percent of total billed charges,,,80,,211.2,percent of total billed charges,,,55,,145.2,percent of total billed charges,,,55,,145.2,percent of total billed charges,,,65,,171.6,percent of total billed charges,,,78,,205.92,percent of total billed charges,,,70,,184.8,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,365,
XR Transthoracic Shoulder Right,73020,CPT,,,RT,both,,,264,158.4,,45.5,,120.12,percent of total billed charges,,,45.3,,119.59,percent of total billed charges,,,51,,134.64,percent of total billed charges,,,,,,,,,80,,211.2,percent of total billed charges,,,61.4,,162.1,percent of total billed charges,,,57.4,,151.54,percent of total billed charges,,,81,,213.84,percent of total billed charges,,,51.5,,135.96,percent of total billed charges,,365,,,,fee schedule,,,85,,224.4,percent of total billed charges,,,85,,224.4,percent of total billed charges,,,49,,129.36,percent of total billed charges,,,90,,237.6,percent of total billed charges,,,65,,171.6,percent of total billed charges,,,80,,211.2,percent of total billed charges,,,55,,145.2,percent of total billed charges,,,55,,145.2,percent of total billed charges,,,65,,171.6,percent of total billed charges,,,78,,205.92,percent of total billed charges,,,70,,184.8,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,365,
XR AC Joints Bilateral w/ + w/o wts,73050,CPT,,,,both,,,497,298.2,,45.5,,226.14,percent of total billed charges,,,45.3,,225.14,percent of total billed charges,,,51,,253.47,percent of total billed charges,,,,,,,,,80,,397.6,percent of total billed charges,,,61.4,,305.16,percent of total billed charges,,,57.4,,285.28,percent of total billed charges,,,81,,402.57,percent of total billed charges,,,51.5,,255.96,percent of total billed charges,,365,,,,fee schedule,,,85,,422.45,percent of total billed charges,,,85,,422.45,percent of total billed charges,,,49,,243.53,percent of total billed charges,,,90,,447.3,percent of total billed charges,,,65,,323.05,percent of total billed charges,,,80,,397.6,percent of total billed charges,,,55,,273.35,percent of total billed charges,,,55,,273.35,percent of total billed charges,,,65,,323.05,percent of total billed charges,,,78,,387.66,percent of total billed charges,,,70,,347.9,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,447.3,
XR Humerus Left,73060,CPT,,,LT,both,,,735,441,,45.5,,334.43,percent of total billed charges,,,45.3,,332.96,percent of total billed charges,,,51,,374.85,percent of total billed charges,,,,,,,,,80,,588,percent of total billed charges,,,61.4,,451.29,percent of total billed charges,,,57.4,,421.89,percent of total billed charges,,,81,,595.35,percent of total billed charges,,,51.5,,378.53,percent of total billed charges,,365,,,,fee schedule,,,85,,624.75,percent of total billed charges,,,85,,624.75,percent of total billed charges,,,49,,360.15,percent of total billed charges,,,90,,661.5,percent of total billed charges,,,65,,477.75,percent of total billed charges,,,80,,588,percent of total billed charges,,,55,,404.25,percent of total billed charges,,,55,,404.25,percent of total billed charges,,,65,,477.75,percent of total billed charges,,,78,,573.3,percent of total billed charges,,,70,,514.5,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,661.5,
Cranial Cervical Torticollis,L0113,HCPCS,,,,outpatient,,,646,387.6,,45.5,,293.93,percent of total billed charges,,,45.3,,292.64,percent of total billed charges,,,39,,251.94,percent of total billed charges,,,,,,,,,80,,516.8,percent of total billed charges,,,61.4,,396.64,percent of total billed charges,,,57.4,,370.8,percent of total billed charges,,,81,,523.26,percent of total billed charges,,,39,,251.94,percent of total billed charges,,,57.6,,372.1,percent of total billed charges,,,85,,549.1,percent of total billed charges,,,85,,549.1,percent of total billed charges,,,49,,316.54,percent of total billed charges,,,90,,581.4,percent of total billed charges,,,65,,419.9,percent of total billed charges,,,80,,516.8,percent of total billed charges,,,55,,355.3,percent of total billed charges,,,55,,355.3,percent of total billed charges,,,65,,419.9,percent of total billed charges,,,78,,503.88,percent of total billed charges,,,70,,452.2,percent of total billed charges,,,,,,,,343.6,,,,100% of Medicare,,343.6,,,,100% of Medicare,,343.6,,,,100% of Medicare,,343.6,,,,100% of Medicare,,343.6,,,,100% of Medicare,,343.6,,,,100% of Medicare,,343.6,,,,100% of Medicare,,343.6,,,,100% of Medicare,,343.6,,,,100% of Medicare,,343.6,,,,100% of Medicare,,343.6,,,,100% of Medicare,,343.6,,,,100% of Medicare,,,343.6,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,251.94,581.4,
Foam Collar,L0120,HCPCS,,,,outpatient,,,142,85.2,,45.5,,64.61,percent of total billed charges,,,45.3,,64.33,percent of total billed charges,,,39,,55.38,percent of total billed charges,,,,,,,,,80,,113.6,percent of total billed charges,,,61.4,,87.19,percent of total billed charges,,,57.4,,81.51,percent of total billed charges,,,81,,115.02,percent of total billed charges,,,39,,55.38,percent of total billed charges,,,57.6,,81.79,percent of total billed charges,,,85,,120.7,percent of total billed charges,,,85,,120.7,percent of total billed charges,,,49,,69.58,percent of total billed charges,,,90,,127.8,percent of total billed charges,,,65,,92.3,percent of total billed charges,,,80,,113.6,percent of total billed charges,,,55,,78.1,percent of total billed charges,,,55,,78.1,percent of total billed charges,,,65,,92.3,percent of total billed charges,,,78,,110.76,percent of total billed charges,,,70,,99.4,percent of total billed charges,,,,,,,,31.87,,,,100% of Medicare,,31.87,,,,100% of Medicare,,31.87,,,,100% of Medicare,,31.87,,,,100% of Medicare,,31.87,,,,100% of Medicare,,31.87,,,,100% of Medicare,,31.87,,,,100% of Medicare,,31.87,,,,100% of Medicare,,31.87,,,,100% of Medicare,,31.87,,,,100% of Medicare,,31.87,,,,100% of Medicare,,31.87,,,,100% of Medicare,,,31.87,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,31.87,127.8,
"Cervical Collar, Flexible, Thermoplastic, Molded to Patient",L0130,HCPCS,,,,outpatient,,,390,234,,45.5,,177.45,percent of total billed charges,,,45.3,,176.67,percent of total billed charges,,,39,,152.1,percent of total billed charges,,,,,,,,,80,,312,percent of total billed charges,,,61.4,,239.46,percent of total billed charges,,,57.4,,223.86,percent of total billed charges,,,81,,315.9,percent of total billed charges,,,39,,152.1,percent of total billed charges,,,57.6,,224.64,percent of total billed charges,,,85,,331.5,percent of total billed charges,,,85,,331.5,percent of total billed charges,,,49,,191.1,percent of total billed charges,,,90,,351,percent of total billed charges,,,65,,253.5,percent of total billed charges,,,80,,312,percent of total billed charges,,,55,,214.5,percent of total billed charges,,,55,,214.5,percent of total billed charges,,,65,,253.5,percent of total billed charges,,,78,,304.2,percent of total billed charges,,,70,,273,percent of total billed charges,,,,,,,,183.91,,,,100% of Medicare,,183.91,,,,100% of Medicare,,183.91,,,,100% of Medicare,,183.91,,,,100% of Medicare,,183.91,,,,100% of Medicare,,183.91,,,,100% of Medicare,,183.91,,,,100% of Medicare,,183.91,,,,100% of Medicare,,183.91,,,,100% of Medicare,,183.91,,,,100% of Medicare,,183.91,,,,100% of Medicare,,183.91,,,,100% of Medicare,,,183.91,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,152.1,351,
"Cervical Collar, Semi-Rigid, Adjustable Plastic",L0140,HCPCS,,,,outpatient,,,156,93.6,,45.5,,70.98,percent of total billed charges,,,45.3,,70.67,percent of total billed charges,,,39,,60.84,percent of total billed charges,,,,,,,,,80,,124.8,percent of total billed charges,,,61.4,,95.78,percent of total billed charges,,,57.4,,89.54,percent of total billed charges,,,81,,126.36,percent of total billed charges,,,39,,60.84,percent of total billed charges,,,57.6,,89.86,percent of total billed charges,,,85,,132.6,percent of total billed charges,,,85,,132.6,percent of total billed charges,,,49,,76.44,percent of total billed charges,,,90,,140.4,percent of total billed charges,,,65,,101.4,percent of total billed charges,,,80,,124.8,percent of total billed charges,,,55,,85.8,percent of total billed charges,,,55,,85.8,percent of total billed charges,,,65,,101.4,percent of total billed charges,,,78,,121.68,percent of total billed charges,,,70,,109.2,percent of total billed charges,,,,,,,,72.12,,,,100% of Medicare,,72.12,,,,100% of Medicare,,72.12,,,,100% of Medicare,,72.12,,,,100% of Medicare,,72.12,,,,100% of Medicare,,72.12,,,,100% of Medicare,,72.12,,,,100% of Medicare,,72.12,,,,100% of Medicare,,72.12,,,,100% of Medicare,,72.12,,,,100% of Medicare,,72.12,,,,100% of Medicare,,72.12,,,,100% of Medicare,,,72.12,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,60.84,140.4,
"Cervical Collar, Semi-Rigid, Adjustable Molded Chin Cup",L0150,HCPCS,,,,outpatient,,,577,346.2,,45.5,,262.54,percent of total billed charges,,,45.3,,261.38,percent of total billed charges,,,39,,225.03,percent of total billed charges,,,,,,,,,80,,461.6,percent of total billed charges,,,61.4,,354.28,percent of total billed charges,,,57.4,,331.2,percent of total billed charges,,,81,,467.37,percent of total billed charges,,,39,,225.03,percent of total billed charges,,,57.6,,332.35,percent of total billed charges,,,85,,490.45,percent of total billed charges,,,85,,490.45,percent of total billed charges,,,49,,282.73,percent of total billed charges,,,90,,519.3,percent of total billed charges,,,65,,375.05,percent of total billed charges,,,80,,461.6,percent of total billed charges,,,55,,317.35,percent of total billed charges,,,55,,317.35,percent of total billed charges,,,65,,375.05,percent of total billed charges,,,78,,450.06,percent of total billed charges,,,70,,403.9,percent of total billed charges,,,,,,,,128.96,,,,100% of Medicare,,128.96,,,,100% of Medicare,,128.96,,,,100% of Medicare,,128.96,,,,100% of Medicare,,128.96,,,,100% of Medicare,,128.96,,,,100% of Medicare,,128.96,,,,100% of Medicare,,128.96,,,,100% of Medicare,,128.96,,,,100% of Medicare,,128.96,,,,100% of Medicare,,128.96,,,,100% of Medicare,,128.96,,,,100% of Medicare,,,128.96,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,128.96,519.3,
"Cervical Collar, Semi-Rigid, Wire-Frame",L0160,HCPCS,,,,outpatient,,,817,490.2,,45.5,,371.74,percent of total billed charges,,,45.3,,370.1,percent of total billed charges,,,39,,318.63,percent of total billed charges,,,,,,,,,80,,653.6,percent of total billed charges,,,61.4,,501.64,percent of total billed charges,,,57.4,,468.96,percent of total billed charges,,,81,,661.77,percent of total billed charges,,,39,,318.63,percent of total billed charges,,,57.6,,470.59,percent of total billed charges,,,85,,694.45,percent of total billed charges,,,85,,694.45,percent of total billed charges,,,49,,400.33,percent of total billed charges,,,90,,735.3,percent of total billed charges,,,65,,531.05,percent of total billed charges,,,80,,653.6,percent of total billed charges,,,55,,449.35,percent of total billed charges,,,55,,449.35,percent of total billed charges,,,65,,531.05,percent of total billed charges,,,78,,637.26,percent of total billed charges,,,70,,571.9,percent of total billed charges,,,,,,,,188.31,,,,100% of Medicare,,188.31,,,,100% of Medicare,,188.31,,,,100% of Medicare,,188.31,,,,100% of Medicare,,188.31,,,,100% of Medicare,,188.31,,,,100% of Medicare,,188.31,,,,100% of Medicare,,188.31,,,,100% of Medicare,,188.31,,,,100% of Medicare,,188.31,,,,100% of Medicare,,188.31,,,,100% of Medicare,,188.31,,,,100% of Medicare,,,188.31,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,188.31,735.3,
"Collar, Semi-Rigid 2-Piece",L0172,HCPCS,,,,outpatient,,,761,456.6,,45.5,,346.26,percent of total billed charges,,,45.3,,344.73,percent of total billed charges,,,39,,296.79,percent of total billed charges,,,,,,,,,80,,608.8,percent of total billed charges,,,61.4,,467.25,percent of total billed charges,,,57.4,,436.81,percent of total billed charges,,,81,,616.41,percent of total billed charges,,,39,,296.79,percent of total billed charges,,,57.6,,438.34,percent of total billed charges,,,85,,646.85,percent of total billed charges,,,85,,646.85,percent of total billed charges,,,49,,372.89,percent of total billed charges,,,90,,684.9,percent of total billed charges,,,65,,494.65,percent of total billed charges,,,80,,608.8,percent of total billed charges,,,55,,418.55,percent of total billed charges,,,55,,418.55,percent of total billed charges,,,65,,494.65,percent of total billed charges,,,78,,593.58,percent of total billed charges,,,70,,532.7,percent of total billed charges,,,,,,,,170.64,,,,100% of Medicare,,170.64,,,,100% of Medicare,,170.64,,,,100% of Medicare,,170.64,,,,100% of Medicare,,170.64,,,,100% of Medicare,,170.64,,,,100% of Medicare,,170.64,,,,100% of Medicare,,170.64,,,,100% of Medicare,,170.64,,,,100% of Medicare,,170.64,,,,100% of Medicare,,170.64,,,,100% of Medicare,,170.64,,,,100% of Medicare,,,170.64,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,170.64,684.9,
"Collar, Cervical, w/ Thoracic Extensions",L0174,HCPCS,,,,outpatient,,,1497,898.2,,45.5,,681.14,percent of total billed charges,,,45.3,,678.14,percent of total billed charges,,,39,,583.83,percent of total billed charges,,,,,,,,,80,,1197.6,percent of total billed charges,,,61.4,,919.16,percent of total billed charges,,,57.4,,859.28,percent of total billed charges,,,81,,1212.57,percent of total billed charges,,,39,,583.83,percent of total billed charges,,,57.6,,862.27,percent of total billed charges,,,85,,1272.45,percent of total billed charges,,,85,,1272.45,percent of total billed charges,,,49,,733.53,percent of total billed charges,,,90,,1347.3,percent of total billed charges,,,65,,973.05,percent of total billed charges,,,80,,1197.6,percent of total billed charges,,,55,,823.35,percent of total billed charges,,,55,,823.35,percent of total billed charges,,,65,,973.05,percent of total billed charges,,,78,,1167.66,percent of total billed charges,,,70,,1047.9,percent of total billed charges,,,,,,,,335.53,,,,100% of Medicare,,335.53,,,,100% of Medicare,,335.53,,,,100% of Medicare,,335.53,,,,100% of Medicare,,335.53,,,,100% of Medicare,,335.53,,,,100% of Medicare,,335.53,,,,100% of Medicare,,335.53,,,,100% of Medicare,,335.53,,,,100% of Medicare,,335.53,,,,100% of Medicare,,335.53,,,,100% of Medicare,,335.53,,,,100% of Medicare,,,335.53,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,335.53,1347.3,
"Cervical Collar, Muti-Post, Occip/Mand Supports, Adjustable",L0180,HCPCS,,,,outpatient,,,2428,1456.8,,45.5,,1104.74,percent of total billed charges,,,45.3,,1099.88,percent of total billed charges,,,39,,946.92,percent of total billed charges,,,,,,,,,80,,1942.4,percent of total billed charges,,,61.4,,1490.79,percent of total billed charges,,,57.4,,1393.67,percent of total billed charges,,,81,,1966.68,percent of total billed charges,,,39,,946.92,percent of total billed charges,,,57.6,,1398.53,percent of total billed charges,,,85,,2063.8,percent of total billed charges,,,85,,2063.8,percent of total billed charges,,,49,,1189.72,percent of total billed charges,,,90,,2185.2,percent of total billed charges,,,65,,1578.2,percent of total billed charges,,,80,,1942.4,percent of total billed charges,,,55,,1335.4,percent of total billed charges,,,55,,1335.4,percent of total billed charges,,,65,,1578.2,percent of total billed charges,,,78,,1893.84,percent of total billed charges,,,70,,1699.6,percent of total billed charges,,,,,,,,543.58,,,,100% of Medicare,,543.58,,,,100% of Medicare,,543.58,,,,100% of Medicare,,543.58,,,,100% of Medicare,,543.58,,,,100% of Medicare,,543.58,,,,100% of Medicare,,543.58,,,,100% of Medicare,,543.58,,,,100% of Medicare,,543.58,,,,100% of Medicare,,543.58,,,,100% of Medicare,,543.58,,,,100% of Medicare,,543.58,,,,100% of Medicare,,,543.58,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,543.58,2185.2,
"Collar, Cervical, SOMI",L0190,HCPCS,,,,outpatient,,,2862,1717.2,,45.5,,1302.21,percent of total billed charges,,,45.3,,1296.49,percent of total billed charges,,,39,,1116.18,percent of total billed charges,,,,,,,,,80,,2289.6,percent of total billed charges,,,61.4,,1757.27,percent of total billed charges,,,57.4,,1642.79,percent of total billed charges,,,81,,2318.22,percent of total billed charges,,,39,,1116.18,percent of total billed charges,,,57.6,,1648.51,percent of total billed charges,,,85,,2432.7,percent of total billed charges,,,85,,2432.7,percent of total billed charges,,,49,,1402.38,percent of total billed charges,,,90,,2575.8,percent of total billed charges,,,65,,1860.3,percent of total billed charges,,,80,,2289.6,percent of total billed charges,,,55,,1574.1,percent of total billed charges,,,55,,1574.1,percent of total billed charges,,,65,,1860.3,percent of total billed charges,,,78,,2232.36,percent of total billed charges,,,70,,2003.4,percent of total billed charges,,,,,,,,641.1,,,,100% of Medicare,,641.1,,,,100% of Medicare,,641.1,,,,100% of Medicare,,641.1,,,,100% of Medicare,,641.1,,,,100% of Medicare,,641.1,,,,100% of Medicare,,641.1,,,,100% of Medicare,,641.1,,,,100% of Medicare,,641.1,,,,100% of Medicare,,641.1,,,,100% of Medicare,,641.1,,,,100% of Medicare,,641.1,,,,100% of Medicare,,,641.1,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,641.1,2575.8,
"Collar, Cervical Multiple",L0200,HCPCS,,,,outpatient,,,3320,1992,,45.5,,1510.6,percent of total billed charges,,,45.3,,1503.96,percent of total billed charges,,,39,,1294.8,percent of total billed charges,,,,,,,,,80,,2656,percent of total billed charges,,,61.4,,2038.48,percent of total billed charges,,,57.4,,1905.68,percent of total billed charges,,,81,,2689.2,percent of total billed charges,,,39,,1294.8,percent of total billed charges,,,57.6,,1912.32,percent of total billed charges,,,85,,2822,percent of total billed charges,,,85,,2822,percent of total billed charges,,,49,,1626.8,percent of total billed charges,,,90,,2988,percent of total billed charges,,,65,,2158,percent of total billed charges,,,80,,2656,percent of total billed charges,,,55,,1826,percent of total billed charges,,,55,,1826,percent of total billed charges,,,65,,2158,percent of total billed charges,,,78,,2589.6,percent of total billed charges,,,70,,2324,percent of total billed charges,,,,,,,,743.62,,,,100% of Medicare,,743.62,,,,100% of Medicare,,743.62,,,,100% of Medicare,,743.62,,,,100% of Medicare,,743.62,,,,100% of Medicare,,743.62,,,,100% of Medicare,,743.62,,,,100% of Medicare,,743.62,,,,100% of Medicare,,743.62,,,,100% of Medicare,,743.62,,,,100% of Medicare,,743.62,,,,100% of Medicare,,743.62,,,,100% of Medicare,,,743.62,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,743.62,2988,
"Rib Belt, Thoracic, Custom Fabricated",L0220,HCPCS,,,,outpatient,,,332,199.2,,45.5,,151.06,percent of total billed charges,,,45.3,,150.4,percent of total billed charges,,,39,,129.48,percent of total billed charges,,,,,,,,,80,,265.6,percent of total billed charges,,,61.4,,203.85,percent of total billed charges,,,57.4,,190.57,percent of total billed charges,,,81,,268.92,percent of total billed charges,,,39,,129.48,percent of total billed charges,,,57.6,,191.23,percent of total billed charges,,,85,,282.2,percent of total billed charges,,,85,,282.2,percent of total billed charges,,,49,,162.68,percent of total billed charges,,,90,,298.8,percent of total billed charges,,,65,,215.8,percent of total billed charges,,,80,,265.6,percent of total billed charges,,,55,,182.6,percent of total billed charges,,,55,,182.6,percent of total billed charges,,,65,,215.8,percent of total billed charges,,,78,,258.96,percent of total billed charges,,,70,,232.4,percent of total billed charges,,,,,,,,155.65,,,,100% of Medicare,,155.65,,,,100% of Medicare,,155.65,,,,100% of Medicare,,155.65,,,,100% of Medicare,,155.65,,,,100% of Medicare,,155.65,,,,100% of Medicare,,155.65,,,,100% of Medicare,,155.65,,,,100% of Medicare,,155.65,,,,100% of Medicare,,155.65,,,,100% of Medicare,,155.65,,,,100% of Medicare,,155.65,,,,100% of Medicare,,,155.65,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,129.48,298.8,
"L0450 Thoracic-Lumbar-Sacral Orthosis, Flexible, Prefabricated",L0450,HCPCS,,,,outpatient,,,876,525.6,,45.5,,398.58,percent of total billed charges,,,45.3,,396.83,percent of total billed charges,,,39,,341.64,percent of total billed charges,,,,,,,,,80,,700.8,percent of total billed charges,,,61.4,,537.86,percent of total billed charges,,,57.4,,502.82,percent of total billed charges,,,81,,709.56,percent of total billed charges,,,39,,341.64,percent of total billed charges,,,57.6,,504.58,percent of total billed charges,,,85,,744.6,percent of total billed charges,,,85,,744.6,percent of total billed charges,,,49,,429.24,percent of total billed charges,,,90,,788.4,percent of total billed charges,,,65,,569.4,percent of total billed charges,,,80,,700.8,percent of total billed charges,,,55,,481.8,percent of total billed charges,,,55,,481.8,percent of total billed charges,,,65,,569.4,percent of total billed charges,,,78,,683.28,percent of total billed charges,,,70,,613.2,percent of total billed charges,,,,,,,,119.94,,,,100% of Medicare,,119.94,,,,100% of Medicare,,119.94,,,,100% of Medicare,,119.94,,,,100% of Medicare,,119.94,,,,100% of Medicare,,119.94,,,,100% of Medicare,,119.94,,,,100% of Medicare,,119.94,,,,100% of Medicare,,119.94,,,,100% of Medicare,,119.94,,,,100% of Medicare,,119.94,,,,100% of Medicare,,119.94,,,,100% of Medicare,,,119.94,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,119.94,788.4,
"L0452 Thoracic-Lumbar-Sacral Orthosis, Flexible, Custom Fabricated",L0452,HCPCS,,,,outpatient,,,1825,1095,,45.5,,830.38,percent of total billed charges,,,45.3,,826.73,percent of total billed charges,,,39,,711.75,percent of total billed charges,,,,,,,,,80,,1460,percent of total billed charges,,,61.4,,1120.55,percent of total billed charges,,,57.4,,1047.55,percent of total billed charges,,,81,,1478.25,percent of total billed charges,,,39,,711.75,percent of total billed charges,,,57.6,,1051.2,percent of total billed charges,,,85,,1551.25,percent of total billed charges,,,85,,1551.25,percent of total billed charges,,,49,,894.25,percent of total billed charges,,,90,,1642.5,percent of total billed charges,,,65,,1186.25,percent of total billed charges,,,80,,1460,percent of total billed charges,,,55,,1003.75,percent of total billed charges,,,55,,1003.75,percent of total billed charges,,,65,,1186.25,percent of total billed charges,,,78,,1423.5,percent of total billed charges,,,70,,1277.5,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,711.75,1642.5,
"Thoracic-Lumbar-Sacral Orthosis, Flexible, Prefabricated, Sacrococcygeal T9",L0454,HCPCS,,,,outpatient,,,1864,1118.4,,45.5,,848.12,percent of total billed charges,,,45.3,,844.39,percent of total billed charges,,,39,,726.96,percent of total billed charges,,,,,,,,,80,,1491.2,percent of total billed charges,,,61.4,,1144.5,percent of total billed charges,,,57.4,,1069.94,percent of total billed charges,,,81,,1509.84,percent of total billed charges,,,39,,726.96,percent of total billed charges,,,57.6,,1073.66,percent of total billed charges,,,85,,1584.4,percent of total billed charges,,,85,,1584.4,percent of total billed charges,,,49,,913.36,percent of total billed charges,,,90,,1677.6,percent of total billed charges,,,65,,1211.6,percent of total billed charges,,,80,,1491.2,percent of total billed charges,,,55,,1025.2,percent of total billed charges,,,55,,1025.2,percent of total billed charges,,,65,,1211.6,percent of total billed charges,,,78,,1453.92,percent of total billed charges,,,70,,1304.8,percent of total billed charges,,,,,,,,417.86,,,,100% of Medicare,,417.86,,,,100% of Medicare,,417.86,,,,100% of Medicare,,417.86,,,,100% of Medicare,,417.86,,,,100% of Medicare,,417.86,,,,100% of Medicare,,417.86,,,,100% of Medicare,,417.86,,,,100% of Medicare,,417.86,,,,100% of Medicare,,417.86,,,,100% of Medicare,,417.86,,,,100% of Medicare,,417.86,,,,100% of Medicare,,,417.86,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,417.86,1677.6,
TLSO FLEX TRNK SJ-T9 PRE OTS (L0455),L0455,HCPCS,,,,outpatient,,,1727,1036.2,,45.5,,785.79,percent of total billed charges,,,45.3,,782.33,percent of total billed charges,,,39,,673.53,percent of total billed charges,,,,,,,,,80,,1381.6,percent of total billed charges,,,61.4,,1060.38,percent of total billed charges,,,57.4,,991.3,percent of total billed charges,,,81,,1398.87,percent of total billed charges,,,39,,673.53,percent of total billed charges,,,57.6,,994.75,percent of total billed charges,,,85,,1467.95,percent of total billed charges,,,85,,1467.95,percent of total billed charges,,,49,,846.23,percent of total billed charges,,,90,,1554.3,percent of total billed charges,,,65,,1122.55,percent of total billed charges,,,80,,1381.6,percent of total billed charges,,,55,,949.85,percent of total billed charges,,,55,,949.85,percent of total billed charges,,,65,,1122.55,percent of total billed charges,,,78,,1347.06,percent of total billed charges,,,70,,1208.9,percent of total billed charges,,,,,,,,222.65,,,,100% of Medicare,,222.65,,,,100% of Medicare,,222.65,,,,100% of Medicare,,222.65,,,,100% of Medicare,,222.65,,,,100% of Medicare,,222.65,,,,100% of Medicare,,222.65,,,,100% of Medicare,,222.65,,,,100% of Medicare,,222.65,,,,100% of Medicare,,222.65,,,,100% of Medicare,,222.65,,,,100% of Medicare,,222.65,,,,100% of Medicare,,,222.65,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,222.65,1554.3,
"Thoracic-Lumbar-Sacral Orthosis, Flexible, Dorsolumbar, Prefabricated",L0456,HCPCS,,,,outpatient,,,2490,1494,,45.5,,1132.95,percent of total billed charges,,,45.3,,1127.97,percent of total billed charges,,,39,,971.1,percent of total billed charges,,,,,,,,,80,,1992,percent of total billed charges,,,61.4,,1528.86,percent of total billed charges,,,57.4,,1429.26,percent of total billed charges,,,81,,2016.9,percent of total billed charges,,,39,,971.1,percent of total billed charges,,,57.6,,1434.24,percent of total billed charges,,,85,,2116.5,percent of total billed charges,,,85,,2116.5,percent of total billed charges,,,49,,1220.1,percent of total billed charges,,,90,,2241,percent of total billed charges,,,65,,1618.5,percent of total billed charges,,,80,,1992,percent of total billed charges,,,55,,1369.5,percent of total billed charges,,,55,,1369.5,percent of total billed charges,,,65,,1618.5,percent of total billed charges,,,78,,1942.2,percent of total billed charges,,,70,,1743,percent of total billed charges,,,,,,,,1198.34,,,,100% of Medicare,,1198.34,,,,100% of Medicare,,1198.34,,,,100% of Medicare,,1198.34,,,,100% of Medicare,,1198.34,,,,100% of Medicare,,1198.34,,,,100% of Medicare,,1198.34,,,,100% of Medicare,,1198.34,,,,100% of Medicare,,1198.34,,,,100% of Medicare,,1198.34,,,,100% of Medicare,,1198.34,,,,100% of Medicare,,1198.34,,,,100% of Medicare,,,1198.34,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,971.1,2241,
"Thoracic-Lumbar-Sacral Orthosis, 2 Rigid Plastic Shells, Symphis-Xipho Prefabricated",L0458,HCPCS,,,,outpatient,,,2302,1381.2,,45.5,,1047.41,percent of total billed charges,,,45.3,,1042.81,percent of total billed charges,,,39,,897.78,percent of total billed charges,,,,,,,,,80,,1841.6,percent of total billed charges,,,61.4,,1413.43,percent of total billed charges,,,57.4,,1321.35,percent of total billed charges,,,81,,1864.62,percent of total billed charges,,,39,,897.78,percent of total billed charges,,,57.6,,1325.95,percent of total billed charges,,,85,,1956.7,percent of total billed charges,,,85,,1956.7,percent of total billed charges,,,49,,1127.98,percent of total billed charges,,,90,,2071.8,percent of total billed charges,,,65,,1496.3,percent of total billed charges,,,80,,1841.6,percent of total billed charges,,,55,,1266.1,percent of total billed charges,,,55,,1266.1,percent of total billed charges,,,65,,1496.3,percent of total billed charges,,,78,,1795.56,percent of total billed charges,,,70,,1611.4,percent of total billed charges,,,,,,,,1074.57,,,,100% of Medicare,,1074.57,,,,100% of Medicare,,1074.57,,,,100% of Medicare,,1074.57,,,,100% of Medicare,,1074.57,,,,100% of Medicare,,1074.57,,,,100% of Medicare,,1074.57,,,,100% of Medicare,,1074.57,,,,100% of Medicare,,1074.57,,,,100% of Medicare,,1074.57,,,,100% of Medicare,,1074.57,,,,100% of Medicare,,1074.57,,,,100% of Medicare,,,1074.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,897.78,2071.8,
"Thoracic-Lumbar-Sacral Orthosis, 2 Rigid Plastic Shells, Symphis-Stren, Prefabricated",L0460,HCPCS,,,,outpatient,,,3365,2019,,45.5,,1531.08,percent of total billed charges,,,45.3,,1524.35,percent of total billed charges,,,39,,1312.35,percent of total billed charges,,,,,,,,,80,,2692,percent of total billed charges,,,61.4,,2066.11,percent of total billed charges,,,57.4,,1931.51,percent of total billed charges,,,81,,2725.65,percent of total billed charges,,,39,,1312.35,percent of total billed charges,,,57.6,,1938.24,percent of total billed charges,,,85,,2860.25,percent of total billed charges,,,85,,2860.25,percent of total billed charges,,,49,,1648.85,percent of total billed charges,,,90,,3028.5,percent of total billed charges,,,65,,2187.25,percent of total billed charges,,,80,,2692,percent of total billed charges,,,55,,1850.75,percent of total billed charges,,,55,,1850.75,percent of total billed charges,,,65,,2187.25,percent of total billed charges,,,78,,2624.7,percent of total billed charges,,,70,,2355.5,percent of total billed charges,,,,,,,,1209.49,,,,100% of Medicare,,1209.49,,,,100% of Medicare,,1209.49,,,,100% of Medicare,,1209.49,,,,100% of Medicare,,1209.49,,,,100% of Medicare,,1209.49,,,,100% of Medicare,,1209.49,,,,100% of Medicare,,1209.49,,,,100% of Medicare,,1209.49,,,,100% of Medicare,,1209.49,,,,100% of Medicare,,1209.49,,,,100% of Medicare,,1209.49,,,,100% of Medicare,,,1209.49,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1209.49,3028.5,
"Thoracic-Lumbar-Sacral Orthosis, 3 Rigid Shells, Sagittal-Tran, Prefabricated",L0462,HCPCS,,,,outpatient,,,3218,1930.8,,45.5,,1464.19,percent of total billed charges,,,45.3,,1457.75,percent of total billed charges,,,39,,1255.02,percent of total billed charges,,,,,,,,,80,,2574.4,percent of total billed charges,,,61.4,,1975.85,percent of total billed charges,,,57.4,,1847.13,percent of total billed charges,,,81,,2606.58,percent of total billed charges,,,39,,1255.02,percent of total billed charges,,,57.6,,1853.57,percent of total billed charges,,,85,,2735.3,percent of total billed charges,,,85,,2735.3,percent of total billed charges,,,49,,1576.82,percent of total billed charges,,,90,,2896.2,percent of total billed charges,,,65,,2091.7,percent of total billed charges,,,80,,2574.4,percent of total billed charges,,,55,,1769.9,percent of total billed charges,,,55,,1769.9,percent of total billed charges,,,65,,2091.7,percent of total billed charges,,,78,,2510.04,percent of total billed charges,,,70,,2252.6,percent of total billed charges,,,,,,,,1504.38,,,,100% of Medicare,,1504.38,,,,100% of Medicare,,1504.38,,,,100% of Medicare,,1504.38,,,,100% of Medicare,,1504.38,,,,100% of Medicare,,1504.38,,,,100% of Medicare,,1504.38,,,,100% of Medicare,,1504.38,,,,100% of Medicare,,1504.38,,,,100% of Medicare,,1504.38,,,,100% of Medicare,,1504.38,,,,100% of Medicare,,1504.38,,,,100% of Medicare,,,1504.38,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1255.02,2896.2,
"Thoracic-Lumbar-Sacral Orthosis, 4 Rigid Shells, Sagittal-Coronal, Prefabricated",L0464,HCPCS,,,,outpatient,,,3835,2301,,45.5,,1744.93,percent of total billed charges,,,45.3,,1737.26,percent of total billed charges,,,39,,1495.65,percent of total billed charges,,,,,,,,,80,,3068,percent of total billed charges,,,61.4,,2354.69,percent of total billed charges,,,57.4,,2201.29,percent of total billed charges,,,81,,3106.35,percent of total billed charges,,,39,,1495.65,percent of total billed charges,,,57.6,,2208.96,percent of total billed charges,,,85,,3259.75,percent of total billed charges,,,85,,3259.75,percent of total billed charges,,,49,,1879.15,percent of total billed charges,,,90,,3451.5,percent of total billed charges,,,65,,2492.75,percent of total billed charges,,,80,,3068,percent of total billed charges,,,55,,2109.25,percent of total billed charges,,,55,,2109.25,percent of total billed charges,,,65,,2492.75,percent of total billed charges,,,78,,2991.3,percent of total billed charges,,,70,,2684.5,percent of total billed charges,,,,,,,,1790.97,,,,100% of Medicare,,1790.97,,,,100% of Medicare,,1790.97,,,,100% of Medicare,,1790.97,,,,100% of Medicare,,1790.97,,,,100% of Medicare,,1790.97,,,,100% of Medicare,,1790.97,,,,100% of Medicare,,1790.97,,,,100% of Medicare,,1790.97,,,,100% of Medicare,,1790.97,,,,100% of Medicare,,1790.97,,,,100% of Medicare,,1790.97,,,,100% of Medicare,,,1790.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1495.65,3451.5,
"Thoracic-Lumbar-Sacral Orthosis, Rigid Frame, Prefabricated, Soft Anterior/Posterior",L0466,HCPCS,,,,outpatient,,,1981,1188.6,,45.5,,901.36,percent of total billed charges,,,45.3,,897.39,percent of total billed charges,,,39,,772.59,percent of total billed charges,,,,,,,,,80,,1584.8,percent of total billed charges,,,61.4,,1216.33,percent of total billed charges,,,57.4,,1137.09,percent of total billed charges,,,81,,1604.61,percent of total billed charges,,,39,,772.59,percent of total billed charges,,,57.6,,1141.06,percent of total billed charges,,,85,,1683.85,percent of total billed charges,,,85,,1683.85,percent of total billed charges,,,49,,970.69,percent of total billed charges,,,90,,1782.9,percent of total billed charges,,,65,,1287.65,percent of total billed charges,,,80,,1584.8,percent of total billed charges,,,55,,1089.55,percent of total billed charges,,,55,,1089.55,percent of total billed charges,,,65,,1287.65,percent of total billed charges,,,78,,1545.18,percent of total billed charges,,,70,,1386.7,percent of total billed charges,,,,,,,,457.12,,,,100% of Medicare,,457.12,,,,100% of Medicare,,457.12,,,,100% of Medicare,,457.12,,,,100% of Medicare,,457.12,,,,100% of Medicare,,457.12,,,,100% of Medicare,,457.12,,,,100% of Medicare,,457.12,,,,100% of Medicare,,457.12,,,,100% of Medicare,,457.12,,,,100% of Medicare,,457.12,,,,100% of Medicare,,457.12,,,,100% of Medicare,,,457.12,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,457.12,1782.9,
"Thoracic-Lumbar-Sacral Orthosis, Rigid Frame, Prefabricated, Pelvic",L0468,HCPCS,,,,outpatient,,,2556,1533.6,,45.5,,1162.98,percent of total billed charges,,,45.3,,1157.87,percent of total billed charges,,,39,,996.84,percent of total billed charges,,,,,,,,,80,,2044.8,percent of total billed charges,,,61.4,,1569.38,percent of total billed charges,,,57.4,,1467.14,percent of total billed charges,,,81,,2070.36,percent of total billed charges,,,39,,996.84,percent of total billed charges,,,57.6,,1472.26,percent of total billed charges,,,85,,2172.6,percent of total billed charges,,,85,,2172.6,percent of total billed charges,,,49,,1252.44,percent of total billed charges,,,90,,2300.4,percent of total billed charges,,,65,,1661.4,percent of total billed charges,,,80,,2044.8,percent of total billed charges,,,55,,1405.8,percent of total billed charges,,,55,,1405.8,percent of total billed charges,,,65,,1661.4,percent of total billed charges,,,78,,1993.68,percent of total billed charges,,,70,,1789.2,percent of total billed charges,,,,,,,,572.88,,,,100% of Medicare,,572.88,,,,100% of Medicare,,572.88,,,,100% of Medicare,,572.88,,,,100% of Medicare,,572.88,,,,100% of Medicare,,572.88,,,,100% of Medicare,,572.88,,,,100% of Medicare,,572.88,,,,100% of Medicare,,572.88,,,,100% of Medicare,,572.88,,,,100% of Medicare,,572.88,,,,100% of Medicare,,572.88,,,,100% of Medicare,,,572.88,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,572.88,2300.4,
TLSO RIG FRAM PELVIC PRE OTS (L0469),L0469,HCPCS,,,,outpatient,,,2368,1420.8,,45.5,,1077.44,percent of total billed charges,,,45.3,,1072.7,percent of total billed charges,,,39,,923.52,percent of total billed charges,,,,,,,,,80,,1894.4,percent of total billed charges,,,61.4,,1453.95,percent of total billed charges,,,57.4,,1359.23,percent of total billed charges,,,81,,1918.08,percent of total billed charges,,,39,,923.52,percent of total billed charges,,,57.6,,1363.97,percent of total billed charges,,,85,,2012.8,percent of total billed charges,,,85,,2012.8,percent of total billed charges,,,49,,1160.32,percent of total billed charges,,,90,,2131.2,percent of total billed charges,,,65,,1539.2,percent of total billed charges,,,80,,1894.4,percent of total billed charges,,,55,,1302.4,percent of total billed charges,,,55,,1302.4,percent of total billed charges,,,65,,1539.2,percent of total billed charges,,,78,,1847.04,percent of total billed charges,,,70,,1657.6,percent of total billed charges,,,,,,,,318.17,,,,100% of Medicare,,318.17,,,,100% of Medicare,,318.17,,,,100% of Medicare,,318.17,,,,100% of Medicare,,318.17,,,,100% of Medicare,,318.17,,,,100% of Medicare,,318.17,,,,100% of Medicare,,318.17,,,,100% of Medicare,,318.17,,,,100% of Medicare,,318.17,,,,100% of Medicare,,318.17,,,,100% of Medicare,,318.17,,,,100% of Medicare,,,318.17,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,318.17,2131.2,
"Thoracic-Lumbar-Sacral Orthosis, Triplaner Control, Prefabricated, Subclavicular",L0470,HCPCS,,,,outpatient,,,1697,1018.2,,45.5,,772.14,percent of total billed charges,,,45.3,,768.74,percent of total billed charges,,,39,,661.83,percent of total billed charges,,,,,,,,,80,,1357.6,percent of total billed charges,,,61.4,,1041.96,percent of total billed charges,,,57.4,,974.08,percent of total billed charges,,,81,,1374.57,percent of total billed charges,,,39,,661.83,percent of total billed charges,,,57.6,,977.47,percent of total billed charges,,,85,,1442.45,percent of total billed charges,,,85,,1442.45,percent of total billed charges,,,49,,831.53,percent of total billed charges,,,90,,1527.3,percent of total billed charges,,,65,,1103.05,percent of total billed charges,,,80,,1357.6,percent of total billed charges,,,55,,933.35,percent of total billed charges,,,55,,933.35,percent of total billed charges,,,65,,1103.05,percent of total billed charges,,,78,,1323.66,percent of total billed charges,,,70,,1187.9,percent of total billed charges,,,,,,,,792.74,,,,100% of Medicare,,792.74,,,,100% of Medicare,,792.74,,,,100% of Medicare,,792.74,,,,100% of Medicare,,792.74,,,,100% of Medicare,,792.74,,,,100% of Medicare,,792.74,,,,100% of Medicare,,792.74,,,,100% of Medicare,,792.74,,,,100% of Medicare,,792.74,,,,100% of Medicare,,792.74,,,,100% of Medicare,,792.74,,,,100% of Medicare,,,792.74,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,661.83,1527.3,
"Thoracic-Lumbar-Sacral Orthosis, Hyperextension Rigid Frame, Triplaner Control, Prefabricated",L0472,HCPCS,,,,outpatient,,,2115,1269,,45.5,,962.33,percent of total billed charges,,,45.3,,958.1,percent of total billed charges,,,39,,824.85,percent of total billed charges,,,,,,,,,80,,1692,percent of total billed charges,,,61.4,,1298.61,percent of total billed charges,,,57.4,,1214.01,percent of total billed charges,,,81,,1713.15,percent of total billed charges,,,39,,824.85,percent of total billed charges,,,57.6,,1218.24,percent of total billed charges,,,85,,1797.75,percent of total billed charges,,,85,,1797.75,percent of total billed charges,,,49,,1036.35,percent of total billed charges,,,90,,1903.5,percent of total billed charges,,,65,,1374.75,percent of total billed charges,,,80,,1692,percent of total billed charges,,,55,,1163.25,percent of total billed charges,,,55,,1163.25,percent of total billed charges,,,65,,1374.75,percent of total billed charges,,,78,,1649.7,percent of total billed charges,,,70,,1480.5,percent of total billed charges,,,,,,,,487.8,,,,100% of Medicare,,487.8,,,,100% of Medicare,,487.8,,,,100% of Medicare,,487.8,,,,100% of Medicare,,487.8,,,,100% of Medicare,,487.8,,,,100% of Medicare,,487.8,,,,100% of Medicare,,487.8,,,,100% of Medicare,,487.8,,,,100% of Medicare,,487.8,,,,100% of Medicare,,487.8,,,,100% of Medicare,,487.8,,,,100% of Medicare,,,487.8,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,487.8,1903.5,
"L0490 Thoracic-Lumbar-Sacral Orthosis, 1-Piece Rigid Shell w/ Overlanding, Prefabricated, Sagittal-C",L0490,HCPCS,,,,outpatient,,,731,438.6,,45.5,,332.61,percent of total billed charges,,,45.3,,331.14,percent of total billed charges,,,39,,285.09,percent of total billed charges,,,,,,,,,80,,584.8,percent of total billed charges,,,61.4,,448.83,percent of total billed charges,,,57.4,,419.59,percent of total billed charges,,,81,,592.11,percent of total billed charges,,,39,,285.09,percent of total billed charges,,,57.6,,421.06,percent of total billed charges,,,85,,621.35,percent of total billed charges,,,85,,621.35,percent of total billed charges,,,49,,358.19,percent of total billed charges,,,90,,657.9,percent of total billed charges,,,65,,475.15,percent of total billed charges,,,80,,584.8,percent of total billed charges,,,55,,402.05,percent of total billed charges,,,55,,402.05,percent of total billed charges,,,65,,475.15,percent of total billed charges,,,78,,570.18,percent of total billed charges,,,70,,511.7,percent of total billed charges,,,,,,,,340.82,,,,100% of Medicare,,340.82,,,,100% of Medicare,,340.82,,,,100% of Medicare,,340.82,,,,100% of Medicare,,340.82,,,,100% of Medicare,,340.82,,,,100% of Medicare,,340.82,,,,100% of Medicare,,340.82,,,,100% of Medicare,,340.82,,,,100% of Medicare,,340.82,,,,100% of Medicare,,340.82,,,,100% of Medicare,,340.82,,,,100% of Medicare,,,340.82,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,285.09,657.9,
"Thoracic-Lumbar-Sacral Orthosis 3-Piece Rigid Shell, Sagittal-Coronal, Prefabricated",L0492,HCPCS,,,,outpatient,,,1288,772.8,,45.5,,586.04,percent of total billed charges,,,45.3,,583.46,percent of total billed charges,,,39,,502.32,percent of total billed charges,,,,,,,,,80,,1030.4,percent of total billed charges,,,61.4,,790.83,percent of total billed charges,,,57.4,,739.31,percent of total billed charges,,,81,,1043.28,percent of total billed charges,,,39,,502.32,percent of total billed charges,,,57.6,,741.89,percent of total billed charges,,,85,,1094.8,percent of total billed charges,,,85,,1094.8,percent of total billed charges,,,49,,631.12,percent of total billed charges,,,90,,1159.2,percent of total billed charges,,,65,,837.2,percent of total billed charges,,,80,,1030.4,percent of total billed charges,,,55,,708.4,percent of total billed charges,,,55,,708.4,percent of total billed charges,,,65,,837.2,percent of total billed charges,,,78,,1004.64,percent of total billed charges,,,70,,901.6,percent of total billed charges,,,,,,,,602.54,,,,100% of Medicare,,602.54,,,,100% of Medicare,,602.54,,,,100% of Medicare,,602.54,,,,100% of Medicare,,602.54,,,,100% of Medicare,,602.54,,,,100% of Medicare,,602.54,,,,100% of Medicare,,602.54,,,,100% of Medicare,,602.54,,,,100% of Medicare,,602.54,,,,100% of Medicare,,602.54,,,,100% of Medicare,,602.54,,,,100% of Medicare,,,602.54,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,502.32,1159.2,
"Sacoilac, Flexible, Prefabricated, Pelvic-Sacral Support",L0621,HCPCS,,,,outpatient,,,466,279.6,,45.5,,212.03,percent of total billed charges,,,45.3,,211.1,percent of total billed charges,,,39,,181.74,percent of total billed charges,,,,,,,,,80,,372.8,percent of total billed charges,,,61.4,,286.12,percent of total billed charges,,,57.4,,267.48,percent of total billed charges,,,81,,377.46,percent of total billed charges,,,39,,181.74,percent of total billed charges,,,57.6,,268.42,percent of total billed charges,,,85,,396.1,percent of total billed charges,,,85,,396.1,percent of total billed charges,,,49,,228.34,percent of total billed charges,,,90,,419.4,percent of total billed charges,,,65,,302.9,percent of total billed charges,,,80,,372.8,percent of total billed charges,,,55,,256.3,percent of total billed charges,,,55,,256.3,percent of total billed charges,,,65,,302.9,percent of total billed charges,,,78,,363.48,percent of total billed charges,,,70,,326.2,percent of total billed charges,,,,,,,,63.23,,,,100% of Medicare,,63.23,,,,100% of Medicare,,63.23,,,,100% of Medicare,,63.23,,,,100% of Medicare,,63.23,,,,100% of Medicare,,63.23,,,,100% of Medicare,,63.23,,,,100% of Medicare,,63.23,,,,100% of Medicare,,63.23,,,,100% of Medicare,,63.23,,,,100% of Medicare,,63.23,,,,100% of Medicare,,63.23,,,,100% of Medicare,,,63.23,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,63.23,419.4,
"Sacoilac, Flexible, Custom Fabricated, Pelvic-Sacral Support",L0622,HCPCS,,,,outpatient,,,691,414.6,,45.5,,314.41,percent of total billed charges,,,45.3,,313.02,percent of total billed charges,,,39,,269.49,percent of total billed charges,,,,,,,,,80,,552.8,percent of total billed charges,,,61.4,,424.27,percent of total billed charges,,,57.4,,396.63,percent of total billed charges,,,81,,559.71,percent of total billed charges,,,39,,269.49,percent of total billed charges,,,57.6,,398.02,percent of total billed charges,,,85,,587.35,percent of total billed charges,,,85,,587.35,percent of total billed charges,,,49,,338.59,percent of total billed charges,,,90,,621.9,percent of total billed charges,,,65,,449.15,percent of total billed charges,,,80,,552.8,percent of total billed charges,,,55,,380.05,percent of total billed charges,,,55,,380.05,percent of total billed charges,,,65,,449.15,percent of total billed charges,,,78,,538.98,percent of total billed charges,,,70,,483.7,percent of total billed charges,,,,,,,,322.04,,,,100% of Medicare,,322.04,,,,100% of Medicare,,322.04,,,,100% of Medicare,,322.04,,,,100% of Medicare,,322.04,,,,100% of Medicare,,322.04,,,,100% of Medicare,,322.04,,,,100% of Medicare,,322.04,,,,100% of Medicare,,322.04,,,,100% of Medicare,,322.04,,,,100% of Medicare,,322.04,,,,100% of Medicare,,322.04,,,,100% of Medicare,,,322.04,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,269.49,621.9,
"Sacoilac, Rigid or Semi-Rigid Panels, Prefabricated, Pely-Sacral Support",L0623,HCPCS,,,,outpatient,,,428,256.8,,45.5,,194.74,percent of total billed charges,,,45.3,,193.88,percent of total billed charges,,,39,,166.92,percent of total billed charges,,,,,,,,,80,,342.4,percent of total billed charges,,,61.4,,262.79,percent of total billed charges,,,57.4,,245.67,percent of total billed charges,,,81,,346.68,percent of total billed charges,,,39,,166.92,percent of total billed charges,,,57.6,,246.53,percent of total billed charges,,,85,,363.8,percent of total billed charges,,,85,,363.8,percent of total billed charges,,,49,,209.72,percent of total billed charges,,,90,,385.2,percent of total billed charges,,,65,,278.2,percent of total billed charges,,,80,,342.4,percent of total billed charges,,,55,,235.4,percent of total billed charges,,,55,,235.4,percent of total billed charges,,,65,,278.2,percent of total billed charges,,,78,,333.84,percent of total billed charges,,,70,,299.6,percent of total billed charges,,,,,,,,113.35,,,,100% of Medicare,,113.35,,,,100% of Medicare,,113.35,,,,100% of Medicare,,113.35,,,,100% of Medicare,,113.35,,,,100% of Medicare,,113.35,,,,100% of Medicare,,113.35,,,,100% of Medicare,,113.35,,,,100% of Medicare,,113.35,,,,100% of Medicare,,113.35,,,,100% of Medicare,,113.35,,,,100% of Medicare,,113.35,,,,100% of Medicare,,,113.35,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,113.35,385.2,
"Sacoilac, Rigid or Semi-Rigid Panels, Pelvic-Sagittal Support, Custom Fabricated",L0624,HCPCS,,,,outpatient,,,135,81,,45.5,,61.43,percent of total billed charges,,,45.3,,61.16,percent of total billed charges,,,39,,52.65,percent of total billed charges,,,,,,,,,80,,108,percent of total billed charges,,,61.4,,82.89,percent of total billed charges,,,57.4,,77.49,percent of total billed charges,,,81,,109.35,percent of total billed charges,,,39,,52.65,percent of total billed charges,,,57.6,,77.76,percent of total billed charges,,,85,,114.75,percent of total billed charges,,,85,,114.75,percent of total billed charges,,,49,,66.15,percent of total billed charges,,,90,,121.5,percent of total billed charges,,,65,,87.75,percent of total billed charges,,,80,,108,percent of total billed charges,,,55,,74.25,percent of total billed charges,,,55,,74.25,percent of total billed charges,,,65,,87.75,percent of total billed charges,,,78,,105.3,percent of total billed charges,,,70,,94.5,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,52.65,121.5,
"Lumbar Orthosis, Flexible, Prefabricated, w/ Straps, L1-L5",L0625,HCPCS,,,,outpatient,,,296,177.6,,45.5,,134.68,percent of total billed charges,,,45.3,,134.09,percent of total billed charges,,,39,,115.44,percent of total billed charges,,,,,,,,,80,,236.8,percent of total billed charges,,,61.4,,181.74,percent of total billed charges,,,57.4,,169.9,percent of total billed charges,,,81,,239.76,percent of total billed charges,,,39,,115.44,percent of total billed charges,,,57.6,,170.5,percent of total billed charges,,,85,,251.6,percent of total billed charges,,,85,,251.6,percent of total billed charges,,,49,,145.04,percent of total billed charges,,,90,,266.4,percent of total billed charges,,,65,,192.4,percent of total billed charges,,,80,,236.8,percent of total billed charges,,,55,,162.8,percent of total billed charges,,,55,,162.8,percent of total billed charges,,,65,,192.4,percent of total billed charges,,,78,,230.88,percent of total billed charges,,,70,,207.2,percent of total billed charges,,,,,,,,35.37,,,,100% of Medicare,,35.37,,,,100% of Medicare,,35.37,,,,100% of Medicare,,35.37,,,,100% of Medicare,,35.37,,,,100% of Medicare,,35.37,,,,100% of Medicare,,35.37,,,,100% of Medicare,,35.37,,,,100% of Medicare,,35.37,,,,100% of Medicare,,35.37,,,,100% of Medicare,,35.37,,,,100% of Medicare,,35.37,,,,100% of Medicare,,,35.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,35.37,266.4,
"Lumbar Orthosis, Sagittal, Prefabricated, w/ Pads/Stays/Straps, Adjustable",L0626,HCPCS,,,,outpatient,,,421,252.6,,45.5,,191.56,percent of total billed charges,,,45.3,,190.71,percent of total billed charges,,,39,,164.19,percent of total billed charges,,,,,,,,,80,,336.8,percent of total billed charges,,,61.4,,258.49,percent of total billed charges,,,57.4,,241.65,percent of total billed charges,,,81,,341.01,percent of total billed charges,,,39,,164.19,percent of total billed charges,,,57.6,,242.5,percent of total billed charges,,,85,,357.85,percent of total billed charges,,,85,,357.85,percent of total billed charges,,,49,,206.29,percent of total billed charges,,,90,,378.9,percent of total billed charges,,,65,,273.65,percent of total billed charges,,,80,,336.8,percent of total billed charges,,,55,,231.55,percent of total billed charges,,,55,,231.55,percent of total billed charges,,,65,,273.65,percent of total billed charges,,,78,,328.38,percent of total billed charges,,,70,,294.7,percent of total billed charges,,,,,,,,93.91,,,,100% of Medicare,,93.91,,,,100% of Medicare,,93.91,,,,100% of Medicare,,93.91,,,,100% of Medicare,,93.91,,,,100% of Medicare,,93.91,,,,100% of Medicare,,93.91,,,,100% of Medicare,,93.91,,,,100% of Medicare,,93.91,,,,100% of Medicare,,93.91,,,,100% of Medicare,,93.91,,,,100% of Medicare,,93.91,,,,100% of Medicare,,,93.91,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,93.91,378.9,
"Lumbar Orthosis, Sagittal, Prefabricated, Rigid Panels",L0627,HCPCS,,,,outpatient,,,1028,616.8,,45.5,,467.74,percent of total billed charges,,,45.3,,465.68,percent of total billed charges,,,39,,400.92,percent of total billed charges,,,,,,,,,80,,822.4,percent of total billed charges,,,61.4,,631.19,percent of total billed charges,,,57.4,,590.07,percent of total billed charges,,,81,,832.68,percent of total billed charges,,,39,,400.92,percent of total billed charges,,,57.6,,592.13,percent of total billed charges,,,85,,873.8,percent of total billed charges,,,85,,873.8,percent of total billed charges,,,49,,503.72,percent of total billed charges,,,90,,925.2,percent of total billed charges,,,65,,668.2,percent of total billed charges,,,80,,822.4,percent of total billed charges,,,55,,565.4,percent of total billed charges,,,55,,565.4,percent of total billed charges,,,65,,668.2,percent of total billed charges,,,78,,801.84,percent of total billed charges,,,70,,719.6,percent of total billed charges,,,,,,,,495.23,,,,100% of Medicare,,495.23,,,,100% of Medicare,,495.23,,,,100% of Medicare,,495.23,,,,100% of Medicare,,495.23,,,,100% of Medicare,,495.23,,,,100% of Medicare,,495.23,,,,100% of Medicare,,495.23,,,,100% of Medicare,,495.23,,,,100% of Medicare,,495.23,,,,100% of Medicare,,495.23,,,,100% of Medicare,,495.23,,,,100% of Medicare,,,495.23,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,400.92,925.2,
"Lumbar-Sacral Orthosis, Flexible, Prefabricated, Sac - T9, w/o Rigid Stays",L0628,HCPCS,,,,outpatient,,,439,263.4,,45.5,,199.75,percent of total billed charges,,,45.3,,198.87,percent of total billed charges,,,39,,171.21,percent of total billed charges,,,,,,,,,80,,351.2,percent of total billed charges,,,61.4,,269.55,percent of total billed charges,,,57.4,,251.99,percent of total billed charges,,,81,,355.59,percent of total billed charges,,,39,,171.21,percent of total billed charges,,,57.6,,252.86,percent of total billed charges,,,85,,373.15,percent of total billed charges,,,85,,373.15,percent of total billed charges,,,49,,215.11,percent of total billed charges,,,90,,395.1,percent of total billed charges,,,65,,285.35,percent of total billed charges,,,80,,351.2,percent of total billed charges,,,55,,241.45,percent of total billed charges,,,55,,241.45,percent of total billed charges,,,65,,285.35,percent of total billed charges,,,78,,342.42,percent of total billed charges,,,70,,307.3,percent of total billed charges,,,,,,,,53.86,,,,100% of Medicare,,53.86,,,,100% of Medicare,,53.86,,,,100% of Medicare,,53.86,,,,100% of Medicare,,53.86,,,,100% of Medicare,,53.86,,,,100% of Medicare,,53.86,,,,100% of Medicare,,53.86,,,,100% of Medicare,,53.86,,,,100% of Medicare,,53.86,,,,100% of Medicare,,53.86,,,,100% of Medicare,,53.86,,,,100% of Medicare,,,53.86,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,53.86,395.1,
"Lumbar-Sacral Orthosis, Flexible pendulous abd Custom Fabricated",L0629,HCPCS,,,,both,,,250,150,,45.5,,113.75,percent of total billed charges,,,45.3,,113.25,percent of total billed charges,,,39,,97.5,percent of total billed charges,,,,,,,,,80,,200,percent of total billed charges,,,61.4,,153.5,percent of total billed charges,,,57.4,,143.5,percent of total billed charges,,,81,,202.5,percent of total billed charges,,,39,,97.5,percent of total billed charges,,,57.6,,144,percent of total billed charges,,,85,,212.5,percent of total billed charges,,,85,,212.5,percent of total billed charges,,,49,,122.5,percent of total billed charges,,,90,,225,percent of total billed charges,,,65,,162.5,percent of total billed charges,,,80,,200,percent of total billed charges,,,55,,137.5,percent of total billed charges,,,55,,137.5,percent of total billed charges,,,65,,162.5,percent of total billed charges,,,78,,195,percent of total billed charges,,,70,,175,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,97.5,225,
"Lumbar-Sacral Orthosis, Flexible, Prefabricated, Sac - T9, w/o Rigid Stays",L0629,HCPCS,,,,outpatient,,,439,263.4,,45.5,,199.75,percent of total billed charges,,,45.3,,198.87,percent of total billed charges,,,39,,171.21,percent of total billed charges,,,,,,,,,80,,351.2,percent of total billed charges,,,61.4,,269.55,percent of total billed charges,,,57.4,,251.99,percent of total billed charges,,,81,,355.59,percent of total billed charges,,,39,,171.21,percent of total billed charges,,,57.6,,252.86,percent of total billed charges,,,85,,373.15,percent of total billed charges,,,85,,373.15,percent of total billed charges,,,49,,215.11,percent of total billed charges,,,90,,395.1,percent of total billed charges,,,65,,285.35,percent of total billed charges,,,80,,351.2,percent of total billed charges,,,55,,241.45,percent of total billed charges,,,55,,241.45,percent of total billed charges,,,65,,285.35,percent of total billed charges,,,78,,342.42,percent of total billed charges,,,70,,307.3,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,171.21,395.1,
"Lumbar-Sacral Orthosis, Rigid Posterior, Prefabricated, Sac - T9",L0630,HCPCS,,,,outpatient,,,874,524.4,,45.5,,397.67,percent of total billed charges,,,45.3,,395.92,percent of total billed charges,,,39,,340.86,percent of total billed charges,,,,,,,,,80,,699.2,percent of total billed charges,,,61.4,,536.64,percent of total billed charges,,,57.4,,501.68,percent of total billed charges,,,81,,707.94,percent of total billed charges,,,39,,340.86,percent of total billed charges,,,57.6,,503.42,percent of total billed charges,,,85,,742.9,percent of total billed charges,,,85,,742.9,percent of total billed charges,,,49,,428.26,percent of total billed charges,,,90,,786.6,percent of total billed charges,,,65,,568.1,percent of total billed charges,,,80,,699.2,percent of total billed charges,,,55,,480.7,percent of total billed charges,,,55,,480.7,percent of total billed charges,,,65,,568.1,percent of total billed charges,,,78,,681.72,percent of total billed charges,,,70,,611.8,percent of total billed charges,,,,,,,,195.15,,,,100% of Medicare,,195.15,,,,100% of Medicare,,195.15,,,,100% of Medicare,,195.15,,,,100% of Medicare,,195.15,,,,100% of Medicare,,195.15,,,,100% of Medicare,,195.15,,,,100% of Medicare,,195.15,,,,100% of Medicare,,195.15,,,,100% of Medicare,,195.15,,,,100% of Medicare,,195.15,,,,100% of Medicare,,195.15,,,,100% of Medicare,,,195.15,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,195.15,786.6,
"Lumbar-Sacral Orthosis, Rigid Anterior, Sac - T9, Prefabricated",L0631,HCPCS,,,,outpatient,,,2646,1587.6,,45.5,,1203.93,percent of total billed charges,,,45.3,,1198.64,percent of total billed charges,,,39,,1031.94,percent of total billed charges,,,,,,,,,80,,2116.8,percent of total billed charges,,,61.4,,1624.64,percent of total billed charges,,,57.4,,1518.8,percent of total billed charges,,,81,,2143.26,percent of total billed charges,,,39,,1031.94,percent of total billed charges,,,57.6,,1524.1,percent of total billed charges,,,85,,2249.1,percent of total billed charges,,,85,,2249.1,percent of total billed charges,,,49,,1296.54,percent of total billed charges,,,90,,2381.4,percent of total billed charges,,,65,,1719.9,percent of total billed charges,,,80,,2116.8,percent of total billed charges,,,55,,1455.3,percent of total billed charges,,,55,,1455.3,percent of total billed charges,,,65,,1719.9,percent of total billed charges,,,78,,2063.88,percent of total billed charges,,,70,,1852.2,percent of total billed charges,,,,,,,,1236.86,,,,100% of Medicare,,1236.86,,,,100% of Medicare,,1236.86,,,,100% of Medicare,,1236.86,,,,100% of Medicare,,1236.86,,,,100% of Medicare,,1236.86,,,,100% of Medicare,,1236.86,,,,100% of Medicare,,1236.86,,,,100% of Medicare,,1236.86,,,,100% of Medicare,,1236.86,,,,100% of Medicare,,1236.86,,,,100% of Medicare,,1236.86,,,,100% of Medicare,,,1236.86,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1031.94,2381.4,
"Lumbar-Sacral Orthosis, Rigid Anterior-Posterior Panels, Sagittal-Coronal Control, Custom Fabricated",L0632,HCPCS,,,,outpatient,,,3329,1997.4,,45.5,,1514.7,percent of total billed charges,,,45.3,,1508.04,percent of total billed charges,,,39,,1298.31,percent of total billed charges,,,,,,,,,80,,2663.2,percent of total billed charges,,,61.4,,2044.01,percent of total billed charges,,,57.4,,1910.85,percent of total billed charges,,,81,,2696.49,percent of total billed charges,,,39,,1298.31,percent of total billed charges,,,57.6,,1917.5,percent of total billed charges,,,85,,2829.65,percent of total billed charges,,,85,,2829.65,percent of total billed charges,,,49,,1631.21,percent of total billed charges,,,90,,2996.1,percent of total billed charges,,,65,,2163.85,percent of total billed charges,,,80,,2663.2,percent of total billed charges,,,55,,1830.95,percent of total billed charges,,,55,,1830.95,percent of total billed charges,,,65,,2163.85,percent of total billed charges,,,78,,2596.62,percent of total billed charges,,,70,,2330.3,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1298.31,2996.1,
"L0633 Lumbar-Sacral Orthosis, Rigid Posterior Panels, Sagittal-Coronal, Prefabricated",L0633,HCPCS,,,,outpatient,,,1542,925.2,,45.5,,701.61,percent of total billed charges,,,45.3,,698.53,percent of total billed charges,,,39,,601.38,percent of total billed charges,,,,,,,,,80,,1233.6,percent of total billed charges,,,61.4,,946.79,percent of total billed charges,,,57.4,,885.11,percent of total billed charges,,,81,,1249.02,percent of total billed charges,,,39,,601.38,percent of total billed charges,,,57.6,,888.19,percent of total billed charges,,,85,,1310.7,percent of total billed charges,,,85,,1310.7,percent of total billed charges,,,49,,755.58,percent of total billed charges,,,90,,1387.8,percent of total billed charges,,,65,,1002.3,percent of total billed charges,,,80,,1233.6,percent of total billed charges,,,55,,848.1,percent of total billed charges,,,55,,848.1,percent of total billed charges,,,65,,1002.3,percent of total billed charges,,,78,,1202.76,percent of total billed charges,,,70,,1079.4,percent of total billed charges,,,,,,,,345.5,,,,100% of Medicare,,345.5,,,,100% of Medicare,,345.5,,,,100% of Medicare,,345.5,,,,100% of Medicare,,345.5,,,,100% of Medicare,,345.5,,,,100% of Medicare,,345.5,,,,100% of Medicare,,345.5,,,,100% of Medicare,,345.5,,,,100% of Medicare,,345.5,,,,100% of Medicare,,345.5,,,,100% of Medicare,,345.5,,,,100% of Medicare,,,345.5,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,345.5,1387.8,
"L0635 LSO Sag Rigid Panel, Pre",L0635,HCPCS,,,,outpatient,,,2553,1531.8,,45.5,,1161.62,percent of total billed charges,,,45.3,,1156.51,percent of total billed charges,,,39,,995.67,percent of total billed charges,,,,,,,,,80,,2042.4,percent of total billed charges,,,61.4,,1567.54,percent of total billed charges,,,57.4,,1465.42,percent of total billed charges,,,81,,2067.93,percent of total billed charges,,,39,,995.67,percent of total billed charges,,,57.6,,1470.53,percent of total billed charges,,,85,,2170.05,percent of total billed charges,,,85,,2170.05,percent of total billed charges,,,49,,1250.97,percent of total billed charges,,,90,,2297.7,percent of total billed charges,,,65,,1659.45,percent of total billed charges,,,80,,2042.4,percent of total billed charges,,,55,,1404.15,percent of total billed charges,,,55,,1404.15,percent of total billed charges,,,65,,1659.45,percent of total billed charges,,,78,,1991.34,percent of total billed charges,,,70,,1787.1,percent of total billed charges,,,,,,,,1203.94,,,,100% of Medicare,,1203.94,,,,100% of Medicare,,1203.94,,,,100% of Medicare,,1203.94,,,,100% of Medicare,,1203.94,,,,100% of Medicare,,1203.94,,,,100% of Medicare,,1203.94,,,,100% of Medicare,,1203.94,,,,100% of Medicare,,1203.94,,,,100% of Medicare,,1203.94,,,,100% of Medicare,,1203.94,,,,100% of Medicare,,1203.94,,,,100% of Medicare,,,1203.94,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,995.67,2297.7,
"L0636 LSO Sag Rigid Panel, Cust",L0636,HCPCS,,,,outpatient,,,3462,2077.2,,45.5,,1575.21,percent of total billed charges,,,45.3,,1568.29,percent of total billed charges,,,39,,1350.18,percent of total billed charges,,,,,,,,,80,,2769.6,percent of total billed charges,,,61.4,,2125.67,percent of total billed charges,,,57.4,,1987.19,percent of total billed charges,,,81,,2804.22,percent of total billed charges,,,39,,1350.18,percent of total billed charges,,,57.6,,1994.11,percent of total billed charges,,,85,,2942.7,percent of total billed charges,,,85,,2942.7,percent of total billed charges,,,49,,1696.38,percent of total billed charges,,,90,,3115.8,percent of total billed charges,,,65,,2250.3,percent of total billed charges,,,80,,2769.6,percent of total billed charges,,,55,,1904.1,percent of total billed charges,,,55,,1904.1,percent of total billed charges,,,65,,2250.3,percent of total billed charges,,,78,,2700.36,percent of total billed charges,,,70,,2423.4,percent of total billed charges,,,,,,,,1633.55,,,,100% of Medicare,,1633.55,,,,100% of Medicare,,1633.55,,,,100% of Medicare,,1633.55,,,,100% of Medicare,,1633.55,,,,100% of Medicare,,1633.55,,,,100% of Medicare,,1633.55,,,,100% of Medicare,,1633.55,,,,100% of Medicare,,1633.55,,,,100% of Medicare,,1633.55,,,,100% of Medicare,,1633.55,,,,100% of Medicare,,1633.55,,,,100% of Medicare,,,1633.55,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1350.18,3115.8,
"Lumbar-Sacral Orthosis, Rigid Anterior-Posterior Frame/Panels, Sagittal-Coronal, Prefabricated",L0637,HCPCS,,,,outpatient,,,3340,2004,,45.5,,1519.7,percent of total billed charges,,,45.3,,1513.02,percent of total billed charges,,,39,,1302.6,percent of total billed charges,,,,,,,,,80,,2672,percent of total billed charges,,,61.4,,2050.76,percent of total billed charges,,,57.4,,1917.16,percent of total billed charges,,,81,,2705.4,percent of total billed charges,,,39,,1302.6,percent of total billed charges,,,57.6,,1923.84,percent of total billed charges,,,85,,2839,percent of total billed charges,,,85,,2839,percent of total billed charges,,,49,,1636.6,percent of total billed charges,,,90,,3006,percent of total billed charges,,,65,,2171,percent of total billed charges,,,80,,2672,percent of total billed charges,,,55,,1837,percent of total billed charges,,,55,,1837,percent of total billed charges,,,65,,2171,percent of total billed charges,,,78,,2605.2,percent of total billed charges,,,70,,2338,percent of total billed charges,,,,,,,,1560.91,,,,100% of Medicare,,1560.91,,,,100% of Medicare,,1560.91,,,,100% of Medicare,,1560.91,,,,100% of Medicare,,1560.91,,,,100% of Medicare,,1560.91,,,,100% of Medicare,,1560.91,,,,100% of Medicare,,1560.91,,,,100% of Medicare,,1560.91,,,,100% of Medicare,,1560.91,,,,100% of Medicare,,1560.91,,,,100% of Medicare,,1560.91,,,,100% of Medicare,,,1560.91,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1302.6,3006,
"Lumbar-Sacral Orthosis, Rigid Posterior Frame/Panels, Sagittal-Coronal, Custom Fabricated",L0638,HCPCS,,,,outpatient,,,3400,2040,,45.5,,1547,percent of total billed charges,,,45.3,,1540.2,percent of total billed charges,,,39,,1326,percent of total billed charges,,,,,,,,,80,,2720,percent of total billed charges,,,61.4,,2087.6,percent of total billed charges,,,57.4,,1951.6,percent of total billed charges,,,81,,2754,percent of total billed charges,,,39,,1326,percent of total billed charges,,,57.6,,1958.4,percent of total billed charges,,,85,,2890,percent of total billed charges,,,85,,2890,percent of total billed charges,,,49,,1666,percent of total billed charges,,,90,,3060,percent of total billed charges,,,65,,2210,percent of total billed charges,,,80,,2720,percent of total billed charges,,,55,,1870,percent of total billed charges,,,55,,1870,percent of total billed charges,,,65,,2210,percent of total billed charges,,,78,,2652,percent of total billed charges,,,70,,2380,percent of total billed charges,,,,,,,,1589.13,,,,100% of Medicare,,1589.13,,,,100% of Medicare,,1589.13,,,,100% of Medicare,,1589.13,,,,100% of Medicare,,1589.13,,,,100% of Medicare,,1589.13,,,,100% of Medicare,,1589.13,,,,100% of Medicare,,1589.13,,,,100% of Medicare,,1589.13,,,,100% of Medicare,,1589.13,,,,100% of Medicare,,1589.13,,,,100% of Medicare,,1589.13,,,,100% of Medicare,,,1589.13,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1326,3060,
"L0639 Lumbar-Sacral Orthosis, Sac - T9, Prefabricated",L0639,HCPCS,,,,outpatient,,,3340,2004,,45.5,,1519.7,percent of total billed charges,,,45.3,,1513.02,percent of total billed charges,,,39,,1302.6,percent of total billed charges,,,,,,,,,80,,2672,percent of total billed charges,,,61.4,,2050.76,percent of total billed charges,,,57.4,,1917.16,percent of total billed charges,,,81,,2705.4,percent of total billed charges,,,39,,1302.6,percent of total billed charges,,,57.6,,1923.84,percent of total billed charges,,,85,,2839,percent of total billed charges,,,85,,2839,percent of total billed charges,,,49,,1636.6,percent of total billed charges,,,90,,3006,percent of total billed charges,,,65,,2171,percent of total billed charges,,,80,,2672,percent of total billed charges,,,55,,1837,percent of total billed charges,,,55,,1837,percent of total billed charges,,,65,,2171,percent of total billed charges,,,78,,2605.2,percent of total billed charges,,,70,,2338,percent of total billed charges,,,,,,,,1560.91,,,,100% of Medicare,,1560.91,,,,100% of Medicare,,1560.91,,,,100% of Medicare,,1560.91,,,,100% of Medicare,,1560.91,,,,100% of Medicare,,1560.91,,,,100% of Medicare,,1560.91,,,,100% of Medicare,,1560.91,,,,100% of Medicare,,1560.91,,,,100% of Medicare,,1560.91,,,,100% of Medicare,,1560.91,,,,100% of Medicare,,1560.91,,,,100% of Medicare,,,1560.91,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1302.6,3006,
LO RIG POS PNL L1-L5 PRE OTS (L0641),L0641,HCPCS,,,,outpatient,,,388,232.8,,45.5,,176.54,percent of total billed charges,,,45.3,,175.76,percent of total billed charges,,,39,,151.32,percent of total billed charges,,,,,,,,,80,,310.4,percent of total billed charges,,,61.4,,238.23,percent of total billed charges,,,57.4,,222.71,percent of total billed charges,,,81,,314.28,percent of total billed charges,,,39,,151.32,percent of total billed charges,,,57.6,,223.49,percent of total billed charges,,,85,,329.8,percent of total billed charges,,,85,,329.8,percent of total billed charges,,,49,,190.12,percent of total billed charges,,,90,,349.2,percent of total billed charges,,,65,,252.2,percent of total billed charges,,,80,,310.4,percent of total billed charges,,,55,,213.4,percent of total billed charges,,,55,,213.4,percent of total billed charges,,,65,,252.2,percent of total billed charges,,,78,,302.64,percent of total billed charges,,,70,,271.6,percent of total billed charges,,,,,,,,50.05,,,,100% of Medicare,,50.05,,,,100% of Medicare,,50.05,,,,100% of Medicare,,50.05,,,,100% of Medicare,,50.05,,,,100% of Medicare,,50.05,,,,100% of Medicare,,50.05,,,,100% of Medicare,,50.05,,,,100% of Medicare,,50.05,,,,100% of Medicare,,50.05,,,,100% of Medicare,,50.05,,,,100% of Medicare,,50.05,,,,100% of Medicare,,,50.05,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,50.05,349.2,
LSO SAG CTR RIGI POS PRE OTS (L0643),L0643,HCPCS,,,,outpatient,,,808,484.8,,45.5,,367.64,percent of total billed charges,,,45.3,,366.02,percent of total billed charges,,,39,,315.12,percent of total billed charges,,,,,,,,,80,,646.4,percent of total billed charges,,,61.4,,496.11,percent of total billed charges,,,57.4,,463.79,percent of total billed charges,,,81,,654.48,percent of total billed charges,,,39,,315.12,percent of total billed charges,,,57.6,,465.41,percent of total billed charges,,,85,,686.8,percent of total billed charges,,,85,,686.8,percent of total billed charges,,,49,,395.92,percent of total billed charges,,,90,,727.2,percent of total billed charges,,,65,,525.2,percent of total billed charges,,,80,,646.4,percent of total billed charges,,,55,,444.4,percent of total billed charges,,,55,,444.4,percent of total billed charges,,,65,,525.2,percent of total billed charges,,,78,,630.24,percent of total billed charges,,,70,,565.6,percent of total billed charges,,,,,,,,103.99,,,,100% of Medicare,,103.99,,,,100% of Medicare,,103.99,,,,100% of Medicare,,103.99,,,,100% of Medicare,,103.99,,,,100% of Medicare,,103.99,,,,100% of Medicare,,103.99,,,,100% of Medicare,,103.99,,,,100% of Medicare,,103.99,,,,100% of Medicare,,103.99,,,,100% of Medicare,,103.99,,,,100% of Medicare,,103.99,,,,100% of Medicare,,,103.99,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,103.99,727.2,
LSO SC R POS/LAT PNL PRE OTS (L0649),L0649,HCPCS,,,,outpatient,,,1428,856.8,,45.5,,649.74,percent of total billed charges,,,45.3,,646.88,percent of total billed charges,,,39,,556.92,percent of total billed charges,,,,,,,,,80,,1142.4,percent of total billed charges,,,61.4,,876.79,percent of total billed charges,,,57.4,,819.67,percent of total billed charges,,,81,,1156.68,percent of total billed charges,,,39,,556.92,percent of total billed charges,,,57.6,,822.53,percent of total billed charges,,,85,,1213.8,percent of total billed charges,,,85,,1213.8,percent of total billed charges,,,49,,699.72,percent of total billed charges,,,90,,1285.2,percent of total billed charges,,,65,,928.2,percent of total billed charges,,,80,,1142.4,percent of total billed charges,,,55,,785.4,percent of total billed charges,,,55,,785.4,percent of total billed charges,,,65,,928.2,percent of total billed charges,,,78,,1113.84,percent of total billed charges,,,70,,999.6,percent of total billed charges,,,,,,,,184.14,,,,100% of Medicare,,184.14,,,,100% of Medicare,,184.14,,,,100% of Medicare,,184.14,,,,100% of Medicare,,184.14,,,,100% of Medicare,,184.14,,,,100% of Medicare,,184.14,,,,100% of Medicare,,184.14,,,,100% of Medicare,,184.14,,,,100% of Medicare,,184.14,,,,100% of Medicare,,184.14,,,,100% of Medicare,,184.14,,,,100% of Medicare,,,184.14,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,184.14,1285.2,
"Addition to Halo Procedure, MRI Compatible System Rings/Pins",L0859,HCPCS,,,,outpatient,,,3020,1812,,45.5,,1374.1,percent of total billed charges,,,45.3,,1368.06,percent of total billed charges,,,39,,1177.8,percent of total billed charges,,,,,,,,,80,,2416,percent of total billed charges,,,61.4,,1854.28,percent of total billed charges,,,57.4,,1733.48,percent of total billed charges,,,81,,2446.2,percent of total billed charges,,,39,,1177.8,percent of total billed charges,,,57.6,,1739.52,percent of total billed charges,,,85,,2567,percent of total billed charges,,,85,,2567,percent of total billed charges,,,49,,1479.8,percent of total billed charges,,,90,,2718,percent of total billed charges,,,65,,1963,percent of total billed charges,,,80,,2416,percent of total billed charges,,,55,,1661,percent of total billed charges,,,55,,1661,percent of total billed charges,,,65,,1963,percent of total billed charges,,,78,,2355.6,percent of total billed charges,,,70,,2114,percent of total billed charges,,,,,,,,1372.45,,,,100% of Medicare,,1372.45,,,,100% of Medicare,,1372.45,,,,100% of Medicare,,1372.45,,,,100% of Medicare,,1372.45,,,,100% of Medicare,,1372.45,,,,100% of Medicare,,1372.45,,,,100% of Medicare,,1372.45,,,,100% of Medicare,,1372.45,,,,100% of Medicare,,1372.45,,,,100% of Medicare,,1372.45,,,,100% of Medicare,,1372.45,,,,100% of Medicare,,,1372.45,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1177.8,2718,
Halo Replacement Liner/Interface,L0861,HCPCS,,,,outpatient,,,1160,696,,45.5,,527.8,percent of total billed charges,,,45.3,,525.48,percent of total billed charges,,,39,,452.4,percent of total billed charges,,,,,,,,,80,,928,percent of total billed charges,,,61.4,,712.24,percent of total billed charges,,,57.4,,665.84,percent of total billed charges,,,81,,939.6,percent of total billed charges,,,39,,452.4,percent of total billed charges,,,57.6,,668.16,percent of total billed charges,,,85,,986,percent of total billed charges,,,85,,986,percent of total billed charges,,,49,,568.4,percent of total billed charges,,,90,,1044,percent of total billed charges,,,65,,754,percent of total billed charges,,,80,,928,percent of total billed charges,,,55,,638,percent of total billed charges,,,55,,638,percent of total billed charges,,,65,,754,percent of total billed charges,,,78,,904.8,percent of total billed charges,,,70,,812,percent of total billed charges,,,,,,,,259.7,,,,100% of Medicare,,259.7,,,,100% of Medicare,,259.7,,,,100% of Medicare,,259.7,,,,100% of Medicare,,259.7,,,,100% of Medicare,,259.7,,,,100% of Medicare,,259.7,,,,100% of Medicare,,259.7,,,,100% of Medicare,,259.7,,,,100% of Medicare,,259.7,,,,100% of Medicare,,259.7,,,,100% of Medicare,,259.7,,,,100% of Medicare,,,259.7,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,259.7,1044,
"Thoracic-Lumbar-Sacral Orthosis, Corset Front",L0970,HCPCS,,,,outpatient,,,403,241.8,,45.5,,183.37,percent of total billed charges,,,45.3,,182.56,percent of total billed charges,,,39,,157.17,percent of total billed charges,,,,,,,,,80,,322.4,percent of total billed charges,,,61.4,,247.44,percent of total billed charges,,,57.4,,231.32,percent of total billed charges,,,81,,326.43,percent of total billed charges,,,39,,157.17,percent of total billed charges,,,57.6,,232.13,percent of total billed charges,,,85,,342.55,percent of total billed charges,,,85,,342.55,percent of total billed charges,,,49,,197.47,percent of total billed charges,,,90,,362.7,percent of total billed charges,,,65,,261.95,percent of total billed charges,,,80,,322.4,percent of total billed charges,,,55,,221.65,percent of total billed charges,,,55,,221.65,percent of total billed charges,,,65,,261.95,percent of total billed charges,,,78,,314.34,percent of total billed charges,,,70,,282.1,percent of total billed charges,,,,,,,,128.76,,,,100% of Medicare,,128.76,,,,100% of Medicare,,128.76,,,,100% of Medicare,,128.76,,,,100% of Medicare,,128.76,,,,100% of Medicare,,128.76,,,,100% of Medicare,,128.76,,,,100% of Medicare,,128.76,,,,100% of Medicare,,128.76,,,,100% of Medicare,,128.76,,,,100% of Medicare,,128.76,,,,100% of Medicare,,128.76,,,,100% of Medicare,,,128.76,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,128.76,362.7,
"Lumbar-Sacral Orthosis, Corset Front",L0972,HCPCS,,,,outpatient,,,391,234.6,,45.5,,177.91,percent of total billed charges,,,45.3,,177.12,percent of total billed charges,,,39,,152.49,percent of total billed charges,,,,,,,,,80,,312.8,percent of total billed charges,,,61.4,,240.07,percent of total billed charges,,,57.4,,224.43,percent of total billed charges,,,81,,316.71,percent of total billed charges,,,39,,152.49,percent of total billed charges,,,57.6,,225.22,percent of total billed charges,,,85,,332.35,percent of total billed charges,,,85,,332.35,percent of total billed charges,,,49,,191.59,percent of total billed charges,,,90,,351.9,percent of total billed charges,,,65,,254.15,percent of total billed charges,,,80,,312.8,percent of total billed charges,,,55,,215.05,percent of total billed charges,,,55,,215.05,percent of total billed charges,,,65,,254.15,percent of total billed charges,,,78,,304.98,percent of total billed charges,,,70,,273.7,percent of total billed charges,,,,,,,,117.2,,,,100% of Medicare,,117.2,,,,100% of Medicare,,117.2,,,,100% of Medicare,,117.2,,,,100% of Medicare,,117.2,,,,100% of Medicare,,117.2,,,,100% of Medicare,,117.2,,,,100% of Medicare,,117.2,,,,100% of Medicare,,117.2,,,,100% of Medicare,,117.2,,,,100% of Medicare,,117.2,,,,100% of Medicare,,117.2,,,,100% of Medicare,,,117.2,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,117.2,351.9,
"Thoracic-Lumbar-Sacral Orthosis, Full Corset",L0974,HCPCS,,,,outpatient,,,606,363.6,,45.5,,275.73,percent of total billed charges,,,45.3,,274.52,percent of total billed charges,,,39,,236.34,percent of total billed charges,,,,,,,,,80,,484.8,percent of total billed charges,,,61.4,,372.08,percent of total billed charges,,,57.4,,347.84,percent of total billed charges,,,81,,490.86,percent of total billed charges,,,39,,236.34,percent of total billed charges,,,57.6,,349.06,percent of total billed charges,,,85,,515.1,percent of total billed charges,,,85,,515.1,percent of total billed charges,,,49,,296.94,percent of total billed charges,,,90,,545.4,percent of total billed charges,,,65,,393.9,percent of total billed charges,,,80,,484.8,percent of total billed charges,,,55,,333.3,percent of total billed charges,,,55,,333.3,percent of total billed charges,,,65,,393.9,percent of total billed charges,,,78,,472.68,percent of total billed charges,,,70,,424.2,percent of total billed charges,,,,,,,,210.55,,,,100% of Medicare,,210.55,,,,100% of Medicare,,210.55,,,,100% of Medicare,,210.55,,,,100% of Medicare,,210.55,,,,100% of Medicare,,210.55,,,,100% of Medicare,,210.55,,,,100% of Medicare,,210.55,,,,100% of Medicare,,210.55,,,,100% of Medicare,,210.55,,,,100% of Medicare,,210.55,,,,100% of Medicare,,210.55,,,,100% of Medicare,,,210.55,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,210.55,545.4,
"Lumbar-Sacral Orthosis, Full Corset",L0976,HCPCS,,,,outpatient,,,804,482.4,,45.5,,365.82,percent of total billed charges,,,45.3,,364.21,percent of total billed charges,,,39,,313.56,percent of total billed charges,,,,,,,,,80,,643.2,percent of total billed charges,,,61.4,,493.66,percent of total billed charges,,,57.4,,461.5,percent of total billed charges,,,81,,651.24,percent of total billed charges,,,39,,313.56,percent of total billed charges,,,57.6,,463.1,percent of total billed charges,,,85,,683.4,percent of total billed charges,,,85,,683.4,percent of total billed charges,,,49,,393.96,percent of total billed charges,,,90,,723.6,percent of total billed charges,,,65,,522.6,percent of total billed charges,,,80,,643.2,percent of total billed charges,,,55,,442.2,percent of total billed charges,,,55,,442.2,percent of total billed charges,,,65,,522.6,percent of total billed charges,,,78,,627.12,percent of total billed charges,,,70,,562.8,percent of total billed charges,,,,,,,,180.14,,,,100% of Medicare,,180.14,,,,100% of Medicare,,180.14,,,,100% of Medicare,,180.14,,,,100% of Medicare,,180.14,,,,100% of Medicare,,180.14,,,,100% of Medicare,,180.14,,,,100% of Medicare,,180.14,,,,100% of Medicare,,180.14,,,,100% of Medicare,,180.14,,,,100% of Medicare,,180.14,,,,100% of Medicare,,180.14,,,,100% of Medicare,,,180.14,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,180.14,723.6,
"Crutch, Axillary Extension",L0978,HCPCS,,,,outpatient,,,523,313.8,,45.5,,237.97,percent of total billed charges,,,45.3,,236.92,percent of total billed charges,,,39,,203.97,percent of total billed charges,,,,,,,,,80,,418.4,percent of total billed charges,,,61.4,,321.12,percent of total billed charges,,,57.4,,300.2,percent of total billed charges,,,81,,423.63,percent of total billed charges,,,39,,203.97,percent of total billed charges,,,57.6,,301.25,percent of total billed charges,,,85,,444.55,percent of total billed charges,,,85,,444.55,percent of total billed charges,,,49,,256.27,percent of total billed charges,,,90,,470.7,percent of total billed charges,,,65,,339.95,percent of total billed charges,,,80,,418.4,percent of total billed charges,,,55,,287.65,percent of total billed charges,,,55,,287.65,percent of total billed charges,,,65,,339.95,percent of total billed charges,,,78,,407.94,percent of total billed charges,,,70,,366.1,percent of total billed charges,,,,,,,,226.72,,,,100% of Medicare,,226.72,,,,100% of Medicare,,226.72,,,,100% of Medicare,,226.72,,,,100% of Medicare,,226.72,,,,100% of Medicare,,226.72,,,,100% of Medicare,,226.72,,,,100% of Medicare,,226.72,,,,100% of Medicare,,226.72,,,,100% of Medicare,,226.72,,,,100% of Medicare,,226.72,,,,100% of Medicare,,226.72,,,,100% of Medicare,,,226.72,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,203.97,470.7,
"Peroneal Straps, Pair",L0980,HCPCS,,,,outpatient,,,45,27,,45.5,,20.48,percent of total billed charges,,,45.3,,20.39,percent of total billed charges,,,39,,17.55,percent of total billed charges,,,,,,,,,80,,36,percent of total billed charges,,,61.4,,27.63,percent of total billed charges,,,57.4,,25.83,percent of total billed charges,,,81,,36.45,percent of total billed charges,,,39,,17.55,percent of total billed charges,,,57.6,,25.92,percent of total billed charges,,,85,,38.25,percent of total billed charges,,,85,,38.25,percent of total billed charges,,,49,,22.05,percent of total billed charges,,,90,,40.5,percent of total billed charges,,,65,,29.25,percent of total billed charges,,,80,,36,percent of total billed charges,,,55,,24.75,percent of total billed charges,,,55,,24.75,percent of total billed charges,,,65,,29.25,percent of total billed charges,,,78,,35.1,percent of total billed charges,,,70,,31.5,percent of total billed charges,,,,,,,,20.58,,,,100% of Medicare,,20.58,,,,100% of Medicare,,20.58,,,,100% of Medicare,,20.58,,,,100% of Medicare,,20.58,,,,100% of Medicare,,20.58,,,,100% of Medicare,,20.58,,,,100% of Medicare,,20.58,,,,100% of Medicare,,20.58,,,,100% of Medicare,,20.58,,,,100% of Medicare,,20.58,,,,100% of Medicare,,20.58,,,,100% of Medicare,,,20.58,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,17.55,40.5,
"Stocking, Supporter Grips, Set of 4, Replacement",L0982,HCPCS,,,,outpatient,,,42,25.2,,45.5,,19.11,percent of total billed charges,,,45.3,,19.03,percent of total billed charges,,,39,,16.38,percent of total billed charges,,,,,,,,,80,,33.6,percent of total billed charges,,,61.4,,25.79,percent of total billed charges,,,57.4,,24.11,percent of total billed charges,,,81,,34.02,percent of total billed charges,,,39,,16.38,percent of total billed charges,,,57.6,,24.19,percent of total billed charges,,,85,,35.7,percent of total billed charges,,,85,,35.7,percent of total billed charges,,,49,,20.58,percent of total billed charges,,,90,,37.8,percent of total billed charges,,,65,,27.3,percent of total billed charges,,,80,,33.6,percent of total billed charges,,,55,,23.1,percent of total billed charges,,,55,,23.1,percent of total billed charges,,,65,,27.3,percent of total billed charges,,,78,,32.76,percent of total billed charges,,,70,,29.4,percent of total billed charges,,,,,,,,18.85,,,,100% of Medicare,,18.85,,,,100% of Medicare,,18.85,,,,100% of Medicare,,18.85,,,,100% of Medicare,,18.85,,,,100% of Medicare,,18.85,,,,100% of Medicare,,18.85,,,,100% of Medicare,,18.85,,,,100% of Medicare,,18.85,,,,100% of Medicare,,18.85,,,,100% of Medicare,,18.85,,,,100% of Medicare,,18.85,,,,100% of Medicare,,,18.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,16.38,37.8,
"Lumbar-Sacral Orthosis, Protective Body Sock for Spine",L0984,HCPCS,,,,outpatient,,,365,219,,45.5,,166.08,percent of total billed charges,,,45.3,,165.35,percent of total billed charges,,,39,,142.35,percent of total billed charges,,,,,,,,,80,,292,percent of total billed charges,,,61.4,,224.11,percent of total billed charges,,,57.4,,209.51,percent of total billed charges,,,81,,295.65,percent of total billed charges,,,39,,142.35,percent of total billed charges,,,57.6,,210.24,percent of total billed charges,,,85,,310.25,percent of total billed charges,,,85,,310.25,percent of total billed charges,,,49,,178.85,percent of total billed charges,,,90,,328.5,percent of total billed charges,,,65,,237.25,percent of total billed charges,,,80,,292,percent of total billed charges,,,55,,200.75,percent of total billed charges,,,55,,200.75,percent of total billed charges,,,65,,237.25,percent of total billed charges,,,78,,284.7,percent of total billed charges,,,70,,255.5,percent of total billed charges,,,,,,,,81.53,,,,100% of Medicare,,81.53,,,,100% of Medicare,,81.53,,,,100% of Medicare,,81.53,,,,100% of Medicare,,81.53,,,,100% of Medicare,,81.53,,,,100% of Medicare,,81.53,,,,100% of Medicare,,81.53,,,,100% of Medicare,,81.53,,,,100% of Medicare,,81.53,,,,100% of Medicare,,81.53,,,,100% of Medicare,,81.53,,,,100% of Medicare,,,81.53,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,81.53,328.5,
"Cervical-Thoracic-Lumbar-Sacral Orthosis, Addition, Axilla Sling",L1010,HCPCS,,,,outpatient,,,215,129,,45.5,,97.83,percent of total billed charges,,,45.3,,97.4,percent of total billed charges,,,39,,83.85,percent of total billed charges,,,,,,,,,80,,172,percent of total billed charges,,,61.4,,132.01,percent of total billed charges,,,57.4,,123.41,percent of total billed charges,,,81,,174.15,percent of total billed charges,,,39,,83.85,percent of total billed charges,,,57.6,,123.84,percent of total billed charges,,,85,,182.75,percent of total billed charges,,,85,,182.75,percent of total billed charges,,,49,,105.35,percent of total billed charges,,,90,,193.5,percent of total billed charges,,,65,,139.75,percent of total billed charges,,,80,,172,percent of total billed charges,,,55,,118.25,percent of total billed charges,,,55,,118.25,percent of total billed charges,,,65,,139.75,percent of total billed charges,,,78,,167.7,percent of total billed charges,,,70,,150.5,percent of total billed charges,,,,,,,,100.82,,,,100% of Medicare,,100.82,,,,100% of Medicare,,100.82,,,,100% of Medicare,,100.82,,,,100% of Medicare,,100.82,,,,100% of Medicare,,100.82,,,,100% of Medicare,,100.82,,,,100% of Medicare,,100.82,,,,100% of Medicare,,100.82,,,,100% of Medicare,,100.82,,,,100% of Medicare,,100.82,,,,100% of Medicare,,100.82,,,,100% of Medicare,,,100.82,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,83.85,193.5,
"Cervical-Thoracic-Lumbar-Sacral Orthosis, Addition, Kyphosis Pad",L1020,HCPCS,,,,outpatient,,,581,348.6,,45.5,,264.36,percent of total billed charges,,,45.3,,263.19,percent of total billed charges,,,39,,226.59,percent of total billed charges,,,,,,,,,80,,464.8,percent of total billed charges,,,61.4,,356.73,percent of total billed charges,,,57.4,,333.49,percent of total billed charges,,,81,,470.61,percent of total billed charges,,,39,,226.59,percent of total billed charges,,,57.6,,334.66,percent of total billed charges,,,85,,493.85,percent of total billed charges,,,85,,493.85,percent of total billed charges,,,49,,284.69,percent of total billed charges,,,90,,522.9,percent of total billed charges,,,65,,377.65,percent of total billed charges,,,80,,464.8,percent of total billed charges,,,55,,319.55,percent of total billed charges,,,55,,319.55,percent of total billed charges,,,65,,377.65,percent of total billed charges,,,78,,453.18,percent of total billed charges,,,70,,406.7,percent of total billed charges,,,,,,,,129.84,,,,100% of Medicare,,129.84,,,,100% of Medicare,,129.84,,,,100% of Medicare,,129.84,,,,100% of Medicare,,129.84,,,,100% of Medicare,,129.84,,,,100% of Medicare,,129.84,,,,100% of Medicare,,129.84,,,,100% of Medicare,,129.84,,,,100% of Medicare,,129.84,,,,100% of Medicare,,129.84,,,,100% of Medicare,,129.84,,,,100% of Medicare,,,129.84,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,129.84,522.9,
"Cervical-Thoracic-Lumbar-Sacral Orthosis, Addition, Kyphosis Pad, Floating",L1025,HCPCS,,,,outpatient,,,398,238.8,,45.5,,181.09,percent of total billed charges,,,45.3,,180.29,percent of total billed charges,,,39,,155.22,percent of total billed charges,,,,,,,,,80,,318.4,percent of total billed charges,,,61.4,,244.37,percent of total billed charges,,,57.4,,228.45,percent of total billed charges,,,81,,322.38,percent of total billed charges,,,39,,155.22,percent of total billed charges,,,57.6,,229.25,percent of total billed charges,,,85,,338.3,percent of total billed charges,,,85,,338.3,percent of total billed charges,,,49,,195.02,percent of total billed charges,,,90,,358.2,percent of total billed charges,,,65,,258.7,percent of total billed charges,,,80,,318.4,percent of total billed charges,,,55,,218.9,percent of total billed charges,,,55,,218.9,percent of total billed charges,,,65,,258.7,percent of total billed charges,,,78,,310.44,percent of total billed charges,,,70,,278.6,percent of total billed charges,,,,,,,,187.31,,,,100% of Medicare,,187.31,,,,100% of Medicare,,187.31,,,,100% of Medicare,,187.31,,,,100% of Medicare,,187.31,,,,100% of Medicare,,187.31,,,,100% of Medicare,,187.31,,,,100% of Medicare,,187.31,,,,100% of Medicare,,187.31,,,,100% of Medicare,,187.31,,,,100% of Medicare,,187.31,,,,100% of Medicare,,187.31,,,,100% of Medicare,,,187.31,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,155.22,358.2,
"Cervical-Thoracic-Lumbar-Sacral Orthosis, Addition, Lumbar Bolster Pad",L1030,HCPCS,,,,outpatient,,,424,254.4,,45.5,,192.92,percent of total billed charges,,,45.3,,192.07,percent of total billed charges,,,39,,165.36,percent of total billed charges,,,,,,,,,80,,339.2,percent of total billed charges,,,61.4,,260.34,percent of total billed charges,,,57.4,,243.38,percent of total billed charges,,,81,,343.44,percent of total billed charges,,,39,,165.36,percent of total billed charges,,,57.6,,244.22,percent of total billed charges,,,85,,360.4,percent of total billed charges,,,85,,360.4,percent of total billed charges,,,49,,207.76,percent of total billed charges,,,90,,381.6,percent of total billed charges,,,65,,275.6,percent of total billed charges,,,80,,339.2,percent of total billed charges,,,55,,233.2,percent of total billed charges,,,55,,233.2,percent of total billed charges,,,65,,275.6,percent of total billed charges,,,78,,330.72,percent of total billed charges,,,70,,296.8,percent of total billed charges,,,,,,,,94.34,,,,100% of Medicare,,94.34,,,,100% of Medicare,,94.34,,,,100% of Medicare,,94.34,,,,100% of Medicare,,94.34,,,,100% of Medicare,,94.34,,,,100% of Medicare,,94.34,,,,100% of Medicare,,94.34,,,,100% of Medicare,,94.34,,,,100% of Medicare,,94.34,,,,100% of Medicare,,94.34,,,,100% of Medicare,,94.34,,,,100% of Medicare,,,94.34,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,94.34,381.6,
"Cervical-Thoracic-Lumbar-Sacral Orthosis, Addition, Lumbar Rib Pad",L1040,HCPCS,,,,outpatient,,,227,136.2,,45.5,,103.29,percent of total billed charges,,,45.3,,102.83,percent of total billed charges,,,39,,88.53,percent of total billed charges,,,,,,,,,80,,181.6,percent of total billed charges,,,61.4,,139.38,percent of total billed charges,,,57.4,,130.3,percent of total billed charges,,,81,,183.87,percent of total billed charges,,,39,,88.53,percent of total billed charges,,,57.6,,130.75,percent of total billed charges,,,85,,192.95,percent of total billed charges,,,85,,192.95,percent of total billed charges,,,49,,111.23,percent of total billed charges,,,90,,204.3,percent of total billed charges,,,65,,147.55,percent of total billed charges,,,80,,181.6,percent of total billed charges,,,55,,124.85,percent of total billed charges,,,55,,124.85,percent of total billed charges,,,65,,147.55,percent of total billed charges,,,78,,177.06,percent of total billed charges,,,70,,158.9,percent of total billed charges,,,,,,,,106.82,,,,100% of Medicare,,106.82,,,,100% of Medicare,,106.82,,,,100% of Medicare,,106.82,,,,100% of Medicare,,106.82,,,,100% of Medicare,,106.82,,,,100% of Medicare,,106.82,,,,100% of Medicare,,106.82,,,,100% of Medicare,,106.82,,,,100% of Medicare,,106.82,,,,100% of Medicare,,106.82,,,,100% of Medicare,,106.82,,,,100% of Medicare,,,106.82,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,88.53,204.3,
"Cervical-Thoracic-Lumbar-Sacral Orthosis, Addition, Sternal Pad",L1050,HCPCS,,,,outpatient,,,543,325.8,,45.5,,247.07,percent of total billed charges,,,45.3,,245.98,percent of total billed charges,,,39,,211.77,percent of total billed charges,,,,,,,,,80,,434.4,percent of total billed charges,,,61.4,,333.4,percent of total billed charges,,,57.4,,311.68,percent of total billed charges,,,81,,439.83,percent of total billed charges,,,39,,211.77,percent of total billed charges,,,57.6,,312.77,percent of total billed charges,,,85,,461.55,percent of total billed charges,,,85,,461.55,percent of total billed charges,,,49,,266.07,percent of total billed charges,,,90,,488.7,percent of total billed charges,,,65,,352.95,percent of total billed charges,,,80,,434.4,percent of total billed charges,,,55,,298.65,percent of total billed charges,,,55,,298.65,percent of total billed charges,,,65,,352.95,percent of total billed charges,,,78,,423.54,percent of total billed charges,,,70,,380.1,percent of total billed charges,,,,,,,,120.89,,,,100% of Medicare,,120.89,,,,100% of Medicare,,120.89,,,,100% of Medicare,,120.89,,,,100% of Medicare,,120.89,,,,100% of Medicare,,120.89,,,,100% of Medicare,,120.89,,,,100% of Medicare,,120.89,,,,100% of Medicare,,120.89,,,,100% of Medicare,,120.89,,,,100% of Medicare,,120.89,,,,100% of Medicare,,120.89,,,,100% of Medicare,,,120.89,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,120.89,488.7,
"Cervical-Thoracic-Lumbar-Sacral Orthosis, Addition, Thoracic Pad",L1060,HCPCS,,,,outpatient,,,584,350.4,,45.5,,265.72,percent of total billed charges,,,45.3,,264.55,percent of total billed charges,,,39,,227.76,percent of total billed charges,,,,,,,,,80,,467.2,percent of total billed charges,,,61.4,,358.58,percent of total billed charges,,,57.4,,335.22,percent of total billed charges,,,81,,473.04,percent of total billed charges,,,39,,227.76,percent of total billed charges,,,57.6,,336.38,percent of total billed charges,,,85,,496.4,percent of total billed charges,,,85,,496.4,percent of total billed charges,,,49,,286.16,percent of total billed charges,,,90,,525.6,percent of total billed charges,,,65,,379.6,percent of total billed charges,,,80,,467.2,percent of total billed charges,,,55,,321.2,percent of total billed charges,,,55,,321.2,percent of total billed charges,,,65,,379.6,percent of total billed charges,,,78,,455.52,percent of total billed charges,,,70,,408.8,percent of total billed charges,,,,,,,,130.49,,,,100% of Medicare,,130.49,,,,100% of Medicare,,130.49,,,,100% of Medicare,,130.49,,,,100% of Medicare,,130.49,,,,100% of Medicare,,130.49,,,,100% of Medicare,,130.49,,,,100% of Medicare,,130.49,,,,100% of Medicare,,130.49,,,,100% of Medicare,,130.49,,,,100% of Medicare,,130.49,,,,100% of Medicare,,130.49,,,,100% of Medicare,,,130.49,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,130.49,525.6,
"Cervical-Thoracic-Lumbar-Sacral Orthosis, Addition, Trapeze Sling",L1070,HCPCS,,,,outpatient,,,290,174,,45.5,,131.95,percent of total billed charges,,,45.3,,131.37,percent of total billed charges,,,39,,113.1,percent of total billed charges,,,,,,,,,80,,232,percent of total billed charges,,,61.4,,178.06,percent of total billed charges,,,57.4,,166.46,percent of total billed charges,,,81,,234.9,percent of total billed charges,,,39,,113.1,percent of total billed charges,,,57.6,,167.04,percent of total billed charges,,,85,,246.5,percent of total billed charges,,,85,,246.5,percent of total billed charges,,,49,,142.1,percent of total billed charges,,,90,,261,percent of total billed charges,,,65,,188.5,percent of total billed charges,,,80,,232,percent of total billed charges,,,55,,159.5,percent of total billed charges,,,55,,159.5,percent of total billed charges,,,65,,188.5,percent of total billed charges,,,78,,226.2,percent of total billed charges,,,70,,203,percent of total billed charges,,,,,,,,135.17,,,,100% of Medicare,,135.17,,,,100% of Medicare,,135.17,,,,100% of Medicare,,135.17,,,,100% of Medicare,,135.17,,,,100% of Medicare,,135.17,,,,100% of Medicare,,135.17,,,,100% of Medicare,,135.17,,,,100% of Medicare,,135.17,,,,100% of Medicare,,135.17,,,,100% of Medicare,,135.17,,,,100% of Medicare,,135.17,,,,100% of Medicare,,,135.17,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,113.1,261,
"Cervical-Thoracic-Lumbar-Sacral Orthosis, Addition, Outrigger",L1080,HCPCS,,,,outpatient,,,135,81,,45.5,,61.43,percent of total billed charges,,,45.3,,61.16,percent of total billed charges,,,39,,52.65,percent of total billed charges,,,,,,,,,80,,108,percent of total billed charges,,,61.4,,82.89,percent of total billed charges,,,57.4,,77.49,percent of total billed charges,,,81,,109.35,percent of total billed charges,,,39,,52.65,percent of total billed charges,,,57.6,,77.76,percent of total billed charges,,,85,,114.75,percent of total billed charges,,,85,,114.75,percent of total billed charges,,,49,,66.15,percent of total billed charges,,,90,,121.5,percent of total billed charges,,,65,,87.75,percent of total billed charges,,,80,,108,percent of total billed charges,,,55,,74.25,percent of total billed charges,,,55,,74.25,percent of total billed charges,,,65,,87.75,percent of total billed charges,,,78,,105.3,percent of total billed charges,,,70,,94.5,percent of total billed charges,,,,,,,,63.04,,,,100% of Medicare,,63.04,,,,100% of Medicare,,63.04,,,,100% of Medicare,,63.04,,,,100% of Medicare,,63.04,,,,100% of Medicare,,63.04,,,,100% of Medicare,,63.04,,,,100% of Medicare,,63.04,,,,100% of Medicare,,63.04,,,,100% of Medicare,,63.04,,,,100% of Medicare,,63.04,,,,100% of Medicare,,63.04,,,,100% of Medicare,,,63.04,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,52.65,121.5,
"Cervical-Thoracic-Lumbar-Sacral Orthosis, Addition, Bil Outrigger w. Extension",L1085,HCPCS,,,,outpatient,,,449,269.4,,45.5,,204.3,percent of total billed charges,,,45.3,,203.4,percent of total billed charges,,,39,,175.11,percent of total billed charges,,,,,,,,,80,,359.2,percent of total billed charges,,,61.4,,275.69,percent of total billed charges,,,57.4,,257.73,percent of total billed charges,,,81,,363.69,percent of total billed charges,,,39,,175.11,percent of total billed charges,,,57.6,,258.62,percent of total billed charges,,,85,,381.65,percent of total billed charges,,,85,,381.65,percent of total billed charges,,,49,,220.01,percent of total billed charges,,,90,,404.1,percent of total billed charges,,,65,,291.85,percent of total billed charges,,,80,,359.2,percent of total billed charges,,,55,,246.95,percent of total billed charges,,,55,,246.95,percent of total billed charges,,,65,,291.85,percent of total billed charges,,,78,,350.22,percent of total billed charges,,,70,,314.3,percent of total billed charges,,,,,,,,211.05,,,,100% of Medicare,,211.05,,,,100% of Medicare,,211.05,,,,100% of Medicare,,211.05,,,,100% of Medicare,,211.05,,,,100% of Medicare,,211.05,,,,100% of Medicare,,211.05,,,,100% of Medicare,,211.05,,,,100% of Medicare,,211.05,,,,100% of Medicare,,211.05,,,,100% of Medicare,,211.05,,,,100% of Medicare,,211.05,,,,100% of Medicare,,,211.05,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,175.11,404.1,
"Cervical-Thoracic-Lumbar-Sacral Orthosis, Addition, Lumbar Sling",L1090,HCPCS,,,,outpatient,,,256,153.6,,45.5,,116.48,percent of total billed charges,,,45.3,,115.97,percent of total billed charges,,,39,,99.84,percent of total billed charges,,,,,,,,,80,,204.8,percent of total billed charges,,,61.4,,157.18,percent of total billed charges,,,57.4,,146.94,percent of total billed charges,,,81,,207.36,percent of total billed charges,,,39,,99.84,percent of total billed charges,,,57.6,,147.46,percent of total billed charges,,,85,,217.6,percent of total billed charges,,,85,,217.6,percent of total billed charges,,,49,,125.44,percent of total billed charges,,,90,,230.4,percent of total billed charges,,,65,,166.4,percent of total billed charges,,,80,,204.8,percent of total billed charges,,,55,,140.8,percent of total billed charges,,,55,,140.8,percent of total billed charges,,,65,,166.4,percent of total billed charges,,,78,,199.68,percent of total billed charges,,,70,,179.2,percent of total billed charges,,,,,,,,121.24,,,,100% of Medicare,,121.24,,,,100% of Medicare,,121.24,,,,100% of Medicare,,121.24,,,,100% of Medicare,,121.24,,,,100% of Medicare,,121.24,,,,100% of Medicare,,121.24,,,,100% of Medicare,,121.24,,,,100% of Medicare,,121.24,,,,100% of Medicare,,121.24,,,,100% of Medicare,,121.24,,,,100% of Medicare,,121.24,,,,100% of Medicare,,,121.24,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,99.84,230.4,
"Cervical-Thoracic-Lumbar-Sacral Orthosis, Addition, Ring Flange, Plastic/Leather",L1100,HCPCS,,,,outpatient,,,486,291.6,,45.5,,221.13,percent of total billed charges,,,45.3,,220.16,percent of total billed charges,,,39,,189.54,percent of total billed charges,,,,,,,,,80,,388.8,percent of total billed charges,,,61.4,,298.4,percent of total billed charges,,,57.4,,278.96,percent of total billed charges,,,81,,393.66,percent of total billed charges,,,39,,189.54,percent of total billed charges,,,57.6,,279.94,percent of total billed charges,,,85,,413.1,percent of total billed charges,,,85,,413.1,percent of total billed charges,,,49,,238.14,percent of total billed charges,,,90,,437.4,percent of total billed charges,,,65,,315.9,percent of total billed charges,,,80,,388.8,percent of total billed charges,,,55,,267.3,percent of total billed charges,,,55,,267.3,percent of total billed charges,,,65,,315.9,percent of total billed charges,,,78,,379.08,percent of total billed charges,,,70,,340.2,percent of total billed charges,,,,,,,,228.81,,,,100% of Medicare,,228.81,,,,100% of Medicare,,228.81,,,,100% of Medicare,,228.81,,,,100% of Medicare,,228.81,,,,100% of Medicare,,228.81,,,,100% of Medicare,,228.81,,,,100% of Medicare,,228.81,,,,100% of Medicare,,228.81,,,,100% of Medicare,,228.81,,,,100% of Medicare,,228.81,,,,100% of Medicare,,228.81,,,,100% of Medicare,,,228.81,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,189.54,437.4,
"Cervical-Thoracic-Lumbar-Sacral Orthosis, Addition, Ring Flange, Plastic/Leather Molded to Pt",L1110,HCPCS,,,,outpatient,,,818,490.8,,45.5,,372.19,percent of total billed charges,,,45.3,,370.55,percent of total billed charges,,,39,,319.02,percent of total billed charges,,,,,,,,,80,,654.4,percent of total billed charges,,,61.4,,502.25,percent of total billed charges,,,57.4,,469.53,percent of total billed charges,,,81,,662.58,percent of total billed charges,,,39,,319.02,percent of total billed charges,,,57.6,,471.17,percent of total billed charges,,,85,,695.3,percent of total billed charges,,,85,,695.3,percent of total billed charges,,,49,,400.82,percent of total billed charges,,,90,,736.2,percent of total billed charges,,,65,,531.7,percent of total billed charges,,,80,,654.4,percent of total billed charges,,,55,,449.9,percent of total billed charges,,,55,,449.9,percent of total billed charges,,,65,,531.7,percent of total billed charges,,,78,,638.04,percent of total billed charges,,,70,,572.6,percent of total billed charges,,,,,,,,383.64,,,,100% of Medicare,,383.64,,,,100% of Medicare,,383.64,,,,100% of Medicare,,383.64,,,,100% of Medicare,,383.64,,,,100% of Medicare,,383.64,,,,100% of Medicare,,383.64,,,,100% of Medicare,,383.64,,,,100% of Medicare,,383.64,,,,100% of Medicare,,383.64,,,,100% of Medicare,,383.64,,,,100% of Medicare,,383.64,,,,100% of Medicare,,,383.64,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,319.02,736.2,
"Cervical-Thoracic-Lumbar-Sacral Orthosis, Addition, Covers for Upright",L1120,HCPCS,,,,outpatient,,,99,59.4,,45.5,,45.05,percent of total billed charges,,,45.3,,44.85,percent of total billed charges,,,39,,38.61,percent of total billed charges,,,,,,,,,80,,79.2,percent of total billed charges,,,61.4,,60.79,percent of total billed charges,,,57.4,,56.83,percent of total billed charges,,,81,,80.19,percent of total billed charges,,,39,,38.61,percent of total billed charges,,,57.6,,57.02,percent of total billed charges,,,85,,84.15,percent of total billed charges,,,85,,84.15,percent of total billed charges,,,49,,48.51,percent of total billed charges,,,90,,89.1,percent of total billed charges,,,65,,64.35,percent of total billed charges,,,80,,79.2,percent of total billed charges,,,55,,54.45,percent of total billed charges,,,55,,54.45,percent of total billed charges,,,65,,64.35,percent of total billed charges,,,78,,77.22,percent of total billed charges,,,70,,69.3,percent of total billed charges,,,,,,,,45.82,,,,100% of Medicare,,45.82,,,,100% of Medicare,,45.82,,,,100% of Medicare,,45.82,,,,100% of Medicare,,45.82,,,,100% of Medicare,,45.82,,,,100% of Medicare,,45.82,,,,100% of Medicare,,45.82,,,,100% of Medicare,,45.82,,,,100% of Medicare,,45.82,,,,100% of Medicare,,45.82,,,,100% of Medicare,,45.82,,,,100% of Medicare,,,45.82,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,38.61,89.1,
"Thoracic-Lumbar-Sacral Orthosis, Addition, Lateral/Thoracic Extension",L1210,HCPCS,,,,outpatient,,,625,375,,45.5,,284.38,percent of total billed charges,,,45.3,,283.13,percent of total billed charges,,,39,,243.75,percent of total billed charges,,,,,,,,,80,,500,percent of total billed charges,,,61.4,,383.75,percent of total billed charges,,,57.4,,358.75,percent of total billed charges,,,81,,506.25,percent of total billed charges,,,39,,243.75,percent of total billed charges,,,57.6,,360,percent of total billed charges,,,85,,531.25,percent of total billed charges,,,85,,531.25,percent of total billed charges,,,49,,306.25,percent of total billed charges,,,90,,562.5,percent of total billed charges,,,65,,406.25,percent of total billed charges,,,80,,500,percent of total billed charges,,,55,,343.75,percent of total billed charges,,,55,,343.75,percent of total billed charges,,,65,,406.25,percent of total billed charges,,,78,,487.5,percent of total billed charges,,,70,,437.5,percent of total billed charges,,,,,,,,294.78,,,,100% of Medicare,,294.78,,,,100% of Medicare,,294.78,,,,100% of Medicare,,294.78,,,,100% of Medicare,,294.78,,,,100% of Medicare,,294.78,,,,100% of Medicare,,294.78,,,,100% of Medicare,,294.78,,,,100% of Medicare,,294.78,,,,100% of Medicare,,294.78,,,,100% of Medicare,,294.78,,,,100% of Medicare,,294.78,,,,100% of Medicare,,,294.78,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,243.75,562.5,
"Thoracic-Lumbar-Sacral Orthosis, Addition, Anterior/Thoracic Extension",L1220,HCPCS,,,,outpatient,,,612,367.2,,45.5,,278.46,percent of total billed charges,,,45.3,,277.24,percent of total billed charges,,,39,,238.68,percent of total billed charges,,,,,,,,,80,,489.6,percent of total billed charges,,,61.4,,375.77,percent of total billed charges,,,57.4,,351.29,percent of total billed charges,,,81,,495.72,percent of total billed charges,,,39,,238.68,percent of total billed charges,,,57.6,,352.51,percent of total billed charges,,,85,,520.2,percent of total billed charges,,,85,,520.2,percent of total billed charges,,,49,,299.88,percent of total billed charges,,,90,,550.8,percent of total billed charges,,,65,,397.8,percent of total billed charges,,,80,,489.6,percent of total billed charges,,,55,,336.6,percent of total billed charges,,,55,,336.6,percent of total billed charges,,,65,,397.8,percent of total billed charges,,,78,,477.36,percent of total billed charges,,,70,,428.4,percent of total billed charges,,,,,,,,286.92,,,,100% of Medicare,,286.92,,,,100% of Medicare,,286.92,,,,100% of Medicare,,286.92,,,,100% of Medicare,,286.92,,,,100% of Medicare,,286.92,,,,100% of Medicare,,286.92,,,,100% of Medicare,,286.92,,,,100% of Medicare,,286.92,,,,100% of Medicare,,286.92,,,,100% of Medicare,,286.92,,,,100% of Medicare,,286.92,,,,100% of Medicare,,,286.92,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,238.68,550.8,
"Thoracic-Lumbar-Sacral Orthosis, Addition, Milwaukee Type Superstructure",L1230,HCPCS,,,,outpatient,,,1708,1024.8,,45.5,,777.14,percent of total billed charges,,,45.3,,773.72,percent of total billed charges,,,39,,666.12,percent of total billed charges,,,,,,,,,80,,1366.4,percent of total billed charges,,,61.4,,1048.71,percent of total billed charges,,,57.4,,980.39,percent of total billed charges,,,81,,1383.48,percent of total billed charges,,,39,,666.12,percent of total billed charges,,,57.6,,983.81,percent of total billed charges,,,85,,1451.8,percent of total billed charges,,,85,,1451.8,percent of total billed charges,,,49,,836.92,percent of total billed charges,,,90,,1537.2,percent of total billed charges,,,65,,1110.2,percent of total billed charges,,,80,,1366.4,percent of total billed charges,,,55,,939.4,percent of total billed charges,,,55,,939.4,percent of total billed charges,,,65,,1110.2,percent of total billed charges,,,78,,1332.24,percent of total billed charges,,,70,,1195.6,percent of total billed charges,,,,,,,,803.78,,,,100% of Medicare,,803.78,,,,100% of Medicare,,803.78,,,,100% of Medicare,,803.78,,,,100% of Medicare,,803.78,,,,100% of Medicare,,803.78,,,,100% of Medicare,,803.78,,,,100% of Medicare,,803.78,,,,100% of Medicare,,803.78,,,,100% of Medicare,,803.78,,,,100% of Medicare,,803.78,,,,100% of Medicare,,803.78,,,,100% of Medicare,,,803.78,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,666.12,1537.2,
"Thoracic-Lumbar-Sacral Orthosis, Addition, Lumbar Derotation Pad",L1240,HCPCS,,,,outpatient,,,235,141,,45.5,,106.93,percent of total billed charges,,,45.3,,106.46,percent of total billed charges,,,39,,91.65,percent of total billed charges,,,,,,,,,80,,188,percent of total billed charges,,,61.4,,144.29,percent of total billed charges,,,57.4,,134.89,percent of total billed charges,,,81,,190.35,percent of total billed charges,,,39,,91.65,percent of total billed charges,,,57.6,,135.36,percent of total billed charges,,,85,,199.75,percent of total billed charges,,,85,,199.75,percent of total billed charges,,,49,,115.15,percent of total billed charges,,,90,,211.5,percent of total billed charges,,,65,,152.75,percent of total billed charges,,,80,,188,percent of total billed charges,,,55,,129.25,percent of total billed charges,,,55,,129.25,percent of total billed charges,,,65,,152.75,percent of total billed charges,,,78,,183.3,percent of total billed charges,,,70,,164.5,percent of total billed charges,,,,,,,,109.58,,,,100% of Medicare,,109.58,,,,100% of Medicare,,109.58,,,,100% of Medicare,,109.58,,,,100% of Medicare,,109.58,,,,100% of Medicare,,109.58,,,,100% of Medicare,,109.58,,,,100% of Medicare,,109.58,,,,100% of Medicare,,109.58,,,,100% of Medicare,,109.58,,,,100% of Medicare,,109.58,,,,100% of Medicare,,109.58,,,,100% of Medicare,,,109.58,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.65,211.5,
"Thoracic-Lumbar-Sacral Orthosis, Addition, Anterior Asis Pad",L1250,HCPCS,,,,outpatient,,,427,256.2,,45.5,,194.29,percent of total billed charges,,,45.3,,193.43,percent of total billed charges,,,39,,166.53,percent of total billed charges,,,,,,,,,80,,341.6,percent of total billed charges,,,61.4,,262.18,percent of total billed charges,,,57.4,,245.1,percent of total billed charges,,,81,,345.87,percent of total billed charges,,,39,,166.53,percent of total billed charges,,,57.6,,245.95,percent of total billed charges,,,85,,362.95,percent of total billed charges,,,85,,362.95,percent of total billed charges,,,49,,209.23,percent of total billed charges,,,90,,384.3,percent of total billed charges,,,65,,277.55,percent of total billed charges,,,80,,341.6,percent of total billed charges,,,55,,234.85,percent of total billed charges,,,55,,234.85,percent of total billed charges,,,65,,277.55,percent of total billed charges,,,78,,333.06,percent of total billed charges,,,70,,298.9,percent of total billed charges,,,,,,,,95.29,,,,100% of Medicare,,95.29,,,,100% of Medicare,,95.29,,,,100% of Medicare,,95.29,,,,100% of Medicare,,95.29,,,,100% of Medicare,,95.29,,,,100% of Medicare,,95.29,,,,100% of Medicare,,95.29,,,,100% of Medicare,,95.29,,,,100% of Medicare,,95.29,,,,100% of Medicare,,95.29,,,,100% of Medicare,,95.29,,,,100% of Medicare,,,95.29,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,95.29,384.3,
"Thoracic-Lumbar-Sacral Orthosis, Addition, Anterior Thoracic Derotation Pad",L1260,HCPCS,,,,outpatient,,,244,146.4,,45.5,,111.02,percent of total billed charges,,,45.3,,110.53,percent of total billed charges,,,39,,95.16,percent of total billed charges,,,,,,,,,80,,195.2,percent of total billed charges,,,61.4,,149.82,percent of total billed charges,,,57.4,,140.06,percent of total billed charges,,,81,,197.64,percent of total billed charges,,,39,,95.16,percent of total billed charges,,,57.6,,140.54,percent of total billed charges,,,85,,207.4,percent of total billed charges,,,85,,207.4,percent of total billed charges,,,49,,119.56,percent of total billed charges,,,90,,219.6,percent of total billed charges,,,65,,158.6,percent of total billed charges,,,80,,195.2,percent of total billed charges,,,55,,134.2,percent of total billed charges,,,55,,134.2,percent of total billed charges,,,65,,158.6,percent of total billed charges,,,78,,190.32,percent of total billed charges,,,70,,170.8,percent of total billed charges,,,,,,,,113.64,,,,100% of Medicare,,113.64,,,,100% of Medicare,,113.64,,,,100% of Medicare,,113.64,,,,100% of Medicare,,113.64,,,,100% of Medicare,,113.64,,,,100% of Medicare,,113.64,,,,100% of Medicare,,113.64,,,,100% of Medicare,,113.64,,,,100% of Medicare,,113.64,,,,100% of Medicare,,113.64,,,,100% of Medicare,,113.64,,,,100% of Medicare,,,113.64,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,95.16,219.6,
"Thoracic-Lumbar-Sacral Orthosis, Addition, Abdominal Pad",L1270,HCPCS,,,,outpatient,,,210,126,,45.5,,95.55,percent of total billed charges,,,45.3,,95.13,percent of total billed charges,,,39,,81.9,percent of total billed charges,,,,,,,,,80,,168,percent of total billed charges,,,61.4,,128.94,percent of total billed charges,,,57.4,,120.54,percent of total billed charges,,,81,,170.1,percent of total billed charges,,,39,,81.9,percent of total billed charges,,,57.6,,120.96,percent of total billed charges,,,85,,178.5,percent of total billed charges,,,85,,178.5,percent of total billed charges,,,49,,102.9,percent of total billed charges,,,90,,189,percent of total billed charges,,,65,,136.5,percent of total billed charges,,,80,,168,percent of total billed charges,,,55,,115.5,percent of total billed charges,,,55,,115.5,percent of total billed charges,,,65,,136.5,percent of total billed charges,,,78,,163.8,percent of total billed charges,,,70,,147,percent of total billed charges,,,,,,,,99.86,,,,100% of Medicare,,99.86,,,,100% of Medicare,,99.86,,,,100% of Medicare,,99.86,,,,100% of Medicare,,99.86,,,,100% of Medicare,,99.86,,,,100% of Medicare,,99.86,,,,100% of Medicare,,99.86,,,,100% of Medicare,,99.86,,,,100% of Medicare,,99.86,,,,100% of Medicare,,99.86,,,,100% of Medicare,,99.86,,,,100% of Medicare,,,99.86,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,81.9,189,
"Thoracic-Lumbar-Sacral Orthosis, Addition, Rib Gusset, Elastic",L1280,HCPCS,,,,outpatient,,,225,135,,45.5,,102.38,percent of total billed charges,,,45.3,,101.93,percent of total billed charges,,,39,,87.75,percent of total billed charges,,,,,,,,,80,,180,percent of total billed charges,,,61.4,,138.15,percent of total billed charges,,,57.4,,129.15,percent of total billed charges,,,81,,182.25,percent of total billed charges,,,39,,87.75,percent of total billed charges,,,57.6,,129.6,percent of total billed charges,,,85,,191.25,percent of total billed charges,,,85,,191.25,percent of total billed charges,,,49,,110.25,percent of total billed charges,,,90,,202.5,percent of total billed charges,,,65,,146.25,percent of total billed charges,,,80,,180,percent of total billed charges,,,55,,123.75,percent of total billed charges,,,55,,123.75,percent of total billed charges,,,65,,146.25,percent of total billed charges,,,78,,175.5,percent of total billed charges,,,70,,157.5,percent of total billed charges,,,,,,,,105.28,,,,100% of Medicare,,105.28,,,,100% of Medicare,,105.28,,,,100% of Medicare,,105.28,,,,100% of Medicare,,105.28,,,,100% of Medicare,,105.28,,,,100% of Medicare,,105.28,,,,100% of Medicare,,105.28,,,,100% of Medicare,,105.28,,,,100% of Medicare,,105.28,,,,100% of Medicare,,105.28,,,,100% of Medicare,,105.28,,,,100% of Medicare,,,105.28,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,87.75,202.5,
"Thoracic-Lumbar-Sacral Orthosis, Addition, Lateral Trochanteric Pad",L1290,HCPCS,,,,outpatient,,,420,252,,45.5,,191.1,percent of total billed charges,,,45.3,,190.26,percent of total billed charges,,,39,,163.8,percent of total billed charges,,,,,,,,,80,,336,percent of total billed charges,,,61.4,,257.88,percent of total billed charges,,,57.4,,241.08,percent of total billed charges,,,81,,340.2,percent of total billed charges,,,39,,163.8,percent of total billed charges,,,57.6,,241.92,percent of total billed charges,,,85,,357,percent of total billed charges,,,85,,357,percent of total billed charges,,,49,,205.8,percent of total billed charges,,,90,,378,percent of total billed charges,,,65,,273,percent of total billed charges,,,80,,336,percent of total billed charges,,,55,,231,percent of total billed charges,,,55,,231,percent of total billed charges,,,65,,273,percent of total billed charges,,,78,,327.6,percent of total billed charges,,,70,,294,percent of total billed charges,,,,,,,,93.62,,,,100% of Medicare,,93.62,,,,100% of Medicare,,93.62,,,,100% of Medicare,,93.62,,,,100% of Medicare,,93.62,,,,100% of Medicare,,93.62,,,,100% of Medicare,,93.62,,,,100% of Medicare,,93.62,,,,100% of Medicare,,93.62,,,,100% of Medicare,,93.62,,,,100% of Medicare,,93.62,,,,100% of Medicare,,93.62,,,,100% of Medicare,,,93.62,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,93.62,378,
"Thoracic, pectus carinatum orthosis, custom fabricated",L1320,HCPCS,,,,outpatient,,,2575,1545,,45.5,,1171.63,percent of total billed charges,,,45.3,,1166.48,percent of total billed charges,,,51,,1313.25,percent of total billed charges,,,,,,,,,80,,2060,percent of total billed charges,,,61.4,,1581.05,percent of total billed charges,,,57.4,,1478.05,percent of total billed charges,,,81,,2085.75,percent of total billed charges,,,51.5,,1326.13,percent of total billed charges,,,57.6,,1483.2,percent of total billed charges,,,85,,2188.75,percent of total billed charges,,,85,,2188.75,percent of total billed charges,,,49,,1261.75,percent of total billed charges,,,90,,2317.5,percent of total billed charges,,,65,,1673.75,percent of total billed charges,,,80,,2060,percent of total billed charges,,,55,,1416.25,percent of total billed charges,,,55,,1416.25,percent of total billed charges,,,65,,1673.75,percent of total billed charges,,,78,,2008.5,percent of total billed charges,,,70,,1802.5,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1166.48,2317.5,
"L1499 - Spinal orthosis, not otherwise specified",L1499,HCPCS,,,,both,,,136.55,81.93,,45.5,,62.13,percent of total billed charges,,,45.3,,61.86,percent of total billed charges,,,39,,53.25,percent of total billed charges,,,,,,,,,80,,109.24,percent of total billed charges,,,61.4,,83.84,percent of total billed charges,,,57.4,,78.38,percent of total billed charges,,,81,,110.61,percent of total billed charges,,,51.5,,70.32,percent of total billed charges,,,57.6,,78.65,percent of total billed charges,,,85,,116.07,percent of total billed charges,,,85,,116.07,percent of total billed charges,,,49,,66.91,percent of total billed charges,,,90,,122.9,percent of total billed charges,,,65,,88.76,percent of total billed charges,,,80,,109.24,percent of total billed charges,,,55,,75.1,percent of total billed charges,,,55,,75.1,percent of total billed charges,,,65,,88.76,percent of total billed charges,,,78,,106.51,percent of total billed charges,,,70,,95.59,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG rate,100% of IL Medicaid,,,,,EAPG rate,100% of IL Medicaid,,,,,EAPG rate,100% of IL Medicaid,,,,,EAPG rate,100% of IL Medicaid,53.25,122.9,
"Hip Orthosis, Abduction Control, Flexible, Frejka Type w/ Cover",L1600,HCPCS,,,,outpatient,,,693,415.8,,45.5,,315.32,percent of total billed charges,,,45.3,,313.93,percent of total billed charges,,,39,,270.27,percent of total billed charges,,,,,,,,,80,,554.4,percent of total billed charges,,,61.4,,425.5,percent of total billed charges,,,57.4,,397.78,percent of total billed charges,,,81,,561.33,percent of total billed charges,,,39,,270.27,percent of total billed charges,,,57.6,,399.17,percent of total billed charges,,,85,,589.05,percent of total billed charges,,,85,,589.05,percent of total billed charges,,,49,,339.57,percent of total billed charges,,,90,,623.7,percent of total billed charges,,,65,,450.45,percent of total billed charges,,,80,,554.4,percent of total billed charges,,,55,,381.15,percent of total billed charges,,,55,,381.15,percent of total billed charges,,,65,,450.45,percent of total billed charges,,,78,,540.54,percent of total billed charges,,,70,,485.1,percent of total billed charges,,,,,,,,155.26,,,,100% of Medicare,,155.26,,,,100% of Medicare,,155.26,,,,100% of Medicare,,155.26,,,,100% of Medicare,,155.26,,,,100% of Medicare,,155.26,,,,100% of Medicare,,155.26,,,,100% of Medicare,,155.26,,,,100% of Medicare,,155.26,,,,100% of Medicare,,155.26,,,,100% of Medicare,,155.26,,,,100% of Medicare,,155.26,,,,100% of Medicare,,,155.26,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,155.26,623.7,
"Hip Orthosis, Adbuction Control, Flexible, Frejka Cover Only",L1610,HCPCS,,,,outpatient,,,295,177,,45.5,,134.23,percent of total billed charges,,,45.3,,133.64,percent of total billed charges,,,39,,115.05,percent of total billed charges,,,,,,,,,80,,236,percent of total billed charges,,,61.4,,181.13,percent of total billed charges,,,57.4,,169.33,percent of total billed charges,,,81,,238.95,percent of total billed charges,,,39,,115.05,percent of total billed charges,,,57.6,,169.92,percent of total billed charges,,,85,,250.75,percent of total billed charges,,,85,,250.75,percent of total billed charges,,,49,,144.55,percent of total billed charges,,,90,,265.5,percent of total billed charges,,,65,,191.75,percent of total billed charges,,,80,,236,percent of total billed charges,,,55,,162.25,percent of total billed charges,,,55,,162.25,percent of total billed charges,,,65,,191.75,percent of total billed charges,,,78,,230.1,percent of total billed charges,,,70,,206.5,percent of total billed charges,,,,,,,,65.94,,,,100% of Medicare,,65.94,,,,100% of Medicare,,65.94,,,,100% of Medicare,,65.94,,,,100% of Medicare,,65.94,,,,100% of Medicare,,65.94,,,,100% of Medicare,,65.94,,,,100% of Medicare,,65.94,,,,100% of Medicare,,65.94,,,,100% of Medicare,,65.94,,,,100% of Medicare,,65.94,,,,100% of Medicare,,65.94,,,,100% of Medicare,,,65.94,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,65.94,265.5,
"Hip Orthosis, Abduction Control, Flexible, Pavlik Harness",L1620,HCPCS,,,,outpatient,,,403,241.8,,45.5,,183.37,percent of total billed charges,,,45.3,,182.56,percent of total billed charges,,,39,,157.17,percent of total billed charges,,,,,,,,,80,,322.4,percent of total billed charges,,,61.4,,247.44,percent of total billed charges,,,57.4,,231.32,percent of total billed charges,,,81,,326.43,percent of total billed charges,,,39,,157.17,percent of total billed charges,,,57.6,,232.13,percent of total billed charges,,,85,,342.55,percent of total billed charges,,,85,,342.55,percent of total billed charges,,,49,,197.47,percent of total billed charges,,,90,,362.7,percent of total billed charges,,,65,,261.95,percent of total billed charges,,,80,,322.4,percent of total billed charges,,,55,,221.65,percent of total billed charges,,,55,,221.65,percent of total billed charges,,,65,,261.95,percent of total billed charges,,,78,,314.34,percent of total billed charges,,,70,,282.1,percent of total billed charges,,,,,,,,189.31,,,,100% of Medicare,,189.31,,,,100% of Medicare,,189.31,,,,100% of Medicare,,189.31,,,,100% of Medicare,,189.31,,,,100% of Medicare,,189.31,,,,100% of Medicare,,189.31,,,,100% of Medicare,,189.31,,,,100% of Medicare,,189.31,,,,100% of Medicare,,189.31,,,,100% of Medicare,,189.31,,,,100% of Medicare,,189.31,,,,100% of Medicare,,,189.31,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,157.17,362.7,
"Hip Orthosis, Abduction Control, Semi-Flexible (Von Rosen Type)",L1630,HCPCS,,,,outpatient,,,544,326.4,,45.5,,247.52,percent of total billed charges,,,45.3,,246.43,percent of total billed charges,,,39,,212.16,percent of total billed charges,,,,,,,,,80,,435.2,percent of total billed charges,,,61.4,,334.02,percent of total billed charges,,,57.4,,312.26,percent of total billed charges,,,81,,440.64,percent of total billed charges,,,39,,212.16,percent of total billed charges,,,57.6,,313.34,percent of total billed charges,,,85,,462.4,percent of total billed charges,,,85,,462.4,percent of total billed charges,,,49,,266.56,percent of total billed charges,,,90,,489.6,percent of total billed charges,,,65,,353.6,percent of total billed charges,,,80,,435.2,percent of total billed charges,,,55,,299.2,percent of total billed charges,,,55,,299.2,percent of total billed charges,,,65,,353.6,percent of total billed charges,,,78,,424.32,percent of total billed charges,,,70,,380.8,percent of total billed charges,,,,,,,,254.53,,,,100% of Medicare,,254.53,,,,100% of Medicare,,254.53,,,,100% of Medicare,,254.53,,,,100% of Medicare,,254.53,,,,100% of Medicare,,254.53,,,,100% of Medicare,,254.53,,,,100% of Medicare,,254.53,,,,100% of Medicare,,254.53,,,,100% of Medicare,,254.53,,,,100% of Medicare,,254.53,,,,100% of Medicare,,254.53,,,,100% of Medicare,,,254.53,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,212.16,489.6,
"Hip Orthosis, Abduction Control, Static, Pelvic Band/Spreader Bar, Thigh",L1640,HCPCS,,,,outpatient,,,2546,1527.6,,45.5,,1158.43,percent of total billed charges,,,45.3,,1153.34,percent of total billed charges,,,39,,992.94,percent of total billed charges,,,,,,,,,80,,2036.8,percent of total billed charges,,,61.4,,1563.24,percent of total billed charges,,,57.4,,1461.4,percent of total billed charges,,,81,,2062.26,percent of total billed charges,,,39,,992.94,percent of total billed charges,,,57.6,,1466.5,percent of total billed charges,,,85,,2164.1,percent of total billed charges,,,85,,2164.1,percent of total billed charges,,,49,,1247.54,percent of total billed charges,,,90,,2291.4,percent of total billed charges,,,65,,1654.9,percent of total billed charges,,,80,,2036.8,percent of total billed charges,,,55,,1400.3,percent of total billed charges,,,55,,1400.3,percent of total billed charges,,,65,,1654.9,percent of total billed charges,,,78,,1985.88,percent of total billed charges,,,70,,1782.2,percent of total billed charges,,,,,,,,570.38,,,,100% of Medicare,,570.38,,,,100% of Medicare,,570.38,,,,100% of Medicare,,570.38,,,,100% of Medicare,,570.38,,,,100% of Medicare,,570.38,,,,100% of Medicare,,570.38,,,,100% of Medicare,,570.38,,,,100% of Medicare,,570.38,,,,100% of Medicare,,570.38,,,,100% of Medicare,,570.38,,,,100% of Medicare,,570.38,,,,100% of Medicare,,,570.38,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,570.38,2291.4,
"Hip Orthosis, Abduction Control, Static, Adjustable (Ilfeld Type)",L1650,HCPCS,,,,outpatient,,,631,378.6,,45.5,,287.11,percent of total billed charges,,,45.3,,285.84,percent of total billed charges,,,39,,246.09,percent of total billed charges,,,,,,,,,80,,504.8,percent of total billed charges,,,61.4,,387.43,percent of total billed charges,,,57.4,,362.19,percent of total billed charges,,,81,,511.11,percent of total billed charges,,,39,,246.09,percent of total billed charges,,,57.6,,363.46,percent of total billed charges,,,85,,536.35,percent of total billed charges,,,85,,536.35,percent of total billed charges,,,49,,309.19,percent of total billed charges,,,90,,567.9,percent of total billed charges,,,65,,410.15,percent of total billed charges,,,80,,504.8,percent of total billed charges,,,55,,347.05,percent of total billed charges,,,55,,347.05,percent of total billed charges,,,65,,410.15,percent of total billed charges,,,78,,492.18,percent of total billed charges,,,70,,441.7,percent of total billed charges,,,,,,,,297.13,,,,100% of Medicare,,297.13,,,,100% of Medicare,,297.13,,,,100% of Medicare,,297.13,,,,100% of Medicare,,297.13,,,,100% of Medicare,,297.13,,,,100% of Medicare,,297.13,,,,100% of Medicare,,297.13,,,,100% of Medicare,,297.13,,,,100% of Medicare,,297.13,,,,100% of Medicare,,297.13,,,,100% of Medicare,,297.13,,,,100% of Medicare,,,297.13,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,246.09,567.9,
Hip Orthosis Bilateral Thighcuffs w/ Spreader Bar,L1652,HCPCS,,,,outpatient,,,1916,1149.6,,45.5,,871.78,percent of total billed charges,,,45.3,,867.95,percent of total billed charges,,,39,,747.24,percent of total billed charges,,,,,,,,,80,,1532.8,percent of total billed charges,,,61.4,,1176.42,percent of total billed charges,,,57.4,,1099.78,percent of total billed charges,,,81,,1551.96,percent of total billed charges,,,39,,747.24,percent of total billed charges,,,57.6,,1103.62,percent of total billed charges,,,85,,1628.6,percent of total billed charges,,,85,,1628.6,percent of total billed charges,,,49,,938.84,percent of total billed charges,,,90,,1724.4,percent of total billed charges,,,65,,1245.4,percent of total billed charges,,,80,,1532.8,percent of total billed charges,,,55,,1053.8,percent of total billed charges,,,55,,1053.8,percent of total billed charges,,,65,,1245.4,percent of total billed charges,,,78,,1494.48,percent of total billed charges,,,70,,1341.2,percent of total billed charges,,,,,,,,429.5,,,,100% of Medicare,,429.5,,,,100% of Medicare,,429.5,,,,100% of Medicare,,429.5,,,,100% of Medicare,,429.5,,,,100% of Medicare,,429.5,,,,100% of Medicare,,429.5,,,,100% of Medicare,,429.5,,,,100% of Medicare,,429.5,,,,100% of Medicare,,429.5,,,,100% of Medicare,,429.5,,,,100% of Medicare,,429.5,,,,100% of Medicare,,,429.5,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,429.5,1724.4,
"Hip Orthosis, Abduction Control",L1660,HCPCS,,,,outpatient,,,542,325.2,,45.5,,246.61,percent of total billed charges,,,45.3,,245.53,percent of total billed charges,,,39,,211.38,percent of total billed charges,,,,,,,,,80,,433.6,percent of total billed charges,,,61.4,,332.79,percent of total billed charges,,,57.4,,311.11,percent of total billed charges,,,81,,439.02,percent of total billed charges,,,39,,211.38,percent of total billed charges,,,57.6,,312.19,percent of total billed charges,,,85,,460.7,percent of total billed charges,,,85,,460.7,percent of total billed charges,,,49,,265.58,percent of total billed charges,,,90,,487.8,percent of total billed charges,,,65,,352.3,percent of total billed charges,,,80,,433.6,percent of total billed charges,,,55,,298.1,percent of total billed charges,,,55,,298.1,percent of total billed charges,,,65,,352.3,percent of total billed charges,,,78,,422.76,percent of total billed charges,,,70,,379.4,percent of total billed charges,,,,,,,,217.73,,,,100% of Medicare,,217.73,,,,100% of Medicare,,217.73,,,,100% of Medicare,,217.73,,,,100% of Medicare,,217.73,,,,100% of Medicare,,217.73,,,,100% of Medicare,,217.73,,,,100% of Medicare,,217.73,,,,100% of Medicare,,217.73,,,,100% of Medicare,,217.73,,,,100% of Medicare,,217.73,,,,100% of Medicare,,217.73,,,,100% of Medicare,,,217.73,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,211.38,487.8,
"Legg Perthes Orthosis, Toronto Type",L1700,HCPCS,,,,outpatient,,,3989,2393.4,,45.5,,1815,percent of total billed charges,,,45.3,,1807.02,percent of total billed charges,,,39,,1555.71,percent of total billed charges,,,,,,,,,80,,3191.2,percent of total billed charges,,,61.4,,2449.25,percent of total billed charges,,,57.4,,2289.69,percent of total billed charges,,,81,,3231.09,percent of total billed charges,,,39,,1555.71,percent of total billed charges,,,57.6,,2297.66,percent of total billed charges,,,85,,3390.65,percent of total billed charges,,,85,,3390.65,percent of total billed charges,,,49,,1954.61,percent of total billed charges,,,90,,3590.1,percent of total billed charges,,,65,,2592.85,percent of total billed charges,,,80,,3191.2,percent of total billed charges,,,55,,2193.95,percent of total billed charges,,,55,,2193.95,percent of total billed charges,,,65,,2592.85,percent of total billed charges,,,78,,3111.42,percent of total billed charges,,,70,,2792.3,percent of total billed charges,,,,,,,,1874.55,,,,100% of Medicare,,1874.55,,,,100% of Medicare,,1874.55,,,,100% of Medicare,,1874.55,,,,100% of Medicare,,1874.55,,,,100% of Medicare,,1874.55,,,,100% of Medicare,,1874.55,,,,100% of Medicare,,1874.55,,,,100% of Medicare,,1874.55,,,,100% of Medicare,,1874.55,,,,100% of Medicare,,1874.55,,,,100% of Medicare,,1874.55,,,,100% of Medicare,,,1874.55,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1555.71,3590.1,
"Legg Perthes Orthosis, Trilateral, Tachdijan Type",L1720,HCPCS,,,,outpatient,,,3779,2267.4,,45.5,,1719.45,percent of total billed charges,,,45.3,,1711.89,percent of total billed charges,,,39,,1473.81,percent of total billed charges,,,,,,,,,80,,3023.2,percent of total billed charges,,,61.4,,2320.31,percent of total billed charges,,,57.4,,2169.15,percent of total billed charges,,,81,,3060.99,percent of total billed charges,,,39,,1473.81,percent of total billed charges,,,57.6,,2176.7,percent of total billed charges,,,85,,3212.15,percent of total billed charges,,,85,,3212.15,percent of total billed charges,,,49,,1851.71,percent of total billed charges,,,90,,3401.1,percent of total billed charges,,,65,,2456.35,percent of total billed charges,,,80,,3023.2,percent of total billed charges,,,55,,2078.45,percent of total billed charges,,,55,,2078.45,percent of total billed charges,,,65,,2456.35,percent of total billed charges,,,78,,2947.62,percent of total billed charges,,,70,,2645.3,percent of total billed charges,,,,,,,,1777.39,,,,100% of Medicare,,1777.39,,,,100% of Medicare,,1777.39,,,,100% of Medicare,,1777.39,,,,100% of Medicare,,1777.39,,,,100% of Medicare,,1777.39,,,,100% of Medicare,,1777.39,,,,100% of Medicare,,1777.39,,,,100% of Medicare,,1777.39,,,,100% of Medicare,,1777.39,,,,100% of Medicare,,1777.39,,,,100% of Medicare,,1777.39,,,,100% of Medicare,,,1777.39,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1473.81,3401.1,
Scottish Rite Orthosis,L1730,HCPCS,,,,outpatient,,,3882,2329.2,,45.5,,1766.31,percent of total billed charges,,,45.3,,1758.55,percent of total billed charges,,,39,,1513.98,percent of total billed charges,,,,,,,,,80,,3105.6,percent of total billed charges,,,61.4,,2383.55,percent of total billed charges,,,57.4,,2228.27,percent of total billed charges,,,81,,3144.42,percent of total billed charges,,,39,,1513.98,percent of total billed charges,,,57.6,,2236.03,percent of total billed charges,,,85,,3299.7,percent of total billed charges,,,85,,3299.7,percent of total billed charges,,,49,,1902.18,percent of total billed charges,,,90,,3493.8,percent of total billed charges,,,65,,2523.3,percent of total billed charges,,,80,,3105.6,percent of total billed charges,,,55,,2135.1,percent of total billed charges,,,55,,2135.1,percent of total billed charges,,,65,,2523.3,percent of total billed charges,,,78,,3027.96,percent of total billed charges,,,70,,2717.4,percent of total billed charges,,,,,,,,1500.51,,,,100% of Medicare,,1500.51,,,,100% of Medicare,,1500.51,,,,100% of Medicare,,1500.51,,,,100% of Medicare,,1500.51,,,,100% of Medicare,,1500.51,,,,100% of Medicare,,1500.51,,,,100% of Medicare,,1500.51,,,,100% of Medicare,,1500.51,,,,100% of Medicare,,1500.51,,,,100% of Medicare,,1500.51,,,,100% of Medicare,,1500.51,,,,100% of Medicare,,,1500.51,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1500.51,3493.8,
"Knee Orthosis, Elastic w/ Joints",L1810,HCPCS,,,,outpatient,,,552,331.2,,45.5,,251.16,percent of total billed charges,,,45.3,,250.06,percent of total billed charges,,,39,,215.28,percent of total billed charges,,,,,,,,,80,,441.6,percent of total billed charges,,,61.4,,338.93,percent of total billed charges,,,57.4,,316.85,percent of total billed charges,,,81,,447.12,percent of total billed charges,,,39,,215.28,percent of total billed charges,,,57.6,,317.95,percent of total billed charges,,,85,,469.2,percent of total billed charges,,,85,,469.2,percent of total billed charges,,,49,,270.48,percent of total billed charges,,,90,,496.8,percent of total billed charges,,,65,,358.8,percent of total billed charges,,,80,,441.6,percent of total billed charges,,,55,,303.6,percent of total billed charges,,,55,,303.6,percent of total billed charges,,,65,,358.8,percent of total billed charges,,,78,,430.56,percent of total billed charges,,,70,,386.4,percent of total billed charges,,,,,,,,124.04,,,,100% of Medicare,,124.04,,,,100% of Medicare,,124.04,,,,100% of Medicare,,124.04,,,,100% of Medicare,,124.04,,,,100% of Medicare,,124.04,,,,100% of Medicare,,124.04,,,,100% of Medicare,,124.04,,,,100% of Medicare,,124.04,,,,100% of Medicare,,124.04,,,,100% of Medicare,,124.04,,,,100% of Medicare,,124.04,,,,100% of Medicare,,,124.04,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,124.04,496.8,
KO ELASTIC W/JOINTS PRE OTS (L1812),L1812,HCPCS,,,,outpatient,,,497,298.2,,45.5,,226.14,percent of total billed charges,,,45.3,,225.14,percent of total billed charges,,,39,,193.83,percent of total billed charges,,,,,,,,,80,,397.6,percent of total billed charges,,,61.4,,305.16,percent of total billed charges,,,57.4,,285.28,percent of total billed charges,,,81,,402.57,percent of total billed charges,,,39,,193.83,percent of total billed charges,,,57.6,,286.27,percent of total billed charges,,,85,,422.45,percent of total billed charges,,,85,,422.45,percent of total billed charges,,,49,,243.53,percent of total billed charges,,,90,,447.3,percent of total billed charges,,,65,,323.05,percent of total billed charges,,,80,,397.6,percent of total billed charges,,,55,,273.35,percent of total billed charges,,,55,,273.35,percent of total billed charges,,,65,,323.05,percent of total billed charges,,,78,,387.66,percent of total billed charges,,,70,,347.9,percent of total billed charges,,,,,,,,76.45,,,,100% of Medicare,,76.45,,,,100% of Medicare,,76.45,,,,100% of Medicare,,76.45,,,,100% of Medicare,,76.45,,,,100% of Medicare,,76.45,,,,100% of Medicare,,76.45,,,,100% of Medicare,,76.45,,,,100% of Medicare,,76.45,,,,100% of Medicare,,76.45,,,,100% of Medicare,,76.45,,,,100% of Medicare,,76.45,,,,100% of Medicare,,,76.45,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,76.45,447.3,
"Knee Orthosis, Elastic w/ Condylar Pads and Joints",L1820,HCPCS,,,,outpatient,,,766,459.6,,45.5,,348.53,percent of total billed charges,,,45.3,,347,percent of total billed charges,,,39,,298.74,percent of total billed charges,,,,,,,,,80,,612.8,percent of total billed charges,,,61.4,,470.32,percent of total billed charges,,,57.4,,439.68,percent of total billed charges,,,81,,620.46,percent of total billed charges,,,39,,298.74,percent of total billed charges,,,57.6,,441.22,percent of total billed charges,,,85,,651.1,percent of total billed charges,,,85,,651.1,percent of total billed charges,,,49,,375.34,percent of total billed charges,,,90,,689.4,percent of total billed charges,,,65,,497.9,percent of total billed charges,,,80,,612.8,percent of total billed charges,,,55,,421.3,percent of total billed charges,,,55,,421.3,percent of total billed charges,,,65,,497.9,percent of total billed charges,,,78,,597.48,percent of total billed charges,,,70,,536.2,percent of total billed charges,,,,,,,,171.23,,,,100% of Medicare,,171.23,,,,100% of Medicare,,171.23,,,,100% of Medicare,,171.23,,,,100% of Medicare,,171.23,,,,100% of Medicare,,171.23,,,,100% of Medicare,,171.23,,,,100% of Medicare,,171.23,,,,100% of Medicare,,171.23,,,,100% of Medicare,,171.23,,,,100% of Medicare,,171.23,,,,100% of Medicare,,171.23,,,,100% of Medicare,,,171.23,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,171.23,689.4,
"Knee Orthosis, Immobilizer, Canvas",L1830,HCPCS,,,,outpatient,,,448,268.8,,45.5,,203.84,percent of total billed charges,,,45.3,,202.94,percent of total billed charges,,,39,,174.72,percent of total billed charges,,,,,,,,,80,,358.4,percent of total billed charges,,,61.4,,275.07,percent of total billed charges,,,57.4,,257.15,percent of total billed charges,,,81,,362.88,percent of total billed charges,,,39,,174.72,percent of total billed charges,,,57.6,,258.05,percent of total billed charges,,,85,,380.8,percent of total billed charges,,,85,,380.8,percent of total billed charges,,,49,,219.52,percent of total billed charges,,,90,,403.2,percent of total billed charges,,,65,,291.2,percent of total billed charges,,,80,,358.4,percent of total billed charges,,,55,,246.4,percent of total billed charges,,,55,,246.4,percent of total billed charges,,,65,,291.2,percent of total billed charges,,,78,,349.44,percent of total billed charges,,,70,,313.6,percent of total billed charges,,,,,,,,68.89,,,,100% of Medicare,,68.89,,,,100% of Medicare,,68.89,,,,100% of Medicare,,68.89,,,,100% of Medicare,,68.89,,,,100% of Medicare,,68.89,,,,100% of Medicare,,68.89,,,,100% of Medicare,,68.89,,,,100% of Medicare,,68.89,,,,100% of Medicare,,68.89,,,,100% of Medicare,,68.89,,,,100% of Medicare,,68.89,,,,100% of Medicare,,,68.89,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,68.89,403.2,
"Knee Orthosis, Positional, Locking Knee Joint, Prefabricated",L1831,HCPCS,,,,outpatient,,,1583,949.8,,45.5,,720.27,percent of total billed charges,,,45.3,,717.1,percent of total billed charges,,,39,,617.37,percent of total billed charges,,,,,,,,,80,,1266.4,percent of total billed charges,,,61.4,,971.96,percent of total billed charges,,,57.4,,908.64,percent of total billed charges,,,81,,1282.23,percent of total billed charges,,,39,,617.37,percent of total billed charges,,,57.6,,911.81,percent of total billed charges,,,85,,1345.55,percent of total billed charges,,,85,,1345.55,percent of total billed charges,,,49,,775.67,percent of total billed charges,,,90,,1424.7,percent of total billed charges,,,65,,1028.95,percent of total billed charges,,,80,,1266.4,percent of total billed charges,,,55,,870.65,percent of total billed charges,,,55,,870.65,percent of total billed charges,,,65,,1028.95,percent of total billed charges,,,78,,1234.74,percent of total billed charges,,,70,,1108.1,percent of total billed charges,,,,,,,,354.61,,,,100% of Medicare,,354.61,,,,100% of Medicare,,354.61,,,,100% of Medicare,,354.61,,,,100% of Medicare,,354.61,,,,100% of Medicare,,354.61,,,,100% of Medicare,,354.61,,,,100% of Medicare,,354.61,,,,100% of Medicare,,354.61,,,,100% of Medicare,,354.61,,,,100% of Medicare,,354.61,,,,100% of Medicare,,354.61,,,,100% of Medicare,,,354.61,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,354.61,1424.7,
"Knee Orthosis, Positional Adjustable Knee Joints, Rigid Supports",L1832,HCPCS,,,,outpatient,,,3705,2223,,45.5,,1685.78,percent of total billed charges,,,45.3,,1678.37,percent of total billed charges,,,39,,1444.95,percent of total billed charges,,,,,,,,,80,,2964,percent of total billed charges,,,61.4,,2274.87,percent of total billed charges,,,57.4,,2126.67,percent of total billed charges,,,81,,3001.05,percent of total billed charges,,,39,,1444.95,percent of total billed charges,,,57.6,,2134.08,percent of total billed charges,,,85,,3149.25,percent of total billed charges,,,85,,3149.25,percent of total billed charges,,,49,,1815.45,percent of total billed charges,,,90,,3334.5,percent of total billed charges,,,65,,2408.25,percent of total billed charges,,,80,,2964,percent of total billed charges,,,55,,2037.75,percent of total billed charges,,,55,,2037.75,percent of total billed charges,,,65,,2408.25,percent of total billed charges,,,78,,2889.9,percent of total billed charges,,,70,,2593.5,percent of total billed charges,,,,,,,,829.91,,,,100% of Medicare,,829.91,,,,100% of Medicare,,829.91,,,,100% of Medicare,,829.91,,,,100% of Medicare,,829.91,,,,100% of Medicare,,829.91,,,,100% of Medicare,,829.91,,,,100% of Medicare,,829.91,,,,100% of Medicare,,829.91,,,,100% of Medicare,,829.91,,,,100% of Medicare,,829.91,,,,100% of Medicare,,829.91,,,,100% of Medicare,,,829.91,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,829.91,3334.5,
KO ADJ JNT POS R SUP PRE OTS (L1833),L1833,HCPCS,,,,outpatient,,,3430,2058,,45.5,,1560.65,percent of total billed charges,,,45.3,,1553.79,percent of total billed charges,,,39,,1337.7,percent of total billed charges,,,,,,,,,80,,2744,percent of total billed charges,,,61.4,,2106.02,percent of total billed charges,,,57.4,,1968.82,percent of total billed charges,,,81,,2778.3,percent of total billed charges,,,39,,1337.7,percent of total billed charges,,,57.6,,1975.68,percent of total billed charges,,,85,,2915.5,percent of total billed charges,,,85,,2915.5,percent of total billed charges,,,49,,1680.7,percent of total billed charges,,,90,,3087,percent of total billed charges,,,65,,2229.5,percent of total billed charges,,,80,,2744,percent of total billed charges,,,55,,1886.5,percent of total billed charges,,,55,,1886.5,percent of total billed charges,,,65,,2229.5,percent of total billed charges,,,78,,2675.4,percent of total billed charges,,,70,,2401,percent of total billed charges,,,,,,,,496.23,,,,100% of Medicare,,496.23,,,,100% of Medicare,,496.23,,,,100% of Medicare,,496.23,,,,100% of Medicare,,496.23,,,,100% of Medicare,,496.23,,,,100% of Medicare,,496.23,,,,100% of Medicare,,496.23,,,,100% of Medicare,,496.23,,,,100% of Medicare,,496.23,,,,100% of Medicare,,496.23,,,,100% of Medicare,,496.23,,,,100% of Medicare,,,496.23,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,496.23,3087,
"Knee Orthosis, Rigid, Molded to Patient, w/o Knee Joint",L1834,HCPCS,,,,outpatient,,,3790,2274,,45.5,,1724.45,percent of total billed charges,,,45.3,,1716.87,percent of total billed charges,,,39,,1478.1,percent of total billed charges,,,,,,,,,80,,3032,percent of total billed charges,,,61.4,,2327.06,percent of total billed charges,,,57.4,,2175.46,percent of total billed charges,,,81,,3069.9,percent of total billed charges,,,39,,1478.1,percent of total billed charges,,,57.6,,2183.04,percent of total billed charges,,,85,,3221.5,percent of total billed charges,,,85,,3221.5,percent of total billed charges,,,49,,1857.1,percent of total billed charges,,,90,,3411,percent of total billed charges,,,65,,2463.5,percent of total billed charges,,,80,,3032,percent of total billed charges,,,55,,2084.5,percent of total billed charges,,,55,,2084.5,percent of total billed charges,,,65,,2463.5,percent of total billed charges,,,78,,2956.2,percent of total billed charges,,,70,,2653,percent of total billed charges,,,,,,,,874.53,,,,100% of Medicare,,874.53,,,,100% of Medicare,,874.53,,,,100% of Medicare,,874.53,,,,100% of Medicare,,874.53,,,,100% of Medicare,,874.53,,,,100% of Medicare,,874.53,,,,100% of Medicare,,874.53,,,,100% of Medicare,,874.53,,,,100% of Medicare,,874.53,,,,100% of Medicare,,874.53,,,,100% of Medicare,,874.53,,,,100% of Medicare,,,874.53,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,874.53,3411,
"Knee Orthosis, Rigid, Prefabricated, w/o Knee Joint, w/ Soft Interface",L1836,HCPCS,,,,outpatient,,,345,207,,45.5,,156.98,percent of total billed charges,,,45.3,,156.29,percent of total billed charges,,,39,,134.55,percent of total billed charges,,,,,,,,,80,,276,percent of total billed charges,,,61.4,,211.83,percent of total billed charges,,,57.4,,198.03,percent of total billed charges,,,81,,279.45,percent of total billed charges,,,39,,134.55,percent of total billed charges,,,57.6,,198.72,percent of total billed charges,,,85,,293.25,percent of total billed charges,,,85,,293.25,percent of total billed charges,,,49,,169.05,percent of total billed charges,,,90,,310.5,percent of total billed charges,,,65,,224.25,percent of total billed charges,,,80,,276,percent of total billed charges,,,55,,189.75,percent of total billed charges,,,55,,189.75,percent of total billed charges,,,65,,224.25,percent of total billed charges,,,78,,269.1,percent of total billed charges,,,70,,241.5,percent of total billed charges,,,,,,,,97.41,,,,100% of Medicare,,97.41,,,,100% of Medicare,,97.41,,,,100% of Medicare,,97.41,,,,100% of Medicare,,97.41,,,,100% of Medicare,,97.41,,,,100% of Medicare,,97.41,,,,100% of Medicare,,97.41,,,,100% of Medicare,,97.41,,,,100% of Medicare,,97.41,,,,100% of Medicare,,97.41,,,,100% of Medicare,,97.41,,,,100% of Medicare,,,97.41,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,97.41,310.5,
"Knee Orthosis, Derotation, Medial/Lateral, Custom Fabricated",L1840,HCPCS,,,,outpatient,,,2258,1354.8,,45.5,,1027.39,percent of total billed charges,,,45.3,,1022.87,percent of total billed charges,,,39,,880.62,percent of total billed charges,,,,,,,,,80,,1806.4,percent of total billed charges,,,61.4,,1386.41,percent of total billed charges,,,57.4,,1296.09,percent of total billed charges,,,81,,1828.98,percent of total billed charges,,,39,,880.62,percent of total billed charges,,,57.6,,1300.61,percent of total billed charges,,,85,,1919.3,percent of total billed charges,,,85,,1919.3,percent of total billed charges,,,49,,1106.42,percent of total billed charges,,,90,,2032.2,percent of total billed charges,,,65,,1467.7,percent of total billed charges,,,80,,1806.4,percent of total billed charges,,,55,,1241.9,percent of total billed charges,,,55,,1241.9,percent of total billed charges,,,65,,1467.7,percent of total billed charges,,,78,,1761.24,percent of total billed charges,,,70,,1580.6,percent of total billed charges,,,,,,,,1133.06,,,,100% of Medicare,,1133.06,,,,100% of Medicare,,1133.06,,,,100% of Medicare,,1133.06,,,,100% of Medicare,,1133.06,,,,100% of Medicare,,1133.06,,,,100% of Medicare,,1133.06,,,,100% of Medicare,,1133.06,,,,100% of Medicare,,1133.06,,,,100% of Medicare,,1133.06,,,,100% of Medicare,,1133.06,,,,100% of Medicare,,1133.06,,,,100% of Medicare,,,1133.06,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,880.62,2032.2,
"Knee Orthosis, Single Upright w/ Adjustable Joint, Medial/Lateral, Prefabricated",L1843,HCPCS,,,,outpatient,,,2527,1516.2,,45.5,,1149.79,percent of total billed charges,,,45.3,,1144.73,percent of total billed charges,,,39,,985.53,percent of total billed charges,,,,,,,,,80,,2021.6,percent of total billed charges,,,61.4,,1551.58,percent of total billed charges,,,57.4,,1450.5,percent of total billed charges,,,81,,2046.87,percent of total billed charges,,,39,,985.53,percent of total billed charges,,,57.6,,1455.55,percent of total billed charges,,,85,,2147.95,percent of total billed charges,,,85,,2147.95,percent of total billed charges,,,49,,1238.23,percent of total billed charges,,,90,,2274.3,percent of total billed charges,,,65,,1642.55,percent of total billed charges,,,80,,2021.6,percent of total billed charges,,,55,,1389.85,percent of total billed charges,,,55,,1389.85,percent of total billed charges,,,65,,1642.55,percent of total billed charges,,,78,,1971.06,percent of total billed charges,,,70,,1768.9,percent of total billed charges,,,,,,,,1081.09,,,,100% of Medicare,,1081.09,,,,100% of Medicare,,1081.09,,,,100% of Medicare,,1081.09,,,,100% of Medicare,,1081.09,,,,100% of Medicare,,1081.09,,,,100% of Medicare,,1081.09,,,,100% of Medicare,,1081.09,,,,100% of Medicare,,1081.09,,,,100% of Medicare,,1081.09,,,,100% of Medicare,,1081.09,,,,100% of Medicare,,1081.09,,,,100% of Medicare,,,1081.09,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,985.53,2274.3,
L1847 KO Adjustable with air Chambers,L1847,HCPCS,,,,outpatient,,,3062,1837.2,,45.5,,1393.21,percent of total billed charges,,,45.3,,1387.09,percent of total billed charges,,,39,,1194.18,percent of total billed charges,,,,,,,,,80,,2449.6,percent of total billed charges,,,61.4,,1880.07,percent of total billed charges,,,57.4,,1757.59,percent of total billed charges,,,81,,2480.22,percent of total billed charges,,,39,,1194.18,percent of total billed charges,,,57.6,,1763.71,percent of total billed charges,,,85,,2602.7,percent of total billed charges,,,85,,2602.7,percent of total billed charges,,,49,,1500.38,percent of total billed charges,,,90,,2755.8,percent of total billed charges,,,65,,1990.3,percent of total billed charges,,,80,,2449.6,percent of total billed charges,,,55,,1684.1,percent of total billed charges,,,55,,1684.1,percent of total billed charges,,,65,,1990.3,percent of total billed charges,,,78,,2388.36,percent of total billed charges,,,70,,2143.4,percent of total billed charges,,,,,,,,693,,,,100% of Medicare,,693,,,,100% of Medicare,,693,,,,100% of Medicare,,693,,,,100% of Medicare,,693,,,,100% of Medicare,,693,,,,100% of Medicare,,693,,,,100% of Medicare,,693,,,,100% of Medicare,,693,,,,100% of Medicare,,693,,,,100% of Medicare,,693,,,,100% of Medicare,,693,,,,100% of Medicare,,,693,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,693,2755.8,
KO DBL UPRIGHT W/AIR PRE OTS (L1848),L1848,HCPCS,,,,outpatient,,,2863,1717.8,,45.5,,1302.67,percent of total billed charges,,,45.3,,1296.94,percent of total billed charges,,,39,,1116.57,percent of total billed charges,,,,,,,,,80,,2290.4,percent of total billed charges,,,61.4,,1757.88,percent of total billed charges,,,57.4,,1643.36,percent of total billed charges,,,81,,2319.03,percent of total billed charges,,,39,,1116.57,percent of total billed charges,,,57.6,,1649.09,percent of total billed charges,,,85,,2433.55,percent of total billed charges,,,85,,2433.55,percent of total billed charges,,,49,,1402.87,percent of total billed charges,,,90,,2576.7,percent of total billed charges,,,65,,1860.95,percent of total billed charges,,,80,,2290.4,percent of total billed charges,,,55,,1574.65,percent of total billed charges,,,55,,1574.65,percent of total billed charges,,,65,,1860.95,percent of total billed charges,,,78,,2233.14,percent of total billed charges,,,70,,2004.1,percent of total billed charges,,,,,,,,693,,,,100% of Medicare,,693,,,,100% of Medicare,,693,,,,100% of Medicare,,693,,,,100% of Medicare,,693,,,,100% of Medicare,,693,,,,100% of Medicare,,693,,,,100% of Medicare,,693,,,,100% of Medicare,,693,,,,100% of Medicare,,693,,,,100% of Medicare,,693,,,,100% of Medicare,,693,,,,100% of Medicare,,,693,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,693,2576.7,
"Knee Orthosis, Swedish Style",L1850,HCPCS,,,,outpatient,,,1532,919.2,,45.5,,697.06,percent of total billed charges,,,45.3,,694,percent of total billed charges,,,39,,597.48,percent of total billed charges,,,,,,,,,80,,1225.6,percent of total billed charges,,,61.4,,940.65,percent of total billed charges,,,57.4,,879.37,percent of total billed charges,,,81,,1240.92,percent of total billed charges,,,39,,597.48,percent of total billed charges,,,57.6,,882.43,percent of total billed charges,,,85,,1302.2,percent of total billed charges,,,85,,1302.2,percent of total billed charges,,,49,,750.68,percent of total billed charges,,,90,,1378.8,percent of total billed charges,,,65,,995.8,percent of total billed charges,,,80,,1225.6,percent of total billed charges,,,55,,842.6,percent of total billed charges,,,55,,842.6,percent of total billed charges,,,65,,995.8,percent of total billed charges,,,78,,1194.96,percent of total billed charges,,,70,,1072.4,percent of total billed charges,,,,,,,,224.35,,,,100% of Medicare,,224.35,,,,100% of Medicare,,224.35,,,,100% of Medicare,,224.35,,,,100% of Medicare,,224.35,,,,100% of Medicare,,224.35,,,,100% of Medicare,,224.35,,,,100% of Medicare,,224.35,,,,100% of Medicare,,224.35,,,,100% of Medicare,,224.35,,,,100% of Medicare,,224.35,,,,100% of Medicare,,224.35,,,,100% of Medicare,,,224.35,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,224.35,1378.8,
"Ankle-Foot Orthosis, Spring Wire, Dorsiflexion Calf Band",L1900,HCPCS,,,,outpatient,,,785,471,,45.5,,357.18,percent of total billed charges,,,45.3,,355.61,percent of total billed charges,,,39,,306.15,percent of total billed charges,,,,,,,,,80,,628,percent of total billed charges,,,61.4,,481.99,percent of total billed charges,,,57.4,,450.59,percent of total billed charges,,,81,,635.85,percent of total billed charges,,,39,,306.15,percent of total billed charges,,,57.6,,452.16,percent of total billed charges,,,85,,667.25,percent of total billed charges,,,85,,667.25,percent of total billed charges,,,49,,384.65,percent of total billed charges,,,90,,706.5,percent of total billed charges,,,65,,510.25,percent of total billed charges,,,80,,628,percent of total billed charges,,,55,,431.75,percent of total billed charges,,,55,,431.75,percent of total billed charges,,,65,,510.25,percent of total billed charges,,,78,,612.3,percent of total billed charges,,,70,,549.5,percent of total billed charges,,,,,,,,343.76,,,,100% of Medicare,,343.76,,,,100% of Medicare,,343.76,,,,100% of Medicare,,343.76,,,,100% of Medicare,,343.76,,,,100% of Medicare,,343.76,,,,100% of Medicare,,343.76,,,,100% of Medicare,,343.76,,,,100% of Medicare,,343.76,,,,100% of Medicare,,343.76,,,,100% of Medicare,,343.76,,,,100% of Medicare,,343.76,,,,100% of Medicare,,,343.76,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,306.15,706.5,
"Ankle-Foot Orthosis, Ankle Gauntlet",L1902,HCPCS,,,,outpatient,,,402,241.2,,45.5,,182.91,percent of total billed charges,,,45.3,,182.11,percent of total billed charges,,,39,,156.78,percent of total billed charges,,,,,,,,,80,,321.6,percent of total billed charges,,,61.4,,246.83,percent of total billed charges,,,57.4,,230.75,percent of total billed charges,,,81,,325.62,percent of total billed charges,,,39,,156.78,percent of total billed charges,,,57.6,,231.55,percent of total billed charges,,,85,,341.7,percent of total billed charges,,,85,,341.7,percent of total billed charges,,,49,,196.98,percent of total billed charges,,,90,,361.8,percent of total billed charges,,,65,,261.3,percent of total billed charges,,,80,,321.6,percent of total billed charges,,,55,,221.1,percent of total billed charges,,,55,,221.1,percent of total billed charges,,,65,,261.3,percent of total billed charges,,,78,,313.56,percent of total billed charges,,,70,,281.4,percent of total billed charges,,,,,,,,89.93,,,,100% of Medicare,,89.93,,,,100% of Medicare,,89.93,,,,100% of Medicare,,89.93,,,,100% of Medicare,,89.93,,,,100% of Medicare,,89.93,,,19156.16,100% of Medicare,,89.93,,,,100% of Medicare,,89.93,,,,100% of Medicare,,89.93,,,,100% of Medicare,,89.93,,,,100% of Medicare,,89.93,,,,100% of Medicare,,89.93,,,,100% of Medicare,,,89.93,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,89.93,19156.16,
"Ankle-Foot Orthosis, Molded Ankle Gauntlet",L1904,HCPCS,,,,outpatient,,,2358,1414.8,,45.5,,1072.89,percent of total billed charges,,,45.3,,1068.17,percent of total billed charges,,,39,,919.62,percent of total billed charges,,,,,,,,,80,,1886.4,percent of total billed charges,,,61.4,,1447.81,percent of total billed charges,,,57.4,,1353.49,percent of total billed charges,,,81,,1909.98,percent of total billed charges,,,39,,919.62,percent of total billed charges,,,57.6,,1358.21,percent of total billed charges,,,85,,2004.3,percent of total billed charges,,,85,,2004.3,percent of total billed charges,,,49,,1155.42,percent of total billed charges,,,90,,2122.2,percent of total billed charges,,,65,,1532.7,percent of total billed charges,,,80,,1886.4,percent of total billed charges,,,55,,1296.9,percent of total billed charges,,,55,,1296.9,percent of total billed charges,,,65,,1532.7,percent of total billed charges,,,78,,1839.24,percent of total billed charges,,,70,,1650.6,percent of total billed charges,,,,,,,,543.84,,,,100% of Medicare,,543.84,,,,100% of Medicare,,543.84,,,,100% of Medicare,,543.84,,,,100% of Medicare,,543.84,,,,100% of Medicare,,543.84,,,35571.60571,100% of Medicare,,543.84,,,,100% of Medicare,,543.84,,,,100% of Medicare,,543.84,,,,100% of Medicare,,543.84,,,,100% of Medicare,,543.84,,,,100% of Medicare,,543.84,,,,100% of Medicare,,,543.84,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,543.84,35571.61,
"Ankle foot orthosis, multiligamentous ankle support, prefabricated, off-the-shelf",L1906,HCPCS,,,,outpatient,,,608,364.8,,45.5,,276.64,percent of total billed charges,,,45.3,,275.42,percent of total billed charges,,,39,,237.12,percent of total billed charges,,,,,,,,,80,,486.4,percent of total billed charges,,,61.4,,373.31,percent of total billed charges,,,57.4,,348.99,percent of total billed charges,,,81,,492.48,percent of total billed charges,,,39,,237.12,percent of total billed charges,,,57.6,,350.21,percent of total billed charges,,,85,,516.8,percent of total billed charges,,,85,,516.8,percent of total billed charges,,,49,,297.92,percent of total billed charges,,,90,,547.2,percent of total billed charges,,,65,,395.2,percent of total billed charges,,,80,,486.4,percent of total billed charges,,,55,,334.4,percent of total billed charges,,,55,,334.4,percent of total billed charges,,,65,,395.2,percent of total billed charges,,,78,,474.24,percent of total billed charges,,,70,,425.6,percent of total billed charges,,,,,,,,135.49,,,,100% of Medicare,,135.49,,,,100% of Medicare,,135.49,,,,100% of Medicare,,135.49,,,,100% of Medicare,,135.49,,,,100% of Medicare,,135.49,,,29322.01571,100% of Medicare,,135.49,,,,100% of Medicare,,135.49,,,,100% of Medicare,,135.49,,,,100% of Medicare,,135.49,,,,100% of Medicare,,135.49,,,,100% of Medicare,,135.49,,,,100% of Medicare,,,135.49,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,135.49,29322.02,
"Ankle-Foot Orthosis, Supramalleolar w/ Straps",L1907,HCPCS,,,,outpatient,,,3027,1816.2,,45.5,,1377.29,percent of total billed charges,,,45.3,,1371.23,percent of total billed charges,,,39,,1180.53,percent of total billed charges,,,,,,,,,80,,2421.6,percent of total billed charges,,,61.4,,1858.58,percent of total billed charges,,,57.4,,1737.5,percent of total billed charges,,,81,,2451.87,percent of total billed charges,,,39,,1180.53,percent of total billed charges,,,57.6,,1743.55,percent of total billed charges,,,85,,2572.95,percent of total billed charges,,,85,,2572.95,percent of total billed charges,,,49,,1483.23,percent of total billed charges,,,90,,2724.3,percent of total billed charges,,,65,,1967.55,percent of total billed charges,,,80,,2421.6,percent of total billed charges,,,55,,1664.85,percent of total billed charges,,,55,,1664.85,percent of total billed charges,,,65,,1967.55,percent of total billed charges,,,78,,2361.06,percent of total billed charges,,,70,,2118.9,percent of total billed charges,,,,,,,,677.99,,,,100% of Medicare,,677.99,,,,100% of Medicare,,677.99,,,,100% of Medicare,,677.99,,,,100% of Medicare,,677.99,,,,100% of Medicare,,677.99,,,,100% of Medicare,,677.99,,,,100% of Medicare,,677.99,,,,100% of Medicare,,677.99,,,,100% of Medicare,,677.99,,,,100% of Medicare,,677.99,,,,100% of Medicare,,677.99,,,,100% of Medicare,,,677.99,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,677.99,2724.3,
"Ankle-Foot Orthosis, Posterior, Single Bar, Clasp Attach to Shoe Counter",L1910,HCPCS,,,,outpatient,,,724,434.4,,45.5,,329.42,percent of total billed charges,,,45.3,,327.97,percent of total billed charges,,,39,,282.36,percent of total billed charges,,,,,,,,,80,,579.2,percent of total billed charges,,,61.4,,444.54,percent of total billed charges,,,57.4,,415.58,percent of total billed charges,,,81,,586.44,percent of total billed charges,,,39,,282.36,percent of total billed charges,,,57.6,,417.02,percent of total billed charges,,,85,,615.4,percent of total billed charges,,,85,,615.4,percent of total billed charges,,,49,,354.76,percent of total billed charges,,,90,,651.6,percent of total billed charges,,,65,,470.6,percent of total billed charges,,,80,,579.2,percent of total billed charges,,,55,,398.2,percent of total billed charges,,,55,,398.2,percent of total billed charges,,,65,,470.6,percent of total billed charges,,,78,,564.72,percent of total billed charges,,,70,,506.8,percent of total billed charges,,,,,,,,337.89,,,,100% of Medicare,,337.89,,,,100% of Medicare,,337.89,,,,100% of Medicare,,337.89,,,,100% of Medicare,,337.89,,,,100% of Medicare,,337.89,,,,100% of Medicare,,337.89,,,,100% of Medicare,,337.89,,,,100% of Medicare,,337.89,,,,100% of Medicare,,337.89,,,,100% of Medicare,,337.89,,,,100% of Medicare,,337.89,,,,100% of Medicare,,,337.89,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,282.36,651.6,
"Ankle-Foot Orthosis, Single Upright w/ Static or Adjustable Stop",L1920,HCPCS,,,,outpatient,,,2211,1326.6,,45.5,,1006.01,percent of total billed charges,,,45.3,,1001.58,percent of total billed charges,,,39,,862.29,percent of total billed charges,,,,,,,,,80,,1768.8,percent of total billed charges,,,61.4,,1357.55,percent of total billed charges,,,57.4,,1269.11,percent of total billed charges,,,81,,1790.91,percent of total billed charges,,,39,,862.29,percent of total billed charges,,,57.6,,1273.54,percent of total billed charges,,,85,,1879.35,percent of total billed charges,,,85,,1879.35,percent of total billed charges,,,49,,1083.39,percent of total billed charges,,,90,,1989.9,percent of total billed charges,,,65,,1437.15,percent of total billed charges,,,80,,1768.8,percent of total billed charges,,,55,,1216.05,percent of total billed charges,,,55,,1216.05,percent of total billed charges,,,65,,1437.15,percent of total billed charges,,,78,,1724.58,percent of total billed charges,,,70,,1547.7,percent of total billed charges,,,,,,,,494.96,,,,100% of Medicare,,494.96,,,,100% of Medicare,,494.96,,,,100% of Medicare,,494.96,,,,100% of Medicare,,494.96,,,,100% of Medicare,,494.96,,,17159.675,100% of Medicare,,494.96,,,,100% of Medicare,,494.96,,,,100% of Medicare,,494.96,,,,100% of Medicare,,494.96,,,,100% of Medicare,,494.96,,,,100% of Medicare,,494.96,,,,100% of Medicare,,,494.96,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,494.96,17159.68,
"Ankle-Foot Orthosis, Prefabricated includes Fit and Adjustment",L1930,HCPCS,,,,outpatient,,,1357,814.2,,45.5,,617.44,percent of total billed charges,,,45.3,,614.72,percent of total billed charges,,,39,,529.23,percent of total billed charges,,,,,,,,,80,,1085.6,percent of total billed charges,,,61.4,,833.2,percent of total billed charges,,,57.4,,778.92,percent of total billed charges,,,81,,1099.17,percent of total billed charges,,,39,,529.23,percent of total billed charges,,,57.6,,781.63,percent of total billed charges,,,85,,1153.45,percent of total billed charges,,,85,,1153.45,percent of total billed charges,,,49,,664.93,percent of total billed charges,,,90,,1221.3,percent of total billed charges,,,65,,882.05,percent of total billed charges,,,80,,1085.6,percent of total billed charges,,,55,,746.35,percent of total billed charges,,,55,,746.35,percent of total billed charges,,,65,,882.05,percent of total billed charges,,,78,,1058.46,percent of total billed charges,,,70,,949.9,percent of total billed charges,,,,,,,,303.53,,,,100% of Medicare,,303.53,,,,100% of Medicare,,303.53,,,,100% of Medicare,,303.53,,,,100% of Medicare,,303.53,,,,100% of Medicare,,303.53,,,,100% of Medicare,,303.53,,,,100% of Medicare,,303.53,,,,100% of Medicare,,303.53,,,,100% of Medicare,,303.53,,,,100% of Medicare,,303.53,,,,100% of Medicare,,303.53,,,,100% of Medicare,,,303.53,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,303.53,1221.3,
"Ankle-Foot Orthosis, Plastic, Molded to Patient",L1940,HCPCS,,,,outpatient,,,2619,1571.4,,45.5,,1191.65,percent of total billed charges,,,45.3,,1186.41,percent of total billed charges,,,39,,1021.41,percent of total billed charges,,,,,,,,,80,,2095.2,percent of total billed charges,,,61.4,,1608.07,percent of total billed charges,,,57.4,,1503.31,percent of total billed charges,,,81,,2121.39,percent of total billed charges,,,39,,1021.41,percent of total billed charges,,,57.6,,1508.54,percent of total billed charges,,,85,,2226.15,percent of total billed charges,,,85,,2226.15,percent of total billed charges,,,49,,1283.31,percent of total billed charges,,,90,,2357.1,percent of total billed charges,,,65,,1702.35,percent of total billed charges,,,80,,2095.2,percent of total billed charges,,,55,,1440.45,percent of total billed charges,,,55,,1440.45,percent of total billed charges,,,65,,1702.35,percent of total billed charges,,,78,,2042.82,percent of total billed charges,,,70,,1833.3,percent of total billed charges,,,,,,,,586.74,,,,100% of Medicare,,586.74,,,,100% of Medicare,,586.74,,,,100% of Medicare,,586.74,,,,100% of Medicare,,586.74,,,,100% of Medicare,,586.74,,,16270.29143,100% of Medicare,,586.74,,,,100% of Medicare,,586.74,,,,100% of Medicare,,586.74,,,,100% of Medicare,,586.74,,,,100% of Medicare,,586.74,,,,100% of Medicare,,586.74,,,,100% of Medicare,,,586.74,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,586.74,16270.29,
"Ankle-Foot Orthosis, Spiral, Plastic, Custom Fabricated",L1950,HCPCS,,,,outpatient,,,1971,1182.6,,45.5,,896.81,percent of total billed charges,,,45.3,,892.86,percent of total billed charges,,,39,,768.69,percent of total billed charges,,,,,,,,,80,,1576.8,percent of total billed charges,,,61.4,,1210.19,percent of total billed charges,,,57.4,,1131.35,percent of total billed charges,,,81,,1596.51,percent of total billed charges,,,39,,768.69,percent of total billed charges,,,57.6,,1135.3,percent of total billed charges,,,85,,1675.35,percent of total billed charges,,,85,,1675.35,percent of total billed charges,,,49,,965.79,percent of total billed charges,,,90,,1773.9,percent of total billed charges,,,65,,1281.15,percent of total billed charges,,,80,,1576.8,percent of total billed charges,,,55,,1084.05,percent of total billed charges,,,55,,1084.05,percent of total billed charges,,,65,,1281.15,percent of total billed charges,,,78,,1537.38,percent of total billed charges,,,70,,1379.7,percent of total billed charges,,,,,,,,926.61,,,,100% of Medicare,,926.61,,,,100% of Medicare,,926.61,,,,100% of Medicare,,926.61,,,,100% of Medicare,,926.61,,,,100% of Medicare,,926.61,,,,100% of Medicare,,926.61,,,,100% of Medicare,,926.61,,,,100% of Medicare,,926.61,,,,100% of Medicare,,926.61,,,,100% of Medicare,,926.61,,,,100% of Medicare,,926.61,,,,100% of Medicare,,,926.61,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,768.69,1773.9,
"Ankle-Foot Orthosis, Plastic, Posterior Solid Ankle, Molded to Patient",L1960,HCPCS,,,,outpatient,,,3334,2000.4,,45.5,,1516.97,percent of total billed charges,,,45.3,,1510.3,percent of total billed charges,,,39,,1300.26,percent of total billed charges,,,,,,,,,80,,2667.2,percent of total billed charges,,,61.4,,2047.08,percent of total billed charges,,,57.4,,1913.72,percent of total billed charges,,,81,,2700.54,percent of total billed charges,,,39,,1300.26,percent of total billed charges,,,57.6,,1920.38,percent of total billed charges,,,85,,2833.9,percent of total billed charges,,,85,,2833.9,percent of total billed charges,,,49,,1633.66,percent of total billed charges,,,90,,3000.6,percent of total billed charges,,,65,,2167.1,percent of total billed charges,,,80,,2667.2,percent of total billed charges,,,55,,1833.7,percent of total billed charges,,,55,,1833.7,percent of total billed charges,,,65,,2167.1,percent of total billed charges,,,78,,2600.52,percent of total billed charges,,,70,,2333.8,percent of total billed charges,,,,,,,,746.86,,,,100% of Medicare,,746.86,,,,100% of Medicare,,746.86,,,,100% of Medicare,,746.86,,,,100% of Medicare,,746.86,,,,100% of Medicare,,746.86,,,23333.60576,100% of Medicare,,746.86,,,,100% of Medicare,,746.86,,,,100% of Medicare,,746.86,,,,100% of Medicare,,746.86,,,,100% of Medicare,,746.86,,,,100% of Medicare,,746.86,,,,100% of Medicare,,,746.86,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,746.86,23333.61,
"Ankle-Foot Orthosis, Plastic, w/ Ankle Joint, Molded to Patient",L1970,HCPCS,,,,outpatient,,,3726,2235.6,,45.5,,1695.33,percent of total billed charges,,,45.3,,1687.88,percent of total billed charges,,,39,,1453.14,percent of total billed charges,,,,,,,,,80,,2980.8,percent of total billed charges,,,61.4,,2287.76,percent of total billed charges,,,57.4,,2138.72,percent of total billed charges,,,81,,3018.06,percent of total billed charges,,,39,,1453.14,percent of total billed charges,,,57.6,,2146.18,percent of total billed charges,,,85,,3167.1,percent of total billed charges,,,85,,3167.1,percent of total billed charges,,,49,,1825.74,percent of total billed charges,,,90,,3353.4,percent of total billed charges,,,65,,2421.9,percent of total billed charges,,,80,,2980.8,percent of total billed charges,,,55,,2049.3,percent of total billed charges,,,55,,2049.3,percent of total billed charges,,,65,,2421.9,percent of total billed charges,,,78,,2906.28,percent of total billed charges,,,70,,2608.2,percent of total billed charges,,,,,,,,833.93,,,,100% of Medicare,,833.93,,,,100% of Medicare,,833.93,,,,100% of Medicare,,833.93,,,,100% of Medicare,,833.93,,,,100% of Medicare,,833.93,,,31498.86174,100% of Medicare,,833.93,,,,100% of Medicare,,833.93,,,,100% of Medicare,,833.93,,,,100% of Medicare,,833.93,,,,100% of Medicare,,833.93,,,,100% of Medicare,,833.93,,,,100% of Medicare,,,833.93,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,833.93,31498.86,
"Ankle-Foot Orthosis, Plastic or Other Material, w/ Ankle Jt, Prefabricated",L1971,HCPCS,,,,outpatient,,,2449,1469.4,,45.5,,1114.3,percent of total billed charges,,,45.3,,1109.4,percent of total billed charges,,,39,,955.11,percent of total billed charges,,,,,,,,,80,,1959.2,percent of total billed charges,,,61.4,,1503.69,percent of total billed charges,,,57.4,,1405.73,percent of total billed charges,,,81,,1983.69,percent of total billed charges,,,39,,955.11,percent of total billed charges,,,57.6,,1410.62,percent of total billed charges,,,85,,2081.65,percent of total billed charges,,,85,,2081.65,percent of total billed charges,,,49,,1200.01,percent of total billed charges,,,90,,2204.1,percent of total billed charges,,,65,,1591.85,percent of total billed charges,,,80,,1959.2,percent of total billed charges,,,55,,1346.95,percent of total billed charges,,,55,,1346.95,percent of total billed charges,,,65,,1591.85,percent of total billed charges,,,78,,1910.22,percent of total billed charges,,,70,,1714.3,percent of total billed charges,,,,,,,,564.8,,,,100% of Medicare,,564.8,,,,100% of Medicare,,564.8,,,,100% of Medicare,,564.8,,,,100% of Medicare,,564.8,,,,100% of Medicare,,564.8,,,35212.48333,100% of Medicare,,564.8,,,,100% of Medicare,,564.8,,,,100% of Medicare,,564.8,,,,100% of Medicare,,564.8,,,,100% of Medicare,,564.8,,,,100% of Medicare,,564.8,,,,100% of Medicare,,,564.8,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,564.8,35212.48,
"Ankle-Foot Orthosis, Single Upright, Plantar/Dorsiflex, Solid Stirrup, Calf Cuff",L1980,HCPCS,,,,outpatient,,,1032,619.2,,45.5,,469.56,percent of total billed charges,,,45.3,,467.5,percent of total billed charges,,,39,,402.48,percent of total billed charges,,,,,,,,,80,,825.6,percent of total billed charges,,,61.4,,633.65,percent of total billed charges,,,57.4,,592.37,percent of total billed charges,,,81,,835.92,percent of total billed charges,,,39,,402.48,percent of total billed charges,,,57.6,,594.43,percent of total billed charges,,,85,,877.2,percent of total billed charges,,,85,,877.2,percent of total billed charges,,,49,,505.68,percent of total billed charges,,,90,,928.8,percent of total billed charges,,,65,,670.8,percent of total billed charges,,,80,,825.6,percent of total billed charges,,,55,,567.6,percent of total billed charges,,,55,,567.6,percent of total billed charges,,,65,,670.8,percent of total billed charges,,,78,,804.96,percent of total billed charges,,,70,,722.4,percent of total billed charges,,,,,,,,486.48,,,,100% of Medicare,,486.48,,,,100% of Medicare,,486.48,,,,100% of Medicare,,486.48,,,,100% of Medicare,,486.48,,,,100% of Medicare,,486.48,,,23890.86,100% of Medicare,,486.48,,,,100% of Medicare,,486.48,,,,100% of Medicare,,486.48,,,,100% of Medicare,,486.48,,,,100% of Medicare,,486.48,,,,100% of Medicare,,486.48,,,,100% of Medicare,,,486.48,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,402.48,23890.86,
"Ankle-Foot Orthosis, Double Upright, Plantar Dorsiflexion, Solid Stirrup",L1990,HCPCS,,,,outpatient,,,2512,1507.2,,45.5,,1142.96,percent of total billed charges,,,45.3,,1137.94,percent of total billed charges,,,39,,979.68,percent of total billed charges,,,,,,,,,80,,2009.6,percent of total billed charges,,,61.4,,1542.37,percent of total billed charges,,,57.4,,1441.89,percent of total billed charges,,,81,,2034.72,percent of total billed charges,,,39,,979.68,percent of total billed charges,,,57.6,,1446.91,percent of total billed charges,,,85,,2135.2,percent of total billed charges,,,85,,2135.2,percent of total billed charges,,,49,,1230.88,percent of total billed charges,,,90,,2260.8,percent of total billed charges,,,65,,1632.8,percent of total billed charges,,,80,,2009.6,percent of total billed charges,,,55,,1381.6,percent of total billed charges,,,55,,1381.6,percent of total billed charges,,,65,,1632.8,percent of total billed charges,,,78,,1959.36,percent of total billed charges,,,70,,1758.4,percent of total billed charges,,,,,,,,563.04,,,,100% of Medicare,,563.04,,,,100% of Medicare,,563.04,,,,100% of Medicare,,563.04,,,,100% of Medicare,,563.04,,,,100% of Medicare,,563.04,,,18658.10167,100% of Medicare,,563.04,,,,100% of Medicare,,563.04,,,,100% of Medicare,,563.04,,,,100% of Medicare,,563.04,,,,100% of Medicare,,563.04,,,,100% of Medicare,,563.04,,,,100% of Medicare,,,563.04,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,563.04,18658.1,
"Knee-Ankle-Foot Orthosis, Single Upright, Free Ankle, w/out Knee Jt",L2010,HCPCS,,,,outpatient,,,2235,1341,,45.5,,1016.93,percent of total billed charges,,,45.3,,1012.46,percent of total billed charges,,,39,,871.65,percent of total billed charges,,,,,,,,,80,,1788,percent of total billed charges,,,61.4,,1372.29,percent of total billed charges,,,57.4,,1282.89,percent of total billed charges,,,81,,1810.35,percent of total billed charges,,,39,,871.65,percent of total billed charges,,,57.6,,1287.36,percent of total billed charges,,,85,,1899.75,percent of total billed charges,,,85,,1899.75,percent of total billed charges,,,49,,1095.15,percent of total billed charges,,,90,,2011.5,percent of total billed charges,,,65,,1452.75,percent of total billed charges,,,80,,1788,percent of total billed charges,,,55,,1229.25,percent of total billed charges,,,55,,1229.25,percent of total billed charges,,,65,,1452.75,percent of total billed charges,,,78,,1743.3,percent of total billed charges,,,70,,1564.5,percent of total billed charges,,,,,,,,1051.31,,,,100% of Medicare,,1051.31,,,,100% of Medicare,,1051.31,,,,100% of Medicare,,1051.31,,,,100% of Medicare,,1051.31,,,,100% of Medicare,,1051.31,,,,100% of Medicare,,1051.31,,,,100% of Medicare,,1051.31,,,,100% of Medicare,,1051.31,,,,100% of Medicare,,1051.31,,,,100% of Medicare,,1051.31,,,,100% of Medicare,,1051.31,,,,100% of Medicare,,,1051.31,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,871.65,2011.5,
"Knee-Ankle-Foot Orthosis, Double Upright, Free Ankle, w/out Knee Joint",L2030,HCPCS,,,,outpatient,,,2694,1616.4,,45.5,,1225.77,percent of total billed charges,,,45.3,,1220.38,percent of total billed charges,,,39,,1050.66,percent of total billed charges,,,,,,,,,80,,2155.2,percent of total billed charges,,,61.4,,1654.12,percent of total billed charges,,,57.4,,1546.36,percent of total billed charges,,,81,,2182.14,percent of total billed charges,,,39,,1050.66,percent of total billed charges,,,57.6,,1551.74,percent of total billed charges,,,85,,2289.9,percent of total billed charges,,,85,,2289.9,percent of total billed charges,,,49,,1320.06,percent of total billed charges,,,90,,2424.6,percent of total billed charges,,,65,,1751.1,percent of total billed charges,,,80,,2155.2,percent of total billed charges,,,55,,1481.7,percent of total billed charges,,,55,,1481.7,percent of total billed charges,,,65,,1751.1,percent of total billed charges,,,78,,2101.32,percent of total billed charges,,,70,,1885.8,percent of total billed charges,,,,,,,,1305.09,,,,100% of Medicare,,1305.09,,,,100% of Medicare,,1305.09,,,,100% of Medicare,,1305.09,,,,100% of Medicare,,1305.09,,,,100% of Medicare,,1305.09,,,,100% of Medicare,,1305.09,,,,100% of Medicare,,1305.09,,,,100% of Medicare,,1305.09,,,,100% of Medicare,,1305.09,,,,100% of Medicare,,1305.09,,,,100% of Medicare,,1305.09,,,,100% of Medicare,,,1305.09,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1050.66,2424.6,
"Knee-Ankle-Foot Orthosis, Full Plastic, Static, Prefabricated, Pediatric Size",L2035,HCPCS,,,,outpatient,,,446,267.6,,45.5,,202.93,percent of total billed charges,,,45.3,,202.04,percent of total billed charges,,,39,,173.94,percent of total billed charges,,,,,,,,,80,,356.8,percent of total billed charges,,,61.4,,273.84,percent of total billed charges,,,57.4,,256,percent of total billed charges,,,81,,361.26,percent of total billed charges,,,39,,173.94,percent of total billed charges,,,57.6,,256.9,percent of total billed charges,,,85,,379.1,percent of total billed charges,,,85,,379.1,percent of total billed charges,,,49,,218.54,percent of total billed charges,,,90,,401.4,percent of total billed charges,,,65,,289.9,percent of total billed charges,,,80,,356.8,percent of total billed charges,,,55,,245.3,percent of total billed charges,,,55,,245.3,percent of total billed charges,,,65,,289.9,percent of total billed charges,,,78,,347.88,percent of total billed charges,,,70,,312.2,percent of total billed charges,,,,,,,,208.74,,,,100% of Medicare,,208.74,,,,100% of Medicare,,208.74,,,,100% of Medicare,,208.74,,,,100% of Medicare,,208.74,,,,100% of Medicare,,208.74,,,,100% of Medicare,,208.74,,,,100% of Medicare,,208.74,,,,100% of Medicare,,208.74,,,,100% of Medicare,,208.74,,,,100% of Medicare,,208.74,,,,100% of Medicare,,208.74,,,,100% of Medicare,,,208.74,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,173.94,401.4,
"Knee-Ankle-Foot Orthosis, Full Plastic, w/out Knee Jt, Multi Axis, Ankle Molded",L2038,HCPCS,,,,outpatient,,,3276,1965.6,,45.5,,1490.58,percent of total billed charges,,,45.3,,1484.03,percent of total billed charges,,,39,,1277.64,percent of total billed charges,,,,,,,,,80,,2620.8,percent of total billed charges,,,61.4,,2011.46,percent of total billed charges,,,57.4,,1880.42,percent of total billed charges,,,81,,2653.56,percent of total billed charges,,,39,,1277.64,percent of total billed charges,,,57.6,,1886.98,percent of total billed charges,,,85,,2784.6,percent of total billed charges,,,85,,2784.6,percent of total billed charges,,,49,,1605.24,percent of total billed charges,,,90,,2948.4,percent of total billed charges,,,65,,2129.4,percent of total billed charges,,,80,,2620.8,percent of total billed charges,,,55,,1801.8,percent of total billed charges,,,55,,1801.8,percent of total billed charges,,,65,,2129.4,percent of total billed charges,,,78,,2555.28,percent of total billed charges,,,70,,2293.2,percent of total billed charges,,,,,,,,1610.72,,,,100% of Medicare,,1610.72,,,,100% of Medicare,,1610.72,,,,100% of Medicare,,1610.72,,,,100% of Medicare,,1610.72,,,,100% of Medicare,,1610.72,,,,100% of Medicare,,1610.72,,,,100% of Medicare,,1610.72,,,,100% of Medicare,,1610.72,,,,100% of Medicare,,1610.72,,,,100% of Medicare,,1610.72,,,,100% of Medicare,,1610.72,,,,100% of Medicare,,,1610.72,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1277.64,2948.4,
"Hip-Knee-Ankle-Foot Orthosis, Torsion Control, Bilateral Rotation Straps",L2040,HCPCS,,,,outpatient,,,522,313.2,,45.5,,237.51,percent of total billed charges,,,45.3,,236.47,percent of total billed charges,,,39,,203.58,percent of total billed charges,,,,,,,,,80,,417.6,percent of total billed charges,,,61.4,,320.51,percent of total billed charges,,,57.4,,299.63,percent of total billed charges,,,81,,422.82,percent of total billed charges,,,39,,203.58,percent of total billed charges,,,57.6,,300.67,percent of total billed charges,,,85,,443.7,percent of total billed charges,,,85,,443.7,percent of total billed charges,,,49,,255.78,percent of total billed charges,,,90,,469.8,percent of total billed charges,,,65,,339.3,percent of total billed charges,,,80,,417.6,percent of total billed charges,,,55,,287.1,percent of total billed charges,,,55,,287.1,percent of total billed charges,,,65,,339.3,percent of total billed charges,,,78,,407.16,percent of total billed charges,,,70,,365.4,percent of total billed charges,,,,,,,,243.75,,,,100% of Medicare,,243.75,,,,100% of Medicare,,243.75,,,,100% of Medicare,,243.75,,,,100% of Medicare,,243.75,,,,100% of Medicare,,243.75,,,,100% of Medicare,,243.75,,,,100% of Medicare,,243.75,,,,100% of Medicare,,243.75,,,,100% of Medicare,,243.75,,,,100% of Medicare,,243.75,,,,100% of Medicare,,243.75,,,,100% of Medicare,,,243.75,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,203.58,469.8,
"Hip-Knee-Ankle-Foot Orthosis, Torsion Control, Bil Torsion Cables, Hip Jt Straps",L2050,HCPCS,,,,outpatient,,,2546,1527.6,,45.5,,1158.43,percent of total billed charges,,,45.3,,1153.34,percent of total billed charges,,,39,,992.94,percent of total billed charges,,,,,,,,,80,,2036.8,percent of total billed charges,,,61.4,,1563.24,percent of total billed charges,,,57.4,,1461.4,percent of total billed charges,,,81,,2062.26,percent of total billed charges,,,39,,992.94,percent of total billed charges,,,57.6,,1466.5,percent of total billed charges,,,85,,2164.1,percent of total billed charges,,,85,,2164.1,percent of total billed charges,,,49,,1247.54,percent of total billed charges,,,90,,2291.4,percent of total billed charges,,,65,,1654.9,percent of total billed charges,,,80,,2036.8,percent of total billed charges,,,55,,1400.3,percent of total billed charges,,,55,,1400.3,percent of total billed charges,,,65,,1654.9,percent of total billed charges,,,78,,1985.88,percent of total billed charges,,,70,,1782.2,percent of total billed charges,,,,,,,,587.14,,,,100% of Medicare,,587.14,,,,100% of Medicare,,587.14,,,,100% of Medicare,,587.14,,,,100% of Medicare,,587.14,,,,100% of Medicare,,587.14,,,,100% of Medicare,,587.14,,,,100% of Medicare,,587.14,,,,100% of Medicare,,587.14,,,,100% of Medicare,,587.14,,,,100% of Medicare,,587.14,,,,100% of Medicare,,587.14,,,,100% of Medicare,,,587.14,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,587.14,2291.4,
"Hip-Knee-Ankle-Foot Orthosis, Torsion Control, Bilateral Torsion Cables",L2060,HCPCS,,,,outpatient,,,2924,1754.4,,45.5,,1330.42,percent of total billed charges,,,45.3,,1324.57,percent of total billed charges,,,39,,1140.36,percent of total billed charges,,,,,,,,,80,,2339.2,percent of total billed charges,,,61.4,,1795.34,percent of total billed charges,,,57.4,,1678.38,percent of total billed charges,,,81,,2368.44,percent of total billed charges,,,39,,1140.36,percent of total billed charges,,,57.6,,1684.22,percent of total billed charges,,,85,,2485.4,percent of total billed charges,,,85,,2485.4,percent of total billed charges,,,49,,1432.76,percent of total billed charges,,,90,,2631.6,percent of total billed charges,,,65,,1900.6,percent of total billed charges,,,80,,2339.2,percent of total billed charges,,,55,,1608.2,percent of total billed charges,,,55,,1608.2,percent of total billed charges,,,65,,1900.6,percent of total billed charges,,,78,,2280.72,percent of total billed charges,,,70,,2046.8,percent of total billed charges,,,,,,,,734.39,,,,100% of Medicare,,734.39,,,,100% of Medicare,,734.39,,,,100% of Medicare,,734.39,,,,100% of Medicare,,734.39,,,,100% of Medicare,,734.39,,,,100% of Medicare,,734.39,,,,100% of Medicare,,734.39,,,,100% of Medicare,,734.39,,,,100% of Medicare,,734.39,,,,100% of Medicare,,734.39,,,,100% of Medicare,,734.39,,,,100% of Medicare,,,734.39,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,734.39,2631.6,
"Hip-Knee-Ankle-Foot Orthosis, Torsion Control, Unilateral Rotation Straps",L2070,HCPCS,,,,outpatient,,,398,238.8,,45.5,,181.09,percent of total billed charges,,,45.3,,180.29,percent of total billed charges,,,39,,155.22,percent of total billed charges,,,,,,,,,80,,318.4,percent of total billed charges,,,61.4,,244.37,percent of total billed charges,,,57.4,,228.45,percent of total billed charges,,,81,,322.38,percent of total billed charges,,,39,,155.22,percent of total billed charges,,,57.6,,229.25,percent of total billed charges,,,85,,338.3,percent of total billed charges,,,85,,338.3,percent of total billed charges,,,49,,195.02,percent of total billed charges,,,90,,358.2,percent of total billed charges,,,65,,258.7,percent of total billed charges,,,80,,318.4,percent of total billed charges,,,55,,218.9,percent of total billed charges,,,55,,218.9,percent of total billed charges,,,65,,258.7,percent of total billed charges,,,78,,310.44,percent of total billed charges,,,70,,278.6,percent of total billed charges,,,,,,,,187.01,,,,100% of Medicare,,187.01,,,,100% of Medicare,,187.01,,,,100% of Medicare,,187.01,,,,100% of Medicare,,187.01,,,,100% of Medicare,,187.01,,,,100% of Medicare,,187.01,,,,100% of Medicare,,187.01,,,,100% of Medicare,,187.01,,,,100% of Medicare,,187.01,,,,100% of Medicare,,187.01,,,,100% of Medicare,,187.01,,,,100% of Medicare,,,187.01,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,155.22,358.2,
"Hip-Knee-Ankle-Foot Orthosis, Torsion Control, Unilateral Cable, Hip Jt",L2080,HCPCS,,,,outpatient,,,956,573.6,,45.5,,434.98,percent of total billed charges,,,45.3,,433.07,percent of total billed charges,,,39,,372.84,percent of total billed charges,,,,,,,,,80,,764.8,percent of total billed charges,,,61.4,,586.98,percent of total billed charges,,,57.4,,548.74,percent of total billed charges,,,81,,774.36,percent of total billed charges,,,39,,372.84,percent of total billed charges,,,57.6,,550.66,percent of total billed charges,,,85,,812.6,percent of total billed charges,,,85,,812.6,percent of total billed charges,,,49,,468.44,percent of total billed charges,,,90,,860.4,percent of total billed charges,,,65,,621.4,percent of total billed charges,,,80,,764.8,percent of total billed charges,,,55,,525.8,percent of total billed charges,,,55,,525.8,percent of total billed charges,,,65,,621.4,percent of total billed charges,,,78,,745.68,percent of total billed charges,,,70,,669.2,percent of total billed charges,,,,,,,,449.64,,,,100% of Medicare,,449.64,,,,100% of Medicare,,449.64,,,,100% of Medicare,,449.64,,,,100% of Medicare,,449.64,,,,100% of Medicare,,449.64,,,,100% of Medicare,,449.64,,,,100% of Medicare,,449.64,,,,100% of Medicare,,449.64,,,,100% of Medicare,,449.64,,,,100% of Medicare,,449.64,,,,100% of Medicare,,449.64,,,,100% of Medicare,,,449.64,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,372.84,860.4,
"Hip-Knee-Ankle-Foot Orthosis, Torsion Control, Unilateral Cable, Ball Bearing Joint",L2090,HCPCS,,,,outpatient,,,2674,1604.4,,45.5,,1216.67,percent of total billed charges,,,45.3,,1211.32,percent of total billed charges,,,39,,1042.86,percent of total billed charges,,,,,,,,,80,,2139.2,percent of total billed charges,,,61.4,,1641.84,percent of total billed charges,,,57.4,,1534.88,percent of total billed charges,,,81,,2165.94,percent of total billed charges,,,39,,1042.86,percent of total billed charges,,,57.6,,1540.22,percent of total billed charges,,,85,,2272.9,percent of total billed charges,,,85,,2272.9,percent of total billed charges,,,49,,1310.26,percent of total billed charges,,,90,,2406.6,percent of total billed charges,,,65,,1738.1,percent of total billed charges,,,80,,2139.2,percent of total billed charges,,,55,,1470.7,percent of total billed charges,,,55,,1470.7,percent of total billed charges,,,65,,1738.1,percent of total billed charges,,,78,,2085.72,percent of total billed charges,,,70,,1871.8,percent of total billed charges,,,,,,,,599.09,,,,100% of Medicare,,599.09,,,,100% of Medicare,,599.09,,,,100% of Medicare,,599.09,,,,100% of Medicare,,599.09,,,,100% of Medicare,,599.09,,,,100% of Medicare,,599.09,,,,100% of Medicare,,599.09,,,,100% of Medicare,,599.09,,,,100% of Medicare,,599.09,,,,100% of Medicare,,599.09,,,,100% of Medicare,,599.09,,,,100% of Medicare,,,599.09,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,599.09,2406.6,
"Ankle-Foot Orthosis, Tibial Fracture Orthosis, Thermoplastic, Molded to Pt",L2106,HCPCS,,,,outpatient,,,2020,1212,,45.5,,919.1,percent of total billed charges,,,45.3,,915.06,percent of total billed charges,,,39,,787.8,percent of total billed charges,,,,,,,,,80,,1616,percent of total billed charges,,,61.4,,1240.28,percent of total billed charges,,,57.4,,1159.48,percent of total billed charges,,,81,,1636.2,percent of total billed charges,,,39,,787.8,percent of total billed charges,,,57.6,,1163.52,percent of total billed charges,,,85,,1717,percent of total billed charges,,,85,,1717,percent of total billed charges,,,49,,989.8,percent of total billed charges,,,90,,1818,percent of total billed charges,,,65,,1313,percent of total billed charges,,,80,,1616,percent of total billed charges,,,55,,1111,percent of total billed charges,,,55,,1111,percent of total billed charges,,,65,,1313,percent of total billed charges,,,78,,1575.6,percent of total billed charges,,,70,,1414,percent of total billed charges,,,,,,,,949.69,,,,100% of Medicare,,949.69,,,,100% of Medicare,,949.69,,,,100% of Medicare,,949.69,,,,100% of Medicare,,949.69,,,,100% of Medicare,,949.69,,,,100% of Medicare,,949.69,,,,100% of Medicare,,949.69,,,,100% of Medicare,,949.69,,,,100% of Medicare,,949.69,,,,100% of Medicare,,949.69,,,,100% of Medicare,,949.69,,,,100% of Medicare,,,949.69,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,787.8,1818,
"Ankle-Foot Orthosis, Tibial Fracture Orthosis, Molded to Pt",L2108,HCPCS,,,,outpatient,,,2945,1767,,45.5,,1339.98,percent of total billed charges,,,45.3,,1334.09,percent of total billed charges,,,39,,1148.55,percent of total billed charges,,,,,,,,,80,,2356,percent of total billed charges,,,61.4,,1808.23,percent of total billed charges,,,57.4,,1690.43,percent of total billed charges,,,81,,2385.45,percent of total billed charges,,,39,,1148.55,percent of total billed charges,,,57.6,,1696.32,percent of total billed charges,,,85,,2503.25,percent of total billed charges,,,85,,2503.25,percent of total billed charges,,,49,,1443.05,percent of total billed charges,,,90,,2650.5,percent of total billed charges,,,65,,1914.25,percent of total billed charges,,,80,,2356,percent of total billed charges,,,55,,1619.75,percent of total billed charges,,,55,,1619.75,percent of total billed charges,,,65,,1914.25,percent of total billed charges,,,78,,2297.1,percent of total billed charges,,,70,,2061.5,percent of total billed charges,,,,,,,,1385.15,,,,100% of Medicare,,1385.15,,,,100% of Medicare,,1385.15,,,,100% of Medicare,,1385.15,,,,100% of Medicare,,1385.15,,,,100% of Medicare,,1385.15,,,,100% of Medicare,,1385.15,,,,100% of Medicare,,1385.15,,,,100% of Medicare,,1385.15,,,,100% of Medicare,,1385.15,,,,100% of Medicare,,1385.15,,,,100% of Medicare,,1385.15,,,,100% of Medicare,,,1385.15,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1148.55,2650.5,
"Ankle-Foot Orthosis, Soft, Tibial Fracture Orthosis",L2112,HCPCS,,,,outpatient,,,2712,1627.2,,45.5,,1233.96,percent of total billed charges,,,45.3,,1228.54,percent of total billed charges,,,39,,1057.68,percent of total billed charges,,,,,,,,,80,,2169.6,percent of total billed charges,,,61.4,,1665.17,percent of total billed charges,,,57.4,,1556.69,percent of total billed charges,,,81,,2196.72,percent of total billed charges,,,39,,1057.68,percent of total billed charges,,,57.6,,1562.11,percent of total billed charges,,,85,,2305.2,percent of total billed charges,,,85,,2305.2,percent of total billed charges,,,49,,1328.88,percent of total billed charges,,,90,,2440.8,percent of total billed charges,,,65,,1762.8,percent of total billed charges,,,80,,2169.6,percent of total billed charges,,,55,,1491.6,percent of total billed charges,,,55,,1491.6,percent of total billed charges,,,65,,1762.8,percent of total billed charges,,,78,,2115.36,percent of total billed charges,,,70,,1898.4,percent of total billed charges,,,,,,,,607.86,,,,100% of Medicare,,607.86,,,,100% of Medicare,,607.86,,,,100% of Medicare,,607.86,,,,100% of Medicare,,607.86,,,,100% of Medicare,,607.86,,,27757.0475,100% of Medicare,,607.86,,,,100% of Medicare,,607.86,,,,100% of Medicare,,607.86,,,,100% of Medicare,,607.86,,,,100% of Medicare,,607.86,,,,100% of Medicare,,607.86,,,,100% of Medicare,,,607.86,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,607.86,27757.05,
"Ankle-Foot Orthosis, Tibial Fracture Orthosis, Semi-Rigid",L2114,HCPCS,,,,outpatient,,,1622,973.2,,45.5,,738.01,percent of total billed charges,,,45.3,,734.77,percent of total billed charges,,,39,,632.58,percent of total billed charges,,,,,,,,,80,,1297.6,percent of total billed charges,,,61.4,,995.91,percent of total billed charges,,,57.4,,931.03,percent of total billed charges,,,81,,1313.82,percent of total billed charges,,,39,,632.58,percent of total billed charges,,,57.6,,934.27,percent of total billed charges,,,85,,1378.7,percent of total billed charges,,,85,,1378.7,percent of total billed charges,,,49,,794.78,percent of total billed charges,,,90,,1459.8,percent of total billed charges,,,65,,1054.3,percent of total billed charges,,,80,,1297.6,percent of total billed charges,,,55,,892.1,percent of total billed charges,,,55,,892.1,percent of total billed charges,,,65,,1054.3,percent of total billed charges,,,78,,1265.16,percent of total billed charges,,,70,,1135.4,percent of total billed charges,,,,,,,,761.36,,,,100% of Medicare,,761.36,,,,100% of Medicare,,761.36,,,,100% of Medicare,,761.36,,,,100% of Medicare,,761.36,,,,100% of Medicare,,761.36,,,,100% of Medicare,,761.36,,,,100% of Medicare,,761.36,,,,100% of Medicare,,761.36,,,,100% of Medicare,,761.36,,,,100% of Medicare,,761.36,,,,100% of Medicare,,761.36,,,,100% of Medicare,,,761.36,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,632.58,1459.8,
"Ankle-Foot Orthosis, Rigid, Tibial Fracture Orthosis",L2116,HCPCS,,,,outpatient,,,2014,1208.4,,45.5,,916.37,percent of total billed charges,,,45.3,,912.34,percent of total billed charges,,,39,,785.46,percent of total billed charges,,,,,,,,,80,,1611.2,percent of total billed charges,,,61.4,,1236.6,percent of total billed charges,,,57.4,,1156.04,percent of total billed charges,,,81,,1631.34,percent of total billed charges,,,39,,785.46,percent of total billed charges,,,57.6,,1160.06,percent of total billed charges,,,85,,1711.9,percent of total billed charges,,,85,,1711.9,percent of total billed charges,,,49,,986.86,percent of total billed charges,,,90,,1812.6,percent of total billed charges,,,65,,1309.1,percent of total billed charges,,,80,,1611.2,percent of total billed charges,,,55,,1107.7,percent of total billed charges,,,55,,1107.7,percent of total billed charges,,,65,,1309.1,percent of total billed charges,,,78,,1570.92,percent of total billed charges,,,70,,1409.8,percent of total billed charges,,,,,,,,928.63,,,,100% of Medicare,,928.63,,,,100% of Medicare,,928.63,,,,100% of Medicare,,928.63,,,,100% of Medicare,,928.63,,,,100% of Medicare,,928.63,,,,100% of Medicare,,928.63,,,,100% of Medicare,,928.63,,,,100% of Medicare,,928.63,,,,100% of Medicare,,928.63,,,,100% of Medicare,,928.63,,,,100% of Medicare,,928.63,,,,100% of Medicare,,,928.63,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,785.46,1812.6,
"Knee-Ankle-Foot Orthosis, Femoral Fx, Thermoplastic Type, Custom Fabricated",L2126,HCPCS,,,,outpatient,,,3269,1961.4,,45.5,,1487.4,percent of total billed charges,,,45.3,,1480.86,percent of total billed charges,,,39,,1274.91,percent of total billed charges,,,,,,,,,80,,2615.2,percent of total billed charges,,,61.4,,2007.17,percent of total billed charges,,,57.4,,1876.41,percent of total billed charges,,,81,,2647.89,percent of total billed charges,,,39,,1274.91,percent of total billed charges,,,57.6,,1882.94,percent of total billed charges,,,85,,2778.65,percent of total billed charges,,,85,,2778.65,percent of total billed charges,,,49,,1601.81,percent of total billed charges,,,90,,2942.1,percent of total billed charges,,,65,,2124.85,percent of total billed charges,,,80,,2615.2,percent of total billed charges,,,55,,1797.95,percent of total billed charges,,,55,,1797.95,percent of total billed charges,,,65,,2124.85,percent of total billed charges,,,78,,2549.82,percent of total billed charges,,,70,,2288.3,percent of total billed charges,,,,,,,,1538.47,,,,100% of Medicare,,1538.47,,,,100% of Medicare,,1538.47,,,,100% of Medicare,,1538.47,,,,100% of Medicare,,1538.47,,,,100% of Medicare,,1538.47,,,,100% of Medicare,,1538.47,,,,100% of Medicare,,1538.47,,,,100% of Medicare,,1538.47,,,,100% of Medicare,,1538.47,,,,100% of Medicare,,1538.47,,,,100% of Medicare,,1538.47,,,,100% of Medicare,,,1538.47,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1274.91,2942.1,
"Knee-Ankle-Foot Orthosis, Molded to Patient, Femoral Fracture Orthosis",L2128,HCPCS,,,,outpatient,,,3844,2306.4,,45.5,,1749.02,percent of total billed charges,,,45.3,,1741.33,percent of total billed charges,,,39,,1499.16,percent of total billed charges,,,,,,,,,80,,3075.2,percent of total billed charges,,,61.4,,2360.22,percent of total billed charges,,,57.4,,2206.46,percent of total billed charges,,,81,,3113.64,percent of total billed charges,,,39,,1499.16,percent of total billed charges,,,57.6,,2214.14,percent of total billed charges,,,85,,3267.4,percent of total billed charges,,,85,,3267.4,percent of total billed charges,,,49,,1883.56,percent of total billed charges,,,90,,3459.6,percent of total billed charges,,,65,,2498.6,percent of total billed charges,,,80,,3075.2,percent of total billed charges,,,55,,2114.2,percent of total billed charges,,,55,,2114.2,percent of total billed charges,,,65,,2498.6,percent of total billed charges,,,78,,2998.32,percent of total billed charges,,,70,,2690.8,percent of total billed charges,,,,,,,,1931.8,,,,100% of Medicare,,1931.8,,,,100% of Medicare,,1931.8,,,,100% of Medicare,,1931.8,,,,100% of Medicare,,1931.8,,,,100% of Medicare,,1931.8,,,,100% of Medicare,,1931.8,,,,100% of Medicare,,1931.8,,,,100% of Medicare,,1931.8,,,,100% of Medicare,,1931.8,,,,100% of Medicare,,1931.8,,,,100% of Medicare,,1931.8,,,,100% of Medicare,,,1931.8,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1499.16,3459.6,
"Knee-Ankle-Foot Orthosis, Soft, Femoral Fx",L2132,HCPCS,,,,outpatient,,,2494,1496.4,,45.5,,1134.77,percent of total billed charges,,,45.3,,1129.78,percent of total billed charges,,,39,,972.66,percent of total billed charges,,,,,,,,,80,,1995.2,percent of total billed charges,,,61.4,,1531.32,percent of total billed charges,,,57.4,,1431.56,percent of total billed charges,,,81,,2020.14,percent of total billed charges,,,39,,972.66,percent of total billed charges,,,57.6,,1436.54,percent of total billed charges,,,85,,2119.9,percent of total billed charges,,,85,,2119.9,percent of total billed charges,,,49,,1222.06,percent of total billed charges,,,90,,2244.6,percent of total billed charges,,,65,,1621.1,percent of total billed charges,,,80,,1995.2,percent of total billed charges,,,55,,1371.7,percent of total billed charges,,,55,,1371.7,percent of total billed charges,,,65,,1621.1,percent of total billed charges,,,78,,1945.32,percent of total billed charges,,,70,,1745.8,percent of total billed charges,,,,,,,,1172.57,,,,100% of Medicare,,1172.57,,,,100% of Medicare,,1172.57,,,,100% of Medicare,,1172.57,,,,100% of Medicare,,1172.57,,,,100% of Medicare,,1172.57,,,,100% of Medicare,,1172.57,,,,100% of Medicare,,1172.57,,,,100% of Medicare,,1172.57,,,,100% of Medicare,,1172.57,,,,100% of Medicare,,1172.57,,,,100% of Medicare,,1172.57,,,,100% of Medicare,,,1172.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,972.66,2244.6,
"Knee-Ankle-Foot Orthosis, Semi-Rigid, Femoral Fx",L2134,HCPCS,,,,outpatient,,,2951,1770.6,,45.5,,1342.71,percent of total billed charges,,,45.3,,1336.8,percent of total billed charges,,,39,,1150.89,percent of total billed charges,,,,,,,,,80,,2360.8,percent of total billed charges,,,61.4,,1811.91,percent of total billed charges,,,57.4,,1693.87,percent of total billed charges,,,81,,2390.31,percent of total billed charges,,,39,,1150.89,percent of total billed charges,,,57.6,,1699.78,percent of total billed charges,,,85,,2508.35,percent of total billed charges,,,85,,2508.35,percent of total billed charges,,,49,,1445.99,percent of total billed charges,,,90,,2655.9,percent of total billed charges,,,65,,1918.15,percent of total billed charges,,,80,,2360.8,percent of total billed charges,,,55,,1623.05,percent of total billed charges,,,55,,1623.05,percent of total billed charges,,,65,,1918.15,percent of total billed charges,,,78,,2301.78,percent of total billed charges,,,70,,2065.7,percent of total billed charges,,,,,,,,1388.47,,,,100% of Medicare,,1388.47,,,,100% of Medicare,,1388.47,,,,100% of Medicare,,1388.47,,,,100% of Medicare,,1388.47,,,,100% of Medicare,,1388.47,,,,100% of Medicare,,1388.47,,,,100% of Medicare,,1388.47,,,,100% of Medicare,,1388.47,,,,100% of Medicare,,1388.47,,,,100% of Medicare,,1388.47,,,,100% of Medicare,,1388.47,,,,100% of Medicare,,,1388.47,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1150.89,2655.9,
"Knee-Ankle-Foot Orthosis, Rigid, Femoral Fx",L2136,HCPCS,,,,outpatient,,,3231,1938.6,,45.5,,1470.11,percent of total billed charges,,,45.3,,1463.64,percent of total billed charges,,,39,,1260.09,percent of total billed charges,,,,,,,,,80,,2584.8,percent of total billed charges,,,61.4,,1983.83,percent of total billed charges,,,57.4,,1854.59,percent of total billed charges,,,81,,2617.11,percent of total billed charges,,,39,,1260.09,percent of total billed charges,,,57.6,,1861.06,percent of total billed charges,,,85,,2746.35,percent of total billed charges,,,85,,2746.35,percent of total billed charges,,,49,,1583.19,percent of total billed charges,,,90,,2907.9,percent of total billed charges,,,65,,2100.15,percent of total billed charges,,,80,,2584.8,percent of total billed charges,,,55,,1777.05,percent of total billed charges,,,55,,1777.05,percent of total billed charges,,,65,,2100.15,percent of total billed charges,,,78,,2520.18,percent of total billed charges,,,70,,2261.7,percent of total billed charges,,,,,,,,1519.47,,,,100% of Medicare,,1519.47,,,,100% of Medicare,,1519.47,,,,100% of Medicare,,1519.47,,,,100% of Medicare,,1519.47,,,,100% of Medicare,,1519.47,,,,100% of Medicare,,1519.47,,,,100% of Medicare,,1519.47,,,,100% of Medicare,,1519.47,,,,100% of Medicare,,1519.47,,,,100% of Medicare,,1519.47,,,,100% of Medicare,,1519.47,,,,100% of Medicare,,,1519.47,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1260.09,2907.9,
"Lower Extremity Foot Orthosis Addition, Plastic, Shoe Insert w/ Ankle Jts",L2180,HCPCS,,,,outpatient,,,366,219.6,,45.5,,166.53,percent of total billed charges,,,45.3,,165.8,percent of total billed charges,,,39,,142.74,percent of total billed charges,,,,,,,,,80,,292.8,percent of total billed charges,,,61.4,,224.72,percent of total billed charges,,,57.4,,210.08,percent of total billed charges,,,81,,296.46,percent of total billed charges,,,39,,142.74,percent of total billed charges,,,57.6,,210.82,percent of total billed charges,,,85,,311.1,percent of total billed charges,,,85,,311.1,percent of total billed charges,,,49,,179.34,percent of total billed charges,,,90,,329.4,percent of total billed charges,,,65,,237.9,percent of total billed charges,,,80,,292.8,percent of total billed charges,,,55,,201.3,percent of total billed charges,,,55,,201.3,percent of total billed charges,,,65,,237.9,percent of total billed charges,,,78,,285.48,percent of total billed charges,,,70,,256.2,percent of total billed charges,,,,,,,,159.73,,,,100% of Medicare,,159.73,,,,100% of Medicare,,159.73,,,,100% of Medicare,,159.73,,,,100% of Medicare,,159.73,,,,100% of Medicare,,159.73,,,,100% of Medicare,,159.73,,,,100% of Medicare,,159.73,,,,100% of Medicare,,159.73,,,,100% of Medicare,,159.73,,,,100% of Medicare,,159.73,,,,100% of Medicare,,159.73,,,,100% of Medicare,,,159.73,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,142.74,329.4,
"Lower Extremity Foot Orthosis Addition, Drop Lock Knee Jt",L2182,HCPCS,,,,outpatient,,,616,369.6,,45.5,,280.28,percent of total billed charges,,,45.3,,279.05,percent of total billed charges,,,39,,240.24,percent of total billed charges,,,,,,,,,80,,492.8,percent of total billed charges,,,61.4,,378.22,percent of total billed charges,,,57.4,,353.58,percent of total billed charges,,,81,,498.96,percent of total billed charges,,,39,,240.24,percent of total billed charges,,,57.6,,354.82,percent of total billed charges,,,85,,523.6,percent of total billed charges,,,85,,523.6,percent of total billed charges,,,49,,301.84,percent of total billed charges,,,90,,554.4,percent of total billed charges,,,65,,400.4,percent of total billed charges,,,80,,492.8,percent of total billed charges,,,55,,338.8,percent of total billed charges,,,55,,338.8,percent of total billed charges,,,65,,400.4,percent of total billed charges,,,78,,480.48,percent of total billed charges,,,70,,431.2,percent of total billed charges,,,,,,,,137.68,,,,100% of Medicare,,137.68,,,,100% of Medicare,,137.68,,,,100% of Medicare,,137.68,,,,100% of Medicare,,137.68,,,,100% of Medicare,,137.68,,,,100% of Medicare,,137.68,,,,100% of Medicare,,137.68,,,,100% of Medicare,,137.68,,,,100% of Medicare,,137.68,,,,100% of Medicare,,137.68,,,,100% of Medicare,,137.68,,,,100% of Medicare,,,137.68,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,137.68,554.4,
"Lower Extremity Foot Orthosis Addition, Limited Motion Knee Jt",L2184,HCPCS,,,,outpatient,,,320,192,,45.5,,145.6,percent of total billed charges,,,45.3,,144.96,percent of total billed charges,,,39,,124.8,percent of total billed charges,,,,,,,,,80,,256,percent of total billed charges,,,61.4,,196.48,percent of total billed charges,,,57.4,,183.68,percent of total billed charges,,,81,,259.2,percent of total billed charges,,,39,,124.8,percent of total billed charges,,,57.6,,184.32,percent of total billed charges,,,85,,272,percent of total billed charges,,,85,,272,percent of total billed charges,,,49,,156.8,percent of total billed charges,,,90,,288,percent of total billed charges,,,65,,208,percent of total billed charges,,,80,,256,percent of total billed charges,,,55,,176,percent of total billed charges,,,55,,176,percent of total billed charges,,,65,,208,percent of total billed charges,,,78,,249.6,percent of total billed charges,,,70,,224,percent of total billed charges,,,,,,,,139.56,,,,100% of Medicare,,139.56,,,,100% of Medicare,,139.56,,,,100% of Medicare,,139.56,,,,100% of Medicare,,139.56,,,,100% of Medicare,,139.56,,,,100% of Medicare,,139.56,,,,100% of Medicare,,139.56,,,,100% of Medicare,,139.56,,,,100% of Medicare,,139.56,,,,100% of Medicare,,139.56,,,,100% of Medicare,,139.56,,,,100% of Medicare,,,139.56,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,124.8,288,
"Lower Extremity Foot Orthosis Addition, Adj Motion Knee Jt, Lerman Type",L2186,HCPCS,,,,outpatient,,,415,249,,45.5,,188.83,percent of total billed charges,,,45.3,,188,percent of total billed charges,,,39,,161.85,percent of total billed charges,,,,,,,,,80,,332,percent of total billed charges,,,61.4,,254.81,percent of total billed charges,,,57.4,,238.21,percent of total billed charges,,,81,,336.15,percent of total billed charges,,,39,,161.85,percent of total billed charges,,,57.6,,239.04,percent of total billed charges,,,85,,352.75,percent of total billed charges,,,85,,352.75,percent of total billed charges,,,49,,203.35,percent of total billed charges,,,90,,373.5,percent of total billed charges,,,65,,269.75,percent of total billed charges,,,80,,332,percent of total billed charges,,,55,,228.25,percent of total billed charges,,,55,,228.25,percent of total billed charges,,,65,,269.75,percent of total billed charges,,,78,,323.7,percent of total billed charges,,,70,,290.5,percent of total billed charges,,,,,,,,185.6,,,,100% of Medicare,,185.6,,,,100% of Medicare,,185.6,,,,100% of Medicare,,185.6,,,,100% of Medicare,,185.6,,,,100% of Medicare,,185.6,,,,100% of Medicare,,185.6,,,,100% of Medicare,,185.6,,,,100% of Medicare,,185.6,,,,100% of Medicare,,185.6,,,,100% of Medicare,,185.6,,,,100% of Medicare,,185.6,,,,100% of Medicare,,,185.6,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,161.85,373.5,
"Lower Extremity Foot Orthosis Addition, Quadrilateral Brim",L2188,HCPCS,,,,outpatient,,,777,466.2,,45.5,,353.54,percent of total billed charges,,,45.3,,351.98,percent of total billed charges,,,39,,303.03,percent of total billed charges,,,,,,,,,80,,621.6,percent of total billed charges,,,61.4,,477.08,percent of total billed charges,,,57.4,,446,percent of total billed charges,,,81,,629.37,percent of total billed charges,,,39,,303.03,percent of total billed charges,,,57.6,,447.55,percent of total billed charges,,,85,,660.45,percent of total billed charges,,,85,,660.45,percent of total billed charges,,,49,,380.73,percent of total billed charges,,,90,,699.3,percent of total billed charges,,,65,,505.05,percent of total billed charges,,,80,,621.6,percent of total billed charges,,,55,,427.35,percent of total billed charges,,,55,,427.35,percent of total billed charges,,,65,,505.05,percent of total billed charges,,,78,,606.06,percent of total billed charges,,,70,,543.9,percent of total billed charges,,,,,,,,337.4,,,,100% of Medicare,,337.4,,,,100% of Medicare,,337.4,,,,100% of Medicare,,337.4,,,,100% of Medicare,,337.4,,,,100% of Medicare,,337.4,,,,100% of Medicare,,337.4,,,,100% of Medicare,,337.4,,,,100% of Medicare,,337.4,,,,100% of Medicare,,337.4,,,,100% of Medicare,,337.4,,,,100% of Medicare,,337.4,,,,100% of Medicare,,,337.4,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,303.03,699.3,
"Lower Extremity Foot Orthosis Addition, Waist belt",L2190,HCPCS,,,,outpatient,,,236,141.6,,45.5,,107.38,percent of total billed charges,,,45.3,,106.91,percent of total billed charges,,,39,,92.04,percent of total billed charges,,,,,,,,,80,,188.8,percent of total billed charges,,,61.4,,144.9,percent of total billed charges,,,57.4,,135.46,percent of total billed charges,,,81,,191.16,percent of total billed charges,,,39,,92.04,percent of total billed charges,,,57.6,,135.94,percent of total billed charges,,,85,,200.6,percent of total billed charges,,,85,,200.6,percent of total billed charges,,,49,,115.64,percent of total billed charges,,,90,,212.4,percent of total billed charges,,,65,,153.4,percent of total billed charges,,,80,,188.8,percent of total billed charges,,,55,,129.8,percent of total billed charges,,,55,,129.8,percent of total billed charges,,,65,,153.4,percent of total billed charges,,,78,,184.08,percent of total billed charges,,,70,,165.2,percent of total billed charges,,,,,,,,102.77,,,,100% of Medicare,,102.77,,,,100% of Medicare,,102.77,,,,100% of Medicare,,102.77,,,,100% of Medicare,,102.77,,,,100% of Medicare,,102.77,,,,100% of Medicare,,102.77,,,,100% of Medicare,,102.77,,,,100% of Medicare,,102.77,,,,100% of Medicare,,102.77,,,,100% of Medicare,,102.77,,,,100% of Medicare,,102.77,,,,100% of Medicare,,,102.77,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,92.04,212.4,
"Lower Extremity Foot Orthosis Addition, Hip Jt, Pelvic Band/Belt, High Flange",L2192,HCPCS,,,,outpatient,,,920,552,,45.5,,418.6,percent of total billed charges,,,45.3,,416.76,percent of total billed charges,,,39,,358.8,percent of total billed charges,,,,,,,,,80,,736,percent of total billed charges,,,61.4,,564.88,percent of total billed charges,,,57.4,,528.08,percent of total billed charges,,,81,,745.2,percent of total billed charges,,,39,,358.8,percent of total billed charges,,,57.6,,529.92,percent of total billed charges,,,85,,782,percent of total billed charges,,,85,,782,percent of total billed charges,,,49,,450.8,percent of total billed charges,,,90,,828,percent of total billed charges,,,65,,598,percent of total billed charges,,,80,,736,percent of total billed charges,,,55,,506,percent of total billed charges,,,55,,506,percent of total billed charges,,,65,,598,percent of total billed charges,,,78,,717.6,percent of total billed charges,,,70,,644,percent of total billed charges,,,,,,,,401.69,,,,100% of Medicare,,401.69,,,,100% of Medicare,,401.69,,,,100% of Medicare,,401.69,,,,100% of Medicare,,401.69,,,,100% of Medicare,,401.69,,,,100% of Medicare,,401.69,,,,100% of Medicare,,401.69,,,,100% of Medicare,,401.69,,,,100% of Medicare,,401.69,,,,100% of Medicare,,401.69,,,,100% of Medicare,,401.69,,,,100% of Medicare,,,401.69,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,358.8,828,
"Lower Extremity Addition, Limited Ankle Motion Joint",L2200,HCPCS,,,,outpatient,,,272,163.2,,45.5,,123.76,percent of total billed charges,,,45.3,,123.22,percent of total billed charges,,,39,,106.08,percent of total billed charges,,,,,,,,,80,,217.6,percent of total billed charges,,,61.4,,167.01,percent of total billed charges,,,57.4,,156.13,percent of total billed charges,,,81,,220.32,percent of total billed charges,,,39,,106.08,percent of total billed charges,,,57.6,,156.67,percent of total billed charges,,,85,,231.2,percent of total billed charges,,,85,,231.2,percent of total billed charges,,,49,,133.28,percent of total billed charges,,,90,,244.8,percent of total billed charges,,,65,,176.8,percent of total billed charges,,,80,,217.6,percent of total billed charges,,,55,,149.6,percent of total billed charges,,,55,,149.6,percent of total billed charges,,,65,,176.8,percent of total billed charges,,,78,,212.16,percent of total billed charges,,,70,,190.4,percent of total billed charges,,,,,,,,60.54,,,,100% of Medicare,,60.54,,,,100% of Medicare,,60.54,,,,100% of Medicare,,60.54,,,,100% of Medicare,,60.54,,,,100% of Medicare,,60.54,,,,100% of Medicare,,60.54,,,,100% of Medicare,,60.54,,,,100% of Medicare,,60.54,,,,100% of Medicare,,60.54,,,,100% of Medicare,,60.54,,,,100% of Medicare,,60.54,,,,100% of Medicare,,,60.54,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,60.54,244.8,
"Lower Extremity Addition, Dorsiflexion/Plantarflexion Assist Joint",L2210,HCPCS,,,,outpatient,,,341,204.6,,45.5,,155.16,percent of total billed charges,,,45.3,,154.47,percent of total billed charges,,,39,,132.99,percent of total billed charges,,,,,,,,,80,,272.8,percent of total billed charges,,,61.4,,209.37,percent of total billed charges,,,57.4,,195.73,percent of total billed charges,,,81,,276.21,percent of total billed charges,,,39,,132.99,percent of total billed charges,,,57.6,,196.42,percent of total billed charges,,,85,,289.85,percent of total billed charges,,,85,,289.85,percent of total billed charges,,,49,,167.09,percent of total billed charges,,,90,,306.9,percent of total billed charges,,,65,,221.65,percent of total billed charges,,,80,,272.8,percent of total billed charges,,,55,,187.55,percent of total billed charges,,,55,,187.55,percent of total billed charges,,,65,,221.65,percent of total billed charges,,,78,,265.98,percent of total billed charges,,,70,,238.7,percent of total billed charges,,,,,,,,75.73,,,,100% of Medicare,,75.73,,,,100% of Medicare,,75.73,,,,100% of Medicare,,75.73,,,,100% of Medicare,,75.73,,,,100% of Medicare,,75.73,,,,100% of Medicare,,75.73,,,,100% of Medicare,,75.73,,,,100% of Medicare,,75.73,,,,100% of Medicare,,75.73,,,,100% of Medicare,,75.73,,,,100% of Medicare,,75.73,,,,100% of Medicare,,,75.73,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,75.73,306.9,
"Lower Extremity Addition, Dorsiflexion/Plantarflexion/Resistance Assist Ankle Joint",L2220,HCPCS,,,,outpatient,,,434,260.4,,45.5,,197.47,percent of total billed charges,,,45.3,,196.6,percent of total billed charges,,,39,,169.26,percent of total billed charges,,,,,,,,,80,,347.2,percent of total billed charges,,,61.4,,266.48,percent of total billed charges,,,57.4,,249.12,percent of total billed charges,,,81,,351.54,percent of total billed charges,,,39,,169.26,percent of total billed charges,,,57.6,,249.98,percent of total billed charges,,,85,,368.9,percent of total billed charges,,,85,,368.9,percent of total billed charges,,,49,,212.66,percent of total billed charges,,,90,,390.6,percent of total billed charges,,,65,,282.1,percent of total billed charges,,,80,,347.2,percent of total billed charges,,,55,,238.7,percent of total billed charges,,,55,,238.7,percent of total billed charges,,,65,,282.1,percent of total billed charges,,,78,,338.52,percent of total billed charges,,,70,,303.8,percent of total billed charges,,,,,,,,97.48,,,,100% of Medicare,,97.48,,,,100% of Medicare,,97.48,,,,100% of Medicare,,97.48,,,,100% of Medicare,,97.48,,,,100% of Medicare,,97.48,,,,100% of Medicare,,97.48,,,,100% of Medicare,,97.48,,,,100% of Medicare,,97.48,,,,100% of Medicare,,97.48,,,,100% of Medicare,,97.48,,,,100% of Medicare,,97.48,,,,100% of Medicare,,,97.48,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,97.48,390.6,
"Lower Extremity Addition, Split Flat Caliper Stirrups, Plate Attachment",L2230,HCPCS,,,,outpatient,,,512,307.2,,45.5,,232.96,percent of total billed charges,,,45.3,,231.94,percent of total billed charges,,,39,,199.68,percent of total billed charges,,,,,,,,,80,,409.6,percent of total billed charges,,,61.4,,314.37,percent of total billed charges,,,57.4,,293.89,percent of total billed charges,,,81,,414.72,percent of total billed charges,,,39,,199.68,percent of total billed charges,,,57.6,,294.91,percent of total billed charges,,,85,,435.2,percent of total billed charges,,,85,,435.2,percent of total billed charges,,,49,,250.88,percent of total billed charges,,,90,,460.8,percent of total billed charges,,,65,,332.8,percent of total billed charges,,,80,,409.6,percent of total billed charges,,,55,,281.6,percent of total billed charges,,,55,,281.6,percent of total billed charges,,,65,,332.8,percent of total billed charges,,,78,,399.36,percent of total billed charges,,,70,,358.4,percent of total billed charges,,,,,,,,115.26,,,,100% of Medicare,,115.26,,,,100% of Medicare,,115.26,,,,100% of Medicare,,115.26,,,,100% of Medicare,,115.26,,,,100% of Medicare,,115.26,,,,100% of Medicare,,115.26,,,,100% of Medicare,,115.26,,,,100% of Medicare,,115.26,,,,100% of Medicare,,115.26,,,,100% of Medicare,,115.26,,,,100% of Medicare,,115.26,,,,100% of Medicare,,,115.26,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,115.26,460.8,
"L2232 Rocker bottom, Cus Fab Only",L2232,HCPCS,,,,outpatient,,,523,313.8,,45.5,,237.97,percent of total billed charges,,,45.3,,236.92,percent of total billed charges,,,39,,203.97,percent of total billed charges,,,,,,,,,80,,418.4,percent of total billed charges,,,61.4,,321.12,percent of total billed charges,,,57.4,,300.2,percent of total billed charges,,,81,,423.63,percent of total billed charges,,,39,,203.97,percent of total billed charges,,,57.6,,301.25,percent of total billed charges,,,85,,444.55,percent of total billed charges,,,85,,444.55,percent of total billed charges,,,49,,256.27,percent of total billed charges,,,90,,470.7,percent of total billed charges,,,65,,339.95,percent of total billed charges,,,80,,418.4,percent of total billed charges,,,55,,287.65,percent of total billed charges,,,55,,287.65,percent of total billed charges,,,65,,339.95,percent of total billed charges,,,78,,407.94,percent of total billed charges,,,70,,366.1,percent of total billed charges,,,,,,,,117.04,,,,100% of Medicare,,117.04,,,,100% of Medicare,,117.04,,,,100% of Medicare,,117.04,,,,100% of Medicare,,117.04,,,,100% of Medicare,,117.04,,,,100% of Medicare,,117.04,,,,100% of Medicare,,117.04,,,,100% of Medicare,,117.04,,,,100% of Medicare,,117.04,,,,100% of Medicare,,117.04,,,,100% of Medicare,,117.04,,,,100% of Medicare,,,117.04,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,117.04,470.7,
"Lower Extremity Addition, Round caliper, Plate Attachment",L2240,HCPCS,,,,outpatient,,,510,306,,45.5,,232.05,percent of total billed charges,,,45.3,,231.03,percent of total billed charges,,,39,,198.9,percent of total billed charges,,,,,,,,,80,,408,percent of total billed charges,,,61.4,,313.14,percent of total billed charges,,,57.4,,292.74,percent of total billed charges,,,81,,413.1,percent of total billed charges,,,39,,198.9,percent of total billed charges,,,57.6,,293.76,percent of total billed charges,,,85,,433.5,percent of total billed charges,,,85,,433.5,percent of total billed charges,,,49,,249.9,percent of total billed charges,,,90,,459,percent of total billed charges,,,65,,331.5,percent of total billed charges,,,80,,408,percent of total billed charges,,,55,,280.5,percent of total billed charges,,,55,,280.5,percent of total billed charges,,,65,,331.5,percent of total billed charges,,,78,,397.8,percent of total billed charges,,,70,,357,percent of total billed charges,,,,,,,,114.72,,,,100% of Medicare,,114.72,,,,100% of Medicare,,114.72,,,,100% of Medicare,,114.72,,,,100% of Medicare,,114.72,,,,100% of Medicare,,114.72,,,,100% of Medicare,,114.72,,,,100% of Medicare,,114.72,,,,100% of Medicare,,114.72,,,,100% of Medicare,,114.72,,,,100% of Medicare,,114.72,,,,100% of Medicare,,114.72,,,,100% of Medicare,,,114.72,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,114.72,459,
"Lower Extremity Addition, Foot Plate, Stirrup Attachment, Molded to Patient",L2250,HCPCS,,,,outpatient,,,2209,1325.4,,45.5,,1005.1,percent of total billed charges,,,45.3,,1000.68,percent of total billed charges,,,39,,861.51,percent of total billed charges,,,,,,,,,80,,1767.2,percent of total billed charges,,,61.4,,1356.33,percent of total billed charges,,,57.4,,1267.97,percent of total billed charges,,,81,,1789.29,percent of total billed charges,,,39,,861.51,percent of total billed charges,,,57.6,,1272.38,percent of total billed charges,,,85,,1877.65,percent of total billed charges,,,85,,1877.65,percent of total billed charges,,,49,,1082.41,percent of total billed charges,,,90,,1988.1,percent of total billed charges,,,65,,1435.85,percent of total billed charges,,,80,,1767.2,percent of total billed charges,,,55,,1214.95,percent of total billed charges,,,55,,1214.95,percent of total billed charges,,,65,,1435.85,percent of total billed charges,,,78,,1723.02,percent of total billed charges,,,70,,1546.3,percent of total billed charges,,,,,,,,402.45,,,,100% of Medicare,,402.45,,,,100% of Medicare,,402.45,,,,100% of Medicare,,402.45,,,,100% of Medicare,,402.45,,,,100% of Medicare,,402.45,,,,100% of Medicare,,402.45,,,,100% of Medicare,,402.45,,,,100% of Medicare,,402.45,,,,100% of Medicare,,402.45,,,,100% of Medicare,,402.45,,,,100% of Medicare,,402.45,,,,100% of Medicare,,,402.45,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,402.45,1988.1,
"Lower Extremity Addition, Reinforced Solid Stirrups, Craig-Scott Style",L2260,HCPCS,,,,outpatient,,,1006,603.6,,45.5,,457.73,percent of total billed charges,,,45.3,,455.72,percent of total billed charges,,,39,,392.34,percent of total billed charges,,,,,,,,,80,,804.8,percent of total billed charges,,,61.4,,617.68,percent of total billed charges,,,57.4,,577.44,percent of total billed charges,,,81,,814.86,percent of total billed charges,,,39,,392.34,percent of total billed charges,,,57.6,,579.46,percent of total billed charges,,,85,,855.1,percent of total billed charges,,,85,,855.1,percent of total billed charges,,,49,,492.94,percent of total billed charges,,,90,,905.4,percent of total billed charges,,,65,,653.9,percent of total billed charges,,,80,,804.8,percent of total billed charges,,,55,,553.3,percent of total billed charges,,,55,,553.3,percent of total billed charges,,,65,,653.9,percent of total billed charges,,,78,,784.68,percent of total billed charges,,,70,,704.2,percent of total billed charges,,,,,,,,225.84,,,,100% of Medicare,,225.84,,,,100% of Medicare,,225.84,,,,100% of Medicare,,225.84,,,,100% of Medicare,,225.84,,,,100% of Medicare,,225.84,,,,100% of Medicare,,225.84,,,,100% of Medicare,,225.84,,,,100% of Medicare,,225.84,,,,100% of Medicare,,225.84,,,,100% of Medicare,,225.84,,,,100% of Medicare,,225.84,,,,100% of Medicare,,,225.84,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,225.84,905.4,
"Addition to lower extremity, Long tongue stirrup",L2265,HCPCS,,,,outpatient,,,737,442.2,,45.5,,335.34,percent of total billed charges,,,45.3,,333.86,percent of total billed charges,,,39,,287.43,percent of total billed charges,,,,,,,,,80,,589.6,percent of total billed charges,,,61.4,,452.52,percent of total billed charges,,,57.4,,423.04,percent of total billed charges,,,81,,596.97,percent of total billed charges,,,39,,287.43,percent of total billed charges,,,57.6,,424.51,percent of total billed charges,,,85,,626.45,percent of total billed charges,,,85,,626.45,percent of total billed charges,,,49,,361.13,percent of total billed charges,,,90,,663.3,percent of total billed charges,,,65,,479.05,percent of total billed charges,,,80,,589.6,percent of total billed charges,,,55,,405.35,percent of total billed charges,,,55,,405.35,percent of total billed charges,,,65,,479.05,percent of total billed charges,,,78,,574.86,percent of total billed charges,,,70,,515.9,percent of total billed charges,,,,,,,,161.97,,,,100% of Medicare,,161.97,,,,100% of Medicare,,161.97,,,,100% of Medicare,,161.97,,,,100% of Medicare,,161.97,,,,100% of Medicare,,161.97,,,,100% of Medicare,,161.97,,,,100% of Medicare,,161.97,,,,100% of Medicare,,161.97,,,,100% of Medicare,,161.97,,,,100% of Medicare,,161.97,,,,100% of Medicare,,161.97,,,,100% of Medicare,,,161.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,161.97,663.3,
"Lower Extremity Addition, Valgus/Varus Correction T-Strap",L2270,HCPCS,,,,outpatient,,,330,198,,45.5,,150.15,percent of total billed charges,,,45.3,,149.49,percent of total billed charges,,,39,,128.7,percent of total billed charges,,,,,,,,,80,,264,percent of total billed charges,,,61.4,,202.62,percent of total billed charges,,,57.4,,189.42,percent of total billed charges,,,81,,267.3,percent of total billed charges,,,39,,128.7,percent of total billed charges,,,57.6,,190.08,percent of total billed charges,,,85,,280.5,percent of total billed charges,,,85,,280.5,percent of total billed charges,,,49,,161.7,percent of total billed charges,,,90,,297,percent of total billed charges,,,65,,214.5,percent of total billed charges,,,80,,264,percent of total billed charges,,,55,,181.5,percent of total billed charges,,,55,,181.5,percent of total billed charges,,,65,,214.5,percent of total billed charges,,,78,,257.4,percent of total billed charges,,,70,,231,percent of total billed charges,,,,,,,,74.27,,,,100% of Medicare,,74.27,,,,100% of Medicare,,74.27,,,,100% of Medicare,,74.27,,,,100% of Medicare,,74.27,,,,100% of Medicare,,74.27,,,,100% of Medicare,,74.27,,,,100% of Medicare,,74.27,,,,100% of Medicare,,74.27,,,,100% of Medicare,,74.27,,,,100% of Medicare,,74.27,,,,100% of Medicare,,74.27,,,,100% of Medicare,,,74.27,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,74.27,297,
"Lower Extremity Addition, Valgus/Varus Correction Plastic Modification",L2275,HCPCS,,,,outpatient,,,702,421.2,,45.5,,319.41,percent of total billed charges,,,45.3,,318.01,percent of total billed charges,,,39,,273.78,percent of total billed charges,,,,,,,,,80,,561.6,percent of total billed charges,,,61.4,,431.03,percent of total billed charges,,,57.4,,402.95,percent of total billed charges,,,81,,568.62,percent of total billed charges,,,39,,273.78,percent of total billed charges,,,57.6,,404.35,percent of total billed charges,,,85,,596.7,percent of total billed charges,,,85,,596.7,percent of total billed charges,,,49,,343.98,percent of total billed charges,,,90,,631.8,percent of total billed charges,,,65,,456.3,percent of total billed charges,,,80,,561.6,percent of total billed charges,,,55,,386.1,percent of total billed charges,,,55,,386.1,percent of total billed charges,,,65,,456.3,percent of total billed charges,,,78,,547.56,percent of total billed charges,,,70,,491.4,percent of total billed charges,,,,,,,,157.05,,,,100% of Medicare,,157.05,,,,100% of Medicare,,157.05,,,,100% of Medicare,,157.05,,,,100% of Medicare,,157.05,,,,100% of Medicare,,157.05,,,,100% of Medicare,,157.05,,,,100% of Medicare,,157.05,,,,100% of Medicare,,157.05,,,,100% of Medicare,,157.05,,,,100% of Medicare,,157.05,,,,100% of Medicare,,157.05,,,,100% of Medicare,,,157.05,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,157.05,631.8,
"Lower Extremity Addition, Molded Inner Boot",L2280,HCPCS,,,,outpatient,,,3037,1822.2,,45.5,,1381.84,percent of total billed charges,,,45.3,,1375.76,percent of total billed charges,,,39,,1184.43,percent of total billed charges,,,,,,,,,80,,2429.6,percent of total billed charges,,,61.4,,1864.72,percent of total billed charges,,,57.4,,1743.24,percent of total billed charges,,,81,,2459.97,percent of total billed charges,,,39,,1184.43,percent of total billed charges,,,57.6,,1749.31,percent of total billed charges,,,85,,2581.45,percent of total billed charges,,,85,,2581.45,percent of total billed charges,,,49,,1488.13,percent of total billed charges,,,90,,2733.3,percent of total billed charges,,,65,,1974.05,percent of total billed charges,,,80,,2429.6,percent of total billed charges,,,55,,1670.35,percent of total billed charges,,,55,,1670.35,percent of total billed charges,,,65,,1974.05,percent of total billed charges,,,78,,2368.86,percent of total billed charges,,,70,,2125.9,percent of total billed charges,,,,,,,,680.18,,,,100% of Medicare,,680.18,,,,100% of Medicare,,680.18,,,,100% of Medicare,,680.18,,,,100% of Medicare,,680.18,,,,100% of Medicare,,680.18,,,,100% of Medicare,,680.18,,,,100% of Medicare,,680.18,,,,100% of Medicare,,680.18,,,,100% of Medicare,,680.18,,,,100% of Medicare,,680.18,,,,100% of Medicare,,680.18,,,,100% of Medicare,,,680.18,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,680.18,2733.3,
"Lower Extremity Addition, Abduction Bar, Jointed, Adjustable",L2300,HCPCS,,,,outpatient,,,612,367.2,,45.5,,278.46,percent of total billed charges,,,45.3,,277.24,percent of total billed charges,,,39,,238.68,percent of total billed charges,,,,,,,,,80,,489.6,percent of total billed charges,,,61.4,,375.77,percent of total billed charges,,,57.4,,351.29,percent of total billed charges,,,81,,495.72,percent of total billed charges,,,39,,238.68,percent of total billed charges,,,57.6,,352.51,percent of total billed charges,,,85,,520.2,percent of total billed charges,,,85,,520.2,percent of total billed charges,,,49,,299.88,percent of total billed charges,,,90,,550.8,percent of total billed charges,,,65,,397.8,percent of total billed charges,,,80,,489.6,percent of total billed charges,,,55,,336.6,percent of total billed charges,,,55,,336.6,percent of total billed charges,,,65,,397.8,percent of total billed charges,,,78,,477.36,percent of total billed charges,,,70,,428.4,percent of total billed charges,,,,,,,,303.33,,,,100% of Medicare,,303.33,,,,100% of Medicare,,303.33,,,,100% of Medicare,,303.33,,,,100% of Medicare,,303.33,,,,100% of Medicare,,303.33,,,,100% of Medicare,,303.33,,,,100% of Medicare,,303.33,,,,100% of Medicare,,303.33,,,,100% of Medicare,,303.33,,,,100% of Medicare,,303.33,,,,100% of Medicare,,303.33,,,,100% of Medicare,,,303.33,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,238.68,550.8,
"Lower Extremity Addition, Abduction Bar, Straight",L2310,HCPCS,,,,outpatient,,,604,362.4,,45.5,,274.82,percent of total billed charges,,,45.3,,273.61,percent of total billed charges,,,39,,235.56,percent of total billed charges,,,,,,,,,80,,483.2,percent of total billed charges,,,61.4,,370.86,percent of total billed charges,,,57.4,,346.7,percent of total billed charges,,,81,,489.24,percent of total billed charges,,,39,,235.56,percent of total billed charges,,,57.6,,347.9,percent of total billed charges,,,85,,513.4,percent of total billed charges,,,85,,513.4,percent of total billed charges,,,49,,295.96,percent of total billed charges,,,90,,543.6,percent of total billed charges,,,65,,392.6,percent of total billed charges,,,80,,483.2,percent of total billed charges,,,55,,332.2,percent of total billed charges,,,55,,332.2,percent of total billed charges,,,65,,392.6,percent of total billed charges,,,78,,471.12,percent of total billed charges,,,70,,422.8,percent of total billed charges,,,,,,,,138.6,,,,100% of Medicare,,138.6,,,,100% of Medicare,,138.6,,,,100% of Medicare,,138.6,,,,100% of Medicare,,138.6,,,,100% of Medicare,,138.6,,,,100% of Medicare,,138.6,,,,100% of Medicare,,138.6,,,,100% of Medicare,,138.6,,,,100% of Medicare,,138.6,,,,100% of Medicare,,138.6,,,,100% of Medicare,,138.6,,,,100% of Medicare,,,138.6,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,138.6,543.6,
"Lower Extremity Addition, Non-Molded Lacer, Custom Fabricated",L2320,HCPCS,,,,outpatient,,,1036,621.6,,45.5,,471.38,percent of total billed charges,,,45.3,,469.31,percent of total billed charges,,,39,,404.04,percent of total billed charges,,,,,,,,,80,,828.8,percent of total billed charges,,,61.4,,636.1,percent of total billed charges,,,57.4,,594.66,percent of total billed charges,,,81,,839.16,percent of total billed charges,,,39,,404.04,percent of total billed charges,,,57.6,,596.74,percent of total billed charges,,,85,,880.6,percent of total billed charges,,,85,,880.6,percent of total billed charges,,,49,,507.64,percent of total billed charges,,,90,,932.4,percent of total billed charges,,,65,,673.4,percent of total billed charges,,,80,,828.8,percent of total billed charges,,,55,,569.8,percent of total billed charges,,,55,,569.8,percent of total billed charges,,,65,,673.4,percent of total billed charges,,,78,,808.08,percent of total billed charges,,,70,,725.2,percent of total billed charges,,,,,,,,232.43,,,,100% of Medicare,,232.43,,,,100% of Medicare,,232.43,,,,100% of Medicare,,232.43,,,,100% of Medicare,,232.43,,,,100% of Medicare,,232.43,,,,100% of Medicare,,232.43,,,,100% of Medicare,,232.43,,,,100% of Medicare,,232.43,,,,100% of Medicare,,232.43,,,,100% of Medicare,,232.43,,,,100% of Medicare,,232.43,,,,100% of Medicare,,,232.43,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,232.43,932.4,
"Lower Extremity Addition, Lacer, Molded to Patient, Custom Fabricated",L2330,HCPCS,,,,outpatient,,,1920,1152,,45.5,,873.6,percent of total billed charges,,,45.3,,869.76,percent of total billed charges,,,39,,748.8,percent of total billed charges,,,,,,,,,80,,1536,percent of total billed charges,,,61.4,,1178.88,percent of total billed charges,,,57.4,,1102.08,percent of total billed charges,,,81,,1555.2,percent of total billed charges,,,39,,748.8,percent of total billed charges,,,57.6,,1105.92,percent of total billed charges,,,85,,1632,percent of total billed charges,,,85,,1632,percent of total billed charges,,,49,,940.8,percent of total billed charges,,,90,,1728,percent of total billed charges,,,65,,1248,percent of total billed charges,,,80,,1536,percent of total billed charges,,,55,,1056,percent of total billed charges,,,55,,1056,percent of total billed charges,,,65,,1248,percent of total billed charges,,,78,,1497.6,percent of total billed charges,,,70,,1344,percent of total billed charges,,,,,,,,442.37,,,,100% of Medicare,,442.37,,,,100% of Medicare,,442.37,,,,100% of Medicare,,442.37,,,,100% of Medicare,,442.37,,,,100% of Medicare,,442.37,,,,100% of Medicare,,442.37,,,,100% of Medicare,,442.37,,,,100% of Medicare,,442.37,,,,100% of Medicare,,442.37,,,,100% of Medicare,,442.37,,,,100% of Medicare,,442.37,,,,100% of Medicare,,,442.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,442.37,1728,
"Lower Extremity Addition, Anterior Swing Band",L2335,HCPCS,,,,outpatient,,,718,430.8,,45.5,,326.69,percent of total billed charges,,,45.3,,325.25,percent of total billed charges,,,39,,280.02,percent of total billed charges,,,,,,,,,80,,574.4,percent of total billed charges,,,61.4,,440.85,percent of total billed charges,,,57.4,,412.13,percent of total billed charges,,,81,,581.58,percent of total billed charges,,,39,,280.02,percent of total billed charges,,,57.6,,413.57,percent of total billed charges,,,85,,610.3,percent of total billed charges,,,85,,610.3,percent of total billed charges,,,49,,351.82,percent of total billed charges,,,90,,646.2,percent of total billed charges,,,65,,466.7,percent of total billed charges,,,80,,574.4,percent of total billed charges,,,55,,394.9,percent of total billed charges,,,55,,394.9,percent of total billed charges,,,65,,466.7,percent of total billed charges,,,78,,560.04,percent of total billed charges,,,70,,502.6,percent of total billed charges,,,,,,,,338.69,,,,100% of Medicare,,338.69,,,,100% of Medicare,,338.69,,,,100% of Medicare,,338.69,,,,100% of Medicare,,338.69,,,,100% of Medicare,,338.69,,,,100% of Medicare,,338.69,,,,100% of Medicare,,338.69,,,,100% of Medicare,,338.69,,,,100% of Medicare,,338.69,,,,100% of Medicare,,338.69,,,,100% of Medicare,,338.69,,,,100% of Medicare,,,338.69,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,280.02,646.2,
"Lower Extremity Addition, Pre-Tibial Shell, Molded to Patient",L2340,HCPCS,,,,outpatient,,,2247,1348.2,,45.5,,1022.39,percent of total billed charges,,,45.3,,1017.89,percent of total billed charges,,,39,,876.33,percent of total billed charges,,,,,,,,,80,,1797.6,percent of total billed charges,,,61.4,,1379.66,percent of total billed charges,,,57.4,,1289.78,percent of total billed charges,,,81,,1820.07,percent of total billed charges,,,39,,876.33,percent of total billed charges,,,57.6,,1294.27,percent of total billed charges,,,85,,1909.95,percent of total billed charges,,,85,,1909.95,percent of total billed charges,,,49,,1101.03,percent of total billed charges,,,90,,2022.3,percent of total billed charges,,,65,,1460.55,percent of total billed charges,,,80,,1797.6,percent of total billed charges,,,55,,1235.85,percent of total billed charges,,,55,,1235.85,percent of total billed charges,,,65,,1460.55,percent of total billed charges,,,78,,1752.66,percent of total billed charges,,,70,,1572.9,percent of total billed charges,,,,,,,,503.51,,,,100% of Medicare,,503.51,,,,100% of Medicare,,503.51,,,,100% of Medicare,,503.51,,,,100% of Medicare,,503.51,,,,100% of Medicare,,503.51,,,,100% of Medicare,,503.51,,,,100% of Medicare,,503.51,,,,100% of Medicare,,503.51,,,,100% of Medicare,,503.51,,,,100% of Medicare,,503.51,,,,100% of Medicare,,503.51,,,,100% of Medicare,,,503.51,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,503.51,2022.3,
"Lower Extremity Addition, PTB Socket, Molded to Patient",L2350,HCPCS,,,,outpatient,,,1925,1155,,45.5,,875.88,percent of total billed charges,,,45.3,,872.03,percent of total billed charges,,,39,,750.75,percent of total billed charges,,,,,,,,,80,,1540,percent of total billed charges,,,61.4,,1181.95,percent of total billed charges,,,57.4,,1104.95,percent of total billed charges,,,81,,1559.25,percent of total billed charges,,,39,,750.75,percent of total billed charges,,,57.6,,1108.8,percent of total billed charges,,,85,,1636.25,percent of total billed charges,,,85,,1636.25,percent of total billed charges,,,49,,943.25,percent of total billed charges,,,90,,1732.5,percent of total billed charges,,,65,,1251.25,percent of total billed charges,,,80,,1540,percent of total billed charges,,,55,,1058.75,percent of total billed charges,,,55,,1058.75,percent of total billed charges,,,65,,1251.25,percent of total billed charges,,,78,,1501.5,percent of total billed charges,,,70,,1347.5,percent of total billed charges,,,,,,,,1003.85,,,,100% of Medicare,,1003.85,,,,100% of Medicare,,1003.85,,,,100% of Medicare,,1003.85,,,,100% of Medicare,,1003.85,,,,100% of Medicare,,1003.85,,,,100% of Medicare,,1003.85,,,,100% of Medicare,,1003.85,,,,100% of Medicare,,1003.85,,,,100% of Medicare,,1003.85,,,,100% of Medicare,,1003.85,,,,100% of Medicare,,1003.85,,,,100% of Medicare,,,1003.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,750.75,1732.5,
"Lower Extremity Addition, Extended Steel Shank",L2360,HCPCS,,,,outpatient,,,279,167.4,,45.5,,126.95,percent of total billed charges,,,45.3,,126.39,percent of total billed charges,,,39,,108.81,percent of total billed charges,,,,,,,,,80,,223.2,percent of total billed charges,,,61.4,,171.31,percent of total billed charges,,,57.4,,160.15,percent of total billed charges,,,81,,225.99,percent of total billed charges,,,39,,108.81,percent of total billed charges,,,57.6,,160.7,percent of total billed charges,,,85,,237.15,percent of total billed charges,,,85,,237.15,percent of total billed charges,,,49,,136.71,percent of total billed charges,,,90,,251.1,percent of total billed charges,,,65,,181.35,percent of total billed charges,,,80,,223.2,percent of total billed charges,,,55,,153.45,percent of total billed charges,,,55,,153.45,percent of total billed charges,,,65,,181.35,percent of total billed charges,,,78,,217.62,percent of total billed charges,,,70,,195.3,percent of total billed charges,,,,,,,,62.13,,,,100% of Medicare,,62.13,,,,100% of Medicare,,62.13,,,,100% of Medicare,,62.13,,,,100% of Medicare,,62.13,,,,100% of Medicare,,62.13,,,,100% of Medicare,,62.13,,,,100% of Medicare,,62.13,,,,100% of Medicare,,62.13,,,,100% of Medicare,,62.13,,,,100% of Medicare,,62.13,,,,100% of Medicare,,62.13,,,,100% of Medicare,,,62.13,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,62.13,251.1,
"Lower Extremity Addition, Patten Bottom",L2370,HCPCS,,,,outpatient,,,868,520.8,,45.5,,394.94,percent of total billed charges,,,45.3,,393.2,percent of total billed charges,,,39,,338.52,percent of total billed charges,,,,,,,,,80,,694.4,percent of total billed charges,,,61.4,,532.95,percent of total billed charges,,,57.4,,498.23,percent of total billed charges,,,81,,703.08,percent of total billed charges,,,39,,338.52,percent of total billed charges,,,57.6,,499.97,percent of total billed charges,,,85,,737.8,percent of total billed charges,,,85,,737.8,percent of total billed charges,,,49,,425.32,percent of total billed charges,,,90,,781.2,percent of total billed charges,,,65,,564.2,percent of total billed charges,,,80,,694.4,percent of total billed charges,,,55,,477.4,percent of total billed charges,,,55,,477.4,percent of total billed charges,,,65,,564.2,percent of total billed charges,,,78,,677.04,percent of total billed charges,,,70,,607.6,percent of total billed charges,,,,,,,,385.6,,,,100% of Medicare,,385.6,,,,100% of Medicare,,385.6,,,,100% of Medicare,,385.6,,,,100% of Medicare,,385.6,,,,100% of Medicare,,385.6,,,,100% of Medicare,,385.6,,,,100% of Medicare,,385.6,,,,100% of Medicare,,385.6,,,,100% of Medicare,,385.6,,,,100% of Medicare,,385.6,,,,100% of Medicare,,385.6,,,,100% of Medicare,,,385.6,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,338.52,781.2,
"Lower Extremity Addition, Torsion Control, Ankle Jt, Half Solid Stirrup",L2375,HCPCS,,,,outpatient,,,342,205.2,,45.5,,155.61,percent of total billed charges,,,45.3,,154.93,percent of total billed charges,,,39,,133.38,percent of total billed charges,,,,,,,,,80,,273.6,percent of total billed charges,,,61.4,,209.99,percent of total billed charges,,,57.4,,196.31,percent of total billed charges,,,81,,277.02,percent of total billed charges,,,39,,133.38,percent of total billed charges,,,57.6,,196.99,percent of total billed charges,,,85,,290.7,percent of total billed charges,,,85,,290.7,percent of total billed charges,,,49,,167.58,percent of total billed charges,,,90,,307.8,percent of total billed charges,,,65,,222.3,percent of total billed charges,,,80,,273.6,percent of total billed charges,,,55,,188.1,percent of total billed charges,,,55,,188.1,percent of total billed charges,,,65,,222.3,percent of total billed charges,,,78,,266.76,percent of total billed charges,,,70,,239.4,percent of total billed charges,,,,,,,,148.25,,,,100% of Medicare,,148.25,,,,100% of Medicare,,148.25,,,,100% of Medicare,,148.25,,,,100% of Medicare,,148.25,,,,100% of Medicare,,148.25,,,,100% of Medicare,,148.25,,,,100% of Medicare,,148.25,,,,100% of Medicare,,148.25,,,,100% of Medicare,,148.25,,,,100% of Medicare,,148.25,,,,100% of Medicare,,148.25,,,,100% of Medicare,,,148.25,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,133.38,307.8,
"Lower Extremity Addition, Torsion Control, Straight Knee Jt",L2380,HCPCS,,,,outpatient,,,348,208.8,,45.5,,158.34,percent of total billed charges,,,45.3,,157.64,percent of total billed charges,,,39,,135.72,percent of total billed charges,,,,,,,,,80,,278.4,percent of total billed charges,,,61.4,,213.67,percent of total billed charges,,,57.4,,199.75,percent of total billed charges,,,81,,281.88,percent of total billed charges,,,39,,135.72,percent of total billed charges,,,57.6,,200.45,percent of total billed charges,,,85,,295.8,percent of total billed charges,,,85,,295.8,percent of total billed charges,,,49,,170.52,percent of total billed charges,,,90,,313.2,percent of total billed charges,,,65,,226.2,percent of total billed charges,,,80,,278.4,percent of total billed charges,,,55,,191.4,percent of total billed charges,,,55,,191.4,percent of total billed charges,,,65,,226.2,percent of total billed charges,,,78,,271.44,percent of total billed charges,,,70,,243.6,percent of total billed charges,,,,,,,,155.49,,,,100% of Medicare,,155.49,,,,100% of Medicare,,155.49,,,,100% of Medicare,,155.49,,,,100% of Medicare,,155.49,,,,100% of Medicare,,155.49,,,,100% of Medicare,,155.49,,,,100% of Medicare,,155.49,,,,100% of Medicare,,155.49,,,,100% of Medicare,,155.49,,,,100% of Medicare,,155.49,,,,100% of Medicare,,155.49,,,,100% of Medicare,,,155.49,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,135.72,313.2,
"Lower Extremity Addition, Straight Knee Joint, Heavy Duty",L2385,HCPCS,,,,outpatient,,,768,460.8,,45.5,,349.44,percent of total billed charges,,,45.3,,347.9,percent of total billed charges,,,39,,299.52,percent of total billed charges,,,,,,,,,80,,614.4,percent of total billed charges,,,61.4,,471.55,percent of total billed charges,,,57.4,,440.83,percent of total billed charges,,,81,,622.08,percent of total billed charges,,,39,,299.52,percent of total billed charges,,,57.6,,442.37,percent of total billed charges,,,85,,652.8,percent of total billed charges,,,85,,652.8,percent of total billed charges,,,49,,376.32,percent of total billed charges,,,90,,691.2,percent of total billed charges,,,65,,499.2,percent of total billed charges,,,80,,614.4,percent of total billed charges,,,55,,422.4,percent of total billed charges,,,55,,422.4,percent of total billed charges,,,65,,499.2,percent of total billed charges,,,78,,599.04,percent of total billed charges,,,70,,537.6,percent of total billed charges,,,,,,,,177.04,,,,100% of Medicare,,177.04,,,,100% of Medicare,,177.04,,,,100% of Medicare,,177.04,,,,100% of Medicare,,177.04,,,,100% of Medicare,,177.04,,,,100% of Medicare,,177.04,,,,100% of Medicare,,177.04,,,,100% of Medicare,,177.04,,,,100% of Medicare,,177.04,,,,100% of Medicare,,177.04,,,,100% of Medicare,,177.04,,,,100% of Medicare,,,177.04,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,177.04,691.2,
L2387 Polycentric Knee JT,L2387,HCPCS,,,,outpatient,,,999,599.4,,45.5,,454.55,percent of total billed charges,,,45.3,,452.55,percent of total billed charges,,,39,,389.61,percent of total billed charges,,,,,,,,,80,,799.2,percent of total billed charges,,,61.4,,613.39,percent of total billed charges,,,57.4,,573.43,percent of total billed charges,,,81,,809.19,percent of total billed charges,,,39,,389.61,percent of total billed charges,,,57.6,,575.42,percent of total billed charges,,,85,,849.15,percent of total billed charges,,,85,,849.15,percent of total billed charges,,,49,,489.51,percent of total billed charges,,,90,,899.1,percent of total billed charges,,,65,,649.35,percent of total billed charges,,,80,,799.2,percent of total billed charges,,,55,,549.45,percent of total billed charges,,,55,,549.45,percent of total billed charges,,,65,,649.35,percent of total billed charges,,,78,,779.22,percent of total billed charges,,,70,,699.3,percent of total billed charges,,,,,,,,230,,,,100% of Medicare,,230,,,,100% of Medicare,,230,,,,100% of Medicare,,230,,,,100% of Medicare,,230,,,,100% of Medicare,,230,,,,100% of Medicare,,230,,,,100% of Medicare,,230,,,,100% of Medicare,,230,,,,100% of Medicare,,230,,,,100% of Medicare,,230,,,,100% of Medicare,,230,,,,100% of Medicare,,,230,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,230,899.1,
"Lower Extremity Addition, Offset Knee Joint",L2390,HCPCS,,,,outpatient,,,551,330.6,,45.5,,250.71,percent of total billed charges,,,45.3,,249.6,percent of total billed charges,,,39,,214.89,percent of total billed charges,,,,,,,,,80,,440.8,percent of total billed charges,,,61.4,,338.31,percent of total billed charges,,,57.4,,316.27,percent of total billed charges,,,81,,446.31,percent of total billed charges,,,39,,214.89,percent of total billed charges,,,57.6,,317.38,percent of total billed charges,,,85,,468.35,percent of total billed charges,,,85,,468.35,percent of total billed charges,,,49,,269.99,percent of total billed charges,,,90,,495.9,percent of total billed charges,,,65,,358.15,percent of total billed charges,,,80,,440.8,percent of total billed charges,,,55,,303.05,percent of total billed charges,,,55,,303.05,percent of total billed charges,,,65,,358.15,percent of total billed charges,,,78,,429.78,percent of total billed charges,,,70,,385.7,percent of total billed charges,,,,,,,,123.32,,,,100% of Medicare,,123.32,,,,100% of Medicare,,123.32,,,,100% of Medicare,,123.32,,,,100% of Medicare,,123.32,,,,100% of Medicare,,123.32,,,,100% of Medicare,,123.32,,,,100% of Medicare,,123.32,,,,100% of Medicare,,123.32,,,,100% of Medicare,,123.32,,,,100% of Medicare,,123.32,,,,100% of Medicare,,123.32,,,,100% of Medicare,,,123.32,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,123.32,495.9,
"Lower Extremity Addition, Offset Knee Joint, Heavy Duty",L2395,HCPCS,,,,outpatient,,,762,457.2,,45.5,,346.71,percent of total billed charges,,,45.3,,345.19,percent of total billed charges,,,39,,297.18,percent of total billed charges,,,,,,,,,80,,609.6,percent of total billed charges,,,61.4,,467.87,percent of total billed charges,,,57.4,,437.39,percent of total billed charges,,,81,,617.22,percent of total billed charges,,,39,,297.18,percent of total billed charges,,,57.6,,438.91,percent of total billed charges,,,85,,647.7,percent of total billed charges,,,85,,647.7,percent of total billed charges,,,49,,373.38,percent of total billed charges,,,90,,685.8,percent of total billed charges,,,65,,495.3,percent of total billed charges,,,80,,609.6,percent of total billed charges,,,55,,419.1,percent of total billed charges,,,55,,419.1,percent of total billed charges,,,65,,495.3,percent of total billed charges,,,78,,594.36,percent of total billed charges,,,70,,533.4,percent of total billed charges,,,,,,,,176.27,,,,100% of Medicare,,176.27,,,,100% of Medicare,,176.27,,,,100% of Medicare,,176.27,,,,100% of Medicare,,176.27,,,,100% of Medicare,,176.27,,,,100% of Medicare,,176.27,,,,100% of Medicare,,176.27,,,,100% of Medicare,,176.27,,,,100% of Medicare,,176.27,,,,100% of Medicare,,176.27,,,,100% of Medicare,,176.27,,,,100% of Medicare,,,176.27,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,176.27,685.8,
"Lower Extremity Addition, Suspension Sleeve",L2397,HCPCS,,,,outpatient,,,277,166.2,,45.5,,126.04,percent of total billed charges,,,45.3,,125.48,percent of total billed charges,,,39,,108.03,percent of total billed charges,,,,,,,,,80,,221.6,percent of total billed charges,,,61.4,,170.08,percent of total billed charges,,,57.4,,159,percent of total billed charges,,,81,,224.37,percent of total billed charges,,,39,,108.03,percent of total billed charges,,,57.6,,159.55,percent of total billed charges,,,85,,235.45,percent of total billed charges,,,85,,235.45,percent of total billed charges,,,49,,135.73,percent of total billed charges,,,90,,249.3,percent of total billed charges,,,65,,180.05,percent of total billed charges,,,80,,221.6,percent of total billed charges,,,55,,152.35,percent of total billed charges,,,55,,152.35,percent of total billed charges,,,65,,180.05,percent of total billed charges,,,78,,216.06,percent of total billed charges,,,70,,193.9,percent of total billed charges,,,,,,,,147.06,,,,100% of Medicare,,147.06,,,,100% of Medicare,,147.06,,,,100% of Medicare,,147.06,,,,100% of Medicare,,147.06,,,,100% of Medicare,,147.06,,,,100% of Medicare,,147.06,,,,100% of Medicare,,147.06,,,,100% of Medicare,,147.06,,,,100% of Medicare,,147.06,,,,100% of Medicare,,147.06,,,,100% of Medicare,,147.06,,,,100% of Medicare,,,147.06,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,108.03,249.3,
"Addition, Knee Joint, Drop Lock, Stance or Swing",L2405,HCPCS,,,,outpatient,,,455,273,,45.5,,207.03,percent of total billed charges,,,45.3,,206.12,percent of total billed charges,,,39,,177.45,percent of total billed charges,,,,,,,,,80,,364,percent of total billed charges,,,61.4,,279.37,percent of total billed charges,,,57.4,,261.17,percent of total billed charges,,,81,,368.55,percent of total billed charges,,,39,,177.45,percent of total billed charges,,,57.6,,262.08,percent of total billed charges,,,85,,386.75,percent of total billed charges,,,85,,386.75,percent of total billed charges,,,49,,222.95,percent of total billed charges,,,90,,409.5,percent of total billed charges,,,65,,295.75,percent of total billed charges,,,80,,364,percent of total billed charges,,,55,,250.25,percent of total billed charges,,,55,,250.25,percent of total billed charges,,,65,,295.75,percent of total billed charges,,,78,,354.9,percent of total billed charges,,,70,,318.5,percent of total billed charges,,,,,,,,105.04,,,,100% of Medicare,,105.04,,,,100% of Medicare,,105.04,,,,100% of Medicare,,105.04,,,,100% of Medicare,,105.04,,,,100% of Medicare,,105.04,,,,100% of Medicare,,105.04,,,,100% of Medicare,,105.04,,,,100% of Medicare,,105.04,,,,100% of Medicare,,105.04,,,,100% of Medicare,,105.04,,,,100% of Medicare,,105.04,,,,100% of Medicare,,,105.04,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,105.04,409.5,
"Addition, Knee Joint, Cam Lock",L2415,HCPCS,,,,outpatient,,,653,391.8,,45.5,,297.12,percent of total billed charges,,,45.3,,295.81,percent of total billed charges,,,39,,254.67,percent of total billed charges,,,,,,,,,80,,522.4,percent of total billed charges,,,61.4,,400.94,percent of total billed charges,,,57.4,,374.82,percent of total billed charges,,,81,,528.93,percent of total billed charges,,,39,,254.67,percent of total billed charges,,,57.6,,376.13,percent of total billed charges,,,85,,555.05,percent of total billed charges,,,85,,555.05,percent of total billed charges,,,49,,319.97,percent of total billed charges,,,90,,587.7,percent of total billed charges,,,65,,424.45,percent of total billed charges,,,80,,522.4,percent of total billed charges,,,55,,359.15,percent of total billed charges,,,55,,359.15,percent of total billed charges,,,65,,424.45,percent of total billed charges,,,78,,509.34,percent of total billed charges,,,70,,457.1,percent of total billed charges,,,,,,,,146.37,,,,100% of Medicare,,146.37,,,,100% of Medicare,,146.37,,,,100% of Medicare,,146.37,,,,100% of Medicare,,146.37,,,,100% of Medicare,,146.37,,,,100% of Medicare,,146.37,,,,100% of Medicare,,146.37,,,,100% of Medicare,,146.37,,,,100% of Medicare,,146.37,,,,100% of Medicare,,146.37,,,,100% of Medicare,,146.37,,,,100% of Medicare,,,146.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,146.37,587.7,
"Addition, Knee Joint, Disc/Dial Lock",L2425,HCPCS,,,,outpatient,,,773,463.8,,45.5,,351.72,percent of total billed charges,,,45.3,,350.17,percent of total billed charges,,,39,,301.47,percent of total billed charges,,,,,,,,,80,,618.4,percent of total billed charges,,,61.4,,474.62,percent of total billed charges,,,57.4,,443.7,percent of total billed charges,,,81,,626.13,percent of total billed charges,,,39,,301.47,percent of total billed charges,,,57.6,,445.25,percent of total billed charges,,,85,,657.05,percent of total billed charges,,,85,,657.05,percent of total billed charges,,,49,,378.77,percent of total billed charges,,,90,,695.7,percent of total billed charges,,,65,,502.45,percent of total billed charges,,,80,,618.4,percent of total billed charges,,,55,,425.15,percent of total billed charges,,,55,,425.15,percent of total billed charges,,,65,,502.45,percent of total billed charges,,,78,,602.94,percent of total billed charges,,,70,,541.1,percent of total billed charges,,,,,,,,172.72,,,,100% of Medicare,,172.72,,,,100% of Medicare,,172.72,,,,100% of Medicare,,172.72,,,,100% of Medicare,,172.72,,,,100% of Medicare,,172.72,,,,100% of Medicare,,172.72,,,,100% of Medicare,,172.72,,,,100% of Medicare,,172.72,,,,100% of Medicare,,172.72,,,,100% of Medicare,,172.72,,,,100% of Medicare,,172.72,,,,100% of Medicare,,,172.72,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,172.72,695.7,
"Addition, Knee Joint, Ratchet",L2430,HCPCS,,,,outpatient,,,750,450,,45.5,,341.25,percent of total billed charges,,,45.3,,339.75,percent of total billed charges,,,39,,292.5,percent of total billed charges,,,,,,,,,80,,600,percent of total billed charges,,,61.4,,460.5,percent of total billed charges,,,57.4,,430.5,percent of total billed charges,,,81,,607.5,percent of total billed charges,,,39,,292.5,percent of total billed charges,,,57.6,,432,percent of total billed charges,,,85,,637.5,percent of total billed charges,,,85,,637.5,percent of total billed charges,,,49,,367.5,percent of total billed charges,,,90,,675,percent of total billed charges,,,65,,487.5,percent of total billed charges,,,80,,600,percent of total billed charges,,,55,,412.5,percent of total billed charges,,,55,,412.5,percent of total billed charges,,,65,,487.5,percent of total billed charges,,,78,,585,percent of total billed charges,,,70,,525,percent of total billed charges,,,,,,,,172.72,,,,100% of Medicare,,172.72,,,,100% of Medicare,,172.72,,,,100% of Medicare,,172.72,,,,100% of Medicare,,172.72,,,,100% of Medicare,,172.72,,,,100% of Medicare,,172.72,,,,100% of Medicare,,172.72,,,,100% of Medicare,,172.72,,,,100% of Medicare,,172.72,,,,100% of Medicare,,172.72,,,,100% of Medicare,,172.72,,,,100% of Medicare,,,172.72,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,172.72,675,
"Addition, Knee Joint, Lift Loop for Drop Lock Ring",L2492,HCPCS,,,,outpatient,,,612,367.2,,45.5,,278.46,percent of total billed charges,,,45.3,,277.24,percent of total billed charges,,,39,,238.68,percent of total billed charges,,,,,,,,,80,,489.6,percent of total billed charges,,,61.4,,375.77,percent of total billed charges,,,57.4,,351.29,percent of total billed charges,,,81,,495.72,percent of total billed charges,,,39,,238.68,percent of total billed charges,,,57.6,,352.51,percent of total billed charges,,,85,,520.2,percent of total billed charges,,,85,,520.2,percent of total billed charges,,,49,,299.88,percent of total billed charges,,,90,,550.8,percent of total billed charges,,,65,,397.8,percent of total billed charges,,,80,,489.6,percent of total billed charges,,,55,,336.6,percent of total billed charges,,,55,,336.6,percent of total billed charges,,,65,,397.8,percent of total billed charges,,,78,,477.36,percent of total billed charges,,,70,,428.4,percent of total billed charges,,,,,,,,141.32,,,,100% of Medicare,,141.32,,,,100% of Medicare,,141.32,,,,100% of Medicare,,141.32,,,,100% of Medicare,,141.32,,,,100% of Medicare,,141.32,,,,100% of Medicare,,141.32,,,,100% of Medicare,,141.32,,,,100% of Medicare,,141.32,,,,100% of Medicare,,141.32,,,,100% of Medicare,,141.32,,,,100% of Medicare,,141.32,,,,100% of Medicare,,,141.32,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,141.32,550.8,
"Lower Extremity Addition, Thigh/Gluteal/Ischial Weight Bearing Ring",L2500,HCPCS,,,,outpatient,,,869,521.4,,45.5,,395.4,percent of total billed charges,,,45.3,,393.66,percent of total billed charges,,,39,,338.91,percent of total billed charges,,,,,,,,,80,,695.2,percent of total billed charges,,,61.4,,533.57,percent of total billed charges,,,57.4,,498.81,percent of total billed charges,,,81,,703.89,percent of total billed charges,,,39,,338.91,percent of total billed charges,,,57.6,,500.54,percent of total billed charges,,,85,,738.65,percent of total billed charges,,,85,,738.65,percent of total billed charges,,,49,,425.81,percent of total billed charges,,,90,,782.1,percent of total billed charges,,,65,,564.85,percent of total billed charges,,,80,,695.2,percent of total billed charges,,,55,,477.95,percent of total billed charges,,,55,,477.95,percent of total billed charges,,,65,,564.85,percent of total billed charges,,,78,,677.82,percent of total billed charges,,,70,,608.3,percent of total billed charges,,,,,,,,377.04,,,,100% of Medicare,,377.04,,,,100% of Medicare,,377.04,,,,100% of Medicare,,377.04,,,,100% of Medicare,,377.04,,,,100% of Medicare,,377.04,,,,100% of Medicare,,377.04,,,,100% of Medicare,,377.04,,,,100% of Medicare,,377.04,,,,100% of Medicare,,377.04,,,,100% of Medicare,,377.04,,,,100% of Medicare,,377.04,,,,100% of Medicare,,,377.04,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,338.91,782.1,
"Lower Extremity Addition, Thigh/Weight Bearing Quadrilateral Brim",L2510,HCPCS,,,,outpatient,,,2977,1786.2,,45.5,,1354.54,percent of total billed charges,,,45.3,,1348.58,percent of total billed charges,,,39,,1161.03,percent of total billed charges,,,,,,,,,80,,2381.6,percent of total billed charges,,,61.4,,1827.88,percent of total billed charges,,,57.4,,1708.8,percent of total billed charges,,,81,,2411.37,percent of total billed charges,,,39,,1161.03,percent of total billed charges,,,57.6,,1714.75,percent of total billed charges,,,85,,2530.45,percent of total billed charges,,,85,,2530.45,percent of total billed charges,,,49,,1458.73,percent of total billed charges,,,90,,2679.3,percent of total billed charges,,,65,,1935.05,percent of total billed charges,,,80,,2381.6,percent of total billed charges,,,55,,1637.35,percent of total billed charges,,,55,,1637.35,percent of total billed charges,,,65,,1935.05,percent of total billed charges,,,78,,2322.06,percent of total billed charges,,,70,,2083.9,percent of total billed charges,,,,,,,,971.75,,,,100% of Medicare,,971.75,,,,100% of Medicare,,971.75,,,,100% of Medicare,,971.75,,,,100% of Medicare,,971.75,,,,100% of Medicare,,971.75,,,,100% of Medicare,,971.75,,,,100% of Medicare,,971.75,,,,100% of Medicare,,971.75,,,,100% of Medicare,,971.75,,,,100% of Medicare,,971.75,,,,100% of Medicare,,971.75,,,,100% of Medicare,,,971.75,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,971.75,2679.3,
"Lower Extremity Addition, Thigh Weight Bearing, Quadrilateral Brim, Custom Fit",L2520,HCPCS,,,,outpatient,,,1486,891.6,,45.5,,676.13,percent of total billed charges,,,45.3,,673.16,percent of total billed charges,,,39,,579.54,percent of total billed charges,,,,,,,,,80,,1188.8,percent of total billed charges,,,61.4,,912.4,percent of total billed charges,,,57.4,,852.96,percent of total billed charges,,,81,,1203.66,percent of total billed charges,,,39,,579.54,percent of total billed charges,,,57.6,,855.94,percent of total billed charges,,,85,,1263.1,percent of total billed charges,,,85,,1263.1,percent of total billed charges,,,49,,728.14,percent of total billed charges,,,90,,1337.4,percent of total billed charges,,,65,,965.9,percent of total billed charges,,,80,,1188.8,percent of total billed charges,,,55,,817.3,percent of total billed charges,,,55,,817.3,percent of total billed charges,,,65,,965.9,percent of total billed charges,,,78,,1159.08,percent of total billed charges,,,70,,1040.2,percent of total billed charges,,,,,,,,647.63,,,,100% of Medicare,,647.63,,,,100% of Medicare,,647.63,,,,100% of Medicare,,647.63,,,,100% of Medicare,,647.63,,,,100% of Medicare,,647.63,,,,100% of Medicare,,647.63,,,,100% of Medicare,,647.63,,,,100% of Medicare,,647.63,,,,100% of Medicare,,647.63,,,,100% of Medicare,,647.63,,,,100% of Medicare,,647.63,,,,100% of Medicare,,,647.63,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,579.54,1337.4,
"Lower Extremity Addition, Thigh/Weight Bearing Ischial Containment Brim, Molded to PT",L2525,HCPCS,,,,outpatient,,,2743,1645.8,,45.5,,1248.07,percent of total billed charges,,,45.3,,1242.58,percent of total billed charges,,,39,,1069.77,percent of total billed charges,,,,,,,,,80,,2194.4,percent of total billed charges,,,61.4,,1684.2,percent of total billed charges,,,57.4,,1574.48,percent of total billed charges,,,81,,2221.83,percent of total billed charges,,,39,,1069.77,percent of total billed charges,,,57.6,,1579.97,percent of total billed charges,,,85,,2331.55,percent of total billed charges,,,85,,2331.55,percent of total billed charges,,,49,,1344.07,percent of total billed charges,,,90,,2468.7,percent of total billed charges,,,65,,1782.95,percent of total billed charges,,,80,,2194.4,percent of total billed charges,,,55,,1508.65,percent of total billed charges,,,55,,1508.65,percent of total billed charges,,,65,,1782.95,percent of total billed charges,,,78,,2139.54,percent of total billed charges,,,70,,1920.1,percent of total billed charges,,,,,,,,1373.3,,,,100% of Medicare,,1373.3,,,,100% of Medicare,,1373.3,,,,100% of Medicare,,1373.3,,,,100% of Medicare,,1373.3,,,,100% of Medicare,,1373.3,,,,100% of Medicare,,1373.3,,,,100% of Medicare,,1373.3,,,,100% of Medicare,,1373.3,,,,100% of Medicare,,1373.3,,,,100% of Medicare,,1373.3,,,,100% of Medicare,,1373.3,,,,100% of Medicare,,,1373.3,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1069.77,2468.7,
"Lower Extremity Addition, Thigh Weight Bearing Ischial Containment, Custom Fit",L2526,HCPCS,,,,outpatient,,,1771,1062.6,,45.5,,805.81,percent of total billed charges,,,45.3,,802.26,percent of total billed charges,,,39,,690.69,percent of total billed charges,,,,,,,,,80,,1416.8,percent of total billed charges,,,61.4,,1087.39,percent of total billed charges,,,57.4,,1016.55,percent of total billed charges,,,81,,1434.51,percent of total billed charges,,,39,,690.69,percent of total billed charges,,,57.6,,1020.1,percent of total billed charges,,,85,,1505.35,percent of total billed charges,,,85,,1505.35,percent of total billed charges,,,49,,867.79,percent of total billed charges,,,90,,1593.9,percent of total billed charges,,,65,,1151.15,percent of total billed charges,,,80,,1416.8,percent of total billed charges,,,55,,974.05,percent of total billed charges,,,55,,974.05,percent of total billed charges,,,65,,1151.15,percent of total billed charges,,,78,,1381.38,percent of total billed charges,,,70,,1239.7,percent of total billed charges,,,,,,,,771.65,,,,100% of Medicare,,771.65,,,,100% of Medicare,,771.65,,,,100% of Medicare,,771.65,,,,100% of Medicare,,771.65,,,,100% of Medicare,,771.65,,,,100% of Medicare,,771.65,,,,100% of Medicare,,771.65,,,,100% of Medicare,,771.65,,,,100% of Medicare,,771.65,,,,100% of Medicare,,771.65,,,,100% of Medicare,,771.65,,,,100% of Medicare,,,771.65,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,690.69,1593.9,
"Lower Extremity Addition, Thigh Weight Bearing Lacer, Non-Molded",L2530,HCPCS,,,,outpatient,,,663,397.8,,45.5,,301.67,percent of total billed charges,,,45.3,,300.34,percent of total billed charges,,,39,,258.57,percent of total billed charges,,,,,,,,,80,,530.4,percent of total billed charges,,,61.4,,407.08,percent of total billed charges,,,57.4,,380.56,percent of total billed charges,,,81,,537.03,percent of total billed charges,,,39,,258.57,percent of total billed charges,,,57.6,,381.89,percent of total billed charges,,,85,,563.55,percent of total billed charges,,,85,,563.55,percent of total billed charges,,,49,,324.87,percent of total billed charges,,,90,,596.7,percent of total billed charges,,,65,,430.95,percent of total billed charges,,,80,,530.4,percent of total billed charges,,,55,,364.65,percent of total billed charges,,,55,,364.65,percent of total billed charges,,,65,,430.95,percent of total billed charges,,,78,,517.14,percent of total billed charges,,,70,,464.1,percent of total billed charges,,,,,,,,288.95,,,,100% of Medicare,,288.95,,,,100% of Medicare,,288.95,,,,100% of Medicare,,288.95,,,,100% of Medicare,,288.95,,,,100% of Medicare,,288.95,,,,100% of Medicare,,288.95,,,,100% of Medicare,,288.95,,,,100% of Medicare,,288.95,,,,100% of Medicare,,288.95,,,,100% of Medicare,,288.95,,,,100% of Medicare,,288.95,,,,100% of Medicare,,,288.95,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,258.57,596.7,
Lower Extremity Addition Thigh/Weight Bearing Lacer,L2540,HCPCS,,,,outpatient,,,2371,1422.6,,45.5,,1078.81,percent of total billed charges,,,45.3,,1074.06,percent of total billed charges,,,39,,924.69,percent of total billed charges,,,,,,,,,80,,1896.8,percent of total billed charges,,,61.4,,1455.79,percent of total billed charges,,,57.4,,1360.95,percent of total billed charges,,,81,,1920.51,percent of total billed charges,,,39,,924.69,percent of total billed charges,,,57.6,,1365.7,percent of total billed charges,,,85,,2015.35,percent of total billed charges,,,85,,2015.35,percent of total billed charges,,,49,,1161.79,percent of total billed charges,,,90,,2133.9,percent of total billed charges,,,65,,1541.15,percent of total billed charges,,,80,,1896.8,percent of total billed charges,,,55,,1304.05,percent of total billed charges,,,55,,1304.05,percent of total billed charges,,,65,,1541.15,percent of total billed charges,,,78,,1849.38,percent of total billed charges,,,70,,1659.7,percent of total billed charges,,,,,,,,546.76,,,,100% of Medicare,,546.76,,,,100% of Medicare,,546.76,,,,100% of Medicare,,546.76,,,,100% of Medicare,,546.76,,,,100% of Medicare,,546.76,,,,100% of Medicare,,546.76,,,,100% of Medicare,,546.76,,,,100% of Medicare,,546.76,,,,100% of Medicare,,546.76,,,,100% of Medicare,,546.76,,,,100% of Medicare,,546.76,,,,100% of Medicare,,,546.76,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,546.76,2133.9,
"Lower Extremity Addition, Thigh Weight Bearing, High Roll Cuff",L2550,HCPCS,,,,outpatient,,,945,567,,45.5,,429.98,percent of total billed charges,,,45.3,,428.09,percent of total billed charges,,,39,,368.55,percent of total billed charges,,,,,,,,,80,,756,percent of total billed charges,,,61.4,,580.23,percent of total billed charges,,,57.4,,542.43,percent of total billed charges,,,81,,765.45,percent of total billed charges,,,39,,368.55,percent of total billed charges,,,57.6,,544.32,percent of total billed charges,,,85,,803.25,percent of total billed charges,,,85,,803.25,percent of total billed charges,,,49,,463.05,percent of total billed charges,,,90,,850.5,percent of total billed charges,,,65,,614.25,percent of total billed charges,,,80,,756,percent of total billed charges,,,55,,519.75,percent of total billed charges,,,55,,519.75,percent of total billed charges,,,65,,614.25,percent of total billed charges,,,78,,737.1,percent of total billed charges,,,70,,661.5,percent of total billed charges,,,,,,,,409.96,,,,100% of Medicare,,409.96,,,,100% of Medicare,,409.96,,,,100% of Medicare,,409.96,,,,100% of Medicare,,409.96,,,,100% of Medicare,,409.96,,,,100% of Medicare,,409.96,,,,100% of Medicare,,409.96,,,,100% of Medicare,,409.96,,,,100% of Medicare,,409.96,,,,100% of Medicare,,409.96,,,,100% of Medicare,,409.96,,,,100% of Medicare,,,409.96,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,368.55,850.5,
"Lower Extremity Addition, Pelvic Control, Hip Jt, Clevis Type Jt",L2570,HCPCS,,,,outpatient,,,1234,740.4,,45.5,,561.47,percent of total billed charges,,,45.3,,559,percent of total billed charges,,,39,,481.26,percent of total billed charges,,,,,,,,,80,,987.2,percent of total billed charges,,,61.4,,757.68,percent of total billed charges,,,57.4,,708.32,percent of total billed charges,,,81,,999.54,percent of total billed charges,,,39,,481.26,percent of total billed charges,,,57.6,,710.78,percent of total billed charges,,,85,,1048.9,percent of total billed charges,,,85,,1048.9,percent of total billed charges,,,49,,604.66,percent of total billed charges,,,90,,1110.6,percent of total billed charges,,,65,,802.1,percent of total billed charges,,,80,,987.2,percent of total billed charges,,,55,,678.7,percent of total billed charges,,,55,,678.7,percent of total billed charges,,,65,,802.1,percent of total billed charges,,,78,,962.52,percent of total billed charges,,,70,,863.8,percent of total billed charges,,,,,,,,536.6,,,,100% of Medicare,,536.6,,,,100% of Medicare,,536.6,,,,100% of Medicare,,536.6,,,,100% of Medicare,,536.6,,,,100% of Medicare,,536.6,,,,100% of Medicare,,536.6,,,,100% of Medicare,,536.6,,,,100% of Medicare,,536.6,,,,100% of Medicare,,536.6,,,,100% of Medicare,,536.6,,,,100% of Medicare,,536.6,,,,100% of Medicare,,,536.6,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,481.26,1110.6,
"Lower Extremity Addition, Pelvic Control Sling",L2580,HCPCS,,,,outpatient,,,2336,1401.6,,45.5,,1062.88,percent of total billed charges,,,45.3,,1058.21,percent of total billed charges,,,39,,911.04,percent of total billed charges,,,,,,,,,80,,1868.8,percent of total billed charges,,,61.4,,1434.3,percent of total billed charges,,,57.4,,1340.86,percent of total billed charges,,,81,,1892.16,percent of total billed charges,,,39,,911.04,percent of total billed charges,,,57.6,,1345.54,percent of total billed charges,,,85,,1985.6,percent of total billed charges,,,85,,1985.6,percent of total billed charges,,,49,,1144.64,percent of total billed charges,,,90,,2102.4,percent of total billed charges,,,65,,1518.4,percent of total billed charges,,,80,,1868.8,percent of total billed charges,,,55,,1284.8,percent of total billed charges,,,55,,1284.8,percent of total billed charges,,,65,,1518.4,percent of total billed charges,,,78,,1822.08,percent of total billed charges,,,70,,1635.2,percent of total billed charges,,,,,,,,522.86,,,,100% of Medicare,,522.86,,,,100% of Medicare,,522.86,,,,100% of Medicare,,522.86,,,,100% of Medicare,,522.86,,,,100% of Medicare,,522.86,,,,100% of Medicare,,522.86,,,,100% of Medicare,,522.86,,,,100% of Medicare,,522.86,,,,100% of Medicare,,522.86,,,,100% of Medicare,,522.86,,,,100% of Medicare,,522.86,,,,100% of Medicare,,,522.86,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,522.86,2102.4,
"Lower Extremity Addition, Pelvic Control, Hip Jt, Clevis Type Free",L2600,HCPCS,,,,outpatient,,,573,343.8,,45.5,,260.72,percent of total billed charges,,,45.3,,259.57,percent of total billed charges,,,39,,223.47,percent of total billed charges,,,,,,,,,80,,458.4,percent of total billed charges,,,61.4,,351.82,percent of total billed charges,,,57.4,,328.9,percent of total billed charges,,,81,,464.13,percent of total billed charges,,,39,,223.47,percent of total billed charges,,,57.6,,330.05,percent of total billed charges,,,85,,487.05,percent of total billed charges,,,85,,487.05,percent of total billed charges,,,49,,280.77,percent of total billed charges,,,90,,515.7,percent of total billed charges,,,65,,372.45,percent of total billed charges,,,80,,458.4,percent of total billed charges,,,55,,315.15,percent of total billed charges,,,55,,315.15,percent of total billed charges,,,65,,372.45,percent of total billed charges,,,78,,446.94,percent of total billed charges,,,70,,401.1,percent of total billed charges,,,,,,,,256.98,,,,100% of Medicare,,256.98,,,,100% of Medicare,,256.98,,,,100% of Medicare,,256.98,,,,100% of Medicare,,256.98,,,,100% of Medicare,,256.98,,,,100% of Medicare,,256.98,,,,100% of Medicare,,256.98,,,,100% of Medicare,,256.98,,,,100% of Medicare,,256.98,,,,100% of Medicare,,256.98,,,,100% of Medicare,,256.98,,,,100% of Medicare,,,256.98,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,223.47,515.7,
"Lower Extremity Addition, Pelvic Control, Hip Jt, Clevis/Thrust Lock",L2610,HCPCS,,,,outpatient,,,1233,739.8,,45.5,,561.02,percent of total billed charges,,,45.3,,558.55,percent of total billed charges,,,39,,480.87,percent of total billed charges,,,,,,,,,80,,986.4,percent of total billed charges,,,61.4,,757.06,percent of total billed charges,,,57.4,,707.74,percent of total billed charges,,,81,,998.73,percent of total billed charges,,,39,,480.87,percent of total billed charges,,,57.6,,710.21,percent of total billed charges,,,85,,1048.05,percent of total billed charges,,,85,,1048.05,percent of total billed charges,,,49,,604.17,percent of total billed charges,,,90,,1109.7,percent of total billed charges,,,65,,801.45,percent of total billed charges,,,80,,986.4,percent of total billed charges,,,55,,678.15,percent of total billed charges,,,55,,678.15,percent of total billed charges,,,65,,801.45,percent of total billed charges,,,78,,961.74,percent of total billed charges,,,70,,863.1,percent of total billed charges,,,,,,,,283.97,,,,100% of Medicare,,283.97,,,,100% of Medicare,,283.97,,,,100% of Medicare,,283.97,,,,100% of Medicare,,283.97,,,,100% of Medicare,,283.97,,,,100% of Medicare,,283.97,,,,100% of Medicare,,283.97,,,,100% of Medicare,,283.97,,,,100% of Medicare,,283.97,,,,100% of Medicare,,283.97,,,,100% of Medicare,,283.97,,,,100% of Medicare,,,283.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,283.97,1109.7,
"Lower Extremity Addition, Pelvic Control Hip Joint, Heavy Duty",L2620,HCPCS,,,,outpatient,,,1346,807.6,,45.5,,612.43,percent of total billed charges,,,45.3,,609.74,percent of total billed charges,,,39,,524.94,percent of total billed charges,,,,,,,,,80,,1076.8,percent of total billed charges,,,61.4,,826.44,percent of total billed charges,,,57.4,,772.6,percent of total billed charges,,,81,,1090.26,percent of total billed charges,,,39,,524.94,percent of total billed charges,,,57.6,,775.3,percent of total billed charges,,,85,,1144.1,percent of total billed charges,,,85,,1144.1,percent of total billed charges,,,49,,659.54,percent of total billed charges,,,90,,1211.4,percent of total billed charges,,,65,,874.9,percent of total billed charges,,,80,,1076.8,percent of total billed charges,,,55,,740.3,percent of total billed charges,,,55,,740.3,percent of total billed charges,,,65,,874.9,percent of total billed charges,,,78,,1049.88,percent of total billed charges,,,70,,942.2,percent of total billed charges,,,,,,,,301.22,,,,100% of Medicare,,301.22,,,,100% of Medicare,,301.22,,,,100% of Medicare,,301.22,,,,100% of Medicare,,301.22,,,,100% of Medicare,,301.22,,,,100% of Medicare,,301.22,,,,100% of Medicare,,301.22,,,,100% of Medicare,,301.22,,,,100% of Medicare,,301.22,,,,100% of Medicare,,301.22,,,,100% of Medicare,,301.22,,,,100% of Medicare,,,301.22,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,301.22,1211.4,
"Lower Extremity Addition, Pelvic Control, Hip Jt, Adjustable Flexion",L2622,HCPCS,,,,outpatient,,,1710,1026,,45.5,,778.05,percent of total billed charges,,,45.3,,774.63,percent of total billed charges,,,39,,666.9,percent of total billed charges,,,,,,,,,80,,1368,percent of total billed charges,,,61.4,,1049.94,percent of total billed charges,,,57.4,,981.54,percent of total billed charges,,,81,,1385.1,percent of total billed charges,,,39,,666.9,percent of total billed charges,,,57.6,,984.96,percent of total billed charges,,,85,,1453.5,percent of total billed charges,,,85,,1453.5,percent of total billed charges,,,49,,837.9,percent of total billed charges,,,90,,1539,percent of total billed charges,,,65,,1111.5,percent of total billed charges,,,80,,1368,percent of total billed charges,,,55,,940.5,percent of total billed charges,,,55,,940.5,percent of total billed charges,,,65,,1111.5,percent of total billed charges,,,78,,1333.8,percent of total billed charges,,,70,,1197,percent of total billed charges,,,,,,,,383.4,,,,100% of Medicare,,383.4,,,,100% of Medicare,,383.4,,,,100% of Medicare,,383.4,,,,100% of Medicare,,383.4,,,,100% of Medicare,,383.4,,,,100% of Medicare,,383.4,,,,100% of Medicare,,383.4,,,,100% of Medicare,,383.4,,,,100% of Medicare,,383.4,,,,100% of Medicare,,383.4,,,,100% of Medicare,,383.4,,,,100% of Medicare,,,383.4,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,383.4,1539,
"Lower Extremity Addition, Pelvic Control, Hip Jt, Adj/Flex/Ext/Abd",L2624,HCPCS,,,,outpatient,,,1079,647.4,,45.5,,490.95,percent of total billed charges,,,45.3,,488.79,percent of total billed charges,,,39,,420.81,percent of total billed charges,,,,,,,,,80,,863.2,percent of total billed charges,,,61.4,,662.51,percent of total billed charges,,,57.4,,619.35,percent of total billed charges,,,81,,873.99,percent of total billed charges,,,39,,420.81,percent of total billed charges,,,57.6,,621.5,percent of total billed charges,,,85,,917.15,percent of total billed charges,,,85,,917.15,percent of total billed charges,,,49,,528.71,percent of total billed charges,,,90,,971.1,percent of total billed charges,,,65,,701.35,percent of total billed charges,,,80,,863.2,percent of total billed charges,,,55,,593.45,percent of total billed charges,,,55,,593.45,percent of total billed charges,,,65,,701.35,percent of total billed charges,,,78,,841.62,percent of total billed charges,,,70,,755.3,percent of total billed charges,,,,,,,,470.12,,,,100% of Medicare,,470.12,,,,100% of Medicare,,470.12,,,,100% of Medicare,,470.12,,,,100% of Medicare,,470.12,,,,100% of Medicare,,470.12,,,,100% of Medicare,,470.12,,,,100% of Medicare,,470.12,,,,100% of Medicare,,470.12,,,,100% of Medicare,,470.12,,,,100% of Medicare,,470.12,,,,100% of Medicare,,470.12,,,,100% of Medicare,,,470.12,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,420.81,971.1,
"Lower Extremity Addition, Pelvic Control, Band/Belt, Unilateral",L2630,HCPCS,,,,outpatient,,,643,385.8,,45.5,,292.57,percent of total billed charges,,,45.3,,291.28,percent of total billed charges,,,39,,250.77,percent of total billed charges,,,,,,,,,80,,514.4,percent of total billed charges,,,61.4,,394.8,percent of total billed charges,,,57.4,,369.08,percent of total billed charges,,,81,,520.83,percent of total billed charges,,,39,,250.77,percent of total billed charges,,,57.6,,370.37,percent of total billed charges,,,85,,546.55,percent of total billed charges,,,85,,546.55,percent of total billed charges,,,49,,315.07,percent of total billed charges,,,90,,578.7,percent of total billed charges,,,65,,417.95,percent of total billed charges,,,80,,514.4,percent of total billed charges,,,55,,353.65,percent of total billed charges,,,55,,353.65,percent of total billed charges,,,65,,417.95,percent of total billed charges,,,78,,501.54,percent of total billed charges,,,70,,450.1,percent of total billed charges,,,,,,,,278.97,,,,100% of Medicare,,278.97,,,,100% of Medicare,,278.97,,,,100% of Medicare,,278.97,,,,100% of Medicare,,278.97,,,,100% of Medicare,,278.97,,,,100% of Medicare,,278.97,,,,100% of Medicare,,278.97,,,,100% of Medicare,,278.97,,,,100% of Medicare,,278.97,,,,100% of Medicare,,278.97,,,,100% of Medicare,,278.97,,,,100% of Medicare,,,278.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,250.77,578.7,
"Lower Extremity Addition, Pelvic Control Band/Belt",L2640,HCPCS,,,,outpatient,,,1691,1014.6,,45.5,,769.41,percent of total billed charges,,,45.3,,766.02,percent of total billed charges,,,39,,659.49,percent of total billed charges,,,,,,,,,80,,1352.8,percent of total billed charges,,,61.4,,1038.27,percent of total billed charges,,,57.4,,970.63,percent of total billed charges,,,81,,1369.71,percent of total billed charges,,,39,,659.49,percent of total billed charges,,,57.6,,974.02,percent of total billed charges,,,85,,1437.35,percent of total billed charges,,,85,,1437.35,percent of total billed charges,,,49,,828.59,percent of total billed charges,,,90,,1521.9,percent of total billed charges,,,65,,1099.15,percent of total billed charges,,,80,,1352.8,percent of total billed charges,,,55,,930.05,percent of total billed charges,,,55,,930.05,percent of total billed charges,,,65,,1099.15,percent of total billed charges,,,78,,1318.98,percent of total billed charges,,,70,,1183.7,percent of total billed charges,,,,,,,,378.59,,,,100% of Medicare,,378.59,,,,100% of Medicare,,378.59,,,,100% of Medicare,,378.59,,,,100% of Medicare,,378.59,,,,100% of Medicare,,378.59,,,,100% of Medicare,,378.59,,,,100% of Medicare,,378.59,,,,100% of Medicare,,378.59,,,,100% of Medicare,,378.59,,,,100% of Medicare,,378.59,,,,100% of Medicare,,378.59,,,,100% of Medicare,,,378.59,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,378.59,1521.9,
"Lower Extremity Addition, Pelvic/Thoracic Control Gluteal Pad",L2650,HCPCS,,,,outpatient,,,745,447,,45.5,,338.98,percent of total billed charges,,,45.3,,337.49,percent of total billed charges,,,39,,290.55,percent of total billed charges,,,,,,,,,80,,596,percent of total billed charges,,,61.4,,457.43,percent of total billed charges,,,57.4,,427.63,percent of total billed charges,,,81,,603.45,percent of total billed charges,,,39,,290.55,percent of total billed charges,,,57.6,,429.12,percent of total billed charges,,,85,,633.25,percent of total billed charges,,,85,,633.25,percent of total billed charges,,,49,,365.05,percent of total billed charges,,,90,,670.5,percent of total billed charges,,,65,,484.25,percent of total billed charges,,,80,,596,percent of total billed charges,,,55,,409.75,percent of total billed charges,,,55,,409.75,percent of total billed charges,,,65,,484.25,percent of total billed charges,,,78,,581.1,percent of total billed charges,,,70,,521.5,percent of total billed charges,,,,,,,,166.73,,,,100% of Medicare,,166.73,,,,100% of Medicare,,166.73,,,,100% of Medicare,,166.73,,,,100% of Medicare,,166.73,,,,100% of Medicare,,166.73,,,,100% of Medicare,,166.73,,,,100% of Medicare,,166.73,,,,100% of Medicare,,166.73,,,,100% of Medicare,,166.73,,,,100% of Medicare,,166.73,,,,100% of Medicare,,166.73,,,,100% of Medicare,,,166.73,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,166.73,670.5,
"Lower Extremity Addition, Thoracic Control Band",L2660,HCPCS,,,,outpatient,,,960,576,,45.5,,436.8,percent of total billed charges,,,45.3,,434.88,percent of total billed charges,,,39,,374.4,percent of total billed charges,,,,,,,,,80,,768,percent of total billed charges,,,61.4,,589.44,percent of total billed charges,,,57.4,,551.04,percent of total billed charges,,,81,,777.6,percent of total billed charges,,,39,,374.4,percent of total billed charges,,,57.6,,552.96,percent of total billed charges,,,85,,816,percent of total billed charges,,,85,,816,percent of total billed charges,,,49,,470.4,percent of total billed charges,,,90,,864,percent of total billed charges,,,65,,624,percent of total billed charges,,,80,,768,percent of total billed charges,,,55,,528,percent of total billed charges,,,55,,528,percent of total billed charges,,,65,,624,percent of total billed charges,,,78,,748.8,percent of total billed charges,,,70,,672,percent of total billed charges,,,,,,,,215.88,,,,100% of Medicare,,215.88,,,,100% of Medicare,,215.88,,,,100% of Medicare,,215.88,,,,100% of Medicare,,215.88,,,,100% of Medicare,,215.88,,,,100% of Medicare,,215.88,,,,100% of Medicare,,215.88,,,,100% of Medicare,,215.88,,,,100% of Medicare,,215.88,,,,100% of Medicare,,215.88,,,,100% of Medicare,,215.88,,,,100% of Medicare,,,215.88,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,215.88,864,
"Lower Extremity Addition, Thoracic Control, Paraspinal Uprights",L2670,HCPCS,,,,outpatient,,,444,266.4,,45.5,,202.02,percent of total billed charges,,,45.3,,201.13,percent of total billed charges,,,39,,173.16,percent of total billed charges,,,,,,,,,80,,355.2,percent of total billed charges,,,61.4,,272.62,percent of total billed charges,,,57.4,,254.86,percent of total billed charges,,,81,,359.64,percent of total billed charges,,,39,,173.16,percent of total billed charges,,,57.6,,255.74,percent of total billed charges,,,85,,377.4,percent of total billed charges,,,85,,377.4,percent of total billed charges,,,49,,217.56,percent of total billed charges,,,90,,399.6,percent of total billed charges,,,65,,288.6,percent of total billed charges,,,80,,355.2,percent of total billed charges,,,55,,244.2,percent of total billed charges,,,55,,244.2,percent of total billed charges,,,65,,288.6,percent of total billed charges,,,78,,346.32,percent of total billed charges,,,70,,310.8,percent of total billed charges,,,,,,,,192.17,,,,100% of Medicare,,192.17,,,,100% of Medicare,,192.17,,,,100% of Medicare,,192.17,,,,100% of Medicare,,192.17,,,,100% of Medicare,,192.17,,,,100% of Medicare,,192.17,,,,100% of Medicare,,192.17,,,,100% of Medicare,,192.17,,,,100% of Medicare,,192.17,,,,100% of Medicare,,192.17,,,,100% of Medicare,,192.17,,,,100% of Medicare,,,192.17,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,173.16,399.6,
"Lower Extremity Addition, Thoracic Control Lateral Supports Uprights",L2680,HCPCS,,,,outpatient,,,765,459,,45.5,,348.08,percent of total billed charges,,,45.3,,346.55,percent of total billed charges,,,39,,298.35,percent of total billed charges,,,,,,,,,80,,612,percent of total billed charges,,,61.4,,469.71,percent of total billed charges,,,57.4,,439.11,percent of total billed charges,,,81,,619.65,percent of total billed charges,,,39,,298.35,percent of total billed charges,,,57.6,,440.64,percent of total billed charges,,,85,,650.25,percent of total billed charges,,,85,,650.25,percent of total billed charges,,,49,,374.85,percent of total billed charges,,,90,,688.5,percent of total billed charges,,,65,,497.25,percent of total billed charges,,,80,,612,percent of total billed charges,,,55,,420.75,percent of total billed charges,,,55,,420.75,percent of total billed charges,,,65,,497.25,percent of total billed charges,,,78,,596.7,percent of total billed charges,,,70,,535.5,percent of total billed charges,,,,,,,,176.29,,,,100% of Medicare,,176.29,,,,100% of Medicare,,176.29,,,,100% of Medicare,,176.29,,,,100% of Medicare,,176.29,,,,100% of Medicare,,176.29,,,,100% of Medicare,,176.29,,,,100% of Medicare,,176.29,,,,100% of Medicare,,176.29,,,,100% of Medicare,,176.29,,,,100% of Medicare,,176.29,,,,100% of Medicare,,176.29,,,,100% of Medicare,,,176.29,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,176.29,688.5,
"Lower Extremity Orthosis Addition, Plating Chrome/Nickel",L2750,HCPCS,,,,outpatient,,,217,130.2,,45.5,,98.74,percent of total billed charges,,,45.3,,98.3,percent of total billed charges,,,39,,84.63,percent of total billed charges,,,,,,,,,80,,173.6,percent of total billed charges,,,61.4,,133.24,percent of total billed charges,,,57.4,,124.56,percent of total billed charges,,,81,,175.77,percent of total billed charges,,,39,,84.63,percent of total billed charges,,,57.6,,124.99,percent of total billed charges,,,85,,184.45,percent of total billed charges,,,85,,184.45,percent of total billed charges,,,49,,106.33,percent of total billed charges,,,90,,195.3,percent of total billed charges,,,65,,141.05,percent of total billed charges,,,80,,173.6,percent of total billed charges,,,55,,119.35,percent of total billed charges,,,55,,119.35,percent of total billed charges,,,65,,141.05,percent of total billed charges,,,78,,169.26,percent of total billed charges,,,70,,151.9,percent of total billed charges,,,,,,,,94.16,,,,100% of Medicare,,94.16,,,,100% of Medicare,,94.16,,,,100% of Medicare,,94.16,,,,100% of Medicare,,94.16,,,,100% of Medicare,,94.16,,,,100% of Medicare,,94.16,,,,100% of Medicare,,94.16,,,,100% of Medicare,,94.16,,,,100% of Medicare,,94.16,,,,100% of Medicare,,94.16,,,,100% of Medicare,,94.16,,,,100% of Medicare,,,94.16,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,84.63,195.3,
"Lower Extremity Orthosis Addition, Carbon Lamination",L2755,HCPCS,,,,outpatient,,,703,421.8,,45.5,,319.87,percent of total billed charges,,,45.3,,318.46,percent of total billed charges,,,39,,274.17,percent of total billed charges,,,,,,,,,80,,562.4,percent of total billed charges,,,61.4,,431.64,percent of total billed charges,,,57.4,,403.52,percent of total billed charges,,,81,,569.43,percent of total billed charges,,,39,,274.17,percent of total billed charges,,,57.6,,404.93,percent of total billed charges,,,85,,597.55,percent of total billed charges,,,85,,597.55,percent of total billed charges,,,49,,344.47,percent of total billed charges,,,90,,632.7,percent of total billed charges,,,65,,456.95,percent of total billed charges,,,80,,562.4,percent of total billed charges,,,55,,386.65,percent of total billed charges,,,55,,386.65,percent of total billed charges,,,65,,456.95,percent of total billed charges,,,78,,548.34,percent of total billed charges,,,70,,492.1,percent of total billed charges,,,,,,,,157.43,,,,100% of Medicare,,157.43,,,,100% of Medicare,,157.43,,,,100% of Medicare,,157.43,,,,100% of Medicare,,157.43,,,,100% of Medicare,,157.43,,,,100% of Medicare,,157.43,,,,100% of Medicare,,157.43,,,,100% of Medicare,,157.43,,,,100% of Medicare,,157.43,,,,100% of Medicare,,157.43,,,,100% of Medicare,,157.43,,,,100% of Medicare,,,157.43,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,157.43,632.7,
"Lower Extremity Orthosis Addition, Extension Per Bar",L2760,HCPCS,,,,outpatient,,,569,341.4,,45.5,,258.9,percent of total billed charges,,,45.3,,257.76,percent of total billed charges,,,39,,221.91,percent of total billed charges,,,,,,,,,80,,455.2,percent of total billed charges,,,61.4,,349.37,percent of total billed charges,,,57.4,,326.61,percent of total billed charges,,,81,,460.89,percent of total billed charges,,,39,,221.91,percent of total billed charges,,,57.6,,327.74,percent of total billed charges,,,85,,483.65,percent of total billed charges,,,85,,483.65,percent of total billed charges,,,49,,278.81,percent of total billed charges,,,90,,512.1,percent of total billed charges,,,65,,369.85,percent of total billed charges,,,80,,455.2,percent of total billed charges,,,55,,312.95,percent of total billed charges,,,55,,312.95,percent of total billed charges,,,65,,369.85,percent of total billed charges,,,78,,443.82,percent of total billed charges,,,70,,398.3,percent of total billed charges,,,,,,,,68.45,,,,100% of Medicare,,68.45,,,,100% of Medicare,,68.45,,,,100% of Medicare,,68.45,,,,100% of Medicare,,68.45,,,,100% of Medicare,,68.45,,,,100% of Medicare,,68.45,,,,100% of Medicare,,68.45,,,,100% of Medicare,,68.45,,,,100% of Medicare,,68.45,,,,100% of Medicare,,68.45,,,,100% of Medicare,,68.45,,,,100% of Medicare,,,68.45,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,68.45,512.1,
"Lower Extremity Orthosis Addition, Sidebar Disconnect",L2768,HCPCS,,,,outpatient,,,702,421.2,,45.5,,319.41,percent of total billed charges,,,45.3,,318.01,percent of total billed charges,,,39,,273.78,percent of total billed charges,,,,,,,,,80,,561.6,percent of total billed charges,,,61.4,,431.03,percent of total billed charges,,,57.4,,402.95,percent of total billed charges,,,81,,568.62,percent of total billed charges,,,39,,273.78,percent of total billed charges,,,57.6,,404.35,percent of total billed charges,,,85,,596.7,percent of total billed charges,,,85,,596.7,percent of total billed charges,,,49,,343.98,percent of total billed charges,,,90,,631.8,percent of total billed charges,,,65,,456.3,percent of total billed charges,,,80,,561.6,percent of total billed charges,,,55,,386.1,percent of total billed charges,,,55,,386.1,percent of total billed charges,,,65,,456.3,percent of total billed charges,,,78,,547.56,percent of total billed charges,,,70,,491.4,percent of total billed charges,,,,,,,,156.97,,,,100% of Medicare,,156.97,,,,100% of Medicare,,156.97,,,,100% of Medicare,,156.97,,,,100% of Medicare,,156.97,,,,100% of Medicare,,156.97,,,,100% of Medicare,,156.97,,,,100% of Medicare,,156.97,,,,100% of Medicare,,156.97,,,,100% of Medicare,,156.97,,,,100% of Medicare,,156.97,,,,100% of Medicare,,156.97,,,,100% of Medicare,,,156.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,156.97,631.8,
"Lower Extremity Addition, Non-Corrosive Finish Bar",L2780,HCPCS,,,,outpatient,,,342,205.2,,45.5,,155.61,percent of total billed charges,,,45.3,,154.93,percent of total billed charges,,,39,,133.38,percent of total billed charges,,,,,,,,,80,,273.6,percent of total billed charges,,,61.4,,209.99,percent of total billed charges,,,57.4,,196.31,percent of total billed charges,,,81,,277.02,percent of total billed charges,,,39,,133.38,percent of total billed charges,,,57.6,,196.99,percent of total billed charges,,,85,,290.7,percent of total billed charges,,,85,,290.7,percent of total billed charges,,,49,,167.58,percent of total billed charges,,,90,,307.8,percent of total billed charges,,,65,,222.3,percent of total billed charges,,,80,,273.6,percent of total billed charges,,,55,,188.1,percent of total billed charges,,,55,,188.1,percent of total billed charges,,,65,,222.3,percent of total billed charges,,,78,,266.76,percent of total billed charges,,,70,,239.4,percent of total billed charges,,,,,,,,76.25,,,,100% of Medicare,,76.25,,,,100% of Medicare,,76.25,,,,100% of Medicare,,76.25,,,,100% of Medicare,,76.25,,,,100% of Medicare,,76.25,,,,100% of Medicare,,76.25,,,,100% of Medicare,,76.25,,,,100% of Medicare,,76.25,,,,100% of Medicare,,76.25,,,,100% of Medicare,,76.25,,,,100% of Medicare,,76.25,,,,100% of Medicare,,,76.25,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,76.25,307.8,
"Lower Extremity Orthosis Addition, Drop Lock Retainer",L2785,HCPCS,,,,outpatient,,,156,93.6,,45.5,,70.98,percent of total billed charges,,,45.3,,70.67,percent of total billed charges,,,39,,60.84,percent of total billed charges,,,,,,,,,80,,124.8,percent of total billed charges,,,61.4,,95.78,percent of total billed charges,,,57.4,,89.54,percent of total billed charges,,,81,,126.36,percent of total billed charges,,,39,,60.84,percent of total billed charges,,,57.6,,89.86,percent of total billed charges,,,85,,132.6,percent of total billed charges,,,85,,132.6,percent of total billed charges,,,49,,76.44,percent of total billed charges,,,90,,140.4,percent of total billed charges,,,65,,101.4,percent of total billed charges,,,80,,124.8,percent of total billed charges,,,55,,85.8,percent of total billed charges,,,55,,85.8,percent of total billed charges,,,65,,101.4,percent of total billed charges,,,78,,121.68,percent of total billed charges,,,70,,109.2,percent of total billed charges,,,,,,,,35.7,,,,100% of Medicare,,35.7,,,,100% of Medicare,,35.7,,,,100% of Medicare,,35.7,,,,100% of Medicare,,35.7,,,,100% of Medicare,,35.7,,,,100% of Medicare,,35.7,,,,100% of Medicare,,35.7,,,,100% of Medicare,,35.7,,,,100% of Medicare,,35.7,,,,100% of Medicare,,35.7,,,,100% of Medicare,,35.7,,,,100% of Medicare,,,35.7,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,35.7,140.4,
"Lower Extremity Orthosis Addition, Full Knee Cap",L2795,HCPCS,,,,outpatient,,,431,258.6,,45.5,,196.11,percent of total billed charges,,,45.3,,195.24,percent of total billed charges,,,39,,168.09,percent of total billed charges,,,,,,,,,80,,344.8,percent of total billed charges,,,61.4,,264.63,percent of total billed charges,,,57.4,,247.39,percent of total billed charges,,,81,,349.11,percent of total billed charges,,,39,,168.09,percent of total billed charges,,,57.6,,248.26,percent of total billed charges,,,85,,366.35,percent of total billed charges,,,85,,366.35,percent of total billed charges,,,49,,211.19,percent of total billed charges,,,90,,387.9,percent of total billed charges,,,65,,280.15,percent of total billed charges,,,80,,344.8,percent of total billed charges,,,55,,237.05,percent of total billed charges,,,55,,237.05,percent of total billed charges,,,65,,280.15,percent of total billed charges,,,78,,336.18,percent of total billed charges,,,70,,301.7,percent of total billed charges,,,,,,,,98.82,,,,100% of Medicare,,98.82,,,,100% of Medicare,,98.82,,,,100% of Medicare,,98.82,,,,100% of Medicare,,98.82,,,,100% of Medicare,,98.82,,,,100% of Medicare,,98.82,,,,100% of Medicare,,98.82,,,,100% of Medicare,,98.82,,,,100% of Medicare,,98.82,,,,100% of Medicare,,98.82,,,,100% of Medicare,,98.82,,,,100% of Medicare,,,98.82,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,98.82,387.9,
"Lower Extremity Orthosis Addition, Knee Cap, Medial/Lateral Pull",L2800,HCPCS,,,,outpatient,,,544,326.4,,45.5,,247.52,percent of total billed charges,,,45.3,,246.43,percent of total billed charges,,,39,,212.16,percent of total billed charges,,,,,,,,,80,,435.2,percent of total billed charges,,,61.4,,334.02,percent of total billed charges,,,57.4,,312.26,percent of total billed charges,,,81,,440.64,percent of total billed charges,,,39,,212.16,percent of total billed charges,,,57.6,,313.34,percent of total billed charges,,,85,,462.4,percent of total billed charges,,,85,,462.4,percent of total billed charges,,,49,,266.56,percent of total billed charges,,,90,,489.6,percent of total billed charges,,,65,,353.6,percent of total billed charges,,,80,,435.2,percent of total billed charges,,,55,,299.2,percent of total billed charges,,,55,,299.2,percent of total billed charges,,,65,,353.6,percent of total billed charges,,,78,,424.32,percent of total billed charges,,,70,,380.8,percent of total billed charges,,,,,,,,121.33,,,,100% of Medicare,,121.33,,,,100% of Medicare,,121.33,,,,100% of Medicare,,121.33,,,,100% of Medicare,,121.33,,,,100% of Medicare,,121.33,,,,100% of Medicare,,121.33,,,,100% of Medicare,,121.33,,,,100% of Medicare,,121.33,,,,100% of Medicare,,121.33,,,,100% of Medicare,,121.33,,,,100% of Medicare,,121.33,,,,100% of Medicare,,,121.33,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,121.33,489.6,
"Lower Extremity Orthosis Addition, Condylar Pad",L2810,HCPCS,,,,outpatient,,,439,263.4,,45.5,,199.75,percent of total billed charges,,,45.3,,198.87,percent of total billed charges,,,39,,171.21,percent of total billed charges,,,,,,,,,80,,351.2,percent of total billed charges,,,61.4,,269.55,percent of total billed charges,,,57.4,,251.99,percent of total billed charges,,,81,,355.59,percent of total billed charges,,,39,,171.21,percent of total billed charges,,,57.6,,252.86,percent of total billed charges,,,85,,373.15,percent of total billed charges,,,85,,373.15,percent of total billed charges,,,49,,215.11,percent of total billed charges,,,90,,395.1,percent of total billed charges,,,65,,285.35,percent of total billed charges,,,80,,351.2,percent of total billed charges,,,55,,241.45,percent of total billed charges,,,55,,241.45,percent of total billed charges,,,65,,285.35,percent of total billed charges,,,78,,342.42,percent of total billed charges,,,70,,307.3,percent of total billed charges,,,,,,,,98.41,,,,100% of Medicare,,98.41,,,,100% of Medicare,,98.41,,,,100% of Medicare,,98.41,,,,100% of Medicare,,98.41,,,,100% of Medicare,,98.41,,,,100% of Medicare,,98.41,,,,100% of Medicare,,98.41,,,,100% of Medicare,,98.41,,,,100% of Medicare,,98.41,,,,100% of Medicare,,98.41,,,,100% of Medicare,,98.41,,,,100% of Medicare,,,98.41,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,98.41,395.1,
"Lower Extremity Orthosis Addition, Soft Interface for Molded Plastic, Below Knee",L2820,HCPCS,,,,outpatient,,,436,261.6,,45.5,,198.38,percent of total billed charges,,,45.3,,197.51,percent of total billed charges,,,39,,170.04,percent of total billed charges,,,,,,,,,80,,348.8,percent of total billed charges,,,61.4,,267.7,percent of total billed charges,,,57.4,,250.26,percent of total billed charges,,,81,,353.16,percent of total billed charges,,,39,,170.04,percent of total billed charges,,,57.6,,251.14,percent of total billed charges,,,85,,370.6,percent of total billed charges,,,85,,370.6,percent of total billed charges,,,49,,213.64,percent of total billed charges,,,90,,392.4,percent of total billed charges,,,65,,283.4,percent of total billed charges,,,80,,348.8,percent of total billed charges,,,55,,239.8,percent of total billed charges,,,55,,239.8,percent of total billed charges,,,65,,283.4,percent of total billed charges,,,78,,340.08,percent of total billed charges,,,70,,305.2,percent of total billed charges,,,,,,,,97.83,,,,100% of Medicare,,97.83,,,,100% of Medicare,,97.83,,,,100% of Medicare,,97.83,,,,100% of Medicare,,97.83,,,,100% of Medicare,,97.83,,,,100% of Medicare,,97.83,,,,100% of Medicare,,97.83,,,,100% of Medicare,,97.83,,,,100% of Medicare,,97.83,,,,100% of Medicare,,97.83,,,,100% of Medicare,,97.83,,,,100% of Medicare,,,97.83,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,97.83,392.4,
"Lower Extremity Orthosis Addition, Soft Interface for Molded Plastic, Above Knee",L2830,HCPCS,,,,outpatient,,,471,282.6,,45.5,,214.31,percent of total billed charges,,,45.3,,213.36,percent of total billed charges,,,39,,183.69,percent of total billed charges,,,,,,,,,80,,376.8,percent of total billed charges,,,61.4,,289.19,percent of total billed charges,,,57.4,,270.35,percent of total billed charges,,,81,,381.51,percent of total billed charges,,,39,,183.69,percent of total billed charges,,,57.6,,271.3,percent of total billed charges,,,85,,400.35,percent of total billed charges,,,85,,400.35,percent of total billed charges,,,49,,230.79,percent of total billed charges,,,90,,423.9,percent of total billed charges,,,65,,306.15,percent of total billed charges,,,80,,376.8,percent of total billed charges,,,55,,259.05,percent of total billed charges,,,55,,259.05,percent of total billed charges,,,65,,306.15,percent of total billed charges,,,78,,367.38,percent of total billed charges,,,70,,329.7,percent of total billed charges,,,,,,,,105.84,,,,100% of Medicare,,105.84,,,,100% of Medicare,,105.84,,,,100% of Medicare,,105.84,,,,100% of Medicare,,105.84,,,,100% of Medicare,,105.84,,,,100% of Medicare,,105.84,,,,100% of Medicare,,105.84,,,,100% of Medicare,,105.84,,,,100% of Medicare,,105.84,,,,100% of Medicare,,105.84,,,,100% of Medicare,,105.84,,,,100% of Medicare,,,105.84,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,105.84,423.9,
"Lower Extremity Orthosis, Tibial Length Sock, Fx or Equal",L2840,HCPCS,,,,outpatient,,,235,141,,45.5,,106.93,percent of total billed charges,,,45.3,,106.46,percent of total billed charges,,,39,,91.65,percent of total billed charges,,,,,,,,,80,,188,percent of total billed charges,,,61.4,,144.29,percent of total billed charges,,,57.4,,134.89,percent of total billed charges,,,81,,190.35,percent of total billed charges,,,39,,91.65,percent of total billed charges,,,57.6,,135.36,percent of total billed charges,,,85,,199.75,percent of total billed charges,,,85,,199.75,percent of total billed charges,,,49,,115.15,percent of total billed charges,,,90,,211.5,percent of total billed charges,,,65,,152.75,percent of total billed charges,,,80,,188,percent of total billed charges,,,55,,129.25,percent of total billed charges,,,55,,129.25,percent of total billed charges,,,65,,152.75,percent of total billed charges,,,78,,183.3,percent of total billed charges,,,70,,164.5,percent of total billed charges,,,,,,,,51.98,,,,100% of Medicare,,51.98,,,,100% of Medicare,,51.98,,,,100% of Medicare,,51.98,,,,100% of Medicare,,51.98,,,,100% of Medicare,,51.98,,,,100% of Medicare,,51.98,,,,100% of Medicare,,51.98,,,,100% of Medicare,,51.98,,,,100% of Medicare,,51.98,,,,100% of Medicare,,51.98,,,,100% of Medicare,,51.98,,,,100% of Medicare,,,51.98,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,51.98,211.5,
"Lower Extremity Orthosis Addition, Femoral Length Sock, Fx or Equal",L2850,HCPCS,,,,outpatient,,,325,195,,45.5,,147.88,percent of total billed charges,,,45.3,,147.23,percent of total billed charges,,,39,,126.75,percent of total billed charges,,,,,,,,,80,,260,percent of total billed charges,,,61.4,,199.55,percent of total billed charges,,,57.4,,186.55,percent of total billed charges,,,81,,263.25,percent of total billed charges,,,39,,126.75,percent of total billed charges,,,57.6,,187.2,percent of total billed charges,,,85,,276.25,percent of total billed charges,,,85,,276.25,percent of total billed charges,,,49,,159.25,percent of total billed charges,,,90,,292.5,percent of total billed charges,,,65,,211.25,percent of total billed charges,,,80,,260,percent of total billed charges,,,55,,178.75,percent of total billed charges,,,55,,178.75,percent of total billed charges,,,65,,211.25,percent of total billed charges,,,78,,253.5,percent of total billed charges,,,70,,227.5,percent of total billed charges,,,,,,,,72.88,,,,100% of Medicare,,72.88,,,,100% of Medicare,,72.88,,,,100% of Medicare,,72.88,,,,100% of Medicare,,72.88,,,,100% of Medicare,,72.88,,,,100% of Medicare,,72.88,,,,100% of Medicare,,72.88,,,,100% of Medicare,,72.88,,,,100% of Medicare,,72.88,,,,100% of Medicare,,72.88,,,,100% of Medicare,,72.88,,,,100% of Medicare,,,72.88,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,72.88,292.5,
"L2999 - Lower extremity orthosis, not otherwise specified",L2999,HCPCS,,,,both,,,268.13,160.88,,45.5,,122,percent of total billed charges,,,45.3,,121.46,percent of total billed charges,,,39,,104.57,percent of total billed charges,,,,,,,,,80,,214.5,percent of total billed charges,,,61.4,,164.63,percent of total billed charges,,,57.4,,153.91,percent of total billed charges,,,81,,217.19,percent of total billed charges,,,51.5,,138.09,percent of total billed charges,,,57.6,,154.44,percent of total billed charges,,,85,,227.91,percent of total billed charges,,,85,,227.91,percent of total billed charges,,,49,,131.38,percent of total billed charges,,,90,,241.32,percent of total billed charges,,,65,,174.28,percent of total billed charges,,,80,,214.5,percent of total billed charges,,,55,,147.47,percent of total billed charges,,,55,,147.47,percent of total billed charges,,,65,,174.28,percent of total billed charges,,,78,,209.14,percent of total billed charges,,,70,,187.69,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG rate,100% of IL Medicaid,,,,,EAPG rate,100% of IL Medicaid,,,,,EAPG rate,100% of IL Medicaid,,,,,EAPG rate,100% of IL Medicaid,104.57,241.32,
"Foot Insert, Removable, UCB Type, Molded to Patient",L3000,HCPCS,,,,outpatient,,,1691,1014.6,,45.5,,769.41,percent of total billed charges,,,45.3,,766.02,percent of total billed charges,,,39,,659.49,percent of total billed charges,,,,,,,,,80,,1352.8,percent of total billed charges,,,61.4,,1038.27,percent of total billed charges,,,57.4,,970.63,percent of total billed charges,,,81,,1369.71,percent of total billed charges,,,39,,659.49,percent of total billed charges,,,57.6,,974.02,percent of total billed charges,,,85,,1437.35,percent of total billed charges,,,85,,1437.35,percent of total billed charges,,,49,,828.59,percent of total billed charges,,,90,,1521.9,percent of total billed charges,,,65,,1099.15,percent of total billed charges,,,80,,1352.8,percent of total billed charges,,,55,,930.05,percent of total billed charges,,,55,,930.05,percent of total billed charges,,,65,,1099.15,percent of total billed charges,,,78,,1318.98,percent of total billed charges,,,70,,1183.7,percent of total billed charges,,,,,,,,378.49,,,,100% of Medicare,,378.49,,,,100% of Medicare,,378.49,,,,100% of Medicare,,378.49,,,,100% of Medicare,,378.49,,,,100% of Medicare,,378.49,,,,100% of Medicare,,378.49,,,,100% of Medicare,,378.49,,,,100% of Medicare,,378.49,,,,100% of Medicare,,378.49,,,,100% of Medicare,,378.49,,,,100% of Medicare,,378.49,,,,100% of Medicare,,,378.49,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,378.49,1521.9,
"Foot Insert, Removable, Spenco, Molded to Patient",L3001,HCPCS,,,,outpatient,,,711,426.6,,45.5,,323.51,percent of total billed charges,,,45.3,,322.08,percent of total billed charges,,,39,,277.29,percent of total billed charges,,,,,,,,,80,,568.8,percent of total billed charges,,,61.4,,436.55,percent of total billed charges,,,57.4,,408.11,percent of total billed charges,,,81,,575.91,percent of total billed charges,,,39,,277.29,percent of total billed charges,,,57.6,,409.54,percent of total billed charges,,,85,,604.35,percent of total billed charges,,,85,,604.35,percent of total billed charges,,,49,,348.39,percent of total billed charges,,,90,,639.9,percent of total billed charges,,,65,,462.15,percent of total billed charges,,,80,,568.8,percent of total billed charges,,,55,,391.05,percent of total billed charges,,,55,,391.05,percent of total billed charges,,,65,,462.15,percent of total billed charges,,,78,,554.58,percent of total billed charges,,,70,,497.7,percent of total billed charges,,,,,,,,159.37,,,,100% of Medicare,,159.37,,,,100% of Medicare,,159.37,,,,100% of Medicare,,159.37,,,,100% of Medicare,,159.37,,,,100% of Medicare,,159.37,,,,100% of Medicare,,159.37,,,,100% of Medicare,,159.37,,,,100% of Medicare,,159.37,,,,100% of Medicare,,159.37,,,,100% of Medicare,,159.37,,,,100% of Medicare,,159.37,,,,100% of Medicare,,,159.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,159.37,639.9,
"Foot Insert, Removable, Plastizote Insert, Molded to Patient",L3002,HCPCS,,,,outpatient,,,873,523.8,,45.5,,397.22,percent of total billed charges,,,45.3,,395.47,percent of total billed charges,,,39,,340.47,percent of total billed charges,,,,,,,,,80,,698.4,percent of total billed charges,,,61.4,,536.02,percent of total billed charges,,,57.4,,501.1,percent of total billed charges,,,81,,707.13,percent of total billed charges,,,39,,340.47,percent of total billed charges,,,57.6,,502.85,percent of total billed charges,,,85,,742.05,percent of total billed charges,,,85,,742.05,percent of total billed charges,,,49,,427.77,percent of total billed charges,,,90,,785.7,percent of total billed charges,,,65,,567.45,percent of total billed charges,,,80,,698.4,percent of total billed charges,,,55,,480.15,percent of total billed charges,,,55,,480.15,percent of total billed charges,,,65,,567.45,percent of total billed charges,,,78,,680.94,percent of total billed charges,,,70,,611.1,percent of total billed charges,,,,,,,,194.59,,,,100% of Medicare,,194.59,,,,100% of Medicare,,194.59,,,,100% of Medicare,,194.59,,,,100% of Medicare,,194.59,,,,100% of Medicare,,194.59,,,,100% of Medicare,,194.59,,,,100% of Medicare,,194.59,,,,100% of Medicare,,194.59,,,,100% of Medicare,,194.59,,,,100% of Medicare,,194.59,,,,100% of Medicare,,194.59,,,,100% of Medicare,,,194.59,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,194.59,785.7,
"Foot Insert, Removable, Silicone Gel, Molded to Patient",L3003,HCPCS,,,,outpatient,,,562,337.2,,45.5,,255.71,percent of total billed charges,,,45.3,,254.59,percent of total billed charges,,,39,,219.18,percent of total billed charges,,,,,,,,,80,,449.6,percent of total billed charges,,,61.4,,345.07,percent of total billed charges,,,57.4,,322.59,percent of total billed charges,,,81,,455.22,percent of total billed charges,,,39,,219.18,percent of total billed charges,,,57.6,,323.71,percent of total billed charges,,,85,,477.7,percent of total billed charges,,,85,,477.7,percent of total billed charges,,,49,,275.38,percent of total billed charges,,,90,,505.8,percent of total billed charges,,,65,,365.3,percent of total billed charges,,,80,,449.6,percent of total billed charges,,,55,,309.1,percent of total billed charges,,,55,,309.1,percent of total billed charges,,,65,,365.3,percent of total billed charges,,,78,,438.36,percent of total billed charges,,,70,,393.4,percent of total billed charges,,,,,,,,209.91,,,,100% of Medicare,,209.91,,,,100% of Medicare,,209.91,,,,100% of Medicare,,209.91,,,,100% of Medicare,,209.91,,,,100% of Medicare,,209.91,,,,100% of Medicare,,209.91,,,,100% of Medicare,,209.91,,,,100% of Medicare,,209.91,,,,100% of Medicare,,209.91,,,,100% of Medicare,,209.91,,,,100% of Medicare,,209.91,,,,100% of Medicare,,,209.91,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,209.91,505.8,
"Foot Insert, Removable, Longitudinal Arch Support, Molded to Patient",L3010,HCPCS,,,,outpatient,,,943,565.8,,45.5,,429.07,percent of total billed charges,,,45.3,,427.18,percent of total billed charges,,,39,,367.77,percent of total billed charges,,,,,,,,,80,,754.4,percent of total billed charges,,,61.4,,579,percent of total billed charges,,,57.4,,541.28,percent of total billed charges,,,81,,763.83,percent of total billed charges,,,39,,367.77,percent of total billed charges,,,57.6,,543.17,percent of total billed charges,,,85,,801.55,percent of total billed charges,,,85,,801.55,percent of total billed charges,,,49,,462.07,percent of total billed charges,,,90,,848.7,percent of total billed charges,,,65,,612.95,percent of total billed charges,,,80,,754.4,percent of total billed charges,,,55,,518.65,percent of total billed charges,,,55,,518.65,percent of total billed charges,,,65,,612.95,percent of total billed charges,,,78,,735.54,percent of total billed charges,,,70,,660.1,percent of total billed charges,,,,,,,,209.91,,,,100% of Medicare,,209.91,,,,100% of Medicare,,209.91,,,,100% of Medicare,,209.91,,,,100% of Medicare,,209.91,,,,100% of Medicare,,209.91,,,,100% of Medicare,,209.91,,,,100% of Medicare,,209.91,,,,100% of Medicare,,209.91,,,,100% of Medicare,,209.91,,,,100% of Medicare,,209.91,,,,100% of Medicare,,209.91,,,,100% of Medicare,,,209.91,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,209.91,848.7,
"Foot Insert, Removable, Longitudinal Support",L3020,HCPCS,,,,outpatient,,,1068,640.8,,45.5,,485.94,percent of total billed charges,,,45.3,,483.8,percent of total billed charges,,,39,,416.52,percent of total billed charges,,,,,,,,,80,,854.4,percent of total billed charges,,,61.4,,655.75,percent of total billed charges,,,57.4,,613.03,percent of total billed charges,,,81,,865.08,percent of total billed charges,,,39,,416.52,percent of total billed charges,,,57.6,,615.17,percent of total billed charges,,,85,,907.8,percent of total billed charges,,,85,,907.8,percent of total billed charges,,,49,,523.32,percent of total billed charges,,,90,,961.2,percent of total billed charges,,,65,,694.2,percent of total billed charges,,,80,,854.4,percent of total billed charges,,,55,,587.4,percent of total billed charges,,,55,,587.4,percent of total billed charges,,,65,,694.2,percent of total billed charges,,,78,,833.04,percent of total billed charges,,,70,,747.6,percent of total billed charges,,,,,,,,239.05,,,,100% of Medicare,,239.05,,,,100% of Medicare,,239.05,,,,100% of Medicare,,239.05,,,,100% of Medicare,,239.05,,,,100% of Medicare,,239.05,,,,100% of Medicare,,239.05,,,,100% of Medicare,,239.05,,,,100% of Medicare,,239.05,,,,100% of Medicare,,239.05,,,,100% of Medicare,,239.05,,,,100% of Medicare,,239.05,,,,100% of Medicare,,,239.05,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,239.05,961.2,
"Foot Insert, Removable, Formed to Patient Foot",L3030,HCPCS,,,,outpatient,,,410,246,,45.5,,186.55,percent of total billed charges,,,45.3,,185.73,percent of total billed charges,,,39,,159.9,percent of total billed charges,,,,,,,,,80,,328,percent of total billed charges,,,61.4,,251.74,percent of total billed charges,,,57.4,,235.34,percent of total billed charges,,,81,,332.1,percent of total billed charges,,,39,,159.9,percent of total billed charges,,,57.6,,236.16,percent of total billed charges,,,85,,348.5,percent of total billed charges,,,85,,348.5,percent of total billed charges,,,49,,200.9,percent of total billed charges,,,90,,369,percent of total billed charges,,,65,,266.5,percent of total billed charges,,,80,,328,percent of total billed charges,,,55,,225.5,percent of total billed charges,,,55,,225.5,percent of total billed charges,,,65,,266.5,percent of total billed charges,,,78,,319.8,percent of total billed charges,,,70,,287,percent of total billed charges,,,,,,,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,,91.93,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.93,369,
HI STRNGTH LTWT FOOT INSERT EACH,L3031,HCPCS,,,,outpatient,,,277,166.2,,45.5,,126.04,percent of total billed charges,,,45.3,,125.48,percent of total billed charges,,,39,,108.03,percent of total billed charges,,,,,,,,,80,,221.6,percent of total billed charges,,,61.4,,170.08,percent of total billed charges,,,57.4,,159,percent of total billed charges,,,81,,224.37,percent of total billed charges,,,39,,108.03,percent of total billed charges,,,57.6,,159.55,percent of total billed charges,,,85,,235.45,percent of total billed charges,,,85,,235.45,percent of total billed charges,,,49,,135.73,percent of total billed charges,,,90,,249.3,percent of total billed charges,,,65,,180.05,percent of total billed charges,,,80,,221.6,percent of total billed charges,,,55,,152.35,percent of total billed charges,,,55,,152.35,percent of total billed charges,,,65,,180.05,percent of total billed charges,,,78,,216.06,percent of total billed charges,,,70,,193.9,percent of total billed charges,,,,,,,,147.56,,,,100% of Medicare,,147.56,,,,100% of Medicare,,147.56,,,,100% of Medicare,,147.56,,,,100% of Medicare,,147.56,,,,100% of Medicare,,147.56,,,,100% of Medicare,,147.56,,,,100% of Medicare,,147.56,,,,100% of Medicare,,147.56,,,,100% of Medicare,,147.56,,,,100% of Medicare,,147.56,,,,100% of Medicare,,147.56,,,,100% of Medicare,,,147.56,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,108.03,249.3,
"Foot Insert, Removable, Pre-Molded, Longitudinal Arch Support",L3040,HCPCS,,,,outpatient,,,246,147.6,,45.5,,111.93,percent of total billed charges,,,45.3,,111.44,percent of total billed charges,,,39,,95.94,percent of total billed charges,,,,,,,,,80,,196.8,percent of total billed charges,,,61.4,,151.04,percent of total billed charges,,,57.4,,141.2,percent of total billed charges,,,81,,199.26,percent of total billed charges,,,39,,95.94,percent of total billed charges,,,57.6,,141.7,percent of total billed charges,,,85,,209.1,percent of total billed charges,,,85,,209.1,percent of total billed charges,,,49,,120.54,percent of total billed charges,,,90,,221.4,percent of total billed charges,,,65,,159.9,percent of total billed charges,,,80,,196.8,percent of total billed charges,,,55,,135.3,percent of total billed charges,,,55,,135.3,percent of total billed charges,,,65,,159.9,percent of total billed charges,,,78,,191.88,percent of total billed charges,,,70,,172.2,percent of total billed charges,,,,,,,,56.71,,,,100% of Medicare,,56.71,,,,100% of Medicare,,56.71,,,,100% of Medicare,,56.71,,,,100% of Medicare,,56.71,,,,100% of Medicare,,56.71,,,,100% of Medicare,,56.71,,,,100% of Medicare,,56.71,,,,100% of Medicare,,56.71,,,,100% of Medicare,,56.71,,,,100% of Medicare,,56.71,,,,100% of Medicare,,56.71,,,,100% of Medicare,,,56.71,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,56.71,221.4,
"Foot Insert, Removable, Pre-Molded, Metatarsal Arch Support",L3050,HCPCS,,,,outpatient,,,253,151.8,,45.5,,115.12,percent of total billed charges,,,45.3,,114.61,percent of total billed charges,,,39,,98.67,percent of total billed charges,,,,,,,,,80,,202.4,percent of total billed charges,,,61.4,,155.34,percent of total billed charges,,,57.4,,145.22,percent of total billed charges,,,81,,204.93,percent of total billed charges,,,39,,98.67,percent of total billed charges,,,57.6,,145.73,percent of total billed charges,,,85,,215.05,percent of total billed charges,,,85,,215.05,percent of total billed charges,,,49,,123.97,percent of total billed charges,,,90,,227.7,percent of total billed charges,,,65,,164.45,percent of total billed charges,,,80,,202.4,percent of total billed charges,,,55,,139.15,percent of total billed charges,,,55,,139.15,percent of total billed charges,,,65,,164.45,percent of total billed charges,,,78,,197.34,percent of total billed charges,,,70,,177.1,percent of total billed charges,,,,,,,,56.71,,,,100% of Medicare,,56.71,,,,100% of Medicare,,56.71,,,,100% of Medicare,,56.71,,,,100% of Medicare,,56.71,,,,100% of Medicare,,56.71,,,,100% of Medicare,,56.71,,,,100% of Medicare,,56.71,,,,100% of Medicare,,56.71,,,,100% of Medicare,,56.71,,,,100% of Medicare,,56.71,,,,100% of Medicare,,56.71,,,,100% of Medicare,,,56.71,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,56.71,227.7,
"Foot Insert, Removable, Pre-Molded, Longitudinal/Metatarsal Support",L3060,HCPCS,,,,outpatient,,,359,215.4,,45.5,,163.35,percent of total billed charges,,,45.3,,162.63,percent of total billed charges,,,39,,140.01,percent of total billed charges,,,,,,,,,80,,287.2,percent of total billed charges,,,61.4,,220.43,percent of total billed charges,,,57.4,,206.07,percent of total billed charges,,,81,,290.79,percent of total billed charges,,,39,,140.01,percent of total billed charges,,,57.6,,206.78,percent of total billed charges,,,85,,305.15,percent of total billed charges,,,85,,305.15,percent of total billed charges,,,49,,175.91,percent of total billed charges,,,90,,323.1,percent of total billed charges,,,65,,233.35,percent of total billed charges,,,80,,287.2,percent of total billed charges,,,55,,197.45,percent of total billed charges,,,55,,197.45,percent of total billed charges,,,65,,233.35,percent of total billed charges,,,78,,280.02,percent of total billed charges,,,70,,251.3,percent of total billed charges,,,,,,,,88.87,,,,100% of Medicare,,88.87,,,,100% of Medicare,,88.87,,,,100% of Medicare,,88.87,,,,100% of Medicare,,88.87,,,,100% of Medicare,,88.87,,,,100% of Medicare,,88.87,,,,100% of Medicare,,88.87,,,,100% of Medicare,,88.87,,,,100% of Medicare,,88.87,,,,100% of Medicare,,88.87,,,,100% of Medicare,,88.87,,,,100% of Medicare,,,88.87,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,88.87,323.1,
"Foot Orthosis, Non-Removable, Longitudinal Arch Support, Attached to Shoe",L3070,HCPCS,,,,outpatient,,,170,102,,45.5,,77.35,percent of total billed charges,,,45.3,,77.01,percent of total billed charges,,,39,,66.3,percent of total billed charges,,,,,,,,,80,,136,percent of total billed charges,,,61.4,,104.38,percent of total billed charges,,,57.4,,97.58,percent of total billed charges,,,81,,137.7,percent of total billed charges,,,39,,66.3,percent of total billed charges,,,57.6,,97.92,percent of total billed charges,,,85,,144.5,percent of total billed charges,,,85,,144.5,percent of total billed charges,,,49,,83.3,percent of total billed charges,,,90,,153,percent of total billed charges,,,65,,110.5,percent of total billed charges,,,80,,136,percent of total billed charges,,,55,,93.5,percent of total billed charges,,,55,,93.5,percent of total billed charges,,,65,,110.5,percent of total billed charges,,,78,,132.6,percent of total billed charges,,,70,,119,percent of total billed charges,,,,,,,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,,38.31,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,38.31,153,
"Foot Orthosis, Non-Removable, Metatarsal Support, Attached to Shoe",L3080,HCPCS,,,,outpatient,,,170,102,,45.5,,77.35,percent of total billed charges,,,45.3,,77.01,percent of total billed charges,,,39,,66.3,percent of total billed charges,,,,,,,,,80,,136,percent of total billed charges,,,61.4,,104.38,percent of total billed charges,,,57.4,,97.58,percent of total billed charges,,,81,,137.7,percent of total billed charges,,,39,,66.3,percent of total billed charges,,,57.6,,97.92,percent of total billed charges,,,85,,144.5,percent of total billed charges,,,85,,144.5,percent of total billed charges,,,49,,83.3,percent of total billed charges,,,90,,153,percent of total billed charges,,,65,,110.5,percent of total billed charges,,,80,,136,percent of total billed charges,,,55,,93.5,percent of total billed charges,,,55,,93.5,percent of total billed charges,,,65,,110.5,percent of total billed charges,,,78,,132.6,percent of total billed charges,,,70,,119,percent of total billed charges,,,,,,,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,,38.31,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,38.31,153,
"Foot Orthosis, Arch Support, Longitudinal/Metatarsal, Attached to Shoe",L3090,HCPCS,,,,outpatient,,,108,64.8,,45.5,,49.14,percent of total billed charges,,,45.3,,48.92,percent of total billed charges,,,39,,42.12,percent of total billed charges,,,,,,,,,80,,86.4,percent of total billed charges,,,61.4,,66.31,percent of total billed charges,,,57.4,,61.99,percent of total billed charges,,,81,,87.48,percent of total billed charges,,,39,,42.12,percent of total billed charges,,,57.6,,62.21,percent of total billed charges,,,85,,91.8,percent of total billed charges,,,85,,91.8,percent of total billed charges,,,49,,52.92,percent of total billed charges,,,90,,97.2,percent of total billed charges,,,65,,70.2,percent of total billed charges,,,80,,86.4,percent of total billed charges,,,55,,59.4,percent of total billed charges,,,55,,59.4,percent of total billed charges,,,65,,70.2,percent of total billed charges,,,78,,84.24,percent of total billed charges,,,70,,75.6,percent of total billed charges,,,,,,,,49.04,,,,100% of Medicare,,49.04,,,,100% of Medicare,,49.04,,,,100% of Medicare,,49.04,,,,100% of Medicare,,49.04,,,,100% of Medicare,,49.04,,,,100% of Medicare,,49.04,,,,100% of Medicare,,49.04,,,,100% of Medicare,,49.04,,,,100% of Medicare,,49.04,,,,100% of Medicare,,49.04,,,,100% of Medicare,,49.04,,,,100% of Medicare,,,49.04,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,42.12,97.2,
Hallus-Valgus Night Dynamic Splint,L3100,HCPCS,,,,outpatient,,,235,141,,45.5,,106.93,percent of total billed charges,,,45.3,,106.46,percent of total billed charges,,,39,,91.65,percent of total billed charges,,,,,,,,,80,,188,percent of total billed charges,,,61.4,,144.29,percent of total billed charges,,,57.4,,134.89,percent of total billed charges,,,81,,190.35,percent of total billed charges,,,39,,91.65,percent of total billed charges,,,57.6,,135.36,percent of total billed charges,,,85,,199.75,percent of total billed charges,,,85,,199.75,percent of total billed charges,,,49,,115.15,percent of total billed charges,,,90,,211.5,percent of total billed charges,,,65,,152.75,percent of total billed charges,,,80,,188,percent of total billed charges,,,55,,129.25,percent of total billed charges,,,55,,129.25,percent of total billed charges,,,65,,152.75,percent of total billed charges,,,78,,183.3,percent of total billed charges,,,70,,164.5,percent of total billed charges,,,,,,,,52.12,,,,100% of Medicare,,52.12,,,,100% of Medicare,,52.12,,,,100% of Medicare,,52.12,,,,100% of Medicare,,52.12,,,,100% of Medicare,,52.12,,,,100% of Medicare,,52.12,,,,100% of Medicare,,52.12,,,,100% of Medicare,,52.12,,,,100% of Medicare,,52.12,,,,100% of Medicare,,52.12,,,,100% of Medicare,,52.12,,,,100% of Medicare,,,52.12,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,52.12,211.5,
"Foot Orthosis, Abduction Rotation Bar, Incl Shoes",L3140,HCPCS,,,,outpatient,,,232,139.2,,45.5,,105.56,percent of total billed charges,,,45.3,,105.1,percent of total billed charges,,,39,,90.48,percent of total billed charges,,,,,,,,,80,,185.6,percent of total billed charges,,,61.4,,142.45,percent of total billed charges,,,57.4,,133.17,percent of total billed charges,,,81,,187.92,percent of total billed charges,,,39,,90.48,percent of total billed charges,,,57.6,,133.63,percent of total billed charges,,,85,,197.2,percent of total billed charges,,,85,,197.2,percent of total billed charges,,,49,,113.68,percent of total billed charges,,,90,,208.8,percent of total billed charges,,,65,,150.8,percent of total billed charges,,,80,,185.6,percent of total billed charges,,,55,,127.6,percent of total billed charges,,,55,,127.6,percent of total billed charges,,,65,,150.8,percent of total billed charges,,,78,,180.96,percent of total billed charges,,,70,,162.4,percent of total billed charges,,,,,,,,107.26,,,,100% of Medicare,,107.26,,,,100% of Medicare,,107.26,,,,100% of Medicare,,107.26,,,,100% of Medicare,,107.26,,,,100% of Medicare,,107.26,,,,100% of Medicare,,107.26,,,,100% of Medicare,,107.26,,,,100% of Medicare,,107.26,,,,100% of Medicare,,107.26,,,,100% of Medicare,,107.26,,,,100% of Medicare,,107.26,,,,100% of Medicare,,,107.26,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,90.48,208.8,
"Foot Orthosis, Abduction Rotation Bar, w/out Shoes",L3150,HCPCS,,,,outpatient,,,299,179.4,,45.5,,136.05,percent of total billed charges,,,45.3,,135.45,percent of total billed charges,,,39,,116.61,percent of total billed charges,,,,,,,,,80,,239.2,percent of total billed charges,,,61.4,,183.59,percent of total billed charges,,,57.4,,171.63,percent of total billed charges,,,81,,242.19,percent of total billed charges,,,39,,116.61,percent of total billed charges,,,57.6,,172.22,percent of total billed charges,,,85,,254.15,percent of total billed charges,,,85,,254.15,percent of total billed charges,,,49,,146.51,percent of total billed charges,,,90,,269.1,percent of total billed charges,,,65,,194.35,percent of total billed charges,,,80,,239.2,percent of total billed charges,,,55,,164.45,percent of total billed charges,,,55,,164.45,percent of total billed charges,,,65,,194.35,percent of total billed charges,,,78,,233.22,percent of total billed charges,,,70,,209.3,percent of total billed charges,,,,,,,,98.09,,,,100% of Medicare,,98.09,,,,100% of Medicare,,98.09,,,,100% of Medicare,,98.09,,,,100% of Medicare,,98.09,,,,100% of Medicare,,98.09,,,,100% of Medicare,,98.09,,,,100% of Medicare,,98.09,,,,100% of Medicare,,98.09,,,,100% of Medicare,,98.09,,,,100% of Medicare,,98.09,,,,100% of Medicare,,98.09,,,,100% of Medicare,,,98.09,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,98.09,269.1,
"Plastic Heel Stabilizer, Cup",L3170,HCPCS,,,,outpatient,,,277,166.2,,45.5,,126.04,percent of total billed charges,,,45.3,,125.48,percent of total billed charges,,,39,,108.03,percent of total billed charges,,,,,,,,,80,,221.6,percent of total billed charges,,,61.4,,170.08,percent of total billed charges,,,57.4,,159,percent of total billed charges,,,81,,224.37,percent of total billed charges,,,39,,108.03,percent of total billed charges,,,57.6,,159.55,percent of total billed charges,,,85,,235.45,percent of total billed charges,,,85,,235.45,percent of total billed charges,,,49,,135.73,percent of total billed charges,,,90,,249.3,percent of total billed charges,,,65,,180.05,percent of total billed charges,,,80,,221.6,percent of total billed charges,,,55,,152.35,percent of total billed charges,,,55,,152.35,percent of total billed charges,,,65,,180.05,percent of total billed charges,,,78,,216.06,percent of total billed charges,,,70,,193.9,percent of total billed charges,,,,,,,,61.29,,,,100% of Medicare,,61.29,,,,100% of Medicare,,61.29,,,,100% of Medicare,,61.29,,,,100% of Medicare,,61.29,,,,100% of Medicare,,61.29,,,,100% of Medicare,,61.29,,,,100% of Medicare,,61.29,,,,100% of Medicare,,61.29,,,,100% of Medicare,,61.29,,,,100% of Medicare,,61.29,,,,100% of Medicare,,61.29,,,,100% of Medicare,,,61.29,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,61.29,249.3,
"Orthopedic Shoe, Womens, Oxford, Used as Part of Brace",L3224,HCPCS,,,,outpatient,,,365,219,,45.5,,166.08,percent of total billed charges,,,45.3,,165.35,percent of total billed charges,,,39,,142.35,percent of total billed charges,,,,,,,,,80,,292,percent of total billed charges,,,61.4,,224.11,percent of total billed charges,,,57.4,,209.51,percent of total billed charges,,,81,,295.65,percent of total billed charges,,,39,,142.35,percent of total billed charges,,,57.6,,210.24,percent of total billed charges,,,85,,310.25,percent of total billed charges,,,85,,310.25,percent of total billed charges,,,49,,178.85,percent of total billed charges,,,90,,328.5,percent of total billed charges,,,65,,237.25,percent of total billed charges,,,80,,292,percent of total billed charges,,,55,,200.75,percent of total billed charges,,,55,,200.75,percent of total billed charges,,,65,,237.25,percent of total billed charges,,,78,,284.7,percent of total billed charges,,,70,,255.5,percent of total billed charges,,,,,,,,81.41,,,,100% of Medicare,,81.41,,,,100% of Medicare,,81.41,,,,100% of Medicare,,81.41,,,,100% of Medicare,,81.41,,,,100% of Medicare,,81.41,,,,100% of Medicare,,81.41,,,,100% of Medicare,,81.41,,,,100% of Medicare,,81.41,,,,100% of Medicare,,81.41,,,,100% of Medicare,,81.41,,,,100% of Medicare,,81.41,,,,100% of Medicare,,,81.41,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,81.41,328.5,
"Orthopedic Shoe, Mens, Oxford, Used as Part of Brace",L3225,HCPCS,,,,outpatient,,,232,139.2,,45.5,,105.56,percent of total billed charges,,,45.3,,105.1,percent of total billed charges,,,39,,90.48,percent of total billed charges,,,,,,,,,80,,185.6,percent of total billed charges,,,61.4,,142.45,percent of total billed charges,,,57.4,,133.17,percent of total billed charges,,,81,,187.92,percent of total billed charges,,,39,,90.48,percent of total billed charges,,,57.6,,133.63,percent of total billed charges,,,85,,197.2,percent of total billed charges,,,85,,197.2,percent of total billed charges,,,49,,113.68,percent of total billed charges,,,90,,208.8,percent of total billed charges,,,65,,150.8,percent of total billed charges,,,80,,185.6,percent of total billed charges,,,55,,127.6,percent of total billed charges,,,55,,127.6,percent of total billed charges,,,65,,150.8,percent of total billed charges,,,78,,180.96,percent of total billed charges,,,70,,162.4,percent of total billed charges,,,,,,,,88.92,,,,100% of Medicare,,88.92,,,,100% of Medicare,,88.92,,,,100% of Medicare,,88.92,,,,100% of Medicare,,88.92,,,,100% of Medicare,,88.92,,,,100% of Medicare,,88.92,,,,100% of Medicare,,88.92,,,,100% of Medicare,,88.92,,,,100% of Medicare,,88.92,,,,100% of Medicare,,88.92,,,,100% of Medicare,,88.92,,,,100% of Medicare,,,88.92,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,88.92,208.8,
"Orthopedic Shoe, Custom, Depth Inlay",L3230,HCPCS,,,,outpatient,,,3467,2080.2,,45.5,,1577.49,percent of total billed charges,,,45.3,,1570.55,percent of total billed charges,,,39,,1352.13,percent of total billed charges,,,,,,,,,80,,2773.6,percent of total billed charges,,,61.4,,2128.74,percent of total billed charges,,,57.4,,1990.06,percent of total billed charges,,,81,,2808.27,percent of total billed charges,,,39,,1352.13,percent of total billed charges,,,57.6,,1996.99,percent of total billed charges,,,85,,2946.95,percent of total billed charges,,,85,,2946.95,percent of total billed charges,,,49,,1698.83,percent of total billed charges,,,90,,3120.3,percent of total billed charges,,,65,,2253.55,percent of total billed charges,,,80,,2773.6,percent of total billed charges,,,55,,1906.85,percent of total billed charges,,,55,,1906.85,percent of total billed charges,,,65,,2253.55,percent of total billed charges,,,78,,2704.26,percent of total billed charges,,,70,,2426.9,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1352.13,3120.3,
L3252 Custom Plastazote Ea,L3252,HCPCS,,,,outpatient,,,206,123.6,,45.5,,93.73,percent of total billed charges,,,45.3,,93.32,percent of total billed charges,,,39,,80.34,percent of total billed charges,,,,,,,,,80,,164.8,percent of total billed charges,,,61.4,,126.48,percent of total billed charges,,,57.4,,118.24,percent of total billed charges,,,81,,166.86,percent of total billed charges,,,39,,80.34,percent of total billed charges,,,57.6,,118.66,percent of total billed charges,,,85,,175.1,percent of total billed charges,,,85,,175.1,percent of total billed charges,,,49,,100.94,percent of total billed charges,,,90,,185.4,percent of total billed charges,,,65,,133.9,percent of total billed charges,,,80,,164.8,percent of total billed charges,,,55,,113.3,percent of total billed charges,,,55,,113.3,percent of total billed charges,,,65,,133.9,percent of total billed charges,,,78,,160.68,percent of total billed charges,,,70,,144.2,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,80.34,185.4,
"Orthopedic Shoe, Custom Plastizote",L3253,HCPCS,,,,outpatient,,,199,119.4,,45.5,,90.55,percent of total billed charges,,,45.3,,90.15,percent of total billed charges,,,39,,77.61,percent of total billed charges,,,,,,,,,80,,159.2,percent of total billed charges,,,61.4,,122.19,percent of total billed charges,,,57.4,,114.23,percent of total billed charges,,,81,,161.19,percent of total billed charges,,,39,,77.61,percent of total billed charges,,,57.6,,114.62,percent of total billed charges,,,85,,169.15,percent of total billed charges,,,85,,169.15,percent of total billed charges,,,49,,97.51,percent of total billed charges,,,90,,179.1,percent of total billed charges,,,65,,129.35,percent of total billed charges,,,80,,159.2,percent of total billed charges,,,55,,109.45,percent of total billed charges,,,55,,109.45,percent of total billed charges,,,65,,129.35,percent of total billed charges,,,78,,155.22,percent of total billed charges,,,70,,139.3,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,77.61,179.1,
L3254 Non Standard Size/Width Pr,L3254,HCPCS,,,,outpatient,,,253,151.8,,45.5,,115.12,percent of total billed charges,,,45.3,,114.61,percent of total billed charges,,,39,,98.67,percent of total billed charges,,,,,,,,,80,,202.4,percent of total billed charges,,,61.4,,155.34,percent of total billed charges,,,57.4,,145.22,percent of total billed charges,,,81,,204.93,percent of total billed charges,,,39,,98.67,percent of total billed charges,,,57.6,,145.73,percent of total billed charges,,,85,,215.05,percent of total billed charges,,,85,,215.05,percent of total billed charges,,,49,,123.97,percent of total billed charges,,,90,,227.7,percent of total billed charges,,,65,,164.45,percent of total billed charges,,,80,,202.4,percent of total billed charges,,,55,,139.15,percent of total billed charges,,,55,,139.15,percent of total billed charges,,,65,,164.45,percent of total billed charges,,,78,,197.34,percent of total billed charges,,,70,,177.1,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,98.67,227.7,
L3255 Non Standard Size/Length Pr,L3255,HCPCS,,,,outpatient,,,220,132,,45.5,,100.1,percent of total billed charges,,,45.3,,99.66,percent of total billed charges,,,39,,85.8,percent of total billed charges,,,,,,,,,80,,176,percent of total billed charges,,,61.4,,135.08,percent of total billed charges,,,57.4,,126.28,percent of total billed charges,,,81,,178.2,percent of total billed charges,,,39,,85.8,percent of total billed charges,,,57.6,,126.72,percent of total billed charges,,,85,,187,percent of total billed charges,,,85,,187,percent of total billed charges,,,49,,107.8,percent of total billed charges,,,90,,198,percent of total billed charges,,,65,,143,percent of total billed charges,,,80,,176,percent of total billed charges,,,55,,121,percent of total billed charges,,,55,,121,percent of total billed charges,,,65,,143,percent of total billed charges,,,78,,171.6,percent of total billed charges,,,70,,154,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,85.8,198,
L3257 Split Size Additional charge,L3257,HCPCS,,,,outpatient,,,296,177.6,,45.5,,134.68,percent of total billed charges,,,45.3,,134.09,percent of total billed charges,,,39,,115.44,percent of total billed charges,,,,,,,,,80,,236.8,percent of total billed charges,,,61.4,,181.74,percent of total billed charges,,,57.4,,169.9,percent of total billed charges,,,81,,239.76,percent of total billed charges,,,39,,115.44,percent of total billed charges,,,57.6,,170.5,percent of total billed charges,,,85,,251.6,percent of total billed charges,,,85,,251.6,percent of total billed charges,,,49,,145.04,percent of total billed charges,,,90,,266.4,percent of total billed charges,,,65,,192.4,percent of total billed charges,,,80,,236.8,percent of total billed charges,,,55,,162.8,percent of total billed charges,,,55,,162.8,percent of total billed charges,,,65,,192.4,percent of total billed charges,,,78,,230.88,percent of total billed charges,,,70,,207.2,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,115.44,266.4,
"Lift, Heel, Tapered to Metatarsal, Per Inch",L3300,HCPCS,,,,outpatient,,,281,168.6,,45.5,,127.86,percent of total billed charges,,,45.3,,127.29,percent of total billed charges,,,39,,109.59,percent of total billed charges,,,,,,,,,80,,224.8,percent of total billed charges,,,61.4,,172.53,percent of total billed charges,,,57.4,,161.29,percent of total billed charges,,,81,,227.61,percent of total billed charges,,,39,,109.59,percent of total billed charges,,,57.6,,161.86,percent of total billed charges,,,85,,238.85,percent of total billed charges,,,85,,238.85,percent of total billed charges,,,49,,137.69,percent of total billed charges,,,90,,252.9,percent of total billed charges,,,65,,182.65,percent of total billed charges,,,80,,224.8,percent of total billed charges,,,55,,154.55,percent of total billed charges,,,55,,154.55,percent of total billed charges,,,65,,182.65,percent of total billed charges,,,78,,219.18,percent of total billed charges,,,70,,196.7,percent of total billed charges,,,,,,,,62.84,,,,100% of Medicare,,62.84,,,,100% of Medicare,,62.84,,,,100% of Medicare,,62.84,,,,100% of Medicare,,62.84,,,,100% of Medicare,,62.84,,,,100% of Medicare,,62.84,,,,100% of Medicare,,62.84,,,,100% of Medicare,,62.84,,,,100% of Medicare,,62.84,,,,100% of Medicare,,62.84,,,,100% of Medicare,,62.84,,,,100% of Medicare,,,62.84,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,62.84,252.9,
"Lift, Heel and Sole, Neoprene, Per Inch",L3310,HCPCS,,,,outpatient,,,439,263.4,,45.5,,199.75,percent of total billed charges,,,45.3,,198.87,percent of total billed charges,,,39,,171.21,percent of total billed charges,,,,,,,,,80,,351.2,percent of total billed charges,,,61.4,,269.55,percent of total billed charges,,,57.4,,251.99,percent of total billed charges,,,81,,355.59,percent of total billed charges,,,39,,171.21,percent of total billed charges,,,57.6,,252.86,percent of total billed charges,,,85,,373.15,percent of total billed charges,,,85,,373.15,percent of total billed charges,,,49,,215.11,percent of total billed charges,,,90,,395.1,percent of total billed charges,,,65,,285.35,percent of total billed charges,,,80,,351.2,percent of total billed charges,,,55,,241.45,percent of total billed charges,,,55,,241.45,percent of total billed charges,,,65,,285.35,percent of total billed charges,,,78,,342.42,percent of total billed charges,,,70,,307.3,percent of total billed charges,,,,,,,,98.09,,,,100% of Medicare,,98.09,,,,100% of Medicare,,98.09,,,,100% of Medicare,,98.09,,,,100% of Medicare,,98.09,,,,100% of Medicare,,98.09,,,,100% of Medicare,,98.09,,,,100% of Medicare,,98.09,,,,100% of Medicare,,98.09,,,,100% of Medicare,,98.09,,,,100% of Medicare,,98.09,,,,100% of Medicare,,98.09,,,,100% of Medicare,,,98.09,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,98.09,395.1,
"Lift, Heel and Sole, Cork, Per Inch",L3320,HCPCS,,,,outpatient,,,202,121.2,,45.5,,91.91,percent of total billed charges,,,45.3,,91.51,percent of total billed charges,,,39,,78.78,percent of total billed charges,,,,,,,,,80,,161.6,percent of total billed charges,,,61.4,,124.03,percent of total billed charges,,,57.4,,115.95,percent of total billed charges,,,81,,163.62,percent of total billed charges,,,39,,78.78,percent of total billed charges,,,57.6,,116.35,percent of total billed charges,,,85,,171.7,percent of total billed charges,,,85,,171.7,percent of total billed charges,,,49,,98.98,percent of total billed charges,,,90,,181.8,percent of total billed charges,,,65,,131.3,percent of total billed charges,,,80,,161.6,percent of total billed charges,,,55,,111.1,percent of total billed charges,,,55,,111.1,percent of total billed charges,,,65,,131.3,percent of total billed charges,,,78,,157.56,percent of total billed charges,,,70,,141.4,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,78.78,181.8,
"Lift, Metal Extension (Skate)",L3330,HCPCS,,,,outpatient,,,1450,870,,45.5,,659.75,percent of total billed charges,,,45.3,,656.85,percent of total billed charges,,,39,,565.5,percent of total billed charges,,,,,,,,,80,,1160,percent of total billed charges,,,61.4,,890.3,percent of total billed charges,,,57.4,,832.3,percent of total billed charges,,,81,,1174.5,percent of total billed charges,,,39,,565.5,percent of total billed charges,,,57.6,,835.2,percent of total billed charges,,,85,,1232.5,percent of total billed charges,,,85,,1232.5,percent of total billed charges,,,49,,710.5,percent of total billed charges,,,90,,1305,percent of total billed charges,,,65,,942.5,percent of total billed charges,,,80,,1160,percent of total billed charges,,,55,,797.5,percent of total billed charges,,,55,,797.5,percent of total billed charges,,,65,,942.5,percent of total billed charges,,,78,,1131,percent of total billed charges,,,70,,1015,percent of total billed charges,,,,,,,,681.87,,,,100% of Medicare,,681.87,,,,100% of Medicare,,681.87,,,,100% of Medicare,,681.87,,,,100% of Medicare,,681.87,,,,100% of Medicare,,681.87,,,,100% of Medicare,,681.87,,,,100% of Medicare,,681.87,,,,100% of Medicare,,681.87,,,,100% of Medicare,,681.87,,,,100% of Medicare,,681.87,,,,100% of Medicare,,681.87,,,,100% of Medicare,,,681.87,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,565.5,1305,
"Lift, Inside Shoe, Tapered, Per Inch",L3332,HCPCS,,,,outpatient,,,386,231.6,,45.5,,175.63,percent of total billed charges,,,45.3,,174.86,percent of total billed charges,,,39,,150.54,percent of total billed charges,,,,,,,,,80,,308.8,percent of total billed charges,,,61.4,,237,percent of total billed charges,,,57.4,,221.56,percent of total billed charges,,,81,,312.66,percent of total billed charges,,,39,,150.54,percent of total billed charges,,,57.6,,222.34,percent of total billed charges,,,85,,328.1,percent of total billed charges,,,85,,328.1,percent of total billed charges,,,49,,189.14,percent of total billed charges,,,90,,347.4,percent of total billed charges,,,65,,250.9,percent of total billed charges,,,80,,308.8,percent of total billed charges,,,55,,212.3,percent of total billed charges,,,55,,212.3,percent of total billed charges,,,65,,250.9,percent of total billed charges,,,78,,301.08,percent of total billed charges,,,70,,270.2,percent of total billed charges,,,,,,,,88.87,,,,100% of Medicare,,88.87,,,,100% of Medicare,,88.87,,,,100% of Medicare,,88.87,,,,100% of Medicare,,88.87,,,,100% of Medicare,,88.87,,,,100% of Medicare,,88.87,,,,100% of Medicare,,88.87,,,,100% of Medicare,,88.87,,,,100% of Medicare,,88.87,,,,100% of Medicare,,88.87,,,,100% of Medicare,,88.87,,,,100% of Medicare,,,88.87,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,88.87,347.4,
"Lift, Heel, Per Inch",L3334,HCPCS,,,,outpatient,,,206,123.6,,45.5,,93.73,percent of total billed charges,,,45.3,,93.32,percent of total billed charges,,,39,,80.34,percent of total billed charges,,,,,,,,,80,,164.8,percent of total billed charges,,,61.4,,126.48,percent of total billed charges,,,57.4,,118.24,percent of total billed charges,,,81,,166.86,percent of total billed charges,,,39,,80.34,percent of total billed charges,,,57.6,,118.66,percent of total billed charges,,,85,,175.1,percent of total billed charges,,,85,,175.1,percent of total billed charges,,,49,,100.94,percent of total billed charges,,,90,,185.4,percent of total billed charges,,,65,,133.9,percent of total billed charges,,,80,,164.8,percent of total billed charges,,,55,,113.3,percent of total billed charges,,,55,,113.3,percent of total billed charges,,,65,,133.9,percent of total billed charges,,,78,,160.68,percent of total billed charges,,,70,,144.2,percent of total billed charges,,,,,,,,45.95,,,,100% of Medicare,,45.95,,,,100% of Medicare,,45.95,,,,100% of Medicare,,45.95,,,,100% of Medicare,,45.95,,,,100% of Medicare,,45.95,,,,100% of Medicare,,45.95,,,,100% of Medicare,,45.95,,,,100% of Medicare,,45.95,,,,100% of Medicare,,45.95,,,,100% of Medicare,,45.95,,,,100% of Medicare,,45.95,,,,100% of Medicare,,,45.95,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,45.95,185.4,
"Wedge, Heel, Sach",L3340,HCPCS,,,,outpatient,,,461,276.6,,45.5,,209.76,percent of total billed charges,,,45.3,,208.83,percent of total billed charges,,,39,,179.79,percent of total billed charges,,,,,,,,,80,,368.8,percent of total billed charges,,,61.4,,283.05,percent of total billed charges,,,57.4,,264.61,percent of total billed charges,,,81,,373.41,percent of total billed charges,,,39,,179.79,percent of total billed charges,,,57.6,,265.54,percent of total billed charges,,,85,,391.85,percent of total billed charges,,,85,,391.85,percent of total billed charges,,,49,,225.89,percent of total billed charges,,,90,,414.9,percent of total billed charges,,,65,,299.65,percent of total billed charges,,,80,,368.8,percent of total billed charges,,,55,,253.55,percent of total billed charges,,,55,,253.55,percent of total billed charges,,,65,,299.65,percent of total billed charges,,,78,,359.58,percent of total billed charges,,,70,,322.7,percent of total billed charges,,,,,,,,102.69,,,,100% of Medicare,,102.69,,,,100% of Medicare,,102.69,,,,100% of Medicare,,102.69,,,,100% of Medicare,,102.69,,,,100% of Medicare,,102.69,,,,100% of Medicare,,102.69,,,,100% of Medicare,,102.69,,,,100% of Medicare,,102.69,,,,100% of Medicare,,102.69,,,,100% of Medicare,,102.69,,,,100% of Medicare,,102.69,,,,100% of Medicare,,,102.69,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,102.69,414.9,
"Wedge, Heel",L3350,HCPCS,,,,outpatient,,,122,73.2,,45.5,,55.51,percent of total billed charges,,,45.3,,55.27,percent of total billed charges,,,39,,47.58,percent of total billed charges,,,,,,,,,80,,97.6,percent of total billed charges,,,61.4,,74.91,percent of total billed charges,,,57.4,,70.03,percent of total billed charges,,,81,,98.82,percent of total billed charges,,,39,,47.58,percent of total billed charges,,,57.6,,70.27,percent of total billed charges,,,85,,103.7,percent of total billed charges,,,85,,103.7,percent of total billed charges,,,49,,59.78,percent of total billed charges,,,90,,109.8,percent of total billed charges,,,65,,79.3,percent of total billed charges,,,80,,97.6,percent of total billed charges,,,55,,67.1,percent of total billed charges,,,55,,67.1,percent of total billed charges,,,65,,79.3,percent of total billed charges,,,78,,95.16,percent of total billed charges,,,70,,85.4,percent of total billed charges,,,,,,,,27.56,,,,100% of Medicare,,27.56,,,,100% of Medicare,,27.56,,,,100% of Medicare,,27.56,,,,100% of Medicare,,27.56,,,,100% of Medicare,,27.56,,,,100% of Medicare,,27.56,,,,100% of Medicare,,27.56,,,,100% of Medicare,,27.56,,,,100% of Medicare,,27.56,,,,100% of Medicare,,27.56,,,,100% of Medicare,,27.56,,,,100% of Medicare,,,27.56,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,27.56,109.8,
"Wedge, Sole, Outside Sole",L3360,HCPCS,,,,outpatient,,,193,115.8,,45.5,,87.82,percent of total billed charges,,,45.3,,87.43,percent of total billed charges,,,39,,75.27,percent of total billed charges,,,,,,,,,80,,154.4,percent of total billed charges,,,61.4,,118.5,percent of total billed charges,,,57.4,,110.78,percent of total billed charges,,,81,,156.33,percent of total billed charges,,,39,,75.27,percent of total billed charges,,,57.6,,111.17,percent of total billed charges,,,85,,164.05,percent of total billed charges,,,85,,164.05,percent of total billed charges,,,49,,94.57,percent of total billed charges,,,90,,173.7,percent of total billed charges,,,65,,125.45,percent of total billed charges,,,80,,154.4,percent of total billed charges,,,55,,106.15,percent of total billed charges,,,55,,106.15,percent of total billed charges,,,65,,125.45,percent of total billed charges,,,78,,150.54,percent of total billed charges,,,70,,135.1,percent of total billed charges,,,,,,,,42.9,,,,100% of Medicare,,42.9,,,,100% of Medicare,,42.9,,,,100% of Medicare,,42.9,,,,100% of Medicare,,42.9,,,,100% of Medicare,,42.9,,,,100% of Medicare,,42.9,,,,100% of Medicare,,42.9,,,,100% of Medicare,,42.9,,,,100% of Medicare,,42.9,,,,100% of Medicare,,42.9,,,,100% of Medicare,,42.9,,,,100% of Medicare,,,42.9,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,42.9,173.7,
"Wedge, Sole, Between Sole",L3370,HCPCS,,,,outpatient,,,260,156,,45.5,,118.3,percent of total billed charges,,,45.3,,117.78,percent of total billed charges,,,39,,101.4,percent of total billed charges,,,,,,,,,80,,208,percent of total billed charges,,,61.4,,159.64,percent of total billed charges,,,57.4,,149.24,percent of total billed charges,,,81,,210.6,percent of total billed charges,,,39,,101.4,percent of total billed charges,,,57.6,,149.76,percent of total billed charges,,,85,,221,percent of total billed charges,,,85,,221,percent of total billed charges,,,49,,127.4,percent of total billed charges,,,90,,234,percent of total billed charges,,,65,,169,percent of total billed charges,,,80,,208,percent of total billed charges,,,55,,143,percent of total billed charges,,,55,,143,percent of total billed charges,,,65,,169,percent of total billed charges,,,78,,202.8,percent of total billed charges,,,70,,182,percent of total billed charges,,,,,,,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,,59.76,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,59.76,234,
"Wedge, Clubfoot",L3380,HCPCS,,,,outpatient,,,268,160.8,,45.5,,121.94,percent of total billed charges,,,45.3,,121.4,percent of total billed charges,,,39,,104.52,percent of total billed charges,,,,,,,,,80,,214.4,percent of total billed charges,,,61.4,,164.55,percent of total billed charges,,,57.4,,153.83,percent of total billed charges,,,81,,217.08,percent of total billed charges,,,39,,104.52,percent of total billed charges,,,57.6,,154.37,percent of total billed charges,,,85,,227.8,percent of total billed charges,,,85,,227.8,percent of total billed charges,,,49,,131.32,percent of total billed charges,,,90,,241.2,percent of total billed charges,,,65,,174.2,percent of total billed charges,,,80,,214.4,percent of total billed charges,,,55,,147.4,percent of total billed charges,,,55,,147.4,percent of total billed charges,,,65,,174.2,percent of total billed charges,,,78,,209.04,percent of total billed charges,,,70,,187.6,percent of total billed charges,,,,,,,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,,59.76,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,59.76,241.2,
"Wedge, Outflare",L3390,HCPCS,,,,outpatient,,,260,156,,45.5,,118.3,percent of total billed charges,,,45.3,,117.78,percent of total billed charges,,,39,,101.4,percent of total billed charges,,,,,,,,,80,,208,percent of total billed charges,,,61.4,,159.64,percent of total billed charges,,,57.4,,149.24,percent of total billed charges,,,81,,210.6,percent of total billed charges,,,39,,101.4,percent of total billed charges,,,57.6,,149.76,percent of total billed charges,,,85,,221,percent of total billed charges,,,85,,221,percent of total billed charges,,,49,,127.4,percent of total billed charges,,,90,,234,percent of total billed charges,,,65,,169,percent of total billed charges,,,80,,208,percent of total billed charges,,,55,,143,percent of total billed charges,,,55,,143,percent of total billed charges,,,65,,169,percent of total billed charges,,,78,,202.8,percent of total billed charges,,,70,,182,percent of total billed charges,,,,,,,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,59.76,,,,100% of Medicare,,,59.76,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,59.76,234,
"Wedge, Metatarsal Bar, Rocker",L3400,HCPCS,,,,outpatient,,,217,130.2,,45.5,,98.74,percent of total billed charges,,,45.3,,98.3,percent of total billed charges,,,39,,84.63,percent of total billed charges,,,,,,,,,80,,173.6,percent of total billed charges,,,61.4,,133.24,percent of total billed charges,,,57.4,,124.56,percent of total billed charges,,,81,,175.77,percent of total billed charges,,,39,,84.63,percent of total billed charges,,,57.6,,124.99,percent of total billed charges,,,85,,184.45,percent of total billed charges,,,85,,184.45,percent of total billed charges,,,49,,106.33,percent of total billed charges,,,90,,195.3,percent of total billed charges,,,65,,141.05,percent of total billed charges,,,80,,173.6,percent of total billed charges,,,55,,119.35,percent of total billed charges,,,55,,119.35,percent of total billed charges,,,65,,141.05,percent of total billed charges,,,78,,169.26,percent of total billed charges,,,70,,151.9,percent of total billed charges,,,,,,,,49.04,,,,100% of Medicare,,49.04,,,,100% of Medicare,,49.04,,,,100% of Medicare,,49.04,,,,100% of Medicare,,49.04,,,,100% of Medicare,,49.04,,,,100% of Medicare,,49.04,,,,100% of Medicare,,49.04,,,,100% of Medicare,,49.04,,,,100% of Medicare,,49.04,,,,100% of Medicare,,49.04,,,,100% of Medicare,,49.04,,,,100% of Medicare,,,49.04,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,49.04,195.3,
"L3410 Metatarsal bar wedge, between sole",L3410,HCPCS,,,,outpatient,,,492,295.2,,45.5,,223.86,percent of total billed charges,,,45.3,,222.88,percent of total billed charges,,,39,,191.88,percent of total billed charges,,,,,,,,,80,,393.6,percent of total billed charges,,,61.4,,302.09,percent of total billed charges,,,57.4,,282.41,percent of total billed charges,,,81,,398.52,percent of total billed charges,,,39,,191.88,percent of total billed charges,,,57.6,,283.39,percent of total billed charges,,,85,,418.2,percent of total billed charges,,,85,,418.2,percent of total billed charges,,,49,,241.08,percent of total billed charges,,,90,,442.8,percent of total billed charges,,,65,,319.8,percent of total billed charges,,,80,,393.6,percent of total billed charges,,,55,,270.6,percent of total billed charges,,,55,,270.6,percent of total billed charges,,,65,,319.8,percent of total billed charges,,,78,,383.76,percent of total billed charges,,,70,,344.4,percent of total billed charges,,,,,,,,111.85,,,,100% of Medicare,,111.85,,,,100% of Medicare,,111.85,,,,100% of Medicare,,111.85,,,,100% of Medicare,,111.85,,,,100% of Medicare,,111.85,,,,100% of Medicare,,111.85,,,,100% of Medicare,,111.85,,,,100% of Medicare,,111.85,,,,100% of Medicare,,111.85,,,,100% of Medicare,,111.85,,,,100% of Medicare,,111.85,,,,100% of Medicare,,,111.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,111.85,442.8,
"Wedge, Heel/Full Sole, Between Sole",L3420,HCPCS,,,,outpatient,,,294,176.4,,45.5,,133.77,percent of total billed charges,,,45.3,,133.18,percent of total billed charges,,,39,,114.66,percent of total billed charges,,,,,,,,,80,,235.2,percent of total billed charges,,,61.4,,180.52,percent of total billed charges,,,57.4,,168.76,percent of total billed charges,,,81,,238.14,percent of total billed charges,,,39,,114.66,percent of total billed charges,,,57.6,,169.34,percent of total billed charges,,,85,,249.9,percent of total billed charges,,,85,,249.9,percent of total billed charges,,,49,,144.06,percent of total billed charges,,,90,,264.6,percent of total billed charges,,,65,,191.1,percent of total billed charges,,,80,,235.2,percent of total billed charges,,,55,,161.7,percent of total billed charges,,,55,,161.7,percent of total billed charges,,,65,,191.1,percent of total billed charges,,,78,,229.32,percent of total billed charges,,,70,,205.8,percent of total billed charges,,,,,,,,65.89,,,,100% of Medicare,,65.89,,,,100% of Medicare,,65.89,,,,100% of Medicare,,65.89,,,,100% of Medicare,,65.89,,,,100% of Medicare,,65.89,,,,100% of Medicare,,65.89,,,,100% of Medicare,,65.89,,,,100% of Medicare,,65.89,,,,100% of Medicare,,65.89,,,,100% of Medicare,,65.89,,,,100% of Medicare,,65.89,,,,100% of Medicare,,,65.89,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,65.89,264.6,
"Heel, Counter, Plastic Reinforced",L3430,HCPCS,,,,outpatient,,,71,42.6,,45.5,,32.31,percent of total billed charges,,,45.3,,32.16,percent of total billed charges,,,39,,27.69,percent of total billed charges,,,,,,,,,80,,56.8,percent of total billed charges,,,61.4,,43.59,percent of total billed charges,,,57.4,,40.75,percent of total billed charges,,,81,,57.51,percent of total billed charges,,,39,,27.69,percent of total billed charges,,,57.6,,40.9,percent of total billed charges,,,85,,60.35,percent of total billed charges,,,85,,60.35,percent of total billed charges,,,49,,34.79,percent of total billed charges,,,90,,63.9,percent of total billed charges,,,65,,46.15,percent of total billed charges,,,80,,56.8,percent of total billed charges,,,55,,39.05,percent of total billed charges,,,55,,39.05,percent of total billed charges,,,65,,46.15,percent of total billed charges,,,78,,55.38,percent of total billed charges,,,70,,49.7,percent of total billed charges,,,,,,,,193.08,,,,100% of Medicare,,193.08,,,,100% of Medicare,,193.08,,,,100% of Medicare,,193.08,,,,100% of Medicare,,193.08,,,,100% of Medicare,,193.08,,,,100% of Medicare,,193.08,,,,100% of Medicare,,193.08,,,,100% of Medicare,,193.08,,,,100% of Medicare,,193.08,,,,100% of Medicare,,193.08,,,,100% of Medicare,,193.08,,,,100% of Medicare,,,193.08,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,27.69,193.08,
"Heel, Counter, Leather Reinforced",L3440,HCPCS,,,,outpatient,,,410,246,,45.5,,186.55,percent of total billed charges,,,45.3,,185.73,percent of total billed charges,,,39,,159.9,percent of total billed charges,,,,,,,,,80,,328,percent of total billed charges,,,61.4,,251.74,percent of total billed charges,,,57.4,,235.34,percent of total billed charges,,,81,,332.1,percent of total billed charges,,,39,,159.9,percent of total billed charges,,,57.6,,236.16,percent of total billed charges,,,85,,348.5,percent of total billed charges,,,85,,348.5,percent of total billed charges,,,49,,200.9,percent of total billed charges,,,90,,369,percent of total billed charges,,,65,,266.5,percent of total billed charges,,,80,,328,percent of total billed charges,,,55,,225.5,percent of total billed charges,,,55,,225.5,percent of total billed charges,,,65,,266.5,percent of total billed charges,,,78,,319.8,percent of total billed charges,,,70,,287,percent of total billed charges,,,,,,,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,,91.93,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.93,369,
"Heel, Sach Cushion Type",L3450,HCPCS,,,,outpatient,,,127,76.2,,45.5,,57.79,percent of total billed charges,,,45.3,,57.53,percent of total billed charges,,,39,,49.53,percent of total billed charges,,,,,,,,,80,,101.6,percent of total billed charges,,,61.4,,77.98,percent of total billed charges,,,57.4,,72.9,percent of total billed charges,,,81,,102.87,percent of total billed charges,,,39,,49.53,percent of total billed charges,,,57.6,,73.15,percent of total billed charges,,,85,,107.95,percent of total billed charges,,,85,,107.95,percent of total billed charges,,,49,,62.23,percent of total billed charges,,,90,,114.3,percent of total billed charges,,,65,,82.55,percent of total billed charges,,,80,,101.6,percent of total billed charges,,,55,,69.85,percent of total billed charges,,,55,,69.85,percent of total billed charges,,,65,,82.55,percent of total billed charges,,,78,,99.06,percent of total billed charges,,,70,,88.9,percent of total billed charges,,,,,,,,127.15,,,,100% of Medicare,,127.15,,,,100% of Medicare,,127.15,,,,100% of Medicare,,127.15,,,,100% of Medicare,,127.15,,,,100% of Medicare,,127.15,,,,100% of Medicare,,127.15,,,,100% of Medicare,,127.15,,,,100% of Medicare,,127.15,,,,100% of Medicare,,127.15,,,,100% of Medicare,,127.15,,,,100% of Medicare,,127.15,,,,100% of Medicare,,,127.15,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,49.53,127.15,
"Heel, New Rubber, Standard",L3460,HCPCS,,,,outpatient,,,184,110.4,,45.5,,83.72,percent of total billed charges,,,45.3,,83.35,percent of total billed charges,,,39,,71.76,percent of total billed charges,,,,,,,,,80,,147.2,percent of total billed charges,,,61.4,,112.98,percent of total billed charges,,,57.4,,105.62,percent of total billed charges,,,81,,149.04,percent of total billed charges,,,39,,71.76,percent of total billed charges,,,57.6,,105.98,percent of total billed charges,,,85,,156.4,percent of total billed charges,,,85,,156.4,percent of total billed charges,,,49,,90.16,percent of total billed charges,,,90,,165.6,percent of total billed charges,,,65,,119.6,percent of total billed charges,,,80,,147.2,percent of total billed charges,,,55,,101.2,percent of total billed charges,,,55,,101.2,percent of total billed charges,,,65,,119.6,percent of total billed charges,,,78,,143.52,percent of total billed charges,,,70,,128.8,percent of total billed charges,,,,,,,,41.39,,,,100% of Medicare,,41.39,,,,100% of Medicare,,41.39,,,,100% of Medicare,,41.39,,,,100% of Medicare,,41.39,,,,100% of Medicare,,41.39,,,,100% of Medicare,,41.39,,,,100% of Medicare,,41.39,,,,100% of Medicare,,41.39,,,,100% of Medicare,,41.39,,,,100% of Medicare,,41.39,,,,100% of Medicare,,41.39,,,,100% of Medicare,,,41.39,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,41.39,165.6,
"Heel, Thomas w/ Wedge",L3465,HCPCS,,,,outpatient,,,80,48,,45.5,,36.4,percent of total billed charges,,,45.3,,36.24,percent of total billed charges,,,39,,31.2,percent of total billed charges,,,,,,,,,80,,64,percent of total billed charges,,,61.4,,49.12,percent of total billed charges,,,57.4,,45.92,percent of total billed charges,,,81,,64.8,percent of total billed charges,,,39,,31.2,percent of total billed charges,,,57.6,,46.08,percent of total billed charges,,,85,,68,percent of total billed charges,,,85,,68,percent of total billed charges,,,49,,39.2,percent of total billed charges,,,90,,72,percent of total billed charges,,,65,,52,percent of total billed charges,,,80,,64,percent of total billed charges,,,55,,44,percent of total billed charges,,,55,,44,percent of total billed charges,,,65,,52,percent of total billed charges,,,78,,62.4,percent of total billed charges,,,70,,56,percent of total billed charges,,,,,,,,70.53,,,,100% of Medicare,,70.53,,,,100% of Medicare,,70.53,,,,100% of Medicare,,70.53,,,,100% of Medicare,,70.53,,,,100% of Medicare,,70.53,,,,100% of Medicare,,70.53,,,,100% of Medicare,,70.53,,,,100% of Medicare,,70.53,,,,100% of Medicare,,70.53,,,,100% of Medicare,,70.53,,,,100% of Medicare,,70.53,,,,100% of Medicare,,,70.53,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,31.2,72,
"Heel, Thomas Extended to Ball",L3470,HCPCS,,,,outpatient,,,161,96.6,,45.5,,73.26,percent of total billed charges,,,45.3,,72.93,percent of total billed charges,,,39,,62.79,percent of total billed charges,,,,,,,,,80,,128.8,percent of total billed charges,,,61.4,,98.85,percent of total billed charges,,,57.4,,92.41,percent of total billed charges,,,81,,130.41,percent of total billed charges,,,39,,62.79,percent of total billed charges,,,57.6,,92.74,percent of total billed charges,,,85,,136.85,percent of total billed charges,,,85,,136.85,percent of total billed charges,,,49,,78.89,percent of total billed charges,,,90,,144.9,percent of total billed charges,,,65,,104.65,percent of total billed charges,,,80,,128.8,percent of total billed charges,,,55,,88.55,percent of total billed charges,,,55,,88.55,percent of total billed charges,,,65,,104.65,percent of total billed charges,,,78,,125.58,percent of total billed charges,,,70,,112.7,percent of total billed charges,,,,,,,,75.07,,,,100% of Medicare,,75.07,,,,100% of Medicare,,75.07,,,,100% of Medicare,,75.07,,,,100% of Medicare,,75.07,,,,100% of Medicare,,75.07,,,,100% of Medicare,,75.07,,,,100% of Medicare,,75.07,,,,100% of Medicare,,75.07,,,,100% of Medicare,,75.07,,,,100% of Medicare,,75.07,,,,100% of Medicare,,75.07,,,,100% of Medicare,,,75.07,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,62.79,144.9,
L3480 Pad & Depression for Spur,L3480,HCPCS,,,,outpatient,,,329,197.4,,45.5,,149.7,percent of total billed charges,,,45.3,,149.04,percent of total billed charges,,,39,,128.31,percent of total billed charges,,,,,,,,,80,,263.2,percent of total billed charges,,,61.4,,202.01,percent of total billed charges,,,57.4,,188.85,percent of total billed charges,,,81,,266.49,percent of total billed charges,,,39,,128.31,percent of total billed charges,,,57.6,,189.5,percent of total billed charges,,,85,,279.65,percent of total billed charges,,,85,,279.65,percent of total billed charges,,,49,,161.21,percent of total billed charges,,,90,,296.1,percent of total billed charges,,,65,,213.85,percent of total billed charges,,,80,,263.2,percent of total billed charges,,,55,,180.95,percent of total billed charges,,,55,,180.95,percent of total billed charges,,,65,,213.85,percent of total billed charges,,,78,,256.62,percent of total billed charges,,,70,,230.3,percent of total billed charges,,,,,,,,75.07,,,,100% of Medicare,,75.07,,,,100% of Medicare,,75.07,,,,100% of Medicare,,75.07,,,,100% of Medicare,,75.07,,,,100% of Medicare,,75.07,,,,100% of Medicare,,75.07,,,,100% of Medicare,,75.07,,,,100% of Medicare,,75.07,,,,100% of Medicare,,75.07,,,,100% of Medicare,,75.07,,,,100% of Medicare,,75.07,,,,100% of Medicare,,,75.07,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,75.07,296.1,
"Heel, Pad, Removable for Spur",L3485,HCPCS,,,,outpatient,,,73,43.8,,45.5,,33.22,percent of total billed charges,,,45.3,,33.07,percent of total billed charges,,,39,,28.47,percent of total billed charges,,,,,,,,,80,,58.4,percent of total billed charges,,,61.4,,44.82,percent of total billed charges,,,57.4,,41.9,percent of total billed charges,,,81,,59.13,percent of total billed charges,,,39,,28.47,percent of total billed charges,,,57.6,,42.05,percent of total billed charges,,,85,,62.05,percent of total billed charges,,,85,,62.05,percent of total billed charges,,,49,,35.77,percent of total billed charges,,,90,,65.7,percent of total billed charges,,,65,,47.45,percent of total billed charges,,,80,,58.4,percent of total billed charges,,,55,,40.15,percent of total billed charges,,,55,,40.15,percent of total billed charges,,,65,,47.45,percent of total billed charges,,,78,,56.94,percent of total billed charges,,,70,,51.1,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,28.47,65.7,
"Insole, Leather",L3500,HCPCS,,,,outpatient,,,65,39,,45.5,,29.58,percent of total billed charges,,,45.3,,29.45,percent of total billed charges,,,39,,25.35,percent of total billed charges,,,,,,,,,80,,52,percent of total billed charges,,,61.4,,39.91,percent of total billed charges,,,57.4,,37.31,percent of total billed charges,,,81,,52.65,percent of total billed charges,,,39,,25.35,percent of total billed charges,,,57.6,,37.44,percent of total billed charges,,,85,,55.25,percent of total billed charges,,,85,,55.25,percent of total billed charges,,,49,,31.85,percent of total billed charges,,,90,,58.5,percent of total billed charges,,,65,,42.25,percent of total billed charges,,,80,,52,percent of total billed charges,,,55,,35.75,percent of total billed charges,,,55,,35.75,percent of total billed charges,,,65,,42.25,percent of total billed charges,,,78,,50.7,percent of total billed charges,,,70,,45.5,percent of total billed charges,,,,,,,,35.23,,,,100% of Medicare,,35.23,,,,100% of Medicare,,35.23,,,,100% of Medicare,,35.23,,,,100% of Medicare,,35.23,,,,100% of Medicare,,35.23,,,,100% of Medicare,,35.23,,,,100% of Medicare,,35.23,,,,100% of Medicare,,35.23,,,,100% of Medicare,,35.23,,,,100% of Medicare,,35.23,,,,100% of Medicare,,35.23,,,,100% of Medicare,,,35.23,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,25.35,58.5,
"Insole, Rubber",L3510,HCPCS,,,,outpatient,,,58,34.8,,45.5,,26.39,percent of total billed charges,,,45.3,,26.27,percent of total billed charges,,,39,,22.62,percent of total billed charges,,,,,,,,,80,,46.4,percent of total billed charges,,,61.4,,35.61,percent of total billed charges,,,57.4,,33.29,percent of total billed charges,,,81,,46.98,percent of total billed charges,,,39,,22.62,percent of total billed charges,,,57.6,,33.41,percent of total billed charges,,,85,,49.3,percent of total billed charges,,,85,,49.3,percent of total billed charges,,,49,,28.42,percent of total billed charges,,,90,,52.2,percent of total billed charges,,,65,,37.7,percent of total billed charges,,,80,,46.4,percent of total billed charges,,,55,,31.9,percent of total billed charges,,,55,,31.9,percent of total billed charges,,,65,,37.7,percent of total billed charges,,,78,,45.24,percent of total billed charges,,,70,,40.6,percent of total billed charges,,,,,,,,35.23,,,,100% of Medicare,,35.23,,,,100% of Medicare,,35.23,,,,100% of Medicare,,35.23,,,,100% of Medicare,,35.23,,,,100% of Medicare,,35.23,,,,100% of Medicare,,35.23,,,,100% of Medicare,,35.23,,,,100% of Medicare,,35.23,,,,100% of Medicare,,35.23,,,,100% of Medicare,,35.23,,,,100% of Medicare,,35.23,,,,100% of Medicare,,,35.23,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,22.62,52.2,
"Orthopedic Shoe Addition, Insole, Felt Covered w/ Leather",L3520,HCPCS,,,,outpatient,,,80,48,,45.5,,36.4,percent of total billed charges,,,45.3,,36.24,percent of total billed charges,,,39,,31.2,percent of total billed charges,,,,,,,,,80,,64,percent of total billed charges,,,61.4,,49.12,percent of total billed charges,,,57.4,,45.92,percent of total billed charges,,,81,,64.8,percent of total billed charges,,,39,,31.2,percent of total billed charges,,,57.6,,46.08,percent of total billed charges,,,85,,68,percent of total billed charges,,,85,,68,percent of total billed charges,,,49,,39.2,percent of total billed charges,,,90,,72,percent of total billed charges,,,65,,52,percent of total billed charges,,,80,,64,percent of total billed charges,,,55,,44,percent of total billed charges,,,55,,44,percent of total billed charges,,,65,,52,percent of total billed charges,,,78,,62.4,percent of total billed charges,,,70,,56,percent of total billed charges,,,,,,,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,,38.31,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,31.2,72,
"Orthopedic Shoe Addition, Sole, Half",L3530,HCPCS,,,,outpatient,,,165,99,,45.5,,75.08,percent of total billed charges,,,45.3,,74.75,percent of total billed charges,,,39,,64.35,percent of total billed charges,,,,,,,,,80,,132,percent of total billed charges,,,61.4,,101.31,percent of total billed charges,,,57.4,,94.71,percent of total billed charges,,,81,,133.65,percent of total billed charges,,,39,,64.35,percent of total billed charges,,,57.6,,95.04,percent of total billed charges,,,85,,140.25,percent of total billed charges,,,85,,140.25,percent of total billed charges,,,49,,80.85,percent of total billed charges,,,90,,148.5,percent of total billed charges,,,65,,107.25,percent of total billed charges,,,80,,132,percent of total billed charges,,,55,,90.75,percent of total billed charges,,,55,,90.75,percent of total billed charges,,,65,,107.25,percent of total billed charges,,,78,,128.7,percent of total billed charges,,,70,,115.5,percent of total billed charges,,,,,,,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,38.31,,,,100% of Medicare,,,38.31,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,38.31,148.5,
"Orthopedic Shoe Addition, Sole, Full",L3540,HCPCS,,,,outpatient,,,277,166.2,,45.5,,126.04,percent of total billed charges,,,45.3,,125.48,percent of total billed charges,,,39,,108.03,percent of total billed charges,,,,,,,,,80,,221.6,percent of total billed charges,,,61.4,,170.08,percent of total billed charges,,,57.4,,159,percent of total billed charges,,,81,,224.37,percent of total billed charges,,,39,,108.03,percent of total billed charges,,,57.6,,159.55,percent of total billed charges,,,85,,235.45,percent of total billed charges,,,85,,235.45,percent of total billed charges,,,49,,135.73,percent of total billed charges,,,90,,249.3,percent of total billed charges,,,65,,180.05,percent of total billed charges,,,80,,221.6,percent of total billed charges,,,55,,152.35,percent of total billed charges,,,55,,152.35,percent of total billed charges,,,65,,180.05,percent of total billed charges,,,78,,216.06,percent of total billed charges,,,70,,193.9,percent of total billed charges,,,,,,,,61.29,,,,100% of Medicare,,61.29,,,,100% of Medicare,,61.29,,,,100% of Medicare,,61.29,,,,100% of Medicare,,61.29,,,,100% of Medicare,,61.29,,,,100% of Medicare,,61.29,,,,100% of Medicare,,61.29,,,,100% of Medicare,,61.29,,,,100% of Medicare,,61.29,,,,100% of Medicare,,61.29,,,,100% of Medicare,,61.29,,,,100% of Medicare,,,61.29,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,61.29,249.3,
"Orthopedic Shoe Addition, Toe Tap Standard",L3550,HCPCS,,,,outpatient,,,45,27,,45.5,,20.48,percent of total billed charges,,,45.3,,20.39,percent of total billed charges,,,39,,17.55,percent of total billed charges,,,,,,,,,80,,36,percent of total billed charges,,,61.4,,27.63,percent of total billed charges,,,57.4,,25.83,percent of total billed charges,,,81,,36.45,percent of total billed charges,,,39,,17.55,percent of total billed charges,,,57.6,,25.92,percent of total billed charges,,,85,,38.25,percent of total billed charges,,,85,,38.25,percent of total billed charges,,,49,,22.05,percent of total billed charges,,,90,,40.5,percent of total billed charges,,,65,,29.25,percent of total billed charges,,,80,,36,percent of total billed charges,,,55,,24.75,percent of total billed charges,,,55,,24.75,percent of total billed charges,,,65,,29.25,percent of total billed charges,,,78,,35.1,percent of total billed charges,,,70,,31.5,percent of total billed charges,,,,,,,,10.77,,,,100% of Medicare,,10.77,,,,100% of Medicare,,10.77,,,,100% of Medicare,,10.77,,,,100% of Medicare,,10.77,,,,100% of Medicare,,10.77,,,,100% of Medicare,,10.77,,,,100% of Medicare,,10.77,,,,100% of Medicare,,10.77,,,,100% of Medicare,,10.77,,,,100% of Medicare,,10.77,,,,100% of Medicare,,10.77,,,,100% of Medicare,,,10.77,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,10.77,40.5,
"Orthopedic Shoe Addition, Toe Tap Horseshoe",L3560,HCPCS,,,,outpatient,,,69,41.4,,45.5,,31.4,percent of total billed charges,,,45.3,,31.26,percent of total billed charges,,,39,,26.91,percent of total billed charges,,,,,,,,,80,,55.2,percent of total billed charges,,,61.4,,42.37,percent of total billed charges,,,57.4,,39.61,percent of total billed charges,,,81,,55.89,percent of total billed charges,,,39,,26.91,percent of total billed charges,,,57.6,,39.74,percent of total billed charges,,,85,,58.65,percent of total billed charges,,,85,,58.65,percent of total billed charges,,,49,,33.81,percent of total billed charges,,,90,,62.1,percent of total billed charges,,,65,,44.85,percent of total billed charges,,,80,,55.2,percent of total billed charges,,,55,,37.95,percent of total billed charges,,,55,,37.95,percent of total billed charges,,,65,,44.85,percent of total billed charges,,,78,,53.82,percent of total billed charges,,,70,,48.3,percent of total billed charges,,,,,,,,27.56,,,,100% of Medicare,,27.56,,,,100% of Medicare,,27.56,,,,100% of Medicare,,27.56,,,,100% of Medicare,,27.56,,,,100% of Medicare,,27.56,,,,100% of Medicare,,27.56,,,,100% of Medicare,,27.56,,,,100% of Medicare,,27.56,,,,100% of Medicare,,27.56,,,,100% of Medicare,,27.56,,,,100% of Medicare,,27.56,,,,100% of Medicare,,,27.56,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,26.91,62.1,
"Orthopedic Shoe Addition, Special Extension to Instep (leather w/ Eyelet)",L3570,HCPCS,,,,outpatient,,,236,141.6,,45.5,,107.38,percent of total billed charges,,,45.3,,106.91,percent of total billed charges,,,39,,92.04,percent of total billed charges,,,,,,,,,80,,188.8,percent of total billed charges,,,61.4,,144.9,percent of total billed charges,,,57.4,,135.46,percent of total billed charges,,,81,,191.16,percent of total billed charges,,,39,,92.04,percent of total billed charges,,,57.6,,135.94,percent of total billed charges,,,85,,200.6,percent of total billed charges,,,85,,200.6,percent of total billed charges,,,49,,115.64,percent of total billed charges,,,90,,212.4,percent of total billed charges,,,65,,153.4,percent of total billed charges,,,80,,188.8,percent of total billed charges,,,55,,129.8,percent of total billed charges,,,55,,129.8,percent of total billed charges,,,65,,153.4,percent of total billed charges,,,78,,184.08,percent of total billed charges,,,70,,165.2,percent of total billed charges,,,,,,,,102.69,,,,100% of Medicare,,102.69,,,,100% of Medicare,,102.69,,,,100% of Medicare,,102.69,,,,100% of Medicare,,102.69,,,,100% of Medicare,,102.69,,,,100% of Medicare,,102.69,,,,100% of Medicare,,102.69,,,,100% of Medicare,,102.69,,,,100% of Medicare,,102.69,,,,100% of Medicare,,102.69,,,,100% of Medicare,,102.69,,,,100% of Medicare,,,102.69,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,92.04,212.4,
"Orthopedic Shoe Addition, Convert to Velcro Closure",L3580,HCPCS,,,,outpatient,,,349,209.4,,45.5,,158.8,percent of total billed charges,,,45.3,,158.1,percent of total billed charges,,,39,,136.11,percent of total billed charges,,,,,,,,,80,,279.2,percent of total billed charges,,,61.4,,214.29,percent of total billed charges,,,57.4,,200.33,percent of total billed charges,,,81,,282.69,percent of total billed charges,,,39,,136.11,percent of total billed charges,,,57.6,,201.02,percent of total billed charges,,,85,,296.65,percent of total billed charges,,,85,,296.65,percent of total billed charges,,,49,,171.01,percent of total billed charges,,,90,,314.1,percent of total billed charges,,,65,,226.85,percent of total billed charges,,,80,,279.2,percent of total billed charges,,,55,,191.95,percent of total billed charges,,,55,,191.95,percent of total billed charges,,,65,,226.85,percent of total billed charges,,,78,,272.22,percent of total billed charges,,,70,,244.3,percent of total billed charges,,,,,,,,78.14,,,,100% of Medicare,,78.14,,,,100% of Medicare,,78.14,,,,100% of Medicare,,78.14,,,,100% of Medicare,,78.14,,,,100% of Medicare,,78.14,,,,100% of Medicare,,78.14,,,,100% of Medicare,,78.14,,,,100% of Medicare,,78.14,,,,100% of Medicare,,78.14,,,,100% of Medicare,,78.14,,,,100% of Medicare,,78.14,,,,100% of Medicare,,,78.14,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,78.14,314.1,
"Orthopedic Shoe Addition, Convert Firm Counter to Soft",L3590,HCPCS,,,,outpatient,,,151,90.6,,45.5,,68.71,percent of total billed charges,,,45.3,,68.4,percent of total billed charges,,,39,,58.89,percent of total billed charges,,,,,,,,,80,,120.8,percent of total billed charges,,,61.4,,92.71,percent of total billed charges,,,57.4,,86.67,percent of total billed charges,,,81,,122.31,percent of total billed charges,,,39,,58.89,percent of total billed charges,,,57.6,,86.98,percent of total billed charges,,,85,,128.35,percent of total billed charges,,,85,,128.35,percent of total billed charges,,,49,,73.99,percent of total billed charges,,,90,,135.9,percent of total billed charges,,,65,,98.15,percent of total billed charges,,,80,,120.8,percent of total billed charges,,,55,,83.05,percent of total billed charges,,,55,,83.05,percent of total billed charges,,,65,,98.15,percent of total billed charges,,,78,,117.78,percent of total billed charges,,,70,,105.7,percent of total billed charges,,,,,,,,64.37,,,,100% of Medicare,,64.37,,,,100% of Medicare,,64.37,,,,100% of Medicare,,64.37,,,,100% of Medicare,,64.37,,,,100% of Medicare,,64.37,,,,100% of Medicare,,64.37,,,,100% of Medicare,,64.37,,,,100% of Medicare,,64.37,,,,100% of Medicare,,64.37,,,,100% of Medicare,,64.37,,,,100% of Medicare,,64.37,,,,100% of Medicare,,,64.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,58.89,135.9,
"Orthopedic Shoe Addition, March Bar",L3595,HCPCS,,,,outpatient,,,117,70.2,,45.5,,53.24,percent of total billed charges,,,45.3,,53,percent of total billed charges,,,39,,45.63,percent of total billed charges,,,,,,,,,80,,93.6,percent of total billed charges,,,61.4,,71.84,percent of total billed charges,,,57.4,,67.16,percent of total billed charges,,,81,,94.77,percent of total billed charges,,,39,,45.63,percent of total billed charges,,,57.6,,67.39,percent of total billed charges,,,85,,99.45,percent of total billed charges,,,85,,99.45,percent of total billed charges,,,49,,57.33,percent of total billed charges,,,90,,105.3,percent of total billed charges,,,65,,76.05,percent of total billed charges,,,80,,93.6,percent of total billed charges,,,55,,64.35,percent of total billed charges,,,55,,64.35,percent of total billed charges,,,65,,76.05,percent of total billed charges,,,78,,91.26,percent of total billed charges,,,70,,81.9,percent of total billed charges,,,,,,,,50.53,,,,100% of Medicare,,50.53,,,,100% of Medicare,,50.53,,,,100% of Medicare,,50.53,,,,100% of Medicare,,50.53,,,,100% of Medicare,,50.53,,,,100% of Medicare,,50.53,,,,100% of Medicare,,50.53,,,,100% of Medicare,,50.53,,,,100% of Medicare,,50.53,,,,100% of Medicare,,50.53,,,,100% of Medicare,,50.53,,,,100% of Medicare,,,50.53,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,45.63,105.3,
"Orthosis, Transfer, Caliper Plate",L3600,HCPCS,,,,outpatient,,,143,85.8,,45.5,,65.07,percent of total billed charges,,,45.3,,64.78,percent of total billed charges,,,39,,55.77,percent of total billed charges,,,,,,,,,80,,114.4,percent of total billed charges,,,61.4,,87.8,percent of total billed charges,,,57.4,,82.08,percent of total billed charges,,,81,,115.83,percent of total billed charges,,,39,,55.77,percent of total billed charges,,,57.6,,82.37,percent of total billed charges,,,85,,121.55,percent of total billed charges,,,85,,121.55,percent of total billed charges,,,49,,70.07,percent of total billed charges,,,90,,128.7,percent of total billed charges,,,65,,92.95,percent of total billed charges,,,80,,114.4,percent of total billed charges,,,55,,78.65,percent of total billed charges,,,55,,78.65,percent of total billed charges,,,65,,92.95,percent of total billed charges,,,78,,111.54,percent of total billed charges,,,70,,100.1,percent of total billed charges,,,,,,,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,,91.93,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,55.77,128.7,
"TRANSFER  OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, CALIPER PLATE, NEW",L3610,HCPCS,,,,outpatient,,,569,341.4,,45.5,,258.9,percent of total billed charges,,,45.3,,257.76,percent of total billed charges,,,39,,221.91,percent of total billed charges,,,,,,,,,80,,455.2,percent of total billed charges,,,61.4,,349.37,percent of total billed charges,,,57.4,,326.61,percent of total billed charges,,,81,,460.89,percent of total billed charges,,,39,,221.91,percent of total billed charges,,,57.6,,327.74,percent of total billed charges,,,85,,483.65,percent of total billed charges,,,85,,483.65,percent of total billed charges,,,49,,278.81,percent of total billed charges,,,90,,512.1,percent of total billed charges,,,65,,369.85,percent of total billed charges,,,80,,455.2,percent of total billed charges,,,55,,312.95,percent of total billed charges,,,55,,312.95,percent of total billed charges,,,65,,369.85,percent of total billed charges,,,78,,443.82,percent of total billed charges,,,70,,398.3,percent of total billed charges,,,,,,,,121.06,,,,100% of Medicare,,121.06,,,,100% of Medicare,,121.06,,,,100% of Medicare,,121.06,,,,100% of Medicare,,121.06,,,,100% of Medicare,,121.06,,,,100% of Medicare,,121.06,,,,100% of Medicare,,121.06,,,,100% of Medicare,,121.06,,,,100% of Medicare,,121.06,,,,100% of Medicare,,121.06,,,,100% of Medicare,,121.06,,,,100% of Medicare,,,121.06,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,121.06,512.1,
"Orthosis, Transfer, Existing Stirrup",L3620,HCPCS,,,,outpatient,,,398,238.8,,45.5,,181.09,percent of total billed charges,,,45.3,,180.29,percent of total billed charges,,,39,,155.22,percent of total billed charges,,,,,,,,,80,,318.4,percent of total billed charges,,,61.4,,244.37,percent of total billed charges,,,57.4,,228.45,percent of total billed charges,,,81,,322.38,percent of total billed charges,,,39,,155.22,percent of total billed charges,,,57.6,,229.25,percent of total billed charges,,,85,,338.3,percent of total billed charges,,,85,,338.3,percent of total billed charges,,,49,,195.02,percent of total billed charges,,,90,,358.2,percent of total billed charges,,,65,,258.7,percent of total billed charges,,,80,,318.4,percent of total billed charges,,,55,,218.9,percent of total billed charges,,,55,,218.9,percent of total billed charges,,,65,,258.7,percent of total billed charges,,,78,,310.44,percent of total billed charges,,,70,,278.6,percent of total billed charges,,,,,,,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,91.93,,,,100% of Medicare,,,91.93,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.93,358.2,
"Orthosis, Transfer, New Stirrup",L3630,HCPCS,,,,outpatient,,,543,325.8,,45.5,,247.07,percent of total billed charges,,,45.3,,245.98,percent of total billed charges,,,39,,211.77,percent of total billed charges,,,,,,,,,80,,434.4,percent of total billed charges,,,61.4,,333.4,percent of total billed charges,,,57.4,,311.68,percent of total billed charges,,,81,,439.83,percent of total billed charges,,,39,,211.77,percent of total billed charges,,,57.6,,312.77,percent of total billed charges,,,85,,461.55,percent of total billed charges,,,85,,461.55,percent of total billed charges,,,49,,266.07,percent of total billed charges,,,90,,488.7,percent of total billed charges,,,65,,352.95,percent of total billed charges,,,80,,434.4,percent of total billed charges,,,55,,298.65,percent of total billed charges,,,55,,298.65,percent of total billed charges,,,65,,352.95,percent of total billed charges,,,78,,423.54,percent of total billed charges,,,70,,380.1,percent of total billed charges,,,,,,,,121.06,,,,100% of Medicare,,121.06,,,,100% of Medicare,,121.06,,,,100% of Medicare,,121.06,,,,100% of Medicare,,121.06,,,,100% of Medicare,,121.06,,,,100% of Medicare,,121.06,,,,100% of Medicare,,121.06,,,,100% of Medicare,,121.06,,,,100% of Medicare,,121.06,,,,100% of Medicare,,121.06,,,,100% of Medicare,,121.06,,,,100% of Medicare,,,121.06,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,121.06,488.7,
"Shoulder Orthosis, Figure 8 Abduction Restrainer",L3650,HCPCS,,,,outpatient,,,355,213,,45.5,,161.53,percent of total billed charges,,,45.3,,160.82,percent of total billed charges,,,39,,138.45,percent of total billed charges,,,,,,,,,80,,284,percent of total billed charges,,,61.4,,217.97,percent of total billed charges,,,57.4,,203.77,percent of total billed charges,,,81,,287.55,percent of total billed charges,,,39,,138.45,percent of total billed charges,,,57.6,,204.48,percent of total billed charges,,,85,,301.75,percent of total billed charges,,,85,,301.75,percent of total billed charges,,,49,,173.95,percent of total billed charges,,,90,,319.5,percent of total billed charges,,,65,,230.75,percent of total billed charges,,,80,,284,percent of total billed charges,,,55,,195.25,percent of total billed charges,,,55,,195.25,percent of total billed charges,,,65,,230.75,percent of total billed charges,,,78,,276.9,percent of total billed charges,,,70,,248.5,percent of total billed charges,,,,,,,,79.02,,,,100% of Medicare,,79.02,,,,100% of Medicare,,79.02,,,,100% of Medicare,,79.02,,,,100% of Medicare,,79.02,,,,100% of Medicare,,79.02,,,,100% of Medicare,,79.02,,,,100% of Medicare,,79.02,,,,100% of Medicare,,79.02,,,,100% of Medicare,,79.02,,,,100% of Medicare,,79.02,,,,100% of Medicare,,79.02,,,,100% of Medicare,,,79.02,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,79.02,319.5,
"Shoulder Orthosis, Figure of Eight, Canvas",L3660,HCPCS,,,,outpatient,,,505,303,,45.5,,229.78,percent of total billed charges,,,45.3,,228.77,percent of total billed charges,,,39,,196.95,percent of total billed charges,,,,,,,,,80,,404,percent of total billed charges,,,61.4,,310.07,percent of total billed charges,,,57.4,,289.87,percent of total billed charges,,,81,,409.05,percent of total billed charges,,,39,,196.95,percent of total billed charges,,,57.6,,290.88,percent of total billed charges,,,85,,429.25,percent of total billed charges,,,85,,429.25,percent of total billed charges,,,49,,247.45,percent of total billed charges,,,90,,454.5,percent of total billed charges,,,65,,328.25,percent of total billed charges,,,80,,404,percent of total billed charges,,,55,,277.75,percent of total billed charges,,,55,,277.75,percent of total billed charges,,,65,,328.25,percent of total billed charges,,,78,,393.9,percent of total billed charges,,,70,,353.5,percent of total billed charges,,,,,,,,113.31,,,,100% of Medicare,,113.31,,,,100% of Medicare,,113.31,,,,100% of Medicare,,113.31,,,,100% of Medicare,,113.31,,,,100% of Medicare,,113.31,,,,100% of Medicare,,113.31,,,,100% of Medicare,,113.31,,,,100% of Medicare,,113.31,,,,100% of Medicare,,113.31,,,,100% of Medicare,,113.31,,,,100% of Medicare,,113.31,,,,100% of Medicare,,,113.31,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,113.31,454.5,
"Shoulder Orthosis, Acro/Clavicular Canvas",L3670,HCPCS,,,,outpatient,,,555,333,,45.5,,252.53,percent of total billed charges,,,45.3,,251.42,percent of total billed charges,,,39,,216.45,percent of total billed charges,,,,,,,,,80,,444,percent of total billed charges,,,61.4,,340.77,percent of total billed charges,,,57.4,,318.57,percent of total billed charges,,,81,,449.55,percent of total billed charges,,,39,,216.45,percent of total billed charges,,,57.6,,319.68,percent of total billed charges,,,85,,471.75,percent of total billed charges,,,85,,471.75,percent of total billed charges,,,49,,271.95,percent of total billed charges,,,90,,499.5,percent of total billed charges,,,65,,360.75,percent of total billed charges,,,80,,444,percent of total billed charges,,,55,,305.25,percent of total billed charges,,,55,,305.25,percent of total billed charges,,,65,,360.75,percent of total billed charges,,,78,,432.9,percent of total billed charges,,,70,,388.5,percent of total billed charges,,,,,,,,124.66,,,,100% of Medicare,,124.66,,,,100% of Medicare,,124.66,,,,100% of Medicare,,124.66,,,,100% of Medicare,,124.66,,,,100% of Medicare,,124.66,,,,100% of Medicare,,124.66,,,,100% of Medicare,,124.66,,,,100% of Medicare,,124.66,,,,100% of Medicare,,124.66,,,,100% of Medicare,,124.66,,,,100% of Medicare,,124.66,,,,100% of Medicare,,,124.66,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,124.66,499.5,
"Shoulder Orthosis, Cap Design, Custom Fabricated",L3671,HCPCS,,,,outpatient,,,2014,1208.4,,45.5,,916.37,percent of total billed charges,,,45.3,,912.34,percent of total billed charges,,,39,,785.46,percent of total billed charges,,,,,,,,,80,,1611.2,percent of total billed charges,,,61.4,,1236.6,percent of total billed charges,,,57.4,,1156.04,percent of total billed charges,,,81,,1631.34,percent of total billed charges,,,39,,785.46,percent of total billed charges,,,57.6,,1160.06,percent of total billed charges,,,85,,1711.9,percent of total billed charges,,,85,,1711.9,percent of total billed charges,,,49,,986.86,percent of total billed charges,,,90,,1812.6,percent of total billed charges,,,65,,1309.1,percent of total billed charges,,,80,,1611.2,percent of total billed charges,,,55,,1107.7,percent of total billed charges,,,55,,1107.7,percent of total billed charges,,,65,,1309.1,percent of total billed charges,,,78,,1570.92,percent of total billed charges,,,70,,1409.8,percent of total billed charges,,,,,,,,988.03,,,,100% of Medicare,,988.03,,,,100% of Medicare,,988.03,,,,100% of Medicare,,988.03,,,,100% of Medicare,,988.03,,,,100% of Medicare,,988.03,,,,100% of Medicare,,988.03,,,,100% of Medicare,,988.03,,,,100% of Medicare,,988.03,,,,100% of Medicare,,988.03,,,,100% of Medicare,,988.03,,,,100% of Medicare,,988.03,,,,100% of Medicare,,,988.03,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,785.46,1812.6,
"L3675 Shoulder orthosis (SO), vest type abduction restrainer, canvas webbing type or equal, prefabri",L3675,HCPCS,,,,outpatient,,,821,492.6,,45.5,,373.56,percent of total billed charges,,,45.3,,371.91,percent of total billed charges,,,39,,320.19,percent of total billed charges,,,,,,,,,80,,656.8,percent of total billed charges,,,61.4,,504.09,percent of total billed charges,,,57.4,,471.25,percent of total billed charges,,,81,,665.01,percent of total billed charges,,,39,,320.19,percent of total billed charges,,,57.6,,472.9,percent of total billed charges,,,85,,697.85,percent of total billed charges,,,85,,697.85,percent of total billed charges,,,49,,402.29,percent of total billed charges,,,90,,738.9,percent of total billed charges,,,65,,533.65,percent of total billed charges,,,80,,656.8,percent of total billed charges,,,55,,451.55,percent of total billed charges,,,55,,451.55,percent of total billed charges,,,65,,533.65,percent of total billed charges,,,78,,640.38,percent of total billed charges,,,70,,574.7,percent of total billed charges,,,,,,,,192.46,,,,100% of Medicare,,192.46,,,,100% of Medicare,,192.46,,,,100% of Medicare,,192.46,,,,100% of Medicare,,192.46,,,,100% of Medicare,,192.46,,,,100% of Medicare,,192.46,,,,100% of Medicare,,192.46,,,,100% of Medicare,,192.46,,,,100% of Medicare,,192.46,,,,100% of Medicare,,192.46,,,,100% of Medicare,,192.46,,,,100% of Medicare,,,192.46,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,192.46,738.9,
OT Elbow Orthosis Left Charge L3702,L3702,HCPCS,,,LT,both,,,951,570.6,,45.5,,432.71,percent of total billed charges,,,45.3,,430.8,percent of total billed charges,,,39,,370.89,percent of total billed charges,,,,,,,,,80,,760.8,percent of total billed charges,,,61.4,,583.91,percent of total billed charges,,,57.4,,545.87,percent of total billed charges,,,81,,770.31,percent of total billed charges,,,39,,370.89,percent of total billed charges,,,57.6,,547.78,percent of total billed charges,,,85,,808.35,percent of total billed charges,,,85,,808.35,percent of total billed charges,,,49,,465.99,percent of total billed charges,,,90,,855.9,percent of total billed charges,,,65,,618.15,percent of total billed charges,,,80,,760.8,percent of total billed charges,,,55,,523.05,percent of total billed charges,,,55,,523.05,percent of total billed charges,,,65,,618.15,percent of total billed charges,,,78,,741.78,percent of total billed charges,,,70,,665.7,percent of total billed charges,,,,,,,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,,316.64,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,316.64,855.9,
OT Elbow Orthosis Right Charge L3702,L3702,HCPCS,,,RT,both,,,951,570.6,,45.5,,432.71,percent of total billed charges,,,45.3,,430.8,percent of total billed charges,,,39,,370.89,percent of total billed charges,,,,,,,,,80,,760.8,percent of total billed charges,,,61.4,,583.91,percent of total billed charges,,,57.4,,545.87,percent of total billed charges,,,81,,770.31,percent of total billed charges,,,39,,370.89,percent of total billed charges,,,57.6,,547.78,percent of total billed charges,,,85,,808.35,percent of total billed charges,,,85,,808.35,percent of total billed charges,,,49,,465.99,percent of total billed charges,,,90,,855.9,percent of total billed charges,,,65,,618.15,percent of total billed charges,,,80,,760.8,percent of total billed charges,,,55,,523.05,percent of total billed charges,,,55,,523.05,percent of total billed charges,,,65,,618.15,percent of total billed charges,,,78,,741.78,percent of total billed charges,,,70,,665.7,percent of total billed charges,,,,,,,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,,316.64,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,316.64,855.9,
"Elbow Orthosis, Elastic, Custom Fabricated",L3702,HCPCS,,,,outpatient,,,1415,849,,45.5,,643.83,percent of total billed charges,,,45.3,,641,percent of total billed charges,,,39,,551.85,percent of total billed charges,,,,,,,,,80,,1132,percent of total billed charges,,,61.4,,868.81,percent of total billed charges,,,57.4,,812.21,percent of total billed charges,,,81,,1146.15,percent of total billed charges,,,39,,551.85,percent of total billed charges,,,57.6,,815.04,percent of total billed charges,,,85,,1202.75,percent of total billed charges,,,85,,1202.75,percent of total billed charges,,,49,,693.35,percent of total billed charges,,,90,,1273.5,percent of total billed charges,,,65,,919.75,percent of total billed charges,,,80,,1132,percent of total billed charges,,,55,,778.25,percent of total billed charges,,,55,,778.25,percent of total billed charges,,,65,,919.75,percent of total billed charges,,,78,,1103.7,percent of total billed charges,,,70,,990.5,percent of total billed charges,,,,,,,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,316.64,,,,100% of Medicare,,,316.64,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,316.64,1273.5,
"Elbow Orthosis, Elastic w/ Metal Jts",L3710,HCPCS,,,,outpatient,,,680,408,,45.5,,309.4,percent of total billed charges,,,45.3,,308.04,percent of total billed charges,,,39,,265.2,percent of total billed charges,,,,,,,,,80,,544,percent of total billed charges,,,61.4,,417.52,percent of total billed charges,,,57.4,,390.32,percent of total billed charges,,,81,,550.8,percent of total billed charges,,,39,,265.2,percent of total billed charges,,,57.6,,391.68,percent of total billed charges,,,85,,578,percent of total billed charges,,,85,,578,percent of total billed charges,,,49,,333.2,percent of total billed charges,,,90,,612,percent of total billed charges,,,65,,442,percent of total billed charges,,,80,,544,percent of total billed charges,,,55,,374,percent of total billed charges,,,55,,374,percent of total billed charges,,,65,,442,percent of total billed charges,,,78,,530.4,percent of total billed charges,,,70,,476,percent of total billed charges,,,,,,,,156.57,,,,100% of Medicare,,156.57,,,,100% of Medicare,,156.57,,,,100% of Medicare,,156.57,,,,100% of Medicare,,156.57,,,,100% of Medicare,,156.57,,,,100% of Medicare,,156.57,,,,100% of Medicare,,156.57,,,,100% of Medicare,,156.57,,,,100% of Medicare,,156.57,,,,100% of Medicare,,156.57,,,,100% of Medicare,,156.57,,,,100% of Medicare,,,156.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,156.57,612,
"Elbow Orthosis, Double Upright w/ Forearm/Arm Cuffs, Free Motion",L3720,HCPCS,,,,outpatient,,,3346,2007.6,,45.5,,1522.43,percent of total billed charges,,,45.3,,1515.74,percent of total billed charges,,,39,,1304.94,percent of total billed charges,,,,,,,,,80,,2676.8,percent of total billed charges,,,61.4,,2054.44,percent of total billed charges,,,57.4,,1920.6,percent of total billed charges,,,81,,2710.26,percent of total billed charges,,,39,,1304.94,percent of total billed charges,,,57.6,,1927.3,percent of total billed charges,,,85,,2844.1,percent of total billed charges,,,85,,2844.1,percent of total billed charges,,,49,,1639.54,percent of total billed charges,,,90,,3011.4,percent of total billed charges,,,65,,2174.9,percent of total billed charges,,,80,,2676.8,percent of total billed charges,,,55,,1840.3,percent of total billed charges,,,55,,1840.3,percent of total billed charges,,,65,,2174.9,percent of total billed charges,,,78,,2609.88,percent of total billed charges,,,70,,2342.2,percent of total billed charges,,,,,,,,749.24,,,,100% of Medicare,,749.24,,,,100% of Medicare,,749.24,,,,100% of Medicare,,749.24,,,,100% of Medicare,,749.24,,,,100% of Medicare,,749.24,,,,100% of Medicare,,749.24,,,,100% of Medicare,,749.24,,,,100% of Medicare,,749.24,,,,100% of Medicare,,749.24,,,,100% of Medicare,,749.24,,,,100% of Medicare,,749.24,,,,100% of Medicare,,,749.24,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,749.24,3011.4,
"EO with Joint, Prefabricated Custom Fit",L3760,HCPCS,,,,outpatient,,,2446,1467.6,,45.5,,1112.93,percent of total billed charges,,,45.3,,1108.04,percent of total billed charges,,,39,,953.94,percent of total billed charges,,,,,,,,,80,,1956.8,percent of total billed charges,,,61.4,,1501.84,percent of total billed charges,,,57.4,,1404,percent of total billed charges,,,81,,1981.26,percent of total billed charges,,,39,,953.94,percent of total billed charges,,,57.6,,1408.9,percent of total billed charges,,,85,,2079.1,percent of total billed charges,,,85,,2079.1,percent of total billed charges,,,49,,1198.54,percent of total billed charges,,,90,,2201.4,percent of total billed charges,,,65,,1589.9,percent of total billed charges,,,80,,1956.8,percent of total billed charges,,,55,,1345.3,percent of total billed charges,,,55,,1345.3,percent of total billed charges,,,65,,1589.9,percent of total billed charges,,,78,,1907.88,percent of total billed charges,,,70,,1712.2,percent of total billed charges,,,,,,,,548.39,,,,100% of Medicare,,548.39,,,,100% of Medicare,,548.39,,,,100% of Medicare,,548.39,,,,100% of Medicare,,548.39,,,,100% of Medicare,,548.39,,,,100% of Medicare,,548.39,,,,100% of Medicare,,548.39,,,,100% of Medicare,,548.39,,,,100% of Medicare,,548.39,,,,100% of Medicare,,548.39,,,,100% of Medicare,,548.39,,,,100% of Medicare,,,548.39,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,548.39,2201.4,
"L3761 Elbow orthosis with adjustable position locking joint (s), prefabricated, off-the-shelf",L3761,HCPCS,,,,outpatient,,,1995,1197,,45.5,,907.73,percent of total billed charges,,,45.3,,903.74,percent of total billed charges,,,39,,778.05,percent of total billed charges,,,,,,,,,80,,1596,percent of total billed charges,,,61.4,,1224.93,percent of total billed charges,,,57.4,,1145.13,percent of total billed charges,,,81,,1615.95,percent of total billed charges,,,39,,778.05,percent of total billed charges,,,57.6,,1149.12,percent of total billed charges,,,85,,1695.75,percent of total billed charges,,,85,,1695.75,percent of total billed charges,,,49,,977.55,percent of total billed charges,,,90,,1795.5,percent of total billed charges,,,65,,1296.75,percent of total billed charges,,,80,,1596,percent of total billed charges,,,55,,1097.25,percent of total billed charges,,,55,,1097.25,percent of total billed charges,,,65,,1296.75,percent of total billed charges,,,78,,1556.1,percent of total billed charges,,,70,,1396.5,percent of total billed charges,,,,,,,,548.39,,,,100% of Medicare,,548.39,,,,100% of Medicare,,548.39,,,,100% of Medicare,,548.39,,,,100% of Medicare,,548.39,,,,100% of Medicare,,548.39,,,,100% of Medicare,,548.39,,,,100% of Medicare,,548.39,,,,100% of Medicare,,548.39,,,,100% of Medicare,,548.39,,,,100% of Medicare,,548.39,,,,100% of Medicare,,548.39,,,,100% of Medicare,,,548.39,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,548.39,1795.5,
"Elbow Orthosis, Rigid w/o Joints, Prefabricated",L3762,HCPCS,,,,outpatient,,,527,316.2,,45.5,,239.79,percent of total billed charges,,,45.3,,238.73,percent of total billed charges,,,39,,205.53,percent of total billed charges,,,,,,,,,80,,421.6,percent of total billed charges,,,61.4,,323.58,percent of total billed charges,,,57.4,,302.5,percent of total billed charges,,,81,,426.87,percent of total billed charges,,,39,,205.53,percent of total billed charges,,,57.6,,303.55,percent of total billed charges,,,85,,447.95,percent of total billed charges,,,85,,447.95,percent of total billed charges,,,49,,258.23,percent of total billed charges,,,90,,474.3,percent of total billed charges,,,65,,342.55,percent of total billed charges,,,80,,421.6,percent of total billed charges,,,55,,289.85,percent of total billed charges,,,55,,289.85,percent of total billed charges,,,65,,342.55,percent of total billed charges,,,78,,411.06,percent of total billed charges,,,70,,368.9,percent of total billed charges,,,,,,,,117.89,,,,100% of Medicare,,117.89,,,,100% of Medicare,,117.89,,,,100% of Medicare,,117.89,,,,100% of Medicare,,117.89,,,,100% of Medicare,,117.89,,,,100% of Medicare,,117.89,,,,100% of Medicare,,117.89,,,,100% of Medicare,,117.89,,,,100% of Medicare,,117.89,,,,100% of Medicare,,117.89,,,,100% of Medicare,,117.89,,,,100% of Medicare,,,117.89,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,117.89,474.3,
"Elbow-Wrist-Hand Orthosis, Rigid, Custom Fabricated",L3763,HCPCS,,,,outpatient,,,3557,2134.2,,45.5,,1618.44,percent of total billed charges,,,45.3,,1611.32,percent of total billed charges,,,39,,1387.23,percent of total billed charges,,,,,,,,,80,,2845.6,percent of total billed charges,,,61.4,,2184,percent of total billed charges,,,57.4,,2041.72,percent of total billed charges,,,81,,2881.17,percent of total billed charges,,,39,,1387.23,percent of total billed charges,,,57.6,,2048.83,percent of total billed charges,,,85,,3023.45,percent of total billed charges,,,85,,3023.45,percent of total billed charges,,,49,,1742.93,percent of total billed charges,,,90,,3201.3,percent of total billed charges,,,65,,2312.05,percent of total billed charges,,,80,,2845.6,percent of total billed charges,,,55,,1956.35,percent of total billed charges,,,55,,1956.35,percent of total billed charges,,,65,,2312.05,percent of total billed charges,,,78,,2774.46,percent of total billed charges,,,70,,2489.9,percent of total billed charges,,,,,,,,820.58,,,,100% of Medicare,,820.58,,,,100% of Medicare,,820.58,,,,100% of Medicare,,820.58,,,,100% of Medicare,,820.58,,,,100% of Medicare,,820.58,,,,100% of Medicare,,820.58,,,,100% of Medicare,,820.58,,,,100% of Medicare,,820.58,,,,100% of Medicare,,820.58,,,,100% of Medicare,,820.58,,,,100% of Medicare,,820.58,,,,100% of Medicare,,,820.58,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,820.58,3201.3,
"Elbow-Wrist-Hand Orthosis, Nontorsion Joints, Custom Fabricated",L3764,HCPCS,,,,outpatient,,,3835,2301,,45.5,,1744.93,percent of total billed charges,,,45.3,,1737.26,percent of total billed charges,,,39,,1495.65,percent of total billed charges,,,,,,,,,80,,3068,percent of total billed charges,,,61.4,,2354.69,percent of total billed charges,,,57.4,,2201.29,percent of total billed charges,,,81,,3106.35,percent of total billed charges,,,39,,1495.65,percent of total billed charges,,,57.6,,2208.96,percent of total billed charges,,,85,,3259.75,percent of total billed charges,,,85,,3259.75,percent of total billed charges,,,49,,1879.15,percent of total billed charges,,,90,,3451.5,percent of total billed charges,,,65,,2492.75,percent of total billed charges,,,80,,3068,percent of total billed charges,,,55,,2109.25,percent of total billed charges,,,55,,2109.25,percent of total billed charges,,,65,,2492.75,percent of total billed charges,,,78,,2991.3,percent of total billed charges,,,70,,2684.5,percent of total billed charges,,,,,,,,858.76,,,,100% of Medicare,,858.76,,,,100% of Medicare,,858.76,,,,100% of Medicare,,858.76,,,,100% of Medicare,,858.76,,,,100% of Medicare,,858.76,,,,100% of Medicare,,858.76,,,,100% of Medicare,,858.76,,,,100% of Medicare,,858.76,,,,100% of Medicare,,858.76,,,,100% of Medicare,,858.76,,,,100% of Medicare,,858.76,,,,100% of Medicare,,,858.76,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,858.76,3451.5,
"Elbow-Wrist-Hand-Finger Orthosis, Rigid Custom Fabricated",L3765,HCPCS,,,,outpatient,,,2868,1720.8,,45.5,,1304.94,percent of total billed charges,,,45.3,,1299.2,percent of total billed charges,,,39,,1118.52,percent of total billed charges,,,,,,,,,80,,2294.4,percent of total billed charges,,,61.4,,1760.95,percent of total billed charges,,,57.4,,1646.23,percent of total billed charges,,,81,,2323.08,percent of total billed charges,,,39,,1118.52,percent of total billed charges,,,57.6,,1651.97,percent of total billed charges,,,85,,2437.8,percent of total billed charges,,,85,,2437.8,percent of total billed charges,,,49,,1405.32,percent of total billed charges,,,90,,2581.2,percent of total billed charges,,,65,,1864.2,percent of total billed charges,,,80,,2294.4,percent of total billed charges,,,55,,1577.4,percent of total billed charges,,,55,,1577.4,percent of total billed charges,,,65,,1864.2,percent of total billed charges,,,78,,2237.04,percent of total billed charges,,,70,,2007.6,percent of total billed charges,,,,,,,,1406.03,,,,100% of Medicare,,1406.03,,,,100% of Medicare,,1406.03,,,,100% of Medicare,,1406.03,,,,100% of Medicare,,1406.03,,,,100% of Medicare,,1406.03,,,,100% of Medicare,,1406.03,,,,100% of Medicare,,1406.03,,,,100% of Medicare,,1406.03,,,,100% of Medicare,,1406.03,,,,100% of Medicare,,1406.03,,,,100% of Medicare,,1406.03,,,,100% of Medicare,,,1406.03,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1118.52,2581.2,
"Elbow-Wrist-Hand-Finger Orthosis, Nontorsion Joints, Custom Fabricated",L3766,HCPCS,,,,outpatient,,,3037,1822.2,,45.5,,1381.84,percent of total billed charges,,,45.3,,1375.76,percent of total billed charges,,,39,,1184.43,percent of total billed charges,,,,,,,,,80,,2429.6,percent of total billed charges,,,61.4,,1864.72,percent of total billed charges,,,57.4,,1743.24,percent of total billed charges,,,81,,2459.97,percent of total billed charges,,,39,,1184.43,percent of total billed charges,,,57.6,,1749.31,percent of total billed charges,,,85,,2581.45,percent of total billed charges,,,85,,2581.45,percent of total billed charges,,,49,,1488.13,percent of total billed charges,,,90,,2733.3,percent of total billed charges,,,65,,1974.05,percent of total billed charges,,,80,,2429.6,percent of total billed charges,,,55,,1670.35,percent of total billed charges,,,55,,1670.35,percent of total billed charges,,,65,,1974.05,percent of total billed charges,,,78,,2368.86,percent of total billed charges,,,70,,2125.9,percent of total billed charges,,,,,,,,1488.9,,,,100% of Medicare,,1488.9,,,,100% of Medicare,,1488.9,,,,100% of Medicare,,1488.9,,,,100% of Medicare,,1488.9,,,,100% of Medicare,,1488.9,,,,100% of Medicare,,1488.9,,,,100% of Medicare,,1488.9,,,,100% of Medicare,,1488.9,,,,100% of Medicare,,1488.9,,,,100% of Medicare,,1488.9,,,,100% of Medicare,,1488.9,,,,100% of Medicare,,,1488.9,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1184.43,2733.3,
OT WHFO Orthosis Left Charge L3806,L3806,HCPCS,,,LT,both,,,1493,895.8,,45.5,,679.32,percent of total billed charges,,,45.3,,676.33,percent of total billed charges,,,39,,582.27,percent of total billed charges,,,,,,,,,80,,1194.4,percent of total billed charges,,,61.4,,916.7,percent of total billed charges,,,57.4,,856.98,percent of total billed charges,,,81,,1209.33,percent of total billed charges,,,39,,582.27,percent of total billed charges,,,57.6,,859.97,percent of total billed charges,,,85,,1269.05,percent of total billed charges,,,85,,1269.05,percent of total billed charges,,,49,,731.57,percent of total billed charges,,,90,,1343.7,percent of total billed charges,,,65,,970.45,percent of total billed charges,,,80,,1194.4,percent of total billed charges,,,55,,821.15,percent of total billed charges,,,55,,821.15,percent of total billed charges,,,65,,970.45,percent of total billed charges,,,78,,1164.54,percent of total billed charges,,,70,,1045.1,percent of total billed charges,,,,,,,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,,498.07,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,498.07,1343.7,
OT WHFO Orthosis Right Charge L3806,L3806,HCPCS,,,RT,both,,,1493,895.8,,45.5,,679.32,percent of total billed charges,,,45.3,,676.33,percent of total billed charges,,,39,,582.27,percent of total billed charges,,,,,,,,,80,,1194.4,percent of total billed charges,,,61.4,,916.7,percent of total billed charges,,,57.4,,856.98,percent of total billed charges,,,81,,1209.33,percent of total billed charges,,,39,,582.27,percent of total billed charges,,,57.6,,859.97,percent of total billed charges,,,85,,1269.05,percent of total billed charges,,,85,,1269.05,percent of total billed charges,,,49,,731.57,percent of total billed charges,,,90,,1343.7,percent of total billed charges,,,65,,970.45,percent of total billed charges,,,80,,1194.4,percent of total billed charges,,,55,,821.15,percent of total billed charges,,,55,,821.15,percent of total billed charges,,,65,,970.45,percent of total billed charges,,,78,,1164.54,percent of total billed charges,,,70,,1045.1,percent of total billed charges,,,,,,,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,498.07,,,,100% of Medicare,,,498.07,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,498.07,1343.7,
OT WHFO Left Charge L3807,L3807,HCPCS,,,LT,both,,,814,488.4,,45.5,,370.37,percent of total billed charges,,,45.3,,368.74,percent of total billed charges,,,39,,317.46,percent of total billed charges,,,,,,,,,80,,651.2,percent of total billed charges,,,61.4,,499.8,percent of total billed charges,,,57.4,,467.24,percent of total billed charges,,,81,,659.34,percent of total billed charges,,,39,,317.46,percent of total billed charges,,,57.6,,468.86,percent of total billed charges,,,85,,691.9,percent of total billed charges,,,85,,691.9,percent of total billed charges,,,49,,398.86,percent of total billed charges,,,90,,732.6,percent of total billed charges,,,65,,529.1,percent of total billed charges,,,80,,651.2,percent of total billed charges,,,55,,447.7,percent of total billed charges,,,55,,447.7,percent of total billed charges,,,65,,529.1,percent of total billed charges,,,78,,634.92,percent of total billed charges,,,70,,569.8,percent of total billed charges,,,,,,,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,,274.19,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,274.19,732.6,
OT WHFO Right Charge L3807,L3807,HCPCS,,,RT,both,,,814,488.4,,45.5,,370.37,percent of total billed charges,,,45.3,,368.74,percent of total billed charges,,,39,,317.46,percent of total billed charges,,,,,,,,,80,,651.2,percent of total billed charges,,,61.4,,499.8,percent of total billed charges,,,57.4,,467.24,percent of total billed charges,,,81,,659.34,percent of total billed charges,,,39,,317.46,percent of total billed charges,,,57.6,,468.86,percent of total billed charges,,,85,,691.9,percent of total billed charges,,,85,,691.9,percent of total billed charges,,,49,,398.86,percent of total billed charges,,,90,,732.6,percent of total billed charges,,,65,,529.1,percent of total billed charges,,,80,,651.2,percent of total billed charges,,,55,,447.7,percent of total billed charges,,,55,,447.7,percent of total billed charges,,,65,,529.1,percent of total billed charges,,,78,,634.92,percent of total billed charges,,,70,,569.8,percent of total billed charges,,,,,,,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,,274.19,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,274.19,732.6,
"Wrist-Hand-Finger Orthosis, w/o joints, Prefabricated, Includes Fitting and Adjustment",L3807,HCPCS,,,,outpatient,,,1227,736.2,,45.5,,558.29,percent of total billed charges,,,45.3,,555.83,percent of total billed charges,,,39,,478.53,percent of total billed charges,,,,,,,,,80,,981.6,percent of total billed charges,,,61.4,,753.38,percent of total billed charges,,,57.4,,704.3,percent of total billed charges,,,81,,993.87,percent of total billed charges,,,39,,478.53,percent of total billed charges,,,57.6,,706.75,percent of total billed charges,,,85,,1042.95,percent of total billed charges,,,85,,1042.95,percent of total billed charges,,,49,,601.23,percent of total billed charges,,,90,,1104.3,percent of total billed charges,,,65,,797.55,percent of total billed charges,,,80,,981.6,percent of total billed charges,,,55,,674.85,percent of total billed charges,,,55,,674.85,percent of total billed charges,,,65,,797.55,percent of total billed charges,,,78,,957.06,percent of total billed charges,,,70,,858.9,percent of total billed charges,,,,,,,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,,274.19,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,274.19,1104.3,
OT Wrist Hand Finger Orthosis LT L3808,L3808,HCPCS,,,LT,both,,,822,493.2,,45.5,,374.01,percent of total billed charges,,,45.3,,372.37,percent of total billed charges,,,39,,320.58,percent of total billed charges,,,,,,,,,80,,657.6,percent of total billed charges,,,61.4,,504.71,percent of total billed charges,,,57.4,,471.83,percent of total billed charges,,,81,,665.82,percent of total billed charges,,,39,,320.58,percent of total billed charges,,,57.6,,473.47,percent of total billed charges,,,85,,698.7,percent of total billed charges,,,85,,698.7,percent of total billed charges,,,49,,402.78,percent of total billed charges,,,90,,739.8,percent of total billed charges,,,65,,534.3,percent of total billed charges,,,80,,657.6,percent of total billed charges,,,55,,452.1,percent of total billed charges,,,55,,452.1,percent of total billed charges,,,65,,534.3,percent of total billed charges,,,78,,641.16,percent of total billed charges,,,70,,575.4,percent of total billed charges,,,,,,,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,,390.62,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,320.58,739.8,
OT Wrist Hand Finger Orthosis RT L3808,L3808,HCPCS,,,RT,both,,,822,493.2,,45.5,,374.01,percent of total billed charges,,,45.3,,372.37,percent of total billed charges,,,39,,320.58,percent of total billed charges,,,,,,,,,80,,657.6,percent of total billed charges,,,61.4,,504.71,percent of total billed charges,,,57.4,,471.83,percent of total billed charges,,,81,,665.82,percent of total billed charges,,,39,,320.58,percent of total billed charges,,,57.6,,473.47,percent of total billed charges,,,85,,698.7,percent of total billed charges,,,85,,698.7,percent of total billed charges,,,49,,402.78,percent of total billed charges,,,90,,739.8,percent of total billed charges,,,65,,534.3,percent of total billed charges,,,80,,657.6,percent of total billed charges,,,55,,452.1,percent of total billed charges,,,55,,452.1,percent of total billed charges,,,65,,534.3,percent of total billed charges,,,78,,641.16,percent of total billed charges,,,70,,575.4,percent of total billed charges,,,,,,,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,,390.62,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,320.58,739.8,
"WHFO, Rigid without joints, custom fabricated",L3808,HCPCS,,,,outpatient,,,3678,2206.8,,45.5,,1673.49,percent of total billed charges,,,45.3,,1666.13,percent of total billed charges,,,39,,1434.42,percent of total billed charges,,,,,,,,,80,,2942.4,percent of total billed charges,,,61.4,,2258.29,percent of total billed charges,,,57.4,,2111.17,percent of total billed charges,,,81,,2979.18,percent of total billed charges,,,39,,1434.42,percent of total billed charges,,,57.6,,2118.53,percent of total billed charges,,,85,,3126.3,percent of total billed charges,,,85,,3126.3,percent of total billed charges,,,49,,1802.22,percent of total billed charges,,,90,,3310.2,percent of total billed charges,,,65,,2390.7,percent of total billed charges,,,80,,2942.4,percent of total billed charges,,,55,,2022.9,percent of total billed charges,,,55,,2022.9,percent of total billed charges,,,65,,2390.7,percent of total billed charges,,,78,,2868.84,percent of total billed charges,,,70,,2574.6,percent of total billed charges,,,,,,,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,390.62,,,,100% of Medicare,,,390.62,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,390.62,3310.2,
WHFO W/O JOINTS PRE OTS (L3809),L3809,HCPCS,,,,outpatient,,,1133,679.8,,45.5,,515.52,percent of total billed charges,,,45.3,,513.25,percent of total billed charges,,,39,,441.87,percent of total billed charges,,,,,,,,,80,,906.4,percent of total billed charges,,,61.4,,695.66,percent of total billed charges,,,57.4,,650.34,percent of total billed charges,,,81,,917.73,percent of total billed charges,,,39,,441.87,percent of total billed charges,,,57.6,,652.61,percent of total billed charges,,,85,,963.05,percent of total billed charges,,,85,,963.05,percent of total billed charges,,,49,,555.17,percent of total billed charges,,,90,,1019.7,percent of total billed charges,,,65,,736.45,percent of total billed charges,,,80,,906.4,percent of total billed charges,,,55,,623.15,percent of total billed charges,,,55,,623.15,percent of total billed charges,,,65,,736.45,percent of total billed charges,,,78,,883.74,percent of total billed charges,,,70,,793.1,percent of total billed charges,,,,,,,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,274.19,,,,100% of Medicare,,,274.19,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,274.19,1019.7,
"Wrist-Hand Orthosis, Nontorsion Joints, Custom Fabricated",L3905,HCPCS,,,,outpatient,,,2218,1330.8,,45.5,,1009.19,percent of total billed charges,,,45.3,,1004.75,percent of total billed charges,,,39,,865.02,percent of total billed charges,,,,,,,,,80,,1774.4,percent of total billed charges,,,61.4,,1361.85,percent of total billed charges,,,57.4,,1273.13,percent of total billed charges,,,81,,1796.58,percent of total billed charges,,,39,,865.02,percent of total billed charges,,,57.6,,1277.57,percent of total billed charges,,,85,,1885.3,percent of total billed charges,,,85,,1885.3,percent of total billed charges,,,49,,1086.82,percent of total billed charges,,,90,,1996.2,percent of total billed charges,,,65,,1441.7,percent of total billed charges,,,80,,1774.4,percent of total billed charges,,,55,,1219.9,percent of total billed charges,,,55,,1219.9,percent of total billed charges,,,65,,1441.7,percent of total billed charges,,,78,,1730.04,percent of total billed charges,,,70,,1552.6,percent of total billed charges,,,,,,,,1087.41,,,,100% of Medicare,,1087.41,,,,100% of Medicare,,1087.41,,,,100% of Medicare,,1087.41,,,,100% of Medicare,,1087.41,,,,100% of Medicare,,1087.41,,,,100% of Medicare,,1087.41,,,,100% of Medicare,,1087.41,,,,100% of Medicare,,1087.41,,,,100% of Medicare,,1087.41,,,,100% of Medicare,,1087.41,,,,100% of Medicare,,1087.41,,,,100% of Medicare,,,1087.41,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,865.02,1996.2,
OT Wrist Hand Orthosis Left Charge L3906,L3906,HCPCS,,,LT,both,,,1669,1001.4,,45.5,,759.4,percent of total billed charges,,,45.3,,756.06,percent of total billed charges,,,39,,650.91,percent of total billed charges,,,,,,,,,80,,1335.2,percent of total billed charges,,,61.4,,1024.77,percent of total billed charges,,,57.4,,958.01,percent of total billed charges,,,81,,1351.89,percent of total billed charges,,,39,,650.91,percent of total billed charges,,,57.6,,961.34,percent of total billed charges,,,85,,1418.65,percent of total billed charges,,,85,,1418.65,percent of total billed charges,,,49,,817.81,percent of total billed charges,,,90,,1502.1,percent of total billed charges,,,65,,1084.85,percent of total billed charges,,,80,,1335.2,percent of total billed charges,,,55,,917.95,percent of total billed charges,,,55,,917.95,percent of total billed charges,,,65,,1084.85,percent of total billed charges,,,78,,1301.82,percent of total billed charges,,,70,,1168.3,percent of total billed charges,,,,,,,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,,555.68,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,555.68,1502.1,
OT Wrist Hand Orthosis RT Charge L3906,L3906,HCPCS,,,RT,both,,,1669,1001.4,,45.5,,759.4,percent of total billed charges,,,45.3,,756.06,percent of total billed charges,,,39,,650.91,percent of total billed charges,,,,,,,,,80,,1335.2,percent of total billed charges,,,61.4,,1024.77,percent of total billed charges,,,57.4,,958.01,percent of total billed charges,,,81,,1351.89,percent of total billed charges,,,39,,650.91,percent of total billed charges,,,57.6,,961.34,percent of total billed charges,,,85,,1418.65,percent of total billed charges,,,85,,1418.65,percent of total billed charges,,,49,,817.81,percent of total billed charges,,,90,,1502.1,percent of total billed charges,,,65,,1084.85,percent of total billed charges,,,80,,1335.2,percent of total billed charges,,,55,,917.95,percent of total billed charges,,,55,,917.95,percent of total billed charges,,,65,,1084.85,percent of total billed charges,,,78,,1301.82,percent of total billed charges,,,70,,1168.3,percent of total billed charges,,,,,,,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,,555.68,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,555.68,1502.1,
"Wrist-Hand Orthosis, Gauntlet, Molded to Pt",L3906,HCPCS,,,,outpatient,,,2409,1445.4,,45.5,,1096.1,percent of total billed charges,,,45.3,,1091.28,percent of total billed charges,,,39,,939.51,percent of total billed charges,,,,,,,,,80,,1927.2,percent of total billed charges,,,61.4,,1479.13,percent of total billed charges,,,57.4,,1382.77,percent of total billed charges,,,81,,1951.29,percent of total billed charges,,,39,,939.51,percent of total billed charges,,,57.6,,1387.58,percent of total billed charges,,,85,,2047.65,percent of total billed charges,,,85,,2047.65,percent of total billed charges,,,49,,1180.41,percent of total billed charges,,,90,,2168.1,percent of total billed charges,,,65,,1565.85,percent of total billed charges,,,80,,1927.2,percent of total billed charges,,,55,,1324.95,percent of total billed charges,,,55,,1324.95,percent of total billed charges,,,65,,1565.85,percent of total billed charges,,,78,,1879.02,percent of total billed charges,,,70,,1686.3,percent of total billed charges,,,,,,,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,555.68,,,,100% of Medicare,,,555.68,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,555.68,2168.1,
"Wrist-Hand Orthosis, Wrist Extension Control Cock-up, Non-Molded",L3908,HCPCS,,,,outpatient,,,359,215.4,,45.5,,163.35,percent of total billed charges,,,45.3,,162.63,percent of total billed charges,,,39,,140.01,percent of total billed charges,,,,,,,,,80,,287.2,percent of total billed charges,,,61.4,,220.43,percent of total billed charges,,,57.4,,206.07,percent of total billed charges,,,81,,290.79,percent of total billed charges,,,39,,140.01,percent of total billed charges,,,57.6,,206.78,percent of total billed charges,,,85,,305.15,percent of total billed charges,,,85,,305.15,percent of total billed charges,,,49,,175.91,percent of total billed charges,,,90,,323.1,percent of total billed charges,,,65,,233.35,percent of total billed charges,,,80,,287.2,percent of total billed charges,,,55,,197.45,percent of total billed charges,,,55,,197.45,percent of total billed charges,,,65,,233.35,percent of total billed charges,,,78,,280.02,percent of total billed charges,,,70,,251.3,percent of total billed charges,,,,,,,,80.39,,,,100% of Medicare,,80.39,,,,100% of Medicare,,80.39,,,,100% of Medicare,,80.39,,,,100% of Medicare,,80.39,,,,100% of Medicare,,80.39,,,,100% of Medicare,,80.39,,,,100% of Medicare,,80.39,,,,100% of Medicare,,80.39,,,,100% of Medicare,,80.39,,,,100% of Medicare,,80.39,,,,100% of Medicare,,80.39,,,,100% of Medicare,,,80.39,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,80.39,323.1,
"Hand-Finger Orthosis, Flexion Glove w/ Elastic Finger Control",L3912,HCPCS,,,,outpatient,,,246,147.6,,45.5,,111.93,percent of total billed charges,,,45.3,,111.44,percent of total billed charges,,,39,,95.94,percent of total billed charges,,,,,,,,,80,,196.8,percent of total billed charges,,,61.4,,151.04,percent of total billed charges,,,57.4,,141.2,percent of total billed charges,,,81,,199.26,percent of total billed charges,,,39,,95.94,percent of total billed charges,,,57.6,,141.7,percent of total billed charges,,,85,,209.1,percent of total billed charges,,,85,,209.1,percent of total billed charges,,,49,,120.54,percent of total billed charges,,,90,,221.4,percent of total billed charges,,,65,,159.9,percent of total billed charges,,,80,,196.8,percent of total billed charges,,,55,,135.3,percent of total billed charges,,,55,,135.3,percent of total billed charges,,,65,,159.9,percent of total billed charges,,,78,,191.88,percent of total billed charges,,,70,,172.2,percent of total billed charges,,,,,,,,115.53,,,,100% of Medicare,,115.53,,,,100% of Medicare,,115.53,,,,100% of Medicare,,115.53,,,,100% of Medicare,,115.53,,,,100% of Medicare,,115.53,,,,100% of Medicare,,115.53,,,,100% of Medicare,,115.53,,,,100% of Medicare,,115.53,,,,100% of Medicare,,115.53,,,,100% of Medicare,,115.53,,,,100% of Medicare,,115.53,,,,100% of Medicare,,,115.53,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,95.94,221.4,
OT Hand Finger Orthosis LT Charge L3913,L3913,HCPCS,,,LT,both,,,938,562.8,,45.5,,426.79,percent of total billed charges,,,45.3,,424.91,percent of total billed charges,,,39,,365.82,percent of total billed charges,,,,,,,,,80,,750.4,percent of total billed charges,,,61.4,,575.93,percent of total billed charges,,,57.4,,538.41,percent of total billed charges,,,81,,759.78,percent of total billed charges,,,39,,365.82,percent of total billed charges,,,57.6,,540.29,percent of total billed charges,,,85,,797.3,percent of total billed charges,,,85,,797.3,percent of total billed charges,,,49,,459.62,percent of total billed charges,,,90,,844.2,percent of total billed charges,,,65,,609.7,percent of total billed charges,,,80,,750.4,percent of total billed charges,,,55,,515.9,percent of total billed charges,,,55,,515.9,percent of total billed charges,,,65,,609.7,percent of total billed charges,,,78,,731.64,percent of total billed charges,,,70,,656.6,percent of total billed charges,,,,,,,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,,296.96,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,296.96,844.2,
OT Hand Finger Orthosis RT Charge L3913,L3913,HCPCS,,,RT,both,,,938,562.8,,45.5,,426.79,percent of total billed charges,,,45.3,,424.91,percent of total billed charges,,,39,,365.82,percent of total billed charges,,,,,,,,,80,,750.4,percent of total billed charges,,,61.4,,575.93,percent of total billed charges,,,57.4,,538.41,percent of total billed charges,,,81,,759.78,percent of total billed charges,,,39,,365.82,percent of total billed charges,,,57.6,,540.29,percent of total billed charges,,,85,,797.3,percent of total billed charges,,,85,,797.3,percent of total billed charges,,,49,,459.62,percent of total billed charges,,,90,,844.2,percent of total billed charges,,,65,,609.7,percent of total billed charges,,,80,,750.4,percent of total billed charges,,,55,,515.9,percent of total billed charges,,,55,,515.9,percent of total billed charges,,,65,,609.7,percent of total billed charges,,,78,,731.64,percent of total billed charges,,,70,,656.6,percent of total billed charges,,,,,,,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,,296.96,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,296.96,844.2,
"L3913 HFO, w/o JTs, Custom Fab",L3913,HCPCS,,,,outpatient,,,1288,772.8,,45.5,,586.04,percent of total billed charges,,,45.3,,583.46,percent of total billed charges,,,39,,502.32,percent of total billed charges,,,,,,,,,80,,1030.4,percent of total billed charges,,,61.4,,790.83,percent of total billed charges,,,57.4,,739.31,percent of total billed charges,,,81,,1043.28,percent of total billed charges,,,39,,502.32,percent of total billed charges,,,57.6,,741.89,percent of total billed charges,,,85,,1094.8,percent of total billed charges,,,85,,1094.8,percent of total billed charges,,,49,,631.12,percent of total billed charges,,,90,,1159.2,percent of total billed charges,,,65,,837.2,percent of total billed charges,,,80,,1030.4,percent of total billed charges,,,55,,708.4,percent of total billed charges,,,55,,708.4,percent of total billed charges,,,65,,837.2,percent of total billed charges,,,78,,1004.64,percent of total billed charges,,,70,,901.6,percent of total billed charges,,,,,,,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,,296.96,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,296.96,1159.2,
"WHO prefab, one or more nontorsion joints, elastic bands, turnbuckles, padded/unpadded",L3915,HCPCS,,,,outpatient,,,2735,1641,,45.5,,1244.43,percent of total billed charges,,,45.3,,1238.96,percent of total billed charges,,,39,,1066.65,percent of total billed charges,,,,,,,,,80,,2188,percent of total billed charges,,,61.4,,1679.29,percent of total billed charges,,,57.4,,1569.89,percent of total billed charges,,,81,,2215.35,percent of total billed charges,,,39,,1066.65,percent of total billed charges,,,57.6,,1575.36,percent of total billed charges,,,85,,2324.75,percent of total billed charges,,,85,,2324.75,percent of total billed charges,,,49,,1340.15,percent of total billed charges,,,90,,2461.5,percent of total billed charges,,,65,,1777.75,percent of total billed charges,,,80,,2188,percent of total billed charges,,,55,,1504.25,percent of total billed charges,,,55,,1504.25,percent of total billed charges,,,65,,1777.75,percent of total billed charges,,,78,,2133.3,percent of total billed charges,,,70,,1914.5,percent of total billed charges,,,,,,,,582.88,,,,100% of Medicare,,582.88,,,,100% of Medicare,,582.88,,,,100% of Medicare,,582.88,,,,100% of Medicare,,582.88,,,,100% of Medicare,,582.88,,,,100% of Medicare,,582.88,,,,100% of Medicare,,582.88,,,,100% of Medicare,,582.88,,,,100% of Medicare,,582.88,,,,100% of Medicare,,582.88,,,,100% of Medicare,,582.88,,,,100% of Medicare,,,582.88,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,582.88,2461.5,
WHO NONTORSION JNTS PRE OTS (L3916),L3916,HCPCS,,,,outpatient,,,2409,1445.4,,45.5,,1096.1,percent of total billed charges,,,45.3,,1091.28,percent of total billed charges,,,39,,939.51,percent of total billed charges,,,,,,,,,80,,1927.2,percent of total billed charges,,,61.4,,1479.13,percent of total billed charges,,,57.4,,1382.77,percent of total billed charges,,,81,,1951.29,percent of total billed charges,,,39,,939.51,percent of total billed charges,,,57.6,,1387.58,percent of total billed charges,,,85,,2047.65,percent of total billed charges,,,85,,2047.65,percent of total billed charges,,,49,,1180.41,percent of total billed charges,,,90,,2168.1,percent of total billed charges,,,65,,1565.85,percent of total billed charges,,,80,,1927.2,percent of total billed charges,,,55,,1324.95,percent of total billed charges,,,55,,1324.95,percent of total billed charges,,,65,,1565.85,percent of total billed charges,,,78,,1879.02,percent of total billed charges,,,70,,1686.3,percent of total billed charges,,,,,,,,582.88,,,,100% of Medicare,,582.88,,,,100% of Medicare,,582.88,,,,100% of Medicare,,582.88,,,,100% of Medicare,,582.88,,,,100% of Medicare,,582.88,,,,100% of Medicare,,582.88,,,,100% of Medicare,,582.88,,,,100% of Medicare,,582.88,,,,100% of Medicare,,582.88,,,,100% of Medicare,,582.88,,,,100% of Medicare,,582.88,,,,100% of Medicare,,,582.88,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,582.88,2168.1,
"Hand Orthosis, Metacarpal Fx, Prefabricated",L3917,HCPCS,,,,outpatient,,,247,148.2,,45.5,,112.39,percent of total billed charges,,,45.3,,111.89,percent of total billed charges,,,39,,96.33,percent of total billed charges,,,,,,,,,80,,197.6,percent of total billed charges,,,61.4,,151.66,percent of total billed charges,,,57.4,,141.78,percent of total billed charges,,,81,,200.07,percent of total billed charges,,,39,,96.33,percent of total billed charges,,,57.6,,142.27,percent of total billed charges,,,85,,209.95,percent of total billed charges,,,85,,209.95,percent of total billed charges,,,49,,121.03,percent of total billed charges,,,90,,222.3,percent of total billed charges,,,65,,160.55,percent of total billed charges,,,80,,197.6,percent of total billed charges,,,55,,135.85,percent of total billed charges,,,55,,135.85,percent of total billed charges,,,65,,160.55,percent of total billed charges,,,78,,192.66,percent of total billed charges,,,70,,172.9,percent of total billed charges,,,,,,,,115.79,,,,100% of Medicare,,115.79,,,,100% of Medicare,,115.79,,,,100% of Medicare,,115.79,,,,100% of Medicare,,115.79,,,,100% of Medicare,,115.79,,,,100% of Medicare,,115.79,,,,100% of Medicare,,115.79,,,,100% of Medicare,,115.79,,,,100% of Medicare,,115.79,,,,100% of Medicare,,115.79,,,,100% of Medicare,,115.79,,,,100% of Medicare,,,115.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,96.33,222.3,
METACARP FX ORTHOSIS PRE OTS (L3918),L3918,HCPCS,,,,outpatient,,,479,287.4,,45.5,,217.95,percent of total billed charges,,,45.3,,216.99,percent of total billed charges,,,39,,186.81,percent of total billed charges,,,,,,,,,80,,383.2,percent of total billed charges,,,61.4,,294.11,percent of total billed charges,,,57.4,,274.95,percent of total billed charges,,,81,,387.99,percent of total billed charges,,,39,,186.81,percent of total billed charges,,,57.6,,275.9,percent of total billed charges,,,85,,407.15,percent of total billed charges,,,85,,407.15,percent of total billed charges,,,49,,234.71,percent of total billed charges,,,90,,431.1,percent of total billed charges,,,65,,311.35,percent of total billed charges,,,80,,383.2,percent of total billed charges,,,55,,263.45,percent of total billed charges,,,55,,263.45,percent of total billed charges,,,65,,311.35,percent of total billed charges,,,78,,373.62,percent of total billed charges,,,70,,335.3,percent of total billed charges,,,,,,,,115.79,,,,100% of Medicare,,115.79,,,,100% of Medicare,,115.79,,,,100% of Medicare,,115.79,,,,100% of Medicare,,115.79,,,,100% of Medicare,,115.79,,,,100% of Medicare,,115.79,,,,100% of Medicare,,115.79,,,,100% of Medicare,,115.79,,,,100% of Medicare,,115.79,,,,100% of Medicare,,115.79,,,,100% of Medicare,,115.79,,,,100% of Medicare,,,115.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,115.79,431.1,
OT Hand Orthosis Left Charge L3919,L3919,HCPCS,,,LT,both,,,626,375.6,,45.5,,284.83,percent of total billed charges,,,45.3,,283.58,percent of total billed charges,,,39,,244.14,percent of total billed charges,,,,,,,,,80,,500.8,percent of total billed charges,,,61.4,,384.36,percent of total billed charges,,,57.4,,359.32,percent of total billed charges,,,81,,507.06,percent of total billed charges,,,39,,244.14,percent of total billed charges,,,57.6,,360.58,percent of total billed charges,,,85,,532.1,percent of total billed charges,,,85,,532.1,percent of total billed charges,,,49,,306.74,percent of total billed charges,,,90,,563.4,percent of total billed charges,,,65,,406.9,percent of total billed charges,,,80,,500.8,percent of total billed charges,,,55,,344.3,percent of total billed charges,,,55,,344.3,percent of total billed charges,,,65,,406.9,percent of total billed charges,,,78,,488.28,percent of total billed charges,,,70,,438.2,percent of total billed charges,,,,,,,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,,296.96,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,244.14,563.4,
OT Hand Orthosis Right Charge  L3919,L3919,HCPCS,,,RT,both,,,626,375.6,,45.5,,284.83,percent of total billed charges,,,45.3,,283.58,percent of total billed charges,,,39,,244.14,percent of total billed charges,,,,,,,,,80,,500.8,percent of total billed charges,,,61.4,,384.36,percent of total billed charges,,,57.4,,359.32,percent of total billed charges,,,81,,507.06,percent of total billed charges,,,39,,244.14,percent of total billed charges,,,57.6,,360.58,percent of total billed charges,,,85,,532.1,percent of total billed charges,,,85,,532.1,percent of total billed charges,,,49,,306.74,percent of total billed charges,,,90,,563.4,percent of total billed charges,,,65,,406.9,percent of total billed charges,,,80,,500.8,percent of total billed charges,,,55,,344.3,percent of total billed charges,,,55,,344.3,percent of total billed charges,,,65,,406.9,percent of total billed charges,,,78,,488.28,percent of total billed charges,,,70,,438.2,percent of total billed charges,,,,,,,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,,296.96,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,244.14,563.4,
"hand Orthosis, Custom Fabricated",L3919,HCPCS,,,,outpatient,,,1288,772.8,,45.5,,586.04,percent of total billed charges,,,45.3,,583.46,percent of total billed charges,,,39,,502.32,percent of total billed charges,,,,,,,,,80,,1030.4,percent of total billed charges,,,61.4,,790.83,percent of total billed charges,,,57.4,,739.31,percent of total billed charges,,,81,,1043.28,percent of total billed charges,,,39,,502.32,percent of total billed charges,,,57.6,,741.89,percent of total billed charges,,,85,,1094.8,percent of total billed charges,,,85,,1094.8,percent of total billed charges,,,49,,631.12,percent of total billed charges,,,90,,1159.2,percent of total billed charges,,,65,,837.2,percent of total billed charges,,,80,,1030.4,percent of total billed charges,,,55,,708.4,percent of total billed charges,,,55,,708.4,percent of total billed charges,,,65,,837.2,percent of total billed charges,,,78,,1004.64,percent of total billed charges,,,70,,901.6,percent of total billed charges,,,,,,,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,296.96,,,,100% of Medicare,,,296.96,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,296.96,1159.2,
OT HFO Left Charge L3921,L3921,HCPCS,,,LT,both,,,1058,634.8,,45.5,,481.39,percent of total billed charges,,,45.3,,479.27,percent of total billed charges,,,39,,412.62,percent of total billed charges,,,,,,,,,80,,846.4,percent of total billed charges,,,61.4,,649.61,percent of total billed charges,,,57.4,,607.29,percent of total billed charges,,,81,,856.98,percent of total billed charges,,,39,,412.62,percent of total billed charges,,,57.6,,609.41,percent of total billed charges,,,85,,899.3,percent of total billed charges,,,85,,899.3,percent of total billed charges,,,49,,518.42,percent of total billed charges,,,90,,952.2,percent of total billed charges,,,65,,687.7,percent of total billed charges,,,80,,846.4,percent of total billed charges,,,55,,581.9,percent of total billed charges,,,55,,581.9,percent of total billed charges,,,65,,687.7,percent of total billed charges,,,78,,825.24,percent of total billed charges,,,70,,740.6,percent of total billed charges,,,,,,,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,,352.24,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,352.24,952.2,
OT HFO Right Charge L3921,L3921,HCPCS,,,RT,both,,,1058,634.8,,45.5,,481.39,percent of total billed charges,,,45.3,,479.27,percent of total billed charges,,,39,,412.62,percent of total billed charges,,,,,,,,,80,,846.4,percent of total billed charges,,,61.4,,649.61,percent of total billed charges,,,57.4,,607.29,percent of total billed charges,,,81,,856.98,percent of total billed charges,,,39,,412.62,percent of total billed charges,,,57.6,,609.41,percent of total billed charges,,,85,,899.3,percent of total billed charges,,,85,,899.3,percent of total billed charges,,,49,,518.42,percent of total billed charges,,,90,,952.2,percent of total billed charges,,,65,,687.7,percent of total billed charges,,,80,,846.4,percent of total billed charges,,,55,,581.9,percent of total billed charges,,,55,,581.9,percent of total billed charges,,,65,,687.7,percent of total billed charges,,,78,,825.24,percent of total billed charges,,,70,,740.6,percent of total billed charges,,,,,,,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,,352.24,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,352.24,952.2,
"Hand-Finger Orthosis, Nontorsion Joints, Custom Fabricated",L3921,HCPCS,,,,outpatient,,,1573,943.8,,45.5,,715.72,percent of total billed charges,,,45.3,,712.57,percent of total billed charges,,,39,,613.47,percent of total billed charges,,,,,,,,,80,,1258.4,percent of total billed charges,,,61.4,,965.82,percent of total billed charges,,,57.4,,902.9,percent of total billed charges,,,81,,1274.13,percent of total billed charges,,,39,,613.47,percent of total billed charges,,,57.6,,906.05,percent of total billed charges,,,85,,1337.05,percent of total billed charges,,,85,,1337.05,percent of total billed charges,,,49,,770.77,percent of total billed charges,,,90,,1415.7,percent of total billed charges,,,65,,1022.45,percent of total billed charges,,,80,,1258.4,percent of total billed charges,,,55,,865.15,percent of total billed charges,,,55,,865.15,percent of total billed charges,,,65,,1022.45,percent of total billed charges,,,78,,1226.94,percent of total billed charges,,,70,,1101.1,percent of total billed charges,,,,,,,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,352.24,,,,100% of Medicare,,,352.24,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,352.24,1415.7,
"Wrist-Hand Orthosis, Thumb Wrist Spica",L3923,HCPCS,,,,outpatient,,,471,282.6,,45.5,,214.31,percent of total billed charges,,,45.3,,213.36,percent of total billed charges,,,39,,183.69,percent of total billed charges,,,,,,,,,80,,376.8,percent of total billed charges,,,61.4,,289.19,percent of total billed charges,,,57.4,,270.35,percent of total billed charges,,,81,,381.51,percent of total billed charges,,,39,,183.69,percent of total billed charges,,,57.6,,271.3,percent of total billed charges,,,85,,400.35,percent of total billed charges,,,85,,400.35,percent of total billed charges,,,49,,230.79,percent of total billed charges,,,90,,423.9,percent of total billed charges,,,65,,306.15,percent of total billed charges,,,80,,376.8,percent of total billed charges,,,55,,259.05,percent of total billed charges,,,55,,259.05,percent of total billed charges,,,65,,306.15,percent of total billed charges,,,78,,367.38,percent of total billed charges,,,70,,329.7,percent of total billed charges,,,,,,,,105.92,,,,100% of Medicare,,105.92,,,,100% of Medicare,,105.92,,,,100% of Medicare,,105.92,,,,100% of Medicare,,105.92,,,,100% of Medicare,,105.92,,,,100% of Medicare,,105.92,,,,100% of Medicare,,105.92,,,,100% of Medicare,,105.92,,,,100% of Medicare,,105.92,,,,100% of Medicare,,105.92,,,,100% of Medicare,,105.92,,,,100% of Medicare,,,105.92,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,105.92,423.9,
HFO WITHOUT JOINTS PRE OTS (L3924),L3924,HCPCS,,,,outpatient,,,436,261.6,,45.5,,198.38,percent of total billed charges,,,45.3,,197.51,percent of total billed charges,,,39,,170.04,percent of total billed charges,,,,,,,,,80,,348.8,percent of total billed charges,,,61.4,,267.7,percent of total billed charges,,,57.4,,250.26,percent of total billed charges,,,81,,353.16,percent of total billed charges,,,39,,170.04,percent of total billed charges,,,57.6,,251.14,percent of total billed charges,,,85,,370.6,percent of total billed charges,,,85,,370.6,percent of total billed charges,,,49,,213.64,percent of total billed charges,,,90,,392.4,percent of total billed charges,,,65,,283.4,percent of total billed charges,,,80,,348.8,percent of total billed charges,,,55,,239.8,percent of total billed charges,,,55,,239.8,percent of total billed charges,,,65,,283.4,percent of total billed charges,,,78,,340.08,percent of total billed charges,,,70,,305.2,percent of total billed charges,,,,,,,,105.92,,,,100% of Medicare,,105.92,,,,100% of Medicare,,105.92,,,,100% of Medicare,,105.92,,,,100% of Medicare,,105.92,,,,100% of Medicare,,105.92,,,,100% of Medicare,,105.92,,,,100% of Medicare,,105.92,,,,100% of Medicare,,105.92,,,,100% of Medicare,,105.92,,,,100% of Medicare,,105.92,,,,100% of Medicare,,105.92,,,,100% of Medicare,,,105.92,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,105.92,392.4,
"Finger orthosis, non torsion spring",L3925,HCPCS,,,,outpatient,,,161,96.6,,45.5,,73.26,percent of total billed charges,,,45.3,,72.93,percent of total billed charges,,,39,,62.79,percent of total billed charges,,,,,,,,,80,,128.8,percent of total billed charges,,,61.4,,98.85,percent of total billed charges,,,57.4,,92.41,percent of total billed charges,,,81,,130.41,percent of total billed charges,,,39,,62.79,percent of total billed charges,,,57.6,,92.74,percent of total billed charges,,,85,,136.85,percent of total billed charges,,,85,,136.85,percent of total billed charges,,,49,,78.89,percent of total billed charges,,,90,,144.9,percent of total billed charges,,,65,,104.65,percent of total billed charges,,,80,,128.8,percent of total billed charges,,,55,,88.55,percent of total billed charges,,,55,,88.55,percent of total billed charges,,,65,,104.65,percent of total billed charges,,,78,,125.58,percent of total billed charges,,,70,,112.7,percent of total billed charges,,,,,,,,72.03,,,,100% of Medicare,,72.03,,,,100% of Medicare,,72.03,,,,100% of Medicare,,72.03,,,,100% of Medicare,,72.03,,,,100% of Medicare,,72.03,,,,100% of Medicare,,72.03,,,,100% of Medicare,,72.03,,,,100% of Medicare,,72.03,,,,100% of Medicare,,72.03,,,,100% of Medicare,,72.03,,,,100% of Medicare,,72.03,,,,100% of Medicare,,,72.03,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,62.79,144.9,
FO PIP/DIP W/O JOINT/SPRING,L3927,HCPCS,,,,outpatient,,,143,85.8,,45.5,,65.07,percent of total billed charges,,,45.3,,64.78,percent of total billed charges,,,39,,55.77,percent of total billed charges,,,,,,,,,80,,114.4,percent of total billed charges,,,61.4,,87.8,percent of total billed charges,,,57.4,,82.08,percent of total billed charges,,,81,,115.83,percent of total billed charges,,,39,,55.77,percent of total billed charges,,,57.6,,82.37,percent of total billed charges,,,85,,121.55,percent of total billed charges,,,85,,121.55,percent of total billed charges,,,49,,70.07,percent of total billed charges,,,90,,128.7,percent of total billed charges,,,65,,92.95,percent of total billed charges,,,80,,114.4,percent of total billed charges,,,55,,78.65,percent of total billed charges,,,55,,78.65,percent of total billed charges,,,65,,92.95,percent of total billed charges,,,78,,111.54,percent of total billed charges,,,70,,100.1,percent of total billed charges,,,,,,,,38.38,,,,100% of Medicare,,38.38,,,,100% of Medicare,,38.38,,,,100% of Medicare,,38.38,,,,100% of Medicare,,38.38,,,,100% of Medicare,,38.38,,,,100% of Medicare,,38.38,,,,100% of Medicare,,38.38,,,,100% of Medicare,,38.38,,,,100% of Medicare,,38.38,,,,100% of Medicare,,38.38,,,,100% of Medicare,,38.38,,,,100% of Medicare,,,38.38,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,38.38,128.7,
"HFO Nontorsion Joint, Prefabricated",L3929,HCPCS,,,,outpatient,,,448,268.8,,45.5,,203.84,percent of total billed charges,,,45.3,,202.94,percent of total billed charges,,,39,,174.72,percent of total billed charges,,,,,,,,,80,,358.4,percent of total billed charges,,,61.4,,275.07,percent of total billed charges,,,57.4,,257.15,percent of total billed charges,,,81,,362.88,percent of total billed charges,,,39,,174.72,percent of total billed charges,,,57.6,,258.05,percent of total billed charges,,,85,,380.8,percent of total billed charges,,,85,,380.8,percent of total billed charges,,,49,,219.52,percent of total billed charges,,,90,,403.2,percent of total billed charges,,,65,,291.2,percent of total billed charges,,,80,,358.4,percent of total billed charges,,,55,,246.4,percent of total billed charges,,,55,,246.4,percent of total billed charges,,,65,,291.2,percent of total billed charges,,,78,,349.44,percent of total billed charges,,,70,,313.6,percent of total billed charges,,,,,,,,100.16,,,,100% of Medicare,,100.16,,,,100% of Medicare,,100.16,,,,100% of Medicare,,100.16,,,,100% of Medicare,,100.16,,,,100% of Medicare,,100.16,,,,100% of Medicare,,100.16,,,,100% of Medicare,,100.16,,,,100% of Medicare,,100.16,,,,100% of Medicare,,100.16,,,,100% of Medicare,,100.16,,,,100% of Medicare,,100.16,,,,100% of Medicare,,,100.16,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,100.16,403.2,
HFO NONTORSION JNTS PRE OTS (L3930),L3930,HCPCS,,,,outpatient,,,415,249,,45.5,,188.83,percent of total billed charges,,,45.3,,188,percent of total billed charges,,,39,,161.85,percent of total billed charges,,,,,,,,,80,,332,percent of total billed charges,,,61.4,,254.81,percent of total billed charges,,,57.4,,238.21,percent of total billed charges,,,81,,336.15,percent of total billed charges,,,39,,161.85,percent of total billed charges,,,57.6,,239.04,percent of total billed charges,,,85,,352.75,percent of total billed charges,,,85,,352.75,percent of total billed charges,,,49,,203.35,percent of total billed charges,,,90,,373.5,percent of total billed charges,,,65,,269.75,percent of total billed charges,,,80,,332,percent of total billed charges,,,55,,228.25,percent of total billed charges,,,55,,228.25,percent of total billed charges,,,65,,269.75,percent of total billed charges,,,78,,323.7,percent of total billed charges,,,70,,290.5,percent of total billed charges,,,,,,,,100.16,,,,100% of Medicare,,100.16,,,,100% of Medicare,,100.16,,,,100% of Medicare,,100.16,,,,100% of Medicare,,100.16,,,,100% of Medicare,,100.16,,,,100% of Medicare,,100.16,,,,100% of Medicare,,100.16,,,,100% of Medicare,,100.16,,,,100% of Medicare,,100.16,,,,100% of Medicare,,100.16,,,,100% of Medicare,,100.16,,,,100% of Medicare,,,100.16,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,100.16,373.5,
"WHFO Nontorsion Joint, Prefabricated",L3931,HCPCS,,,,outpatient,,,1023,613.8,,45.5,,465.47,percent of total billed charges,,,45.3,,463.42,percent of total billed charges,,,39,,398.97,percent of total billed charges,,,,,,,,,80,,818.4,percent of total billed charges,,,61.4,,628.12,percent of total billed charges,,,57.4,,587.2,percent of total billed charges,,,81,,828.63,percent of total billed charges,,,39,,398.97,percent of total billed charges,,,57.6,,589.25,percent of total billed charges,,,85,,869.55,percent of total billed charges,,,85,,869.55,percent of total billed charges,,,49,,501.27,percent of total billed charges,,,90,,920.7,percent of total billed charges,,,65,,664.95,percent of total billed charges,,,80,,818.4,percent of total billed charges,,,55,,562.65,percent of total billed charges,,,55,,562.65,percent of total billed charges,,,65,,664.95,percent of total billed charges,,,78,,797.94,percent of total billed charges,,,70,,716.1,percent of total billed charges,,,,,,,,228.63,,,,100% of Medicare,,228.63,,,,100% of Medicare,,228.63,,,,100% of Medicare,,228.63,,,,100% of Medicare,,228.63,,,,100% of Medicare,,228.63,,,,100% of Medicare,,228.63,,,,100% of Medicare,,228.63,,,,100% of Medicare,,228.63,,,,100% of Medicare,,228.63,,,,100% of Medicare,,228.63,,,,100% of Medicare,,228.63,,,,100% of Medicare,,,228.63,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,228.63,920.7,
OT Finger Orthosis Left Charge L3933,L3933,HCPCS,,,LT,both,,,705,423,,45.5,,320.78,percent of total billed charges,,,45.3,,319.37,percent of total billed charges,,,39,,274.95,percent of total billed charges,,,,,,,,,80,,564,percent of total billed charges,,,61.4,,432.87,percent of total billed charges,,,57.4,,404.67,percent of total billed charges,,,81,,571.05,percent of total billed charges,,,39,,274.95,percent of total billed charges,,,57.6,,406.08,percent of total billed charges,,,85,,599.25,percent of total billed charges,,,85,,599.25,percent of total billed charges,,,49,,345.45,percent of total billed charges,,,90,,634.5,percent of total billed charges,,,65,,458.25,percent of total billed charges,,,80,,564,percent of total billed charges,,,55,,387.75,percent of total billed charges,,,55,,387.75,percent of total billed charges,,,65,,458.25,percent of total billed charges,,,78,,549.9,percent of total billed charges,,,70,,493.5,percent of total billed charges,,,,,,,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,,233.96,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,233.96,634.5,
OT Finger Orthosis Right Charge L3933,L3933,HCPCS,,,RT,both,,,705,423,,45.5,,320.78,percent of total billed charges,,,45.3,,319.37,percent of total billed charges,,,39,,274.95,percent of total billed charges,,,,,,,,,80,,564,percent of total billed charges,,,61.4,,432.87,percent of total billed charges,,,57.4,,404.67,percent of total billed charges,,,81,,571.05,percent of total billed charges,,,39,,274.95,percent of total billed charges,,,57.6,,406.08,percent of total billed charges,,,85,,599.25,percent of total billed charges,,,85,,599.25,percent of total billed charges,,,49,,345.45,percent of total billed charges,,,90,,634.5,percent of total billed charges,,,65,,458.25,percent of total billed charges,,,80,,564,percent of total billed charges,,,55,,387.75,percent of total billed charges,,,55,,387.75,percent of total billed charges,,,65,,458.25,percent of total billed charges,,,78,,549.9,percent of total billed charges,,,70,,493.5,percent of total billed charges,,,,,,,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,,233.96,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,233.96,634.5,
"L3933 FO, w/o JTs, Custom Fab",L3933,HCPCS,,,,outpatient,,,1032,619.2,,45.5,,469.56,percent of total billed charges,,,45.3,,467.5,percent of total billed charges,,,39,,402.48,percent of total billed charges,,,,,,,,,80,,825.6,percent of total billed charges,,,61.4,,633.65,percent of total billed charges,,,57.4,,592.37,percent of total billed charges,,,81,,835.92,percent of total billed charges,,,39,,402.48,percent of total billed charges,,,57.6,,594.43,percent of total billed charges,,,85,,877.2,percent of total billed charges,,,85,,877.2,percent of total billed charges,,,49,,505.68,percent of total billed charges,,,90,,928.8,percent of total billed charges,,,65,,670.8,percent of total billed charges,,,80,,825.6,percent of total billed charges,,,55,,567.6,percent of total billed charges,,,55,,567.6,percent of total billed charges,,,65,,670.8,percent of total billed charges,,,78,,804.96,percent of total billed charges,,,70,,722.4,percent of total billed charges,,,,,,,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,233.96,,,,100% of Medicare,,,233.96,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,233.96,928.8,
OT FO Left Charge L3935,L3935,HCPCS,,,LT,both,,,725,435,,45.5,,329.88,percent of total billed charges,,,45.3,,328.43,percent of total billed charges,,,39,,282.75,percent of total billed charges,,,,,,,,,80,,580,percent of total billed charges,,,61.4,,445.15,percent of total billed charges,,,57.4,,416.15,percent of total billed charges,,,81,,587.25,percent of total billed charges,,,39,,282.75,percent of total billed charges,,,57.6,,417.6,percent of total billed charges,,,85,,616.25,percent of total billed charges,,,85,,616.25,percent of total billed charges,,,49,,355.25,percent of total billed charges,,,90,,652.5,percent of total billed charges,,,65,,471.25,percent of total billed charges,,,80,,580,percent of total billed charges,,,55,,398.75,percent of total billed charges,,,55,,398.75,percent of total billed charges,,,65,,471.25,percent of total billed charges,,,78,,565.5,percent of total billed charges,,,70,,507.5,percent of total billed charges,,,,,,,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,,242.23,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,242.23,652.5,
OT FO Right Charge L3935,L3935,HCPCS,,,RT,both,,,725,435,,45.5,,329.88,percent of total billed charges,,,45.3,,328.43,percent of total billed charges,,,39,,282.75,percent of total billed charges,,,,,,,,,80,,580,percent of total billed charges,,,61.4,,445.15,percent of total billed charges,,,57.4,,416.15,percent of total billed charges,,,81,,587.25,percent of total billed charges,,,39,,282.75,percent of total billed charges,,,57.6,,417.6,percent of total billed charges,,,85,,616.25,percent of total billed charges,,,85,,616.25,percent of total billed charges,,,49,,355.25,percent of total billed charges,,,90,,652.5,percent of total billed charges,,,65,,471.25,percent of total billed charges,,,80,,580,percent of total billed charges,,,55,,398.75,percent of total billed charges,,,55,,398.75,percent of total billed charges,,,65,,471.25,percent of total billed charges,,,78,,565.5,percent of total billed charges,,,70,,507.5,percent of total billed charges,,,,,,,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,,242.23,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,242.23,652.5,
"L3935 FO, Nontorsion JT, Custom Fab",L3935,HCPCS,,,,outpatient,,,1070,642,,45.5,,486.85,percent of total billed charges,,,45.3,,484.71,percent of total billed charges,,,39,,417.3,percent of total billed charges,,,,,,,,,80,,856,percent of total billed charges,,,61.4,,656.98,percent of total billed charges,,,57.4,,614.18,percent of total billed charges,,,81,,866.7,percent of total billed charges,,,39,,417.3,percent of total billed charges,,,57.6,,616.32,percent of total billed charges,,,85,,909.5,percent of total billed charges,,,85,,909.5,percent of total billed charges,,,49,,524.3,percent of total billed charges,,,90,,963,percent of total billed charges,,,65,,695.5,percent of total billed charges,,,80,,856,percent of total billed charges,,,55,,588.5,percent of total billed charges,,,55,,588.5,percent of total billed charges,,,65,,695.5,percent of total billed charges,,,78,,834.6,percent of total billed charges,,,70,,749,percent of total billed charges,,,,,,,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,242.23,,,,100% of Medicare,,,242.23,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,242.23,963,
"Shoulder-Elbow-Wrist-Hand Orthosis, Airplane Design",L3960,HCPCS,,,,outpatient,,,1860,1116,,45.5,,846.3,percent of total billed charges,,,45.3,,842.58,percent of total billed charges,,,39,,725.4,percent of total billed charges,,,,,,,,,80,,1488,percent of total billed charges,,,61.4,,1142.04,percent of total billed charges,,,57.4,,1067.64,percent of total billed charges,,,81,,1506.6,percent of total billed charges,,,39,,725.4,percent of total billed charges,,,57.6,,1071.36,percent of total billed charges,,,85,,1581,percent of total billed charges,,,85,,1581,percent of total billed charges,,,49,,911.4,percent of total billed charges,,,90,,1674,percent of total billed charges,,,65,,1209,percent of total billed charges,,,80,,1488,percent of total billed charges,,,55,,1023,percent of total billed charges,,,55,,1023,percent of total billed charges,,,65,,1209,percent of total billed charges,,,78,,1450.8,percent of total billed charges,,,70,,1302,percent of total billed charges,,,,,,,,874.56,,,,100% of Medicare,,874.56,,,,100% of Medicare,,874.56,,,,100% of Medicare,,874.56,,,,100% of Medicare,,874.56,,,,100% of Medicare,,874.56,,,,100% of Medicare,,874.56,,,,100% of Medicare,,874.56,,,,100% of Medicare,,874.56,,,,100% of Medicare,,874.56,,,,100% of Medicare,,874.56,,,,100% of Medicare,,874.56,,,,100% of Medicare,,,874.56,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,725.4,1674,
"Shoulder-Elbow Orthosis, shoulder cap w/o joints, custom fab",L3961,HCPCS,,,,outpatient,,,3754,2252.4,,45.5,,1708.07,percent of total billed charges,,,45.3,,1700.56,percent of total billed charges,,,39,,1464.06,percent of total billed charges,,,,,,,,,80,,3003.2,percent of total billed charges,,,61.4,,2304.96,percent of total billed charges,,,57.4,,2154.8,percent of total billed charges,,,81,,3040.74,percent of total billed charges,,,39,,1464.06,percent of total billed charges,,,57.6,,2162.3,percent of total billed charges,,,85,,3190.9,percent of total billed charges,,,85,,3190.9,percent of total billed charges,,,49,,1839.46,percent of total billed charges,,,90,,3378.6,percent of total billed charges,,,65,,2440.1,percent of total billed charges,,,80,,3003.2,percent of total billed charges,,,55,,2064.7,percent of total billed charges,,,55,,2064.7,percent of total billed charges,,,65,,2440.1,percent of total billed charges,,,78,,2928.12,percent of total billed charges,,,70,,2627.8,percent of total billed charges,,,,,,,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,1842.32,,,,100% of Medicare,,,1842.32,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1464.06,3378.6,
"Shoulder-Elbow-Wrist-Hand Orthosis, Abduction Positioning, Erbs Palsey Design",L3962,HCPCS,,,,outpatient,,,1683,1009.8,,45.5,,765.77,percent of total billed charges,,,45.3,,762.4,percent of total billed charges,,,39,,656.37,percent of total billed charges,,,,,,,,,80,,1346.4,percent of total billed charges,,,61.4,,1033.36,percent of total billed charges,,,57.4,,966.04,percent of total billed charges,,,81,,1363.23,percent of total billed charges,,,39,,656.37,percent of total billed charges,,,57.6,,969.41,percent of total billed charges,,,85,,1430.55,percent of total billed charges,,,85,,1430.55,percent of total billed charges,,,49,,824.67,percent of total billed charges,,,90,,1514.7,percent of total billed charges,,,65,,1093.95,percent of total billed charges,,,80,,1346.4,percent of total billed charges,,,55,,925.65,percent of total billed charges,,,55,,925.65,percent of total billed charges,,,65,,1093.95,percent of total billed charges,,,78,,1312.74,percent of total billed charges,,,70,,1178.1,percent of total billed charges,,,,,,,,790.98,,,,100% of Medicare,,790.98,,,,100% of Medicare,,790.98,,,,100% of Medicare,,790.98,,,,100% of Medicare,,790.98,,,,100% of Medicare,,790.98,,,,100% of Medicare,,790.98,,,,100% of Medicare,,790.98,,,,100% of Medicare,,790.98,,,,100% of Medicare,,790.98,,,,100% of Medicare,,790.98,,,,100% of Medicare,,790.98,,,,100% of Medicare,,,790.98,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,656.37,1514.7,
"Upper Extremity, Humeral Fx Cuff",L3980,HCPCS,,,,outpatient,,,1897,1138.2,,45.5,,863.14,percent of total billed charges,,,45.3,,859.34,percent of total billed charges,,,39,,739.83,percent of total billed charges,,,,,,,,,80,,1517.6,percent of total billed charges,,,61.4,,1164.76,percent of total billed charges,,,57.4,,1088.88,percent of total billed charges,,,81,,1536.57,percent of total billed charges,,,39,,739.83,percent of total billed charges,,,57.6,,1092.67,percent of total billed charges,,,85,,1612.45,percent of total billed charges,,,85,,1612.45,percent of total billed charges,,,49,,929.53,percent of total billed charges,,,90,,1707.3,percent of total billed charges,,,65,,1233.05,percent of total billed charges,,,80,,1517.6,percent of total billed charges,,,55,,1043.35,percent of total billed charges,,,55,,1043.35,percent of total billed charges,,,65,,1233.05,percent of total billed charges,,,78,,1479.66,percent of total billed charges,,,70,,1327.9,percent of total billed charges,,,,,,,,424.21,,,,100% of Medicare,,424.21,,,,100% of Medicare,,424.21,,,,100% of Medicare,,424.21,,,,100% of Medicare,,424.21,,,,100% of Medicare,,424.21,,,,100% of Medicare,,424.21,,,,100% of Medicare,,424.21,,,,100% of Medicare,,424.21,,,,100% of Medicare,,424.21,,,,100% of Medicare,,424.21,,,,100% of Medicare,,424.21,,,,100% of Medicare,,,424.21,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,424.21,1707.3,
"Upper Extremity, Radius/Ulner Fx Cuff",L3982,HCPCS,,,,outpatient,,,915,549,,45.5,,416.33,percent of total billed charges,,,45.3,,414.5,percent of total billed charges,,,39,,356.85,percent of total billed charges,,,,,,,,,80,,732,percent of total billed charges,,,61.4,,561.81,percent of total billed charges,,,57.4,,525.21,percent of total billed charges,,,81,,741.15,percent of total billed charges,,,39,,356.85,percent of total billed charges,,,57.6,,527.04,percent of total billed charges,,,85,,777.75,percent of total billed charges,,,85,,777.75,percent of total billed charges,,,49,,448.35,percent of total billed charges,,,90,,823.5,percent of total billed charges,,,65,,594.75,percent of total billed charges,,,80,,732,percent of total billed charges,,,55,,503.25,percent of total billed charges,,,55,,503.25,percent of total billed charges,,,65,,594.75,percent of total billed charges,,,78,,713.7,percent of total billed charges,,,70,,640.5,percent of total billed charges,,,,,,,,430.74,,,,100% of Medicare,,430.74,,,,100% of Medicare,,430.74,,,,100% of Medicare,,430.74,,,,100% of Medicare,,430.74,,,,100% of Medicare,,430.74,,,,100% of Medicare,,430.74,,,,100% of Medicare,,430.74,,,,100% of Medicare,,430.74,,,,100% of Medicare,,430.74,,,,100% of Medicare,,430.74,,,,100% of Medicare,,430.74,,,,100% of Medicare,,,430.74,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,356.85,823.5,
"Upper Extremity, Wrist Fx Cuff",L3984,HCPCS,,,,outpatient,,,874,524.4,,45.5,,397.67,percent of total billed charges,,,45.3,,395.92,percent of total billed charges,,,39,,340.86,percent of total billed charges,,,,,,,,,80,,699.2,percent of total billed charges,,,61.4,,536.64,percent of total billed charges,,,57.4,,501.68,percent of total billed charges,,,81,,707.94,percent of total billed charges,,,39,,340.86,percent of total billed charges,,,57.6,,503.42,percent of total billed charges,,,85,,742.9,percent of total billed charges,,,85,,742.9,percent of total billed charges,,,49,,428.26,percent of total billed charges,,,90,,786.6,percent of total billed charges,,,65,,568.1,percent of total billed charges,,,80,,699.2,percent of total billed charges,,,55,,480.7,percent of total billed charges,,,55,,480.7,percent of total billed charges,,,65,,568.1,percent of total billed charges,,,78,,681.72,percent of total billed charges,,,70,,611.8,percent of total billed charges,,,,,,,,379.44,,,,100% of Medicare,,379.44,,,,100% of Medicare,,379.44,,,,100% of Medicare,,379.44,,,,100% of Medicare,,379.44,,,,100% of Medicare,,379.44,,,,100% of Medicare,,379.44,,,,100% of Medicare,,379.44,,,,100% of Medicare,,379.44,,,,100% of Medicare,,379.44,,,,100% of Medicare,,379.44,,,,100% of Medicare,,379.44,,,,100% of Medicare,,,379.44,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,340.86,786.6,
"Upper Extremity Addition, Sock, Fx or Equal",L3995,HCPCS,,,,outpatient,,,107,64.2,,45.5,,48.69,percent of total billed charges,,,45.3,,48.47,percent of total billed charges,,,39,,41.73,percent of total billed charges,,,,,,,,,80,,85.6,percent of total billed charges,,,61.4,,65.7,percent of total billed charges,,,57.4,,61.42,percent of total billed charges,,,81,,86.67,percent of total billed charges,,,39,,41.73,percent of total billed charges,,,57.6,,61.63,percent of total billed charges,,,85,,90.95,percent of total billed charges,,,85,,90.95,percent of total billed charges,,,49,,52.43,percent of total billed charges,,,90,,96.3,percent of total billed charges,,,65,,69.55,percent of total billed charges,,,80,,85.6,percent of total billed charges,,,55,,58.85,percent of total billed charges,,,55,,58.85,percent of total billed charges,,,65,,69.55,percent of total billed charges,,,78,,83.46,percent of total billed charges,,,70,,74.9,percent of total billed charges,,,,,,,,45.02,,,,100% of Medicare,,45.02,,,,100% of Medicare,,45.02,,,,100% of Medicare,,45.02,,,,100% of Medicare,,45.02,,,,100% of Medicare,,45.02,,,,100% of Medicare,,45.02,,,,100% of Medicare,,45.02,,,,100% of Medicare,,45.02,,,,100% of Medicare,,45.02,,,,100% of Medicare,,45.02,,,,100% of Medicare,,45.02,,,,100% of Medicare,,,45.02,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,41.73,96.3,
"L3999 - Upper limb orthosis, not otherwise specified",L3999,HCPCS,,,,both,,,418.63,251.18,,45.5,,190.48,percent of total billed charges,,,45.3,,189.64,percent of total billed charges,,,39,,163.27,percent of total billed charges,,,,,,,,,80,,334.9,percent of total billed charges,,,61.4,,257.04,percent of total billed charges,,,57.4,,240.29,percent of total billed charges,,,81,,339.09,percent of total billed charges,,,51.5,,215.59,percent of total billed charges,,,57.6,,241.13,percent of total billed charges,,,85,,355.84,percent of total billed charges,,,85,,355.84,percent of total billed charges,,,49,,205.13,percent of total billed charges,,,90,,376.77,percent of total billed charges,,,65,,272.11,percent of total billed charges,,,80,,334.9,percent of total billed charges,,,55,,230.25,percent of total billed charges,,,55,,230.25,percent of total billed charges,,,65,,272.11,percent of total billed charges,,,78,,326.53,percent of total billed charges,,,70,,293.04,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG rate,100% of IL Medicaid,,,,,EAPG rate,100% of IL Medicaid,,,,,EAPG rate,100% of IL Medicaid,,,,,EAPG rate,100% of IL Medicaid,163.27,376.77,
Replace Girdle for Milwaukee Orthosis,L4000,HCPCS,,,,outpatient,,,3657,2194.2,,45.5,,1663.94,percent of total billed charges,,,45.3,,1656.62,percent of total billed charges,,,39,,1426.23,percent of total billed charges,,,,,,,,,80,,2925.6,percent of total billed charges,,,61.4,,2245.4,percent of total billed charges,,,57.4,,2099.12,percent of total billed charges,,,81,,2962.17,percent of total billed charges,,,39,,1426.23,percent of total billed charges,,,57.6,,2106.43,percent of total billed charges,,,85,,3108.45,percent of total billed charges,,,85,,3108.45,percent of total billed charges,,,49,,1791.93,percent of total billed charges,,,90,,3291.3,percent of total billed charges,,,65,,2377.05,percent of total billed charges,,,80,,2925.6,percent of total billed charges,,,55,,2011.35,percent of total billed charges,,,55,,2011.35,percent of total billed charges,,,65,,2377.05,percent of total billed charges,,,78,,2852.46,percent of total billed charges,,,70,,2559.9,percent of total billed charges,,,,,,,,1592.13,,,,100% of Medicare,,1592.13,,,,100% of Medicare,,1592.13,,,,100% of Medicare,,1592.13,,,,100% of Medicare,,1592.13,,,,100% of Medicare,,1592.13,,,,100% of Medicare,,1592.13,,,,100% of Medicare,,1592.13,,,,100% of Medicare,,1592.13,,,,100% of Medicare,,1592.13,,,,100% of Medicare,,1592.13,,,,100% of Medicare,,1592.13,,,,100% of Medicare,,,1592.13,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1426.23,3291.3,
"L4002 Replacement Strap, Any",L4002,HCPCS,,,,outpatient,,,71,42.6,,45.5,,32.31,percent of total billed charges,,,45.3,,32.16,percent of total billed charges,,,39,,27.69,percent of total billed charges,,,,,,,,,80,,56.8,percent of total billed charges,,,61.4,,43.59,percent of total billed charges,,,57.4,,40.75,percent of total billed charges,,,81,,57.51,percent of total billed charges,,,39,,27.69,percent of total billed charges,,,57.6,,40.9,percent of total billed charges,,,85,,60.35,percent of total billed charges,,,85,,60.35,percent of total billed charges,,,49,,34.79,percent of total billed charges,,,90,,63.9,percent of total billed charges,,,65,,46.15,percent of total billed charges,,,80,,56.8,percent of total billed charges,,,55,,39.05,percent of total billed charges,,,55,,39.05,percent of total billed charges,,,65,,46.15,percent of total billed charges,,,78,,55.38,percent of total billed charges,,,70,,49.7,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,27.69,63.9,
Replace Trilateral Socket Brim,L4010,HCPCS,,,,outpatient,,,2221,1332.6,,45.5,,1010.56,percent of total billed charges,,,45.3,,1006.11,percent of total billed charges,,,39,,866.19,percent of total billed charges,,,,,,,,,80,,1776.8,percent of total billed charges,,,61.4,,1363.69,percent of total billed charges,,,57.4,,1274.85,percent of total billed charges,,,81,,1799.01,percent of total billed charges,,,39,,866.19,percent of total billed charges,,,57.6,,1279.3,percent of total billed charges,,,85,,1887.85,percent of total billed charges,,,85,,1887.85,percent of total billed charges,,,49,,1088.29,percent of total billed charges,,,90,,1998.9,percent of total billed charges,,,65,,1443.65,percent of total billed charges,,,80,,1776.8,percent of total billed charges,,,55,,1221.55,percent of total billed charges,,,55,,1221.55,percent of total billed charges,,,65,,1443.65,percent of total billed charges,,,78,,1732.38,percent of total billed charges,,,70,,1554.7,percent of total billed charges,,,,,,,,967.72,,,,100% of Medicare,,967.72,,,,100% of Medicare,,967.72,,,,100% of Medicare,,967.72,,,,100% of Medicare,,967.72,,,,100% of Medicare,,967.72,,,,100% of Medicare,,967.72,,,,100% of Medicare,,967.72,,,,100% of Medicare,,967.72,,,,100% of Medicare,,967.72,,,,100% of Medicare,,967.72,,,,100% of Medicare,,967.72,,,,100% of Medicare,,,967.72,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,866.19,1998.9,
"Replace Quad socket brim, molded to patient model",L4020,HCPCS,,,,outpatient,,,3560,2136,,45.5,,1619.8,percent of total billed charges,,,45.3,,1612.68,percent of total billed charges,,,39,,1388.4,percent of total billed charges,,,,,,,,,80,,2848,percent of total billed charges,,,61.4,,2185.84,percent of total billed charges,,,57.4,,2043.44,percent of total billed charges,,,81,,2883.6,percent of total billed charges,,,39,,1388.4,percent of total billed charges,,,57.6,,2050.56,percent of total billed charges,,,85,,3026,percent of total billed charges,,,85,,3026,percent of total billed charges,,,49,,1744.4,percent of total billed charges,,,90,,3204,percent of total billed charges,,,65,,2314,percent of total billed charges,,,80,,2848,percent of total billed charges,,,55,,1958,percent of total billed charges,,,55,,1958,percent of total billed charges,,,65,,2314,percent of total billed charges,,,78,,2776.8,percent of total billed charges,,,70,,2492,percent of total billed charges,,,,,,,,1162.49,,,,100% of Medicare,,1162.49,,,,100% of Medicare,,1162.49,,,,100% of Medicare,,1162.49,,,,100% of Medicare,,1162.49,,,,100% of Medicare,,1162.49,,,,100% of Medicare,,1162.49,,,,100% of Medicare,,1162.49,,,,100% of Medicare,,1162.49,,,,100% of Medicare,,1162.49,,,,100% of Medicare,,1162.49,,,,100% of Medicare,,1162.49,,,,100% of Medicare,,,1162.49,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1162.49,3204,
"Replace Quad socket brim, custom fitted",L4030,HCPCS,,,,outpatient,,,1138,682.8,,45.5,,517.79,percent of total billed charges,,,45.3,,515.51,percent of total billed charges,,,39,,443.82,percent of total billed charges,,,,,,,,,80,,910.4,percent of total billed charges,,,61.4,,698.73,percent of total billed charges,,,57.4,,653.21,percent of total billed charges,,,81,,921.78,percent of total billed charges,,,39,,443.82,percent of total billed charges,,,57.6,,655.49,percent of total billed charges,,,85,,967.3,percent of total billed charges,,,85,,967.3,percent of total billed charges,,,49,,557.62,percent of total billed charges,,,90,,1024.2,percent of total billed charges,,,65,,739.7,percent of total billed charges,,,80,,910.4,percent of total billed charges,,,55,,625.9,percent of total billed charges,,,55,,625.9,percent of total billed charges,,,65,,739.7,percent of total billed charges,,,78,,887.64,percent of total billed charges,,,70,,796.6,percent of total billed charges,,,,,,,,738.73,,,,100% of Medicare,,738.73,,,,100% of Medicare,,738.73,,,,100% of Medicare,,738.73,,,,100% of Medicare,,738.73,,,,100% of Medicare,,738.73,,,,100% of Medicare,,738.73,,,,100% of Medicare,,738.73,,,,100% of Medicare,,738.73,,,,100% of Medicare,,738.73,,,,100% of Medicare,,738.73,,,,100% of Medicare,,738.73,,,,100% of Medicare,,,738.73,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,443.82,1024.2,
"Replace Molded thigh lacer, for custom orthosis only",L4040,HCPCS,,,,outpatient,,,1138,682.8,,45.5,,517.79,percent of total billed charges,,,45.3,,515.51,percent of total billed charges,,,39,,443.82,percent of total billed charges,,,,,,,,,80,,910.4,percent of total billed charges,,,61.4,,698.73,percent of total billed charges,,,57.4,,653.21,percent of total billed charges,,,81,,921.78,percent of total billed charges,,,39,,443.82,percent of total billed charges,,,57.6,,655.49,percent of total billed charges,,,85,,967.3,percent of total billed charges,,,85,,967.3,percent of total billed charges,,,49,,557.62,percent of total billed charges,,,90,,1024.2,percent of total billed charges,,,65,,739.7,percent of total billed charges,,,80,,910.4,percent of total billed charges,,,55,,625.9,percent of total billed charges,,,55,,625.9,percent of total billed charges,,,65,,739.7,percent of total billed charges,,,78,,887.64,percent of total billed charges,,,70,,796.6,percent of total billed charges,,,,,,,,500.28,,,,100% of Medicare,,500.28,,,,100% of Medicare,,500.28,,,,100% of Medicare,,500.28,,,,100% of Medicare,,500.28,,,,100% of Medicare,,500.28,,,,100% of Medicare,,500.28,,,,100% of Medicare,,500.28,,,,100% of Medicare,,500.28,,,,100% of Medicare,,500.28,,,,100% of Medicare,,500.28,,,,100% of Medicare,,500.28,,,,100% of Medicare,,,500.28,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,443.82,1024.2,
"L4045 Replace non-molded thigh lacer, for custom fabricated orthosis only",L4045,HCPCS,,,,outpatient,,,1625,975,,45.5,,739.38,percent of total billed charges,,,45.3,,736.13,percent of total billed charges,,,39,,633.75,percent of total billed charges,,,,,,,,,80,,1300,percent of total billed charges,,,61.4,,997.75,percent of total billed charges,,,57.4,,932.75,percent of total billed charges,,,81,,1316.25,percent of total billed charges,,,39,,633.75,percent of total billed charges,,,57.6,,936,percent of total billed charges,,,85,,1381.25,percent of total billed charges,,,85,,1381.25,percent of total billed charges,,,49,,796.25,percent of total billed charges,,,90,,1462.5,percent of total billed charges,,,65,,1056.25,percent of total billed charges,,,80,,1300,percent of total billed charges,,,55,,893.75,percent of total billed charges,,,55,,893.75,percent of total billed charges,,,65,,1056.25,percent of total billed charges,,,78,,1267.5,percent of total billed charges,,,70,,1137.5,percent of total billed charges,,,,,,,,369.55,,,,100% of Medicare,,369.55,,,,100% of Medicare,,369.55,,,,100% of Medicare,,369.55,,,,100% of Medicare,,369.55,,,,100% of Medicare,,369.55,,,,100% of Medicare,,369.55,,,,100% of Medicare,,369.55,,,,100% of Medicare,,369.55,,,,100% of Medicare,,369.55,,,,100% of Medicare,,369.55,,,,100% of Medicare,,369.55,,,,100% of Medicare,,,369.55,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,369.55,1462.5,
"Replace Calf Lacer, Molded, Custom Fabrication",L4050,HCPCS,,,,outpatient,,,1519,911.4,,45.5,,691.15,percent of total billed charges,,,45.3,,688.11,percent of total billed charges,,,39,,592.41,percent of total billed charges,,,,,,,,,80,,1215.2,percent of total billed charges,,,61.4,,932.67,percent of total billed charges,,,57.4,,871.91,percent of total billed charges,,,81,,1230.39,percent of total billed charges,,,39,,592.41,percent of total billed charges,,,57.6,,874.94,percent of total billed charges,,,85,,1291.15,percent of total billed charges,,,85,,1291.15,percent of total billed charges,,,49,,744.31,percent of total billed charges,,,90,,1367.1,percent of total billed charges,,,65,,987.35,percent of total billed charges,,,80,,1215.2,percent of total billed charges,,,55,,835.45,percent of total billed charges,,,55,,835.45,percent of total billed charges,,,65,,987.35,percent of total billed charges,,,78,,1184.82,percent of total billed charges,,,70,,1063.3,percent of total billed charges,,,,,,,,495.46,,,,100% of Medicare,,495.46,,,,100% of Medicare,,495.46,,,,100% of Medicare,,495.46,,,,100% of Medicare,,495.46,,,,100% of Medicare,,495.46,,,,100% of Medicare,,495.46,,,,100% of Medicare,,495.46,,,,100% of Medicare,,495.46,,,,100% of Medicare,,495.46,,,,100% of Medicare,,495.46,,,,100% of Medicare,,495.46,,,,100% of Medicare,,,495.46,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,495.46,1367.1,
"Replace Calf Lacer, Non-Molded, Custom Fabrication",L4055,HCPCS,,,,outpatient,,,692,415.2,,45.5,,314.86,percent of total billed charges,,,45.3,,313.48,percent of total billed charges,,,39,,269.88,percent of total billed charges,,,,,,,,,80,,553.6,percent of total billed charges,,,61.4,,424.89,percent of total billed charges,,,57.4,,397.21,percent of total billed charges,,,81,,560.52,percent of total billed charges,,,39,,269.88,percent of total billed charges,,,57.6,,398.59,percent of total billed charges,,,85,,588.2,percent of total billed charges,,,85,,588.2,percent of total billed charges,,,49,,339.08,percent of total billed charges,,,90,,622.8,percent of total billed charges,,,65,,449.8,percent of total billed charges,,,80,,553.6,percent of total billed charges,,,55,,380.6,percent of total billed charges,,,55,,380.6,percent of total billed charges,,,65,,449.8,percent of total billed charges,,,78,,539.76,percent of total billed charges,,,70,,484.4,percent of total billed charges,,,,,,,,301.17,,,,100% of Medicare,,301.17,,,,100% of Medicare,,301.17,,,,100% of Medicare,,301.17,,,,100% of Medicare,,301.17,,,,100% of Medicare,,301.17,,,,100% of Medicare,,301.17,,,,100% of Medicare,,301.17,,,,100% of Medicare,,301.17,,,,100% of Medicare,,301.17,,,,100% of Medicare,,301.17,,,,100% of Medicare,,301.17,,,,100% of Medicare,,,301.17,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,269.88,622.8,
Replace High Roll Cuff,L4060,HCPCS,,,,outpatient,,,904,542.4,,45.5,,411.32,percent of total billed charges,,,45.3,,409.51,percent of total billed charges,,,39,,352.56,percent of total billed charges,,,,,,,,,80,,723.2,percent of total billed charges,,,61.4,,555.06,percent of total billed charges,,,57.4,,518.9,percent of total billed charges,,,81,,732.24,percent of total billed charges,,,39,,352.56,percent of total billed charges,,,57.6,,520.7,percent of total billed charges,,,85,,768.4,percent of total billed charges,,,85,,768.4,percent of total billed charges,,,49,,442.96,percent of total billed charges,,,90,,813.6,percent of total billed charges,,,65,,587.6,percent of total billed charges,,,80,,723.2,percent of total billed charges,,,55,,497.2,percent of total billed charges,,,55,,497.2,percent of total billed charges,,,65,,587.6,percent of total billed charges,,,78,,705.12,percent of total billed charges,,,70,,632.8,percent of total billed charges,,,,,,,,391.49,,,,100% of Medicare,,391.49,,,,100% of Medicare,,391.49,,,,100% of Medicare,,391.49,,,,100% of Medicare,,391.49,,,,100% of Medicare,,391.49,,,,100% of Medicare,,391.49,,,,100% of Medicare,,391.49,,,,100% of Medicare,,391.49,,,,100% of Medicare,,391.49,,,,100% of Medicare,,391.49,,,,100% of Medicare,,391.49,,,,100% of Medicare,,,391.49,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,352.56,813.6,
Replace Proximal and Distal Upright for KAFO,L4070,HCPCS,,,,outpatient,,,1416,849.6,,45.5,,644.28,percent of total billed charges,,,45.3,,641.45,percent of total billed charges,,,39,,552.24,percent of total billed charges,,,,,,,,,80,,1132.8,percent of total billed charges,,,61.4,,869.42,percent of total billed charges,,,57.4,,812.78,percent of total billed charges,,,81,,1146.96,percent of total billed charges,,,39,,552.24,percent of total billed charges,,,57.6,,815.62,percent of total billed charges,,,85,,1203.6,percent of total billed charges,,,85,,1203.6,percent of total billed charges,,,49,,693.84,percent of total billed charges,,,90,,1274.4,percent of total billed charges,,,65,,920.4,percent of total billed charges,,,80,,1132.8,percent of total billed charges,,,55,,778.8,percent of total billed charges,,,55,,778.8,percent of total billed charges,,,65,,920.4,percent of total billed charges,,,78,,1104.48,percent of total billed charges,,,70,,991.2,percent of total billed charges,,,,,,,,317.05,,,,100% of Medicare,,317.05,,,,100% of Medicare,,317.05,,,,100% of Medicare,,317.05,,,,100% of Medicare,,317.05,,,,100% of Medicare,,317.05,,,,100% of Medicare,,317.05,,,,100% of Medicare,,317.05,,,,100% of Medicare,,317.05,,,,100% of Medicare,,317.05,,,,100% of Medicare,,317.05,,,,100% of Medicare,,317.05,,,,100% of Medicare,,,317.05,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,317.05,1274.4,
"Replace Metal bBands KAFO, Proximal Thigh",L4080,HCPCS,,,,outpatient,,,535,321,,45.5,,243.43,percent of total billed charges,,,45.3,,242.36,percent of total billed charges,,,39,,208.65,percent of total billed charges,,,,,,,,,80,,428,percent of total billed charges,,,61.4,,328.49,percent of total billed charges,,,57.4,,307.09,percent of total billed charges,,,81,,433.35,percent of total billed charges,,,39,,208.65,percent of total billed charges,,,57.6,,308.16,percent of total billed charges,,,85,,454.75,percent of total billed charges,,,85,,454.75,percent of total billed charges,,,49,,262.15,percent of total billed charges,,,90,,481.5,percent of total billed charges,,,65,,347.75,percent of total billed charges,,,80,,428,percent of total billed charges,,,55,,294.25,percent of total billed charges,,,55,,294.25,percent of total billed charges,,,65,,347.75,percent of total billed charges,,,78,,417.3,percent of total billed charges,,,70,,374.5,percent of total billed charges,,,,,,,,119.7,,,,100% of Medicare,,119.7,,,,100% of Medicare,,119.7,,,,100% of Medicare,,119.7,,,,100% of Medicare,,119.7,,,,100% of Medicare,,119.7,,,,100% of Medicare,,119.7,,,,100% of Medicare,,119.7,,,,100% of Medicare,,119.7,,,,100% of Medicare,,119.7,,,,100% of Medicare,,119.7,,,,100% of Medicare,,119.7,,,,100% of Medicare,,,119.7,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,119.7,481.5,
"Replace Metals Bands KAFO, Calf or Distal Thigh",L4090,HCPCS,,,,outpatient,,,397,238.2,,45.5,,180.64,percent of total billed charges,,,45.3,,179.84,percent of total billed charges,,,39,,154.83,percent of total billed charges,,,,,,,,,80,,317.6,percent of total billed charges,,,61.4,,243.76,percent of total billed charges,,,57.4,,227.88,percent of total billed charges,,,81,,321.57,percent of total billed charges,,,39,,154.83,percent of total billed charges,,,57.6,,228.67,percent of total billed charges,,,85,,337.45,percent of total billed charges,,,85,,337.45,percent of total billed charges,,,49,,194.53,percent of total billed charges,,,90,,357.3,percent of total billed charges,,,65,,258.05,percent of total billed charges,,,80,,317.6,percent of total billed charges,,,55,,218.35,percent of total billed charges,,,55,,218.35,percent of total billed charges,,,65,,258.05,percent of total billed charges,,,78,,309.66,percent of total billed charges,,,70,,277.9,percent of total billed charges,,,,,,,,101.84,,,,100% of Medicare,,101.84,,,,100% of Medicare,,101.84,,,,100% of Medicare,,101.84,,,,100% of Medicare,,101.84,,,,100% of Medicare,,101.84,,,,100% of Medicare,,101.84,,,,100% of Medicare,,101.84,,,,100% of Medicare,,101.84,,,,100% of Medicare,,101.84,,,,100% of Medicare,,101.84,,,,100% of Medicare,,101.84,,,,100% of Medicare,,,101.84,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,101.84,357.3,
"Replace Leather Cuff, Proximal Thigh",L4100,HCPCS,,,,outpatient,,,530,318,,45.5,,241.15,percent of total billed charges,,,45.3,,240.09,percent of total billed charges,,,39,,206.7,percent of total billed charges,,,,,,,,,80,,424,percent of total billed charges,,,61.4,,325.42,percent of total billed charges,,,57.4,,304.22,percent of total billed charges,,,81,,429.3,percent of total billed charges,,,39,,206.7,percent of total billed charges,,,57.6,,305.28,percent of total billed charges,,,85,,450.5,percent of total billed charges,,,85,,450.5,percent of total billed charges,,,49,,259.7,percent of total billed charges,,,90,,477,percent of total billed charges,,,65,,344.5,percent of total billed charges,,,80,,424,percent of total billed charges,,,55,,291.5,percent of total billed charges,,,55,,291.5,percent of total billed charges,,,65,,344.5,percent of total billed charges,,,78,,413.4,percent of total billed charges,,,70,,371,percent of total billed charges,,,,,,,,122.36,,,,100% of Medicare,,122.36,,,,100% of Medicare,,122.36,,,,100% of Medicare,,122.36,,,,100% of Medicare,,122.36,,,,100% of Medicare,,122.36,,,,100% of Medicare,,122.36,,,,100% of Medicare,,122.36,,,,100% of Medicare,,122.36,,,,100% of Medicare,,122.36,,,,100% of Medicare,,122.36,,,,100% of Medicare,,122.36,,,,100% of Medicare,,,122.36,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,122.36,477,
"Replace Leather Cuff, Calf or Distal Thigh",L4110,HCPCS,,,,outpatient,,,415,249,,45.5,,188.83,percent of total billed charges,,,45.3,,188,percent of total billed charges,,,39,,161.85,percent of total billed charges,,,,,,,,,80,,332,percent of total billed charges,,,61.4,,254.81,percent of total billed charges,,,57.4,,238.21,percent of total billed charges,,,81,,336.15,percent of total billed charges,,,39,,161.85,percent of total billed charges,,,57.6,,239.04,percent of total billed charges,,,85,,352.75,percent of total billed charges,,,85,,352.75,percent of total billed charges,,,49,,203.35,percent of total billed charges,,,90,,373.5,percent of total billed charges,,,65,,269.75,percent of total billed charges,,,80,,332,percent of total billed charges,,,55,,228.25,percent of total billed charges,,,55,,228.25,percent of total billed charges,,,65,,269.75,percent of total billed charges,,,78,,323.7,percent of total billed charges,,,70,,290.5,percent of total billed charges,,,,,,,,95.54,,,,100% of Medicare,,95.54,,,,100% of Medicare,,95.54,,,,100% of Medicare,,95.54,,,,100% of Medicare,,95.54,,,,100% of Medicare,,95.54,,,,100% of Medicare,,95.54,,,,100% of Medicare,,95.54,,,,100% of Medicare,,95.54,,,,100% of Medicare,,95.54,,,,100% of Medicare,,95.54,,,,100% of Medicare,,95.54,,,,100% of Medicare,,,95.54,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,95.54,373.5,
Replace Pretibial Shell,L4130,HCPCS,,,,outpatient,,,1327,796.2,,45.5,,603.79,percent of total billed charges,,,45.3,,601.13,percent of total billed charges,,,39,,517.53,percent of total billed charges,,,,,,,,,80,,1061.6,percent of total billed charges,,,61.4,,814.78,percent of total billed charges,,,57.4,,761.7,percent of total billed charges,,,81,,1074.87,percent of total billed charges,,,39,,517.53,percent of total billed charges,,,57.6,,764.35,percent of total billed charges,,,85,,1127.95,percent of total billed charges,,,85,,1127.95,percent of total billed charges,,,49,,650.23,percent of total billed charges,,,90,,1194.3,percent of total billed charges,,,65,,862.55,percent of total billed charges,,,80,,1061.6,percent of total billed charges,,,55,,729.85,percent of total billed charges,,,55,,729.85,percent of total billed charges,,,65,,862.55,percent of total billed charges,,,78,,1035.06,percent of total billed charges,,,70,,928.9,percent of total billed charges,,,,,,,,577.5,,,,100% of Medicare,,577.5,,,,100% of Medicare,,577.5,,,,100% of Medicare,,577.5,,,,100% of Medicare,,577.5,,,,100% of Medicare,,577.5,,,,100% of Medicare,,577.5,,,,100% of Medicare,,577.5,,,,100% of Medicare,,577.5,,,,100% of Medicare,,577.5,,,,100% of Medicare,,577.5,,,,100% of Medicare,,577.5,,,,100% of Medicare,,,577.5,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,517.53,1194.3,
L4205 Repair Labor 15 minutes,L4205,HCPCS,,,,outpatient,,,151,90.6,,45.5,,68.71,percent of total billed charges,,,45.3,,68.4,percent of total billed charges,,,39,,58.89,percent of total billed charges,,,,,,,,,80,,120.8,percent of total billed charges,,,61.4,,92.71,percent of total billed charges,,,57.4,,86.67,percent of total billed charges,,,81,,122.31,percent of total billed charges,,,39,,58.89,percent of total billed charges,,,57.6,,86.98,percent of total billed charges,,,85,,128.35,percent of total billed charges,,,85,,128.35,percent of total billed charges,,,49,,73.99,percent of total billed charges,,,90,,135.9,percent of total billed charges,,,65,,98.15,percent of total billed charges,,,80,,120.8,percent of total billed charges,,,55,,83.05,percent of total billed charges,,,55,,83.05,percent of total billed charges,,,65,,98.15,percent of total billed charges,,,78,,117.78,percent of total billed charges,,,70,,105.7,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,58.89,135.9,
Repair/Replace Minor Part,L4210,HCPCS,,,,both,,,52.82,31.69,,45.5,,24.03,percent of total billed charges,,,45.3,,23.93,percent of total billed charges,,,39,,20.6,percent of total billed charges,,,,,,,,,80,,42.26,percent of total billed charges,,,61.4,,32.43,percent of total billed charges,,,57.4,,30.32,percent of total billed charges,,,81,,42.78,percent of total billed charges,,,51.5,,27.2,percent of total billed charges,,,57.6,,30.42,percent of total billed charges,,,85,,44.9,percent of total billed charges,,,85,,44.9,percent of total billed charges,,,49,,25.88,percent of total billed charges,,,90,,47.54,percent of total billed charges,,,65,,34.33,percent of total billed charges,,,80,,42.26,percent of total billed charges,,,55,,29.05,percent of total billed charges,,,55,,29.05,percent of total billed charges,,,65,,34.33,percent of total billed charges,,,78,,41.2,percent of total billed charges,,,70,,36.97,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG rate,100% of IL Medicaid,,,,,EAPG rate,100% of IL Medicaid,,,,,EAPG rate,100% of IL Medicaid,,,,,EAPG rate,100% of IL Medicaid,20.6,47.54,
"Pneumatic Ankle Control Splint, Aircast, Prefabricated",L4350,HCPCS,,,,outpatient,,,522,313.2,,45.5,,237.51,percent of total billed charges,,,45.3,,236.47,percent of total billed charges,,,39,,203.58,percent of total billed charges,,,,,,,,,80,,417.6,percent of total billed charges,,,61.4,,320.51,percent of total billed charges,,,57.4,,299.63,percent of total billed charges,,,81,,422.82,percent of total billed charges,,,39,,203.58,percent of total billed charges,,,57.6,,300.67,percent of total billed charges,,,85,,443.7,percent of total billed charges,,,85,,443.7,percent of total billed charges,,,49,,255.78,percent of total billed charges,,,90,,469.8,percent of total billed charges,,,65,,339.3,percent of total billed charges,,,80,,417.6,percent of total billed charges,,,55,,287.1,percent of total billed charges,,,55,,287.1,percent of total billed charges,,,65,,339.3,percent of total billed charges,,,78,,407.16,percent of total billed charges,,,70,,365.4,percent of total billed charges,,,,,,,,116.57,,,,100% of Medicare,,116.57,,,,100% of Medicare,,116.57,,,,100% of Medicare,,116.57,,,,100% of Medicare,,116.57,,,,100% of Medicare,,116.57,,,,100% of Medicare,,116.57,,,,100% of Medicare,,116.57,,,,100% of Medicare,,116.57,,,,100% of Medicare,,116.57,,,,100% of Medicare,,116.57,,,,100% of Medicare,,116.57,,,,100% of Medicare,,,116.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,116.57,469.8,
"Pneumatic Ankle-Foot Orthosis, w/ or w/out Jts, Prefabricated",L4360,HCPCS,,,,outpatient,,,1396,837.6,,45.5,,635.18,percent of total billed charges,,,45.3,,632.39,percent of total billed charges,,,39,,544.44,percent of total billed charges,,,,,,,,,80,,1116.8,percent of total billed charges,,,61.4,,857.14,percent of total billed charges,,,57.4,,801.3,percent of total billed charges,,,81,,1130.76,percent of total billed charges,,,39,,544.44,percent of total billed charges,,,57.6,,804.1,percent of total billed charges,,,85,,1186.6,percent of total billed charges,,,85,,1186.6,percent of total billed charges,,,49,,684.04,percent of total billed charges,,,90,,1256.4,percent of total billed charges,,,65,,907.4,percent of total billed charges,,,80,,1116.8,percent of total billed charges,,,55,,767.8,percent of total billed charges,,,55,,767.8,percent of total billed charges,,,65,,907.4,percent of total billed charges,,,78,,1088.88,percent of total billed charges,,,70,,977.2,percent of total billed charges,,,,,,,,311.94,,,,100% of Medicare,,311.94,,,,100% of Medicare,,311.94,,,,100% of Medicare,,311.94,,,,100% of Medicare,,311.94,,,,100% of Medicare,,311.94,,,,100% of Medicare,,311.94,,,,100% of Medicare,,311.94,,,,100% of Medicare,,311.94,,,,100% of Medicare,,311.94,,,,100% of Medicare,,311.94,,,,100% of Medicare,,311.94,,,,100% of Medicare,,,311.94,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,311.94,1256.4,
PNEUMA/VAC WALK BOOT PRE OTS (L4361),L4361,HCPCS,,,,outpatient,,,1289,773.4,,45.5,,586.5,percent of total billed charges,,,45.3,,583.92,percent of total billed charges,,,39,,502.71,percent of total billed charges,,,,,,,,,80,,1031.2,percent of total billed charges,,,61.4,,791.45,percent of total billed charges,,,57.4,,739.89,percent of total billed charges,,,81,,1044.09,percent of total billed charges,,,39,,502.71,percent of total billed charges,,,57.6,,742.46,percent of total billed charges,,,85,,1095.65,percent of total billed charges,,,85,,1095.65,percent of total billed charges,,,49,,631.61,percent of total billed charges,,,90,,1160.1,percent of total billed charges,,,65,,837.85,percent of total billed charges,,,80,,1031.2,percent of total billed charges,,,55,,708.95,percent of total billed charges,,,55,,708.95,percent of total billed charges,,,65,,837.85,percent of total billed charges,,,78,,1005.42,percent of total billed charges,,,70,,902.3,percent of total billed charges,,,,,,,,311.94,,,,100% of Medicare,,311.94,,,,100% of Medicare,,311.94,,,,100% of Medicare,,311.94,,,,100% of Medicare,,311.94,,,,100% of Medicare,,311.94,,,,100% of Medicare,,311.94,,,,100% of Medicare,,311.94,,,,100% of Medicare,,311.94,,,,100% of Medicare,,311.94,,,,100% of Medicare,,311.94,,,,100% of Medicare,,311.94,,,,100% of Medicare,,,311.94,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,311.94,1160.1,
"Pneumatic Full Leg Splint, Prefabricated",L4370,HCPCS,,,,outpatient,,,606,363.6,,45.5,,275.73,percent of total billed charges,,,45.3,,274.52,percent of total billed charges,,,39,,236.34,percent of total billed charges,,,,,,,,,80,,484.8,percent of total billed charges,,,61.4,,372.08,percent of total billed charges,,,57.4,,347.84,percent of total billed charges,,,81,,490.86,percent of total billed charges,,,39,,236.34,percent of total billed charges,,,57.6,,349.06,percent of total billed charges,,,85,,515.1,percent of total billed charges,,,85,,515.1,percent of total billed charges,,,49,,296.94,percent of total billed charges,,,90,,545.4,percent of total billed charges,,,65,,393.9,percent of total billed charges,,,80,,484.8,percent of total billed charges,,,55,,333.3,percent of total billed charges,,,55,,333.3,percent of total billed charges,,,65,,393.9,percent of total billed charges,,,78,,472.68,percent of total billed charges,,,70,,424.2,percent of total billed charges,,,,,,,,283.58,,,,100% of Medicare,,283.58,,,,100% of Medicare,,283.58,,,,100% of Medicare,,283.58,,,,100% of Medicare,,283.58,,,,100% of Medicare,,283.58,,,,100% of Medicare,,283.58,,,,100% of Medicare,,283.58,,,,100% of Medicare,,283.58,,,,100% of Medicare,,283.58,,,,100% of Medicare,,283.58,,,,100% of Medicare,,283.58,,,,100% of Medicare,,,283.58,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,236.34,545.4,
Non-Pneumatic Walking Splint,L4386,HCPCS,,,,outpatient,,,852,511.2,,45.5,,387.66,percent of total billed charges,,,45.3,,385.96,percent of total billed charges,,,39,,332.28,percent of total billed charges,,,,,,,,,80,,681.6,percent of total billed charges,,,61.4,,523.13,percent of total billed charges,,,57.4,,489.05,percent of total billed charges,,,81,,690.12,percent of total billed charges,,,39,,332.28,percent of total billed charges,,,57.6,,490.75,percent of total billed charges,,,85,,724.2,percent of total billed charges,,,85,,724.2,percent of total billed charges,,,49,,417.48,percent of total billed charges,,,90,,766.8,percent of total billed charges,,,65,,553.8,percent of total billed charges,,,80,,681.6,percent of total billed charges,,,55,,468.6,percent of total billed charges,,,55,,468.6,percent of total billed charges,,,65,,553.8,percent of total billed charges,,,78,,664.56,percent of total billed charges,,,70,,596.4,percent of total billed charges,,,,,,,,191.04,,,,100% of Medicare,,191.04,,,,100% of Medicare,,191.04,,,,100% of Medicare,,191.04,,,,100% of Medicare,,191.04,,,,100% of Medicare,,191.04,,,,100% of Medicare,,191.04,,,,100% of Medicare,,191.04,,,,100% of Medicare,,191.04,,,,100% of Medicare,,191.04,,,,100% of Medicare,,191.04,,,,100% of Medicare,,191.04,,,,100% of Medicare,,,191.04,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,191.04,766.8,
NON-PNEUM WALK BOOT PRE OTS (L4387),L4387,HCPCS,,,,outpatient,,,788,472.8,,45.5,,358.54,percent of total billed charges,,,45.3,,356.96,percent of total billed charges,,,39,,307.32,percent of total billed charges,,,,,,,,,80,,630.4,percent of total billed charges,,,61.4,,483.83,percent of total billed charges,,,57.4,,452.31,percent of total billed charges,,,81,,638.28,percent of total billed charges,,,39,,307.32,percent of total billed charges,,,57.6,,453.89,percent of total billed charges,,,85,,669.8,percent of total billed charges,,,85,,669.8,percent of total billed charges,,,49,,386.12,percent of total billed charges,,,90,,709.2,percent of total billed charges,,,65,,512.2,percent of total billed charges,,,80,,630.4,percent of total billed charges,,,55,,433.4,percent of total billed charges,,,55,,433.4,percent of total billed charges,,,65,,512.2,percent of total billed charges,,,78,,614.64,percent of total billed charges,,,70,,551.6,percent of total billed charges,,,,,,,,191.04,,,,100% of Medicare,,191.04,,,,100% of Medicare,,191.04,,,,100% of Medicare,,191.04,,,,100% of Medicare,,191.04,,,,100% of Medicare,,191.04,,,,100% of Medicare,,191.04,,,,100% of Medicare,,191.04,,,,100% of Medicare,,191.04,,,,100% of Medicare,,191.04,,,,100% of Medicare,,191.04,,,,100% of Medicare,,191.04,,,,100% of Medicare,,,191.04,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,191.04,709.2,
"Replace Interface, Ankle Contracture Splint",L4392,HCPCS,,,,outpatient,,,70,42,,45.5,,31.85,percent of total billed charges,,,45.3,,31.71,percent of total billed charges,,,39,,27.3,percent of total billed charges,,,,,,,,,80,,56,percent of total billed charges,,,61.4,,42.98,percent of total billed charges,,,57.4,,40.18,percent of total billed charges,,,81,,56.7,percent of total billed charges,,,39,,27.3,percent of total billed charges,,,57.6,,40.32,percent of total billed charges,,,85,,59.5,percent of total billed charges,,,85,,59.5,percent of total billed charges,,,49,,34.3,percent of total billed charges,,,90,,63,percent of total billed charges,,,65,,45.5,percent of total billed charges,,,80,,56,percent of total billed charges,,,55,,38.5,percent of total billed charges,,,55,,38.5,percent of total billed charges,,,65,,45.5,percent of total billed charges,,,78,,54.6,percent of total billed charges,,,70,,49,percent of total billed charges,,,,,,,,28.34,,,,100% of Medicare,,28.34,,,,100% of Medicare,,28.34,,,,100% of Medicare,,28.34,,,,100% of Medicare,,28.34,,,,100% of Medicare,,28.34,,,,100% of Medicare,,28.34,,,,100% of Medicare,,28.34,,,,100% of Medicare,,28.34,,,,100% of Medicare,,28.34,,,,100% of Medicare,,28.34,,,,100% of Medicare,,28.34,,,,100% of Medicare,,,28.34,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,27.3,63,
"Replace Foot, Drop Splint",L4394,HCPCS,,,,outpatient,,,91,54.6,,45.5,,41.41,percent of total billed charges,,,45.3,,41.22,percent of total billed charges,,,39,,35.49,percent of total billed charges,,,,,,,,,80,,72.8,percent of total billed charges,,,61.4,,55.87,percent of total billed charges,,,57.4,,52.23,percent of total billed charges,,,81,,73.71,percent of total billed charges,,,39,,35.49,percent of total billed charges,,,57.6,,52.42,percent of total billed charges,,,85,,77.35,percent of total billed charges,,,85,,77.35,percent of total billed charges,,,49,,44.59,percent of total billed charges,,,90,,81.9,percent of total billed charges,,,65,,59.15,percent of total billed charges,,,80,,72.8,percent of total billed charges,,,55,,50.05,percent of total billed charges,,,55,,50.05,percent of total billed charges,,,65,,59.15,percent of total billed charges,,,78,,70.98,percent of total billed charges,,,70,,63.7,percent of total billed charges,,,,,,,,20.68,,,,100% of Medicare,,20.68,,,,100% of Medicare,,20.68,,,,100% of Medicare,,20.68,,,,100% of Medicare,,20.68,,,,100% of Medicare,,20.68,,,,100% of Medicare,,20.68,,,,100% of Medicare,,20.68,,,,100% of Medicare,,20.68,,,,100% of Medicare,,20.68,,,,100% of Medicare,,20.68,,,,100% of Medicare,,20.68,,,,100% of Medicare,,,20.68,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,20.68,81.9,
Ankle Contracture Splint,L4396,HCPCS,,,,outpatient,,,906,543.6,,45.5,,412.23,percent of total billed charges,,,45.3,,410.42,percent of total billed charges,,,39,,353.34,percent of total billed charges,,,,,,,,,80,,724.8,percent of total billed charges,,,61.4,,556.28,percent of total billed charges,,,57.4,,520.04,percent of total billed charges,,,81,,733.86,percent of total billed charges,,,39,,353.34,percent of total billed charges,,,57.6,,521.86,percent of total billed charges,,,85,,770.1,percent of total billed charges,,,85,,770.1,percent of total billed charges,,,49,,443.94,percent of total billed charges,,,90,,815.4,percent of total billed charges,,,65,,588.9,percent of total billed charges,,,80,,724.8,percent of total billed charges,,,55,,498.3,percent of total billed charges,,,55,,498.3,percent of total billed charges,,,65,,588.9,percent of total billed charges,,,78,,706.68,percent of total billed charges,,,70,,634.2,percent of total billed charges,,,,,,,,202.19,,,,100% of Medicare,,202.19,,,,100% of Medicare,,202.19,,,,100% of Medicare,,202.19,,,,100% of Medicare,,202.19,,,,100% of Medicare,,202.19,,,24028.38,100% of Medicare,,202.19,,,,100% of Medicare,,202.19,,,,100% of Medicare,,202.19,,,,100% of Medicare,,202.19,,,,100% of Medicare,,202.19,,,,100% of Medicare,,202.19,,,,100% of Medicare,,,202.19,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,202.19,24028.38,
STATIC OR DYNAMI AFO PRE OTS (L4397),L4397,HCPCS,,,,outpatient,,,814,488.4,,45.5,,370.37,percent of total billed charges,,,45.3,,368.74,percent of total billed charges,,,39,,317.46,percent of total billed charges,,,,,,,,,80,,651.2,percent of total billed charges,,,61.4,,499.8,percent of total billed charges,,,57.4,,467.24,percent of total billed charges,,,81,,659.34,percent of total billed charges,,,39,,317.46,percent of total billed charges,,,57.6,,468.86,percent of total billed charges,,,85,,691.9,percent of total billed charges,,,85,,691.9,percent of total billed charges,,,49,,398.86,percent of total billed charges,,,90,,732.6,percent of total billed charges,,,65,,529.1,percent of total billed charges,,,80,,651.2,percent of total billed charges,,,55,,447.7,percent of total billed charges,,,55,,447.7,percent of total billed charges,,,65,,529.1,percent of total billed charges,,,78,,634.92,percent of total billed charges,,,70,,569.8,percent of total billed charges,,,,,,,,202.19,,,,100% of Medicare,,202.19,,,,100% of Medicare,,202.19,,,,100% of Medicare,,202.19,,,,100% of Medicare,,202.19,,,,100% of Medicare,,202.19,,,,100% of Medicare,,202.19,,,,100% of Medicare,,202.19,,,,100% of Medicare,,202.19,,,,100% of Medicare,,202.19,,,,100% of Medicare,,202.19,,,,100% of Medicare,,202.19,,,,100% of Medicare,,,202.19,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,202.19,732.6,
Foot Drop Splint,L4398,HCPCS,,,,outpatient,,,416,249.6,,45.5,,189.28,percent of total billed charges,,,45.3,,188.45,percent of total billed charges,,,39,,162.24,percent of total billed charges,,,,,,,,,80,,332.8,percent of total billed charges,,,61.4,,255.42,percent of total billed charges,,,57.4,,238.78,percent of total billed charges,,,81,,336.96,percent of total billed charges,,,39,,162.24,percent of total billed charges,,,57.6,,239.62,percent of total billed charges,,,85,,353.6,percent of total billed charges,,,85,,353.6,percent of total billed charges,,,49,,203.84,percent of total billed charges,,,90,,374.4,percent of total billed charges,,,65,,270.4,percent of total billed charges,,,80,,332.8,percent of total billed charges,,,55,,228.8,percent of total billed charges,,,55,,228.8,percent of total billed charges,,,65,,270.4,percent of total billed charges,,,78,,324.48,percent of total billed charges,,,70,,291.2,percent of total billed charges,,,,,,,,93.06,,,,100% of Medicare,,93.06,,,,100% of Medicare,,93.06,,,,100% of Medicare,,93.06,,,,100% of Medicare,,93.06,,,,100% of Medicare,,93.06,,,,100% of Medicare,,93.06,,,,100% of Medicare,,93.06,,,,100% of Medicare,,93.06,,,,100% of Medicare,,93.06,,,,100% of Medicare,,93.06,,,,100% of Medicare,,93.06,,,,100% of Medicare,,,93.06,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,93.06,374.4,
"Partial foot, shoe insert with longitudinal arch, with toe filler",L5000,HCPCS,,,,outpatient,,,2672,1603.2,,45.5,,1215.76,percent of total billed charges,,,45.3,,1210.42,percent of total billed charges,,,39,,1042.08,percent of total billed charges,,,,,,,,,80,,2137.6,percent of total billed charges,,,61.4,,1640.61,percent of total billed charges,,,57.4,,1533.73,percent of total billed charges,,,81,,2164.32,percent of total billed charges,,,39,,1042.08,percent of total billed charges,,,57.6,,1539.07,percent of total billed charges,,,85,,2271.2,percent of total billed charges,,,85,,2271.2,percent of total billed charges,,,49,,1309.28,percent of total billed charges,,,90,,2404.8,percent of total billed charges,,,65,,1736.8,percent of total billed charges,,,80,,2137.6,percent of total billed charges,,,55,,1469.6,percent of total billed charges,,,55,,1469.6,percent of total billed charges,,,65,,1736.8,percent of total billed charges,,,78,,2084.16,percent of total billed charges,,,70,,1870.4,percent of total billed charges,,,,,,,,691.87,,,,100% of Medicare,,691.87,,,,100% of Medicare,,691.87,,,,100% of Medicare,,691.87,,,,100% of Medicare,,691.87,,,,100% of Medicare,,691.87,,,,100% of Medicare,,691.87,,,,100% of Medicare,,691.87,,,,100% of Medicare,,691.87,,,,100% of Medicare,,691.87,,,,100% of Medicare,,691.87,,,,100% of Medicare,,691.87,,,,100% of Medicare,,,691.87,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,691.87,2404.8,
"Immediate postsurg/early fitting, app of initial rigid drsg including fit/align/susp, each addit cas",L5410,HCPCS,,,,outpatient,,,1223,733.8,,45.5,,556.47,percent of total billed charges,,,45.3,,554.02,percent of total billed charges,,,39,,476.97,percent of total billed charges,,,,,,,,,80,,978.4,percent of total billed charges,,,61.4,,750.92,percent of total billed charges,,,57.4,,702,percent of total billed charges,,,81,,990.63,percent of total billed charges,,,39,,476.97,percent of total billed charges,,,57.6,,704.45,percent of total billed charges,,,85,,1039.55,percent of total billed charges,,,85,,1039.55,percent of total billed charges,,,49,,599.27,percent of total billed charges,,,90,,1100.7,percent of total billed charges,,,65,,794.95,percent of total billed charges,,,80,,978.4,percent of total billed charges,,,55,,672.65,percent of total billed charges,,,55,,672.65,percent of total billed charges,,,65,,794.95,percent of total billed charges,,,78,,953.94,percent of total billed charges,,,70,,856.1,percent of total billed charges,,,,,,,,532.11,,,,100% of Medicare,,532.11,,,,100% of Medicare,,532.11,,,,100% of Medicare,,532.11,,,,100% of Medicare,,532.11,,,,100% of Medicare,,532.11,,,,100% of Medicare,,532.11,,,,100% of Medicare,,532.11,,,,100% of Medicare,,532.11,,,,100% of Medicare,,532.11,,,,100% of Medicare,,532.11,,,,100% of Medicare,,532.11,,,,100% of Medicare,,,532.11,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,476.97,1100.7,
"Immediate postsurg/early fitting, ""AK"" or knee disartic, each addit cast change and realign",L5430,HCPCS,,,,outpatient,,,1515,909,,45.5,,689.33,percent of total billed charges,,,45.3,,686.3,percent of total billed charges,,,39,,590.85,percent of total billed charges,,,,,,,,,80,,1212,percent of total billed charges,,,61.4,,930.21,percent of total billed charges,,,57.4,,869.61,percent of total billed charges,,,81,,1227.15,percent of total billed charges,,,39,,590.85,percent of total billed charges,,,57.6,,872.64,percent of total billed charges,,,85,,1287.75,percent of total billed charges,,,85,,1287.75,percent of total billed charges,,,49,,742.35,percent of total billed charges,,,90,,1363.5,percent of total billed charges,,,65,,984.75,percent of total billed charges,,,80,,1212,percent of total billed charges,,,55,,833.25,percent of total billed charges,,,55,,833.25,percent of total billed charges,,,65,,984.75,percent of total billed charges,,,78,,1181.7,percent of total billed charges,,,70,,1060.5,percent of total billed charges,,,,,,,,660.3,,,,100% of Medicare,,660.3,,,,100% of Medicare,,660.3,,,,100% of Medicare,,660.3,,,,100% of Medicare,,660.3,,,,100% of Medicare,,660.3,,,,100% of Medicare,,660.3,,,,100% of Medicare,,660.3,,,,100% of Medicare,,660.3,,,,100% of Medicare,,660.3,,,,100% of Medicare,,660.3,,,,100% of Medicare,,660.3,,,,100% of Medicare,,,660.3,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,590.85,1363.5,
"Immediate postsurg/early fitting, app of nonweight bearing rigid drsg BK",L5450,HCPCS,,,,outpatient,,,1748,1048.8,,45.5,,795.34,percent of total billed charges,,,45.3,,791.84,percent of total billed charges,,,39,,681.72,percent of total billed charges,,,,,,,,,80,,1398.4,percent of total billed charges,,,61.4,,1073.27,percent of total billed charges,,,57.4,,1003.35,percent of total billed charges,,,81,,1415.88,percent of total billed charges,,,39,,681.72,percent of total billed charges,,,57.6,,1006.85,percent of total billed charges,,,85,,1485.8,percent of total billed charges,,,85,,1485.8,percent of total billed charges,,,49,,856.52,percent of total billed charges,,,90,,1573.2,percent of total billed charges,,,65,,1136.2,percent of total billed charges,,,80,,1398.4,percent of total billed charges,,,55,,961.4,percent of total billed charges,,,55,,961.4,percent of total billed charges,,,65,,1136.2,percent of total billed charges,,,78,,1363.44,percent of total billed charges,,,70,,1223.6,percent of total billed charges,,,,,,,,570.93,,,,100% of Medicare,,570.93,,,,100% of Medicare,,570.93,,,,100% of Medicare,,570.93,,,,100% of Medicare,,570.93,,,,100% of Medicare,,570.93,,,,100% of Medicare,,570.93,,,,100% of Medicare,,570.93,,,,100% of Medicare,,570.93,,,,100% of Medicare,,570.93,,,,100% of Medicare,,570.93,,,,100% of Medicare,,570.93,,,,100% of Medicare,,,570.93,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,570.93,1573.2,
"Immediate postsurg/early fitting, app of nonweight bearing rigid drsg AK",L5460,HCPCS,,,,outpatient,,,1718,1030.8,,45.5,,781.69,percent of total billed charges,,,45.3,,778.25,percent of total billed charges,,,39,,670.02,percent of total billed charges,,,,,,,,,80,,1374.4,percent of total billed charges,,,61.4,,1054.85,percent of total billed charges,,,57.4,,986.13,percent of total billed charges,,,81,,1391.58,percent of total billed charges,,,39,,670.02,percent of total billed charges,,,57.6,,989.57,percent of total billed charges,,,85,,1460.3,percent of total billed charges,,,85,,1460.3,percent of total billed charges,,,49,,841.82,percent of total billed charges,,,90,,1546.2,percent of total billed charges,,,65,,1116.7,percent of total billed charges,,,80,,1374.4,percent of total billed charges,,,55,,944.9,percent of total billed charges,,,55,,944.9,percent of total billed charges,,,65,,1116.7,percent of total billed charges,,,78,,1340.04,percent of total billed charges,,,70,,1202.6,percent of total billed charges,,,,,,,,748.84,,,,100% of Medicare,,748.84,,,,100% of Medicare,,748.84,,,,100% of Medicare,,748.84,,,,100% of Medicare,,748.84,,,,100% of Medicare,,748.84,,,,100% of Medicare,,748.84,,,,100% of Medicare,,748.84,,,,100% of Medicare,,748.84,,,,100% of Medicare,,748.84,,,,100% of Medicare,,748.84,,,,100% of Medicare,,748.84,,,,100% of Medicare,,,748.84,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,670.02,1546.2,
"Addition to LE, quick change self aligning unit, AK or BK, each",L5617,HCPCS,,,,outpatient,,,1570,942,,45.5,,714.35,percent of total billed charges,,,45.3,,711.21,percent of total billed charges,,,39,,612.3,percent of total billed charges,,,,,,,,,80,,1256,percent of total billed charges,,,61.4,,963.98,percent of total billed charges,,,57.4,,901.18,percent of total billed charges,,,81,,1271.7,percent of total billed charges,,,39,,612.3,percent of total billed charges,,,57.6,,904.32,percent of total billed charges,,,85,,1334.5,percent of total billed charges,,,85,,1334.5,percent of total billed charges,,,49,,769.3,percent of total billed charges,,,90,,1413,percent of total billed charges,,,65,,1020.5,percent of total billed charges,,,80,,1256,percent of total billed charges,,,55,,863.5,percent of total billed charges,,,55,,863.5,percent of total billed charges,,,65,,1020.5,percent of total billed charges,,,78,,1224.6,percent of total billed charges,,,70,,1099,percent of total billed charges,,,,,,,,675.45,,,,100% of Medicare,,675.45,,,,100% of Medicare,,675.45,,,,100% of Medicare,,675.45,,,,100% of Medicare,,675.45,,,,100% of Medicare,,675.45,,,,100% of Medicare,,675.45,,,,100% of Medicare,,675.45,,,,100% of Medicare,,675.45,,,,100% of Medicare,,675.45,,,,100% of Medicare,,675.45,,,,100% of Medicare,,675.45,,,,100% of Medicare,,,675.45,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,612.3,1413,
"Addition to LE, test socket, Symes",L5618,HCPCS,,,,outpatient,,,1605,963,,45.5,,730.28,percent of total billed charges,,,45.3,,727.07,percent of total billed charges,,,39,,625.95,percent of total billed charges,,,,,,,,,80,,1284,percent of total billed charges,,,61.4,,985.47,percent of total billed charges,,,57.4,,921.27,percent of total billed charges,,,81,,1300.05,percent of total billed charges,,,39,,625.95,percent of total billed charges,,,57.6,,924.48,percent of total billed charges,,,85,,1364.25,percent of total billed charges,,,85,,1364.25,percent of total billed charges,,,49,,786.45,percent of total billed charges,,,90,,1444.5,percent of total billed charges,,,65,,1043.25,percent of total billed charges,,,80,,1284,percent of total billed charges,,,55,,882.75,percent of total billed charges,,,55,,882.75,percent of total billed charges,,,65,,1043.25,percent of total billed charges,,,78,,1251.9,percent of total billed charges,,,70,,1123.5,percent of total billed charges,,,,,,,,403.36,,,,100% of Medicare,,403.36,,,,100% of Medicare,,403.36,,,,100% of Medicare,,403.36,,,,100% of Medicare,,403.36,,,,100% of Medicare,,403.36,,,,100% of Medicare,,403.36,,,,100% of Medicare,,403.36,,,,100% of Medicare,,403.36,,,,100% of Medicare,,403.36,,,,100% of Medicare,,403.36,,,,100% of Medicare,,403.36,,,,100% of Medicare,,,403.36,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,403.36,1444.5,
"Addition to LE, test socket, BK",L5620,HCPCS,,,,outpatient,,,1383,829.8,,45.5,,629.27,percent of total billed charges,,,45.3,,626.5,percent of total billed charges,,,39,,539.37,percent of total billed charges,,,,,,,,,80,,1106.4,percent of total billed charges,,,61.4,,849.16,percent of total billed charges,,,57.4,,793.84,percent of total billed charges,,,81,,1120.23,percent of total billed charges,,,39,,539.37,percent of total billed charges,,,57.6,,796.61,percent of total billed charges,,,85,,1175.55,percent of total billed charges,,,85,,1175.55,percent of total billed charges,,,49,,677.67,percent of total billed charges,,,90,,1244.7,percent of total billed charges,,,65,,898.95,percent of total billed charges,,,80,,1106.4,percent of total billed charges,,,55,,760.65,percent of total billed charges,,,55,,760.65,percent of total billed charges,,,65,,898.95,percent of total billed charges,,,78,,1078.74,percent of total billed charges,,,70,,968.1,percent of total billed charges,,,,,,,,357.88,,,,100% of Medicare,,357.88,,,,100% of Medicare,,357.88,,,,100% of Medicare,,357.88,,,,100% of Medicare,,357.88,,,,100% of Medicare,,357.88,,,,100% of Medicare,,357.88,,,,100% of Medicare,,357.88,,,,100% of Medicare,,357.88,,,,100% of Medicare,,357.88,,,,100% of Medicare,,357.88,,,,100% of Medicare,,357.88,,,,100% of Medicare,,,357.88,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,357.88,1244.7,
"Addition to LE, test socket, Knee disartic",L5622,HCPCS,,,,outpatient,,,1436,861.6,,45.5,,653.38,percent of total billed charges,,,45.3,,650.51,percent of total billed charges,,,39,,560.04,percent of total billed charges,,,,,,,,,80,,1148.8,percent of total billed charges,,,61.4,,881.7,percent of total billed charges,,,57.4,,824.26,percent of total billed charges,,,81,,1163.16,percent of total billed charges,,,39,,560.04,percent of total billed charges,,,57.6,,827.14,percent of total billed charges,,,85,,1220.6,percent of total billed charges,,,85,,1220.6,percent of total billed charges,,,49,,703.64,percent of total billed charges,,,90,,1292.4,percent of total billed charges,,,65,,933.4,percent of total billed charges,,,80,,1148.8,percent of total billed charges,,,55,,789.8,percent of total billed charges,,,55,,789.8,percent of total billed charges,,,65,,933.4,percent of total billed charges,,,78,,1120.08,percent of total billed charges,,,70,,1005.2,percent of total billed charges,,,,,,,,482.15,,,,100% of Medicare,,482.15,,,,100% of Medicare,,482.15,,,,100% of Medicare,,482.15,,,,100% of Medicare,,482.15,,,,100% of Medicare,,482.15,,,,100% of Medicare,,482.15,,,,100% of Medicare,,482.15,,,,100% of Medicare,,482.15,,,,100% of Medicare,,482.15,,,,100% of Medicare,,482.15,,,,100% of Medicare,,482.15,,,,100% of Medicare,,,482.15,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,482.15,1292.4,
"Addition to LE, test socket, AK",L5624,HCPCS,,,,outpatient,,,1435,861,,45.5,,652.93,percent of total billed charges,,,45.3,,650.06,percent of total billed charges,,,39,,559.65,percent of total billed charges,,,,,,,,,80,,1148,percent of total billed charges,,,61.4,,881.09,percent of total billed charges,,,57.4,,823.69,percent of total billed charges,,,81,,1162.35,percent of total billed charges,,,39,,559.65,percent of total billed charges,,,57.6,,826.56,percent of total billed charges,,,85,,1219.75,percent of total billed charges,,,85,,1219.75,percent of total billed charges,,,49,,703.15,percent of total billed charges,,,90,,1291.5,percent of total billed charges,,,65,,932.75,percent of total billed charges,,,80,,1148,percent of total billed charges,,,55,,789.25,percent of total billed charges,,,55,,789.25,percent of total billed charges,,,65,,932.75,percent of total billed charges,,,78,,1119.3,percent of total billed charges,,,70,,1004.5,percent of total billed charges,,,,,,,,481.97,,,,100% of Medicare,,481.97,,,,100% of Medicare,,481.97,,,,100% of Medicare,,481.97,,,,100% of Medicare,,481.97,,,,100% of Medicare,,481.97,,,,100% of Medicare,,481.97,,,,100% of Medicare,,481.97,,,,100% of Medicare,,481.97,,,,100% of Medicare,,481.97,,,,100% of Medicare,,481.97,,,,100% of Medicare,,481.97,,,,100% of Medicare,,,481.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,481.97,1291.5,
"Addition to LE, test socket, Hip disartic",L5626,HCPCS,,,,outpatient,,,2205,1323,,45.5,,1003.28,percent of total billed charges,,,45.3,,998.87,percent of total billed charges,,,39,,859.95,percent of total billed charges,,,,,,,,,80,,1764,percent of total billed charges,,,61.4,,1353.87,percent of total billed charges,,,57.4,,1265.67,percent of total billed charges,,,81,,1786.05,percent of total billed charges,,,39,,859.95,percent of total billed charges,,,57.6,,1270.08,percent of total billed charges,,,85,,1874.25,percent of total billed charges,,,85,,1874.25,percent of total billed charges,,,49,,1080.45,percent of total billed charges,,,90,,1984.5,percent of total billed charges,,,65,,1433.25,percent of total billed charges,,,80,,1764,percent of total billed charges,,,55,,1212.75,percent of total billed charges,,,55,,1212.75,percent of total billed charges,,,65,,1433.25,percent of total billed charges,,,78,,1719.9,percent of total billed charges,,,70,,1543.5,percent of total billed charges,,,,,,,,763.01,,,,100% of Medicare,,763.01,,,,100% of Medicare,,763.01,,,,100% of Medicare,,763.01,,,,100% of Medicare,,763.01,,,,100% of Medicare,,763.01,,,,100% of Medicare,,763.01,,,,100% of Medicare,,763.01,,,,100% of Medicare,,763.01,,,,100% of Medicare,,763.01,,,,100% of Medicare,,763.01,,,,100% of Medicare,,763.01,,,,100% of Medicare,,,763.01,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,763.01,1984.5,
"Addition to LE, test socket, Hemipel",L5628,HCPCS,,,,outpatient,,,2234,1340.4,,45.5,,1016.47,percent of total billed charges,,,45.3,,1012,percent of total billed charges,,,39,,871.26,percent of total billed charges,,,,,,,,,80,,1787.2,percent of total billed charges,,,61.4,,1371.68,percent of total billed charges,,,57.4,,1282.32,percent of total billed charges,,,81,,1809.54,percent of total billed charges,,,39,,871.26,percent of total billed charges,,,57.6,,1286.78,percent of total billed charges,,,85,,1898.9,percent of total billed charges,,,85,,1898.9,percent of total billed charges,,,49,,1094.66,percent of total billed charges,,,90,,2010.6,percent of total billed charges,,,65,,1452.1,percent of total billed charges,,,80,,1787.2,percent of total billed charges,,,55,,1228.7,percent of total billed charges,,,55,,1228.7,percent of total billed charges,,,65,,1452.1,percent of total billed charges,,,78,,1742.52,percent of total billed charges,,,70,,1563.8,percent of total billed charges,,,,,,,,772.66,,,,100% of Medicare,,772.66,,,,100% of Medicare,,772.66,,,,100% of Medicare,,772.66,,,,100% of Medicare,,772.66,,,,100% of Medicare,,772.66,,,,100% of Medicare,,772.66,,,,100% of Medicare,,772.66,,,,100% of Medicare,,772.66,,,,100% of Medicare,,772.66,,,,100% of Medicare,,772.66,,,,100% of Medicare,,772.66,,,,100% of Medicare,,,772.66,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,772.66,2010.6,
"Addition to LE, BK, acrylic socket",L5629,HCPCS,,,,outpatient,,,1471,882.6,,45.5,,669.31,percent of total billed charges,,,45.3,,666.36,percent of total billed charges,,,39,,573.69,percent of total billed charges,,,,,,,,,80,,1176.8,percent of total billed charges,,,61.4,,903.19,percent of total billed charges,,,57.4,,844.35,percent of total billed charges,,,81,,1191.51,percent of total billed charges,,,39,,573.69,percent of total billed charges,,,57.6,,847.3,percent of total billed charges,,,85,,1250.35,percent of total billed charges,,,85,,1250.35,percent of total billed charges,,,49,,720.79,percent of total billed charges,,,90,,1323.9,percent of total billed charges,,,65,,956.15,percent of total billed charges,,,80,,1176.8,percent of total billed charges,,,55,,809.05,percent of total billed charges,,,55,,809.05,percent of total billed charges,,,65,,956.15,percent of total billed charges,,,78,,1147.38,percent of total billed charges,,,70,,1029.7,percent of total billed charges,,,,,,,,381.43,,,,100% of Medicare,,381.43,,,,100% of Medicare,,381.43,,,,100% of Medicare,,381.43,,,,100% of Medicare,,381.43,,,,100% of Medicare,,381.43,,,,100% of Medicare,,381.43,,,,100% of Medicare,,381.43,,,,100% of Medicare,,381.43,,,,100% of Medicare,,381.43,,,,100% of Medicare,,381.43,,,,100% of Medicare,,381.43,,,,100% of Medicare,,,381.43,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,381.43,1323.9,
"Addition to LE, Symes type, expandable wall socket",L5630,HCPCS,,,,outpatient,,,1630,978,,45.5,,741.65,percent of total billed charges,,,45.3,,738.39,percent of total billed charges,,,39,,635.7,percent of total billed charges,,,,,,,,,80,,1304,percent of total billed charges,,,61.4,,1000.82,percent of total billed charges,,,57.4,,935.62,percent of total billed charges,,,81,,1320.3,percent of total billed charges,,,39,,635.7,percent of total billed charges,,,57.6,,938.88,percent of total billed charges,,,85,,1385.5,percent of total billed charges,,,85,,1385.5,percent of total billed charges,,,49,,798.7,percent of total billed charges,,,90,,1467,percent of total billed charges,,,65,,1059.5,percent of total billed charges,,,80,,1304,percent of total billed charges,,,55,,896.5,percent of total billed charges,,,55,,896.5,percent of total billed charges,,,65,,1059.5,percent of total billed charges,,,78,,1271.4,percent of total billed charges,,,70,,1141,percent of total billed charges,,,,,,,,662.75,,,,100% of Medicare,,662.75,,,,100% of Medicare,,662.75,,,,100% of Medicare,,662.75,,,,100% of Medicare,,662.75,,,,100% of Medicare,,662.75,,,,100% of Medicare,,662.75,,,,100% of Medicare,,662.75,,,,100% of Medicare,,662.75,,,,100% of Medicare,,662.75,,,,100% of Medicare,,662.75,,,,100% of Medicare,,662.75,,,,100% of Medicare,,,662.75,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,635.7,1467,
"Addition to LE, AK or knee disartic, acrylic socket",L5631,HCPCS,,,,outpatient,,,1570,942,,45.5,,714.35,percent of total billed charges,,,45.3,,711.21,percent of total billed charges,,,39,,612.3,percent of total billed charges,,,,,,,,,80,,1256,percent of total billed charges,,,61.4,,963.98,percent of total billed charges,,,57.4,,901.18,percent of total billed charges,,,81,,1271.7,percent of total billed charges,,,39,,612.3,percent of total billed charges,,,57.6,,904.32,percent of total billed charges,,,85,,1334.5,percent of total billed charges,,,85,,1334.5,percent of total billed charges,,,49,,769.3,percent of total billed charges,,,90,,1413,percent of total billed charges,,,65,,1020.5,percent of total billed charges,,,80,,1256,percent of total billed charges,,,55,,863.5,percent of total billed charges,,,55,,863.5,percent of total billed charges,,,65,,1020.5,percent of total billed charges,,,78,,1224.6,percent of total billed charges,,,70,,1099,percent of total billed charges,,,,,,,,527.36,,,,100% of Medicare,,527.36,,,,100% of Medicare,,527.36,,,,100% of Medicare,,527.36,,,,100% of Medicare,,527.36,,,,100% of Medicare,,527.36,,,,100% of Medicare,,527.36,,,,100% of Medicare,,527.36,,,,100% of Medicare,,527.36,,,,100% of Medicare,,527.36,,,,100% of Medicare,,527.36,,,,100% of Medicare,,527.36,,,,100% of Medicare,,,527.36,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,527.36,1413,
"Addition to LE, Symes type, ""PTB"" brim socket design",L5632,HCPCS,,,,outpatient,,,1260,756,,45.5,,573.3,percent of total billed charges,,,45.3,,570.78,percent of total billed charges,,,39,,491.4,percent of total billed charges,,,,,,,,,80,,1008,percent of total billed charges,,,61.4,,773.64,percent of total billed charges,,,57.4,,723.24,percent of total billed charges,,,81,,1020.6,percent of total billed charges,,,39,,491.4,percent of total billed charges,,,57.6,,725.76,percent of total billed charges,,,85,,1071,percent of total billed charges,,,85,,1071,percent of total billed charges,,,49,,617.4,percent of total billed charges,,,90,,1134,percent of total billed charges,,,65,,819,percent of total billed charges,,,80,,1008,percent of total billed charges,,,55,,693,percent of total billed charges,,,55,,693,percent of total billed charges,,,65,,819,percent of total billed charges,,,78,,982.8,percent of total billed charges,,,70,,882,percent of total billed charges,,,,,,,,325.04,,,,100% of Medicare,,325.04,,,,100% of Medicare,,325.04,,,,100% of Medicare,,325.04,,,,100% of Medicare,,325.04,,,,100% of Medicare,,325.04,,,,100% of Medicare,,325.04,,,,100% of Medicare,,325.04,,,,100% of Medicare,,325.04,,,,100% of Medicare,,325.04,,,,100% of Medicare,,325.04,,,,100% of Medicare,,325.04,,,,100% of Medicare,,,325.04,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,325.04,1134,
"Addition to LE, Symes type, posterior opening (Canadian) socket",L5634,HCPCS,,,,outpatient,,,1173,703.8,,45.5,,533.72,percent of total billed charges,,,45.3,,531.37,percent of total billed charges,,,39,,457.47,percent of total billed charges,,,,,,,,,80,,938.4,percent of total billed charges,,,61.4,,720.22,percent of total billed charges,,,57.4,,673.3,percent of total billed charges,,,81,,950.13,percent of total billed charges,,,39,,457.47,percent of total billed charges,,,57.6,,675.65,percent of total billed charges,,,85,,997.05,percent of total billed charges,,,85,,997.05,percent of total billed charges,,,49,,574.77,percent of total billed charges,,,90,,1055.7,percent of total billed charges,,,65,,762.45,percent of total billed charges,,,80,,938.4,percent of total billed charges,,,55,,645.15,percent of total billed charges,,,55,,645.15,percent of total billed charges,,,65,,762.45,percent of total billed charges,,,78,,914.94,percent of total billed charges,,,70,,821.1,percent of total billed charges,,,,,,,,406.49,,,,100% of Medicare,,406.49,,,,100% of Medicare,,406.49,,,,100% of Medicare,,406.49,,,,100% of Medicare,,406.49,,,,100% of Medicare,,406.49,,,,100% of Medicare,,406.49,,,,100% of Medicare,,406.49,,,,100% of Medicare,,406.49,,,,100% of Medicare,,406.49,,,,100% of Medicare,,406.49,,,,100% of Medicare,,406.49,,,,100% of Medicare,,,406.49,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,406.49,1055.7,
"Addition to LE, Symes type, medial opening socket",L5636,HCPCS,,,,outpatient,,,895,537,,45.5,,407.23,percent of total billed charges,,,45.3,,405.44,percent of total billed charges,,,39,,349.05,percent of total billed charges,,,,,,,,,80,,716,percent of total billed charges,,,61.4,,549.53,percent of total billed charges,,,57.4,,513.73,percent of total billed charges,,,81,,724.95,percent of total billed charges,,,39,,349.05,percent of total billed charges,,,57.6,,515.52,percent of total billed charges,,,85,,760.75,percent of total billed charges,,,85,,760.75,percent of total billed charges,,,49,,438.55,percent of total billed charges,,,90,,805.5,percent of total billed charges,,,65,,581.75,percent of total billed charges,,,80,,716,percent of total billed charges,,,55,,492.25,percent of total billed charges,,,55,,492.25,percent of total billed charges,,,65,,581.75,percent of total billed charges,,,78,,698.1,percent of total billed charges,,,70,,626.5,percent of total billed charges,,,,,,,,310.7,,,,100% of Medicare,,310.7,,,,100% of Medicare,,310.7,,,,100% of Medicare,,310.7,,,,100% of Medicare,,310.7,,,,100% of Medicare,,310.7,,,,100% of Medicare,,310.7,,,,100% of Medicare,,310.7,,,,100% of Medicare,,310.7,,,,100% of Medicare,,310.7,,,,100% of Medicare,,310.7,,,,100% of Medicare,,310.7,,,,100% of Medicare,,,310.7,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,310.7,805.5,
"Addition to LE, BK, total contact",L5637,HCPCS,,,,outpatient,,,1779,1067.4,,45.5,,809.45,percent of total billed charges,,,45.3,,805.89,percent of total billed charges,,,39,,693.81,percent of total billed charges,,,,,,,,,80,,1423.2,percent of total billed charges,,,61.4,,1092.31,percent of total billed charges,,,57.4,,1021.15,percent of total billed charges,,,81,,1440.99,percent of total billed charges,,,39,,693.81,percent of total billed charges,,,57.6,,1024.7,percent of total billed charges,,,85,,1512.15,percent of total billed charges,,,85,,1512.15,percent of total billed charges,,,49,,871.71,percent of total billed charges,,,90,,1601.1,percent of total billed charges,,,65,,1156.35,percent of total billed charges,,,80,,1423.2,percent of total billed charges,,,55,,978.45,percent of total billed charges,,,55,,978.45,percent of total billed charges,,,65,,1156.35,percent of total billed charges,,,78,,1387.62,percent of total billed charges,,,70,,1245.3,percent of total billed charges,,,,,,,,462.31,,,,100% of Medicare,,462.31,,,,100% of Medicare,,462.31,,,,100% of Medicare,,462.31,,,,100% of Medicare,,462.31,,,,100% of Medicare,,462.31,,,,100% of Medicare,,462.31,,,,100% of Medicare,,462.31,,,,100% of Medicare,,462.31,,,,100% of Medicare,,462.31,,,,100% of Medicare,,462.31,,,,100% of Medicare,,462.31,,,,100% of Medicare,,,462.31,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,462.31,1601.1,
"Addition to LE, BK, leather socket",L5638,HCPCS,,,,outpatient,,,1808,1084.8,,45.5,,822.64,percent of total billed charges,,,45.3,,819.02,percent of total billed charges,,,39,,705.12,percent of total billed charges,,,,,,,,,80,,1446.4,percent of total billed charges,,,61.4,,1110.11,percent of total billed charges,,,57.4,,1037.79,percent of total billed charges,,,81,,1464.48,percent of total billed charges,,,39,,705.12,percent of total billed charges,,,57.6,,1041.41,percent of total billed charges,,,85,,1536.8,percent of total billed charges,,,85,,1536.8,percent of total billed charges,,,49,,885.92,percent of total billed charges,,,90,,1627.2,percent of total billed charges,,,65,,1175.2,percent of total billed charges,,,80,,1446.4,percent of total billed charges,,,55,,994.4,percent of total billed charges,,,55,,994.4,percent of total billed charges,,,65,,1175.2,percent of total billed charges,,,78,,1410.24,percent of total billed charges,,,70,,1265.6,percent of total billed charges,,,,,,,,778.81,,,,100% of Medicare,,778.81,,,,100% of Medicare,,778.81,,,,100% of Medicare,,778.81,,,,100% of Medicare,,778.81,,,,100% of Medicare,,778.81,,,,100% of Medicare,,778.81,,,,100% of Medicare,,778.81,,,,100% of Medicare,,778.81,,,,100% of Medicare,,778.81,,,,100% of Medicare,,778.81,,,,100% of Medicare,,778.81,,,,100% of Medicare,,,778.81,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,705.12,1627.2,
"Addition to LE, BK, wood socket",L5639,HCPCS,,,,outpatient,,,3123,1873.8,,45.5,,1420.97,percent of total billed charges,,,45.3,,1414.72,percent of total billed charges,,,39,,1217.97,percent of total billed charges,,,,,,,,,80,,2498.4,percent of total billed charges,,,61.4,,1917.52,percent of total billed charges,,,57.4,,1792.6,percent of total billed charges,,,81,,2529.63,percent of total billed charges,,,39,,1217.97,percent of total billed charges,,,57.6,,1798.85,percent of total billed charges,,,85,,2654.55,percent of total billed charges,,,85,,2654.55,percent of total billed charges,,,49,,1530.27,percent of total billed charges,,,90,,2810.7,percent of total billed charges,,,65,,2029.95,percent of total billed charges,,,80,,2498.4,percent of total billed charges,,,55,,1717.65,percent of total billed charges,,,55,,1717.65,percent of total billed charges,,,65,,2029.95,percent of total billed charges,,,78,,2435.94,percent of total billed charges,,,70,,2186.1,percent of total billed charges,,,,,,,,1345.68,,,,100% of Medicare,,1345.68,,,,100% of Medicare,,1345.68,,,,100% of Medicare,,1345.68,,,,100% of Medicare,,1345.68,,,,100% of Medicare,,1345.68,,,,100% of Medicare,,1345.68,,,,100% of Medicare,,1345.68,,,,100% of Medicare,,1345.68,,,,100% of Medicare,,1345.68,,,,100% of Medicare,,1345.68,,,,100% of Medicare,,1345.68,,,,100% of Medicare,,,1345.68,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1217.97,2810.7,
"Addition to LE, knee disartic, leather socket",L5640,HCPCS,,,,outpatient,,,2054,1232.4,,45.5,,934.57,percent of total billed charges,,,45.3,,930.46,percent of total billed charges,,,39,,801.06,percent of total billed charges,,,,,,,,,80,,1643.2,percent of total billed charges,,,61.4,,1261.16,percent of total billed charges,,,57.4,,1179,percent of total billed charges,,,81,,1663.74,percent of total billed charges,,,39,,801.06,percent of total billed charges,,,57.6,,1183.1,percent of total billed charges,,,85,,1745.9,percent of total billed charges,,,85,,1745.9,percent of total billed charges,,,49,,1006.46,percent of total billed charges,,,90,,1848.6,percent of total billed charges,,,65,,1335.1,percent of total billed charges,,,80,,1643.2,percent of total billed charges,,,55,,1129.7,percent of total billed charges,,,55,,1129.7,percent of total billed charges,,,65,,1335.1,percent of total billed charges,,,78,,1602.12,percent of total billed charges,,,70,,1437.8,percent of total billed charges,,,,,,,,884.52,,,,100% of Medicare,,884.52,,,,100% of Medicare,,884.52,,,,100% of Medicare,,884.52,,,,100% of Medicare,,884.52,,,,100% of Medicare,,884.52,,,,100% of Medicare,,884.52,,,,100% of Medicare,,884.52,,,,100% of Medicare,,884.52,,,,100% of Medicare,,884.52,,,,100% of Medicare,,884.52,,,,100% of Medicare,,884.52,,,,100% of Medicare,,,884.52,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,801.06,1848.6,
"Addition to LE, AK, leather socket",L5642,HCPCS,,,,outpatient,,,1903,1141.8,,45.5,,865.87,percent of total billed charges,,,45.3,,862.06,percent of total billed charges,,,39,,742.17,percent of total billed charges,,,,,,,,,80,,1522.4,percent of total billed charges,,,61.4,,1168.44,percent of total billed charges,,,57.4,,1092.32,percent of total billed charges,,,81,,1541.43,percent of total billed charges,,,39,,742.17,percent of total billed charges,,,57.6,,1096.13,percent of total billed charges,,,85,,1617.55,percent of total billed charges,,,85,,1617.55,percent of total billed charges,,,49,,932.47,percent of total billed charges,,,90,,1712.7,percent of total billed charges,,,65,,1236.95,percent of total billed charges,,,80,,1522.4,percent of total billed charges,,,55,,1046.65,percent of total billed charges,,,55,,1046.65,percent of total billed charges,,,65,,1236.95,percent of total billed charges,,,78,,1484.34,percent of total billed charges,,,70,,1332.1,percent of total billed charges,,,,,,,,819.92,,,,100% of Medicare,,819.92,,,,100% of Medicare,,819.92,,,,100% of Medicare,,819.92,,,,100% of Medicare,,819.92,,,,100% of Medicare,,819.92,,,,100% of Medicare,,819.92,,,,100% of Medicare,,819.92,,,,100% of Medicare,,819.92,,,,100% of Medicare,,819.92,,,,100% of Medicare,,819.92,,,,100% of Medicare,,819.92,,,,100% of Medicare,,,819.92,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,742.17,1712.7,
"Addition to LE, AK, wood socket",L5644,HCPCS,,,,outpatient,,,1647,988.2,,45.5,,749.39,percent of total billed charges,,,45.3,,746.09,percent of total billed charges,,,39,,642.33,percent of total billed charges,,,,,,,,,80,,1317.6,percent of total billed charges,,,61.4,,1011.26,percent of total billed charges,,,57.4,,945.38,percent of total billed charges,,,81,,1334.07,percent of total billed charges,,,39,,642.33,percent of total billed charges,,,57.6,,948.67,percent of total billed charges,,,85,,1399.95,percent of total billed charges,,,85,,1399.95,percent of total billed charges,,,49,,807.03,percent of total billed charges,,,90,,1482.3,percent of total billed charges,,,65,,1070.55,percent of total billed charges,,,80,,1317.6,percent of total billed charges,,,55,,905.85,percent of total billed charges,,,55,,905.85,percent of total billed charges,,,65,,1070.55,percent of total billed charges,,,78,,1284.66,percent of total billed charges,,,70,,1152.9,percent of total billed charges,,,,,,,,708.91,,,,100% of Medicare,,708.91,,,,100% of Medicare,,708.91,,,,100% of Medicare,,708.91,,,,100% of Medicare,,708.91,,,,100% of Medicare,,708.91,,,,100% of Medicare,,708.91,,,,100% of Medicare,,708.91,,,,100% of Medicare,,708.91,,,,100% of Medicare,,708.91,,,,100% of Medicare,,708.91,,,,100% of Medicare,,708.91,,,,100% of Medicare,,,708.91,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,642.33,1482.3,
"Addition to LE, BK flexible inner socket, external frame",L5645,HCPCS,,,,outpatient,,,3574,2144.4,,45.5,,1626.17,percent of total billed charges,,,45.3,,1619.02,percent of total billed charges,,,39,,1393.86,percent of total billed charges,,,,,,,,,80,,2859.2,percent of total billed charges,,,61.4,,2194.44,percent of total billed charges,,,57.4,,2051.48,percent of total billed charges,,,81,,2894.94,percent of total billed charges,,,39,,1393.86,percent of total billed charges,,,57.6,,2058.62,percent of total billed charges,,,85,,3037.9,percent of total billed charges,,,85,,3037.9,percent of total billed charges,,,49,,1751.26,percent of total billed charges,,,90,,3216.6,percent of total billed charges,,,65,,2323.1,percent of total billed charges,,,80,,2859.2,percent of total billed charges,,,55,,1965.7,percent of total billed charges,,,55,,1965.7,percent of total billed charges,,,65,,2323.1,percent of total billed charges,,,78,,2787.72,percent of total billed charges,,,70,,2501.8,percent of total billed charges,,,,,,,,1176.04,,,,100% of Medicare,,1176.04,,,,100% of Medicare,,1176.04,,,,100% of Medicare,,1176.04,,,,100% of Medicare,,1176.04,,,,100% of Medicare,,1176.04,,,,100% of Medicare,,1176.04,,,,100% of Medicare,,1176.04,,,,100% of Medicare,,1176.04,,,,100% of Medicare,,1176.04,,,,100% of Medicare,,1176.04,,,,100% of Medicare,,1176.04,,,,100% of Medicare,,,1176.04,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1176.04,3216.6,
"Addition to LE, BK, air cushion socket",L5646,HCPCS,,,,outpatient,,,1732,1039.2,,45.5,,788.06,percent of total billed charges,,,45.3,,784.6,percent of total billed charges,,,39,,675.48,percent of total billed charges,,,,,,,,,80,,1385.6,percent of total billed charges,,,61.4,,1063.45,percent of total billed charges,,,57.4,,994.17,percent of total billed charges,,,81,,1402.92,percent of total billed charges,,,39,,675.48,percent of total billed charges,,,57.6,,997.63,percent of total billed charges,,,85,,1472.2,percent of total billed charges,,,85,,1472.2,percent of total billed charges,,,49,,848.68,percent of total billed charges,,,90,,1558.8,percent of total billed charges,,,65,,1125.8,percent of total billed charges,,,80,,1385.6,percent of total billed charges,,,55,,952.6,percent of total billed charges,,,55,,952.6,percent of total billed charges,,,65,,1125.8,percent of total billed charges,,,78,,1350.96,percent of total billed charges,,,70,,1212.4,percent of total billed charges,,,,,,,,745.29,,,,100% of Medicare,,745.29,,,,100% of Medicare,,745.29,,,,100% of Medicare,,745.29,,,,100% of Medicare,,745.29,,,,100% of Medicare,,745.29,,,,100% of Medicare,,745.29,,,,100% of Medicare,,745.29,,,,100% of Medicare,,745.29,,,,100% of Medicare,,745.29,,,,100% of Medicare,,745.29,,,,100% of Medicare,,745.29,,,,100% of Medicare,,,745.29,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,675.48,1558.8,
"Addition to LE, BK, suction socket",L5647,HCPCS,,,,outpatient,,,2900,1740,,45.5,,1319.5,percent of total billed charges,,,45.3,,1313.7,percent of total billed charges,,,39,,1131,percent of total billed charges,,,,,,,,,80,,2320,percent of total billed charges,,,61.4,,1780.6,percent of total billed charges,,,57.4,,1664.6,percent of total billed charges,,,81,,2349,percent of total billed charges,,,39,,1131,percent of total billed charges,,,57.6,,1670.4,percent of total billed charges,,,85,,2465,percent of total billed charges,,,85,,2465,percent of total billed charges,,,49,,1421,percent of total billed charges,,,90,,2610,percent of total billed charges,,,65,,1885,percent of total billed charges,,,80,,2320,percent of total billed charges,,,55,,1595,percent of total billed charges,,,55,,1595,percent of total billed charges,,,65,,1885,percent of total billed charges,,,78,,2262,percent of total billed charges,,,70,,2030,percent of total billed charges,,,,,,,,954.75,,,,100% of Medicare,,954.75,,,,100% of Medicare,,954.75,,,,100% of Medicare,,954.75,,,,100% of Medicare,,954.75,,,,100% of Medicare,,954.75,,,,100% of Medicare,,954.75,,,,100% of Medicare,,954.75,,,,100% of Medicare,,954.75,,,,100% of Medicare,,954.75,,,,100% of Medicare,,954.75,,,,100% of Medicare,,954.75,,,,100% of Medicare,,,954.75,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,954.75,2610,
"Addition to LE, AK, air cushion socket",L5648,HCPCS,,,,outpatient,,,2047,1228.2,,45.5,,931.39,percent of total billed charges,,,45.3,,927.29,percent of total billed charges,,,39,,798.33,percent of total billed charges,,,,,,,,,80,,1637.6,percent of total billed charges,,,61.4,,1256.86,percent of total billed charges,,,57.4,,1174.98,percent of total billed charges,,,81,,1658.07,percent of total billed charges,,,39,,798.33,percent of total billed charges,,,57.6,,1179.07,percent of total billed charges,,,85,,1739.95,percent of total billed charges,,,85,,1739.95,percent of total billed charges,,,49,,1003.03,percent of total billed charges,,,90,,1842.3,percent of total billed charges,,,65,,1330.55,percent of total billed charges,,,80,,1637.6,percent of total billed charges,,,55,,1125.85,percent of total billed charges,,,55,,1125.85,percent of total billed charges,,,65,,1330.55,percent of total billed charges,,,78,,1596.66,percent of total billed charges,,,70,,1432.9,percent of total billed charges,,,,,,,,880.62,,,,100% of Medicare,,880.62,,,,100% of Medicare,,880.62,,,,100% of Medicare,,880.62,,,,100% of Medicare,,880.62,,,,100% of Medicare,,880.62,,,,100% of Medicare,,880.62,,,,100% of Medicare,,880.62,,,,100% of Medicare,,880.62,,,,100% of Medicare,,880.62,,,,100% of Medicare,,880.62,,,,100% of Medicare,,880.62,,,,100% of Medicare,,,880.62,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,798.33,1842.3,
"Addition to LE, total contact, AK or knee disartic socket",L5650,HCPCS,,,,outpatient,,,1739,1043.4,,45.5,,791.25,percent of total billed charges,,,45.3,,787.77,percent of total billed charges,,,39,,678.21,percent of total billed charges,,,,,,,,,80,,1391.2,percent of total billed charges,,,61.4,,1067.75,percent of total billed charges,,,57.4,,998.19,percent of total billed charges,,,81,,1408.59,percent of total billed charges,,,39,,678.21,percent of total billed charges,,,57.6,,1001.66,percent of total billed charges,,,85,,1478.15,percent of total billed charges,,,85,,1478.15,percent of total billed charges,,,49,,852.11,percent of total billed charges,,,90,,1565.1,percent of total billed charges,,,65,,1130.35,percent of total billed charges,,,80,,1391.2,percent of total billed charges,,,55,,956.45,percent of total billed charges,,,55,,956.45,percent of total billed charges,,,65,,1130.35,percent of total billed charges,,,78,,1356.42,percent of total billed charges,,,70,,1217.3,percent of total billed charges,,,,,,,,585.94,,,,100% of Medicare,,585.94,,,,100% of Medicare,,585.94,,,,100% of Medicare,,585.94,,,,100% of Medicare,,585.94,,,,100% of Medicare,,585.94,,,,100% of Medicare,,585.94,,,,100% of Medicare,,585.94,,,,100% of Medicare,,585.94,,,,100% of Medicare,,585.94,,,,100% of Medicare,,585.94,,,,100% of Medicare,,585.94,,,,100% of Medicare,,,585.94,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,585.94,1565.1,
"Addition to LE, suction suspension, AK or knee disartic socket",L5652,HCPCS,,,,outpatient,,,1554,932.4,,45.5,,707.07,percent of total billed charges,,,45.3,,703.96,percent of total billed charges,,,39,,606.06,percent of total billed charges,,,,,,,,,80,,1243.2,percent of total billed charges,,,61.4,,954.16,percent of total billed charges,,,57.4,,892,percent of total billed charges,,,81,,1258.74,percent of total billed charges,,,39,,606.06,percent of total billed charges,,,57.6,,895.1,percent of total billed charges,,,85,,1320.9,percent of total billed charges,,,85,,1320.9,percent of total billed charges,,,49,,761.46,percent of total billed charges,,,90,,1398.6,percent of total billed charges,,,65,,1010.1,percent of total billed charges,,,80,,1243.2,percent of total billed charges,,,55,,854.7,percent of total billed charges,,,55,,854.7,percent of total billed charges,,,65,,1010.1,percent of total billed charges,,,78,,1212.12,percent of total billed charges,,,70,,1087.8,percent of total billed charges,,,,,,,,523.28,,,,100% of Medicare,,523.28,,,,100% of Medicare,,523.28,,,,100% of Medicare,,523.28,,,,100% of Medicare,,523.28,,,,100% of Medicare,,523.28,,,,100% of Medicare,,523.28,,,,100% of Medicare,,523.28,,,,100% of Medicare,,523.28,,,,100% of Medicare,,523.28,,,,100% of Medicare,,523.28,,,,100% of Medicare,,523.28,,,,100% of Medicare,,,523.28,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,523.28,1398.6,
"Addition to LE, knee disartic, expandable wall socket",L5653,HCPCS,,,,outpatient,,,2360,1416,,45.5,,1073.8,percent of total billed charges,,,45.3,,1069.08,percent of total billed charges,,,39,,920.4,percent of total billed charges,,,,,,,,,80,,1888,percent of total billed charges,,,61.4,,1449.04,percent of total billed charges,,,57.4,,1354.64,percent of total billed charges,,,81,,1911.6,percent of total billed charges,,,39,,920.4,percent of total billed charges,,,57.6,,1359.36,percent of total billed charges,,,85,,2006,percent of total billed charges,,,85,,2006,percent of total billed charges,,,49,,1156.4,percent of total billed charges,,,90,,2124,percent of total billed charges,,,65,,1534,percent of total billed charges,,,80,,1888,percent of total billed charges,,,55,,1298,percent of total billed charges,,,55,,1298,percent of total billed charges,,,65,,1534,percent of total billed charges,,,78,,1840.8,percent of total billed charges,,,70,,1652,percent of total billed charges,,,,,,,,816.48,,,,100% of Medicare,,816.48,,,,100% of Medicare,,816.48,,,,100% of Medicare,,816.48,,,,100% of Medicare,,816.48,,,,100% of Medicare,,816.48,,,,100% of Medicare,,816.48,,,,100% of Medicare,,816.48,,,,100% of Medicare,,816.48,,,,100% of Medicare,,816.48,,,,100% of Medicare,,816.48,,,,100% of Medicare,,816.48,,,,100% of Medicare,,,816.48,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,816.48,2124,
"Addition to LE, socket insert, Synes",L5654,HCPCS,,,,outpatient,,,1404,842.4,,45.5,,638.82,percent of total billed charges,,,45.3,,636.01,percent of total billed charges,,,39,,547.56,percent of total billed charges,,,,,,,,,80,,1123.2,percent of total billed charges,,,61.4,,862.06,percent of total billed charges,,,57.4,,805.9,percent of total billed charges,,,81,,1137.24,percent of total billed charges,,,39,,547.56,percent of total billed charges,,,57.6,,808.7,percent of total billed charges,,,85,,1193.4,percent of total billed charges,,,85,,1193.4,percent of total billed charges,,,49,,687.96,percent of total billed charges,,,90,,1263.6,percent of total billed charges,,,65,,912.6,percent of total billed charges,,,80,,1123.2,percent of total billed charges,,,55,,772.2,percent of total billed charges,,,55,,772.2,percent of total billed charges,,,65,,912.6,percent of total billed charges,,,78,,1095.12,percent of total billed charges,,,70,,982.8,percent of total billed charges,,,,,,,,473.3,,,,100% of Medicare,,473.3,,,,100% of Medicare,,473.3,,,,100% of Medicare,,473.3,,,,100% of Medicare,,473.3,,,,100% of Medicare,,473.3,,,,100% of Medicare,,473.3,,,,100% of Medicare,,473.3,,,,100% of Medicare,,473.3,,,,100% of Medicare,,473.3,,,,100% of Medicare,,473.3,,,,100% of Medicare,,473.3,,,,100% of Medicare,,,473.3,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,473.3,1263.6,
"Addition to LE, socket insert, BK (Kemblo, Pelite, Aliplast, Plastizote or equal)",L5655,HCPCS,,,,outpatient,,,1017,610.2,,45.5,,462.74,percent of total billed charges,,,45.3,,460.7,percent of total billed charges,,,39,,396.63,percent of total billed charges,,,,,,,,,80,,813.6,percent of total billed charges,,,61.4,,624.44,percent of total billed charges,,,57.4,,583.76,percent of total billed charges,,,81,,823.77,percent of total billed charges,,,39,,396.63,percent of total billed charges,,,57.6,,585.79,percent of total billed charges,,,85,,864.45,percent of total billed charges,,,85,,864.45,percent of total billed charges,,,49,,498.33,percent of total billed charges,,,90,,915.3,percent of total billed charges,,,65,,661.05,percent of total billed charges,,,80,,813.6,percent of total billed charges,,,55,,559.35,percent of total billed charges,,,55,,559.35,percent of total billed charges,,,65,,661.05,percent of total billed charges,,,78,,793.26,percent of total billed charges,,,70,,711.9,percent of total billed charges,,,,,,,,341.73,,,,100% of Medicare,,341.73,,,,100% of Medicare,,341.73,,,,100% of Medicare,,341.73,,,,100% of Medicare,,341.73,,,,100% of Medicare,,341.73,,,,100% of Medicare,,341.73,,,,100% of Medicare,,341.73,,,,100% of Medicare,,341.73,,,,100% of Medicare,,341.73,,,,100% of Medicare,,341.73,,,,100% of Medicare,,341.73,,,,100% of Medicare,,,341.73,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,341.73,915.3,
"Addition to LE,socket insert, knee disartic (Kemblo, Pelite, Aliplast, Plastizote or equal)",L5656,HCPCS,,,,outpatient,,,1545,927,,45.5,,702.98,percent of total billed charges,,,45.3,,699.89,percent of total billed charges,,,39,,602.55,percent of total billed charges,,,,,,,,,80,,1236,percent of total billed charges,,,61.4,,948.63,percent of total billed charges,,,57.4,,886.83,percent of total billed charges,,,81,,1251.45,percent of total billed charges,,,39,,602.55,percent of total billed charges,,,57.6,,889.92,percent of total billed charges,,,85,,1313.25,percent of total billed charges,,,85,,1313.25,percent of total billed charges,,,49,,757.05,percent of total billed charges,,,90,,1390.5,percent of total billed charges,,,65,,1004.25,percent of total billed charges,,,80,,1236,percent of total billed charges,,,55,,849.75,percent of total billed charges,,,55,,849.75,percent of total billed charges,,,65,,1004.25,percent of total billed charges,,,78,,1205.1,percent of total billed charges,,,70,,1081.5,percent of total billed charges,,,,,,,,519.16,,,,100% of Medicare,,519.16,,,,100% of Medicare,,519.16,,,,100% of Medicare,,519.16,,,,100% of Medicare,,519.16,,,,100% of Medicare,,519.16,,,,100% of Medicare,,519.16,,,,100% of Medicare,,519.16,,,,100% of Medicare,,519.16,,,,100% of Medicare,,519.16,,,,100% of Medicare,,519.16,,,,100% of Medicare,,519.16,,,,100% of Medicare,,,519.16,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,519.16,1390.5,
"Addition to LE, socket insert, AK (Kemblo, Pelite, Aliplast, Plastizote or equal)",L5658,HCPCS,,,,outpatient,,,2194,1316.4,,45.5,,998.27,percent of total billed charges,,,45.3,,993.88,percent of total billed charges,,,39,,855.66,percent of total billed charges,,,,,,,,,80,,1755.2,percent of total billed charges,,,61.4,,1347.12,percent of total billed charges,,,57.4,,1259.36,percent of total billed charges,,,81,,1777.14,percent of total billed charges,,,39,,855.66,percent of total billed charges,,,57.6,,1263.74,percent of total billed charges,,,85,,1864.9,percent of total billed charges,,,85,,1864.9,percent of total billed charges,,,49,,1075.06,percent of total billed charges,,,90,,1974.6,percent of total billed charges,,,65,,1426.1,percent of total billed charges,,,80,,1755.2,percent of total billed charges,,,55,,1206.7,percent of total billed charges,,,55,,1206.7,percent of total billed charges,,,65,,1426.1,percent of total billed charges,,,78,,1711.32,percent of total billed charges,,,70,,1535.8,percent of total billed charges,,,,,,,,547.98,,,,100% of Medicare,,547.98,,,,100% of Medicare,,547.98,,,,100% of Medicare,,547.98,,,,100% of Medicare,,547.98,,,,100% of Medicare,,547.98,,,,100% of Medicare,,547.98,,,,100% of Medicare,,547.98,,,,100% of Medicare,,547.98,,,,100% of Medicare,,547.98,,,,100% of Medicare,,547.98,,,,100% of Medicare,,547.98,,,,100% of Medicare,,,547.98,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,547.98,1974.6,
"Addition to LE, socket insert, multidurometer, Symes",L5661,HCPCS,,,,outpatient,,,1825,1095,,45.5,,830.38,percent of total billed charges,,,45.3,,826.73,percent of total billed charges,,,39,,711.75,percent of total billed charges,,,,,,,,,80,,1460,percent of total billed charges,,,61.4,,1120.55,percent of total billed charges,,,57.4,,1047.55,percent of total billed charges,,,81,,1478.25,percent of total billed charges,,,39,,711.75,percent of total billed charges,,,57.6,,1051.2,percent of total billed charges,,,85,,1551.25,percent of total billed charges,,,85,,1551.25,percent of total billed charges,,,49,,894.25,percent of total billed charges,,,90,,1642.5,percent of total billed charges,,,65,,1186.25,percent of total billed charges,,,80,,1460,percent of total billed charges,,,55,,1003.75,percent of total billed charges,,,55,,1003.75,percent of total billed charges,,,65,,1186.25,percent of total billed charges,,,78,,1423.5,percent of total billed charges,,,70,,1277.5,percent of total billed charges,,,,,,,,786.24,,,,100% of Medicare,,786.24,,,,100% of Medicare,,786.24,,,,100% of Medicare,,786.24,,,,100% of Medicare,,786.24,,,,100% of Medicare,,786.24,,,,100% of Medicare,,786.24,,,,100% of Medicare,,786.24,,,,100% of Medicare,,786.24,,,,100% of Medicare,,786.24,,,,100% of Medicare,,786.24,,,,100% of Medicare,,786.24,,,,100% of Medicare,,,786.24,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,711.75,1642.5,
"Addition to LE, socket insert, AK, silicone gel or equal",L5665,HCPCS,,,,outpatient,,,2080,1248,,45.5,,946.4,percent of total billed charges,,,45.3,,942.24,percent of total billed charges,,,39,,811.2,percent of total billed charges,,,,,,,,,80,,1664,percent of total billed charges,,,61.4,,1277.12,percent of total billed charges,,,57.4,,1193.92,percent of total billed charges,,,81,,1684.8,percent of total billed charges,,,39,,811.2,percent of total billed charges,,,57.6,,1198.08,percent of total billed charges,,,85,,1768,percent of total billed charges,,,85,,1768,percent of total billed charges,,,49,,1019.2,percent of total billed charges,,,90,,1872,percent of total billed charges,,,65,,1352,percent of total billed charges,,,80,,1664,percent of total billed charges,,,55,,1144,percent of total billed charges,,,55,,1144,percent of total billed charges,,,65,,1352,percent of total billed charges,,,78,,1622.4,percent of total billed charges,,,70,,1456,percent of total billed charges,,,,,,,,698.99,,,,100% of Medicare,,698.99,,,,100% of Medicare,,698.99,,,,100% of Medicare,,698.99,,,,100% of Medicare,,698.99,,,,100% of Medicare,,698.99,,,,100% of Medicare,,698.99,,,,100% of Medicare,,698.99,,,,100% of Medicare,,698.99,,,,100% of Medicare,,698.99,,,,100% of Medicare,,698.99,,,,100% of Medicare,,698.99,,,,100% of Medicare,,,698.99,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,698.99,1872,
"Addition to LE, BK, cuff suspension",L5666,HCPCS,,,,outpatient,,,357,214.2,,45.5,,162.44,percent of total billed charges,,,45.3,,161.72,percent of total billed charges,,,39,,139.23,percent of total billed charges,,,,,,,,,80,,285.6,percent of total billed charges,,,61.4,,219.2,percent of total billed charges,,,57.4,,204.92,percent of total billed charges,,,81,,289.17,percent of total billed charges,,,39,,139.23,percent of total billed charges,,,57.6,,205.63,percent of total billed charges,,,85,,303.45,percent of total billed charges,,,85,,303.45,percent of total billed charges,,,49,,174.93,percent of total billed charges,,,90,,321.3,percent of total billed charges,,,65,,232.05,percent of total billed charges,,,80,,285.6,percent of total billed charges,,,55,,196.35,percent of total billed charges,,,55,,196.35,percent of total billed charges,,,65,,232.05,percent of total billed charges,,,78,,278.46,percent of total billed charges,,,70,,249.9,percent of total billed charges,,,,,,,,92.55,,,,100% of Medicare,,92.55,,,,100% of Medicare,,92.55,,,,100% of Medicare,,92.55,,,,100% of Medicare,,92.55,,,,100% of Medicare,,92.55,,,,100% of Medicare,,92.55,,,,100% of Medicare,,92.55,,,,100% of Medicare,,92.55,,,,100% of Medicare,,92.55,,,,100% of Medicare,,92.55,,,,100% of Medicare,,92.55,,,,100% of Medicare,,,92.55,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,92.55,321.3,
"Addition to LE, BK, molded distal cushion",L5668,HCPCS,,,,outpatient,,,414,248.4,,45.5,,188.37,percent of total billed charges,,,45.3,,187.54,percent of total billed charges,,,39,,161.46,percent of total billed charges,,,,,,,,,80,,331.2,percent of total billed charges,,,61.4,,254.2,percent of total billed charges,,,57.4,,237.64,percent of total billed charges,,,81,,335.34,percent of total billed charges,,,39,,161.46,percent of total billed charges,,,57.6,,238.46,percent of total billed charges,,,85,,351.9,percent of total billed charges,,,85,,351.9,percent of total billed charges,,,49,,202.86,percent of total billed charges,,,90,,372.6,percent of total billed charges,,,65,,269.1,percent of total billed charges,,,80,,331.2,percent of total billed charges,,,55,,227.7,percent of total billed charges,,,55,,227.7,percent of total billed charges,,,65,,269.1,percent of total billed charges,,,78,,322.92,percent of total billed charges,,,70,,289.8,percent of total billed charges,,,,,,,,137.86,,,,100% of Medicare,,137.86,,,,100% of Medicare,,137.86,,,,100% of Medicare,,137.86,,,,100% of Medicare,,137.86,,,,100% of Medicare,,137.86,,,,100% of Medicare,,137.86,,,,100% of Medicare,,137.86,,,,100% of Medicare,,137.86,,,,100% of Medicare,,137.86,,,,100% of Medicare,,137.86,,,,100% of Medicare,,137.86,,,,100% of Medicare,,,137.86,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,137.86,372.6,
"Addition to LE, BK, molded supracondylar suspension (""PTS"" or similar)",L5670,HCPCS,,,,outpatient,,,968,580.8,,45.5,,440.44,percent of total billed charges,,,45.3,,438.5,percent of total billed charges,,,39,,377.52,percent of total billed charges,,,,,,,,,80,,774.4,percent of total billed charges,,,61.4,,594.35,percent of total billed charges,,,57.4,,555.63,percent of total billed charges,,,81,,784.08,percent of total billed charges,,,39,,377.52,percent of total billed charges,,,57.6,,557.57,percent of total billed charges,,,85,,822.8,percent of total billed charges,,,85,,822.8,percent of total billed charges,,,49,,474.32,percent of total billed charges,,,90,,871.2,percent of total billed charges,,,65,,629.2,percent of total billed charges,,,80,,774.4,percent of total billed charges,,,55,,532.4,percent of total billed charges,,,55,,532.4,percent of total billed charges,,,65,,629.2,percent of total billed charges,,,78,,755.04,percent of total billed charges,,,70,,677.6,percent of total billed charges,,,,,,,,325.69,,,,100% of Medicare,,325.69,,,,100% of Medicare,,325.69,,,,100% of Medicare,,325.69,,,,100% of Medicare,,325.69,,,,100% of Medicare,,325.69,,,,100% of Medicare,,325.69,,,,100% of Medicare,,325.69,,,,100% of Medicare,,325.69,,,,100% of Medicare,,325.69,,,,100% of Medicare,,325.69,,,,100% of Medicare,,325.69,,,,100% of Medicare,,,325.69,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,325.69,871.2,
"Addition to LE, BK/AK suspension locking mechanism (shuttle, lanyard or equal), excludes socket inse",L5671,HCPCS,,,,outpatient,,,2393,1435.8,,45.5,,1088.82,percent of total billed charges,,,45.3,,1084.03,percent of total billed charges,,,39,,933.27,percent of total billed charges,,,,,,,,,80,,1914.4,percent of total billed charges,,,61.4,,1469.3,percent of total billed charges,,,57.4,,1373.58,percent of total billed charges,,,81,,1938.33,percent of total billed charges,,,39,,933.27,percent of total billed charges,,,57.6,,1378.37,percent of total billed charges,,,85,,2034.05,percent of total billed charges,,,85,,2034.05,percent of total billed charges,,,49,,1172.57,percent of total billed charges,,,90,,2153.7,percent of total billed charges,,,65,,1555.45,percent of total billed charges,,,80,,1914.4,percent of total billed charges,,,55,,1316.15,percent of total billed charges,,,55,,1316.15,percent of total billed charges,,,65,,1555.45,percent of total billed charges,,,78,,1866.54,percent of total billed charges,,,70,,1675.1,percent of total billed charges,,,,,,,,597.02,,,,100% of Medicare,,597.02,,,,100% of Medicare,,597.02,,,,100% of Medicare,,597.02,,,,100% of Medicare,,597.02,,,,100% of Medicare,,597.02,,,,100% of Medicare,,597.02,,,,100% of Medicare,,597.02,,,,100% of Medicare,,597.02,,,,100% of Medicare,,597.02,,,,100% of Medicare,,597.02,,,,100% of Medicare,,597.02,,,,100% of Medicare,,,597.02,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,597.02,2153.7,
"Addition to LE, BK, removable medial brim",L5672,HCPCS,,,,outpatient,,,1006,603.6,,45.5,,457.73,percent of total billed charges,,,45.3,,455.72,percent of total billed charges,,,39,,392.34,percent of total billed charges,,,,,,,,,80,,804.8,percent of total billed charges,,,61.4,,617.68,percent of total billed charges,,,57.4,,577.44,percent of total billed charges,,,81,,814.86,percent of total billed charges,,,39,,392.34,percent of total billed charges,,,57.6,,579.46,percent of total billed charges,,,85,,855.1,percent of total billed charges,,,85,,855.1,percent of total billed charges,,,49,,492.94,percent of total billed charges,,,90,,905.4,percent of total billed charges,,,65,,653.9,percent of total billed charges,,,80,,804.8,percent of total billed charges,,,55,,553.3,percent of total billed charges,,,55,,553.3,percent of total billed charges,,,65,,653.9,percent of total billed charges,,,78,,784.68,percent of total billed charges,,,70,,704.2,percent of total billed charges,,,,,,,,430.98,,,,100% of Medicare,,430.98,,,,100% of Medicare,,430.98,,,,100% of Medicare,,430.98,,,,100% of Medicare,,430.98,,,,100% of Medicare,,430.98,,,,100% of Medicare,,430.98,,,,100% of Medicare,,430.98,,,,100% of Medicare,,430.98,,,,100% of Medicare,,430.98,,,,100% of Medicare,,430.98,,,,100% of Medicare,,430.98,,,,100% of Medicare,,,430.98,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,392.34,905.4,
"Addition to LE, BK/AK, custom fab or prefab, socket insert, silicone gel, elasto or equal, for use w",L5673,HCPCS,,,,outpatient,,,2885,1731,,45.5,,1312.68,percent of total billed charges,,,45.3,,1306.91,percent of total billed charges,,,39,,1125.15,percent of total billed charges,,,,,,,,,80,,2308,percent of total billed charges,,,61.4,,1771.39,percent of total billed charges,,,57.4,,1655.99,percent of total billed charges,,,81,,2336.85,percent of total billed charges,,,39,,1125.15,percent of total billed charges,,,57.6,,1661.76,percent of total billed charges,,,85,,2452.25,percent of total billed charges,,,85,,2452.25,percent of total billed charges,,,49,,1413.65,percent of total billed charges,,,90,,2596.5,percent of total billed charges,,,65,,1875.25,percent of total billed charges,,,80,,2308,percent of total billed charges,,,55,,1586.75,percent of total billed charges,,,55,,1586.75,percent of total billed charges,,,65,,1875.25,percent of total billed charges,,,78,,2250.3,percent of total billed charges,,,70,,2019.5,percent of total billed charges,,,,,,,,948.84,,,,100% of Medicare,,948.84,,,,100% of Medicare,,948.84,,,,100% of Medicare,,948.84,,,,100% of Medicare,,948.84,,,,100% of Medicare,,948.84,,,,100% of Medicare,,948.84,,,,100% of Medicare,,948.84,,,,100% of Medicare,,948.84,,,,100% of Medicare,,948.84,,,,100% of Medicare,,948.84,,,,100% of Medicare,,948.84,,,,100% of Medicare,,,948.84,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,948.84,2596.5,
"Addition to LE, BK, knee joints, single axis, pair",L5676,HCPCS,,,,outpatient,,,1292,775.2,,45.5,,587.86,percent of total billed charges,,,45.3,,585.28,percent of total billed charges,,,39,,503.88,percent of total billed charges,,,,,,,,,80,,1033.6,percent of total billed charges,,,61.4,,793.29,percent of total billed charges,,,57.4,,741.61,percent of total billed charges,,,81,,1046.52,percent of total billed charges,,,39,,503.88,percent of total billed charges,,,57.6,,744.19,percent of total billed charges,,,85,,1098.2,percent of total billed charges,,,85,,1098.2,percent of total billed charges,,,49,,633.08,percent of total billed charges,,,90,,1162.8,percent of total billed charges,,,65,,839.8,percent of total billed charges,,,80,,1033.6,percent of total billed charges,,,55,,710.6,percent of total billed charges,,,55,,710.6,percent of total billed charges,,,65,,839.8,percent of total billed charges,,,78,,1007.76,percent of total billed charges,,,70,,904.4,percent of total billed charges,,,,,,,,434.94,,,,100% of Medicare,,434.94,,,,100% of Medicare,,434.94,,,,100% of Medicare,,434.94,,,,100% of Medicare,,434.94,,,,100% of Medicare,,434.94,,,,100% of Medicare,,434.94,,,,100% of Medicare,,434.94,,,,100% of Medicare,,434.94,,,,100% of Medicare,,434.94,,,,100% of Medicare,,434.94,,,,100% of Medicare,,434.94,,,,100% of Medicare,,,434.94,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,434.94,1162.8,
"Addition to LE, BK, knee joints, polycentric, pair",L5677,HCPCS,,,,outpatient,,,1924,1154.4,,45.5,,875.42,percent of total billed charges,,,45.3,,871.57,percent of total billed charges,,,39,,750.36,percent of total billed charges,,,,,,,,,80,,1539.2,percent of total billed charges,,,61.4,,1181.34,percent of total billed charges,,,57.4,,1104.38,percent of total billed charges,,,81,,1558.44,percent of total billed charges,,,39,,750.36,percent of total billed charges,,,57.6,,1108.22,percent of total billed charges,,,85,,1635.4,percent of total billed charges,,,85,,1635.4,percent of total billed charges,,,49,,942.76,percent of total billed charges,,,90,,1731.6,percent of total billed charges,,,65,,1250.6,percent of total billed charges,,,80,,1539.2,percent of total billed charges,,,55,,1058.2,percent of total billed charges,,,55,,1058.2,percent of total billed charges,,,65,,1250.6,percent of total billed charges,,,78,,1500.72,percent of total billed charges,,,70,,1346.8,percent of total billed charges,,,,,,,,666.1,,,,100% of Medicare,,666.1,,,,100% of Medicare,,666.1,,,,100% of Medicare,,666.1,,,,100% of Medicare,,666.1,,,,100% of Medicare,,666.1,,,,100% of Medicare,,666.1,,,,100% of Medicare,,666.1,,,,100% of Medicare,,666.1,,,,100% of Medicare,,666.1,,,,100% of Medicare,,666.1,,,,100% of Medicare,,666.1,,,,100% of Medicare,,,666.1,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,666.1,1731.6,
"Addition to LE, BK, joint covers, pair",L5678,HCPCS,,,,outpatient,,,138,82.8,,45.5,,62.79,percent of total billed charges,,,45.3,,62.51,percent of total billed charges,,,39,,53.82,percent of total billed charges,,,,,,,,,80,,110.4,percent of total billed charges,,,61.4,,84.73,percent of total billed charges,,,57.4,,79.21,percent of total billed charges,,,81,,111.78,percent of total billed charges,,,39,,53.82,percent of total billed charges,,,57.6,,79.49,percent of total billed charges,,,85,,117.3,percent of total billed charges,,,85,,117.3,percent of total billed charges,,,49,,67.62,percent of total billed charges,,,90,,124.2,percent of total billed charges,,,65,,89.7,percent of total billed charges,,,80,,110.4,percent of total billed charges,,,55,,75.9,percent of total billed charges,,,55,,75.9,percent of total billed charges,,,65,,89.7,percent of total billed charges,,,78,,107.64,percent of total billed charges,,,70,,96.6,percent of total billed charges,,,,,,,,47.66,,,,100% of Medicare,,47.66,,,,100% of Medicare,,47.66,,,,100% of Medicare,,47.66,,,,100% of Medicare,,47.66,,,,100% of Medicare,,47.66,,,,100% of Medicare,,47.66,,,,100% of Medicare,,47.66,,,,100% of Medicare,,47.66,,,,100% of Medicare,,47.66,,,,100% of Medicare,,47.66,,,,100% of Medicare,,47.66,,,,100% of Medicare,,,47.66,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,47.66,124.2,
"Addit to LE, BK/AK, custom fab or prefab, socket insert, silicone gel, elasto or equal, not for use",L5679,HCPCS,,,,outpatient,,,2402,1441.2,,45.5,,1092.91,percent of total billed charges,,,45.3,,1088.11,percent of total billed charges,,,39,,936.78,percent of total billed charges,,,,,,,,,80,,1921.6,percent of total billed charges,,,61.4,,1474.83,percent of total billed charges,,,57.4,,1378.75,percent of total billed charges,,,81,,1945.62,percent of total billed charges,,,39,,936.78,percent of total billed charges,,,57.6,,1383.55,percent of total billed charges,,,85,,2041.7,percent of total billed charges,,,85,,2041.7,percent of total billed charges,,,49,,1176.98,percent of total billed charges,,,90,,2161.8,percent of total billed charges,,,65,,1561.3,percent of total billed charges,,,80,,1921.6,percent of total billed charges,,,55,,1321.1,percent of total billed charges,,,55,,1321.1,percent of total billed charges,,,65,,1561.3,percent of total billed charges,,,78,,1873.56,percent of total billed charges,,,70,,1681.4,percent of total billed charges,,,,,,,,790.68,,,,100% of Medicare,,790.68,,,,100% of Medicare,,790.68,,,,100% of Medicare,,790.68,,,,100% of Medicare,,790.68,,,,100% of Medicare,,790.68,,,,100% of Medicare,,790.68,,,,100% of Medicare,,790.68,,,,100% of Medicare,,790.68,,,,100% of Medicare,,790.68,,,,100% of Medicare,,790.68,,,,100% of Medicare,,790.68,,,,100% of Medicare,,,790.68,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,790.68,2161.8,
"Addition to LE, BK, thigh lacer, non-molded",L5680,HCPCS,,,,outpatient,,,1086,651.6,,45.5,,494.13,percent of total billed charges,,,45.3,,491.96,percent of total billed charges,,,39,,423.54,percent of total billed charges,,,,,,,,,80,,868.8,percent of total billed charges,,,61.4,,666.8,percent of total billed charges,,,57.4,,623.36,percent of total billed charges,,,81,,879.66,percent of total billed charges,,,39,,423.54,percent of total billed charges,,,57.6,,625.54,percent of total billed charges,,,85,,923.1,percent of total billed charges,,,85,,923.1,percent of total billed charges,,,49,,532.14,percent of total billed charges,,,90,,977.4,percent of total billed charges,,,65,,705.9,percent of total billed charges,,,80,,868.8,percent of total billed charges,,,55,,597.3,percent of total billed charges,,,55,,597.3,percent of total billed charges,,,65,,705.9,percent of total billed charges,,,78,,847.08,percent of total billed charges,,,70,,760.2,percent of total billed charges,,,,,,,,365.32,,,,100% of Medicare,,365.32,,,,100% of Medicare,,365.32,,,,100% of Medicare,,365.32,,,,100% of Medicare,,365.32,,,,100% of Medicare,,365.32,,,,100% of Medicare,,365.32,,,,100% of Medicare,,365.32,,,,100% of Medicare,,365.32,,,,100% of Medicare,,365.32,,,,100% of Medicare,,365.32,,,,100% of Medicare,,365.32,,,,100% of Medicare,,,365.32,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,365.32,977.4,
"Addition to LE, BK, thigh lacer, gluteal/ischial, molded",L5682,HCPCS,,,,outpatient,,,2169,1301.4,,45.5,,986.9,percent of total billed charges,,,45.3,,982.56,percent of total billed charges,,,39,,845.91,percent of total billed charges,,,,,,,,,80,,1735.2,percent of total billed charges,,,61.4,,1331.77,percent of total billed charges,,,57.4,,1245.01,percent of total billed charges,,,81,,1756.89,percent of total billed charges,,,39,,845.91,percent of total billed charges,,,57.6,,1249.34,percent of total billed charges,,,85,,1843.65,percent of total billed charges,,,85,,1843.65,percent of total billed charges,,,49,,1062.81,percent of total billed charges,,,90,,1952.1,percent of total billed charges,,,65,,1409.85,percent of total billed charges,,,80,,1735.2,percent of total billed charges,,,55,,1192.95,percent of total billed charges,,,55,,1192.95,percent of total billed charges,,,65,,1409.85,percent of total billed charges,,,78,,1691.82,percent of total billed charges,,,70,,1518.3,percent of total billed charges,,,,,,,,750.62,,,,100% of Medicare,,750.62,,,,100% of Medicare,,750.62,,,,100% of Medicare,,750.62,,,,100% of Medicare,,750.62,,,,100% of Medicare,,750.62,,,,100% of Medicare,,750.62,,,,100% of Medicare,,750.62,,,,100% of Medicare,,750.62,,,,100% of Medicare,,750.62,,,,100% of Medicare,,750.62,,,,100% of Medicare,,750.62,,,,100% of Medicare,,,750.62,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,750.62,1952.1,
"Addition to LE, BK, fork strap",L5684,HCPCS,,,,outpatient,,,166,99.6,,45.5,,75.53,percent of total billed charges,,,45.3,,75.2,percent of total billed charges,,,39,,64.74,percent of total billed charges,,,,,,,,,80,,132.8,percent of total billed charges,,,61.4,,101.92,percent of total billed charges,,,57.4,,95.28,percent of total billed charges,,,81,,134.46,percent of total billed charges,,,39,,64.74,percent of total billed charges,,,57.6,,95.62,percent of total billed charges,,,85,,141.1,percent of total billed charges,,,85,,141.1,percent of total billed charges,,,49,,81.34,percent of total billed charges,,,90,,149.4,percent of total billed charges,,,65,,107.9,percent of total billed charges,,,80,,132.8,percent of total billed charges,,,55,,91.3,percent of total billed charges,,,55,,91.3,percent of total billed charges,,,65,,107.9,percent of total billed charges,,,78,,129.48,percent of total billed charges,,,70,,116.2,percent of total billed charges,,,,,,,,57.77,,,,100% of Medicare,,57.77,,,,100% of Medicare,,57.77,,,,100% of Medicare,,57.77,,,,100% of Medicare,,57.77,,,,100% of Medicare,,57.77,,,,100% of Medicare,,57.77,,,,100% of Medicare,,57.77,,,,100% of Medicare,,57.77,,,,100% of Medicare,,57.77,,,,100% of Medicare,,57.77,,,,100% of Medicare,,57.77,,,,100% of Medicare,,,57.77,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,57.77,149.4,
"Addition to LE, BK, suspension/sealing sleeve, w/ or w/out valve, any material, each",L5685,HCPCS,,,,outpatient,,,448,268.8,,45.5,,203.84,percent of total billed charges,,,45.3,,202.94,percent of total billed charges,,,39,,174.72,percent of total billed charges,,,,,,,,,80,,358.4,percent of total billed charges,,,61.4,,275.07,percent of total billed charges,,,57.4,,257.15,percent of total billed charges,,,81,,362.88,percent of total billed charges,,,39,,174.72,percent of total billed charges,,,57.6,,258.05,percent of total billed charges,,,85,,380.8,percent of total billed charges,,,85,,380.8,percent of total billed charges,,,49,,219.52,percent of total billed charges,,,90,,403.2,percent of total billed charges,,,65,,291.2,percent of total billed charges,,,80,,358.4,percent of total billed charges,,,55,,246.4,percent of total billed charges,,,55,,246.4,percent of total billed charges,,,65,,291.2,percent of total billed charges,,,78,,349.44,percent of total billed charges,,,70,,313.6,percent of total billed charges,,,,,,,,154.65,,,,100% of Medicare,,154.65,,,,100% of Medicare,,154.65,,,,100% of Medicare,,154.65,,,,100% of Medicare,,154.65,,,,100% of Medicare,,154.65,,,,100% of Medicare,,154.65,,,,100% of Medicare,,154.65,,,,100% of Medicare,,154.65,,,,100% of Medicare,,154.65,,,,100% of Medicare,,154.65,,,,100% of Medicare,,154.65,,,,100% of Medicare,,,154.65,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,154.65,403.2,
"Addition to LE, BK, back check (extension control)",L5686,HCPCS,,,,outpatient,,,204,122.4,,45.5,,92.82,percent of total billed charges,,,45.3,,92.41,percent of total billed charges,,,39,,79.56,percent of total billed charges,,,,,,,,,80,,163.2,percent of total billed charges,,,61.4,,125.26,percent of total billed charges,,,57.4,,117.1,percent of total billed charges,,,81,,165.24,percent of total billed charges,,,39,,79.56,percent of total billed charges,,,57.6,,117.5,percent of total billed charges,,,85,,173.4,percent of total billed charges,,,85,,173.4,percent of total billed charges,,,49,,99.96,percent of total billed charges,,,90,,183.6,percent of total billed charges,,,65,,132.6,percent of total billed charges,,,80,,163.2,percent of total billed charges,,,55,,112.2,percent of total billed charges,,,55,,112.2,percent of total billed charges,,,65,,132.6,percent of total billed charges,,,78,,159.12,percent of total billed charges,,,70,,142.8,percent of total billed charges,,,,,,,,69.48,,,,100% of Medicare,,69.48,,,,100% of Medicare,,69.48,,,,100% of Medicare,,69.48,,,,100% of Medicare,,69.48,,,,100% of Medicare,,69.48,,,,100% of Medicare,,69.48,,,,100% of Medicare,,69.48,,,,100% of Medicare,,69.48,,,,100% of Medicare,,69.48,,,,100% of Medicare,,69.48,,,,100% of Medicare,,69.48,,,,100% of Medicare,,,69.48,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,69.48,183.6,
"Addition to LE, BK, waist belt, webbing",L5688,HCPCS,,,,outpatient,,,214,128.4,,45.5,,97.37,percent of total billed charges,,,45.3,,96.94,percent of total billed charges,,,39,,83.46,percent of total billed charges,,,,,,,,,80,,171.2,percent of total billed charges,,,61.4,,131.4,percent of total billed charges,,,57.4,,122.84,percent of total billed charges,,,81,,173.34,percent of total billed charges,,,39,,83.46,percent of total billed charges,,,57.6,,123.26,percent of total billed charges,,,85,,181.9,percent of total billed charges,,,85,,181.9,percent of total billed charges,,,49,,104.86,percent of total billed charges,,,90,,192.6,percent of total billed charges,,,65,,139.1,percent of total billed charges,,,80,,171.2,percent of total billed charges,,,55,,117.7,percent of total billed charges,,,55,,117.7,percent of total billed charges,,,65,,139.1,percent of total billed charges,,,78,,166.92,percent of total billed charges,,,70,,149.8,percent of total billed charges,,,,,,,,73.8,,,,100% of Medicare,,73.8,,,,100% of Medicare,,73.8,,,,100% of Medicare,,73.8,,,,100% of Medicare,,73.8,,,,100% of Medicare,,73.8,,,,100% of Medicare,,73.8,,,,100% of Medicare,,73.8,,,,100% of Medicare,,73.8,,,,100% of Medicare,,73.8,,,,100% of Medicare,,73.8,,,,100% of Medicare,,73.8,,,,100% of Medicare,,,73.8,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,73.8,192.6,
"Addition to LE, BK, waist belt, padded and lined",L5690,HCPCS,,,,outpatient,,,436,261.6,,45.5,,198.38,percent of total billed charges,,,45.3,,197.51,percent of total billed charges,,,39,,170.04,percent of total billed charges,,,,,,,,,80,,348.8,percent of total billed charges,,,61.4,,267.7,percent of total billed charges,,,57.4,,250.26,percent of total billed charges,,,81,,353.16,percent of total billed charges,,,39,,170.04,percent of total billed charges,,,57.6,,251.14,percent of total billed charges,,,85,,370.6,percent of total billed charges,,,85,,370.6,percent of total billed charges,,,49,,213.64,percent of total billed charges,,,90,,392.4,percent of total billed charges,,,65,,283.4,percent of total billed charges,,,80,,348.8,percent of total billed charges,,,55,,239.8,percent of total billed charges,,,55,,239.8,percent of total billed charges,,,65,,283.4,percent of total billed charges,,,78,,340.08,percent of total billed charges,,,70,,305.2,percent of total billed charges,,,,,,,,150.64,,,,100% of Medicare,,150.64,,,,100% of Medicare,,150.64,,,,100% of Medicare,,150.64,,,,100% of Medicare,,150.64,,,,100% of Medicare,,150.64,,,,100% of Medicare,,150.64,,,,100% of Medicare,,150.64,,,,100% of Medicare,,150.64,,,,100% of Medicare,,150.64,,,,100% of Medicare,,150.64,,,,100% of Medicare,,150.64,,,,100% of Medicare,,,150.64,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,150.64,392.4,
"Addition to LE, AK, pelvic control belt, light",L5692,HCPCS,,,,outpatient,,,458,274.8,,45.5,,208.39,percent of total billed charges,,,45.3,,207.47,percent of total billed charges,,,39,,178.62,percent of total billed charges,,,,,,,,,80,,366.4,percent of total billed charges,,,61.4,,281.21,percent of total billed charges,,,57.4,,262.89,percent of total billed charges,,,81,,370.98,percent of total billed charges,,,39,,178.62,percent of total billed charges,,,57.6,,263.81,percent of total billed charges,,,85,,389.3,percent of total billed charges,,,85,,389.3,percent of total billed charges,,,49,,224.42,percent of total billed charges,,,90,,412.2,percent of total billed charges,,,65,,297.7,percent of total billed charges,,,80,,366.4,percent of total billed charges,,,55,,251.9,percent of total billed charges,,,55,,251.9,percent of total billed charges,,,65,,297.7,percent of total billed charges,,,78,,357.24,percent of total billed charges,,,70,,320.6,percent of total billed charges,,,,,,,,159.48,,,,100% of Medicare,,159.48,,,,100% of Medicare,,159.48,,,,100% of Medicare,,159.48,,,,100% of Medicare,,159.48,,,,100% of Medicare,,159.48,,,,100% of Medicare,,159.48,,,,100% of Medicare,,159.48,,,,100% of Medicare,,159.48,,,,100% of Medicare,,159.48,,,,100% of Medicare,,159.48,,,,100% of Medicare,,159.48,,,,100% of Medicare,,,159.48,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,159.48,412.2,
"Addition to LE, AK, pelvic control belt, padded and lined",L5694,HCPCS,,,,outpatient,,,848,508.8,,45.5,,385.84,percent of total billed charges,,,45.3,,384.14,percent of total billed charges,,,39,,330.72,percent of total billed charges,,,,,,,,,80,,678.4,percent of total billed charges,,,61.4,,520.67,percent of total billed charges,,,57.4,,486.75,percent of total billed charges,,,81,,686.88,percent of total billed charges,,,39,,330.72,percent of total billed charges,,,57.6,,488.45,percent of total billed charges,,,85,,720.8,percent of total billed charges,,,85,,720.8,percent of total billed charges,,,49,,415.52,percent of total billed charges,,,90,,763.2,percent of total billed charges,,,65,,551.2,percent of total billed charges,,,80,,678.4,percent of total billed charges,,,55,,466.4,percent of total billed charges,,,55,,466.4,percent of total billed charges,,,65,,551.2,percent of total billed charges,,,78,,661.44,percent of total billed charges,,,70,,593.6,percent of total billed charges,,,,,,,,217.74,,,,100% of Medicare,,217.74,,,,100% of Medicare,,217.74,,,,100% of Medicare,,217.74,,,,100% of Medicare,,217.74,,,,100% of Medicare,,217.74,,,,100% of Medicare,,217.74,,,,100% of Medicare,,217.74,,,,100% of Medicare,,217.74,,,,100% of Medicare,,217.74,,,,100% of Medicare,,217.74,,,,100% of Medicare,,217.74,,,,100% of Medicare,,,217.74,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,217.74,763.2,
"Addition to LE, AK, pelvic control, sleeve suspension, neoprene or equal, each",L5695,HCPCS,,,,outpatient,,,782,469.2,,45.5,,355.81,percent of total billed charges,,,45.3,,354.25,percent of total billed charges,,,39,,304.98,percent of total billed charges,,,,,,,,,80,,625.6,percent of total billed charges,,,61.4,,480.15,percent of total billed charges,,,57.4,,448.87,percent of total billed charges,,,81,,633.42,percent of total billed charges,,,39,,304.98,percent of total billed charges,,,57.6,,450.43,percent of total billed charges,,,85,,664.7,percent of total billed charges,,,85,,664.7,percent of total billed charges,,,49,,383.18,percent of total billed charges,,,90,,703.8,percent of total billed charges,,,65,,508.3,percent of total billed charges,,,80,,625.6,percent of total billed charges,,,55,,430.1,percent of total billed charges,,,55,,430.1,percent of total billed charges,,,65,,508.3,percent of total billed charges,,,78,,609.96,percent of total billed charges,,,70,,547.4,percent of total billed charges,,,,,,,,195.73,,,,100% of Medicare,,195.73,,,,100% of Medicare,,195.73,,,,100% of Medicare,,195.73,,,,100% of Medicare,,195.73,,,,100% of Medicare,,195.73,,,,100% of Medicare,,195.73,,,,100% of Medicare,,195.73,,,,100% of Medicare,,195.73,,,,100% of Medicare,,195.73,,,,100% of Medicare,,195.73,,,,100% of Medicare,,195.73,,,,100% of Medicare,,,195.73,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,195.73,703.8,
"Addition to LE, AK or knee disartic, pelvic joint",L5696,HCPCS,,,,outpatient,,,683,409.8,,45.5,,310.77,percent of total billed charges,,,45.3,,309.4,percent of total billed charges,,,39,,266.37,percent of total billed charges,,,,,,,,,80,,546.4,percent of total billed charges,,,61.4,,419.36,percent of total billed charges,,,57.4,,392.04,percent of total billed charges,,,81,,553.23,percent of total billed charges,,,39,,266.37,percent of total billed charges,,,57.6,,393.41,percent of total billed charges,,,85,,580.55,percent of total billed charges,,,85,,580.55,percent of total billed charges,,,49,,334.67,percent of total billed charges,,,90,,614.7,percent of total billed charges,,,65,,443.95,percent of total billed charges,,,80,,546.4,percent of total billed charges,,,55,,375.65,percent of total billed charges,,,55,,375.65,percent of total billed charges,,,65,,443.95,percent of total billed charges,,,78,,532.74,percent of total billed charges,,,70,,478.1,percent of total billed charges,,,,,,,,236.44,,,,100% of Medicare,,236.44,,,,100% of Medicare,,236.44,,,,100% of Medicare,,236.44,,,,100% of Medicare,,236.44,,,,100% of Medicare,,236.44,,,,100% of Medicare,,236.44,,,,100% of Medicare,,236.44,,,,100% of Medicare,,236.44,,,,100% of Medicare,,236.44,,,,100% of Medicare,,236.44,,,,100% of Medicare,,236.44,,,,100% of Medicare,,,236.44,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,236.44,614.7,
"Addition to LE, AK or knee disarticulation, pelvic band",L5697,HCPCS,,,,outpatient,,,323,193.8,,45.5,,146.97,percent of total billed charges,,,45.3,,146.32,percent of total billed charges,,,39,,125.97,percent of total billed charges,,,,,,,,,80,,258.4,percent of total billed charges,,,61.4,,198.32,percent of total billed charges,,,57.4,,185.4,percent of total billed charges,,,81,,261.63,percent of total billed charges,,,39,,125.97,percent of total billed charges,,,57.6,,186.05,percent of total billed charges,,,85,,274.55,percent of total billed charges,,,85,,274.55,percent of total billed charges,,,49,,158.27,percent of total billed charges,,,90,,290.7,percent of total billed charges,,,65,,209.95,percent of total billed charges,,,80,,258.4,percent of total billed charges,,,55,,177.65,percent of total billed charges,,,55,,177.65,percent of total billed charges,,,65,,209.95,percent of total billed charges,,,78,,251.94,percent of total billed charges,,,70,,226.1,percent of total billed charges,,,,,,,,112.28,,,,100% of Medicare,,112.28,,,,100% of Medicare,,112.28,,,,100% of Medicare,,112.28,,,,100% of Medicare,,112.28,,,,100% of Medicare,,112.28,,,,100% of Medicare,,112.28,,,,100% of Medicare,,112.28,,,,100% of Medicare,,112.28,,,,100% of Medicare,,112.28,,,,100% of Medicare,,112.28,,,,100% of Medicare,,112.28,,,,100% of Medicare,,,112.28,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,112.28,290.7,
"Addition to LE, AK or knee disartic, Silesian bandage",L5698,HCPCS,,,,outpatient,,,558,334.8,,45.5,,253.89,percent of total billed charges,,,45.3,,252.77,percent of total billed charges,,,39,,217.62,percent of total billed charges,,,,,,,,,80,,446.4,percent of total billed charges,,,61.4,,342.61,percent of total billed charges,,,57.4,,320.29,percent of total billed charges,,,81,,451.98,percent of total billed charges,,,39,,217.62,percent of total billed charges,,,57.6,,321.41,percent of total billed charges,,,85,,474.3,percent of total billed charges,,,85,,474.3,percent of total billed charges,,,49,,273.42,percent of total billed charges,,,90,,502.2,percent of total billed charges,,,65,,362.7,percent of total billed charges,,,80,,446.4,percent of total billed charges,,,55,,306.9,percent of total billed charges,,,55,,306.9,percent of total billed charges,,,65,,362.7,percent of total billed charges,,,78,,435.24,percent of total billed charges,,,70,,390.6,percent of total billed charges,,,,,,,,144.04,,,,100% of Medicare,,144.04,,,,100% of Medicare,,144.04,,,,100% of Medicare,,144.04,,,,100% of Medicare,,144.04,,,,100% of Medicare,,144.04,,,,100% of Medicare,,144.04,,,,100% of Medicare,,144.04,,,,100% of Medicare,,144.04,,,,100% of Medicare,,144.04,,,,100% of Medicare,,144.04,,,,100% of Medicare,,144.04,,,,100% of Medicare,,,144.04,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,144.04,502.2,
"Addition to LE, shoulder harness",L5699,HCPCS,,,,outpatient,,,570,342,,45.5,,259.35,percent of total billed charges,,,45.3,,258.21,percent of total billed charges,,,39,,222.3,percent of total billed charges,,,,,,,,,80,,456,percent of total billed charges,,,61.4,,349.98,percent of total billed charges,,,57.4,,327.18,percent of total billed charges,,,81,,461.7,percent of total billed charges,,,39,,222.3,percent of total billed charges,,,57.6,,328.32,percent of total billed charges,,,85,,484.5,percent of total billed charges,,,85,,484.5,percent of total billed charges,,,49,,279.3,percent of total billed charges,,,90,,513,percent of total billed charges,,,65,,370.5,percent of total billed charges,,,80,,456,percent of total billed charges,,,55,,313.5,percent of total billed charges,,,55,,313.5,percent of total billed charges,,,65,,370.5,percent of total billed charges,,,78,,444.6,percent of total billed charges,,,70,,399,percent of total billed charges,,,,,,,,246.18,,,,100% of Medicare,,246.18,,,,100% of Medicare,,246.18,,,,100% of Medicare,,246.18,,,,100% of Medicare,,246.18,,,,100% of Medicare,,246.18,,,,100% of Medicare,,246.18,,,,100% of Medicare,,246.18,,,,100% of Medicare,,246.18,,,,100% of Medicare,,246.18,,,,100% of Medicare,,246.18,,,,100% of Medicare,,246.18,,,,100% of Medicare,,,246.18,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,222.3,513,
"Custom shaped protective cover, BK",L5704,HCPCS,,,,outpatient,,,2916,1749.6,,45.5,,1326.78,percent of total billed charges,,,45.3,,1320.95,percent of total billed charges,,,39,,1137.24,percent of total billed charges,,,,,,,,,80,,2332.8,percent of total billed charges,,,61.4,,1790.42,percent of total billed charges,,,57.4,,1673.78,percent of total billed charges,,,81,,2361.96,percent of total billed charges,,,39,,1137.24,percent of total billed charges,,,57.6,,1679.62,percent of total billed charges,,,85,,2478.6,percent of total billed charges,,,85,,2478.6,percent of total billed charges,,,49,,1428.84,percent of total billed charges,,,90,,2624.4,percent of total billed charges,,,65,,1895.4,percent of total billed charges,,,80,,2332.8,percent of total billed charges,,,55,,1603.8,percent of total billed charges,,,55,,1603.8,percent of total billed charges,,,65,,1895.4,percent of total billed charges,,,78,,2274.48,percent of total billed charges,,,70,,2041.2,percent of total billed charges,,,,,,,,755.01,,,,100% of Medicare,,755.01,,,,100% of Medicare,,755.01,,,,100% of Medicare,,755.01,,,,100% of Medicare,,755.01,,,,100% of Medicare,,755.01,,,,100% of Medicare,,755.01,,,,100% of Medicare,,755.01,,,,100% of Medicare,,755.01,,,,100% of Medicare,,755.01,,,,100% of Medicare,,755.01,,,,100% of Medicare,,755.01,,,,100% of Medicare,,,755.01,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,755.01,2624.4,
"Addition, exo knee-shin sys, single axis, manual lock",L5710,HCPCS,,,,outpatient,,,1001,600.6,,45.5,,455.46,percent of total billed charges,,,45.3,,453.45,percent of total billed charges,,,39,,390.39,percent of total billed charges,,,,,,,,,80,,800.8,percent of total billed charges,,,61.4,,614.61,percent of total billed charges,,,57.4,,574.57,percent of total billed charges,,,81,,810.81,percent of total billed charges,,,39,,390.39,percent of total billed charges,,,57.6,,576.58,percent of total billed charges,,,85,,850.85,percent of total billed charges,,,85,,850.85,percent of total billed charges,,,49,,490.49,percent of total billed charges,,,90,,900.9,percent of total billed charges,,,65,,650.65,percent of total billed charges,,,80,,800.8,percent of total billed charges,,,55,,550.55,percent of total billed charges,,,55,,550.55,percent of total billed charges,,,65,,650.65,percent of total billed charges,,,78,,780.78,percent of total billed charges,,,70,,700.7,percent of total billed charges,,,,,,,,431.68,,,,100% of Medicare,,431.68,,,,100% of Medicare,,431.68,,,,100% of Medicare,,431.68,,,,100% of Medicare,,431.68,,,,100% of Medicare,,431.68,,,,100% of Medicare,,431.68,,,,100% of Medicare,,431.68,,,,100% of Medicare,,431.68,,,,100% of Medicare,,431.68,,,,100% of Medicare,,431.68,,,,100% of Medicare,,431.68,,,,100% of Medicare,,,431.68,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,390.39,900.9,
"Addition, exo knee-shin sys, single axis, manual lock, ultralight material",L5711,HCPCS,,,,outpatient,,,1683,1009.8,,45.5,,765.77,percent of total billed charges,,,45.3,,762.4,percent of total billed charges,,,39,,656.37,percent of total billed charges,,,,,,,,,80,,1346.4,percent of total billed charges,,,61.4,,1033.36,percent of total billed charges,,,57.4,,966.04,percent of total billed charges,,,81,,1363.23,percent of total billed charges,,,39,,656.37,percent of total billed charges,,,57.6,,969.41,percent of total billed charges,,,85,,1430.55,percent of total billed charges,,,85,,1430.55,percent of total billed charges,,,49,,824.67,percent of total billed charges,,,90,,1514.7,percent of total billed charges,,,65,,1093.95,percent of total billed charges,,,80,,1346.4,percent of total billed charges,,,55,,925.65,percent of total billed charges,,,55,,925.65,percent of total billed charges,,,65,,1093.95,percent of total billed charges,,,78,,1312.74,percent of total billed charges,,,70,,1178.1,percent of total billed charges,,,,,,,,724.48,,,,100% of Medicare,,724.48,,,,100% of Medicare,,724.48,,,,100% of Medicare,,724.48,,,,100% of Medicare,,724.48,,,,100% of Medicare,,724.48,,,,100% of Medicare,,724.48,,,,100% of Medicare,,724.48,,,,100% of Medicare,,724.48,,,,100% of Medicare,,724.48,,,,100% of Medicare,,724.48,,,,100% of Medicare,,724.48,,,,100% of Medicare,,,724.48,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,656.37,1514.7,
"Addition, exo knee-shin sys, single axis, friction swing and stance (safety knee)",L5712,HCPCS,,,,outpatient,,,1200,720,,45.5,,546,percent of total billed charges,,,45.3,,543.6,percent of total billed charges,,,39,,468,percent of total billed charges,,,,,,,,,80,,960,percent of total billed charges,,,61.4,,736.8,percent of total billed charges,,,57.4,,688.8,percent of total billed charges,,,81,,972,percent of total billed charges,,,39,,468,percent of total billed charges,,,57.6,,691.2,percent of total billed charges,,,85,,1020,percent of total billed charges,,,85,,1020,percent of total billed charges,,,49,,588,percent of total billed charges,,,90,,1080,percent of total billed charges,,,65,,780,percent of total billed charges,,,80,,960,percent of total billed charges,,,55,,660,percent of total billed charges,,,55,,660,percent of total billed charges,,,65,,780,percent of total billed charges,,,78,,936,percent of total billed charges,,,70,,840,percent of total billed charges,,,,,,,,517.18,,,,100% of Medicare,,517.18,,,,100% of Medicare,,517.18,,,,100% of Medicare,,517.18,,,,100% of Medicare,,517.18,,,,100% of Medicare,,517.18,,,,100% of Medicare,,517.18,,,,100% of Medicare,,517.18,,,,100% of Medicare,,517.18,,,,100% of Medicare,,517.18,,,,100% of Medicare,,517.18,,,,100% of Medicare,,517.18,,,,100% of Medicare,,,517.18,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,468,1080,
"Addition, exo knee-shin sys, single axis, variable friction swing",L5714,HCPCS,,,,outpatient,,,1223,733.8,,45.5,,556.47,percent of total billed charges,,,45.3,,554.02,percent of total billed charges,,,39,,476.97,percent of total billed charges,,,,,,,,,80,,978.4,percent of total billed charges,,,61.4,,750.92,percent of total billed charges,,,57.4,,702,percent of total billed charges,,,81,,990.63,percent of total billed charges,,,39,,476.97,percent of total billed charges,,,57.6,,704.45,percent of total billed charges,,,85,,1039.55,percent of total billed charges,,,85,,1039.55,percent of total billed charges,,,49,,599.27,percent of total billed charges,,,90,,1100.7,percent of total billed charges,,,65,,794.95,percent of total billed charges,,,80,,978.4,percent of total billed charges,,,55,,672.65,percent of total billed charges,,,55,,672.65,percent of total billed charges,,,65,,794.95,percent of total billed charges,,,78,,953.94,percent of total billed charges,,,70,,856.1,percent of total billed charges,,,,,,,,526.23,,,,100% of Medicare,,526.23,,,,100% of Medicare,,526.23,,,,100% of Medicare,,526.23,,,,100% of Medicare,,526.23,,,,100% of Medicare,,526.23,,,,100% of Medicare,,526.23,,,,100% of Medicare,,526.23,,,,100% of Medicare,,526.23,,,,100% of Medicare,,526.23,,,,100% of Medicare,,526.23,,,,100% of Medicare,,526.23,,,,100% of Medicare,,,526.23,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,476.97,1100.7,
"Addition, exo knee-shin sys, polycentric mechanical stance phase lock",L5716,HCPCS,,,,outpatient,,,2414,1448.4,,45.5,,1098.37,percent of total billed charges,,,45.3,,1093.54,percent of total billed charges,,,39,,941.46,percent of total billed charges,,,,,,,,,80,,1931.2,percent of total billed charges,,,61.4,,1482.2,percent of total billed charges,,,57.4,,1385.64,percent of total billed charges,,,81,,1955.34,percent of total billed charges,,,39,,941.46,percent of total billed charges,,,57.6,,1390.46,percent of total billed charges,,,85,,2051.9,percent of total billed charges,,,85,,2051.9,percent of total billed charges,,,49,,1182.86,percent of total billed charges,,,90,,2172.6,percent of total billed charges,,,65,,1569.1,percent of total billed charges,,,80,,1931.2,percent of total billed charges,,,55,,1327.7,percent of total billed charges,,,55,,1327.7,percent of total billed charges,,,65,,1569.1,percent of total billed charges,,,78,,1882.92,percent of total billed charges,,,70,,1689.8,percent of total billed charges,,,,,,,,1040.55,,,,100% of Medicare,,1040.55,,,,100% of Medicare,,1040.55,,,,100% of Medicare,,1040.55,,,,100% of Medicare,,1040.55,,,,100% of Medicare,,1040.55,,,,100% of Medicare,,1040.55,,,,100% of Medicare,,1040.55,,,,100% of Medicare,,1040.55,,,,100% of Medicare,,1040.55,,,,100% of Medicare,,1040.55,,,,100% of Medicare,,1040.55,,,,100% of Medicare,,,1040.55,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,941.46,2172.6,
"Addition, exo knee-shin sys, polycentric, friction swing and stance",L5718,HCPCS,,,,outpatient,,,2582,1549.2,,45.5,,1174.81,percent of total billed charges,,,45.3,,1169.65,percent of total billed charges,,,39,,1006.98,percent of total billed charges,,,,,,,,,80,,2065.6,percent of total billed charges,,,61.4,,1585.35,percent of total billed charges,,,57.4,,1482.07,percent of total billed charges,,,81,,2091.42,percent of total billed charges,,,39,,1006.98,percent of total billed charges,,,57.6,,1487.23,percent of total billed charges,,,85,,2194.7,percent of total billed charges,,,85,,2194.7,percent of total billed charges,,,49,,1265.18,percent of total billed charges,,,90,,2323.8,percent of total billed charges,,,65,,1678.3,percent of total billed charges,,,80,,2065.6,percent of total billed charges,,,55,,1420.1,percent of total billed charges,,,55,,1420.1,percent of total billed charges,,,65,,1678.3,percent of total billed charges,,,78,,2013.96,percent of total billed charges,,,70,,1807.4,percent of total billed charges,,,,,,,,1112.67,,,,100% of Medicare,,1112.67,,,,100% of Medicare,,1112.67,,,,100% of Medicare,,1112.67,,,,100% of Medicare,,1112.67,,,,100% of Medicare,,1112.67,,,,100% of Medicare,,1112.67,,,,100% of Medicare,,1112.67,,,,100% of Medicare,,1112.67,,,,100% of Medicare,,1112.67,,,,100% of Medicare,,1112.67,,,,100% of Medicare,,1112.67,,,,100% of Medicare,,,1112.67,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1006.98,2323.8,
"Addition, exo knee-shin sys, single axis, pneumatic swing, friction stance",L5722,HCPCS,,,,outpatient,,,3140,1884,,45.5,,1428.7,percent of total billed charges,,,45.3,,1422.42,percent of total billed charges,,,39,,1224.6,percent of total billed charges,,,,,,,,,80,,2512,percent of total billed charges,,,61.4,,1927.96,percent of total billed charges,,,57.4,,1802.36,percent of total billed charges,,,81,,2543.4,percent of total billed charges,,,39,,1224.6,percent of total billed charges,,,57.6,,1808.64,percent of total billed charges,,,85,,2669,percent of total billed charges,,,85,,2669,percent of total billed charges,,,49,,1538.6,percent of total billed charges,,,90,,2826,percent of total billed charges,,,65,,2041,percent of total billed charges,,,80,,2512,percent of total billed charges,,,55,,1727,percent of total billed charges,,,55,,1727,percent of total billed charges,,,65,,2041,percent of total billed charges,,,78,,2449.2,percent of total billed charges,,,70,,2198,percent of total billed charges,,,,,,,,1353.09,,,,100% of Medicare,,1353.09,,,,100% of Medicare,,1353.09,,,,100% of Medicare,,1353.09,,,,100% of Medicare,,1353.09,,,,100% of Medicare,,1353.09,,,,100% of Medicare,,1353.09,,,,100% of Medicare,,1353.09,,,,100% of Medicare,,1353.09,,,,100% of Medicare,,1353.09,,,,100% of Medicare,,1353.09,,,,100% of Medicare,,1353.09,,,,100% of Medicare,,,1353.09,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1224.6,2826,
"Addition, exo knee-shin sys, single axis, pneumatic/hydraulic swing",L5780,HCPCS,,,,outpatient,,,3720,2232,,45.5,,1692.6,percent of total billed charges,,,45.3,,1685.16,percent of total billed charges,,,39,,1450.8,percent of total billed charges,,,,,,,,,80,,2976,percent of total billed charges,,,61.4,,2284.08,percent of total billed charges,,,57.4,,2135.28,percent of total billed charges,,,81,,3013.2,percent of total billed charges,,,39,,1450.8,percent of total billed charges,,,57.6,,2142.72,percent of total billed charges,,,85,,3162,percent of total billed charges,,,85,,3162,percent of total billed charges,,,49,,1822.8,percent of total billed charges,,,90,,3348,percent of total billed charges,,,65,,2418,percent of total billed charges,,,80,,2976,percent of total billed charges,,,55,,2046,percent of total billed charges,,,55,,2046,percent of total billed charges,,,65,,2418,percent of total billed charges,,,78,,2901.6,percent of total billed charges,,,70,,2604,percent of total billed charges,,,,,,,,1602.03,,,,100% of Medicare,,1602.03,,,,100% of Medicare,,1602.03,,,,100% of Medicare,,1602.03,,,,100% of Medicare,,1602.03,,,,100% of Medicare,,1602.03,,,,100% of Medicare,,1602.03,,,,100% of Medicare,,1602.03,,,,100% of Medicare,,1602.03,,,,100% of Medicare,,1602.03,,,,100% of Medicare,,1602.03,,,,100% of Medicare,,1602.03,,,,100% of Medicare,,,1602.03,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1450.8,3348,
"Addition, exo sys,  BK, ultra-light material (titanium, carbon fiber or equal)",L5785,HCPCS,,,,outpatient,,,1980,1188,,45.5,,900.9,percent of total billed charges,,,45.3,,896.94,percent of total billed charges,,,39,,772.2,percent of total billed charges,,,,,,,,,80,,1584,percent of total billed charges,,,61.4,,1215.72,percent of total billed charges,,,57.4,,1136.52,percent of total billed charges,,,81,,1603.8,percent of total billed charges,,,39,,772.2,percent of total billed charges,,,57.6,,1140.48,percent of total billed charges,,,85,,1683,percent of total billed charges,,,85,,1683,percent of total billed charges,,,49,,970.2,percent of total billed charges,,,90,,1782,percent of total billed charges,,,65,,1287,percent of total billed charges,,,80,,1584,percent of total billed charges,,,55,,1089,percent of total billed charges,,,55,,1089,percent of total billed charges,,,65,,1287,percent of total billed charges,,,78,,1544.4,percent of total billed charges,,,70,,1386,percent of total billed charges,,,,,,,,623.59,,,,100% of Medicare,,623.59,,,,100% of Medicare,,623.59,,,,100% of Medicare,,623.59,,,,100% of Medicare,,623.59,,,,100% of Medicare,,623.59,,,,100% of Medicare,,623.59,,,,100% of Medicare,,623.59,,,,100% of Medicare,,623.59,,,,100% of Medicare,,623.59,,,,100% of Medicare,,623.59,,,,100% of Medicare,,623.59,,,,100% of Medicare,,,623.59,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,623.59,1782,
"Addition, exo sys, AK, ultra-light material (titanium, carbon fiber or equal)",L5790,HCPCS,,,,outpatient,,,2777,1666.2,,45.5,,1263.54,percent of total billed charges,,,45.3,,1257.98,percent of total billed charges,,,39,,1083.03,percent of total billed charges,,,,,,,,,80,,2221.6,percent of total billed charges,,,61.4,,1705.08,percent of total billed charges,,,57.4,,1594,percent of total billed charges,,,81,,2249.37,percent of total billed charges,,,39,,1083.03,percent of total billed charges,,,57.6,,1599.55,percent of total billed charges,,,85,,2360.45,percent of total billed charges,,,85,,2360.45,percent of total billed charges,,,49,,1360.73,percent of total billed charges,,,90,,2499.3,percent of total billed charges,,,65,,1805.05,percent of total billed charges,,,80,,2221.6,percent of total billed charges,,,55,,1527.35,percent of total billed charges,,,55,,1527.35,percent of total billed charges,,,65,,1805.05,percent of total billed charges,,,78,,2166.06,percent of total billed charges,,,70,,1943.9,percent of total billed charges,,,,,,,,899.99,,,,100% of Medicare,,899.99,,,,100% of Medicare,,899.99,,,,100% of Medicare,,899.99,,,,100% of Medicare,,899.99,,,,100% of Medicare,,899.99,,,,100% of Medicare,,899.99,,,,100% of Medicare,,899.99,,,,100% of Medicare,,899.99,,,,100% of Medicare,,899.99,,,,100% of Medicare,,899.99,,,,100% of Medicare,,899.99,,,,100% of Medicare,,,899.99,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,899.99,2499.3,
"Addition, exo sys, hip disartic, ultra-light material (titanium, carbon fiber or equal)",L5795,HCPCS,,,,outpatient,,,3724,2234.4,,45.5,,1694.42,percent of total billed charges,,,45.3,,1686.97,percent of total billed charges,,,39,,1452.36,percent of total billed charges,,,,,,,,,80,,2979.2,percent of total billed charges,,,61.4,,2286.54,percent of total billed charges,,,57.4,,2137.58,percent of total billed charges,,,81,,3016.44,percent of total billed charges,,,39,,1452.36,percent of total billed charges,,,57.6,,2145.02,percent of total billed charges,,,85,,3165.4,percent of total billed charges,,,85,,3165.4,percent of total billed charges,,,49,,1824.76,percent of total billed charges,,,90,,3351.6,percent of total billed charges,,,65,,2420.6,percent of total billed charges,,,80,,2979.2,percent of total billed charges,,,55,,2048.2,percent of total billed charges,,,55,,2048.2,percent of total billed charges,,,65,,2420.6,percent of total billed charges,,,78,,2904.72,percent of total billed charges,,,70,,2606.8,percent of total billed charges,,,,,,,,1288.69,,,,100% of Medicare,,1288.69,,,,100% of Medicare,,1288.69,,,,100% of Medicare,,1288.69,,,,100% of Medicare,,1288.69,,,,100% of Medicare,,1288.69,,,,100% of Medicare,,1288.69,,,,100% of Medicare,,1288.69,,,,100% of Medicare,,1288.69,,,,100% of Medicare,,1288.69,,,,100% of Medicare,,1288.69,,,,100% of Medicare,,1288.69,,,,100% of Medicare,,,1288.69,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1288.69,3351.6,
"Addition, endo knee-shin sys, single axis, manual lock",L5810,HCPCS,,,,outpatient,,,2041,1224.6,,45.5,,928.66,percent of total billed charges,,,45.3,,924.57,percent of total billed charges,,,39,,795.99,percent of total billed charges,,,,,,,,,80,,1632.8,percent of total billed charges,,,61.4,,1253.17,percent of total billed charges,,,57.4,,1171.53,percent of total billed charges,,,81,,1653.21,percent of total billed charges,,,39,,795.99,percent of total billed charges,,,57.6,,1175.62,percent of total billed charges,,,85,,1734.85,percent of total billed charges,,,85,,1734.85,percent of total billed charges,,,49,,1000.09,percent of total billed charges,,,90,,1836.9,percent of total billed charges,,,65,,1326.65,percent of total billed charges,,,80,,1632.8,percent of total billed charges,,,55,,1122.55,percent of total billed charges,,,55,,1122.55,percent of total billed charges,,,65,,1326.65,percent of total billed charges,,,78,,1591.98,percent of total billed charges,,,70,,1428.7,percent of total billed charges,,,,,,,,686.6,,,,100% of Medicare,,686.6,,,,100% of Medicare,,686.6,,,,100% of Medicare,,686.6,,,,100% of Medicare,,686.6,,,,100% of Medicare,,686.6,,,,100% of Medicare,,686.6,,,,100% of Medicare,,686.6,,,,100% of Medicare,,686.6,,,,100% of Medicare,,686.6,,,,100% of Medicare,,686.6,,,,100% of Medicare,,686.6,,,,100% of Medicare,,,686.6,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,686.6,1836.9,
"Addition, endo knee-shin sys, single axis, manual lock, ultra-light material",L5811,HCPCS,,,,outpatient,,,2817,1690.2,,45.5,,1281.74,percent of total billed charges,,,45.3,,1276.1,percent of total billed charges,,,39,,1098.63,percent of total billed charges,,,,,,,,,80,,2253.6,percent of total billed charges,,,61.4,,1729.64,percent of total billed charges,,,57.4,,1616.96,percent of total billed charges,,,81,,2281.77,percent of total billed charges,,,39,,1098.63,percent of total billed charges,,,57.6,,1622.59,percent of total billed charges,,,85,,2394.45,percent of total billed charges,,,85,,2394.45,percent of total billed charges,,,49,,1380.33,percent of total billed charges,,,90,,2535.3,percent of total billed charges,,,65,,1831.05,percent of total billed charges,,,80,,2253.6,percent of total billed charges,,,55,,1549.35,percent of total billed charges,,,55,,1549.35,percent of total billed charges,,,65,,1831.05,percent of total billed charges,,,78,,2197.26,percent of total billed charges,,,70,,1971.9,percent of total billed charges,,,,,,,,947.52,,,,100% of Medicare,,947.52,,,,100% of Medicare,,947.52,,,,100% of Medicare,,947.52,,,,100% of Medicare,,947.52,,,,100% of Medicare,,947.52,,,,100% of Medicare,,947.52,,,,100% of Medicare,,947.52,,,,100% of Medicare,,947.52,,,,100% of Medicare,,947.52,,,,100% of Medicare,,947.52,,,,100% of Medicare,,947.52,,,,100% of Medicare,,,947.52,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,947.52,2535.3,
"Addition, endo knee-shin sys, single axis, friction swing and stance (safety knee)",L5812,HCPCS,,,,outpatient,,,2117,1270.2,,45.5,,963.24,percent of total billed charges,,,45.3,,959,percent of total billed charges,,,39,,825.63,percent of total billed charges,,,,,,,,,80,,1693.6,percent of total billed charges,,,61.4,,1299.84,percent of total billed charges,,,57.4,,1215.16,percent of total billed charges,,,81,,1714.77,percent of total billed charges,,,39,,825.63,percent of total billed charges,,,57.6,,1219.39,percent of total billed charges,,,85,,1799.45,percent of total billed charges,,,85,,1799.45,percent of total billed charges,,,49,,1037.33,percent of total billed charges,,,90,,1905.3,percent of total billed charges,,,65,,1376.05,percent of total billed charges,,,80,,1693.6,percent of total billed charges,,,55,,1164.35,percent of total billed charges,,,55,,1164.35,percent of total billed charges,,,65,,1376.05,percent of total billed charges,,,78,,1651.26,percent of total billed charges,,,70,,1481.9,percent of total billed charges,,,,,,,,713.05,,,,100% of Medicare,,713.05,,,,100% of Medicare,,713.05,,,,100% of Medicare,,713.05,,,,100% of Medicare,,713.05,,,,100% of Medicare,,713.05,,,,100% of Medicare,,713.05,,,,100% of Medicare,,713.05,,,,100% of Medicare,,713.05,,,,100% of Medicare,,713.05,,,,100% of Medicare,,713.05,,,,100% of Medicare,,713.05,,,,100% of Medicare,,,713.05,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,713.05,1905.3,
"Addition, endo knee-shin sys, polycentric, mechanical stance phase lock",L5816,HCPCS,,,,outpatient,,,3036,1821.6,,45.5,,1381.38,percent of total billed charges,,,45.3,,1375.31,percent of total billed charges,,,39,,1184.04,percent of total billed charges,,,,,,,,,80,,2428.8,percent of total billed charges,,,61.4,,1864.1,percent of total billed charges,,,57.4,,1742.66,percent of total billed charges,,,81,,2459.16,percent of total billed charges,,,39,,1184.04,percent of total billed charges,,,57.6,,1748.74,percent of total billed charges,,,85,,2580.6,percent of total billed charges,,,85,,2580.6,percent of total billed charges,,,49,,1487.64,percent of total billed charges,,,90,,2732.4,percent of total billed charges,,,65,,1973.4,percent of total billed charges,,,80,,2428.8,percent of total billed charges,,,55,,1669.8,percent of total billed charges,,,55,,1669.8,percent of total billed charges,,,65,,1973.4,percent of total billed charges,,,78,,2368.08,percent of total billed charges,,,70,,2125.2,percent of total billed charges,,,,,,,,1020.74,,,,100% of Medicare,,1020.74,,,,100% of Medicare,,1020.74,,,,100% of Medicare,,1020.74,,,,100% of Medicare,,1020.74,,,,100% of Medicare,,1020.74,,,,100% of Medicare,,1020.74,,,,100% of Medicare,,1020.74,,,,100% of Medicare,,1020.74,,,,100% of Medicare,,1020.74,,,,100% of Medicare,,1020.74,,,,100% of Medicare,,1020.74,,,,100% of Medicare,,,1020.74,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1020.74,2732.4,
"Addition, endo knee-shin sys, polycentric, friction swing and stance",L5818,HCPCS,,,,outpatient,,,3332,1999.2,,45.5,,1516.06,percent of total billed charges,,,45.3,,1509.4,percent of total billed charges,,,39,,1299.48,percent of total billed charges,,,,,,,,,80,,2665.6,percent of total billed charges,,,61.4,,2045.85,percent of total billed charges,,,57.4,,1912.57,percent of total billed charges,,,81,,2698.92,percent of total billed charges,,,39,,1299.48,percent of total billed charges,,,57.6,,1919.23,percent of total billed charges,,,85,,2832.2,percent of total billed charges,,,85,,2832.2,percent of total billed charges,,,49,,1632.68,percent of total billed charges,,,90,,2998.8,percent of total billed charges,,,65,,2165.8,percent of total billed charges,,,80,,2665.6,percent of total billed charges,,,55,,1832.6,percent of total billed charges,,,55,,1832.6,percent of total billed charges,,,65,,2165.8,percent of total billed charges,,,78,,2598.96,percent of total billed charges,,,70,,2332.4,percent of total billed charges,,,,,,,,1152.62,,,,100% of Medicare,,1152.62,,,,100% of Medicare,,1152.62,,,,100% of Medicare,,1152.62,,,,100% of Medicare,,1152.62,,,,100% of Medicare,,1152.62,,,,100% of Medicare,,1152.62,,,,100% of Medicare,,1152.62,,,,100% of Medicare,,1152.62,,,,100% of Medicare,,1152.62,,,,100% of Medicare,,1152.62,,,,100% of Medicare,,1152.62,,,,100% of Medicare,,,1152.62,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1152.62,2998.8,
"Addition, endo knee, polycentric pneumatic swing and stance",L5841,HCPCS,,,,outpatient,,,2750,1650,,45.5,,1251.25,percent of total billed charges,,,45.3,,1245.75,percent of total billed charges,,,39,,1072.5,percent of total billed charges,,,,,,,,,80,,2200,percent of total billed charges,,,61.4,,1688.5,percent of total billed charges,,,57.4,,1578.5,percent of total billed charges,,,81,,2227.5,percent of total billed charges,,,39,,1072.5,percent of total billed charges,,,57.6,,1584,percent of total billed charges,,,85,,2337.5,percent of total billed charges,,,85,,2337.5,percent of total billed charges,,,49,,1347.5,percent of total billed charges,,,90,,2475,percent of total billed charges,,,65,,1787.5,percent of total billed charges,,,80,,2200,percent of total billed charges,,,55,,1512.5,percent of total billed charges,,,55,,1512.5,percent of total billed charges,,,65,,1787.5,percent of total billed charges,,,78,,2145,percent of total billed charges,,,70,,1925,percent of total billed charges,,,,,,,,2759.19,,,,100% of Medicare,,2759.19,,,,100% of Medicare,,2759.19,,,,100% of Medicare,,2759.19,,,,100% of Medicare,,2759.19,,,,100% of Medicare,,2759.19,,,,100% of Medicare,,2759.19,,,,100% of Medicare,,2759.19,,,,100% of Medicare,,2759.19,,,,100% of Medicare,,2759.19,,,,100% of Medicare,,2759.19,,,,100% of Medicare,,2759.19,,,,100% of Medicare,,,2759.19,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1072.5,2759.19,
"Addition, endo knee-shin sys, hydraulic stance extension, dampening feature, adj",L5848,HCPCS,,,,outpatient,,,3749,2249.4,,45.5,,1705.8,percent of total billed charges,,,45.3,,1698.3,percent of total billed charges,,,39,,1462.11,percent of total billed charges,,,,,,,,,80,,2999.2,percent of total billed charges,,,61.4,,2301.89,percent of total billed charges,,,57.4,,2151.93,percent of total billed charges,,,81,,3036.69,percent of total billed charges,,,39,,1462.11,percent of total billed charges,,,57.6,,2159.42,percent of total billed charges,,,85,,3186.65,percent of total billed charges,,,85,,3186.65,percent of total billed charges,,,49,,1837.01,percent of total billed charges,,,90,,3374.1,percent of total billed charges,,,65,,2436.85,percent of total billed charges,,,80,,2999.2,percent of total billed charges,,,55,,2061.95,percent of total billed charges,,,55,,2061.95,percent of total billed charges,,,65,,2436.85,percent of total billed charges,,,78,,2924.22,percent of total billed charges,,,70,,2624.3,percent of total billed charges,,,,,,,,1298.16,,,,100% of Medicare,,1298.16,,,,100% of Medicare,,1298.16,,,,100% of Medicare,,1298.16,,,,100% of Medicare,,1298.16,,,,100% of Medicare,,1298.16,,,,100% of Medicare,,1298.16,,,,100% of Medicare,,1298.16,,,,100% of Medicare,,1298.16,,,,100% of Medicare,,1298.16,,,,100% of Medicare,,1298.16,,,,100% of Medicare,,1298.16,,,,100% of Medicare,,,1298.16,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1298.16,3374.1,
"Addition, endo system, AK or hip disartic, knee extension assist",L5850,HCPCS,,,,outpatient,,,595,357,,45.5,,270.73,percent of total billed charges,,,45.3,,269.54,percent of total billed charges,,,39,,232.05,percent of total billed charges,,,,,,,,,80,,476,percent of total billed charges,,,61.4,,365.33,percent of total billed charges,,,57.4,,341.53,percent of total billed charges,,,81,,481.95,percent of total billed charges,,,39,,232.05,percent of total billed charges,,,57.6,,342.72,percent of total billed charges,,,85,,505.75,percent of total billed charges,,,85,,505.75,percent of total billed charges,,,49,,291.55,percent of total billed charges,,,90,,535.5,percent of total billed charges,,,65,,386.75,percent of total billed charges,,,80,,476,percent of total billed charges,,,55,,327.25,percent of total billed charges,,,55,,327.25,percent of total billed charges,,,65,,386.75,percent of total billed charges,,,78,,464.1,percent of total billed charges,,,70,,416.5,percent of total billed charges,,,,,,,,153.54,,,,100% of Medicare,,153.54,,,,100% of Medicare,,153.54,,,,100% of Medicare,,153.54,,,,100% of Medicare,,153.54,,,,100% of Medicare,,153.54,,,,100% of Medicare,,153.54,,,,100% of Medicare,,153.54,,,,100% of Medicare,,153.54,,,,100% of Medicare,,153.54,,,,100% of Medicare,,153.54,,,,100% of Medicare,,153.54,,,,100% of Medicare,,,153.54,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,153.54,535.5,
"Addition, endo system, hip disartic, mechanical hip extension assist",L5855,HCPCS,,,,outpatient,,,1074,644.4,,45.5,,488.67,percent of total billed charges,,,45.3,,486.52,percent of total billed charges,,,39,,418.86,percent of total billed charges,,,,,,,,,80,,859.2,percent of total billed charges,,,61.4,,659.44,percent of total billed charges,,,57.4,,616.48,percent of total billed charges,,,81,,869.94,percent of total billed charges,,,39,,418.86,percent of total billed charges,,,57.6,,618.62,percent of total billed charges,,,85,,912.9,percent of total billed charges,,,85,,912.9,percent of total billed charges,,,49,,526.26,percent of total billed charges,,,90,,966.6,percent of total billed charges,,,65,,698.1,percent of total billed charges,,,80,,859.2,percent of total billed charges,,,55,,590.7,percent of total billed charges,,,55,,590.7,percent of total billed charges,,,65,,698.1,percent of total billed charges,,,78,,837.72,percent of total billed charges,,,70,,751.8,percent of total billed charges,,,,,,,,370.68,,,,100% of Medicare,,370.68,,,,100% of Medicare,,370.68,,,,100% of Medicare,,370.68,,,,100% of Medicare,,370.68,,,,100% of Medicare,,370.68,,,,100% of Medicare,,370.68,,,,100% of Medicare,,370.68,,,,100% of Medicare,,370.68,,,,100% of Medicare,,370.68,,,,100% of Medicare,,370.68,,,,100% of Medicare,,370.68,,,,100% of Medicare,,,370.68,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,370.68,966.6,
"Addition, endo sys, BK, alignable system",L5910,HCPCS,,,,outpatient,,,1683,1009.8,,45.5,,765.77,percent of total billed charges,,,45.3,,762.4,percent of total billed charges,,,39,,656.37,percent of total billed charges,,,,,,,,,80,,1346.4,percent of total billed charges,,,61.4,,1033.36,percent of total billed charges,,,57.4,,966.04,percent of total billed charges,,,81,,1363.23,percent of total billed charges,,,39,,656.37,percent of total billed charges,,,57.6,,969.41,percent of total billed charges,,,85,,1430.55,percent of total billed charges,,,85,,1430.55,percent of total billed charges,,,49,,824.67,percent of total billed charges,,,90,,1514.7,percent of total billed charges,,,65,,1093.95,percent of total billed charges,,,80,,1346.4,percent of total billed charges,,,55,,925.65,percent of total billed charges,,,55,,925.65,percent of total billed charges,,,65,,1093.95,percent of total billed charges,,,78,,1312.74,percent of total billed charges,,,70,,1178.1,percent of total billed charges,,,,,,,,434.7,,,,100% of Medicare,,434.7,,,,100% of Medicare,,434.7,,,,100% of Medicare,,434.7,,,,100% of Medicare,,434.7,,,,100% of Medicare,,434.7,,,,100% of Medicare,,434.7,,,,100% of Medicare,,434.7,,,,100% of Medicare,,434.7,,,,100% of Medicare,,434.7,,,,100% of Medicare,,434.7,,,,100% of Medicare,,434.7,,,,100% of Medicare,,,434.7,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,434.7,1514.7,
"Addition, endo sys, AK or hip disartic, alignable system",L5920,HCPCS,,,,outpatient,,,2463,1477.8,,45.5,,1120.67,percent of total billed charges,,,45.3,,1115.74,percent of total billed charges,,,39,,960.57,percent of total billed charges,,,,,,,,,80,,1970.4,percent of total billed charges,,,61.4,,1512.28,percent of total billed charges,,,57.4,,1413.76,percent of total billed charges,,,81,,1995.03,percent of total billed charges,,,39,,960.57,percent of total billed charges,,,57.6,,1418.69,percent of total billed charges,,,85,,2093.55,percent of total billed charges,,,85,,2093.55,percent of total billed charges,,,49,,1206.87,percent of total billed charges,,,90,,2216.7,percent of total billed charges,,,65,,1600.95,percent of total billed charges,,,80,,1970.4,percent of total billed charges,,,55,,1354.65,percent of total billed charges,,,55,,1354.65,percent of total billed charges,,,65,,1600.95,percent of total billed charges,,,78,,1921.14,percent of total billed charges,,,70,,1724.1,percent of total billed charges,,,,,,,,636.84,,,,100% of Medicare,,636.84,,,,100% of Medicare,,636.84,,,,100% of Medicare,,636.84,,,,100% of Medicare,,636.84,,,,100% of Medicare,,636.84,,,,100% of Medicare,,636.84,,,,100% of Medicare,,636.84,,,,100% of Medicare,,636.84,,,,100% of Medicare,,636.84,,,,100% of Medicare,,636.84,,,,100% of Medicare,,636.84,,,,100% of Medicare,,,636.84,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,636.84,2216.7,
"Addition, endo sys, AK or knee disartic or hip disartic, manual lock",L5925,HCPCS,,,,outpatient,,,1164,698.4,,45.5,,529.62,percent of total billed charges,,,45.3,,527.29,percent of total billed charges,,,39,,453.96,percent of total billed charges,,,,,,,,,80,,931.2,percent of total billed charges,,,61.4,,714.7,percent of total billed charges,,,57.4,,668.14,percent of total billed charges,,,81,,942.84,percent of total billed charges,,,39,,453.96,percent of total billed charges,,,57.6,,670.46,percent of total billed charges,,,85,,989.4,percent of total billed charges,,,85,,989.4,percent of total billed charges,,,49,,570.36,percent of total billed charges,,,90,,1047.6,percent of total billed charges,,,65,,756.6,percent of total billed charges,,,80,,931.2,percent of total billed charges,,,55,,640.2,percent of total billed charges,,,55,,640.2,percent of total billed charges,,,65,,756.6,percent of total billed charges,,,78,,907.92,percent of total billed charges,,,70,,814.8,percent of total billed charges,,,,,,,,403.29,,,,100% of Medicare,,403.29,,,,100% of Medicare,,403.29,,,,100% of Medicare,,403.29,,,,100% of Medicare,,403.29,,,,100% of Medicare,,403.29,,,,100% of Medicare,,403.29,,,,100% of Medicare,,403.29,,,,100% of Medicare,,403.29,,,,100% of Medicare,,403.29,,,,100% of Medicare,,403.29,,,,100% of Medicare,,403.29,,,,100% of Medicare,,,403.29,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,403.29,1047.6,
ENDOSKELETAL POSITIONAL ROTATE UNIT,L5926,HCPCS,,,,outpatient,,,1971,1182.6,,45.5,,896.81,percent of total billed charges,,,45.3,,892.86,percent of total billed charges,,,39,,768.69,percent of total billed charges,,,,,,,,,80,,1576.8,percent of total billed charges,,,61.4,,1210.19,percent of total billed charges,,,57.4,,1131.35,percent of total billed charges,,,81,,1596.51,percent of total billed charges,,,39,,768.69,percent of total billed charges,,,57.6,,1135.3,percent of total billed charges,,,85,,1675.35,percent of total billed charges,,,85,,1675.35,percent of total billed charges,,,49,,965.79,percent of total billed charges,,,90,,1773.9,percent of total billed charges,,,65,,1281.15,percent of total billed charges,,,80,,1576.8,percent of total billed charges,,,55,,1084.05,percent of total billed charges,,,55,,1084.05,percent of total billed charges,,,65,,1281.15,percent of total billed charges,,,78,,1537.38,percent of total billed charges,,,70,,1379.7,percent of total billed charges,,,,,,,,776.22,,,,100% of Medicare,,776.22,,,,100% of Medicare,,776.22,,,,100% of Medicare,,776.22,,,,100% of Medicare,,776.22,,,,100% of Medicare,,776.22,,,,100% of Medicare,,776.22,,,,100% of Medicare,,776.22,,,,100% of Medicare,,776.22,,,,100% of Medicare,,776.22,,,,100% of Medicare,,776.22,,,,100% of Medicare,,776.22,,,,100% of Medicare,,,776.22,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,768.69,1773.9,
"Addition, endo system, BK, ultra-light material (titanium, carbon fiber or equal)",L5940,HCPCS,,,,outpatient,,,2326,1395.6,,45.5,,1058.33,percent of total billed charges,,,45.3,,1053.68,percent of total billed charges,,,39,,907.14,percent of total billed charges,,,,,,,,,80,,1860.8,percent of total billed charges,,,61.4,,1428.16,percent of total billed charges,,,57.4,,1335.12,percent of total billed charges,,,81,,1884.06,percent of total billed charges,,,39,,907.14,percent of total billed charges,,,57.6,,1339.78,percent of total billed charges,,,85,,1977.1,percent of total billed charges,,,85,,1977.1,percent of total billed charges,,,49,,1139.74,percent of total billed charges,,,90,,2093.4,percent of total billed charges,,,65,,1511.9,percent of total billed charges,,,80,,1860.8,percent of total billed charges,,,55,,1279.3,percent of total billed charges,,,55,,1279.3,percent of total billed charges,,,65,,1511.9,percent of total billed charges,,,78,,1814.28,percent of total billed charges,,,70,,1628.2,percent of total billed charges,,,,,,,,602.05,,,,100% of Medicare,,602.05,,,,100% of Medicare,,602.05,,,,100% of Medicare,,602.05,,,,100% of Medicare,,602.05,,,,100% of Medicare,,602.05,,,,100% of Medicare,,602.05,,,,100% of Medicare,,602.05,,,,100% of Medicare,,602.05,,,,100% of Medicare,,602.05,,,,100% of Medicare,,602.05,,,,100% of Medicare,,602.05,,,,100% of Medicare,,,602.05,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,602.05,2093.4,
"Addition, endo sys, AK, ultra-light material (titanium, carbon fiber or equal)",L5950,HCPCS,,,,outpatient,,,3606,2163.6,,45.5,,1640.73,percent of total billed charges,,,45.3,,1633.52,percent of total billed charges,,,39,,1406.34,percent of total billed charges,,,,,,,,,80,,2884.8,percent of total billed charges,,,61.4,,2214.08,percent of total billed charges,,,57.4,,2069.84,percent of total billed charges,,,81,,2920.86,percent of total billed charges,,,39,,1406.34,percent of total billed charges,,,57.6,,2077.06,percent of total billed charges,,,85,,3065.1,percent of total billed charges,,,85,,3065.1,percent of total billed charges,,,49,,1766.94,percent of total billed charges,,,90,,3245.4,percent of total billed charges,,,65,,2343.9,percent of total billed charges,,,80,,2884.8,percent of total billed charges,,,55,,1983.3,percent of total billed charges,,,55,,1983.3,percent of total billed charges,,,65,,2343.9,percent of total billed charges,,,78,,2812.68,percent of total billed charges,,,70,,2524.2,percent of total billed charges,,,,,,,,933.8,,,,100% of Medicare,,933.8,,,,100% of Medicare,,933.8,,,,100% of Medicare,,933.8,,,,100% of Medicare,,933.8,,,,100% of Medicare,,933.8,,,,100% of Medicare,,933.8,,,,100% of Medicare,,933.8,,,,100% of Medicare,,933.8,,,,100% of Medicare,,933.8,,,,100% of Medicare,,933.8,,,,100% of Medicare,,933.8,,,,100% of Medicare,,,933.8,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,933.8,3245.4,
"Addition, endo sys, BK, flexible protective outer surface covering system",L5962,HCPCS,,,,outpatient,,,2728,1636.8,,45.5,,1241.24,percent of total billed charges,,,45.3,,1235.78,percent of total billed charges,,,39,,1063.92,percent of total billed charges,,,,,,,,,80,,2182.4,percent of total billed charges,,,61.4,,1674.99,percent of total billed charges,,,57.4,,1565.87,percent of total billed charges,,,81,,2209.68,percent of total billed charges,,,39,,1063.92,percent of total billed charges,,,57.6,,1571.33,percent of total billed charges,,,85,,2318.8,percent of total billed charges,,,85,,2318.8,percent of total billed charges,,,49,,1336.72,percent of total billed charges,,,90,,2455.2,percent of total billed charges,,,65,,1773.2,percent of total billed charges,,,80,,2182.4,percent of total billed charges,,,55,,1500.4,percent of total billed charges,,,55,,1500.4,percent of total billed charges,,,65,,1773.2,percent of total billed charges,,,78,,2127.84,percent of total billed charges,,,70,,1909.6,percent of total billed charges,,,,,,,,705.49,,,,100% of Medicare,,705.49,,,,100% of Medicare,,705.49,,,,100% of Medicare,,705.49,,,,100% of Medicare,,705.49,,,,100% of Medicare,,705.49,,,,100% of Medicare,,705.49,,,,100% of Medicare,,705.49,,,,100% of Medicare,,705.49,,,,100% of Medicare,,705.49,,,,100% of Medicare,,705.49,,,,100% of Medicare,,705.49,,,,100% of Medicare,,,705.49,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,705.49,2455.2,
"AllLE prostheses, foot, external keel, SACH foot",L5970,HCPCS,,,,outpatient,,,780,468,,45.5,,354.9,percent of total billed charges,,,45.3,,353.34,percent of total billed charges,,,39,,304.2,percent of total billed charges,,,,,,,,,80,,624,percent of total billed charges,,,61.4,,478.92,percent of total billed charges,,,57.4,,447.72,percent of total billed charges,,,81,,631.8,percent of total billed charges,,,39,,304.2,percent of total billed charges,,,57.6,,449.28,percent of total billed charges,,,85,,663,percent of total billed charges,,,85,,663,percent of total billed charges,,,49,,382.2,percent of total billed charges,,,90,,702,percent of total billed charges,,,65,,507,percent of total billed charges,,,80,,624,percent of total billed charges,,,55,,429,percent of total billed charges,,,55,,429,percent of total billed charges,,,65,,507,percent of total billed charges,,,78,,608.4,percent of total billed charges,,,70,,546,percent of total billed charges,,,,,,,,262.23,,,,100% of Medicare,,262.23,,,,100% of Medicare,,262.23,,,,100% of Medicare,,262.23,,,,100% of Medicare,,262.23,,,,100% of Medicare,,262.23,,,,100% of Medicare,,262.23,,,,100% of Medicare,,262.23,,,,100% of Medicare,,262.23,,,,100% of Medicare,,262.23,,,,100% of Medicare,,262.23,,,,100% of Medicare,,262.23,,,,100% of Medicare,,,262.23,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,262.23,702,
"L5971 All lower extremity prosthesis,solid ankle cushioned heel foot,replacement only",L5971,HCPCS,,,,outpatient,,,757,454.2,,45.5,,344.44,percent of total billed charges,,,45.3,,342.92,percent of total billed charges,,,39,,295.23,percent of total billed charges,,,,,,,,,80,,605.6,percent of total billed charges,,,61.4,,464.8,percent of total billed charges,,,57.4,,434.52,percent of total billed charges,,,81,,613.17,percent of total billed charges,,,39,,295.23,percent of total billed charges,,,57.6,,436.03,percent of total billed charges,,,85,,643.45,percent of total billed charges,,,85,,643.45,percent of total billed charges,,,49,,370.93,percent of total billed charges,,,90,,681.3,percent of total billed charges,,,65,,492.05,percent of total billed charges,,,80,,605.6,percent of total billed charges,,,55,,416.35,percent of total billed charges,,,55,,416.35,percent of total billed charges,,,65,,492.05,percent of total billed charges,,,78,,590.46,percent of total billed charges,,,70,,529.9,percent of total billed charges,,,,,,,,262.23,,,,100% of Medicare,,262.23,,,,100% of Medicare,,262.23,,,,100% of Medicare,,262.23,,,,100% of Medicare,,262.23,,,,100% of Medicare,,262.23,,,,100% of Medicare,,262.23,,,,100% of Medicare,,262.23,,,,100% of Medicare,,262.23,,,,100% of Medicare,,262.23,,,,100% of Medicare,,262.23,,,,100% of Medicare,,262.23,,,,100% of Medicare,,,262.23,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,262.23,681.3,
"All LE prostheses, flexible keel foot, (SAFE, STEN, Bock Dynamic or equal)",L5972,HCPCS,,,,outpatient,,,1418,850.8,,45.5,,645.19,percent of total billed charges,,,45.3,,642.35,percent of total billed charges,,,39,,553.02,percent of total billed charges,,,,,,,,,80,,1134.4,percent of total billed charges,,,61.4,,870.65,percent of total billed charges,,,57.4,,813.93,percent of total billed charges,,,81,,1148.58,percent of total billed charges,,,39,,553.02,percent of total billed charges,,,57.6,,816.77,percent of total billed charges,,,85,,1205.3,percent of total billed charges,,,85,,1205.3,percent of total billed charges,,,49,,694.82,percent of total billed charges,,,90,,1276.2,percent of total billed charges,,,65,,921.7,percent of total billed charges,,,80,,1134.4,percent of total billed charges,,,55,,779.9,percent of total billed charges,,,55,,779.9,percent of total billed charges,,,65,,921.7,percent of total billed charges,,,78,,1106.04,percent of total billed charges,,,70,,992.6,percent of total billed charges,,,,,,,,477.68,,,,100% of Medicare,,477.68,,,,100% of Medicare,,477.68,,,,100% of Medicare,,477.68,,,,100% of Medicare,,477.68,,,,100% of Medicare,,477.68,,,,100% of Medicare,,477.68,,,,100% of Medicare,,477.68,,,,100% of Medicare,,477.68,,,,100% of Medicare,,477.68,,,,100% of Medicare,,477.68,,,,100% of Medicare,,477.68,,,,100% of Medicare,,,477.68,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,477.68,1276.2,
"All lLE prostheses, foot, single axis ankle foot",L5974,HCPCS,,,,outpatient,,,834,500.4,,45.5,,379.47,percent of total billed charges,,,45.3,,377.8,percent of total billed charges,,,39,,325.26,percent of total billed charges,,,,,,,,,80,,667.2,percent of total billed charges,,,61.4,,512.08,percent of total billed charges,,,57.4,,478.72,percent of total billed charges,,,81,,675.54,percent of total billed charges,,,39,,325.26,percent of total billed charges,,,57.6,,480.38,percent of total billed charges,,,85,,708.9,percent of total billed charges,,,85,,708.9,percent of total billed charges,,,49,,408.66,percent of total billed charges,,,90,,750.6,percent of total billed charges,,,65,,542.1,percent of total billed charges,,,80,,667.2,percent of total billed charges,,,55,,458.7,percent of total billed charges,,,55,,458.7,percent of total billed charges,,,65,,542.1,percent of total billed charges,,,78,,650.52,percent of total billed charges,,,70,,583.8,percent of total billed charges,,,,,,,,279.69,,,,100% of Medicare,,279.69,,,,100% of Medicare,,279.69,,,,100% of Medicare,,279.69,,,,100% of Medicare,,279.69,,,,100% of Medicare,,279.69,,,,100% of Medicare,,279.69,,,,100% of Medicare,,279.69,,,,100% of Medicare,,279.69,,,,100% of Medicare,,279.69,,,,100% of Medicare,,279.69,,,,100% of Medicare,,279.69,,,,100% of Medicare,,,279.69,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,279.69,750.6,
"All LE prostheses, combination single axis and flexible keel foot",L5975,HCPCS,,,,outpatient,,,1616,969.6,,45.5,,735.28,percent of total billed charges,,,45.3,,732.05,percent of total billed charges,,,39,,630.24,percent of total billed charges,,,,,,,,,80,,1292.8,percent of total billed charges,,,61.4,,992.22,percent of total billed charges,,,57.4,,927.58,percent of total billed charges,,,81,,1308.96,percent of total billed charges,,,39,,630.24,percent of total billed charges,,,57.6,,930.82,percent of total billed charges,,,85,,1373.6,percent of total billed charges,,,85,,1373.6,percent of total billed charges,,,49,,791.84,percent of total billed charges,,,90,,1454.4,percent of total billed charges,,,65,,1050.4,percent of total billed charges,,,80,,1292.8,percent of total billed charges,,,55,,888.8,percent of total billed charges,,,55,,888.8,percent of total billed charges,,,65,,1050.4,percent of total billed charges,,,78,,1260.48,percent of total billed charges,,,70,,1131.2,percent of total billed charges,,,,,,,,559.67,,,,100% of Medicare,,559.67,,,,100% of Medicare,,559.67,,,,100% of Medicare,,559.67,,,,100% of Medicare,,559.67,,,,100% of Medicare,,559.67,,,,100% of Medicare,,559.67,,,,100% of Medicare,,559.67,,,,100% of Medicare,,559.67,,,,100% of Medicare,,559.67,,,,100% of Medicare,,559.67,,,,100% of Medicare,,559.67,,,,100% of Medicare,,,559.67,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,559.67,1454.4,
"All LE prostheses, energy storing foot (Seattle, Carbon Copy II or equal)",L5976,HCPCS,,,,outpatient,,,2109,1265.4,,45.5,,959.6,percent of total billed charges,,,45.3,,955.38,percent of total billed charges,,,39,,822.51,percent of total billed charges,,,,,,,,,80,,1687.2,percent of total billed charges,,,61.4,,1294.93,percent of total billed charges,,,57.4,,1210.57,percent of total billed charges,,,81,,1708.29,percent of total billed charges,,,39,,822.51,percent of total billed charges,,,57.6,,1214.78,percent of total billed charges,,,85,,1792.65,percent of total billed charges,,,85,,1792.65,percent of total billed charges,,,49,,1033.41,percent of total billed charges,,,90,,1898.1,percent of total billed charges,,,65,,1370.85,percent of total billed charges,,,80,,1687.2,percent of total billed charges,,,55,,1159.95,percent of total billed charges,,,55,,1159.95,percent of total billed charges,,,65,,1370.85,percent of total billed charges,,,78,,1645.02,percent of total billed charges,,,70,,1476.3,percent of total billed charges,,,,,,,,709.45,,,,100% of Medicare,,709.45,,,,100% of Medicare,,709.45,,,,100% of Medicare,,709.45,,,,100% of Medicare,,709.45,,,,100% of Medicare,,709.45,,,,100% of Medicare,,709.45,,,,100% of Medicare,,709.45,,,,100% of Medicare,,709.45,,,,100% of Medicare,,709.45,,,,100% of Medicare,,709.45,,,,100% of Medicare,,709.45,,,,100% of Medicare,,,709.45,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,709.45,1898.1,
"All LE prostheses, foot, multi-axial ankle/foot",L5978,HCPCS,,,,outpatient,,,1118,670.8,,45.5,,508.69,percent of total billed charges,,,45.3,,506.45,percent of total billed charges,,,39,,436.02,percent of total billed charges,,,,,,,,,80,,894.4,percent of total billed charges,,,61.4,,686.45,percent of total billed charges,,,57.4,,641.73,percent of total billed charges,,,81,,905.58,percent of total billed charges,,,39,,436.02,percent of total billed charges,,,57.6,,643.97,percent of total billed charges,,,85,,950.3,percent of total billed charges,,,85,,950.3,percent of total billed charges,,,49,,547.82,percent of total billed charges,,,90,,1006.2,percent of total billed charges,,,65,,726.7,percent of total billed charges,,,80,,894.4,percent of total billed charges,,,55,,614.9,percent of total billed charges,,,55,,614.9,percent of total billed charges,,,65,,726.7,percent of total billed charges,,,78,,872.04,percent of total billed charges,,,70,,782.6,percent of total billed charges,,,,,,,,375.92,,,,100% of Medicare,,375.92,,,,100% of Medicare,,375.92,,,,100% of Medicare,,375.92,,,,100% of Medicare,,375.92,,,,100% of Medicare,,375.92,,,,100% of Medicare,,375.92,,,,100% of Medicare,,375.92,,,,100% of Medicare,,375.92,,,,100% of Medicare,,375.92,,,,100% of Medicare,,375.92,,,,100% of Medicare,,375.92,,,,100% of Medicare,,,375.92,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,375.92,1006.2,
"All exoskeletal lower extremity prostheses, axial rotation unit",L5982,HCPCS,,,,outpatient,,,1819,1091.4,,45.5,,827.65,percent of total billed charges,,,45.3,,824.01,percent of total billed charges,,,39,,709.41,percent of total billed charges,,,,,,,,,80,,1455.2,percent of total billed charges,,,61.4,,1116.87,percent of total billed charges,,,57.4,,1044.11,percent of total billed charges,,,81,,1473.39,percent of total billed charges,,,39,,709.41,percent of total billed charges,,,57.6,,1047.74,percent of total billed charges,,,85,,1546.15,percent of total billed charges,,,85,,1546.15,percent of total billed charges,,,49,,891.31,percent of total billed charges,,,90,,1637.1,percent of total billed charges,,,65,,1182.35,percent of total billed charges,,,80,,1455.2,percent of total billed charges,,,55,,1000.45,percent of total billed charges,,,55,,1000.45,percent of total billed charges,,,65,,1182.35,percent of total billed charges,,,78,,1418.82,percent of total billed charges,,,70,,1273.3,percent of total billed charges,,,,,,,,773.83,,,,100% of Medicare,,773.83,,,,100% of Medicare,,773.83,,,,100% of Medicare,,773.83,,,,100% of Medicare,,773.83,,,,100% of Medicare,,773.83,,,,100% of Medicare,,773.83,,,,100% of Medicare,,773.83,,,,100% of Medicare,,773.83,,,,100% of Medicare,,773.83,,,,100% of Medicare,,773.83,,,,100% of Medicare,,773.83,,,,100% of Medicare,,,773.83,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,709.41,1637.1,
"All endoskeletal LE prostheses, axial rotation unit",L5984,HCPCS,,,,outpatient,,,2998,1798.8,,45.5,,1364.09,percent of total billed charges,,,45.3,,1358.09,percent of total billed charges,,,39,,1169.22,percent of total billed charges,,,,,,,,,80,,2398.4,percent of total billed charges,,,61.4,,1840.77,percent of total billed charges,,,57.4,,1720.85,percent of total billed charges,,,81,,2428.38,percent of total billed charges,,,39,,1169.22,percent of total billed charges,,,57.6,,1726.85,percent of total billed charges,,,85,,2548.3,percent of total billed charges,,,85,,2548.3,percent of total billed charges,,,49,,1469.02,percent of total billed charges,,,90,,2698.2,percent of total billed charges,,,65,,1948.7,percent of total billed charges,,,80,,2398.4,percent of total billed charges,,,55,,1648.9,percent of total billed charges,,,55,,1648.9,percent of total billed charges,,,65,,1948.7,percent of total billed charges,,,78,,2338.44,percent of total billed charges,,,70,,2098.6,percent of total billed charges,,,,,,,,776.22,,,,100% of Medicare,,776.22,,,,100% of Medicare,,776.22,,,,100% of Medicare,,776.22,,,,100% of Medicare,,776.22,,,,100% of Medicare,,776.22,,,,100% of Medicare,,776.22,,,,100% of Medicare,,776.22,,,,100% of Medicare,,776.22,,,,100% of Medicare,,776.22,,,,100% of Medicare,,776.22,,,,100% of Medicare,,776.22,,,,100% of Medicare,,,776.22,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,776.22,2698.2,
"All endoskeletal LE prostheses, dynamic prosthetic pylon",L5985,HCPCS,,,,outpatient,,,799,479.4,,45.5,,363.55,percent of total billed charges,,,45.3,,361.95,percent of total billed charges,,,39,,311.61,percent of total billed charges,,,,,,,,,80,,639.2,percent of total billed charges,,,61.4,,490.59,percent of total billed charges,,,57.4,,458.63,percent of total billed charges,,,81,,647.19,percent of total billed charges,,,39,,311.61,percent of total billed charges,,,57.6,,460.22,percent of total billed charges,,,85,,679.15,percent of total billed charges,,,85,,679.15,percent of total billed charges,,,49,,391.51,percent of total billed charges,,,90,,719.1,percent of total billed charges,,,65,,519.35,percent of total billed charges,,,80,,639.2,percent of total billed charges,,,55,,439.45,percent of total billed charges,,,55,,439.45,percent of total billed charges,,,65,,519.35,percent of total billed charges,,,78,,623.22,percent of total billed charges,,,70,,559.3,percent of total billed charges,,,,,,,,340.91,,,,100% of Medicare,,340.91,,,,100% of Medicare,,340.91,,,,100% of Medicare,,340.91,,,,100% of Medicare,,340.91,,,,100% of Medicare,,340.91,,,,100% of Medicare,,340.91,,,,100% of Medicare,,340.91,,,,100% of Medicare,,340.91,,,,100% of Medicare,,340.91,,,,100% of Medicare,,340.91,,,,100% of Medicare,,340.91,,,,100% of Medicare,,,340.91,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,311.61,719.1,
"All LE prostheses, multi-axial rotation unit (""MCP"" or equal)",L5986,HCPCS,,,,outpatient,,,3628,2176.8,,45.5,,1650.74,percent of total billed charges,,,45.3,,1643.48,percent of total billed charges,,,39,,1414.92,percent of total billed charges,,,,,,,,,80,,2902.4,percent of total billed charges,,,61.4,,2227.59,percent of total billed charges,,,57.4,,2082.47,percent of total billed charges,,,81,,2938.68,percent of total billed charges,,,39,,1414.92,percent of total billed charges,,,57.6,,2089.73,percent of total billed charges,,,85,,3083.8,percent of total billed charges,,,85,,3083.8,percent of total billed charges,,,49,,1777.72,percent of total billed charges,,,90,,3265.2,percent of total billed charges,,,65,,2358.2,percent of total billed charges,,,80,,2902.4,percent of total billed charges,,,55,,1995.4,percent of total billed charges,,,55,,1995.4,percent of total billed charges,,,65,,2358.2,percent of total billed charges,,,78,,2829.84,percent of total billed charges,,,70,,2539.6,percent of total billed charges,,,,,,,,936.35,,,,100% of Medicare,,936.35,,,,100% of Medicare,,936.35,,,,100% of Medicare,,936.35,,,,100% of Medicare,,936.35,,,,100% of Medicare,,936.35,,,,100% of Medicare,,936.35,,,,100% of Medicare,,936.35,,,,100% of Medicare,,936.35,,,,100% of Medicare,,936.35,,,,100% of Medicare,,936.35,,,,100% of Medicare,,936.35,,,,100% of Medicare,,,936.35,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,936.35,3265.2,
"Immediate postsurg/early fitting, app of initial rigid drsg, including fit/align/susp, and 1 cast ch",L6380,HCPCS,,,,outpatient,,,3810,2286,,45.5,,1733.55,percent of total billed charges,,,45.3,,1725.93,percent of total billed charges,,,39,,1485.9,percent of total billed charges,,,,,,,,,80,,3048,percent of total billed charges,,,61.4,,2339.34,percent of total billed charges,,,57.4,,2186.94,percent of total billed charges,,,81,,3086.1,percent of total billed charges,,,39,,1485.9,percent of total billed charges,,,57.6,,2194.56,percent of total billed charges,,,85,,3238.5,percent of total billed charges,,,85,,3238.5,percent of total billed charges,,,49,,1866.9,percent of total billed charges,,,90,,3429,percent of total billed charges,,,65,,2476.5,percent of total billed charges,,,80,,3048,percent of total billed charges,,,55,,2095.5,percent of total billed charges,,,55,,2095.5,percent of total billed charges,,,65,,2476.5,percent of total billed charges,,,78,,2971.8,percent of total billed charges,,,70,,2667,percent of total billed charges,,,,,,,,1709.72,,,,100% of Medicare,,1709.72,,,,100% of Medicare,,1709.72,,,,100% of Medicare,,1709.72,,,,100% of Medicare,,1709.72,,,,100% of Medicare,,1709.72,,,,100% of Medicare,,1709.72,,,,100% of Medicare,,1709.72,,,,100% of Medicare,,1709.72,,,,100% of Medicare,,1709.72,,,,100% of Medicare,,1709.72,,,,100% of Medicare,,1709.72,,,,100% of Medicare,,,1709.72,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1485.9,3429,
"Immediate postsurg/early fitting, each, addit cast change and realignment",L6386,HCPCS,,,,outpatient,,,1260,756,,45.5,,573.3,percent of total billed charges,,,45.3,,570.78,percent of total billed charges,,,39,,491.4,percent of total billed charges,,,,,,,,,80,,1008,percent of total billed charges,,,61.4,,773.64,percent of total billed charges,,,57.4,,723.24,percent of total billed charges,,,81,,1020.6,percent of total billed charges,,,39,,491.4,percent of total billed charges,,,57.6,,725.76,percent of total billed charges,,,85,,1071,percent of total billed charges,,,85,,1071,percent of total billed charges,,,49,,617.4,percent of total billed charges,,,90,,1134,percent of total billed charges,,,65,,819,percent of total billed charges,,,80,,1008,percent of total billed charges,,,55,,693,percent of total billed charges,,,55,,693,percent of total billed charges,,,65,,819,percent of total billed charges,,,78,,982.8,percent of total billed charges,,,70,,882,percent of total billed charges,,,,,,,,564.42,,,,100% of Medicare,,564.42,,,,100% of Medicare,,564.42,,,,100% of Medicare,,564.42,,,,100% of Medicare,,564.42,,,,100% of Medicare,,564.42,,,,100% of Medicare,,564.42,,,,100% of Medicare,,564.42,,,,100% of Medicare,,564.42,,,,100% of Medicare,,564.42,,,,100% of Medicare,,564.42,,,,100% of Medicare,,564.42,,,,100% of Medicare,,,564.42,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,491.4,1134,
"Immediate postsurg/early fitting, app of rigid drsg only",L6388,HCPCS,,,,outpatient,,,1395,837,,45.5,,634.73,percent of total billed charges,,,45.3,,631.94,percent of total billed charges,,,39,,544.05,percent of total billed charges,,,,,,,,,80,,1116,percent of total billed charges,,,61.4,,856.53,percent of total billed charges,,,57.4,,800.73,percent of total billed charges,,,81,,1129.95,percent of total billed charges,,,39,,544.05,percent of total billed charges,,,57.6,,803.52,percent of total billed charges,,,85,,1185.75,percent of total billed charges,,,85,,1185.75,percent of total billed charges,,,49,,683.55,percent of total billed charges,,,90,,1255.5,percent of total billed charges,,,65,,906.75,percent of total billed charges,,,80,,1116,percent of total billed charges,,,55,,767.25,percent of total billed charges,,,55,,767.25,percent of total billed charges,,,65,,906.75,percent of total billed charges,,,78,,1088.1,percent of total billed charges,,,70,,976.5,percent of total billed charges,,,,,,,,621.56,,,,100% of Medicare,,621.56,,,,100% of Medicare,,621.56,,,,100% of Medicare,,621.56,,,,100% of Medicare,,621.56,,,,100% of Medicare,,621.56,,,,100% of Medicare,,621.56,,,,100% of Medicare,,621.56,,,,100% of Medicare,,621.56,,,,100% of Medicare,,621.56,,,,100% of Medicare,,621.56,,,,100% of Medicare,,621.56,,,,100% of Medicare,,,621.56,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,544.05,1255.5,
"UE additions, polycentric hinge, pair",L6600,HCPCS,,,,outpatient,,,637,382.2,,45.5,,289.84,percent of total billed charges,,,45.3,,288.56,percent of total billed charges,,,39,,248.43,percent of total billed charges,,,,,,,,,80,,509.6,percent of total billed charges,,,61.4,,391.12,percent of total billed charges,,,57.4,,365.64,percent of total billed charges,,,81,,515.97,percent of total billed charges,,,39,,248.43,percent of total billed charges,,,57.6,,366.91,percent of total billed charges,,,85,,541.45,percent of total billed charges,,,85,,541.45,percent of total billed charges,,,49,,312.13,percent of total billed charges,,,90,,573.3,percent of total billed charges,,,65,,414.05,percent of total billed charges,,,80,,509.6,percent of total billed charges,,,55,,350.35,percent of total billed charges,,,55,,350.35,percent of total billed charges,,,65,,414.05,percent of total billed charges,,,78,,496.86,percent of total billed charges,,,70,,445.9,percent of total billed charges,,,,,,,,273.82,,,,100% of Medicare,,273.82,,,,100% of Medicare,,273.82,,,,100% of Medicare,,273.82,,,,100% of Medicare,,273.82,,,,100% of Medicare,,273.82,,,,100% of Medicare,,273.82,,,,100% of Medicare,,273.82,,,,100% of Medicare,,273.82,,,,100% of Medicare,,273.82,,,,100% of Medicare,,273.82,,,,100% of Medicare,,273.82,,,,100% of Medicare,,,273.82,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,248.43,573.3,
"UE additions, single pivot hinge, pair",L6605,HCPCS,,,,outpatient,,,815,489,,45.5,,370.83,percent of total billed charges,,,45.3,,369.2,percent of total billed charges,,,39,,317.85,percent of total billed charges,,,,,,,,,80,,652,percent of total billed charges,,,61.4,,500.41,percent of total billed charges,,,57.4,,467.81,percent of total billed charges,,,81,,660.15,percent of total billed charges,,,39,,317.85,percent of total billed charges,,,57.6,,469.44,percent of total billed charges,,,85,,692.75,percent of total billed charges,,,85,,692.75,percent of total billed charges,,,49,,399.35,percent of total billed charges,,,90,,733.5,percent of total billed charges,,,65,,529.75,percent of total billed charges,,,80,,652,percent of total billed charges,,,55,,448.25,percent of total billed charges,,,55,,448.25,percent of total billed charges,,,65,,529.75,percent of total billed charges,,,78,,635.7,percent of total billed charges,,,70,,570.5,percent of total billed charges,,,,,,,,281.84,,,,100% of Medicare,,281.84,,,,100% of Medicare,,281.84,,,,100% of Medicare,,281.84,,,,100% of Medicare,,281.84,,,,100% of Medicare,,281.84,,,,100% of Medicare,,281.84,,,,100% of Medicare,,281.84,,,,100% of Medicare,,281.84,,,,100% of Medicare,,281.84,,,,100% of Medicare,,281.84,,,,100% of Medicare,,281.84,,,,100% of Medicare,,,281.84,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,281.84,733.5,
"UE additions, flexible metal hinge, pair",L6610,HCPCS,,,,outpatient,,,617,370.2,,45.5,,280.74,percent of total billed charges,,,45.3,,279.5,percent of total billed charges,,,39,,240.63,percent of total billed charges,,,,,,,,,80,,493.6,percent of total billed charges,,,61.4,,378.84,percent of total billed charges,,,57.4,,354.16,percent of total billed charges,,,81,,499.77,percent of total billed charges,,,39,,240.63,percent of total billed charges,,,57.6,,355.39,percent of total billed charges,,,85,,524.45,percent of total billed charges,,,85,,524.45,percent of total billed charges,,,49,,302.33,percent of total billed charges,,,90,,555.3,percent of total billed charges,,,65,,401.05,percent of total billed charges,,,80,,493.6,percent of total billed charges,,,55,,339.35,percent of total billed charges,,,55,,339.35,percent of total billed charges,,,65,,401.05,percent of total billed charges,,,78,,481.26,percent of total billed charges,,,70,,431.9,percent of total billed charges,,,,,,,,266.44,,,,100% of Medicare,,266.44,,,,100% of Medicare,,266.44,,,,100% of Medicare,,266.44,,,,100% of Medicare,,266.44,,,,100% of Medicare,,266.44,,,,100% of Medicare,,266.44,,,,100% of Medicare,,266.44,,,,100% of Medicare,,266.44,,,,100% of Medicare,,266.44,,,,100% of Medicare,,266.44,,,,100% of Medicare,,266.44,,,,100% of Medicare,,,266.44,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,240.63,555.3,
"Addition to UE, External power, additional switch",L6611,HCPCS,,,,outpatient,,,1436,861.6,,45.5,,653.38,percent of total billed charges,,,45.3,,650.51,percent of total billed charges,,,39,,560.04,percent of total billed charges,,,,,,,,,80,,1148.8,percent of total billed charges,,,61.4,,881.7,percent of total billed charges,,,57.4,,824.26,percent of total billed charges,,,81,,1163.16,percent of total billed charges,,,39,,560.04,percent of total billed charges,,,57.6,,827.14,percent of total billed charges,,,85,,1220.6,percent of total billed charges,,,85,,1220.6,percent of total billed charges,,,49,,703.64,percent of total billed charges,,,90,,1292.4,percent of total billed charges,,,65,,933.4,percent of total billed charges,,,80,,1148.8,percent of total billed charges,,,55,,789.8,percent of total billed charges,,,55,,789.8,percent of total billed charges,,,65,,933.4,percent of total billed charges,,,78,,1120.08,percent of total billed charges,,,70,,1005.2,percent of total billed charges,,,,,,,,497.03,,,,100% of Medicare,,497.03,,,,100% of Medicare,,497.03,,,,100% of Medicare,,497.03,,,,100% of Medicare,,497.03,,,,100% of Medicare,,497.03,,,,100% of Medicare,,497.03,,,,100% of Medicare,,497.03,,,,100% of Medicare,,497.03,,,,100% of Medicare,,497.03,,,,100% of Medicare,,497.03,,,,100% of Medicare,,497.03,,,,100% of Medicare,,,497.03,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,497.03,1292.4,
"UE additions, disconnect locking wrist unit",L6615,HCPCS,,,,outpatient,,,1001,600.6,,45.5,,455.46,percent of total billed charges,,,45.3,,453.45,percent of total billed charges,,,39,,390.39,percent of total billed charges,,,,,,,,,80,,800.8,percent of total billed charges,,,61.4,,614.61,percent of total billed charges,,,57.4,,574.57,percent of total billed charges,,,81,,810.81,percent of total billed charges,,,39,,390.39,percent of total billed charges,,,57.6,,576.58,percent of total billed charges,,,85,,850.85,percent of total billed charges,,,85,,850.85,percent of total billed charges,,,49,,490.49,percent of total billed charges,,,90,,900.9,percent of total billed charges,,,65,,650.65,percent of total billed charges,,,80,,800.8,percent of total billed charges,,,55,,550.55,percent of total billed charges,,,55,,550.55,percent of total billed charges,,,65,,650.65,percent of total billed charges,,,78,,780.78,percent of total billed charges,,,70,,700.7,percent of total billed charges,,,,,,,,258.63,,,,100% of Medicare,,258.63,,,,100% of Medicare,,258.63,,,,100% of Medicare,,258.63,,,,100% of Medicare,,258.63,,,,100% of Medicare,,258.63,,,,100% of Medicare,,258.63,,,,100% of Medicare,,258.63,,,,100% of Medicare,,258.63,,,,100% of Medicare,,258.63,,,,100% of Medicare,,258.63,,,,100% of Medicare,,258.63,,,,100% of Medicare,,,258.63,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,258.63,900.9,
"UE additions, additional disconnect insert for locking wrist unit each",L6616,HCPCS,,,,outpatient,,,299,179.4,,45.5,,136.05,percent of total billed charges,,,45.3,,135.45,percent of total billed charges,,,39,,116.61,percent of total billed charges,,,,,,,,,80,,239.2,percent of total billed charges,,,61.4,,183.59,percent of total billed charges,,,57.4,,171.63,percent of total billed charges,,,81,,242.19,percent of total billed charges,,,39,,116.61,percent of total billed charges,,,57.6,,172.22,percent of total billed charges,,,85,,254.15,percent of total billed charges,,,85,,254.15,percent of total billed charges,,,49,,146.51,percent of total billed charges,,,90,,269.1,percent of total billed charges,,,65,,194.35,percent of total billed charges,,,80,,239.2,percent of total billed charges,,,55,,164.45,percent of total billed charges,,,55,,164.45,percent of total billed charges,,,65,,194.35,percent of total billed charges,,,78,,233.22,percent of total billed charges,,,70,,209.3,percent of total billed charges,,,,,,,,77.85,,,,100% of Medicare,,77.85,,,,100% of Medicare,,77.85,,,,100% of Medicare,,77.85,,,,100% of Medicare,,77.85,,,,100% of Medicare,,77.85,,,,100% of Medicare,,77.85,,,,100% of Medicare,,77.85,,,,100% of Medicare,,77.85,,,,100% of Medicare,,77.85,,,,100% of Medicare,,77.85,,,,100% of Medicare,,77.85,,,,100% of Medicare,,,77.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,77.85,269.1,
"UE additions, flexion-friction wrist unit",L6620,HCPCS,,,,outpatient,,,1747,1048.2,,45.5,,794.89,percent of total billed charges,,,45.3,,791.39,percent of total billed charges,,,39,,681.33,percent of total billed charges,,,,,,,,,80,,1397.6,percent of total billed charges,,,61.4,,1072.66,percent of total billed charges,,,57.4,,1002.78,percent of total billed charges,,,81,,1415.07,percent of total billed charges,,,39,,681.33,percent of total billed charges,,,57.6,,1006.27,percent of total billed charges,,,85,,1484.95,percent of total billed charges,,,85,,1484.95,percent of total billed charges,,,49,,856.03,percent of total billed charges,,,90,,1572.3,percent of total billed charges,,,65,,1135.55,percent of total billed charges,,,80,,1397.6,percent of total billed charges,,,55,,960.85,percent of total billed charges,,,55,,960.85,percent of total billed charges,,,65,,1135.55,percent of total billed charges,,,78,,1362.66,percent of total billed charges,,,70,,1222.9,percent of total billed charges,,,,,,,,452.13,,,,100% of Medicare,,452.13,,,,100% of Medicare,,452.13,,,,100% of Medicare,,452.13,,,,100% of Medicare,,452.13,,,,100% of Medicare,,452.13,,,,100% of Medicare,,452.13,,,,100% of Medicare,,452.13,,,,100% of Medicare,,452.13,,,,100% of Medicare,,452.13,,,,100% of Medicare,,452.13,,,,100% of Medicare,,452.13,,,,100% of Medicare,,,452.13,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,452.13,1572.3,
"UE additions, spring assisted rotational wrist unit with latch release",L6623,HCPCS,,,,outpatient,,,2559,1535.4,,45.5,,1164.35,percent of total billed charges,,,45.3,,1159.23,percent of total billed charges,,,39,,998.01,percent of total billed charges,,,,,,,,,80,,2047.2,percent of total billed charges,,,61.4,,1571.23,percent of total billed charges,,,57.4,,1468.87,percent of total billed charges,,,81,,2072.79,percent of total billed charges,,,39,,998.01,percent of total billed charges,,,57.6,,1473.98,percent of total billed charges,,,85,,2175.15,percent of total billed charges,,,85,,2175.15,percent of total billed charges,,,49,,1253.91,percent of total billed charges,,,90,,2303.1,percent of total billed charges,,,65,,1663.35,percent of total billed charges,,,80,,2047.2,percent of total billed charges,,,55,,1407.45,percent of total billed charges,,,55,,1407.45,percent of total billed charges,,,65,,1663.35,percent of total billed charges,,,78,,1996.02,percent of total billed charges,,,70,,1791.3,percent of total billed charges,,,,,,,,861.3,,,,100% of Medicare,,861.3,,,,100% of Medicare,,861.3,,,,100% of Medicare,,861.3,,,,100% of Medicare,,861.3,,,,100% of Medicare,,861.3,,,,100% of Medicare,,861.3,,,,100% of Medicare,,861.3,,,,100% of Medicare,,861.3,,,,100% of Medicare,,861.3,,,,100% of Medicare,,861.3,,,,100% of Medicare,,861.3,,,,100% of Medicare,,,861.3,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,861.3,2303.1,
"UE additions, rotation wrist unit with cable lock",L6625,HCPCS,,,,outpatient,,,1846,1107.6,,45.5,,839.93,percent of total billed charges,,,45.3,,836.24,percent of total billed charges,,,39,,719.94,percent of total billed charges,,,,,,,,,80,,1476.8,percent of total billed charges,,,61.4,,1133.44,percent of total billed charges,,,57.4,,1059.6,percent of total billed charges,,,81,,1495.26,percent of total billed charges,,,39,,719.94,percent of total billed charges,,,57.6,,1063.3,percent of total billed charges,,,85,,1569.1,percent of total billed charges,,,85,,1569.1,percent of total billed charges,,,49,,904.54,percent of total billed charges,,,90,,1661.4,percent of total billed charges,,,65,,1199.9,percent of total billed charges,,,80,,1476.8,percent of total billed charges,,,55,,1015.3,percent of total billed charges,,,55,,1015.3,percent of total billed charges,,,65,,1199.9,percent of total billed charges,,,78,,1439.88,percent of total billed charges,,,70,,1292.2,percent of total billed charges,,,,,,,,638.35,,,,100% of Medicare,,638.35,,,,100% of Medicare,,638.35,,,,100% of Medicare,,638.35,,,,100% of Medicare,,638.35,,,,100% of Medicare,,638.35,,,,100% of Medicare,,638.35,,,,100% of Medicare,,638.35,,,,100% of Medicare,,638.35,,,,100% of Medicare,,638.35,,,,100% of Medicare,,638.35,,,,100% of Medicare,,638.35,,,,100% of Medicare,,,638.35,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,638.35,1661.4,
"UE additions, quick disconnect hook adapter, Otto Bock or equal",L6628,HCPCS,,,,outpatient,,,1988,1192.8,,45.5,,904.54,percent of total billed charges,,,45.3,,900.56,percent of total billed charges,,,39,,775.32,percent of total billed charges,,,,,,,,,80,,1590.4,percent of total billed charges,,,61.4,,1220.63,percent of total billed charges,,,57.4,,1141.11,percent of total billed charges,,,81,,1610.28,percent of total billed charges,,,39,,775.32,percent of total billed charges,,,57.6,,1145.09,percent of total billed charges,,,85,,1689.8,percent of total billed charges,,,85,,1689.8,percent of total billed charges,,,49,,974.12,percent of total billed charges,,,90,,1789.2,percent of total billed charges,,,65,,1292.2,percent of total billed charges,,,80,,1590.4,percent of total billed charges,,,55,,1093.4,percent of total billed charges,,,55,,1093.4,percent of total billed charges,,,65,,1292.2,percent of total billed charges,,,78,,1550.64,percent of total billed charges,,,70,,1391.6,percent of total billed charges,,,,,,,,687.12,,,,100% of Medicare,,687.12,,,,100% of Medicare,,687.12,,,,100% of Medicare,,687.12,,,,100% of Medicare,,687.12,,,,100% of Medicare,,687.12,,,,100% of Medicare,,687.12,,,,100% of Medicare,,687.12,,,,100% of Medicare,,687.12,,,,100% of Medicare,,687.12,,,,100% of Medicare,,687.12,,,,100% of Medicare,,687.12,,,,100% of Medicare,,,687.12,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,687.12,1789.2,
"UE additions, quick disconnect lam collar with coupling piece, Otto Bock or equal",L6629,HCPCS,,,,outpatient,,,735,441,,45.5,,334.43,percent of total billed charges,,,45.3,,332.96,percent of total billed charges,,,39,,286.65,percent of total billed charges,,,,,,,,,80,,588,percent of total billed charges,,,61.4,,451.29,percent of total billed charges,,,57.4,,421.89,percent of total billed charges,,,81,,595.35,percent of total billed charges,,,39,,286.65,percent of total billed charges,,,57.6,,423.36,percent of total billed charges,,,85,,624.75,percent of total billed charges,,,85,,624.75,percent of total billed charges,,,49,,360.15,percent of total billed charges,,,90,,661.5,percent of total billed charges,,,65,,477.75,percent of total billed charges,,,80,,588,percent of total billed charges,,,55,,404.25,percent of total billed charges,,,55,,404.25,percent of total billed charges,,,65,,477.75,percent of total billed charges,,,78,,573.3,percent of total billed charges,,,70,,514.5,percent of total billed charges,,,,,,,,234.13,,,,100% of Medicare,,234.13,,,,100% of Medicare,,234.13,,,,100% of Medicare,,234.13,,,,100% of Medicare,,234.13,,,,100% of Medicare,,234.13,,,,100% of Medicare,,234.13,,,,100% of Medicare,,234.13,,,,100% of Medicare,,234.13,,,,100% of Medicare,,234.13,,,,100% of Medicare,,234.13,,,,100% of Medicare,,234.13,,,,100% of Medicare,,,234.13,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,234.13,661.5,
"UE additions, stainless steel, any wrist",L6630,HCPCS,,,,outpatient,,,1048,628.8,,45.5,,476.84,percent of total billed charges,,,45.3,,474.74,percent of total billed charges,,,39,,408.72,percent of total billed charges,,,,,,,,,80,,838.4,percent of total billed charges,,,61.4,,643.47,percent of total billed charges,,,57.4,,601.55,percent of total billed charges,,,81,,848.88,percent of total billed charges,,,39,,408.72,percent of total billed charges,,,57.6,,603.65,percent of total billed charges,,,85,,890.8,percent of total billed charges,,,85,,890.8,percent of total billed charges,,,49,,513.52,percent of total billed charges,,,90,,943.2,percent of total billed charges,,,65,,681.2,percent of total billed charges,,,80,,838.4,percent of total billed charges,,,55,,576.4,percent of total billed charges,,,55,,576.4,percent of total billed charges,,,65,,681.2,percent of total billed charges,,,78,,817.44,percent of total billed charges,,,70,,733.6,percent of total billed charges,,,,,,,,344.9,,,,100% of Medicare,,344.9,,,,100% of Medicare,,344.9,,,,100% of Medicare,,344.9,,,,100% of Medicare,,344.9,,,,100% of Medicare,,344.9,,,,100% of Medicare,,344.9,,,,100% of Medicare,,344.9,,,,100% of Medicare,,344.9,,,,100% of Medicare,,344.9,,,,100% of Medicare,,344.9,,,,100% of Medicare,,344.9,,,,100% of Medicare,,,344.9,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,344.9,943.2,
"UE addition, latex suspension sleeve, each",L6632,HCPCS,,,,outpatient,,,299,179.4,,45.5,,136.05,percent of total billed charges,,,45.3,,135.45,percent of total billed charges,,,39,,116.61,percent of total billed charges,,,,,,,,,80,,239.2,percent of total billed charges,,,61.4,,183.59,percent of total billed charges,,,57.4,,171.63,percent of total billed charges,,,81,,242.19,percent of total billed charges,,,39,,116.61,percent of total billed charges,,,57.6,,172.22,percent of total billed charges,,,85,,254.15,percent of total billed charges,,,85,,254.15,percent of total billed charges,,,49,,146.51,percent of total billed charges,,,90,,269.1,percent of total billed charges,,,65,,194.35,percent of total billed charges,,,80,,239.2,percent of total billed charges,,,55,,164.45,percent of total billed charges,,,55,,164.45,percent of total billed charges,,,65,,194.35,percent of total billed charges,,,78,,233.22,percent of total billed charges,,,70,,209.3,percent of total billed charges,,,,,,,,77.98,,,,100% of Medicare,,77.98,,,,100% of Medicare,,77.98,,,,100% of Medicare,,77.98,,,,100% of Medicare,,77.98,,,,100% of Medicare,,77.98,,,,100% of Medicare,,77.98,,,,100% of Medicare,,77.98,,,,100% of Medicare,,77.98,,,,100% of Medicare,,77.98,,,,100% of Medicare,,77.98,,,,100% of Medicare,,77.98,,,,100% of Medicare,,,77.98,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,77.98,269.1,
"UE addition, lift assist for elbow",L6635,HCPCS,,,,outpatient,,,963,577.8,,45.5,,438.17,percent of total billed charges,,,45.3,,436.24,percent of total billed charges,,,39,,375.57,percent of total billed charges,,,,,,,,,80,,770.4,percent of total billed charges,,,61.4,,591.28,percent of total billed charges,,,57.4,,552.76,percent of total billed charges,,,81,,780.03,percent of total billed charges,,,39,,375.57,percent of total billed charges,,,57.6,,554.69,percent of total billed charges,,,85,,818.55,percent of total billed charges,,,85,,818.55,percent of total billed charges,,,49,,471.87,percent of total billed charges,,,90,,866.7,percent of total billed charges,,,65,,625.95,percent of total billed charges,,,80,,770.4,percent of total billed charges,,,55,,529.65,percent of total billed charges,,,55,,529.65,percent of total billed charges,,,65,,625.95,percent of total billed charges,,,78,,751.14,percent of total billed charges,,,70,,674.1,percent of total billed charges,,,,,,,,249.27,,,,100% of Medicare,,249.27,,,,100% of Medicare,,249.27,,,,100% of Medicare,,249.27,,,,100% of Medicare,,249.27,,,,100% of Medicare,,249.27,,,,100% of Medicare,,249.27,,,,100% of Medicare,,249.27,,,,100% of Medicare,,249.27,,,,100% of Medicare,,249.27,,,,100% of Medicare,,249.27,,,,100% of Medicare,,249.27,,,,100% of Medicare,,,249.27,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,249.27,866.7,
"UE addition, nudge control elbow lock",L6637,HCPCS,,,,outpatient,,,1480,888,,45.5,,673.4,percent of total billed charges,,,45.3,,670.44,percent of total billed charges,,,39,,577.2,percent of total billed charges,,,,,,,,,80,,1184,percent of total billed charges,,,61.4,,908.72,percent of total billed charges,,,57.4,,849.52,percent of total billed charges,,,81,,1198.8,percent of total billed charges,,,39,,577.2,percent of total billed charges,,,57.6,,852.48,percent of total billed charges,,,85,,1258,percent of total billed charges,,,85,,1258,percent of total billed charges,,,49,,725.2,percent of total billed charges,,,90,,1332,percent of total billed charges,,,65,,962,percent of total billed charges,,,80,,1184,percent of total billed charges,,,55,,814,percent of total billed charges,,,55,,814,percent of total billed charges,,,65,,962,percent of total billed charges,,,78,,1154.4,percent of total billed charges,,,70,,1036,percent of total billed charges,,,,,,,,488.04,,,,100% of Medicare,,488.04,,,,100% of Medicare,,488.04,,,,100% of Medicare,,488.04,,,,100% of Medicare,,488.04,,,,100% of Medicare,,488.04,,,,100% of Medicare,,488.04,,,,100% of Medicare,,488.04,,,,100% of Medicare,,488.04,,,,100% of Medicare,,488.04,,,,100% of Medicare,,488.04,,,,100% of Medicare,,488.04,,,,100% of Medicare,,,488.04,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,488.04,1332,
"UE addition, shoulder abduction joint, pair",L6640,HCPCS,,,,outpatient,,,968,580.8,,45.5,,440.44,percent of total billed charges,,,45.3,,438.5,percent of total billed charges,,,39,,377.52,percent of total billed charges,,,,,,,,,80,,774.4,percent of total billed charges,,,61.4,,594.35,percent of total billed charges,,,57.4,,555.63,percent of total billed charges,,,81,,784.08,percent of total billed charges,,,39,,377.52,percent of total billed charges,,,57.6,,557.57,percent of total billed charges,,,85,,822.8,percent of total billed charges,,,85,,822.8,percent of total billed charges,,,49,,474.32,percent of total billed charges,,,90,,871.2,percent of total billed charges,,,65,,629.2,percent of total billed charges,,,80,,774.4,percent of total billed charges,,,55,,532.4,percent of total billed charges,,,55,,532.4,percent of total billed charges,,,65,,629.2,percent of total billed charges,,,78,,755.04,percent of total billed charges,,,70,,677.6,percent of total billed charges,,,,,,,,406.45,,,,100% of Medicare,,406.45,,,,100% of Medicare,,406.45,,,,100% of Medicare,,406.45,,,,100% of Medicare,,406.45,,,,100% of Medicare,,406.45,,,,100% of Medicare,,406.45,,,,100% of Medicare,,406.45,,,,100% of Medicare,,406.45,,,,100% of Medicare,,406.45,,,,100% of Medicare,,406.45,,,,100% of Medicare,,406.45,,,,100% of Medicare,,,406.45,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,377.52,871.2,
"UE addition, excursion amplifier, pulley type",L6641,HCPCS,,,,outpatient,,,719,431.4,,45.5,,327.15,percent of total billed charges,,,45.3,,325.71,percent of total billed charges,,,39,,280.41,percent of total billed charges,,,,,,,,,80,,575.2,percent of total billed charges,,,61.4,,441.47,percent of total billed charges,,,57.4,,412.71,percent of total billed charges,,,81,,582.39,percent of total billed charges,,,39,,280.41,percent of total billed charges,,,57.6,,414.14,percent of total billed charges,,,85,,611.15,percent of total billed charges,,,85,,611.15,percent of total billed charges,,,49,,352.31,percent of total billed charges,,,90,,647.1,percent of total billed charges,,,65,,467.35,percent of total billed charges,,,80,,575.2,percent of total billed charges,,,55,,395.45,percent of total billed charges,,,55,,395.45,percent of total billed charges,,,65,,467.35,percent of total billed charges,,,78,,560.82,percent of total billed charges,,,70,,503.3,percent of total billed charges,,,,,,,,236.68,,,,100% of Medicare,,236.68,,,,100% of Medicare,,236.68,,,,100% of Medicare,,236.68,,,,100% of Medicare,,236.68,,,,100% of Medicare,,236.68,,,,100% of Medicare,,236.68,,,,100% of Medicare,,236.68,,,,100% of Medicare,,236.68,,,,100% of Medicare,,236.68,,,,100% of Medicare,,236.68,,,,100% of Medicare,,236.68,,,,100% of Medicare,,,236.68,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,236.68,647.1,
"UE addition, excursion amplifier, lever type",L6642,HCPCS,,,,outpatient,,,827,496.2,,45.5,,376.29,percent of total billed charges,,,45.3,,374.63,percent of total billed charges,,,39,,322.53,percent of total billed charges,,,,,,,,,80,,661.6,percent of total billed charges,,,61.4,,507.78,percent of total billed charges,,,57.4,,474.7,percent of total billed charges,,,81,,669.87,percent of total billed charges,,,39,,322.53,percent of total billed charges,,,57.6,,476.35,percent of total billed charges,,,85,,702.95,percent of total billed charges,,,85,,702.95,percent of total billed charges,,,49,,405.23,percent of total billed charges,,,90,,744.3,percent of total billed charges,,,65,,537.55,percent of total billed charges,,,80,,661.6,percent of total billed charges,,,55,,454.85,percent of total billed charges,,,55,,454.85,percent of total billed charges,,,65,,537.55,percent of total billed charges,,,78,,645.06,percent of total billed charges,,,70,,578.9,percent of total billed charges,,,,,,,,347.98,,,,100% of Medicare,,347.98,,,,100% of Medicare,,347.98,,,,100% of Medicare,,347.98,,,,100% of Medicare,,347.98,,,,100% of Medicare,,347.98,,,,100% of Medicare,,347.98,,,,100% of Medicare,,347.98,,,,100% of Medicare,,347.98,,,,100% of Medicare,,347.98,,,,100% of Medicare,,347.98,,,,100% of Medicare,,347.98,,,,100% of Medicare,,,347.98,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,322.53,744.3,
"UE addition, shoulder flexion-abduction joint, each",L6645,HCPCS,,,,outpatient,,,1270,762,,45.5,,577.85,percent of total billed charges,,,45.3,,575.31,percent of total billed charges,,,39,,495.3,percent of total billed charges,,,,,,,,,80,,1016,percent of total billed charges,,,61.4,,779.78,percent of total billed charges,,,57.4,,728.98,percent of total billed charges,,,81,,1028.7,percent of total billed charges,,,39,,495.3,percent of total billed charges,,,57.6,,731.52,percent of total billed charges,,,85,,1079.5,percent of total billed charges,,,85,,1079.5,percent of total billed charges,,,49,,622.3,percent of total billed charges,,,90,,1143,percent of total billed charges,,,65,,825.5,percent of total billed charges,,,80,,1016,percent of total billed charges,,,55,,698.5,percent of total billed charges,,,55,,698.5,percent of total billed charges,,,65,,825.5,percent of total billed charges,,,78,,990.6,percent of total billed charges,,,70,,889,percent of total billed charges,,,,,,,,439.56,,,,100% of Medicare,,439.56,,,,100% of Medicare,,439.56,,,,100% of Medicare,,439.56,,,,100% of Medicare,,439.56,,,,100% of Medicare,,439.56,,,,100% of Medicare,,439.56,,,,100% of Medicare,,439.56,,,,100% of Medicare,,439.56,,,,100% of Medicare,,439.56,,,,100% of Medicare,,439.56,,,,100% of Medicare,,439.56,,,,100% of Medicare,,,439.56,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,439.56,1143,
"UE addition, shoulder lock mechanism, body powered actuator",L6647,HCPCS,,,,outpatient,,,1864,1118.4,,45.5,,848.12,percent of total billed charges,,,45.3,,844.39,percent of total billed charges,,,39,,726.96,percent of total billed charges,,,,,,,,,80,,1491.2,percent of total billed charges,,,61.4,,1144.5,percent of total billed charges,,,57.4,,1069.94,percent of total billed charges,,,81,,1509.84,percent of total billed charges,,,39,,726.96,percent of total billed charges,,,57.6,,1073.66,percent of total billed charges,,,85,,1584.4,percent of total billed charges,,,85,,1584.4,percent of total billed charges,,,49,,913.36,percent of total billed charges,,,90,,1677.6,percent of total billed charges,,,65,,1211.6,percent of total billed charges,,,80,,1491.2,percent of total billed charges,,,55,,1025.2,percent of total billed charges,,,55,,1025.2,percent of total billed charges,,,65,,1211.6,percent of total billed charges,,,78,,1453.92,percent of total billed charges,,,70,,1304.8,percent of total billed charges,,,,,,,,626.85,,,,100% of Medicare,,626.85,,,,100% of Medicare,,626.85,,,,100% of Medicare,,626.85,,,,100% of Medicare,,626.85,,,,100% of Medicare,,626.85,,,,100% of Medicare,,626.85,,,,100% of Medicare,,626.85,,,,100% of Medicare,,626.85,,,,100% of Medicare,,626.85,,,,100% of Medicare,,626.85,,,,100% of Medicare,,626.85,,,,100% of Medicare,,,626.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,626.85,1677.6,
"UE addition, shoulder universal joint, each",L6650,HCPCS,,,,outpatient,,,1405,843,,45.5,,639.28,percent of total billed charges,,,45.3,,636.47,percent of total billed charges,,,39,,547.95,percent of total billed charges,,,,,,,,,80,,1124,percent of total billed charges,,,61.4,,862.67,percent of total billed charges,,,57.4,,806.47,percent of total billed charges,,,81,,1138.05,percent of total billed charges,,,39,,547.95,percent of total billed charges,,,57.6,,809.28,percent of total billed charges,,,85,,1194.25,percent of total billed charges,,,85,,1194.25,percent of total billed charges,,,49,,688.45,percent of total billed charges,,,90,,1264.5,percent of total billed charges,,,65,,913.25,percent of total billed charges,,,80,,1124,percent of total billed charges,,,55,,772.75,percent of total billed charges,,,55,,772.75,percent of total billed charges,,,65,,913.25,percent of total billed charges,,,78,,1095.9,percent of total billed charges,,,70,,983.5,percent of total billed charges,,,,,,,,476.75,,,,100% of Medicare,,476.75,,,,100% of Medicare,,476.75,,,,100% of Medicare,,476.75,,,,100% of Medicare,,476.75,,,,100% of Medicare,,476.75,,,,100% of Medicare,,476.75,,,,100% of Medicare,,476.75,,,,100% of Medicare,,476.75,,,,100% of Medicare,,476.75,,,,100% of Medicare,,476.75,,,,100% of Medicare,,476.75,,,,100% of Medicare,,,476.75,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,476.75,1264.5,
"UE addition, standard control cable, extra",L6655,HCPCS,,,,outpatient,,,357,214.2,,45.5,,162.44,percent of total billed charges,,,45.3,,161.72,percent of total billed charges,,,39,,139.23,percent of total billed charges,,,,,,,,,80,,285.6,percent of total billed charges,,,61.4,,219.2,percent of total billed charges,,,57.4,,204.92,percent of total billed charges,,,81,,289.17,percent of total billed charges,,,39,,139.23,percent of total billed charges,,,57.6,,205.63,percent of total billed charges,,,85,,303.45,percent of total billed charges,,,85,,303.45,percent of total billed charges,,,49,,174.93,percent of total billed charges,,,90,,321.3,percent of total billed charges,,,65,,232.05,percent of total billed charges,,,80,,285.6,percent of total billed charges,,,55,,196.35,percent of total billed charges,,,55,,196.35,percent of total billed charges,,,65,,232.05,percent of total billed charges,,,78,,278.46,percent of total billed charges,,,70,,249.9,percent of total billed charges,,,,,,,,92.49,,,,100% of Medicare,,92.49,,,,100% of Medicare,,92.49,,,,100% of Medicare,,92.49,,,,100% of Medicare,,92.49,,,,100% of Medicare,,92.49,,,,100% of Medicare,,92.49,,,,100% of Medicare,,92.49,,,,100% of Medicare,,92.49,,,,100% of Medicare,,92.49,,,,100% of Medicare,,92.49,,,,100% of Medicare,,92.49,,,,100% of Medicare,,,92.49,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,92.49,321.3,
"UE addition, heavy duty control cable",L6660,HCPCS,,,,outpatient,,,481,288.6,,45.5,,218.86,percent of total billed charges,,,45.3,,217.89,percent of total billed charges,,,39,,187.59,percent of total billed charges,,,,,,,,,80,,384.8,percent of total billed charges,,,61.4,,295.33,percent of total billed charges,,,57.4,,276.09,percent of total billed charges,,,81,,389.61,percent of total billed charges,,,39,,187.59,percent of total billed charges,,,57.6,,277.06,percent of total billed charges,,,85,,408.85,percent of total billed charges,,,85,,408.85,percent of total billed charges,,,49,,235.69,percent of total billed charges,,,90,,432.9,percent of total billed charges,,,65,,312.65,percent of total billed charges,,,80,,384.8,percent of total billed charges,,,55,,264.55,percent of total billed charges,,,55,,264.55,percent of total billed charges,,,65,,312.65,percent of total billed charges,,,78,,375.18,percent of total billed charges,,,70,,336.7,percent of total billed charges,,,,,,,,123.76,,,,100% of Medicare,,123.76,,,,100% of Medicare,,123.76,,,,100% of Medicare,,123.76,,,,100% of Medicare,,123.76,,,,100% of Medicare,,123.76,,,,100% of Medicare,,123.76,,,,100% of Medicare,,123.76,,,,100% of Medicare,,123.76,,,,100% of Medicare,,123.76,,,,100% of Medicare,,123.76,,,,100% of Medicare,,123.76,,,,100% of Medicare,,,123.76,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,123.76,432.9,
"UE addition, Teflon or equal, cable lining",L6665,HCPCS,,,,outpatient,,,214,128.4,,45.5,,97.37,percent of total billed charges,,,45.3,,96.94,percent of total billed charges,,,39,,83.46,percent of total billed charges,,,,,,,,,80,,171.2,percent of total billed charges,,,61.4,,131.4,percent of total billed charges,,,57.4,,122.84,percent of total billed charges,,,81,,173.34,percent of total billed charges,,,39,,83.46,percent of total billed charges,,,57.6,,123.26,percent of total billed charges,,,85,,181.9,percent of total billed charges,,,85,,181.9,percent of total billed charges,,,49,,104.86,percent of total billed charges,,,90,,192.6,percent of total billed charges,,,65,,139.1,percent of total billed charges,,,80,,171.2,percent of total billed charges,,,55,,117.7,percent of total billed charges,,,55,,117.7,percent of total billed charges,,,65,,139.1,percent of total billed charges,,,78,,166.92,percent of total billed charges,,,70,,149.8,percent of total billed charges,,,,,,,,55.27,,,,100% of Medicare,,55.27,,,,100% of Medicare,,55.27,,,,100% of Medicare,,55.27,,,,100% of Medicare,,55.27,,,,100% of Medicare,,55.27,,,,100% of Medicare,,55.27,,,,100% of Medicare,,55.27,,,,100% of Medicare,,55.27,,,,100% of Medicare,,55.27,,,,100% of Medicare,,55.27,,,,100% of Medicare,,55.27,,,,100% of Medicare,,,55.27,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,55.27,192.6,
"UE addition, hook to hand, cable adapter",L6670,HCPCS,,,,outpatient,,,225,135,,45.5,,102.38,percent of total billed charges,,,45.3,,101.93,percent of total billed charges,,,39,,87.75,percent of total billed charges,,,,,,,,,80,,180,percent of total billed charges,,,61.4,,138.15,percent of total billed charges,,,57.4,,129.15,percent of total billed charges,,,81,,182.25,percent of total billed charges,,,39,,87.75,percent of total billed charges,,,57.6,,129.6,percent of total billed charges,,,85,,191.25,percent of total billed charges,,,85,,191.25,percent of total billed charges,,,49,,110.25,percent of total billed charges,,,90,,202.5,percent of total billed charges,,,65,,146.25,percent of total billed charges,,,80,,180,percent of total billed charges,,,55,,123.75,percent of total billed charges,,,55,,123.75,percent of total billed charges,,,65,,146.25,percent of total billed charges,,,78,,175.5,percent of total billed charges,,,70,,157.5,percent of total billed charges,,,,,,,,57.56,,,,100% of Medicare,,57.56,,,,100% of Medicare,,57.56,,,,100% of Medicare,,57.56,,,,100% of Medicare,,57.56,,,,100% of Medicare,,57.56,,,,100% of Medicare,,57.56,,,,100% of Medicare,,57.56,,,,100% of Medicare,,57.56,,,,100% of Medicare,,57.56,,,,100% of Medicare,,57.56,,,,100% of Medicare,,57.56,,,,100% of Medicare,,,57.56,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,57.56,202.5,
"UE addition, harness, chest or shoulder, saddle type",L6672,HCPCS,,,,outpatient,,,1051,630.6,,45.5,,478.21,percent of total billed charges,,,45.3,,476.1,percent of total billed charges,,,39,,409.89,percent of total billed charges,,,,,,,,,80,,840.8,percent of total billed charges,,,61.4,,645.31,percent of total billed charges,,,57.4,,603.27,percent of total billed charges,,,81,,851.31,percent of total billed charges,,,39,,409.89,percent of total billed charges,,,57.6,,605.38,percent of total billed charges,,,85,,893.35,percent of total billed charges,,,85,,893.35,percent of total billed charges,,,49,,514.99,percent of total billed charges,,,90,,945.9,percent of total billed charges,,,65,,683.15,percent of total billed charges,,,80,,840.8,percent of total billed charges,,,55,,578.05,percent of total billed charges,,,55,,578.05,percent of total billed charges,,,65,,683.15,percent of total billed charges,,,78,,819.78,percent of total billed charges,,,70,,735.7,percent of total billed charges,,,,,,,,264.15,,,,100% of Medicare,,264.15,,,,100% of Medicare,,264.15,,,,100% of Medicare,,264.15,,,,100% of Medicare,,264.15,,,,100% of Medicare,,264.15,,,,100% of Medicare,,264.15,,,,100% of Medicare,,264.15,,,,100% of Medicare,,264.15,,,,100% of Medicare,,264.15,,,,100% of Medicare,,264.15,,,,100% of Medicare,,264.15,,,,100% of Medicare,,,264.15,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,264.15,945.9,
"UE addition, harness, figure of 8 type, for single control",L6675,HCPCS,,,,outpatient,,,558,334.8,,45.5,,253.89,percent of total billed charges,,,45.3,,252.77,percent of total billed charges,,,39,,217.62,percent of total billed charges,,,,,,,,,80,,446.4,percent of total billed charges,,,61.4,,342.61,percent of total billed charges,,,57.4,,320.29,percent of total billed charges,,,81,,451.98,percent of total billed charges,,,39,,217.62,percent of total billed charges,,,57.6,,321.41,percent of total billed charges,,,85,,474.3,percent of total billed charges,,,85,,474.3,percent of total billed charges,,,49,,273.42,percent of total billed charges,,,90,,502.2,percent of total billed charges,,,65,,362.7,percent of total billed charges,,,80,,446.4,percent of total billed charges,,,55,,306.9,percent of total billed charges,,,55,,306.9,percent of total billed charges,,,65,,362.7,percent of total billed charges,,,78,,435.24,percent of total billed charges,,,70,,390.6,percent of total billed charges,,,,,,,,144.14,,,,100% of Medicare,,144.14,,,,100% of Medicare,,144.14,,,,100% of Medicare,,144.14,,,,100% of Medicare,,144.14,,,,100% of Medicare,,144.14,,,,100% of Medicare,,144.14,,,,100% of Medicare,,144.14,,,,100% of Medicare,,144.14,,,,100% of Medicare,,144.14,,,,100% of Medicare,,144.14,,,,100% of Medicare,,144.14,,,,100% of Medicare,,,144.14,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,144.14,502.2,
"UE addition, harness, figure of 8 type, for dual control",L6676,HCPCS,,,,outpatient,,,585,351,,45.5,,266.18,percent of total billed charges,,,45.3,,265.01,percent of total billed charges,,,39,,228.15,percent of total billed charges,,,,,,,,,80,,468,percent of total billed charges,,,61.4,,359.19,percent of total billed charges,,,57.4,,335.79,percent of total billed charges,,,81,,473.85,percent of total billed charges,,,39,,228.15,percent of total billed charges,,,57.6,,336.96,percent of total billed charges,,,85,,497.25,percent of total billed charges,,,85,,497.25,percent of total billed charges,,,49,,286.65,percent of total billed charges,,,90,,526.5,percent of total billed charges,,,65,,380.25,percent of total billed charges,,,80,,468,percent of total billed charges,,,55,,321.75,percent of total billed charges,,,55,,321.75,percent of total billed charges,,,65,,380.25,percent of total billed charges,,,78,,456.3,percent of total billed charges,,,70,,409.5,percent of total billed charges,,,,,,,,150.8,,,,100% of Medicare,,150.8,,,,100% of Medicare,,150.8,,,,100% of Medicare,,150.8,,,,100% of Medicare,,150.8,,,,100% of Medicare,,150.8,,,,100% of Medicare,,150.8,,,,100% of Medicare,,150.8,,,,100% of Medicare,,150.8,,,,100% of Medicare,,150.8,,,,100% of Medicare,,150.8,,,,100% of Medicare,,150.8,,,,100% of Medicare,,,150.8,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,150.8,526.5,
"L6677 Upper extremity addition,harness,triple control,simultaneous operation of terminal device and",L6677,HCPCS,,,,outpatient,,,798,478.8,,45.5,,363.09,percent of total billed charges,,,45.3,,361.49,percent of total billed charges,,,39,,311.22,percent of total billed charges,,,,,,,,,80,,638.4,percent of total billed charges,,,61.4,,489.97,percent of total billed charges,,,57.4,,458.05,percent of total billed charges,,,81,,646.38,percent of total billed charges,,,39,,311.22,percent of total billed charges,,,57.6,,459.65,percent of total billed charges,,,85,,678.3,percent of total billed charges,,,85,,678.3,percent of total billed charges,,,49,,391.02,percent of total billed charges,,,90,,718.2,percent of total billed charges,,,65,,518.7,percent of total billed charges,,,80,,638.4,percent of total billed charges,,,55,,438.9,percent of total billed charges,,,55,,438.9,percent of total billed charges,,,65,,518.7,percent of total billed charges,,,78,,622.44,percent of total billed charges,,,70,,558.6,percent of total billed charges,,,,,,,,358.1,,,,100% of Medicare,,358.1,,,,100% of Medicare,,358.1,,,,100% of Medicare,,358.1,,,,100% of Medicare,,358.1,,,,100% of Medicare,,358.1,,,,100% of Medicare,,358.1,,,,100% of Medicare,,358.1,,,,100% of Medicare,,358.1,,,,100% of Medicare,,358.1,,,,100% of Medicare,,358.1,,,,100% of Medicare,,358.1,,,,100% of Medicare,,,358.1,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,311.22,718.2,
"UE addition, test socket, wrist disartic or BE",L6680,HCPCS,,,,outpatient,,,1436,861.6,,45.5,,653.38,percent of total billed charges,,,45.3,,650.51,percent of total billed charges,,,39,,560.04,percent of total billed charges,,,,,,,,,80,,1148.8,percent of total billed charges,,,61.4,,881.7,percent of total billed charges,,,57.4,,824.26,percent of total billed charges,,,81,,1163.16,percent of total billed charges,,,39,,560.04,percent of total billed charges,,,57.6,,827.14,percent of total billed charges,,,85,,1220.6,percent of total billed charges,,,85,,1220.6,percent of total billed charges,,,49,,703.64,percent of total billed charges,,,90,,1292.4,percent of total billed charges,,,65,,933.4,percent of total billed charges,,,80,,1148.8,percent of total billed charges,,,55,,789.8,percent of total billed charges,,,55,,789.8,percent of total billed charges,,,65,,933.4,percent of total billed charges,,,78,,1120.08,percent of total billed charges,,,70,,1005.2,percent of total billed charges,,,,,,,,371.28,,,,100% of Medicare,,371.28,,,,100% of Medicare,,371.28,,,,100% of Medicare,,371.28,,,,100% of Medicare,,371.28,,,,100% of Medicare,,371.28,,,,100% of Medicare,,371.28,,,,100% of Medicare,,371.28,,,,100% of Medicare,,371.28,,,,100% of Medicare,,371.28,,,,100% of Medicare,,371.28,,,,100% of Medicare,,371.28,,,,100% of Medicare,,,371.28,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,371.28,1292.4,
"UE addition, test socket, elbow disartic or AE",L6682,HCPCS,,,,outpatient,,,1585,951,,45.5,,721.18,percent of total billed charges,,,45.3,,718.01,percent of total billed charges,,,39,,618.15,percent of total billed charges,,,,,,,,,80,,1268,percent of total billed charges,,,61.4,,973.19,percent of total billed charges,,,57.4,,909.79,percent of total billed charges,,,81,,1283.85,percent of total billed charges,,,39,,618.15,percent of total billed charges,,,57.6,,912.96,percent of total billed charges,,,85,,1347.25,percent of total billed charges,,,85,,1347.25,percent of total billed charges,,,49,,776.65,percent of total billed charges,,,90,,1426.5,percent of total billed charges,,,65,,1030.25,percent of total billed charges,,,80,,1268,percent of total billed charges,,,55,,871.75,percent of total billed charges,,,55,,871.75,percent of total billed charges,,,65,,1030.25,percent of total billed charges,,,78,,1236.3,percent of total billed charges,,,70,,1109.5,percent of total billed charges,,,,,,,,410.5,,,,100% of Medicare,,410.5,,,,100% of Medicare,,410.5,,,,100% of Medicare,,410.5,,,,100% of Medicare,,410.5,,,,100% of Medicare,,410.5,,,,100% of Medicare,,410.5,,,,100% of Medicare,,410.5,,,,100% of Medicare,,410.5,,,,100% of Medicare,,410.5,,,,100% of Medicare,,410.5,,,,100% of Medicare,,410.5,,,,100% of Medicare,,,410.5,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,410.5,1426.5,
"UE addition, test socket, shoulder disartic or interscapular thoracic",L6684,HCPCS,,,,outpatient,,,1614,968.4,,45.5,,734.37,percent of total billed charges,,,45.3,,731.14,percent of total billed charges,,,39,,629.46,percent of total billed charges,,,,,,,,,80,,1291.2,percent of total billed charges,,,61.4,,991,percent of total billed charges,,,57.4,,926.44,percent of total billed charges,,,81,,1307.34,percent of total billed charges,,,39,,629.46,percent of total billed charges,,,57.6,,929.66,percent of total billed charges,,,85,,1371.9,percent of total billed charges,,,85,,1371.9,percent of total billed charges,,,49,,790.86,percent of total billed charges,,,90,,1452.6,percent of total billed charges,,,65,,1049.1,percent of total billed charges,,,80,,1291.2,percent of total billed charges,,,55,,887.7,percent of total billed charges,,,55,,887.7,percent of total billed charges,,,65,,1049.1,percent of total billed charges,,,78,,1258.92,percent of total billed charges,,,70,,1129.8,percent of total billed charges,,,,,,,,557.82,,,,100% of Medicare,,557.82,,,,100% of Medicare,,557.82,,,,100% of Medicare,,557.82,,,,100% of Medicare,,557.82,,,,100% of Medicare,,557.82,,,,100% of Medicare,,557.82,,,,100% of Medicare,,557.82,,,,100% of Medicare,,557.82,,,,100% of Medicare,,557.82,,,,100% of Medicare,,557.82,,,,100% of Medicare,,557.82,,,,100% of Medicare,,,557.82,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,557.82,1452.6,
"UE addition, suction socket",L6686,HCPCS,,,,outpatient,,,3292,1975.2,,45.5,,1497.86,percent of total billed charges,,,45.3,,1491.28,percent of total billed charges,,,39,,1283.88,percent of total billed charges,,,,,,,,,80,,2633.6,percent of total billed charges,,,61.4,,2021.29,percent of total billed charges,,,57.4,,1889.61,percent of total billed charges,,,81,,2666.52,percent of total billed charges,,,39,,1283.88,percent of total billed charges,,,57.6,,1896.19,percent of total billed charges,,,85,,2798.2,percent of total billed charges,,,85,,2798.2,percent of total billed charges,,,49,,1613.08,percent of total billed charges,,,90,,2962.8,percent of total billed charges,,,65,,2139.8,percent of total billed charges,,,80,,2633.6,percent of total billed charges,,,55,,1810.6,percent of total billed charges,,,55,,1810.6,percent of total billed charges,,,65,,2139.8,percent of total billed charges,,,78,,2567.76,percent of total billed charges,,,70,,2304.4,percent of total billed charges,,,,,,,,827.74,,,,100% of Medicare,,827.74,,,,100% of Medicare,,827.74,,,,100% of Medicare,,827.74,,,,100% of Medicare,,827.74,,,,100% of Medicare,,827.74,,,,100% of Medicare,,827.74,,,,100% of Medicare,,827.74,,,,100% of Medicare,,827.74,,,,100% of Medicare,,827.74,,,,100% of Medicare,,827.74,,,,100% of Medicare,,827.74,,,,100% of Medicare,,,827.74,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,827.74,2962.8,
"UE addition, frame type socket, BE or wrist disartic",L6687,HCPCS,,,,outpatient,,,2171,1302.6,,45.5,,987.81,percent of total billed charges,,,45.3,,983.46,percent of total billed charges,,,39,,846.69,percent of total billed charges,,,,,,,,,80,,1736.8,percent of total billed charges,,,61.4,,1332.99,percent of total billed charges,,,57.4,,1246.15,percent of total billed charges,,,81,,1758.51,percent of total billed charges,,,39,,846.69,percent of total billed charges,,,57.6,,1250.5,percent of total billed charges,,,85,,1845.35,percent of total billed charges,,,85,,1845.35,percent of total billed charges,,,49,,1063.79,percent of total billed charges,,,90,,1953.9,percent of total billed charges,,,65,,1411.15,percent of total billed charges,,,80,,1736.8,percent of total billed charges,,,55,,1194.05,percent of total billed charges,,,55,,1194.05,percent of total billed charges,,,65,,1411.15,percent of total billed charges,,,78,,1693.38,percent of total billed charges,,,70,,1519.7,percent of total billed charges,,,,,,,,692.31,,,,100% of Medicare,,692.31,,,,100% of Medicare,,692.31,,,,100% of Medicare,,692.31,,,,100% of Medicare,,692.31,,,,100% of Medicare,,692.31,,,,100% of Medicare,,692.31,,,,100% of Medicare,,692.31,,,,100% of Medicare,,692.31,,,,100% of Medicare,,692.31,,,,100% of Medicare,,692.31,,,,100% of Medicare,,692.31,,,,100% of Medicare,,,692.31,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,692.31,1953.9,
"UE addition, frame type socket, AE or elbow disartic",L6688,HCPCS,,,,outpatient,,,2328,1396.8,,45.5,,1059.24,percent of total billed charges,,,45.3,,1054.58,percent of total billed charges,,,39,,907.92,percent of total billed charges,,,,,,,,,80,,1862.4,percent of total billed charges,,,61.4,,1429.39,percent of total billed charges,,,57.4,,1336.27,percent of total billed charges,,,81,,1885.68,percent of total billed charges,,,39,,907.92,percent of total billed charges,,,57.6,,1340.93,percent of total billed charges,,,85,,1978.8,percent of total billed charges,,,85,,1978.8,percent of total billed charges,,,49,,1140.72,percent of total billed charges,,,90,,2095.2,percent of total billed charges,,,65,,1513.2,percent of total billed charges,,,80,,1862.4,percent of total billed charges,,,55,,1280.4,percent of total billed charges,,,55,,1280.4,percent of total billed charges,,,65,,1513.2,percent of total billed charges,,,78,,1815.84,percent of total billed charges,,,70,,1629.6,percent of total billed charges,,,,,,,,766.21,,,,100% of Medicare,,766.21,,,,100% of Medicare,,766.21,,,,100% of Medicare,,766.21,,,,100% of Medicare,,766.21,,,,100% of Medicare,,766.21,,,,100% of Medicare,,766.21,,,,100% of Medicare,,766.21,,,,100% of Medicare,,766.21,,,,100% of Medicare,,766.21,,,,100% of Medicare,,766.21,,,,100% of Medicare,,766.21,,,,100% of Medicare,,,766.21,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,766.21,2095.2,
"UE addition, frame type socket, shoulder disartic",L6689,HCPCS,,,,outpatient,,,2711,1626.6,,45.5,,1233.51,percent of total billed charges,,,45.3,,1228.08,percent of total billed charges,,,39,,1057.29,percent of total billed charges,,,,,,,,,80,,2168.8,percent of total billed charges,,,61.4,,1664.55,percent of total billed charges,,,57.4,,1556.11,percent of total billed charges,,,81,,2195.91,percent of total billed charges,,,39,,1057.29,percent of total billed charges,,,57.6,,1561.54,percent of total billed charges,,,85,,2304.35,percent of total billed charges,,,85,,2304.35,percent of total billed charges,,,49,,1328.39,percent of total billed charges,,,90,,2439.9,percent of total billed charges,,,65,,1762.15,percent of total billed charges,,,80,,2168.8,percent of total billed charges,,,55,,1491.05,percent of total billed charges,,,55,,1491.05,percent of total billed charges,,,65,,1762.15,percent of total billed charges,,,78,,2114.58,percent of total billed charges,,,70,,1897.7,percent of total billed charges,,,,,,,,913.18,,,,100% of Medicare,,913.18,,,,100% of Medicare,,913.18,,,,100% of Medicare,,913.18,,,,100% of Medicare,,913.18,,,,100% of Medicare,,913.18,,,,100% of Medicare,,913.18,,,,100% of Medicare,,913.18,,,,100% of Medicare,,913.18,,,,100% of Medicare,,913.18,,,,100% of Medicare,,913.18,,,,100% of Medicare,,913.18,,,,100% of Medicare,,,913.18,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,913.18,2439.9,
"UE addition, frame type socket, interscapular-thoracic",L6690,HCPCS,,,,outpatient,,,2561,1536.6,,45.5,,1165.26,percent of total billed charges,,,45.3,,1160.13,percent of total billed charges,,,39,,998.79,percent of total billed charges,,,,,,,,,80,,2048.8,percent of total billed charges,,,61.4,,1572.45,percent of total billed charges,,,57.4,,1470.01,percent of total billed charges,,,81,,2074.41,percent of total billed charges,,,39,,998.79,percent of total billed charges,,,57.6,,1475.14,percent of total billed charges,,,85,,2176.85,percent of total billed charges,,,85,,2176.85,percent of total billed charges,,,49,,1254.89,percent of total billed charges,,,90,,2304.9,percent of total billed charges,,,65,,1664.65,percent of total billed charges,,,80,,2048.8,percent of total billed charges,,,55,,1408.55,percent of total billed charges,,,55,,1408.55,percent of total billed charges,,,65,,1664.65,percent of total billed charges,,,78,,1997.58,percent of total billed charges,,,70,,1792.7,percent of total billed charges,,,,,,,,1075.13,,,,100% of Medicare,,1075.13,,,,100% of Medicare,,1075.13,,,,100% of Medicare,,1075.13,,,,100% of Medicare,,1075.13,,,,100% of Medicare,,1075.13,,,,100% of Medicare,,1075.13,,,,100% of Medicare,,1075.13,,,,100% of Medicare,,1075.13,,,,100% of Medicare,,1075.13,,,,100% of Medicare,,1075.13,,,,100% of Medicare,,1075.13,,,,100% of Medicare,,,1075.13,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,998.79,2304.9,
"UE addition, removable insert",L6691,HCPCS,,,,outpatient,,,1690,1014,,45.5,,768.95,percent of total billed charges,,,45.3,,765.57,percent of total billed charges,,,39,,659.1,percent of total billed charges,,,,,,,,,80,,1352,percent of total billed charges,,,61.4,,1037.66,percent of total billed charges,,,57.4,,970.06,percent of total billed charges,,,81,,1368.9,percent of total billed charges,,,39,,659.1,percent of total billed charges,,,57.6,,973.44,percent of total billed charges,,,85,,1436.5,percent of total billed charges,,,85,,1436.5,percent of total billed charges,,,49,,828.1,percent of total billed charges,,,90,,1521,percent of total billed charges,,,65,,1098.5,percent of total billed charges,,,80,,1352,percent of total billed charges,,,55,,929.5,percent of total billed charges,,,55,,929.5,percent of total billed charges,,,65,,1098.5,percent of total billed charges,,,78,,1318.2,percent of total billed charges,,,70,,1183,percent of total billed charges,,,,,,,,424.39,,,,100% of Medicare,,424.39,,,,100% of Medicare,,424.39,,,,100% of Medicare,,424.39,,,,100% of Medicare,,424.39,,,,100% of Medicare,,424.39,,,,100% of Medicare,,424.39,,,,100% of Medicare,,424.39,,,,100% of Medicare,,424.39,,,,100% of Medicare,,424.39,,,,100% of Medicare,,424.39,,,,100% of Medicare,,424.39,,,,100% of Medicare,,,424.39,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,424.39,1521,
"UE addition, silicone gel insert or equal, each",L6692,HCPCS,,,,outpatient,,,2231,1338.6,,45.5,,1015.11,percent of total billed charges,,,45.3,,1010.64,percent of total billed charges,,,39,,870.09,percent of total billed charges,,,,,,,,,80,,1784.8,percent of total billed charges,,,61.4,,1369.83,percent of total billed charges,,,57.4,,1280.59,percent of total billed charges,,,81,,1807.11,percent of total billed charges,,,39,,870.09,percent of total billed charges,,,57.6,,1285.06,percent of total billed charges,,,85,,1896.35,percent of total billed charges,,,85,,1896.35,percent of total billed charges,,,49,,1093.19,percent of total billed charges,,,90,,2007.9,percent of total billed charges,,,65,,1450.15,percent of total billed charges,,,80,,1784.8,percent of total billed charges,,,55,,1227.05,percent of total billed charges,,,55,,1227.05,percent of total billed charges,,,65,,1450.15,percent of total billed charges,,,78,,1740.18,percent of total billed charges,,,70,,1561.7,percent of total billed charges,,,,,,,,772.09,,,,100% of Medicare,,772.09,,,,100% of Medicare,,772.09,,,,100% of Medicare,,772.09,,,,100% of Medicare,,772.09,,,,100% of Medicare,,772.09,,,,100% of Medicare,,772.09,,,,100% of Medicare,,772.09,,,,100% of Medicare,,772.09,,,,100% of Medicare,,772.09,,,,100% of Medicare,,772.09,,,,100% of Medicare,,772.09,,,,100% of Medicare,,,772.09,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,772.09,2007.9,
"UE Addition, BE/AE, custom fab from mold or prefab, socket insert, silicone gel, elasto or equal, w/",L6694,HCPCS,,,,outpatient,,,2972,1783.2,,45.5,,1352.26,percent of total billed charges,,,45.3,,1346.32,percent of total billed charges,,,39,,1159.08,percent of total billed charges,,,,,,,,,80,,2377.6,percent of total billed charges,,,61.4,,1824.81,percent of total billed charges,,,57.4,,1705.93,percent of total billed charges,,,81,,2407.32,percent of total billed charges,,,39,,1159.08,percent of total billed charges,,,57.6,,1711.87,percent of total billed charges,,,85,,2526.2,percent of total billed charges,,,85,,2526.2,percent of total billed charges,,,49,,1456.28,percent of total billed charges,,,90,,2674.8,percent of total billed charges,,,65,,1931.8,percent of total billed charges,,,80,,2377.6,percent of total billed charges,,,55,,1634.6,percent of total billed charges,,,55,,1634.6,percent of total billed charges,,,65,,1931.8,percent of total billed charges,,,78,,2318.16,percent of total billed charges,,,70,,2080.4,percent of total billed charges,,,,,,,,948.84,,,,100% of Medicare,,948.84,,,,100% of Medicare,,948.84,,,,100% of Medicare,,948.84,,,,100% of Medicare,,948.84,,,,100% of Medicare,,948.84,,,,100% of Medicare,,948.84,,,,100% of Medicare,,948.84,,,,100% of Medicare,,948.84,,,,100% of Medicare,,948.84,,,,100% of Medicare,,948.84,,,,100% of Medicare,,948.84,,,,100% of Medicare,,,948.84,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,948.84,2674.8,
"UE Addition, BE/AE, custom fab from mold or prefab, socket insert, silicone gel, elasto or equal, no",L6695,HCPCS,,,,outpatient,,,1884,1130.4,,45.5,,857.22,percent of total billed charges,,,45.3,,853.45,percent of total billed charges,,,39,,734.76,percent of total billed charges,,,,,,,,,80,,1507.2,percent of total billed charges,,,61.4,,1156.78,percent of total billed charges,,,57.4,,1081.42,percent of total billed charges,,,81,,1526.04,percent of total billed charges,,,39,,734.76,percent of total billed charges,,,57.6,,1085.18,percent of total billed charges,,,85,,1601.4,percent of total billed charges,,,85,,1601.4,percent of total billed charges,,,49,,923.16,percent of total billed charges,,,90,,1695.6,percent of total billed charges,,,65,,1224.6,percent of total billed charges,,,80,,1507.2,percent of total billed charges,,,55,,1036.2,percent of total billed charges,,,55,,1036.2,percent of total billed charges,,,65,,1224.6,percent of total billed charges,,,78,,1469.52,percent of total billed charges,,,70,,1318.8,percent of total billed charges,,,,,,,,790.68,,,,100% of Medicare,,790.68,,,,100% of Medicare,,790.68,,,,100% of Medicare,,790.68,,,,100% of Medicare,,790.68,,,,100% of Medicare,,790.68,,,,100% of Medicare,,790.68,,,,100% of Medicare,,790.68,,,,100% of Medicare,,790.68,,,,100% of Medicare,,790.68,,,,100% of Medicare,,790.68,,,,100% of Medicare,,790.68,,,,100% of Medicare,,,790.68,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,734.76,1695.6,
"UE Addition, BE/AE, custom fab socket insert for congen/atyp, socket insert, silicone gel, elasto or",L6696,HCPCS,,,,outpatient,,,3784,2270.4,,45.5,,1721.72,percent of total billed charges,,,45.3,,1714.15,percent of total billed charges,,,39,,1475.76,percent of total billed charges,,,,,,,,,80,,3027.2,percent of total billed charges,,,61.4,,2323.38,percent of total billed charges,,,57.4,,2172.02,percent of total billed charges,,,81,,3065.04,percent of total billed charges,,,39,,1475.76,percent of total billed charges,,,57.6,,2179.58,percent of total billed charges,,,85,,3216.4,percent of total billed charges,,,85,,3216.4,percent of total billed charges,,,49,,1854.16,percent of total billed charges,,,90,,3405.6,percent of total billed charges,,,65,,2459.6,percent of total billed charges,,,80,,3027.2,percent of total billed charges,,,55,,2081.2,percent of total billed charges,,,55,,2081.2,percent of total billed charges,,,65,,2459.6,percent of total billed charges,,,78,,2951.52,percent of total billed charges,,,70,,2648.8,percent of total billed charges,,,,,,,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,,1587.98,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1475.76,3405.6,
"UE Addition, BE/AE, custom fab socket insert for other than congen/atyp, silicone gel, elasto or equ",L6697,HCPCS,,,,outpatient,,,3784,2270.4,,45.5,,1721.72,percent of total billed charges,,,45.3,,1714.15,percent of total billed charges,,,39,,1475.76,percent of total billed charges,,,,,,,,,80,,3027.2,percent of total billed charges,,,61.4,,2323.38,percent of total billed charges,,,57.4,,2172.02,percent of total billed charges,,,81,,3065.04,percent of total billed charges,,,39,,1475.76,percent of total billed charges,,,57.6,,2179.58,percent of total billed charges,,,85,,3216.4,percent of total billed charges,,,85,,3216.4,percent of total billed charges,,,49,,1854.16,percent of total billed charges,,,90,,3405.6,percent of total billed charges,,,65,,2459.6,percent of total billed charges,,,80,,3027.2,percent of total billed charges,,,55,,2081.2,percent of total billed charges,,,55,,2081.2,percent of total billed charges,,,65,,2459.6,percent of total billed charges,,,78,,2951.52,percent of total billed charges,,,70,,2648.8,percent of total billed charges,,,,,,,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,1587.98,,,,100% of Medicare,,,1587.98,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1475.76,3405.6,
"UE Addition, BE/AE suspension locking mech, excludes socket insert",L6698,HCPCS,,,,outpatient,,,2393,1435.8,,45.5,,1088.82,percent of total billed charges,,,45.3,,1084.03,percent of total billed charges,,,39,,933.27,percent of total billed charges,,,,,,,,,80,,1914.4,percent of total billed charges,,,61.4,,1469.3,percent of total billed charges,,,57.4,,1373.58,percent of total billed charges,,,81,,1938.33,percent of total billed charges,,,39,,933.27,percent of total billed charges,,,57.6,,1378.37,percent of total billed charges,,,85,,2034.05,percent of total billed charges,,,85,,2034.05,percent of total billed charges,,,49,,1172.57,percent of total billed charges,,,90,,2153.7,percent of total billed charges,,,65,,1555.45,percent of total billed charges,,,80,,1914.4,percent of total billed charges,,,55,,1316.15,percent of total billed charges,,,55,,1316.15,percent of total billed charges,,,65,,1555.45,percent of total billed charges,,,78,,1866.54,percent of total billed charges,,,70,,1675.1,percent of total billed charges,,,,,,,,597.02,,,,100% of Medicare,,597.02,,,,100% of Medicare,,597.02,,,,100% of Medicare,,597.02,,,,100% of Medicare,,597.02,,,,100% of Medicare,,597.02,,,,100% of Medicare,,597.02,,,,100% of Medicare,,597.02,,,,100% of Medicare,,597.02,,,,100% of Medicare,,597.02,,,,100% of Medicare,,597.02,,,,100% of Medicare,,597.02,,,,100% of Medicare,,,597.02,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,597.02,2153.7,
"Terminal device, passive hand/mitt",L6703,HCPCS,,,,outpatient,,,1685,1011,,45.5,,766.68,percent of total billed charges,,,45.3,,763.31,percent of total billed charges,,,39,,657.15,percent of total billed charges,,,,,,,,,80,,1348,percent of total billed charges,,,61.4,,1034.59,percent of total billed charges,,,57.4,,967.19,percent of total billed charges,,,81,,1364.85,percent of total billed charges,,,39,,657.15,percent of total billed charges,,,57.6,,970.56,percent of total billed charges,,,85,,1432.25,percent of total billed charges,,,85,,1432.25,percent of total billed charges,,,49,,825.65,percent of total billed charges,,,90,,1516.5,percent of total billed charges,,,65,,1095.25,percent of total billed charges,,,80,,1348,percent of total billed charges,,,55,,926.75,percent of total billed charges,,,55,,926.75,percent of total billed charges,,,65,,1095.25,percent of total billed charges,,,78,,1314.3,percent of total billed charges,,,70,,1179.5,percent of total billed charges,,,,,,,,422.25,,,,100% of Medicare,,422.25,,,,100% of Medicare,,422.25,,,,100% of Medicare,,422.25,,,,100% of Medicare,,422.25,,,,100% of Medicare,,422.25,,,,100% of Medicare,,422.25,,,,100% of Medicare,,422.25,,,,100% of Medicare,,422.25,,,,100% of Medicare,,422.25,,,,100% of Medicare,,422.25,,,,100% of Medicare,,422.25,,,,100% of Medicare,,,422.25,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,422.25,1516.5,
"Terminal device, sport/recreational/work attachmt",L6704,HCPCS,,,,outpatient,,,3548,2128.8,,45.5,,1614.34,percent of total billed charges,,,45.3,,1607.24,percent of total billed charges,,,39,,1383.72,percent of total billed charges,,,,,,,,,80,,2838.4,percent of total billed charges,,,61.4,,2178.47,percent of total billed charges,,,57.4,,2036.55,percent of total billed charges,,,81,,2873.88,percent of total billed charges,,,39,,1383.72,percent of total billed charges,,,57.6,,2043.65,percent of total billed charges,,,85,,3015.8,percent of total billed charges,,,85,,3015.8,percent of total billed charges,,,49,,1738.52,percent of total billed charges,,,90,,3193.2,percent of total billed charges,,,65,,2306.2,percent of total billed charges,,,80,,2838.4,percent of total billed charges,,,55,,1951.4,percent of total billed charges,,,55,,1951.4,percent of total billed charges,,,65,,2306.2,percent of total billed charges,,,78,,2767.44,percent of total billed charges,,,70,,2483.6,percent of total billed charges,,,,,,,,815.05,,,,100% of Medicare,,815.05,,,,100% of Medicare,,815.05,,,,100% of Medicare,,815.05,,,,100% of Medicare,,815.05,,,,100% of Medicare,,815.05,,,,100% of Medicare,,815.05,,,,100% of Medicare,,815.05,,,,100% of Medicare,,815.05,,,,100% of Medicare,,815.05,,,,100% of Medicare,,815.05,,,,100% of Medicare,,815.05,,,,100% of Medicare,,,815.05,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,815.05,3193.2,
"Terminal device, hook voluntary opening",L6706,HCPCS,,,,outpatient,,,2088,1252.8,,45.5,,950.04,percent of total billed charges,,,45.3,,945.86,percent of total billed charges,,,39,,814.32,percent of total billed charges,,,,,,,,,80,,1670.4,percent of total billed charges,,,61.4,,1282.03,percent of total billed charges,,,57.4,,1198.51,percent of total billed charges,,,81,,1691.28,percent of total billed charges,,,39,,814.32,percent of total billed charges,,,57.6,,1202.69,percent of total billed charges,,,85,,1774.8,percent of total billed charges,,,85,,1774.8,percent of total billed charges,,,49,,1023.12,percent of total billed charges,,,90,,1879.2,percent of total billed charges,,,65,,1357.2,percent of total billed charges,,,80,,1670.4,percent of total billed charges,,,55,,1148.4,percent of total billed charges,,,55,,1148.4,percent of total billed charges,,,65,,1357.2,percent of total billed charges,,,78,,1628.64,percent of total billed charges,,,70,,1461.6,percent of total billed charges,,,,,,,,505.79,,,,100% of Medicare,,505.79,,,,100% of Medicare,,505.79,,,,100% of Medicare,,505.79,,,,100% of Medicare,,505.79,,,,100% of Medicare,,505.79,,,,100% of Medicare,,505.79,,,,100% of Medicare,,505.79,,,,100% of Medicare,,505.79,,,,100% of Medicare,,505.79,,,,100% of Medicare,,505.79,,,,100% of Medicare,,505.79,,,,100% of Medicare,,,505.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,505.79,1879.2,
"Terminal device, hook, voluntery closing",L6707,HCPCS,,,,outpatient,,,5221,3132.6,,45.5,,2375.56,percent of total billed charges,,,45.3,,2365.11,percent of total billed charges,,,39,,2036.19,percent of total billed charges,,,,,,,,,80,,4176.8,percent of total billed charges,,,61.4,,3205.69,percent of total billed charges,,,57.4,,2996.85,percent of total billed charges,,,81,,4229.01,percent of total billed charges,,,39,,2036.19,percent of total billed charges,,,57.6,,3007.3,percent of total billed charges,,,85,,4437.85,percent of total billed charges,,,85,,4437.85,percent of total billed charges,,,49,,2558.29,percent of total billed charges,,,90,,4698.9,percent of total billed charges,,,65,,3393.65,percent of total billed charges,,,80,,4176.8,percent of total billed charges,,,55,,2871.55,percent of total billed charges,,,55,,2871.55,percent of total billed charges,,,65,,3393.65,percent of total billed charges,,,78,,4072.38,percent of total billed charges,,,70,,3654.7,percent of total billed charges,,,,,,,,1789.26,,,,100% of Medicare,,1789.26,,,,100% of Medicare,,1789.26,,,,100% of Medicare,,1789.26,,,,100% of Medicare,,1789.26,,,,100% of Medicare,,1789.26,,,,100% of Medicare,,1789.26,,,,100% of Medicare,,1789.26,,,,100% of Medicare,,1789.26,,,,100% of Medicare,,1789.26,,,,100% of Medicare,,1789.26,,,,100% of Medicare,,1789.26,,,,100% of Medicare,,,1789.26,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1789.26,4698.9,
"Terminal device, hand, voluntary opening",L6708,HCPCS,,,,outpatient,,,3418,2050.8,,45.5,,1555.19,percent of total billed charges,,,45.3,,1548.35,percent of total billed charges,,,39,,1333.02,percent of total billed charges,,,,,,,,,80,,2734.4,percent of total billed charges,,,61.4,,2098.65,percent of total billed charges,,,57.4,,1961.93,percent of total billed charges,,,81,,2768.58,percent of total billed charges,,,39,,1333.02,percent of total billed charges,,,57.6,,1968.77,percent of total billed charges,,,85,,2905.3,percent of total billed charges,,,85,,2905.3,percent of total billed charges,,,49,,1674.82,percent of total billed charges,,,90,,3076.2,percent of total billed charges,,,65,,2221.7,percent of total billed charges,,,80,,2734.4,percent of total billed charges,,,55,,1879.9,percent of total billed charges,,,55,,1879.9,percent of total billed charges,,,65,,2221.7,percent of total billed charges,,,78,,2666.04,percent of total billed charges,,,70,,2392.6,percent of total billed charges,,,,,,,,1182.76,,,,100% of Medicare,,1182.76,,,,100% of Medicare,,1182.76,,,,100% of Medicare,,1182.76,,,,100% of Medicare,,1182.76,,,,100% of Medicare,,1182.76,,,,100% of Medicare,,1182.76,,,,100% of Medicare,,1182.76,,,,100% of Medicare,,1182.76,,,,100% of Medicare,,1182.76,,,,100% of Medicare,,1182.76,,,,100% of Medicare,,1182.76,,,,100% of Medicare,,,1182.76,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1182.76,3076.2,
PED TERM DEV HOOK VOL OPEN,L6711,HCPCS,,,,outpatient,,,2369,1421.4,,45.5,,1077.9,percent of total billed charges,,,45.3,,1073.16,percent of total billed charges,,,39,,923.91,percent of total billed charges,,,,,,,,,80,,1895.2,percent of total billed charges,,,61.4,,1454.57,percent of total billed charges,,,57.4,,1359.81,percent of total billed charges,,,81,,1918.89,percent of total billed charges,,,39,,923.91,percent of total billed charges,,,57.6,,1364.54,percent of total billed charges,,,85,,2013.65,percent of total billed charges,,,85,,2013.65,percent of total billed charges,,,49,,1160.81,percent of total billed charges,,,90,,2132.1,percent of total billed charges,,,65,,1539.85,percent of total billed charges,,,80,,1895.2,percent of total billed charges,,,55,,1302.95,percent of total billed charges,,,55,,1302.95,percent of total billed charges,,,65,,1539.85,percent of total billed charges,,,78,,1847.82,percent of total billed charges,,,70,,1658.3,percent of total billed charges,,,,,,,,811.62,,,,100% of Medicare,,811.62,,,,100% of Medicare,,811.62,,,,100% of Medicare,,811.62,,,,100% of Medicare,,811.62,,,,100% of Medicare,,811.62,,,,100% of Medicare,,811.62,,,,100% of Medicare,,811.62,,,,100% of Medicare,,811.62,,,,100% of Medicare,,811.62,,,,100% of Medicare,,811.62,,,,100% of Medicare,,811.62,,,,100% of Medicare,,,811.62,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,811.62,2132.1,
PED TERM DEV HOOK VOL CLOS L6712,L6712,HCPCS,,,,outpatient,,,3789,2273.4,,45.5,,1724,percent of total billed charges,,,45.3,,1716.42,percent of total billed charges,,,39,,1477.71,percent of total billed charges,,,,,,,,,80,,3031.2,percent of total billed charges,,,61.4,,2326.45,percent of total billed charges,,,57.4,,2174.89,percent of total billed charges,,,81,,3069.09,percent of total billed charges,,,39,,1477.71,percent of total billed charges,,,57.6,,2182.46,percent of total billed charges,,,85,,3220.65,percent of total billed charges,,,85,,3220.65,percent of total billed charges,,,49,,1856.61,percent of total billed charges,,,90,,3410.1,percent of total billed charges,,,65,,2462.85,percent of total billed charges,,,80,,3031.2,percent of total billed charges,,,55,,2083.95,percent of total billed charges,,,55,,2083.95,percent of total billed charges,,,65,,2462.85,percent of total billed charges,,,78,,2955.42,percent of total billed charges,,,70,,2652.3,percent of total billed charges,,,,,,,,1494.39,,,,100% of Medicare,,1494.39,,,,100% of Medicare,,1494.39,,,,100% of Medicare,,1494.39,,,,100% of Medicare,,1494.39,,,,100% of Medicare,,1494.39,,,,100% of Medicare,,1494.39,,,,100% of Medicare,,1494.39,,,,100% of Medicare,,1494.39,,,,100% of Medicare,,1494.39,,,,100% of Medicare,,1494.39,,,,100% of Medicare,,1494.39,,,,100% of Medicare,,,1494.39,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1477.71,3410.1,
"Terminal device, modifier wrist flexion",L6805,HCPCS,,,,outpatient,,,1806,1083.6,,45.5,,821.73,percent of total billed charges,,,45.3,,818.12,percent of total billed charges,,,39,,704.34,percent of total billed charges,,,,,,,,,80,,1444.8,percent of total billed charges,,,61.4,,1108.88,percent of total billed charges,,,57.4,,1036.64,percent of total billed charges,,,81,,1462.86,percent of total billed charges,,,39,,704.34,percent of total billed charges,,,57.6,,1040.26,percent of total billed charges,,,85,,1535.1,percent of total billed charges,,,85,,1535.1,percent of total billed charges,,,49,,884.94,percent of total billed charges,,,90,,1625.4,percent of total billed charges,,,65,,1173.9,percent of total billed charges,,,80,,1444.8,percent of total billed charges,,,55,,993.3,percent of total billed charges,,,55,,993.3,percent of total billed charges,,,65,,1173.9,percent of total billed charges,,,78,,1408.68,percent of total billed charges,,,70,,1264.2,percent of total billed charges,,,,,,,,463,,,,100% of Medicare,,463,,,,100% of Medicare,,463,,,,100% of Medicare,,463,,,,100% of Medicare,,463,,,,100% of Medicare,,463,,,,100% of Medicare,,463,,,,100% of Medicare,,463,,,,100% of Medicare,,463,,,,100% of Medicare,,463,,,,100% of Medicare,,463,,,,100% of Medicare,,463,,,,100% of Medicare,,,463,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,463,1625.4,
"Terminal device, pincher tool, Otto Bock or equal",L6810,HCPCS,,,,outpatient,,,718,430.8,,45.5,,326.69,percent of total billed charges,,,45.3,,325.25,percent of total billed charges,,,39,,280.02,percent of total billed charges,,,,,,,,,80,,574.4,percent of total billed charges,,,61.4,,440.85,percent of total billed charges,,,57.4,,412.13,percent of total billed charges,,,81,,581.58,percent of total billed charges,,,39,,280.02,percent of total billed charges,,,57.6,,413.57,percent of total billed charges,,,85,,610.3,percent of total billed charges,,,85,,610.3,percent of total billed charges,,,49,,351.82,percent of total billed charges,,,90,,646.2,percent of total billed charges,,,65,,466.7,percent of total billed charges,,,80,,574.4,percent of total billed charges,,,55,,394.9,percent of total billed charges,,,55,,394.9,percent of total billed charges,,,65,,466.7,percent of total billed charges,,,78,,560.04,percent of total billed charges,,,70,,502.6,percent of total billed charges,,,,,,,,246.14,,,,100% of Medicare,,246.14,,,,100% of Medicare,,246.14,,,,100% of Medicare,,246.14,,,,100% of Medicare,,246.14,,,,100% of Medicare,,246.14,,,,100% of Medicare,,246.14,,,,100% of Medicare,,246.14,,,,100% of Medicare,,246.14,,,,100% of Medicare,,246.14,,,,100% of Medicare,,246.14,,,,100% of Medicare,,246.14,,,,100% of Medicare,,,246.14,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,246.14,646.2,
"UE Pros Addition, glove for terminal device, any material, prefab, incl fit and adj",L6890,HCPCS,,,,outpatient,,,733,439.8,,45.5,,333.52,percent of total billed charges,,,45.3,,332.05,percent of total billed charges,,,39,,285.87,percent of total billed charges,,,,,,,,,80,,586.4,percent of total billed charges,,,61.4,,450.06,percent of total billed charges,,,57.4,,420.74,percent of total billed charges,,,81,,593.73,percent of total billed charges,,,39,,285.87,percent of total billed charges,,,57.6,,422.21,percent of total billed charges,,,85,,623.05,percent of total billed charges,,,85,,623.05,percent of total billed charges,,,49,,359.17,percent of total billed charges,,,90,,659.7,percent of total billed charges,,,65,,476.45,percent of total billed charges,,,80,,586.4,percent of total billed charges,,,55,,403.15,percent of total billed charges,,,55,,403.15,percent of total billed charges,,,65,,476.45,percent of total billed charges,,,78,,571.74,percent of total billed charges,,,70,,513.1,percent of total billed charges,,,,,,,,241.11,,,,100% of Medicare,,241.11,,,,100% of Medicare,,241.11,,,,100% of Medicare,,241.11,,,,100% of Medicare,,241.11,,,,100% of Medicare,,241.11,,,,100% of Medicare,,241.11,,,,100% of Medicare,,241.11,,,,100% of Medicare,,241.11,,,,100% of Medicare,,241.11,,,,100% of Medicare,,241.11,,,,100% of Medicare,,241.11,,,,100% of Medicare,,,241.11,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,241.11,659.7,
"L6895 UE Pros Addition, glove for terminal device, any material, custom fab",L6895,HCPCS,,,,outpatient,,,2352,1411.2,,45.5,,1070.16,percent of total billed charges,,,45.3,,1065.46,percent of total billed charges,,,39,,917.28,percent of total billed charges,,,,,,,,,80,,1881.6,percent of total billed charges,,,61.4,,1444.13,percent of total billed charges,,,57.4,,1350.05,percent of total billed charges,,,81,,1905.12,percent of total billed charges,,,39,,917.28,percent of total billed charges,,,57.6,,1354.75,percent of total billed charges,,,85,,1999.2,percent of total billed charges,,,85,,1999.2,percent of total billed charges,,,49,,1152.48,percent of total billed charges,,,90,,2116.8,percent of total billed charges,,,65,,1528.8,percent of total billed charges,,,80,,1881.6,percent of total billed charges,,,55,,1293.6,percent of total billed charges,,,55,,1293.6,percent of total billed charges,,,65,,1528.8,percent of total billed charges,,,78,,1834.56,percent of total billed charges,,,70,,1646.4,percent of total billed charges,,,,,,,,806.21,,,,100% of Medicare,,806.21,,,,100% of Medicare,,806.21,,,,100% of Medicare,,806.21,,,,100% of Medicare,,806.21,,,,100% of Medicare,,806.21,,,,100% of Medicare,,806.21,,,,100% of Medicare,,806.21,,,,100% of Medicare,,806.21,,,,100% of Medicare,,806.21,,,,100% of Medicare,,806.21,,,,100% of Medicare,,806.21,,,,100% of Medicare,,,806.21,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,806.21,2116.8,
"Hand restoration (incl cast/sahde/measure), replacement glove for above hands",L6915,HCPCS,,,,outpatient,,,2854,1712.4,,45.5,,1298.57,percent of total billed charges,,,45.3,,1292.86,percent of total billed charges,,,39,,1113.06,percent of total billed charges,,,,,,,,,80,,2283.2,percent of total billed charges,,,61.4,,1752.36,percent of total billed charges,,,57.4,,1638.2,percent of total billed charges,,,81,,2311.74,percent of total billed charges,,,39,,1113.06,percent of total billed charges,,,57.6,,1643.9,percent of total billed charges,,,85,,2425.9,percent of total billed charges,,,85,,2425.9,percent of total billed charges,,,49,,1398.46,percent of total billed charges,,,90,,2568.6,percent of total billed charges,,,65,,1855.1,percent of total billed charges,,,80,,2283.2,percent of total billed charges,,,55,,1569.7,percent of total billed charges,,,55,,1569.7,percent of total billed charges,,,65,,1855.1,percent of total billed charges,,,78,,2226.12,percent of total billed charges,,,70,,1997.8,percent of total billed charges,,,,,,,,978.71,,,,100% of Medicare,,978.71,,,,100% of Medicare,,978.71,,,,100% of Medicare,,978.71,,,,100% of Medicare,,978.71,,,,100% of Medicare,,978.71,,,,100% of Medicare,,978.71,,,,100% of Medicare,,978.71,,,,100% of Medicare,,978.71,,,,100% of Medicare,,978.71,,,,100% of Medicare,,978.71,,,,100% of Medicare,,978.71,,,,100% of Medicare,,,978.71,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,978.71,2568.6,
"Six volt battery, Otto Bock or equal, each",L7360,HCPCS,,,,outpatient,,,942,565.2,,45.5,,428.61,percent of total billed charges,,,45.3,,426.73,percent of total billed charges,,,39,,367.38,percent of total billed charges,,,,,,,,,80,,753.6,percent of total billed charges,,,61.4,,578.39,percent of total billed charges,,,57.4,,540.71,percent of total billed charges,,,81,,763.02,percent of total billed charges,,,39,,367.38,percent of total billed charges,,,57.6,,542.59,percent of total billed charges,,,85,,800.7,percent of total billed charges,,,85,,800.7,percent of total billed charges,,,49,,461.58,percent of total billed charges,,,90,,847.8,percent of total billed charges,,,65,,612.3,percent of total billed charges,,,80,,753.6,percent of total billed charges,,,55,,518.1,percent of total billed charges,,,55,,518.1,percent of total billed charges,,,65,,612.3,percent of total billed charges,,,78,,734.76,percent of total billed charges,,,70,,659.4,percent of total billed charges,,,,,,,,319.37,,,,100% of Medicare,,319.37,,,,100% of Medicare,,319.37,,,,100% of Medicare,,319.37,,,,100% of Medicare,,319.37,,,,100% of Medicare,,319.37,,,,100% of Medicare,,319.37,,,,100% of Medicare,,319.37,,,,100% of Medicare,,319.37,,,,100% of Medicare,,319.37,,,,100% of Medicare,,319.37,,,,100% of Medicare,,319.37,,,,100% of Medicare,,,319.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,319.37,847.8,
"Battery Charger, six volt, Otto Bock or equal",L7362,HCPCS,,,,outpatient,,,1026,615.6,,45.5,,466.83,percent of total billed charges,,,45.3,,464.78,percent of total billed charges,,,39,,400.14,percent of total billed charges,,,,,,,,,80,,820.8,percent of total billed charges,,,61.4,,629.96,percent of total billed charges,,,57.4,,588.92,percent of total billed charges,,,81,,831.06,percent of total billed charges,,,39,,400.14,percent of total billed charges,,,57.6,,590.98,percent of total billed charges,,,85,,872.1,percent of total billed charges,,,85,,872.1,percent of total billed charges,,,49,,502.74,percent of total billed charges,,,90,,923.4,percent of total billed charges,,,65,,666.9,percent of total billed charges,,,80,,820.8,percent of total billed charges,,,55,,564.3,percent of total billed charges,,,55,,564.3,percent of total billed charges,,,65,,666.9,percent of total billed charges,,,78,,800.28,percent of total billed charges,,,70,,718.2,percent of total billed charges,,,,,,,,348.89,,,,100% of Medicare,,348.89,,,,100% of Medicare,,348.89,,,,100% of Medicare,,348.89,,,,100% of Medicare,,348.89,,,,100% of Medicare,,348.89,,,23907.84083,100% of Medicare,,348.89,,,,100% of Medicare,,348.89,,,,100% of Medicare,,348.89,,,,100% of Medicare,,348.89,,,,100% of Medicare,,348.89,,,,100% of Medicare,,348.89,,,,100% of Medicare,,,348.89,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,348.89,23907.84,
"Twelve volt battery, Utah or equal, each",L7364,HCPCS,,,,outpatient,,,1472,883.2,,45.5,,669.76,percent of total billed charges,,,45.3,,666.82,percent of total billed charges,,,39,,574.08,percent of total billed charges,,,,,,,,,80,,1177.6,percent of total billed charges,,,61.4,,903.81,percent of total billed charges,,,57.4,,844.93,percent of total billed charges,,,81,,1192.32,percent of total billed charges,,,39,,574.08,percent of total billed charges,,,57.6,,847.87,percent of total billed charges,,,85,,1251.2,percent of total billed charges,,,85,,1251.2,percent of total billed charges,,,49,,721.28,percent of total billed charges,,,90,,1324.8,percent of total billed charges,,,65,,956.8,percent of total billed charges,,,80,,1177.6,percent of total billed charges,,,55,,809.6,percent of total billed charges,,,55,,809.6,percent of total billed charges,,,65,,956.8,percent of total billed charges,,,78,,1148.16,percent of total billed charges,,,70,,1030.4,percent of total billed charges,,,,,,,,617.34,,,,100% of Medicare,,617.34,,,,100% of Medicare,,617.34,,,,100% of Medicare,,617.34,,,,100% of Medicare,,617.34,,,,100% of Medicare,,617.34,,,,100% of Medicare,,617.34,,,,100% of Medicare,,617.34,,,,100% of Medicare,,617.34,,,,100% of Medicare,,617.34,,,,100% of Medicare,,617.34,,,,100% of Medicare,,617.34,,,,100% of Medicare,,,617.34,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,574.08,1324.8,
"Battery Charger, twelve volt, Utah or equal",L7366,HCPCS,,,,outpatient,,,2026,1215.6,,45.5,,921.83,percent of total billed charges,,,45.3,,917.78,percent of total billed charges,,,39,,790.14,percent of total billed charges,,,,,,,,,80,,1620.8,percent of total billed charges,,,61.4,,1243.96,percent of total billed charges,,,57.4,,1162.92,percent of total billed charges,,,81,,1641.06,percent of total billed charges,,,39,,790.14,percent of total billed charges,,,57.6,,1166.98,percent of total billed charges,,,85,,1722.1,percent of total billed charges,,,85,,1722.1,percent of total billed charges,,,49,,992.74,percent of total billed charges,,,90,,1823.4,percent of total billed charges,,,65,,1316.9,percent of total billed charges,,,80,,1620.8,percent of total billed charges,,,55,,1114.3,percent of total billed charges,,,55,,1114.3,percent of total billed charges,,,65,,1316.9,percent of total billed charges,,,78,,1580.28,percent of total billed charges,,,70,,1418.2,percent of total billed charges,,,,,,,,849,,,,100% of Medicare,,849,,,,100% of Medicare,,849,,,,100% of Medicare,,849,,,,100% of Medicare,,849,,,,100% of Medicare,,849,,,31464.75071,100% of Medicare,,849,,,,100% of Medicare,,849,,,,100% of Medicare,,849,,,,100% of Medicare,,849,,,,100% of Medicare,,849,,,,100% of Medicare,,849,,,,100% of Medicare,,,849,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,790.14,31464.75,
"Lithium ion battery, replacement",L7367,HCPCS,,,,outpatient,,,1386,831.6,,45.5,,630.63,percent of total billed charges,,,45.3,,627.86,percent of total billed charges,,,39,,540.54,percent of total billed charges,,,,,,,,,80,,1108.8,percent of total billed charges,,,61.4,,851,percent of total billed charges,,,57.4,,795.56,percent of total billed charges,,,81,,1122.66,percent of total billed charges,,,39,,540.54,percent of total billed charges,,,57.6,,798.34,percent of total billed charges,,,85,,1178.1,percent of total billed charges,,,85,,1178.1,percent of total billed charges,,,49,,679.14,percent of total billed charges,,,90,,1247.4,percent of total billed charges,,,65,,900.9,percent of total billed charges,,,80,,1108.8,percent of total billed charges,,,55,,762.3,percent of total billed charges,,,55,,762.3,percent of total billed charges,,,65,,900.9,percent of total billed charges,,,78,,1081.08,percent of total billed charges,,,70,,970.2,percent of total billed charges,,,,,,,,470.02,,,,100% of Medicare,,470.02,,,,100% of Medicare,,470.02,,,,100% of Medicare,,470.02,,,,100% of Medicare,,470.02,,,,100% of Medicare,,470.02,,,,100% of Medicare,,470.02,,,,100% of Medicare,,470.02,,,,100% of Medicare,,470.02,,,,100% of Medicare,,470.02,,,,100% of Medicare,,470.02,,,,100% of Medicare,,470.02,,,,100% of Medicare,,,470.02,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,470.02,1247.4,
"Lithium ion battery, charger",L7368,HCPCS,,,,outpatient,,,1796,1077.6,,45.5,,817.18,percent of total billed charges,,,45.3,,813.59,percent of total billed charges,,,39,,700.44,percent of total billed charges,,,,,,,,,80,,1436.8,percent of total billed charges,,,61.4,,1102.74,percent of total billed charges,,,57.4,,1030.9,percent of total billed charges,,,81,,1454.76,percent of total billed charges,,,39,,700.44,percent of total billed charges,,,57.6,,1034.5,percent of total billed charges,,,85,,1526.6,percent of total billed charges,,,85,,1526.6,percent of total billed charges,,,49,,880.04,percent of total billed charges,,,90,,1616.4,percent of total billed charges,,,65,,1167.4,percent of total billed charges,,,80,,1436.8,percent of total billed charges,,,55,,987.8,percent of total billed charges,,,55,,987.8,percent of total billed charges,,,65,,1167.4,percent of total billed charges,,,78,,1400.88,percent of total billed charges,,,70,,1257.2,percent of total billed charges,,,,,,,,609.27,,,,100% of Medicare,,609.27,,,,100% of Medicare,,609.27,,,,100% of Medicare,,609.27,,,,100% of Medicare,,609.27,,,,100% of Medicare,,609.27,,,,100% of Medicare,,609.27,,,,100% of Medicare,,609.27,,,,100% of Medicare,,609.27,,,,100% of Medicare,,609.27,,,,100% of Medicare,,609.27,,,,100% of Medicare,,609.27,,,,100% of Medicare,,,609.27,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,609.27,1616.4,
"L7400 Addition to upper extremity prosthesis,below elbow/wrist disarticulation, ultralight material",L7400,HCPCS,,,,outpatient,,,1072,643.2,,45.5,,487.76,percent of total billed charges,,,45.3,,485.62,percent of total billed charges,,,39,,418.08,percent of total billed charges,,,,,,,,,80,,857.6,percent of total billed charges,,,61.4,,658.21,percent of total billed charges,,,57.4,,615.33,percent of total billed charges,,,81,,868.32,percent of total billed charges,,,39,,418.08,percent of total billed charges,,,57.6,,617.47,percent of total billed charges,,,85,,911.2,percent of total billed charges,,,85,,911.2,percent of total billed charges,,,49,,525.28,percent of total billed charges,,,90,,964.8,percent of total billed charges,,,65,,696.8,percent of total billed charges,,,80,,857.6,percent of total billed charges,,,55,,589.6,percent of total billed charges,,,55,,589.6,percent of total billed charges,,,65,,696.8,percent of total billed charges,,,78,,836.16,percent of total billed charges,,,70,,750.4,percent of total billed charges,,,,,,,,369.99,,,,100% of Medicare,,369.99,,,,100% of Medicare,,369.99,,,,100% of Medicare,,369.99,,,,100% of Medicare,,369.99,,,,100% of Medicare,,369.99,,,,100% of Medicare,,369.99,,,,100% of Medicare,,369.99,,,,100% of Medicare,,369.99,,,,100% of Medicare,,369.99,,,,100% of Medicare,,369.99,,,,100% of Medicare,,369.99,,,,100% of Medicare,,,369.99,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,369.99,964.8,
"L7401 Addition to upper extremity prosthesis,above elbow/elbow disarticulation, ultralight material",L7401,HCPCS,,,,outpatient,,,1198,718.8,,45.5,,545.09,percent of total billed charges,,,45.3,,542.69,percent of total billed charges,,,39,,467.22,percent of total billed charges,,,,,,,,,80,,958.4,percent of total billed charges,,,61.4,,735.57,percent of total billed charges,,,57.4,,687.65,percent of total billed charges,,,81,,970.38,percent of total billed charges,,,39,,467.22,percent of total billed charges,,,57.6,,690.05,percent of total billed charges,,,85,,1018.3,percent of total billed charges,,,85,,1018.3,percent of total billed charges,,,49,,587.02,percent of total billed charges,,,90,,1078.2,percent of total billed charges,,,65,,778.7,percent of total billed charges,,,80,,958.4,percent of total billed charges,,,55,,658.9,percent of total billed charges,,,55,,658.9,percent of total billed charges,,,65,,778.7,percent of total billed charges,,,78,,934.44,percent of total billed charges,,,70,,838.6,percent of total billed charges,,,,,,,,414.17,,,,100% of Medicare,,414.17,,,,100% of Medicare,,414.17,,,,100% of Medicare,,414.17,,,,100% of Medicare,,414.17,,,,100% of Medicare,,414.17,,,,100% of Medicare,,414.17,,,,100% of Medicare,,414.17,,,,100% of Medicare,,414.17,,,,100% of Medicare,,414.17,,,,100% of Medicare,,414.17,,,,100% of Medicare,,414.17,,,,100% of Medicare,,,414.17,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,414.17,1078.2,
"L7402 Addition to upper extremity prosthesis,shoulder disarticulation/intrascapular thoracic,ultrali",L7402,HCPCS,,,,outpatient,,,1292,775.2,,45.5,,587.86,percent of total billed charges,,,45.3,,585.28,percent of total billed charges,,,39,,503.88,percent of total billed charges,,,,,,,,,80,,1033.6,percent of total billed charges,,,61.4,,793.29,percent of total billed charges,,,57.4,,741.61,percent of total billed charges,,,81,,1046.52,percent of total billed charges,,,39,,503.88,percent of total billed charges,,,57.6,,744.19,percent of total billed charges,,,85,,1098.2,percent of total billed charges,,,85,,1098.2,percent of total billed charges,,,49,,633.08,percent of total billed charges,,,90,,1162.8,percent of total billed charges,,,65,,839.8,percent of total billed charges,,,80,,1033.6,percent of total billed charges,,,55,,710.6,percent of total billed charges,,,55,,710.6,percent of total billed charges,,,65,,839.8,percent of total billed charges,,,78,,1007.76,percent of total billed charges,,,70,,904.4,percent of total billed charges,,,,,,,,447.32,,,,100% of Medicare,,447.32,,,,100% of Medicare,,447.32,,,,100% of Medicare,,447.32,,,,100% of Medicare,,447.32,,,,100% of Medicare,,447.32,,,,100% of Medicare,,447.32,,,,100% of Medicare,,447.32,,,,100% of Medicare,,447.32,,,,100% of Medicare,,447.32,,,,100% of Medicare,,447.32,,,,100% of Medicare,,447.32,,,,100% of Medicare,,,447.32,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,447.32,1162.8,
"L7403 Addition to upper extremity prosthesis,below elbow/wrist disarticulation,acrylic material",L7403,HCPCS,,,,outpatient,,,1285,771,,45.5,,584.68,percent of total billed charges,,,45.3,,582.11,percent of total billed charges,,,39,,501.15,percent of total billed charges,,,,,,,,,80,,1028,percent of total billed charges,,,61.4,,788.99,percent of total billed charges,,,57.4,,737.59,percent of total billed charges,,,81,,1040.85,percent of total billed charges,,,39,,501.15,percent of total billed charges,,,57.6,,740.16,percent of total billed charges,,,85,,1092.25,percent of total billed charges,,,85,,1092.25,percent of total billed charges,,,49,,629.65,percent of total billed charges,,,90,,1156.5,percent of total billed charges,,,65,,835.25,percent of total billed charges,,,80,,1028,percent of total billed charges,,,55,,706.75,percent of total billed charges,,,55,,706.75,percent of total billed charges,,,65,,835.25,percent of total billed charges,,,78,,1002.3,percent of total billed charges,,,70,,899.5,percent of total billed charges,,,,,,,,444.59,,,,100% of Medicare,,444.59,,,,100% of Medicare,,444.59,,,,100% of Medicare,,444.59,,,,100% of Medicare,,444.59,,,,100% of Medicare,,444.59,,,,100% of Medicare,,444.59,,,,100% of Medicare,,444.59,,,,100% of Medicare,,444.59,,,,100% of Medicare,,444.59,,,,100% of Medicare,,444.59,,,,100% of Medicare,,444.59,,,,100% of Medicare,,,444.59,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,444.59,1156.5,
"L7404 Addition to upper extremity prosthesis,above elbow/elbow disarticulation,acrylic material",L7404,HCPCS,,,,outpatient,,,1939,1163.4,,45.5,,882.25,percent of total billed charges,,,45.3,,878.37,percent of total billed charges,,,39,,756.21,percent of total billed charges,,,,,,,,,80,,1551.2,percent of total billed charges,,,61.4,,1190.55,percent of total billed charges,,,57.4,,1112.99,percent of total billed charges,,,81,,1570.59,percent of total billed charges,,,39,,756.21,percent of total billed charges,,,57.6,,1116.86,percent of total billed charges,,,85,,1648.15,percent of total billed charges,,,85,,1648.15,percent of total billed charges,,,49,,950.11,percent of total billed charges,,,90,,1745.1,percent of total billed charges,,,65,,1260.35,percent of total billed charges,,,80,,1551.2,percent of total billed charges,,,55,,1066.45,percent of total billed charges,,,55,,1066.45,percent of total billed charges,,,65,,1260.35,percent of total billed charges,,,78,,1512.42,percent of total billed charges,,,70,,1357.3,percent of total billed charges,,,,,,,,671.03,,,,100% of Medicare,,671.03,,,,100% of Medicare,,671.03,,,,100% of Medicare,,671.03,,,,100% of Medicare,,671.03,,,,100% of Medicare,,671.03,,,,100% of Medicare,,671.03,,,,100% of Medicare,,671.03,,,,100% of Medicare,,671.03,,,,100% of Medicare,,671.03,,,,100% of Medicare,,671.03,,,,100% of Medicare,,671.03,,,,100% of Medicare,,,671.03,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,671.03,1745.1,
"L7405 Addition to upper extremity prosthesis,shoulder disarticulation/intrascapular thoracic,acrylic",L7405,HCPCS,,,,outpatient,,,2536,1521.6,,45.5,,1153.88,percent of total billed charges,,,45.3,,1148.81,percent of total billed charges,,,39,,989.04,percent of total billed charges,,,,,,,,,80,,2028.8,percent of total billed charges,,,61.4,,1557.1,percent of total billed charges,,,57.4,,1455.66,percent of total billed charges,,,81,,2054.16,percent of total billed charges,,,39,,989.04,percent of total billed charges,,,57.6,,1460.74,percent of total billed charges,,,85,,2155.6,percent of total billed charges,,,85,,2155.6,percent of total billed charges,,,49,,1242.64,percent of total billed charges,,,90,,2282.4,percent of total billed charges,,,65,,1648.4,percent of total billed charges,,,80,,2028.8,percent of total billed charges,,,55,,1394.8,percent of total billed charges,,,55,,1394.8,percent of total billed charges,,,65,,1648.4,percent of total billed charges,,,78,,1978.08,percent of total billed charges,,,70,,1775.2,percent of total billed charges,,,,,,,,877.53,,,,100% of Medicare,,877.53,,,,100% of Medicare,,877.53,,,,100% of Medicare,,877.53,,,,100% of Medicare,,877.53,,,,100% of Medicare,,877.53,,,,100% of Medicare,,877.53,,,,100% of Medicare,,877.53,,,,100% of Medicare,,877.53,,,,100% of Medicare,,877.53,,,,100% of Medicare,,877.53,,,,100% of Medicare,,877.53,,,,100% of Medicare,,,877.53,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,877.53,2282.4,
"Repair of prosthetic device, repair or replace minor parts",L7510,HCPCS,,,,both,,,378.4,227.04,,45.5,,172.17,percent of total billed charges,,,45.3,,171.42,percent of total billed charges,,,39,,147.58,percent of total billed charges,,,,,,,,,80,,302.72,percent of total billed charges,,,61.4,,232.34,percent of total billed charges,,,57.4,,217.2,percent of total billed charges,,,81,,306.5,percent of total billed charges,,,51.5,,194.88,percent of total billed charges,,,57.6,,217.96,percent of total billed charges,,,85,,321.64,percent of total billed charges,,,85,,321.64,percent of total billed charges,,,49,,185.42,percent of total billed charges,,,90,,340.56,percent of total billed charges,,,65,,245.96,percent of total billed charges,,,80,,302.72,percent of total billed charges,,,55,,208.12,percent of total billed charges,,,55,,208.12,percent of total billed charges,,,65,,245.96,percent of total billed charges,,,78,,295.15,percent of total billed charges,,,70,,264.88,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG rate,100% of IL Medicaid,,,,,EAPG rate,100% of IL Medicaid,,,,,EAPG rate,100% of IL Medicaid,,,,,EAPG rate,100% of IL Medicaid,147.58,340.56,
"Repair of prosthetic device, labor component, per 15 minutes",L7520,HCPCS,,,,outpatient,,,147,88.2,,45.5,,66.89,percent of total billed charges,,,45.3,,66.59,percent of total billed charges,,,39,,57.33,percent of total billed charges,,,,,,,,,80,,117.6,percent of total billed charges,,,61.4,,90.26,percent of total billed charges,,,57.4,,84.38,percent of total billed charges,,,81,,119.07,percent of total billed charges,,,39,,57.33,percent of total billed charges,,,57.6,,84.67,percent of total billed charges,,,85,,124.95,percent of total billed charges,,,85,,124.95,percent of total billed charges,,,49,,72.03,percent of total billed charges,,,90,,132.3,percent of total billed charges,,,65,,95.55,percent of total billed charges,,,80,,117.6,percent of total billed charges,,,55,,80.85,percent of total billed charges,,,55,,80.85,percent of total billed charges,,,65,,95.55,percent of total billed charges,,,78,,114.66,percent of total billed charges,,,70,,102.9,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,57.33,132.3,
"L7700 Gasket or seal, for use with prosthetic socket insert, any type, each",L7700,HCPCS,,,,outpatient,,,424,254.4,,45.5,,192.92,percent of total billed charges,,,45.3,,192.07,percent of total billed charges,,,39,,165.36,percent of total billed charges,,,,,,,,,80,,339.2,percent of total billed charges,,,61.4,,260.34,percent of total billed charges,,,57.4,,243.38,percent of total billed charges,,,81,,343.44,percent of total billed charges,,,39,,165.36,percent of total billed charges,,,57.6,,244.22,percent of total billed charges,,,85,,360.4,percent of total billed charges,,,85,,360.4,percent of total billed charges,,,49,,207.76,percent of total billed charges,,,90,,381.6,percent of total billed charges,,,65,,275.6,percent of total billed charges,,,80,,339.2,percent of total billed charges,,,55,,233.2,percent of total billed charges,,,55,,233.2,percent of total billed charges,,,65,,275.6,percent of total billed charges,,,78,,330.72,percent of total billed charges,,,70,,296.8,percent of total billed charges,,,,,,,,180.61,,,,100% of Medicare,,180.61,,,,100% of Medicare,,180.61,,,,100% of Medicare,,180.61,,,,100% of Medicare,,180.61,,,,100% of Medicare,,180.61,,,,100% of Medicare,,180.61,,,,100% of Medicare,,180.61,,,,100% of Medicare,,180.61,,,,100% of Medicare,,180.61,,,,100% of Medicare,,180.61,,,,100% of Medicare,,180.61,,,,100% of Medicare,,,180.61,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,165.36,381.6,
Truss single w/ standard pad,L8300,HCPCS,,,,outpatient,,,192,115.2,,45.5,,87.36,percent of total billed charges,,,45.3,,86.98,percent of total billed charges,,,39,,74.88,percent of total billed charges,,,,,,,,,80,,153.6,percent of total billed charges,,,61.4,,117.89,percent of total billed charges,,,57.4,,110.21,percent of total billed charges,,,81,,155.52,percent of total billed charges,,,39,,74.88,percent of total billed charges,,,57.6,,110.59,percent of total billed charges,,,85,,163.2,percent of total billed charges,,,85,,163.2,percent of total billed charges,,,49,,94.08,percent of total billed charges,,,90,,172.8,percent of total billed charges,,,65,,124.8,percent of total billed charges,,,80,,153.6,percent of total billed charges,,,55,,105.6,percent of total billed charges,,,55,,105.6,percent of total billed charges,,,65,,124.8,percent of total billed charges,,,78,,149.76,percent of total billed charges,,,70,,134.4,percent of total billed charges,,,,,,,,101.25,,,,100% of Medicare,,101.25,,,,100% of Medicare,,101.25,,,,100% of Medicare,,101.25,,,,100% of Medicare,,101.25,,,,100% of Medicare,,101.25,,,,100% of Medicare,,101.25,,,,100% of Medicare,,101.25,,,,100% of Medicare,,101.25,,,,100% of Medicare,,101.25,,,,100% of Medicare,,101.25,,,,100% of Medicare,,101.25,,,,100% of Medicare,,,101.25,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,74.88,172.8,
"Truss, double w/ standard pads",L8310,HCPCS,,,,outpatient,,,338,202.8,,45.5,,153.79,percent of total billed charges,,,45.3,,153.11,percent of total billed charges,,,39,,131.82,percent of total billed charges,,,,,,,,,80,,270.4,percent of total billed charges,,,61.4,,207.53,percent of total billed charges,,,57.4,,194.01,percent of total billed charges,,,81,,273.78,percent of total billed charges,,,39,,131.82,percent of total billed charges,,,57.6,,194.69,percent of total billed charges,,,85,,287.3,percent of total billed charges,,,85,,287.3,percent of total billed charges,,,49,,165.62,percent of total billed charges,,,90,,304.2,percent of total billed charges,,,65,,219.7,percent of total billed charges,,,80,,270.4,percent of total billed charges,,,55,,185.9,percent of total billed charges,,,55,,185.9,percent of total billed charges,,,65,,219.7,percent of total billed charges,,,78,,263.64,percent of total billed charges,,,70,,236.6,percent of total billed charges,,,,,,,,179.36,,,,100% of Medicare,,179.36,,,,100% of Medicare,,179.36,,,,100% of Medicare,,179.36,,,,100% of Medicare,,179.36,,,,100% of Medicare,,179.36,,,,100% of Medicare,,179.36,,,,100% of Medicare,,179.36,,,,100% of Medicare,,179.36,,,,100% of Medicare,,179.36,,,,100% of Medicare,,179.36,,,,100% of Medicare,,179.36,,,,100% of Medicare,,,179.36,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,131.82,304.2,
"Truss, addition standard pad, water pad",L8320,HCPCS,,,,outpatient,,,140,84,,45.5,,63.7,percent of total billed charges,,,45.3,,63.42,percent of total billed charges,,,39,,54.6,percent of total billed charges,,,,,,,,,80,,112,percent of total billed charges,,,61.4,,85.96,percent of total billed charges,,,57.4,,80.36,percent of total billed charges,,,81,,113.4,percent of total billed charges,,,39,,54.6,percent of total billed charges,,,57.6,,80.64,percent of total billed charges,,,85,,119,percent of total billed charges,,,85,,119,percent of total billed charges,,,49,,68.6,percent of total billed charges,,,90,,126,percent of total billed charges,,,65,,91,percent of total billed charges,,,80,,112,percent of total billed charges,,,55,,77,percent of total billed charges,,,55,,77,percent of total billed charges,,,65,,91,percent of total billed charges,,,78,,109.2,percent of total billed charges,,,70,,98,percent of total billed charges,,,,,,,,74.41,,,,100% of Medicare,,74.41,,,,100% of Medicare,,74.41,,,,100% of Medicare,,74.41,,,,100% of Medicare,,74.41,,,,100% of Medicare,,74.41,,,,100% of Medicare,,74.41,,,,100% of Medicare,,74.41,,,,100% of Medicare,,74.41,,,,100% of Medicare,,74.41,,,,100% of Medicare,,74.41,,,,100% of Medicare,,74.41,,,,100% of Medicare,,,74.41,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,54.6,126,
"Truss, addition standard pad, scrotal pad",L8330,HCPCS,,,,outpatient,,,112,67.2,,45.5,,50.96,percent of total billed charges,,,45.3,,50.74,percent of total billed charges,,,39,,43.68,percent of total billed charges,,,,,,,,,80,,89.6,percent of total billed charges,,,61.4,,68.77,percent of total billed charges,,,57.4,,64.29,percent of total billed charges,,,81,,90.72,percent of total billed charges,,,39,,43.68,percent of total billed charges,,,57.6,,64.51,percent of total billed charges,,,85,,95.2,percent of total billed charges,,,85,,95.2,percent of total billed charges,,,49,,54.88,percent of total billed charges,,,90,,100.8,percent of total billed charges,,,65,,72.8,percent of total billed charges,,,80,,89.6,percent of total billed charges,,,55,,61.6,percent of total billed charges,,,55,,61.6,percent of total billed charges,,,65,,72.8,percent of total billed charges,,,78,,87.36,percent of total billed charges,,,70,,78.4,percent of total billed charges,,,,,,,,59.25,,,,100% of Medicare,,59.25,,,,100% of Medicare,,59.25,,,,100% of Medicare,,59.25,,,,100% of Medicare,,59.25,,,,100% of Medicare,,59.25,,,,100% of Medicare,,59.25,,,,100% of Medicare,,59.25,,,,100% of Medicare,,59.25,,,,100% of Medicare,,59.25,,,,100% of Medicare,,59.25,,,,100% of Medicare,,59.25,,,,100% of Medicare,,,59.25,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,43.68,100.8,
"Prosthetic sheath, below knee, each",L8400,HCPCS,,,,outpatient,,,60,36,,45.5,,27.3,percent of total billed charges,,,45.3,,27.18,percent of total billed charges,,,39,,23.4,percent of total billed charges,,,,,,,,,80,,48,percent of total billed charges,,,61.4,,36.84,percent of total billed charges,,,57.4,,34.44,percent of total billed charges,,,81,,48.6,percent of total billed charges,,,39,,23.4,percent of total billed charges,,,57.6,,34.56,percent of total billed charges,,,85,,51,percent of total billed charges,,,85,,51,percent of total billed charges,,,49,,29.4,percent of total billed charges,,,90,,54,percent of total billed charges,,,65,,39,percent of total billed charges,,,80,,48,percent of total billed charges,,,55,,33,percent of total billed charges,,,55,,33,percent of total billed charges,,,65,,39,percent of total billed charges,,,78,,46.8,percent of total billed charges,,,70,,42,percent of total billed charges,,,,,,,,18.89,,,,100% of Medicare,,18.89,,,,100% of Medicare,,18.89,,,,100% of Medicare,,18.89,,,,100% of Medicare,,18.89,,,,100% of Medicare,,18.89,,,,100% of Medicare,,18.89,,,,100% of Medicare,,18.89,,,,100% of Medicare,,18.89,,,,100% of Medicare,,18.89,,,,100% of Medicare,,18.89,,,,100% of Medicare,,18.89,,,,100% of Medicare,,,18.89,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,18.89,54,
"Prosthetic sheath, above knee, each",L8410,HCPCS,,,,outpatient,,,76,45.6,,45.5,,34.58,percent of total billed charges,,,45.3,,34.43,percent of total billed charges,,,39,,29.64,percent of total billed charges,,,,,,,,,80,,60.8,percent of total billed charges,,,61.4,,46.66,percent of total billed charges,,,57.4,,43.62,percent of total billed charges,,,81,,61.56,percent of total billed charges,,,39,,29.64,percent of total billed charges,,,57.6,,43.78,percent of total billed charges,,,85,,64.6,percent of total billed charges,,,85,,64.6,percent of total billed charges,,,49,,37.24,percent of total billed charges,,,90,,68.4,percent of total billed charges,,,65,,49.4,percent of total billed charges,,,80,,60.8,percent of total billed charges,,,55,,41.8,percent of total billed charges,,,55,,41.8,percent of total billed charges,,,65,,49.4,percent of total billed charges,,,78,,59.28,percent of total billed charges,,,70,,53.2,percent of total billed charges,,,,,,,,24.86,,,,100% of Medicare,,24.86,,,,100% of Medicare,,24.86,,,,100% of Medicare,,24.86,,,,100% of Medicare,,24.86,,,,100% of Medicare,,24.86,,,,100% of Medicare,,24.86,,,,100% of Medicare,,24.86,,,,100% of Medicare,,24.86,,,,100% of Medicare,,24.86,,,,100% of Medicare,,24.86,,,,100% of Medicare,,24.86,,,,100% of Medicare,,,24.86,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,24.86,68.4,
"Prosthetic sheath, upper limb, each",L8415,HCPCS,,,,outpatient,,,75,45,,45.5,,34.13,percent of total billed charges,,,45.3,,33.98,percent of total billed charges,,,39,,29.25,percent of total billed charges,,,,,,,,,80,,60,percent of total billed charges,,,61.4,,46.05,percent of total billed charges,,,57.4,,43.05,percent of total billed charges,,,81,,60.75,percent of total billed charges,,,39,,29.25,percent of total billed charges,,,57.6,,43.2,percent of total billed charges,,,85,,63.75,percent of total billed charges,,,85,,63.75,percent of total billed charges,,,49,,36.75,percent of total billed charges,,,90,,67.5,percent of total billed charges,,,65,,48.75,percent of total billed charges,,,80,,60,percent of total billed charges,,,55,,41.25,percent of total billed charges,,,55,,41.25,percent of total billed charges,,,65,,48.75,percent of total billed charges,,,78,,58.5,percent of total billed charges,,,70,,52.5,percent of total billed charges,,,,,,,,25.73,,,,100% of Medicare,,25.73,,,,100% of Medicare,,25.73,,,,100% of Medicare,,25.73,,,,100% of Medicare,,25.73,,,,100% of Medicare,,25.73,,,,100% of Medicare,,25.73,,,,100% of Medicare,,25.73,,,,100% of Medicare,,25.73,,,,100% of Medicare,,25.73,,,,100% of Medicare,,25.73,,,,100% of Medicare,,25.73,,,,100% of Medicare,,,25.73,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,25.73,67.5,
"Prosthetic sheath/sock, including a gel cushion layer, BK or AK, each",L8417,HCPCS,,,,outpatient,,,278,166.8,,45.5,,126.49,percent of total billed charges,,,45.3,,125.93,percent of total billed charges,,,39,,108.42,percent of total billed charges,,,,,,,,,80,,222.4,percent of total billed charges,,,61.4,,170.69,percent of total billed charges,,,57.4,,159.57,percent of total billed charges,,,81,,225.18,percent of total billed charges,,,39,,108.42,percent of total billed charges,,,57.6,,160.13,percent of total billed charges,,,85,,236.3,percent of total billed charges,,,85,,236.3,percent of total billed charges,,,49,,136.22,percent of total billed charges,,,90,,250.2,percent of total billed charges,,,65,,180.7,percent of total billed charges,,,80,,222.4,percent of total billed charges,,,55,,152.9,percent of total billed charges,,,55,,152.9,percent of total billed charges,,,65,,180.7,percent of total billed charges,,,78,,216.84,percent of total billed charges,,,70,,194.6,percent of total billed charges,,,,,,,,90.8,,,,100% of Medicare,,90.8,,,,100% of Medicare,,90.8,,,,100% of Medicare,,90.8,,,,100% of Medicare,,90.8,,,,100% of Medicare,,90.8,,,,100% of Medicare,,90.8,,,,100% of Medicare,,90.8,,,,100% of Medicare,,90.8,,,,100% of Medicare,,90.8,,,,100% of Medicare,,90.8,,,,100% of Medicare,,90.8,,,,100% of Medicare,,,90.8,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,90.8,250.2,
"Prosthetic sock, multiple ply, below knee, each",L8420,HCPCS,,,,outpatient,,,75,45,,45.5,,34.13,percent of total billed charges,,,45.3,,33.98,percent of total billed charges,,,39,,29.25,percent of total billed charges,,,,,,,,,80,,60,percent of total billed charges,,,61.4,,46.05,percent of total billed charges,,,57.4,,43.05,percent of total billed charges,,,81,,60.75,percent of total billed charges,,,39,,29.25,percent of total billed charges,,,57.6,,43.2,percent of total billed charges,,,85,,63.75,percent of total billed charges,,,85,,63.75,percent of total billed charges,,,49,,36.75,percent of total billed charges,,,90,,67.5,percent of total billed charges,,,65,,48.75,percent of total billed charges,,,80,,60,percent of total billed charges,,,55,,41.25,percent of total billed charges,,,55,,41.25,percent of total billed charges,,,65,,48.75,percent of total billed charges,,,78,,58.5,percent of total billed charges,,,70,,52.5,percent of total billed charges,,,,,,,,25.18,,,,100% of Medicare,,25.18,,,,100% of Medicare,,25.18,,,,100% of Medicare,,25.18,,,,100% of Medicare,,25.18,,,,100% of Medicare,,25.18,,,,100% of Medicare,,25.18,,,,100% of Medicare,,25.18,,,,100% of Medicare,,25.18,,,,100% of Medicare,,25.18,,,,100% of Medicare,,25.18,,,,100% of Medicare,,25.18,,,,100% of Medicare,,,25.18,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,25.18,67.5,
"Prosthetic sock, multiple ply, above knee, each",L8430,HCPCS,,,,outpatient,,,85,51,,45.5,,38.68,percent of total billed charges,,,45.3,,38.51,percent of total billed charges,,,39,,33.15,percent of total billed charges,,,,,,,,,80,,68,percent of total billed charges,,,61.4,,52.19,percent of total billed charges,,,57.4,,48.79,percent of total billed charges,,,81,,68.85,percent of total billed charges,,,39,,33.15,percent of total billed charges,,,57.6,,48.96,percent of total billed charges,,,85,,72.25,percent of total billed charges,,,85,,72.25,percent of total billed charges,,,49,,41.65,percent of total billed charges,,,90,,76.5,percent of total billed charges,,,65,,55.25,percent of total billed charges,,,80,,68,percent of total billed charges,,,55,,46.75,percent of total billed charges,,,55,,46.75,percent of total billed charges,,,65,,55.25,percent of total billed charges,,,78,,66.3,percent of total billed charges,,,70,,59.5,percent of total billed charges,,,,,,,,28.52,,,,100% of Medicare,,28.52,,,,100% of Medicare,,28.52,,,,100% of Medicare,,28.52,,,,100% of Medicare,,28.52,,,,100% of Medicare,,28.52,,,,100% of Medicare,,28.52,,,,100% of Medicare,,28.52,,,,100% of Medicare,,28.52,,,,100% of Medicare,,28.52,,,,100% of Medicare,,28.52,,,,100% of Medicare,,28.52,,,,100% of Medicare,,,28.52,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,28.52,76.5,
"Prosthetic sock, multiple ply, upper limb, each",L8435,HCPCS,,,,outpatient,,,78,46.8,,45.5,,35.49,percent of total billed charges,,,45.3,,35.33,percent of total billed charges,,,39,,30.42,percent of total billed charges,,,,,,,,,80,,62.4,percent of total billed charges,,,61.4,,47.89,percent of total billed charges,,,57.4,,44.77,percent of total billed charges,,,81,,63.18,percent of total billed charges,,,39,,30.42,percent of total billed charges,,,57.6,,44.93,percent of total billed charges,,,85,,66.3,percent of total billed charges,,,85,,66.3,percent of total billed charges,,,49,,38.22,percent of total billed charges,,,90,,70.2,percent of total billed charges,,,65,,50.7,percent of total billed charges,,,80,,62.4,percent of total billed charges,,,55,,42.9,percent of total billed charges,,,55,,42.9,percent of total billed charges,,,65,,50.7,percent of total billed charges,,,78,,60.84,percent of total billed charges,,,70,,54.6,percent of total billed charges,,,,,,,,27.1,,,,100% of Medicare,,27.1,,,,100% of Medicare,,27.1,,,,100% of Medicare,,27.1,,,,100% of Medicare,,27.1,,,,100% of Medicare,,27.1,,,,100% of Medicare,,27.1,,,,100% of Medicare,,27.1,,,,100% of Medicare,,27.1,,,,100% of Medicare,,27.1,,,,100% of Medicare,,27.1,,,,100% of Medicare,,27.1,,,,100% of Medicare,,,27.1,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,27.1,70.2,
"Prosthetic shrinker, below knee, each",L8440,HCPCS,,,,outpatient,,,169,101.4,,45.5,,76.9,percent of total billed charges,,,45.3,,76.56,percent of total billed charges,,,39,,65.91,percent of total billed charges,,,,,,,,,80,,135.2,percent of total billed charges,,,61.4,,103.77,percent of total billed charges,,,57.4,,97.01,percent of total billed charges,,,81,,136.89,percent of total billed charges,,,39,,65.91,percent of total billed charges,,,57.6,,97.34,percent of total billed charges,,,85,,143.65,percent of total billed charges,,,85,,143.65,percent of total billed charges,,,49,,82.81,percent of total billed charges,,,90,,152.1,percent of total billed charges,,,65,,109.85,percent of total billed charges,,,80,,135.2,percent of total billed charges,,,55,,92.95,percent of total billed charges,,,55,,92.95,percent of total billed charges,,,65,,109.85,percent of total billed charges,,,78,,131.82,percent of total billed charges,,,70,,118.3,percent of total billed charges,,,,,,,,56.27,,,,100% of Medicare,,56.27,,,,100% of Medicare,,56.27,,,,100% of Medicare,,56.27,,,,100% of Medicare,,56.27,,,,100% of Medicare,,56.27,,,,100% of Medicare,,56.27,,,,100% of Medicare,,56.27,,,,100% of Medicare,,56.27,,,,100% of Medicare,,56.27,,,,100% of Medicare,,56.27,,,,100% of Medicare,,56.27,,,,100% of Medicare,,,56.27,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,56.27,152.1,
"Prosthetic shrinker, above knee, each",L8460,HCPCS,,,,outpatient,,,241,144.6,,45.5,,109.66,percent of total billed charges,,,45.3,,109.17,percent of total billed charges,,,39,,93.99,percent of total billed charges,,,,,,,,,80,,192.8,percent of total billed charges,,,61.4,,147.97,percent of total billed charges,,,57.4,,138.33,percent of total billed charges,,,81,,195.21,percent of total billed charges,,,39,,93.99,percent of total billed charges,,,57.6,,138.82,percent of total billed charges,,,85,,204.85,percent of total billed charges,,,85,,204.85,percent of total billed charges,,,49,,118.09,percent of total billed charges,,,90,,216.9,percent of total billed charges,,,65,,156.65,percent of total billed charges,,,80,,192.8,percent of total billed charges,,,55,,132.55,percent of total billed charges,,,55,,132.55,percent of total billed charges,,,65,,156.65,percent of total billed charges,,,78,,187.98,percent of total billed charges,,,70,,168.7,percent of total billed charges,,,,,,,,79.99,,,,100% of Medicare,,79.99,,,,100% of Medicare,,79.99,,,,100% of Medicare,,79.99,,,,100% of Medicare,,79.99,,,,100% of Medicare,,79.99,,,,100% of Medicare,,79.99,,,,100% of Medicare,,79.99,,,,100% of Medicare,,79.99,,,,100% of Medicare,,79.99,,,,100% of Medicare,,79.99,,,,100% of Medicare,,79.99,,,,100% of Medicare,,,79.99,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,79.99,216.9,
"Prosthetic shrinker, upper limb, each",L8465,HCPCS,,,,outpatient,,,220,132,,45.5,,100.1,percent of total billed charges,,,45.3,,99.66,percent of total billed charges,,,39,,85.8,percent of total billed charges,,,,,,,,,80,,176,percent of total billed charges,,,61.4,,135.08,percent of total billed charges,,,57.4,,126.28,percent of total billed charges,,,81,,178.2,percent of total billed charges,,,39,,85.8,percent of total billed charges,,,57.6,,126.72,percent of total billed charges,,,85,,187,percent of total billed charges,,,85,,187,percent of total billed charges,,,49,,107.8,percent of total billed charges,,,90,,198,percent of total billed charges,,,65,,143,percent of total billed charges,,,80,,176,percent of total billed charges,,,55,,121,percent of total billed charges,,,55,,121,percent of total billed charges,,,65,,143,percent of total billed charges,,,78,,171.6,percent of total billed charges,,,70,,154,percent of total billed charges,,,,,,,,73.93,,,,100% of Medicare,,73.93,,,,100% of Medicare,,73.93,,,,100% of Medicare,,73.93,,,,100% of Medicare,,73.93,,,,100% of Medicare,,73.93,,,,100% of Medicare,,73.93,,,,100% of Medicare,,73.93,,,,100% of Medicare,,73.93,,,,100% of Medicare,,73.93,,,,100% of Medicare,,73.93,,,,100% of Medicare,,73.93,,,,100% of Medicare,,,73.93,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,73.93,198,
"Prosthetic sock, single ply fitting, below knee, each",L8470,HCPCS,,,,outpatient,,,27,16.2,,45.5,,12.29,percent of total billed charges,,,45.3,,12.23,percent of total billed charges,,,39,,10.53,percent of total billed charges,,,,,,,,,80,,21.6,percent of total billed charges,,,61.4,,16.58,percent of total billed charges,,,57.4,,15.5,percent of total billed charges,,,81,,21.87,percent of total billed charges,,,39,,10.53,percent of total billed charges,,,57.6,,15.55,percent of total billed charges,,,85,,22.95,percent of total billed charges,,,85,,22.95,percent of total billed charges,,,49,,13.23,percent of total billed charges,,,90,,24.3,percent of total billed charges,,,65,,17.55,percent of total billed charges,,,80,,21.6,percent of total billed charges,,,55,,14.85,percent of total billed charges,,,55,,14.85,percent of total billed charges,,,65,,17.55,percent of total billed charges,,,78,,21.06,percent of total billed charges,,,70,,18.9,percent of total billed charges,,,,,,,,8.01,,,,100% of Medicare,,8.01,,,,100% of Medicare,,8.01,,,,100% of Medicare,,8.01,,,,100% of Medicare,,8.01,,,,100% of Medicare,,8.01,,,,100% of Medicare,,8.01,,,,100% of Medicare,,8.01,,,,100% of Medicare,,8.01,,,,100% of Medicare,,8.01,,,,100% of Medicare,,8.01,,,,100% of Medicare,,8.01,,,,100% of Medicare,,,8.01,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,8.01,24.3,
"Prosthetic sock, single ply fitting, above knee, each",L8480,HCPCS,,,,outpatient,,,38,22.8,,45.5,,17.29,percent of total billed charges,,,45.3,,17.21,percent of total billed charges,,,39,,14.82,percent of total billed charges,,,,,,,,,80,,30.4,percent of total billed charges,,,61.4,,23.33,percent of total billed charges,,,57.4,,21.81,percent of total billed charges,,,81,,30.78,percent of total billed charges,,,39,,14.82,percent of total billed charges,,,57.6,,21.89,percent of total billed charges,,,85,,32.3,percent of total billed charges,,,85,,32.3,percent of total billed charges,,,49,,18.62,percent of total billed charges,,,90,,34.2,percent of total billed charges,,,65,,24.7,percent of total billed charges,,,80,,30.4,percent of total billed charges,,,55,,20.9,percent of total billed charges,,,55,,20.9,percent of total billed charges,,,65,,24.7,percent of total billed charges,,,78,,29.64,percent of total billed charges,,,70,,26.6,percent of total billed charges,,,,,,,,11.05,,,,100% of Medicare,,11.05,,,,100% of Medicare,,11.05,,,,100% of Medicare,,11.05,,,,100% of Medicare,,11.05,,,,100% of Medicare,,11.05,,,,100% of Medicare,,11.05,,,,100% of Medicare,,11.05,,,,100% of Medicare,,11.05,,,,100% of Medicare,,11.05,,,,100% of Medicare,,11.05,,,,100% of Medicare,,11.05,,,,100% of Medicare,,,11.05,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,11.05,34.2,
"Prosthetic sock, single ply, upper limb, each",L8485,HCPCS,,,,outpatient,,,44,26.4,,45.5,,20.02,percent of total billed charges,,,45.3,,19.93,percent of total billed charges,,,39,,17.16,percent of total billed charges,,,,,,,,,80,,35.2,percent of total billed charges,,,61.4,,27.02,percent of total billed charges,,,57.4,,25.26,percent of total billed charges,,,81,,35.64,percent of total billed charges,,,39,,17.16,percent of total billed charges,,,57.6,,25.34,percent of total billed charges,,,85,,37.4,percent of total billed charges,,,85,,37.4,percent of total billed charges,,,49,,21.56,percent of total billed charges,,,90,,39.6,percent of total billed charges,,,65,,28.6,percent of total billed charges,,,80,,35.2,percent of total billed charges,,,55,,24.2,percent of total billed charges,,,55,,24.2,percent of total billed charges,,,65,,28.6,percent of total billed charges,,,78,,34.32,percent of total billed charges,,,70,,30.8,percent of total billed charges,,,,,,,,14.87,,,,100% of Medicare,,14.87,,,,100% of Medicare,,14.87,,,,100% of Medicare,,14.87,,,,100% of Medicare,,14.87,,,,100% of Medicare,,14.87,,,,100% of Medicare,,14.87,,,,100% of Medicare,,14.87,,,,100% of Medicare,,14.87,,,,100% of Medicare,,14.87,,,,100% of Medicare,,14.87,,,,100% of Medicare,,14.87,,,,100% of Medicare,,,14.87,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,14.87,39.6,
TORSION MECHANISM KNEE/ANKLE,L2861,HCPCS,,,,outpatient,,,312,187.2,,45.5,,141.96,percent of total billed charges,,,45.3,,141.34,percent of total billed charges,,,39,,121.68,percent of total billed charges,,,,,,,,,80,,249.6,percent of total billed charges,,,61.4,,191.57,percent of total billed charges,,,57.4,,179.09,percent of total billed charges,,,81,,252.72,percent of total billed charges,,,39,,121.68,percent of total billed charges,,,57.6,,179.71,percent of total billed charges,,,85,,265.2,percent of total billed charges,,,85,,265.2,percent of total billed charges,,,49,,152.88,percent of total billed charges,,,90,,280.8,percent of total billed charges,,,65,,202.8,percent of total billed charges,,,80,,249.6,percent of total billed charges,,,55,,171.6,percent of total billed charges,,,55,,171.6,percent of total billed charges,,,65,,202.8,percent of total billed charges,,,78,,243.36,percent of total billed charges,,,70,,218.4,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,121.68,280.8,
"Orthopedic Shoe, Ladies, Oxford",L3215,HCPCS,,,,outpatient,,,557,334.2,,45.5,,253.44,percent of total billed charges,,,45.3,,252.32,percent of total billed charges,,,39,,217.23,percent of total billed charges,,,,,,,,,80,,445.6,percent of total billed charges,,,61.4,,342,percent of total billed charges,,,57.4,,319.72,percent of total billed charges,,,81,,451.17,percent of total billed charges,,,39,,217.23,percent of total billed charges,,,57.6,,320.83,percent of total billed charges,,,85,,473.45,percent of total billed charges,,,85,,473.45,percent of total billed charges,,,49,,272.93,percent of total billed charges,,,90,,501.3,percent of total billed charges,,,65,,362.05,percent of total billed charges,,,80,,445.6,percent of total billed charges,,,55,,306.35,percent of total billed charges,,,55,,306.35,percent of total billed charges,,,65,,362.05,percent of total billed charges,,,78,,434.46,percent of total billed charges,,,70,,389.9,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,217.23,501.3,
"Orthopedic Shoe, Ladies, Depth Inlay",L3216,HCPCS,,,,outpatient,,,773,463.8,,45.5,,351.72,percent of total billed charges,,,45.3,,350.17,percent of total billed charges,,,39,,301.47,percent of total billed charges,,,,,,,,,80,,618.4,percent of total billed charges,,,61.4,,474.62,percent of total billed charges,,,57.4,,443.7,percent of total billed charges,,,81,,626.13,percent of total billed charges,,,39,,301.47,percent of total billed charges,,,57.6,,445.25,percent of total billed charges,,,85,,657.05,percent of total billed charges,,,85,,657.05,percent of total billed charges,,,49,,378.77,percent of total billed charges,,,90,,695.7,percent of total billed charges,,,65,,502.45,percent of total billed charges,,,80,,618.4,percent of total billed charges,,,55,,425.15,percent of total billed charges,,,55,,425.15,percent of total billed charges,,,65,,502.45,percent of total billed charges,,,78,,602.94,percent of total billed charges,,,70,,541.1,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,301.47,695.7,
"Orthopedic Shoe, Ladies, High Top Depth Inlay",L3217,HCPCS,,,,outpatient,,,611,366.6,,45.5,,278.01,percent of total billed charges,,,45.3,,276.78,percent of total billed charges,,,39,,238.29,percent of total billed charges,,,,,,,,,80,,488.8,percent of total billed charges,,,61.4,,375.15,percent of total billed charges,,,57.4,,350.71,percent of total billed charges,,,81,,494.91,percent of total billed charges,,,39,,238.29,percent of total billed charges,,,57.6,,351.94,percent of total billed charges,,,85,,519.35,percent of total billed charges,,,85,,519.35,percent of total billed charges,,,49,,299.39,percent of total billed charges,,,90,,549.9,percent of total billed charges,,,65,,397.15,percent of total billed charges,,,80,,488.8,percent of total billed charges,,,55,,336.05,percent of total billed charges,,,55,,336.05,percent of total billed charges,,,65,,397.15,percent of total billed charges,,,78,,476.58,percent of total billed charges,,,70,,427.7,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,238.29,549.9,
"Orthopedic Shoe, Mens, Oxford",L3219,HCPCS,,,,outpatient,,,868,520.8,,45.5,,394.94,percent of total billed charges,,,45.3,,393.2,percent of total billed charges,,,39,,338.52,percent of total billed charges,,,,,,,,,80,,694.4,percent of total billed charges,,,61.4,,532.95,percent of total billed charges,,,57.4,,498.23,percent of total billed charges,,,81,,703.08,percent of total billed charges,,,39,,338.52,percent of total billed charges,,,57.6,,499.97,percent of total billed charges,,,85,,737.8,percent of total billed charges,,,85,,737.8,percent of total billed charges,,,49,,425.32,percent of total billed charges,,,90,,781.2,percent of total billed charges,,,65,,564.2,percent of total billed charges,,,80,,694.4,percent of total billed charges,,,55,,477.4,percent of total billed charges,,,55,,477.4,percent of total billed charges,,,65,,564.2,percent of total billed charges,,,78,,677.04,percent of total billed charges,,,70,,607.6,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,338.52,781.2,
"Orthopedic Shoe, Mens, Depth Inlay",L3221,HCPCS,,,,outpatient,,,964,578.4,,45.5,,438.62,percent of total billed charges,,,45.3,,436.69,percent of total billed charges,,,39,,375.96,percent of total billed charges,,,,,,,,,80,,771.2,percent of total billed charges,,,61.4,,591.9,percent of total billed charges,,,57.4,,553.34,percent of total billed charges,,,81,,780.84,percent of total billed charges,,,39,,375.96,percent of total billed charges,,,57.6,,555.26,percent of total billed charges,,,85,,819.4,percent of total billed charges,,,85,,819.4,percent of total billed charges,,,49,,472.36,percent of total billed charges,,,90,,867.6,percent of total billed charges,,,65,,626.6,percent of total billed charges,,,80,,771.2,percent of total billed charges,,,55,,530.2,percent of total billed charges,,,55,,530.2,percent of total billed charges,,,65,,626.6,percent of total billed charges,,,78,,751.92,percent of total billed charges,,,70,,674.8,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,375.96,867.6,
"Orthopedic Shoe, Mens, High Top Depth Inlay",L3222,HCPCS,,,,outpatient,,,731,438.6,,45.5,,332.61,percent of total billed charges,,,45.3,,331.14,percent of total billed charges,,,39,,285.09,percent of total billed charges,,,,,,,,,80,,584.8,percent of total billed charges,,,61.4,,448.83,percent of total billed charges,,,57.4,,419.59,percent of total billed charges,,,81,,592.11,percent of total billed charges,,,39,,285.09,percent of total billed charges,,,57.6,,421.06,percent of total billed charges,,,85,,621.35,percent of total billed charges,,,85,,621.35,percent of total billed charges,,,49,,358.19,percent of total billed charges,,,90,,657.9,percent of total billed charges,,,65,,475.15,percent of total billed charges,,,80,,584.8,percent of total billed charges,,,55,,402.05,percent of total billed charges,,,55,,402.05,percent of total billed charges,,,65,,475.15,percent of total billed charges,,,78,,570.18,percent of total billed charges,,,70,,511.7,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,285.09,657.9,
Surgical Boot,L3260,HCPCS,,,,outpatient,,,761,456.6,,45.5,,346.26,percent of total billed charges,,,45.3,,344.73,percent of total billed charges,,,39,,296.79,percent of total billed charges,,,,,,,,,80,,608.8,percent of total billed charges,,,61.4,,467.25,percent of total billed charges,,,57.4,,436.81,percent of total billed charges,,,81,,616.41,percent of total billed charges,,,39,,296.79,percent of total billed charges,,,57.6,,438.34,percent of total billed charges,,,85,,646.85,percent of total billed charges,,,85,,646.85,percent of total billed charges,,,49,,372.89,percent of total billed charges,,,90,,684.9,percent of total billed charges,,,65,,494.65,percent of total billed charges,,,80,,608.8,percent of total billed charges,,,55,,418.55,percent of total billed charges,,,55,,418.55,percent of total billed charges,,,65,,494.65,percent of total billed charges,,,78,,593.58,percent of total billed charges,,,70,,532.7,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,296.79,684.9,
TORSION MECHANISM WRIST/ELBO,L3891,HCPCS,,,,outpatient,,,312,187.2,,45.5,,141.96,percent of total billed charges,,,45.3,,141.34,percent of total billed charges,,,39,,121.68,percent of total billed charges,,,,,,,,,80,,249.6,percent of total billed charges,,,61.4,,191.57,percent of total billed charges,,,57.4,,179.09,percent of total billed charges,,,81,,252.72,percent of total billed charges,,,39,,121.68,percent of total billed charges,,,57.6,,179.71,percent of total billed charges,,,85,,265.2,percent of total billed charges,,,85,,265.2,percent of total billed charges,,,49,,152.88,percent of total billed charges,,,90,,280.8,percent of total billed charges,,,65,,202.8,percent of total billed charges,,,80,,249.6,percent of total billed charges,,,55,,171.6,percent of total billed charges,,,55,,171.6,percent of total billed charges,,,65,,202.8,percent of total billed charges,,,78,,243.36,percent of total billed charges,,,70,,218.4,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,121.68,280.8,
"L7600 Prosthetic donning sleeve, any material, ea",L7600,HCPCS,,,,outpatient,,,187,112.2,,45.5,,85.09,percent of total billed charges,,,45.3,,84.71,percent of total billed charges,,,39,,72.93,percent of total billed charges,,,,,,,,,80,,149.6,percent of total billed charges,,,61.4,,114.82,percent of total billed charges,,,57.4,,107.34,percent of total billed charges,,,81,,151.47,percent of total billed charges,,,39,,72.93,percent of total billed charges,,,57.6,,107.71,percent of total billed charges,,,85,,158.95,percent of total billed charges,,,85,,158.95,percent of total billed charges,,,49,,91.63,percent of total billed charges,,,90,,168.3,percent of total billed charges,,,65,,121.55,percent of total billed charges,,,80,,149.6,percent of total billed charges,,,55,,102.85,percent of total billed charges,,,55,,102.85,percent of total billed charges,,,65,,121.55,percent of total billed charges,,,78,,145.86,percent of total billed charges,,,70,,130.9,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,72.93,168.3,
XR Humerus Right,73060,CPT,,,RT,both,,,735,441,,45.5,,334.43,percent of total billed charges,,,45.3,,332.96,percent of total billed charges,,,51,,374.85,percent of total billed charges,,,,,,,,,80,,588,percent of total billed charges,,,61.4,,451.29,percent of total billed charges,,,57.4,,421.89,percent of total billed charges,,,81,,595.35,percent of total billed charges,,,51.5,,378.53,percent of total billed charges,,365,,,,fee schedule,,,85,,624.75,percent of total billed charges,,,85,,624.75,percent of total billed charges,,,49,,360.15,percent of total billed charges,,,90,,661.5,percent of total billed charges,,,65,,477.75,percent of total billed charges,,,80,,588,percent of total billed charges,,,55,,404.25,percent of total billed charges,,,55,,404.25,percent of total billed charges,,,65,,477.75,percent of total billed charges,,,78,,573.3,percent of total billed charges,,,70,,514.5,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,661.5,
XR Elbow 2 Views Left,73070,CPT,,,LT,both,,,463,277.8,,45.5,,210.67,percent of total billed charges,,,45.3,,209.74,percent of total billed charges,,,51,,236.13,percent of total billed charges,,,,,,,,,80,,370.4,percent of total billed charges,,,61.4,,284.28,percent of total billed charges,,,57.4,,265.76,percent of total billed charges,,,81,,375.03,percent of total billed charges,,,51.5,,238.45,percent of total billed charges,,365,,,,fee schedule,,,85,,393.55,percent of total billed charges,,,85,,393.55,percent of total billed charges,,,49,,226.87,percent of total billed charges,,,90,,416.7,percent of total billed charges,,,65,,300.95,percent of total billed charges,,,80,,370.4,percent of total billed charges,,,55,,254.65,percent of total billed charges,,,55,,254.65,percent of total billed charges,,,65,,300.95,percent of total billed charges,,,78,,361.14,percent of total billed charges,,,70,,324.1,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,416.7,
XR Elbow 2 Views Right,73070,CPT,,,RT,both,,,463,277.8,,45.5,,210.67,percent of total billed charges,,,45.3,,209.74,percent of total billed charges,,,51,,236.13,percent of total billed charges,,,,,,,,,80,,370.4,percent of total billed charges,,,61.4,,284.28,percent of total billed charges,,,57.4,,265.76,percent of total billed charges,,,81,,375.03,percent of total billed charges,,,51.5,,238.45,percent of total billed charges,,365,,,,fee schedule,,,85,,393.55,percent of total billed charges,,,85,,393.55,percent of total billed charges,,,49,,226.87,percent of total billed charges,,,90,,416.7,percent of total billed charges,,,65,,300.95,percent of total billed charges,,,80,,370.4,percent of total billed charges,,,55,,254.65,percent of total billed charges,,,55,,254.65,percent of total billed charges,,,65,,300.95,percent of total billed charges,,,78,,361.14,percent of total billed charges,,,70,,324.1,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,416.7,
XR Elbow Complete Left,73080,CPT,,,LT,both,,,623,373.8,,45.5,,283.47,percent of total billed charges,,,45.3,,282.22,percent of total billed charges,,,51,,317.73,percent of total billed charges,,,,,,,,,80,,498.4,percent of total billed charges,,,61.4,,382.52,percent of total billed charges,,,57.4,,357.6,percent of total billed charges,,,81,,504.63,percent of total billed charges,,,51.5,,320.85,percent of total billed charges,,365,,,,fee schedule,,,85,,529.55,percent of total billed charges,,,85,,529.55,percent of total billed charges,,,49,,305.27,percent of total billed charges,,,90,,560.7,percent of total billed charges,,,65,,404.95,percent of total billed charges,,,80,,498.4,percent of total billed charges,,,55,,342.65,percent of total billed charges,,,55,,342.65,percent of total billed charges,,,65,,404.95,percent of total billed charges,,,78,,485.94,percent of total billed charges,,,70,,436.1,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,560.7,
XR Elbow Complete Right,73080,CPT,,,RT,both,,,623,373.8,,45.5,,283.47,percent of total billed charges,,,45.3,,282.22,percent of total billed charges,,,51,,317.73,percent of total billed charges,,,,,,,,,80,,498.4,percent of total billed charges,,,61.4,,382.52,percent of total billed charges,,,57.4,,357.6,percent of total billed charges,,,81,,504.63,percent of total billed charges,,,51.5,,320.85,percent of total billed charges,,365,,,,fee schedule,,,85,,529.55,percent of total billed charges,,,85,,529.55,percent of total billed charges,,,49,,305.27,percent of total billed charges,,,90,,560.7,percent of total billed charges,,,65,,404.95,percent of total billed charges,,,80,,498.4,percent of total billed charges,,,55,,342.65,percent of total billed charges,,,55,,342.65,percent of total billed charges,,,65,,404.95,percent of total billed charges,,,78,,485.94,percent of total billed charges,,,70,,436.1,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,560.7,
XR Forearm 2 Views Left,73090,CPT,,,LT,both,,,610,366,,45.5,,277.55,percent of total billed charges,,,45.3,,276.33,percent of total billed charges,,,51,,311.1,percent of total billed charges,,,,,,,,,80,,488,percent of total billed charges,,,61.4,,374.54,percent of total billed charges,,,57.4,,350.14,percent of total billed charges,,,81,,494.1,percent of total billed charges,,,51.5,,314.15,percent of total billed charges,,365,,,,fee schedule,,,85,,518.5,percent of total billed charges,,,85,,518.5,percent of total billed charges,,,49,,298.9,percent of total billed charges,,,90,,549,percent of total billed charges,,,65,,396.5,percent of total billed charges,,,80,,488,percent of total billed charges,,,55,,335.5,percent of total billed charges,,,55,,335.5,percent of total billed charges,,,65,,396.5,percent of total billed charges,,,78,,475.8,percent of total billed charges,,,70,,427,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,549,
XR Forearm 2 Views Right,73090,CPT,,,RT,both,,,610,366,,45.5,,277.55,percent of total billed charges,,,45.3,,276.33,percent of total billed charges,,,51,,311.1,percent of total billed charges,,,,,,,,,80,,488,percent of total billed charges,,,61.4,,374.54,percent of total billed charges,,,57.4,,350.14,percent of total billed charges,,,81,,494.1,percent of total billed charges,,,51.5,,314.15,percent of total billed charges,,365,,,,fee schedule,,,85,,518.5,percent of total billed charges,,,85,,518.5,percent of total billed charges,,,49,,298.9,percent of total billed charges,,,90,,549,percent of total billed charges,,,65,,396.5,percent of total billed charges,,,80,,488,percent of total billed charges,,,55,,335.5,percent of total billed charges,,,55,,335.5,percent of total billed charges,,,65,,396.5,percent of total billed charges,,,78,,475.8,percent of total billed charges,,,70,,427,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,549,
XR Upper Extremity Infant Left,73092,CPT,,,LT,both,,,335,201,,45.5,,152.43,percent of total billed charges,,,45.3,,151.76,percent of total billed charges,,,51,,170.85,percent of total billed charges,,,,,,,,,80,,268,percent of total billed charges,,,61.4,,205.69,percent of total billed charges,,,57.4,,192.29,percent of total billed charges,,,81,,271.35,percent of total billed charges,,,51.5,,172.53,percent of total billed charges,,365,,,,fee schedule,,,85,,284.75,percent of total billed charges,,,85,,284.75,percent of total billed charges,,,49,,164.15,percent of total billed charges,,,90,,301.5,percent of total billed charges,,,65,,217.75,percent of total billed charges,,,80,,268,percent of total billed charges,,,55,,184.25,percent of total billed charges,,,55,,184.25,percent of total billed charges,,,65,,217.75,percent of total billed charges,,,78,,261.3,percent of total billed charges,,,70,,234.5,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,365,
XR Upper Extremity Infant Right,73092,CPT,,,RT,both,,,335,201,,45.5,,152.43,percent of total billed charges,,,45.3,,151.76,percent of total billed charges,,,51,,170.85,percent of total billed charges,,,,,,,,,80,,268,percent of total billed charges,,,61.4,,205.69,percent of total billed charges,,,57.4,,192.29,percent of total billed charges,,,81,,271.35,percent of total billed charges,,,51.5,,172.53,percent of total billed charges,,365,,,,fee schedule,,,85,,284.75,percent of total billed charges,,,85,,284.75,percent of total billed charges,,,49,,164.15,percent of total billed charges,,,90,,301.5,percent of total billed charges,,,65,,217.75,percent of total billed charges,,,80,,268,percent of total billed charges,,,55,,184.25,percent of total billed charges,,,55,,184.25,percent of total billed charges,,,65,,217.75,percent of total billed charges,,,78,,261.3,percent of total billed charges,,,70,,234.5,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,365,
XR Wrist Navicular View Left,73100,CPT,,,52<and>LT,both,,,551,330.6,,45.5,,250.71,percent of total billed charges,,,45.3,,249.6,percent of total billed charges,,,51,,281.01,percent of total billed charges,,,,,,,,,80,,440.8,percent of total billed charges,,,61.4,,338.31,percent of total billed charges,,,57.4,,316.27,percent of total billed charges,,,81,,446.31,percent of total billed charges,,,51.5,,283.77,percent of total billed charges,,365,,,,fee schedule,,,85,,468.35,percent of total billed charges,,,85,,468.35,percent of total billed charges,,,49,,269.99,percent of total billed charges,,,90,,495.9,percent of total billed charges,,,65,,358.15,percent of total billed charges,,,80,,440.8,percent of total billed charges,,,55,,303.05,percent of total billed charges,,,55,,303.05,percent of total billed charges,,,65,,358.15,percent of total billed charges,,,78,,429.78,percent of total billed charges,,,70,,385.7,percent of total billed charges,,,,,,,,91.79,,,,50% of Medicare,,91.79,,,,50% of Medicare,,91.79,,,,50% of Medicare,,91.79,,,,50% of Medicare,,91.79,,,,50% of Medicare,,91.79,,,,50% of Medicare,,91.79,,,,50% of Medicare,,91.79,,,,50% of Medicare,,91.79,,,,50% of Medicare,,91.79,,,,50% of Medicare,,91.79,,,,50% of Medicare,,91.79,,,,50% of Medicare,,,91.79,,,,50% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,495.9,
XR Wrist 2 Views Left,73100,CPT,,,LT,both,,,551,330.6,,45.5,,250.71,percent of total billed charges,,,45.3,,249.6,percent of total billed charges,,,51,,281.01,percent of total billed charges,,,,,,,,,80,,440.8,percent of total billed charges,,,61.4,,338.31,percent of total billed charges,,,57.4,,316.27,percent of total billed charges,,,81,,446.31,percent of total billed charges,,,51.5,,283.77,percent of total billed charges,,365,,,,fee schedule,,,85,,468.35,percent of total billed charges,,,85,,468.35,percent of total billed charges,,,49,,269.99,percent of total billed charges,,,90,,495.9,percent of total billed charges,,,65,,358.15,percent of total billed charges,,,80,,440.8,percent of total billed charges,,,55,,303.05,percent of total billed charges,,,55,,303.05,percent of total billed charges,,,65,,358.15,percent of total billed charges,,,78,,429.78,percent of total billed charges,,,70,,385.7,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,495.9,
XR Wrist Carpal Tunnel Left,73100,CPT,,,LT<and>52,both,,,551,330.6,,45.5,,250.71,percent of total billed charges,,,45.3,,249.6,percent of total billed charges,,,51,,281.01,percent of total billed charges,,,,,,,,,80,,440.8,percent of total billed charges,,,61.4,,338.31,percent of total billed charges,,,57.4,,316.27,percent of total billed charges,,,81,,446.31,percent of total billed charges,,,51.5,,283.77,percent of total billed charges,,365,,,,fee schedule,,,85,,468.35,percent of total billed charges,,,85,,468.35,percent of total billed charges,,,49,,269.99,percent of total billed charges,,,90,,495.9,percent of total billed charges,,,65,,358.15,percent of total billed charges,,,80,,440.8,percent of total billed charges,,,55,,303.05,percent of total billed charges,,,55,,303.05,percent of total billed charges,,,65,,358.15,percent of total billed charges,,,78,,429.78,percent of total billed charges,,,70,,385.7,percent of total billed charges,,,,,,,,91.79,,,,50% of Medicare,,91.79,,,,50% of Medicare,,91.79,,,,50% of Medicare,,91.79,,,,50% of Medicare,,91.79,,,,50% of Medicare,,91.79,,,,50% of Medicare,,91.79,,,,50% of Medicare,,91.79,,,,50% of Medicare,,91.79,,,,50% of Medicare,,91.79,,,,50% of Medicare,,91.79,,,,50% of Medicare,,91.79,,,,50% of Medicare,,,91.79,,,,50% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,495.9,
XR Wrist 2 Views Right,73100,CPT,,,RT,both,,,551,330.6,,45.5,,250.71,percent of total billed charges,,,45.3,,249.6,percent of total billed charges,,,51,,281.01,percent of total billed charges,,,,,,,,,80,,440.8,percent of total billed charges,,,61.4,,338.31,percent of total billed charges,,,57.4,,316.27,percent of total billed charges,,,81,,446.31,percent of total billed charges,,,51.5,,283.77,percent of total billed charges,,365,,,,fee schedule,,,85,,468.35,percent of total billed charges,,,85,,468.35,percent of total billed charges,,,49,,269.99,percent of total billed charges,,,90,,495.9,percent of total billed charges,,,65,,358.15,percent of total billed charges,,,80,,440.8,percent of total billed charges,,,55,,303.05,percent of total billed charges,,,55,,303.05,percent of total billed charges,,,65,,358.15,percent of total billed charges,,,78,,429.78,percent of total billed charges,,,70,,385.7,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,495.9,
XR Wrist Carpal Tunnel Right,73100,CPT,,,RT<and>52,both,,,551,330.6,,45.5,,250.71,percent of total billed charges,,,45.3,,249.6,percent of total billed charges,,,51,,281.01,percent of total billed charges,,,,,,,,,80,,440.8,percent of total billed charges,,,61.4,,338.31,percent of total billed charges,,,57.4,,316.27,percent of total billed charges,,,81,,446.31,percent of total billed charges,,,51.5,,283.77,percent of total billed charges,,365,,,,fee schedule,,,85,,468.35,percent of total billed charges,,,85,,468.35,percent of total billed charges,,,49,,269.99,percent of total billed charges,,,90,,495.9,percent of total billed charges,,,65,,358.15,percent of total billed charges,,,80,,440.8,percent of total billed charges,,,55,,303.05,percent of total billed charges,,,55,,303.05,percent of total billed charges,,,65,,358.15,percent of total billed charges,,,78,,429.78,percent of total billed charges,,,70,,385.7,percent of total billed charges,,,,,,,,45.9,,,,50% of Medicare,,45.9,,,,50% of Medicare,,45.9,,,,50% of Medicare,,45.9,,,,50% of Medicare,,45.9,,,,50% of Medicare,,45.9,,,,50% of Medicare,,45.9,,,,50% of Medicare,,45.9,,,,50% of Medicare,,45.9,,,,50% of Medicare,,45.9,,,,50% of Medicare,,45.9,,,,50% of Medicare,,45.9,,,,50% of Medicare,,,45.9,,,,50% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,45.9,495.9,
XR Wrist Navicular View Right,73100,CPT,,,RT<and>52,both,,,551,330.6,,45.5,,250.71,percent of total billed charges,,,45.3,,249.6,percent of total billed charges,,,51,,281.01,percent of total billed charges,,,,,,,,,80,,440.8,percent of total billed charges,,,61.4,,338.31,percent of total billed charges,,,57.4,,316.27,percent of total billed charges,,,81,,446.31,percent of total billed charges,,,51.5,,283.77,percent of total billed charges,,365,,,,fee schedule,,,85,,468.35,percent of total billed charges,,,85,,468.35,percent of total billed charges,,,49,,269.99,percent of total billed charges,,,90,,495.9,percent of total billed charges,,,65,,358.15,percent of total billed charges,,,80,,440.8,percent of total billed charges,,,55,,303.05,percent of total billed charges,,,55,,303.05,percent of total billed charges,,,65,,358.15,percent of total billed charges,,,78,,429.78,percent of total billed charges,,,70,,385.7,percent of total billed charges,,,,,,,,45.9,,,,50% of Medicare,,45.9,,,,50% of Medicare,,45.9,,,,50% of Medicare,,45.9,,,,50% of Medicare,,45.9,,,,50% of Medicare,,45.9,,,,50% of Medicare,,45.9,,,,50% of Medicare,,45.9,,,,50% of Medicare,,45.9,,,,50% of Medicare,,45.9,,,,50% of Medicare,,45.9,,,,50% of Medicare,,45.9,,,,50% of Medicare,,,45.9,,,,50% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,45.9,495.9,
XR Wrist Complete Left,73110,CPT,,,LT,both,,,628,376.8,,45.5,,285.74,percent of total billed charges,,,45.3,,284.48,percent of total billed charges,,,51,,320.28,percent of total billed charges,,,,,,,,,80,,502.4,percent of total billed charges,,,61.4,,385.59,percent of total billed charges,,,57.4,,360.47,percent of total billed charges,,,81,,508.68,percent of total billed charges,,,51.5,,323.42,percent of total billed charges,,365,,,,fee schedule,,,85,,533.8,percent of total billed charges,,,85,,533.8,percent of total billed charges,,,49,,307.72,percent of total billed charges,,,90,,565.2,percent of total billed charges,,,65,,408.2,percent of total billed charges,,,80,,502.4,percent of total billed charges,,,55,,345.4,percent of total billed charges,,,55,,345.4,percent of total billed charges,,,65,,408.2,percent of total billed charges,,,78,,489.84,percent of total billed charges,,,70,,439.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,565.2,
XR Wrist Complete Right,73110,CPT,,,RT,both,,,628,376.8,,45.5,,285.74,percent of total billed charges,,,45.3,,284.48,percent of total billed charges,,,51,,320.28,percent of total billed charges,,,,,,,,,80,,502.4,percent of total billed charges,,,61.4,,385.59,percent of total billed charges,,,57.4,,360.47,percent of total billed charges,,,81,,508.68,percent of total billed charges,,,51.5,,323.42,percent of total billed charges,,365,,,,fee schedule,,,85,,533.8,percent of total billed charges,,,85,,533.8,percent of total billed charges,,,49,,307.72,percent of total billed charges,,,90,,565.2,percent of total billed charges,,,65,,408.2,percent of total billed charges,,,80,,502.4,percent of total billed charges,,,55,,345.4,percent of total billed charges,,,55,,345.4,percent of total billed charges,,,65,,408.2,percent of total billed charges,,,78,,489.84,percent of total billed charges,,,70,,439.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,565.2,
XR Hand 2 Views Left,73120,CPT,,,LT,both,,,566,339.6,,45.5,,257.53,percent of total billed charges,,,45.3,,256.4,percent of total billed charges,,,51,,288.66,percent of total billed charges,,,,,,,,,80,,452.8,percent of total billed charges,,,61.4,,347.52,percent of total billed charges,,,57.4,,324.88,percent of total billed charges,,,81,,458.46,percent of total billed charges,,,51.5,,291.49,percent of total billed charges,,365,,,,fee schedule,,,85,,481.1,percent of total billed charges,,,85,,481.1,percent of total billed charges,,,49,,277.34,percent of total billed charges,,,90,,509.4,percent of total billed charges,,,65,,367.9,percent of total billed charges,,,80,,452.8,percent of total billed charges,,,55,,311.3,percent of total billed charges,,,55,,311.3,percent of total billed charges,,,65,,367.9,percent of total billed charges,,,78,,441.48,percent of total billed charges,,,70,,396.2,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,509.4,
XR Hand 2 Views Right,73120,CPT,,,RT,both,,,566,339.6,,45.5,,257.53,percent of total billed charges,,,45.3,,256.4,percent of total billed charges,,,51,,288.66,percent of total billed charges,,,,,,,,,80,,452.8,percent of total billed charges,,,61.4,,347.52,percent of total billed charges,,,57.4,,324.88,percent of total billed charges,,,81,,458.46,percent of total billed charges,,,51.5,,291.49,percent of total billed charges,,365,,,,fee schedule,,,85,,481.1,percent of total billed charges,,,85,,481.1,percent of total billed charges,,,49,,277.34,percent of total billed charges,,,90,,509.4,percent of total billed charges,,,65,,367.9,percent of total billed charges,,,80,,452.8,percent of total billed charges,,,55,,311.3,percent of total billed charges,,,55,,311.3,percent of total billed charges,,,65,,367.9,percent of total billed charges,,,78,,441.48,percent of total billed charges,,,70,,396.2,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,509.4,
XR Hand Complete Left,73130,CPT,,,LT,both,,,636,381.6,,45.5,,289.38,percent of total billed charges,,,45.3,,288.11,percent of total billed charges,,,51,,324.36,percent of total billed charges,,,,,,,,,80,,508.8,percent of total billed charges,,,61.4,,390.5,percent of total billed charges,,,57.4,,365.06,percent of total billed charges,,,81,,515.16,percent of total billed charges,,,51.5,,327.54,percent of total billed charges,,365,,,,fee schedule,,,85,,540.6,percent of total billed charges,,,85,,540.6,percent of total billed charges,,,49,,311.64,percent of total billed charges,,,90,,572.4,percent of total billed charges,,,65,,413.4,percent of total billed charges,,,80,,508.8,percent of total billed charges,,,55,,349.8,percent of total billed charges,,,55,,349.8,percent of total billed charges,,,65,,413.4,percent of total billed charges,,,78,,496.08,percent of total billed charges,,,70,,445.2,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,572.4,
XR Hand Complete Right,73130,CPT,,,RT,both,,,636,381.6,,45.5,,289.38,percent of total billed charges,,,45.3,,288.11,percent of total billed charges,,,51,,324.36,percent of total billed charges,,,,,,,,,80,,508.8,percent of total billed charges,,,61.4,,390.5,percent of total billed charges,,,57.4,,365.06,percent of total billed charges,,,81,,515.16,percent of total billed charges,,,51.5,,327.54,percent of total billed charges,,365,,,,fee schedule,,,85,,540.6,percent of total billed charges,,,85,,540.6,percent of total billed charges,,,49,,311.64,percent of total billed charges,,,90,,572.4,percent of total billed charges,,,65,,413.4,percent of total billed charges,,,80,,508.8,percent of total billed charges,,,55,,349.8,percent of total billed charges,,,55,,349.8,percent of total billed charges,,,65,,413.4,percent of total billed charges,,,78,,496.08,percent of total billed charges,,,70,,445.2,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,572.4,
XR Finger 2nd Digit Left,73140,CPT,,,F1,both,,,508,304.8,,45.5,,231.14,percent of total billed charges,,,45.3,,230.12,percent of total billed charges,,,51,,259.08,percent of total billed charges,,,,,,,,,80,,406.4,percent of total billed charges,,,61.4,,311.91,percent of total billed charges,,,57.4,,291.59,percent of total billed charges,,,81,,411.48,percent of total billed charges,,,51.5,,261.62,percent of total billed charges,,365,,,,fee schedule,,,85,,431.8,percent of total billed charges,,,85,,431.8,percent of total billed charges,,,49,,248.92,percent of total billed charges,,,90,,457.2,percent of total billed charges,,,65,,330.2,percent of total billed charges,,,80,,406.4,percent of total billed charges,,,55,,279.4,percent of total billed charges,,,55,,279.4,percent of total billed charges,,,65,,330.2,percent of total billed charges,,,78,,396.24,percent of total billed charges,,,70,,355.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,457.2,
XR Finger 3rd Digit Left,73140,CPT,,,F2,both,,,508,304.8,,45.5,,231.14,percent of total billed charges,,,45.3,,230.12,percent of total billed charges,,,51,,259.08,percent of total billed charges,,,,,,,,,80,,406.4,percent of total billed charges,,,61.4,,311.91,percent of total billed charges,,,57.4,,291.59,percent of total billed charges,,,81,,411.48,percent of total billed charges,,,51.5,,261.62,percent of total billed charges,,365,,,,fee schedule,,,85,,431.8,percent of total billed charges,,,85,,431.8,percent of total billed charges,,,49,,248.92,percent of total billed charges,,,90,,457.2,percent of total billed charges,,,65,,330.2,percent of total billed charges,,,80,,406.4,percent of total billed charges,,,55,,279.4,percent of total billed charges,,,55,,279.4,percent of total billed charges,,,65,,330.2,percent of total billed charges,,,78,,396.24,percent of total billed charges,,,70,,355.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,457.2,
XR Finger 4th Digit Left,73140,CPT,,,F3,both,,,508,304.8,,45.5,,231.14,percent of total billed charges,,,45.3,,230.12,percent of total billed charges,,,51,,259.08,percent of total billed charges,,,,,,,,,80,,406.4,percent of total billed charges,,,61.4,,311.91,percent of total billed charges,,,57.4,,291.59,percent of total billed charges,,,81,,411.48,percent of total billed charges,,,51.5,,261.62,percent of total billed charges,,365,,,,fee schedule,,,85,,431.8,percent of total billed charges,,,85,,431.8,percent of total billed charges,,,49,,248.92,percent of total billed charges,,,90,,457.2,percent of total billed charges,,,65,,330.2,percent of total billed charges,,,80,,406.4,percent of total billed charges,,,55,,279.4,percent of total billed charges,,,55,,279.4,percent of total billed charges,,,65,,330.2,percent of total billed charges,,,78,,396.24,percent of total billed charges,,,70,,355.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,457.2,
XR Finger 5th Digit Left,73140,CPT,,,F4,both,,,508,304.8,,45.5,,231.14,percent of total billed charges,,,45.3,,230.12,percent of total billed charges,,,51,,259.08,percent of total billed charges,,,,,,,,,80,,406.4,percent of total billed charges,,,61.4,,311.91,percent of total billed charges,,,57.4,,291.59,percent of total billed charges,,,81,,411.48,percent of total billed charges,,,51.5,,261.62,percent of total billed charges,,365,,,,fee schedule,,,85,,431.8,percent of total billed charges,,,85,,431.8,percent of total billed charges,,,49,,248.92,percent of total billed charges,,,90,,457.2,percent of total billed charges,,,65,,330.2,percent of total billed charges,,,80,,406.4,percent of total billed charges,,,55,,279.4,percent of total billed charges,,,55,,279.4,percent of total billed charges,,,65,,330.2,percent of total billed charges,,,78,,396.24,percent of total billed charges,,,70,,355.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,457.2,
XR Finger Thumb Right,73140,CPT,,,F5,both,,,508,304.8,,45.5,,231.14,percent of total billed charges,,,45.3,,230.12,percent of total billed charges,,,51,,259.08,percent of total billed charges,,,,,,,,,80,,406.4,percent of total billed charges,,,61.4,,311.91,percent of total billed charges,,,57.4,,291.59,percent of total billed charges,,,81,,411.48,percent of total billed charges,,,51.5,,261.62,percent of total billed charges,,365,,,,fee schedule,,,85,,431.8,percent of total billed charges,,,85,,431.8,percent of total billed charges,,,49,,248.92,percent of total billed charges,,,90,,457.2,percent of total billed charges,,,65,,330.2,percent of total billed charges,,,80,,406.4,percent of total billed charges,,,55,,279.4,percent of total billed charges,,,55,,279.4,percent of total billed charges,,,65,,330.2,percent of total billed charges,,,78,,396.24,percent of total billed charges,,,70,,355.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,457.2,
XR Finger 2nd Digit Right,73140,CPT,,,F6,both,,,508,304.8,,45.5,,231.14,percent of total billed charges,,,45.3,,230.12,percent of total billed charges,,,51,,259.08,percent of total billed charges,,,,,,,,,80,,406.4,percent of total billed charges,,,61.4,,311.91,percent of total billed charges,,,57.4,,291.59,percent of total billed charges,,,81,,411.48,percent of total billed charges,,,51.5,,261.62,percent of total billed charges,,365,,,,fee schedule,,,85,,431.8,percent of total billed charges,,,85,,431.8,percent of total billed charges,,,49,,248.92,percent of total billed charges,,,90,,457.2,percent of total billed charges,,,65,,330.2,percent of total billed charges,,,80,,406.4,percent of total billed charges,,,55,,279.4,percent of total billed charges,,,55,,279.4,percent of total billed charges,,,65,,330.2,percent of total billed charges,,,78,,396.24,percent of total billed charges,,,70,,355.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,457.2,
XR Finger 3rd Digit Right,73140,CPT,,,F7,both,,,508,304.8,,45.5,,231.14,percent of total billed charges,,,45.3,,230.12,percent of total billed charges,,,51,,259.08,percent of total billed charges,,,,,,,,,80,,406.4,percent of total billed charges,,,61.4,,311.91,percent of total billed charges,,,57.4,,291.59,percent of total billed charges,,,81,,411.48,percent of total billed charges,,,51.5,,261.62,percent of total billed charges,,365,,,,fee schedule,,,85,,431.8,percent of total billed charges,,,85,,431.8,percent of total billed charges,,,49,,248.92,percent of total billed charges,,,90,,457.2,percent of total billed charges,,,65,,330.2,percent of total billed charges,,,80,,406.4,percent of total billed charges,,,55,,279.4,percent of total billed charges,,,55,,279.4,percent of total billed charges,,,65,,330.2,percent of total billed charges,,,78,,396.24,percent of total billed charges,,,70,,355.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,457.2,
"00069-1311-10 - epoetin alfa epbx 20,000 units/mL Soln",Q5106,HCPCS,00069-1311-10,NDC,,both,1,ML,2240.9,1344.54,,45.5,,1019.61,percent of total billed charges,,,45.3,,1015.13,percent of total billed charges,,,51,,1142.86,percent of total billed charges,,,,,,,,,80,,1792.72,percent of total billed charges,,,61.4,,1375.91,percent of total billed charges,,,57.4,,1286.28,percent of total billed charges,,,81,,1815.13,percent of total billed charges,,,51.5,,1154.06,percent of total billed charges,,,57.6,,1290.76,percent of total billed charges,,,85,,1904.77,percent of total billed charges,,,85,,1904.77,percent of total billed charges,,,49,,1098.04,percent of total billed charges,,,90,,2016.81,percent of total billed charges,,,65,,1456.59,percent of total billed charges,,,80,,1792.72,percent of total billed charges,,,55,,1232.5,percent of total billed charges,,,55,,1232.5,percent of total billed charges,,,65,,1456.59,percent of total billed charges,,,78,,1747.9,percent of total billed charges,,,70,,1568.63,percent of total billed charges,,,,,,,,7.94,,,,100% of Medicare,,7.94,,,,100% of Medicare,,7.94,,,,100% of Medicare,,7.94,,,,100% of Medicare,,7.94,,,,100% of Medicare,,7.94,,,,100% of Medicare,,7.94,,,,100% of Medicare,,7.94,,,,100% of Medicare,,7.94,,,,100% of Medicare,,7.94,,,,100% of Medicare,,7.94,,,,100% of Medicare,,7.94,,,,100% of Medicare,,,7.94,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,7.94,2016.81,
XR Finger 4th Digit Right,73140,CPT,,,F8,both,,,508,304.8,,45.5,,231.14,percent of total billed charges,,,45.3,,230.12,percent of total billed charges,,,51,,259.08,percent of total billed charges,,,,,,,,,80,,406.4,percent of total billed charges,,,61.4,,311.91,percent of total billed charges,,,57.4,,291.59,percent of total billed charges,,,81,,411.48,percent of total billed charges,,,51.5,,261.62,percent of total billed charges,,365,,,,fee schedule,,,85,,431.8,percent of total billed charges,,,85,,431.8,percent of total billed charges,,,49,,248.92,percent of total billed charges,,,90,,457.2,percent of total billed charges,,,65,,330.2,percent of total billed charges,,,80,,406.4,percent of total billed charges,,,55,,279.4,percent of total billed charges,,,55,,279.4,percent of total billed charges,,,65,,330.2,percent of total billed charges,,,78,,396.24,percent of total billed charges,,,70,,355.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,457.2,
XR Finger 5th Digit Right,73140,CPT,,,F9,both,,,508,304.8,,45.5,,231.14,percent of total billed charges,,,45.3,,230.12,percent of total billed charges,,,51,,259.08,percent of total billed charges,,,,,,,,,80,,406.4,percent of total billed charges,,,61.4,,311.91,percent of total billed charges,,,57.4,,291.59,percent of total billed charges,,,81,,411.48,percent of total billed charges,,,51.5,,261.62,percent of total billed charges,,365,,,,fee schedule,,,85,,431.8,percent of total billed charges,,,85,,431.8,percent of total billed charges,,,49,,248.92,percent of total billed charges,,,90,,457.2,percent of total billed charges,,,65,,330.2,percent of total billed charges,,,80,,406.4,percent of total billed charges,,,55,,279.4,percent of total billed charges,,,55,,279.4,percent of total billed charges,,,65,,330.2,percent of total billed charges,,,78,,396.24,percent of total billed charges,,,70,,355.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,457.2,
XR Finger Thumb Left,73140,CPT,,,FA,both,,,508,304.8,,45.5,,231.14,percent of total billed charges,,,45.3,,230.12,percent of total billed charges,,,51,,259.08,percent of total billed charges,,,,,,,,,80,,406.4,percent of total billed charges,,,61.4,,311.91,percent of total billed charges,,,57.4,,291.59,percent of total billed charges,,,81,,411.48,percent of total billed charges,,,51.5,,261.62,percent of total billed charges,,365,,,,fee schedule,,,85,,431.8,percent of total billed charges,,,85,,431.8,percent of total billed charges,,,49,,248.92,percent of total billed charges,,,90,,457.2,percent of total billed charges,,,65,,330.2,percent of total billed charges,,,80,,406.4,percent of total billed charges,,,55,,279.4,percent of total billed charges,,,55,,279.4,percent of total billed charges,,,65,,330.2,percent of total billed charges,,,78,,396.24,percent of total billed charges,,,70,,355.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,457.2,
CT Upper Extremity W/O Contrast Bil,73200,CPT,,,50,both,,,3805,2283,,45.5,,1731.28,percent of total billed charges,,,45.3,,1723.67,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3044,percent of total billed charges,,,61.4,,2336.27,percent of total billed charges,,,57.4,,2184.07,percent of total billed charges,,,81,,3082.05,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2191.68,percent of total billed charges,,,85,,3234.25,percent of total billed charges,,,85,,3234.25,percent of total billed charges,,,49,,1864.45,percent of total billed charges,,,90,,3424.5,percent of total billed charges,,,65,,2473.25,percent of total billed charges,,,80,,3044,percent of total billed charges,,,55,,2092.75,percent of total billed charges,,,55,,2092.75,percent of total billed charges,,,65,,2473.25,percent of total billed charges,,,78,,2967.9,percent of total billed charges,,,70,,2663.5,percent of total billed charges,,,,,,,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,,166.28,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,166.28,3424.5,
CT Upper Extremity W/O Contrast Lt,73200,CPT,,,LT,both,,,3805,2283,,45.5,,1731.28,percent of total billed charges,,,45.3,,1723.67,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3044,percent of total billed charges,,,61.4,,2336.27,percent of total billed charges,,,57.4,,2184.07,percent of total billed charges,,,81,,3082.05,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2191.68,percent of total billed charges,,,85,,3234.25,percent of total billed charges,,,85,,3234.25,percent of total billed charges,,,49,,1864.45,percent of total billed charges,,,90,,3424.5,percent of total billed charges,,,65,,2473.25,percent of total billed charges,,,80,,3044,percent of total billed charges,,,55,,2092.75,percent of total billed charges,,,55,,2092.75,percent of total billed charges,,,65,,2473.25,percent of total billed charges,,,78,,2967.9,percent of total billed charges,,,70,,2663.5,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,3424.5,
CT Upper Extremity W/O Contrast Rt,73200,CPT,,,RT,both,,,3805,2283,,45.5,,1731.28,percent of total billed charges,,,45.3,,1723.67,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3044,percent of total billed charges,,,61.4,,2336.27,percent of total billed charges,,,57.4,,2184.07,percent of total billed charges,,,81,,3082.05,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2191.68,percent of total billed charges,,,85,,3234.25,percent of total billed charges,,,85,,3234.25,percent of total billed charges,,,49,,1864.45,percent of total billed charges,,,90,,3424.5,percent of total billed charges,,,65,,2473.25,percent of total billed charges,,,80,,3044,percent of total billed charges,,,55,,2092.75,percent of total billed charges,,,55,,2092.75,percent of total billed charges,,,65,,2473.25,percent of total billed charges,,,78,,2967.9,percent of total billed charges,,,70,,2663.5,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,3424.5,
CT Upper Extremity W/ Contrast Bil,73201,CPT,,,50,both,,,4385,2631,,45.5,,1995.18,percent of total billed charges,,,45.3,,1986.41,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3508,percent of total billed charges,,,61.4,,2692.39,percent of total billed charges,,,57.4,,2516.99,percent of total billed charges,,,81,,3551.85,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2525.76,percent of total billed charges,,,85,,3727.25,percent of total billed charges,,,85,,3727.25,percent of total billed charges,,,49,,2148.65,percent of total billed charges,,,90,,3946.5,percent of total billed charges,,,65,,2850.25,percent of total billed charges,,,80,,3508,percent of total billed charges,,,55,,2411.75,percent of total billed charges,,,55,,2411.75,percent of total billed charges,,,65,,2850.25,percent of total billed charges,,,78,,3420.3,percent of total billed charges,,,70,,3069.5,percent of total billed charges,,,,,,,,558.42,,,,150% of Medicare,,558.42,,,,150% of Medicare,,558.42,,,,150% of Medicare,,558.42,,,,150% of Medicare,,558.42,,,,150% of Medicare,,558.42,,,,150% of Medicare,,558.42,,,,150% of Medicare,,558.42,,,,150% of Medicare,,558.42,,,,150% of Medicare,,558.42,,,,150% of Medicare,,558.42,,,,150% of Medicare,,558.42,,,,150% of Medicare,,,558.42,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,558.42,3946.5,
CT Upper Extremity W/ Contrast Lt,73201,CPT,,,LT,both,,,4385,2631,,45.5,,1995.18,percent of total billed charges,,,45.3,,1986.41,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3508,percent of total billed charges,,,61.4,,2692.39,percent of total billed charges,,,57.4,,2516.99,percent of total billed charges,,,81,,3551.85,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2525.76,percent of total billed charges,,,85,,3727.25,percent of total billed charges,,,85,,3727.25,percent of total billed charges,,,49,,2148.65,percent of total billed charges,,,90,,3946.5,percent of total billed charges,,,65,,2850.25,percent of total billed charges,,,80,,3508,percent of total billed charges,,,55,,2411.75,percent of total billed charges,,,55,,2411.75,percent of total billed charges,,,65,,2850.25,percent of total billed charges,,,78,,3420.3,percent of total billed charges,,,70,,3069.5,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,372.28,3946.5,
CT Upper Extremity W/ Contrast Rt,73201,CPT,,,RT,both,,,4385,2631,,45.5,,1995.18,percent of total billed charges,,,45.3,,1986.41,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3508,percent of total billed charges,,,61.4,,2692.39,percent of total billed charges,,,57.4,,2516.99,percent of total billed charges,,,81,,3551.85,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2525.76,percent of total billed charges,,,85,,3727.25,percent of total billed charges,,,85,,3727.25,percent of total billed charges,,,49,,2148.65,percent of total billed charges,,,90,,3946.5,percent of total billed charges,,,65,,2850.25,percent of total billed charges,,,80,,3508,percent of total billed charges,,,55,,2411.75,percent of total billed charges,,,55,,2411.75,percent of total billed charges,,,65,,2850.25,percent of total billed charges,,,78,,3420.3,percent of total billed charges,,,70,,3069.5,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,372.28,3946.5,
CT Upper Extremity W/&W/O Contrast Bil,73202,CPT,,,50,both,,,5272,3163.2,,45.5,,2398.76,percent of total billed charges,,,45.3,,2388.22,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,4217.6,percent of total billed charges,,,61.4,,3237.01,percent of total billed charges,,,57.4,,3026.13,percent of total billed charges,,,81,,4270.32,percent of total billed charges,,735,,,,fee schedule,,,57.6,,3036.67,percent of total billed charges,,,85,,4481.2,percent of total billed charges,,,85,,4481.2,percent of total billed charges,,,49,,2583.28,percent of total billed charges,,,90,,4744.8,percent of total billed charges,,,65,,3426.8,percent of total billed charges,,,80,,4217.6,percent of total billed charges,,,55,,2899.6,percent of total billed charges,,,55,,2899.6,percent of total billed charges,,,65,,3426.8,percent of total billed charges,,,78,,4112.16,percent of total billed charges,,,70,,3690.4,percent of total billed charges,,,,,,,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,,278.36,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,278.36,4744.8,
CT Upper Extremity W/&W/O Contrast Lt,73202,CPT,,,LT,both,,,5272,3163.2,,45.5,,2398.76,percent of total billed charges,,,45.3,,2388.22,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,4217.6,percent of total billed charges,,,61.4,,3237.01,percent of total billed charges,,,57.4,,3026.13,percent of total billed charges,,,81,,4270.32,percent of total billed charges,,735,,,,fee schedule,,,57.6,,3036.67,percent of total billed charges,,,85,,4481.2,percent of total billed charges,,,85,,4481.2,percent of total billed charges,,,49,,2583.28,percent of total billed charges,,,90,,4744.8,percent of total billed charges,,,65,,3426.8,percent of total billed charges,,,80,,4217.6,percent of total billed charges,,,55,,2899.6,percent of total billed charges,,,55,,2899.6,percent of total billed charges,,,65,,3426.8,percent of total billed charges,,,78,,4112.16,percent of total billed charges,,,70,,3690.4,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,185.57,4744.8,
CT Upper Extremity W/&W/O Contrast Rt,73202,CPT,,,RT,both,,,5272,3163.2,,45.5,,2398.76,percent of total billed charges,,,45.3,,2388.22,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,4217.6,percent of total billed charges,,,61.4,,3237.01,percent of total billed charges,,,57.4,,3026.13,percent of total billed charges,,,81,,4270.32,percent of total billed charges,,735,,,,fee schedule,,,57.6,,3036.67,percent of total billed charges,,,85,,4481.2,percent of total billed charges,,,85,,4481.2,percent of total billed charges,,,49,,2583.28,percent of total billed charges,,,90,,4744.8,percent of total billed charges,,,65,,3426.8,percent of total billed charges,,,80,,4217.6,percent of total billed charges,,,55,,2899.6,percent of total billed charges,,,55,,2899.6,percent of total billed charges,,,65,,3426.8,percent of total billed charges,,,78,,4112.16,percent of total billed charges,,,70,,3690.4,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,185.57,4744.8,
MRA Upper Ext W/O Contrast Lt-73225,73225,CPT,C8935,HCPCS,LT,both,,,2443,1465.8,,45.5,,1111.57,percent of total billed charges,,,45.3,,1106.68,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,1954.4,percent of total billed charges,,,61.4,,1500,percent of total billed charges,,,57.4,,1402.28,percent of total billed charges,,,81,,1978.83,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,1407.17,percent of total billed charges,,,85,,2076.55,percent of total billed charges,,,85,,2076.55,percent of total billed charges,,,49,,1197.07,percent of total billed charges,,,90,,2198.7,percent of total billed charges,,,65,,1587.95,percent of total billed charges,,,80,,1954.4,percent of total billed charges,,,55,,1343.65,percent of total billed charges,,,55,,1343.65,percent of total billed charges,,,65,,1587.95,percent of total billed charges,,,78,,1905.54,percent of total billed charges,,,70,,1710.1,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,251.97,2198.7,
MRA Upper Ext W/O Contrast Rt-73225,73225,CPT,C8935,HCPCS,RT,both,,,2443,1465.8,,45.5,,1111.57,percent of total billed charges,,,45.3,,1106.68,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,1954.4,percent of total billed charges,,,61.4,,1500,percent of total billed charges,,,57.4,,1402.28,percent of total billed charges,,,81,,1978.83,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,1407.17,percent of total billed charges,,,85,,2076.55,percent of total billed charges,,,85,,2076.55,percent of total billed charges,,,49,,1197.07,percent of total billed charges,,,90,,2198.7,percent of total billed charges,,,65,,1587.95,percent of total billed charges,,,80,,1954.4,percent of total billed charges,,,55,,1343.65,percent of total billed charges,,,55,,1343.65,percent of total billed charges,,,65,,1587.95,percent of total billed charges,,,78,,1905.54,percent of total billed charges,,,70,,1710.1,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,251.97,2198.7,
MRA Upper Ext W&W/O Contrast Lt-73225,73225,CPT,C8936,HCPCS,LT,both,,,4468,2680.8,,45.5,,2032.94,percent of total billed charges,,,45.3,,2024,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3574.4,percent of total billed charges,,,61.4,,2743.35,percent of total billed charges,,,57.4,,2564.63,percent of total billed charges,,,81,,3619.08,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2573.57,percent of total billed charges,,,85,,3797.8,percent of total billed charges,,,85,,3797.8,percent of total billed charges,,,49,,2189.32,percent of total billed charges,,,90,,4021.2,percent of total billed charges,,,65,,2904.2,percent of total billed charges,,,80,,3574.4,percent of total billed charges,,,55,,2457.4,percent of total billed charges,,,55,,2457.4,percent of total billed charges,,,65,,2904.2,percent of total billed charges,,,78,,3485.04,percent of total billed charges,,,70,,3127.6,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,372.28,4021.2,
MRA Upper Ext W&W/O Contrast Rt-73225,73225,CPT,C8936,HCPCS,RT,both,,,4468,2680.8,,45.5,,2032.94,percent of total billed charges,,,45.3,,2024,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3574.4,percent of total billed charges,,,61.4,,2743.35,percent of total billed charges,,,57.4,,2564.63,percent of total billed charges,,,81,,3619.08,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2573.57,percent of total billed charges,,,85,,3797.8,percent of total billed charges,,,85,,3797.8,percent of total billed charges,,,49,,2189.32,percent of total billed charges,,,90,,4021.2,percent of total billed charges,,,65,,2904.2,percent of total billed charges,,,80,,3574.4,percent of total billed charges,,,55,,2457.4,percent of total billed charges,,,55,,2457.4,percent of total billed charges,,,65,,2904.2,percent of total billed charges,,,78,,3485.04,percent of total billed charges,,,70,,3127.6,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,372.28,4021.2,
XR Pelvis + Hips Infant/Child,73521,CPT,,,,both,,,398,238.8,,45.5,,181.09,percent of total billed charges,,,45.3,,180.29,percent of total billed charges,,,51,,202.98,percent of total billed charges,,,,,,,,,80,,318.4,percent of total billed charges,,,61.4,,244.37,percent of total billed charges,,,57.4,,228.45,percent of total billed charges,,,81,,322.38,percent of total billed charges,,,51.5,,204.97,percent of total billed charges,,365,,,,fee schedule,,,85,,338.3,percent of total billed charges,,,85,,338.3,percent of total billed charges,,,49,,195.02,percent of total billed charges,,,90,,358.2,percent of total billed charges,,,65,,258.7,percent of total billed charges,,,80,,318.4,percent of total billed charges,,,55,,218.9,percent of total billed charges,,,55,,218.9,percent of total billed charges,,,65,,258.7,percent of total billed charges,,,78,,310.44,percent of total billed charges,,,70,,278.6,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,365,
XR Femur Left,73552,CPT,,,LT,both,,,612,367.2,,45.5,,278.46,percent of total billed charges,,,45.3,,277.24,percent of total billed charges,,,51,,312.12,percent of total billed charges,,,,,,,,,80,,489.6,percent of total billed charges,,,61.4,,375.77,percent of total billed charges,,,57.4,,351.29,percent of total billed charges,,,81,,495.72,percent of total billed charges,,,51.5,,315.18,percent of total billed charges,,365,,,,fee schedule,,,85,,520.2,percent of total billed charges,,,85,,520.2,percent of total billed charges,,,49,,299.88,percent of total billed charges,,,90,,550.8,percent of total billed charges,,,65,,397.8,percent of total billed charges,,,80,,489.6,percent of total billed charges,,,55,,336.6,percent of total billed charges,,,55,,336.6,percent of total billed charges,,,65,,397.8,percent of total billed charges,,,78,,477.36,percent of total billed charges,,,70,,428.4,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,550.8,
XR Femur Right,73552,CPT,,,RT,both,,,612,367.2,,45.5,,278.46,percent of total billed charges,,,45.3,,277.24,percent of total billed charges,,,51,,312.12,percent of total billed charges,,,,,,,,,80,,489.6,percent of total billed charges,,,61.4,,375.77,percent of total billed charges,,,57.4,,351.29,percent of total billed charges,,,81,,495.72,percent of total billed charges,,,51.5,,315.18,percent of total billed charges,,365,,,,fee schedule,,,85,,520.2,percent of total billed charges,,,85,,520.2,percent of total billed charges,,,49,,299.88,percent of total billed charges,,,90,,550.8,percent of total billed charges,,,65,,397.8,percent of total billed charges,,,80,,489.6,percent of total billed charges,,,55,,336.6,percent of total billed charges,,,55,,336.6,percent of total billed charges,,,65,,397.8,percent of total billed charges,,,78,,477.36,percent of total billed charges,,,70,,428.4,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,550.8,
XR Tibia/Fibula Left,73590,CPT,,,LT,both,,,850,510,,45.5,,386.75,percent of total billed charges,,,45.3,,385.05,percent of total billed charges,,,51,,433.5,percent of total billed charges,,,,,,,,,80,,680,percent of total billed charges,,,61.4,,521.9,percent of total billed charges,,,57.4,,487.9,percent of total billed charges,,,81,,688.5,percent of total billed charges,,,51.5,,437.75,percent of total billed charges,,365,,,,fee schedule,,,85,,722.5,percent of total billed charges,,,85,,722.5,percent of total billed charges,,,49,,416.5,percent of total billed charges,,,90,,765,percent of total billed charges,,,65,,552.5,percent of total billed charges,,,80,,680,percent of total billed charges,,,55,,467.5,percent of total billed charges,,,55,,467.5,percent of total billed charges,,,65,,552.5,percent of total billed charges,,,78,,663,percent of total billed charges,,,70,,595,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,765,
XR Tibia/Fibula Right,73590,CPT,,,RT,both,,,850,510,,45.5,,386.75,percent of total billed charges,,,45.3,,385.05,percent of total billed charges,,,51,,433.5,percent of total billed charges,,,,,,,,,80,,680,percent of total billed charges,,,61.4,,521.9,percent of total billed charges,,,57.4,,487.9,percent of total billed charges,,,81,,688.5,percent of total billed charges,,,51.5,,437.75,percent of total billed charges,,365,,,,fee schedule,,,85,,722.5,percent of total billed charges,,,85,,722.5,percent of total billed charges,,,49,,416.5,percent of total billed charges,,,90,,765,percent of total billed charges,,,65,,552.5,percent of total billed charges,,,80,,680,percent of total billed charges,,,55,,467.5,percent of total billed charges,,,55,,467.5,percent of total billed charges,,,65,,552.5,percent of total billed charges,,,78,,663,percent of total billed charges,,,70,,595,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,765,
XR Lower Extremity Infant Left,73592,CPT,,,LT,both,,,277,166.2,,45.5,,126.04,percent of total billed charges,,,45.3,,125.48,percent of total billed charges,,,51,,141.27,percent of total billed charges,,,,,,,,,80,,221.6,percent of total billed charges,,,61.4,,170.08,percent of total billed charges,,,57.4,,159,percent of total billed charges,,,81,,224.37,percent of total billed charges,,,51.5,,142.66,percent of total billed charges,,365,,,,fee schedule,,,85,,235.45,percent of total billed charges,,,85,,235.45,percent of total billed charges,,,49,,135.73,percent of total billed charges,,,90,,249.3,percent of total billed charges,,,65,,180.05,percent of total billed charges,,,80,,221.6,percent of total billed charges,,,55,,152.35,percent of total billed charges,,,55,,152.35,percent of total billed charges,,,65,,180.05,percent of total billed charges,,,78,,216.06,percent of total billed charges,,,70,,193.9,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,365,
XR Lower Extremity Infant Right,73592,CPT,,,RT,both,,,277,166.2,,45.5,,126.04,percent of total billed charges,,,45.3,,125.48,percent of total billed charges,,,51,,141.27,percent of total billed charges,,,,,,,,,80,,221.6,percent of total billed charges,,,61.4,,170.08,percent of total billed charges,,,57.4,,159,percent of total billed charges,,,81,,224.37,percent of total billed charges,,,51.5,,142.66,percent of total billed charges,,365,,,,fee schedule,,,85,,235.45,percent of total billed charges,,,85,,235.45,percent of total billed charges,,,49,,135.73,percent of total billed charges,,,90,,249.3,percent of total billed charges,,,65,,180.05,percent of total billed charges,,,80,,221.6,percent of total billed charges,,,55,,152.35,percent of total billed charges,,,55,,152.35,percent of total billed charges,,,65,,180.05,percent of total billed charges,,,78,,216.06,percent of total billed charges,,,70,,193.9,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,365,
Oasis wound matrix skin sub per sq cm (Q4102),Q4102,HCPCS,,,,outpatient,,,45,27,,45.5,,20.48,percent of total billed charges,,,45.3,,20.39,percent of total billed charges,,,51,,22.95,percent of total billed charges,,,,,,,,,80,,36,percent of total billed charges,,,61.4,,27.63,percent of total billed charges,,,57.4,,25.83,percent of total billed charges,,,81,,36.45,percent of total billed charges,,,51.5,,23.18,percent of total billed charges,,,57.6,,25.92,percent of total billed charges,,,85,,38.25,percent of total billed charges,,,85,,38.25,percent of total billed charges,,,49,,22.05,percent of total billed charges,,,90,,40.5,percent of total billed charges,,,65,,29.25,percent of total billed charges,,,80,,36,percent of total billed charges,,,55,,24.75,percent of total billed charges,,,55,,24.75,percent of total billed charges,,,65,,29.25,percent of total billed charges,,,78,,35.1,percent of total billed charges,,,70,,31.5,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,20.39,40.5,
THERASKIN 2.5 cm x 2.5 cm,Q4121,HCPCS,,,,outpatient,,,2102,1261.2,,45.5,,956.41,percent of total billed charges,,,45.3,,952.21,percent of total billed charges,,,39,,819.78,percent of total billed charges,,,,,,,,,80,,1681.6,percent of total billed charges,,,61.4,,1290.63,percent of total billed charges,,,57.4,,1206.55,percent of total billed charges,,,81,,1702.62,percent of total billed charges,,,39,,819.78,percent of total billed charges,,,57.6,,1210.75,percent of total billed charges,,,85,,1786.7,percent of total billed charges,,,85,,1786.7,percent of total billed charges,,,49,,1029.98,percent of total billed charges,,,90,,1891.8,percent of total billed charges,,,65,,1366.3,percent of total billed charges,,,80,,1681.6,percent of total billed charges,,,55,,1156.1,percent of total billed charges,,,55,,1156.1,percent of total billed charges,,,65,,1366.3,percent of total billed charges,,,78,,1639.56,percent of total billed charges,,,70,,1471.4,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,819.78,1891.8,
THERASKIN 1.75 cm x 1.75 cm,Q4121,HCPCS,,,,outpatient,,,2356,1413.6,,45.5,,1071.98,percent of total billed charges,,,45.3,,1067.27,percent of total billed charges,,,39,,918.84,percent of total billed charges,,,,,,,,,80,,1884.8,percent of total billed charges,,,61.4,,1446.58,percent of total billed charges,,,57.4,,1352.34,percent of total billed charges,,,81,,1908.36,percent of total billed charges,,,39,,918.84,percent of total billed charges,,,57.6,,1357.06,percent of total billed charges,,,85,,2002.6,percent of total billed charges,,,85,,2002.6,percent of total billed charges,,,49,,1154.44,percent of total billed charges,,,90,,2120.4,percent of total billed charges,,,65,,1531.4,percent of total billed charges,,,80,,1884.8,percent of total billed charges,,,55,,1295.8,percent of total billed charges,,,55,,1295.8,percent of total billed charges,,,65,,1531.4,percent of total billed charges,,,78,,1837.68,percent of total billed charges,,,70,,1649.2,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,918.84,2120.4,
THERASKIN 2.5cm x 5.1 cm,Q4121,HCPCS,,,,outpatient,,,2370,1422,,45.5,,1078.35,percent of total billed charges,,,45.3,,1073.61,percent of total billed charges,,,39,,924.3,percent of total billed charges,,,,,,,,,80,,1896,percent of total billed charges,,,61.4,,1455.18,percent of total billed charges,,,57.4,,1360.38,percent of total billed charges,,,81,,1919.7,percent of total billed charges,,,39,,924.3,percent of total billed charges,,,57.6,,1365.12,percent of total billed charges,,,85,,2014.5,percent of total billed charges,,,85,,2014.5,percent of total billed charges,,,49,,1161.3,percent of total billed charges,,,90,,2133,percent of total billed charges,,,65,,1540.5,percent of total billed charges,,,80,,1896,percent of total billed charges,,,55,,1303.5,percent of total billed charges,,,55,,1303.5,percent of total billed charges,,,65,,1540.5,percent of total billed charges,,,78,,1848.6,percent of total billed charges,,,70,,1659,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,924.3,2133,
THERASKIN 4 cm x 6.5 cm,Q4121,HCPCS,,,,outpatient,,,2678,1606.8,,45.5,,1218.49,percent of total billed charges,,,45.3,,1213.13,percent of total billed charges,,,39,,1044.42,percent of total billed charges,,,,,,,,,80,,2142.4,percent of total billed charges,,,61.4,,1644.29,percent of total billed charges,,,57.4,,1537.17,percent of total billed charges,,,81,,2169.18,percent of total billed charges,,,39,,1044.42,percent of total billed charges,,,57.6,,1542.53,percent of total billed charges,,,85,,2276.3,percent of total billed charges,,,85,,2276.3,percent of total billed charges,,,49,,1312.22,percent of total billed charges,,,90,,2410.2,percent of total billed charges,,,65,,1740.7,percent of total billed charges,,,80,,2142.4,percent of total billed charges,,,55,,1472.9,percent of total billed charges,,,55,,1472.9,percent of total billed charges,,,65,,1740.7,percent of total billed charges,,,78,,2088.84,percent of total billed charges,,,70,,1874.6,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1044.42,2410.2,
THERASKIN BVR 5.1cm x 7.6cm,Q4121,HCPCS,,,,outpatient,,,2770,1662,,45.5,,1260.35,percent of total billed charges,,,45.3,,1254.81,percent of total billed charges,,,39,,1080.3,percent of total billed charges,,,,,,,,,80,,2216,percent of total billed charges,,,61.4,,1700.78,percent of total billed charges,,,57.4,,1589.98,percent of total billed charges,,,81,,2243.7,percent of total billed charges,,,39,,1080.3,percent of total billed charges,,,57.6,,1595.52,percent of total billed charges,,,85,,2354.5,percent of total billed charges,,,85,,2354.5,percent of total billed charges,,,49,,1357.3,percent of total billed charges,,,90,,2493,percent of total billed charges,,,65,,1800.5,percent of total billed charges,,,80,,2216,percent of total billed charges,,,55,,1523.5,percent of total billed charges,,,55,,1523.5,percent of total billed charges,,,65,,1800.5,percent of total billed charges,,,78,,2160.6,percent of total billed charges,,,70,,1939,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1080.3,2493,
THERASKIN 7.6cm x 15.24cm,Q4121,HCPCS,,,,outpatient,,,7190,4314,,45.5,,3271.45,percent of total billed charges,,,45.3,,3257.07,percent of total billed charges,,,39,,2804.1,percent of total billed charges,,,,,,,,,80,,5752,percent of total billed charges,,,61.4,,4414.66,percent of total billed charges,,,57.4,,4127.06,percent of total billed charges,,,81,,5823.9,percent of total billed charges,,,39,,2804.1,percent of total billed charges,,,57.6,,4141.44,percent of total billed charges,,,85,,6111.5,percent of total billed charges,,,85,,6111.5,percent of total billed charges,,,49,,3523.1,percent of total billed charges,,,90,,6471,percent of total billed charges,,,65,,4673.5,percent of total billed charges,,,80,,5752,percent of total billed charges,,,55,,3954.5,percent of total billed charges,,,55,,3954.5,percent of total billed charges,,,65,,4673.5,percent of total billed charges,,,78,,5608.2,percent of total billed charges,,,70,,5033,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,2804.1,6471,
Graft Epifix disc 18mm,Q4186,HCPCS,,,,outpatient,,,1616,969.6,,45.5,,735.28,percent of total billed charges,,,45.3,,732.05,percent of total billed charges,,,39,,630.24,percent of total billed charges,,,,,,,,,80,,1292.8,percent of total billed charges,,,61.4,,992.22,percent of total billed charges,,,57.4,,927.58,percent of total billed charges,,,81,,1308.96,percent of total billed charges,,,39,,630.24,percent of total billed charges,,,57.6,,930.82,percent of total billed charges,,,85,,1373.6,percent of total billed charges,,,85,,1373.6,percent of total billed charges,,,49,,791.84,percent of total billed charges,,,90,,1454.4,percent of total billed charges,,,65,,1050.4,percent of total billed charges,,,80,,1292.8,percent of total billed charges,,,55,,888.8,percent of total billed charges,,,55,,888.8,percent of total billed charges,,,65,,1050.4,percent of total billed charges,,,78,,1260.48,percent of total billed charges,,,70,,1131.2,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,630.24,1454.4,
Graft Epifix mesh 2cm x 3 cm,Q4186,HCPCS,,,,outpatient,,,2155,1293,,45.5,,980.53,percent of total billed charges,,,45.3,,976.22,percent of total billed charges,,,39,,840.45,percent of total billed charges,,,,,,,,,80,,1724,percent of total billed charges,,,61.4,,1323.17,percent of total billed charges,,,57.4,,1236.97,percent of total billed charges,,,81,,1745.55,percent of total billed charges,,,39,,840.45,percent of total billed charges,,,57.6,,1241.28,percent of total billed charges,,,85,,1831.75,percent of total billed charges,,,85,,1831.75,percent of total billed charges,,,49,,1055.95,percent of total billed charges,,,90,,1939.5,percent of total billed charges,,,65,,1400.75,percent of total billed charges,,,80,,1724,percent of total billed charges,,,55,,1185.25,percent of total billed charges,,,55,,1185.25,percent of total billed charges,,,65,,1400.75,percent of total billed charges,,,78,,1680.9,percent of total billed charges,,,70,,1508.5,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,840.45,1939.5,
Graft Epifix 2cm x 2cm,Q4186,HCPCS,,,,outpatient,,,2306,1383.6,,45.5,,1049.23,percent of total billed charges,,,45.3,,1044.62,percent of total billed charges,,,39,,899.34,percent of total billed charges,,,,,,,,,80,,1844.8,percent of total billed charges,,,61.4,,1415.88,percent of total billed charges,,,57.4,,1323.64,percent of total billed charges,,,81,,1867.86,percent of total billed charges,,,39,,899.34,percent of total billed charges,,,57.6,,1328.26,percent of total billed charges,,,85,,1960.1,percent of total billed charges,,,85,,1960.1,percent of total billed charges,,,49,,1129.94,percent of total billed charges,,,90,,2075.4,percent of total billed charges,,,65,,1498.9,percent of total billed charges,,,80,,1844.8,percent of total billed charges,,,55,,1268.3,percent of total billed charges,,,55,,1268.3,percent of total billed charges,,,65,,1498.9,percent of total billed charges,,,78,,1798.68,percent of total billed charges,,,70,,1614.2,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,899.34,2075.4,
Graft Epifix mesh 3.5 X 3.5 cm,Q4186,HCPCS,,,,outpatient,,,2472,1483.2,,45.5,,1124.76,percent of total billed charges,,,45.3,,1119.82,percent of total billed charges,,,39,,964.08,percent of total billed charges,,,,,,,,,80,,1977.6,percent of total billed charges,,,61.4,,1517.81,percent of total billed charges,,,57.4,,1418.93,percent of total billed charges,,,81,,2002.32,percent of total billed charges,,,39,,964.08,percent of total billed charges,,,57.6,,1423.87,percent of total billed charges,,,85,,2101.2,percent of total billed charges,,,85,,2101.2,percent of total billed charges,,,49,,1211.28,percent of total billed charges,,,90,,2224.8,percent of total billed charges,,,65,,1606.8,percent of total billed charges,,,80,,1977.6,percent of total billed charges,,,55,,1359.6,percent of total billed charges,,,55,,1359.6,percent of total billed charges,,,65,,1606.8,percent of total billed charges,,,78,,1928.16,percent of total billed charges,,,70,,1730.4,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,964.08,2224.8,
Graft EpiFix 2cm x 4cm,Q4186,HCPCS,,,,outpatient,,,2661,1596.6,,45.5,,1210.76,percent of total billed charges,,,45.3,,1205.43,percent of total billed charges,,,39,,1037.79,percent of total billed charges,,,,,,,,,80,,2128.8,percent of total billed charges,,,61.4,,1633.85,percent of total billed charges,,,57.4,,1527.41,percent of total billed charges,,,81,,2155.41,percent of total billed charges,,,39,,1037.79,percent of total billed charges,,,57.6,,1532.74,percent of total billed charges,,,85,,2261.85,percent of total billed charges,,,85,,2261.85,percent of total billed charges,,,49,,1303.89,percent of total billed charges,,,90,,2394.9,percent of total billed charges,,,65,,1729.65,percent of total billed charges,,,80,,2128.8,percent of total billed charges,,,55,,1463.55,percent of total billed charges,,,55,,1463.55,percent of total billed charges,,,65,,1729.65,percent of total billed charges,,,78,,2075.58,percent of total billed charges,,,70,,1862.7,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1037.79,2394.9,
Graft Epifix mesh 4cm x 4.5 cm,Q4186,HCPCS,,,,outpatient,,,2732,1639.2,,45.5,,1243.06,percent of total billed charges,,,45.3,,1237.6,percent of total billed charges,,,39,,1065.48,percent of total billed charges,,,,,,,,,80,,2185.6,percent of total billed charges,,,61.4,,1677.45,percent of total billed charges,,,57.4,,1568.17,percent of total billed charges,,,81,,2212.92,percent of total billed charges,,,39,,1065.48,percent of total billed charges,,,57.6,,1573.63,percent of total billed charges,,,85,,2322.2,percent of total billed charges,,,85,,2322.2,percent of total billed charges,,,49,,1338.68,percent of total billed charges,,,90,,2458.8,percent of total billed charges,,,65,,1775.8,percent of total billed charges,,,80,,2185.6,percent of total billed charges,,,55,,1502.6,percent of total billed charges,,,55,,1502.6,percent of total billed charges,,,65,,1775.8,percent of total billed charges,,,78,,2130.96,percent of total billed charges,,,70,,1912.4,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1065.48,2458.8,
Graft EpiFix 3cm x 4cm,Q4186,HCPCS,,,,outpatient,,,4740,2844,,45.5,,2156.7,percent of total billed charges,,,45.3,,2147.22,percent of total billed charges,,,39,,1848.6,percent of total billed charges,,,,,,,,,80,,3792,percent of total billed charges,,,61.4,,2910.36,percent of total billed charges,,,57.4,,2720.76,percent of total billed charges,,,81,,3839.4,percent of total billed charges,,,39,,1848.6,percent of total billed charges,,,57.6,,2730.24,percent of total billed charges,,,85,,4029,percent of total billed charges,,,85,,4029,percent of total billed charges,,,49,,2322.6,percent of total billed charges,,,90,,4266,percent of total billed charges,,,65,,3081,percent of total billed charges,,,80,,3792,percent of total billed charges,,,55,,2607,percent of total billed charges,,,55,,2607,percent of total billed charges,,,65,,3081,percent of total billed charges,,,78,,3697.2,percent of total billed charges,,,70,,3318,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1848.6,4266,
Graft EpiFix 4cm x 4cm,Q4186,HCPCS,,,,outpatient,,,5994,3596.4,,45.5,,2727.27,percent of total billed charges,,,45.3,,2715.28,percent of total billed charges,,,39,,2337.66,percent of total billed charges,,,,,,,,,80,,4795.2,percent of total billed charges,,,61.4,,3680.32,percent of total billed charges,,,57.4,,3440.56,percent of total billed charges,,,81,,4855.14,percent of total billed charges,,,39,,2337.66,percent of total billed charges,,,57.6,,3452.54,percent of total billed charges,,,85,,5094.9,percent of total billed charges,,,85,,5094.9,percent of total billed charges,,,49,,2937.06,percent of total billed charges,,,90,,5394.6,percent of total billed charges,,,65,,3896.1,percent of total billed charges,,,80,,4795.2,percent of total billed charges,,,55,,3296.7,percent of total billed charges,,,55,,3296.7,percent of total billed charges,,,65,,3896.1,percent of total billed charges,,,78,,4675.32,percent of total billed charges,,,70,,4195.8,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,2337.66,5394.6,
Graft EpiFix 5cm x 6cm,Q4186,HCPCS,,,,outpatient,,,11377,6826.2,,45.5,,5176.54,percent of total billed charges,,,45.3,,5153.78,percent of total billed charges,,,39,,4437.03,percent of total billed charges,,,,,,,,,80,,9101.6,percent of total billed charges,,,61.4,,6985.48,percent of total billed charges,,,57.4,,6530.4,percent of total billed charges,,,81,,9215.37,percent of total billed charges,,,39,,4437.03,percent of total billed charges,,,57.6,,6553.15,percent of total billed charges,,,85,,9670.45,percent of total billed charges,,,85,,9670.45,percent of total billed charges,,,49,,5574.73,percent of total billed charges,,,90,,10239.3,percent of total billed charges,,,65,,7395.05,percent of total billed charges,,,80,,9101.6,percent of total billed charges,,,55,,6257.35,percent of total billed charges,,,55,,6257.35,percent of total billed charges,,,65,,7395.05,percent of total billed charges,,,78,,8874.06,percent of total billed charges,,,70,,7963.9,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,4437.03,10239.3,
Graft EpiFix 7cm x 7cm,Q4186,HCPCS,,,,outpatient,,,19037,11422.2,,45.5,,8661.84,percent of total billed charges,,,45.3,,8623.76,percent of total billed charges,,,39,,7424.43,percent of total billed charges,,,,,,,,,80,,15229.6,percent of total billed charges,,,61.4,,11688.72,percent of total billed charges,,,57.4,,10927.24,percent of total billed charges,,,81,,15419.97,percent of total billed charges,,,39,,7424.43,percent of total billed charges,,,57.6,,10965.31,percent of total billed charges,,,85,,16181.45,percent of total billed charges,,,85,,16181.45,percent of total billed charges,,,49,,9328.13,percent of total billed charges,,,90,,17133.3,percent of total billed charges,,,65,,12374.05,percent of total billed charges,,,80,,15229.6,percent of total billed charges,,,55,,10470.35,percent of total billed charges,,,55,,10470.35,percent of total billed charges,,,65,,12374.05,percent of total billed charges,,,78,,14848.86,percent of total billed charges,,,70,,13325.9,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,7424.43,17133.3,
Graft EpiCord 1cm x 2 cm,Q4187,HCPCS,,,,outpatient,,,2244,1346.4,,45.5,,1021.02,percent of total billed charges,,,45.3,,1016.53,percent of total billed charges,,,39,,875.16,percent of total billed charges,,,,,,,,,80,,1795.2,percent of total billed charges,,,61.4,,1377.82,percent of total billed charges,,,57.4,,1288.06,percent of total billed charges,,,81,,1817.64,percent of total billed charges,,,39,,875.16,percent of total billed charges,,,57.6,,1292.54,percent of total billed charges,,,85,,1907.4,percent of total billed charges,,,85,,1907.4,percent of total billed charges,,,49,,1099.56,percent of total billed charges,,,90,,2019.6,percent of total billed charges,,,65,,1458.6,percent of total billed charges,,,80,,1795.2,percent of total billed charges,,,55,,1234.2,percent of total billed charges,,,55,,1234.2,percent of total billed charges,,,65,,1458.6,percent of total billed charges,,,78,,1750.32,percent of total billed charges,,,70,,1570.8,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,875.16,2019.6,
Graft EpiCord 2cm x 3 cm,Q4187,HCPCS,,,,outpatient,,,2585,1551,,45.5,,1176.18,percent of total billed charges,,,45.3,,1171.01,percent of total billed charges,,,39,,1008.15,percent of total billed charges,,,,,,,,,80,,2068,percent of total billed charges,,,61.4,,1587.19,percent of total billed charges,,,57.4,,1483.79,percent of total billed charges,,,81,,2093.85,percent of total billed charges,,,39,,1008.15,percent of total billed charges,,,57.6,,1488.96,percent of total billed charges,,,85,,2197.25,percent of total billed charges,,,85,,2197.25,percent of total billed charges,,,49,,1266.65,percent of total billed charges,,,90,,2326.5,percent of total billed charges,,,65,,1680.25,percent of total billed charges,,,80,,2068,percent of total billed charges,,,55,,1421.75,percent of total billed charges,,,55,,1421.75,percent of total billed charges,,,65,,1680.25,percent of total billed charges,,,78,,2016.3,percent of total billed charges,,,70,,1809.5,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1008.15,2326.5,
Graft EpiCord expandable 2cm x 3cm,Q4187,HCPCS,,,,outpatient,,,2752,1651.2,,45.5,,1252.16,percent of total billed charges,,,45.3,,1246.66,percent of total billed charges,,,39,,1073.28,percent of total billed charges,,,,,,,,,80,,2201.6,percent of total billed charges,,,61.4,,1689.73,percent of total billed charges,,,57.4,,1579.65,percent of total billed charges,,,81,,2229.12,percent of total billed charges,,,39,,1073.28,percent of total billed charges,,,57.6,,1585.15,percent of total billed charges,,,85,,2339.2,percent of total billed charges,,,85,,2339.2,percent of total billed charges,,,49,,1348.48,percent of total billed charges,,,90,,2476.8,percent of total billed charges,,,65,,1788.8,percent of total billed charges,,,80,,2201.6,percent of total billed charges,,,55,,1513.6,percent of total billed charges,,,55,,1513.6,percent of total billed charges,,,65,,1788.8,percent of total billed charges,,,78,,2146.56,percent of total billed charges,,,70,,1926.4,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1073.28,2476.8,
Graft Epicord 3cm x 5cm,Q4187,HCPCS,,,,outpatient,,,6460,3876,,45.5,,2939.3,percent of total billed charges,,,45.3,,2926.38,percent of total billed charges,,,39,,2519.4,percent of total billed charges,,,,,,,,,80,,5168,percent of total billed charges,,,61.4,,3966.44,percent of total billed charges,,,57.4,,3708.04,percent of total billed charges,,,81,,5232.6,percent of total billed charges,,,39,,2519.4,percent of total billed charges,,,57.6,,3720.96,percent of total billed charges,,,85,,5491,percent of total billed charges,,,85,,5491,percent of total billed charges,,,49,,3165.4,percent of total billed charges,,,90,,5814,percent of total billed charges,,,65,,4199,percent of total billed charges,,,80,,5168,percent of total billed charges,,,55,,3553,percent of total billed charges,,,55,,3553,percent of total billed charges,,,65,,4199,percent of total billed charges,,,78,,5038.8,percent of total billed charges,,,70,,4522,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,2519.4,5814,
Graft EpiEffect 2cm x 3cm,Q4278,HCPCS,,,,outpatient,,,3420,2052,,45.5,,1556.1,percent of total billed charges,,,45.3,,1549.26,percent of total billed charges,,,39,,1333.8,percent of total billed charges,,,,,,,,,80,,2736,percent of total billed charges,,,61.4,,2099.88,percent of total billed charges,,,57.4,,1963.08,percent of total billed charges,,,81,,2770.2,percent of total billed charges,,,39,,1333.8,percent of total billed charges,,,57.6,,1969.92,percent of total billed charges,,,85,,2907,percent of total billed charges,,,85,,2907,percent of total billed charges,,,49,,1675.8,percent of total billed charges,,,90,,3078,percent of total billed charges,,,65,,2223,percent of total billed charges,,,80,,2736,percent of total billed charges,,,55,,1881,percent of total billed charges,,,55,,1881,percent of total billed charges,,,65,,2223,percent of total billed charges,,,78,,2667.6,percent of total billed charges,,,70,,2394,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1333.8,3078,
Graft EpiEffect 3cm x 5cm,Q4278,HCPCS,,,,outpatient,,,8550,5130,,45.5,,3890.25,percent of total billed charges,,,45.3,,3873.15,percent of total billed charges,,,39,,3334.5,percent of total billed charges,,,,,,,,,80,,6840,percent of total billed charges,,,61.4,,5249.7,percent of total billed charges,,,57.4,,4907.7,percent of total billed charges,,,81,,6925.5,percent of total billed charges,,,39,,3334.5,percent of total billed charges,,,57.6,,4924.8,percent of total billed charges,,,85,,7267.5,percent of total billed charges,,,85,,7267.5,percent of total billed charges,,,49,,4189.5,percent of total billed charges,,,90,,7695,percent of total billed charges,,,65,,5557.5,percent of total billed charges,,,80,,6840,percent of total billed charges,,,55,,4702.5,percent of total billed charges,,,55,,4702.5,percent of total billed charges,,,65,,5557.5,percent of total billed charges,,,78,,6669,percent of total billed charges,,,70,,5985,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,3334.5,7695,
Graft EpiEffect 7cm x 7cm,Q4278,HCPCS,,,,outpatient,,,27930,16758,,45.5,,12708.15,percent of total billed charges,,,45.3,,12652.29,percent of total billed charges,,,39,,10892.7,percent of total billed charges,,,,,,,,,80,,22344,percent of total billed charges,,,61.4,,17149.02,percent of total billed charges,,,57.4,,16031.82,percent of total billed charges,,,81,,22623.3,percent of total billed charges,,,39,,10892.7,percent of total billed charges,,,57.6,,16087.68,percent of total billed charges,,,85,,23740.5,percent of total billed charges,,,85,,23740.5,percent of total billed charges,,,49,,13685.7,percent of total billed charges,,,90,,25137,percent of total billed charges,,,65,,18154.5,percent of total billed charges,,,80,,22344,percent of total billed charges,,,55,,15361.5,percent of total billed charges,,,55,,15361.5,percent of total billed charges,,,65,,18154.5,percent of total billed charges,,,78,,21785.4,percent of total billed charges,,,70,,19551,percent of total billed charges,,,,,,,,,,,,,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,999999999,100% of Medicare,,,,,,999999999,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,10892.7,999999999,
Gastrografin 30ml,Q9963,HCPCS,,,,both,,,107,64.2,,45.5,,48.69,percent of total billed charges,,,45.3,,48.47,percent of total billed charges,,,51,,54.57,percent of total billed charges,,,,,,,,,80,,85.6,percent of total billed charges,,,61.4,,65.7,percent of total billed charges,,,57.4,,61.42,percent of total billed charges,,,81,,86.67,percent of total billed charges,,,51.5,,55.11,percent of total billed charges,,,57.6,,61.63,percent of total billed charges,,,85,,90.95,percent of total billed charges,,,85,,90.95,percent of total billed charges,,,49,,52.43,percent of total billed charges,,,90,,96.3,percent of total billed charges,,,65,,69.55,percent of total billed charges,,,80,,85.6,percent of total billed charges,,,55,,58.85,percent of total billed charges,,,55,,58.85,percent of total billed charges,,,65,,69.55,percent of total billed charges,,,78,,83.46,percent of total billed charges,,,70,,74.9,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,48.47,96.3,
00270-0445-35 - diatrizoate 66%-10% Soln,Q9963,HCPCS,00270-0445-35,NDC,,both,30,ML,225.35,135.21,,45.5,,102.53,percent of total billed charges,,,45.3,,102.08,percent of total billed charges,,,51,,114.93,percent of total billed charges,,,,,,,,,80,,180.28,percent of total billed charges,,,61.4,,138.36,percent of total billed charges,,,57.4,,129.35,percent of total billed charges,,,81,,182.53,percent of total billed charges,,,51.5,,116.06,percent of total billed charges,,,57.6,,129.8,percent of total billed charges,,,85,,191.55,percent of total billed charges,,,85,,191.55,percent of total billed charges,,,49,,110.42,percent of total billed charges,,,90,,202.82,percent of total billed charges,,,65,,146.48,percent of total billed charges,,,80,,180.28,percent of total billed charges,,,55,,123.94,percent of total billed charges,,,55,,123.94,percent of total billed charges,,,65,,146.48,percent of total billed charges,,,78,,175.77,percent of total billed charges,,,70,,157.75,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,102.08,202.82,
00407-1412-30 - iohexol 240 mg/mL Soln,Q9966,HCPCS,00407-1412-30,NDC,,both,1,ML,405.55,243.33,,45.5,,184.53,percent of total billed charges,,,45.3,,183.71,percent of total billed charges,,,51,,206.83,percent of total billed charges,,,,,,,,,80,,324.44,percent of total billed charges,,,61.4,,249.01,percent of total billed charges,,,57.4,,232.79,percent of total billed charges,,,81,,328.5,percent of total billed charges,,,51.5,,208.86,percent of total billed charges,,,57.6,,233.6,percent of total billed charges,,,85,,344.72,percent of total billed charges,,,85,,344.72,percent of total billed charges,,,49,,198.72,percent of total billed charges,,,90,,365,percent of total billed charges,,,65,,263.61,percent of total billed charges,,,80,,324.44,percent of total billed charges,,,55,,223.05,percent of total billed charges,,,55,,223.05,percent of total billed charges,,,65,,263.61,percent of total billed charges,,,78,,316.33,percent of total billed charges,,,70,,283.89,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,183.71,365,
00407-1413-10 - iohexol 300 mg/mL Soln,Q9967,HCPCS,00407-1413-10,NDC,,both,10,ML,483.1,289.86,,45.5,,219.81,percent of total billed charges,,,45.3,,218.84,percent of total billed charges,,,51,,246.38,percent of total billed charges,,,,,,,,,80,,386.48,percent of total billed charges,,,61.4,,296.62,percent of total billed charges,,,57.4,,277.3,percent of total billed charges,,,81,,391.31,percent of total billed charges,,,51.5,,248.8,percent of total billed charges,,,57.6,,278.27,percent of total billed charges,,,85,,410.64,percent of total billed charges,,,85,,410.64,percent of total billed charges,,,49,,236.72,percent of total billed charges,,,90,,434.79,percent of total billed charges,,,65,,314.02,percent of total billed charges,,,80,,386.48,percent of total billed charges,,,55,,265.71,percent of total billed charges,,,55,,265.71,percent of total billed charges,,,65,,314.02,percent of total billed charges,,,78,,376.82,percent of total billed charges,,,70,,338.17,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,218.84,434.79,
00270-1315-47 - iopamidol 61% Soln,Q9967,HCPCS,00270-1315-47,NDC,,both,1,ML,749.05,449.43,,45.5,,340.82,percent of total billed charges,,,45.3,,339.32,percent of total billed charges,,,51,,382.02,percent of total billed charges,,,,,,,,,80,,599.24,percent of total billed charges,,,61.4,,459.92,percent of total billed charges,,,57.4,,429.95,percent of total billed charges,,,81,,606.73,percent of total billed charges,,,51.5,,385.76,percent of total billed charges,,,57.6,,431.45,percent of total billed charges,,,85,,636.69,percent of total billed charges,,,85,,636.69,percent of total billed charges,,,49,,367.03,percent of total billed charges,,,90,,674.15,percent of total billed charges,,,65,,486.88,percent of total billed charges,,,80,,599.24,percent of total billed charges,,,55,,411.98,percent of total billed charges,,,55,,411.98,percent of total billed charges,,,65,,486.88,percent of total billed charges,,,78,,584.26,percent of total billed charges,,,70,,524.34,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,339.32,674.15,
00270-1316-52 - iopamidol 76% Soln,Q9967,HCPCS,00270-1316-52,NDC,,both,1,ML,755.4,453.24,,45.5,,343.71,percent of total billed charges,,,45.3,,342.2,percent of total billed charges,,,51,,385.25,percent of total billed charges,,,,,,,,,80,,604.32,percent of total billed charges,,,61.4,,463.82,percent of total billed charges,,,57.4,,433.6,percent of total billed charges,,,81,,611.87,percent of total billed charges,,,51.5,,389.03,percent of total billed charges,,,57.6,,435.11,percent of total billed charges,,,85,,642.09,percent of total billed charges,,,85,,642.09,percent of total billed charges,,,49,,370.15,percent of total billed charges,,,90,,679.86,percent of total billed charges,,,65,,491.01,percent of total billed charges,,,80,,604.32,percent of total billed charges,,,55,,415.47,percent of total billed charges,,,55,,415.47,percent of total billed charges,,,65,,491.01,percent of total billed charges,,,78,,589.21,percent of total billed charges,,,70,,528.78,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,342.2,679.86,
00270-1412-15 - iopamidol 61% Soln,Q9967,HCPCS,00270-1412-15,NDC,,both,15,ML,878.05,526.83,,45.5,,399.51,percent of total billed charges,,,45.3,,397.76,percent of total billed charges,,,51,,447.81,percent of total billed charges,,,,,,,,,80,,702.44,percent of total billed charges,,,61.4,,539.12,percent of total billed charges,,,57.4,,504,percent of total billed charges,,,81,,711.22,percent of total billed charges,,,51.5,,452.2,percent of total billed charges,,,57.6,,505.76,percent of total billed charges,,,85,,746.34,percent of total billed charges,,,85,,746.34,percent of total billed charges,,,49,,430.24,percent of total billed charges,,,90,,790.25,percent of total billed charges,,,65,,570.73,percent of total billed charges,,,80,,702.44,percent of total billed charges,,,55,,482.93,percent of total billed charges,,,55,,482.93,percent of total billed charges,,,65,,570.73,percent of total billed charges,,,78,,684.88,percent of total billed charges,,,70,,614.64,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,397.76,790.25,
00407-1414-76 - iohexol 350 mg/mL Soln,Q9967,HCPCS,00407-1414-76,NDC,,both,125,ML,1105.2,663.12,,45.5,,502.87,percent of total billed charges,,,45.3,,500.66,percent of total billed charges,,,51,,563.65,percent of total billed charges,,,,,,,,,80,,884.16,percent of total billed charges,,,61.4,,678.59,percent of total billed charges,,,57.4,,634.38,percent of total billed charges,,,81,,895.21,percent of total billed charges,,,51.5,,569.18,percent of total billed charges,,,57.6,,636.6,percent of total billed charges,,,85,,939.42,percent of total billed charges,,,85,,939.42,percent of total billed charges,,,49,,541.55,percent of total billed charges,,,90,,994.68,percent of total billed charges,,,65,,718.38,percent of total billed charges,,,80,,884.16,percent of total billed charges,,,55,,607.86,percent of total billed charges,,,55,,607.86,percent of total billed charges,,,65,,718.38,percent of total billed charges,,,78,,862.06,percent of total billed charges,,,70,,773.64,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,500.66,994.68,
00270-1316-04 - iopamidol 76% Soln,Q9967,HCPCS,00270-1316-04,NDC,,both,1,ML,1179,707.4,,45.5,,536.45,percent of total billed charges,,,45.3,,534.09,percent of total billed charges,,,51,,601.29,percent of total billed charges,,,,,,,,,80,,943.2,percent of total billed charges,,,61.4,,723.91,percent of total billed charges,,,57.4,,676.75,percent of total billed charges,,,81,,954.99,percent of total billed charges,,,51.5,,607.19,percent of total billed charges,,,57.6,,679.1,percent of total billed charges,,,85,,1002.15,percent of total billed charges,,,85,,1002.15,percent of total billed charges,,,49,,577.71,percent of total billed charges,,,90,,1061.1,percent of total billed charges,,,65,,766.35,percent of total billed charges,,,80,,943.2,percent of total billed charges,,,55,,648.45,percent of total billed charges,,,55,,648.45,percent of total billed charges,,,65,,766.35,percent of total billed charges,,,78,,919.62,percent of total billed charges,,,70,,825.3,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,534.09,1061.1,
XR Ankle 2 Views Left,73600,CPT,,,LT,both,,,470,282,,45.5,,213.85,percent of total billed charges,,,45.3,,212.91,percent of total billed charges,,,51,,239.7,percent of total billed charges,,,,,,,,,80,,376,percent of total billed charges,,,61.4,,288.58,percent of total billed charges,,,57.4,,269.78,percent of total billed charges,,,81,,380.7,percent of total billed charges,,,51.5,,242.05,percent of total billed charges,,365,,,,fee schedule,,,85,,399.5,percent of total billed charges,,,85,,399.5,percent of total billed charges,,,49,,230.3,percent of total billed charges,,,90,,423,percent of total billed charges,,,65,,305.5,percent of total billed charges,,,80,,376,percent of total billed charges,,,55,,258.5,percent of total billed charges,,,55,,258.5,percent of total billed charges,,,65,,305.5,percent of total billed charges,,,78,,366.6,percent of total billed charges,,,70,,329,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,423,
XR Ankle 2 Views Right,73600,CPT,,,RT,both,,,470,282,,45.5,,213.85,percent of total billed charges,,,45.3,,212.91,percent of total billed charges,,,51,,239.7,percent of total billed charges,,,,,,,,,80,,376,percent of total billed charges,,,61.4,,288.58,percent of total billed charges,,,57.4,,269.78,percent of total billed charges,,,81,,380.7,percent of total billed charges,,,51.5,,242.05,percent of total billed charges,,365,,,,fee schedule,,,85,,399.5,percent of total billed charges,,,85,,399.5,percent of total billed charges,,,49,,230.3,percent of total billed charges,,,90,,423,percent of total billed charges,,,65,,305.5,percent of total billed charges,,,80,,376,percent of total billed charges,,,55,,258.5,percent of total billed charges,,,55,,258.5,percent of total billed charges,,,65,,305.5,percent of total billed charges,,,78,,366.6,percent of total billed charges,,,70,,329,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,423,
XR Calcaneous Left,73650,CPT,,,LT,both,,,557,334.2,,45.5,,253.44,percent of total billed charges,,,45.3,,252.32,percent of total billed charges,,,51,,284.07,percent of total billed charges,,,,,,,,,80,,445.6,percent of total billed charges,,,61.4,,342,percent of total billed charges,,,57.4,,319.72,percent of total billed charges,,,81,,451.17,percent of total billed charges,,,51.5,,286.86,percent of total billed charges,,365,,,,fee schedule,,,85,,473.45,percent of total billed charges,,,85,,473.45,percent of total billed charges,,,49,,272.93,percent of total billed charges,,,90,,501.3,percent of total billed charges,,,65,,362.05,percent of total billed charges,,,80,,445.6,percent of total billed charges,,,55,,306.35,percent of total billed charges,,,55,,306.35,percent of total billed charges,,,65,,362.05,percent of total billed charges,,,78,,434.46,percent of total billed charges,,,70,,389.9,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,501.3,
XR Calcaneous Right,73650,CPT,,,RT,both,,,557,334.2,,45.5,,253.44,percent of total billed charges,,,45.3,,252.32,percent of total billed charges,,,51,,284.07,percent of total billed charges,,,,,,,,,80,,445.6,percent of total billed charges,,,61.4,,342,percent of total billed charges,,,57.4,,319.72,percent of total billed charges,,,81,,451.17,percent of total billed charges,,,51.5,,286.86,percent of total billed charges,,365,,,,fee schedule,,,85,,473.45,percent of total billed charges,,,85,,473.45,percent of total billed charges,,,49,,272.93,percent of total billed charges,,,90,,501.3,percent of total billed charges,,,65,,362.05,percent of total billed charges,,,80,,445.6,percent of total billed charges,,,55,,306.35,percent of total billed charges,,,55,,306.35,percent of total billed charges,,,65,,362.05,percent of total billed charges,,,78,,434.46,percent of total billed charges,,,70,,389.9,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,501.3,
XR Toes 2nd Digit Left,73660,CPT,,,T1,both,,,338,202.8,,45.5,,153.79,percent of total billed charges,,,45.3,,153.11,percent of total billed charges,,,51,,172.38,percent of total billed charges,,,,,,,,,80,,270.4,percent of total billed charges,,,61.4,,207.53,percent of total billed charges,,,57.4,,194.01,percent of total billed charges,,,81,,273.78,percent of total billed charges,,,51.5,,174.07,percent of total billed charges,,365,,,,fee schedule,,,85,,287.3,percent of total billed charges,,,85,,287.3,percent of total billed charges,,,49,,165.62,percent of total billed charges,,,90,,304.2,percent of total billed charges,,,65,,219.7,percent of total billed charges,,,80,,270.4,percent of total billed charges,,,55,,185.9,percent of total billed charges,,,55,,185.9,percent of total billed charges,,,65,,219.7,percent of total billed charges,,,78,,263.64,percent of total billed charges,,,70,,236.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,365,
XR Toes 3rd Digit Left,73660,CPT,,,T2,both,,,338,202.8,,45.5,,153.79,percent of total billed charges,,,45.3,,153.11,percent of total billed charges,,,51,,172.38,percent of total billed charges,,,,,,,,,80,,270.4,percent of total billed charges,,,61.4,,207.53,percent of total billed charges,,,57.4,,194.01,percent of total billed charges,,,81,,273.78,percent of total billed charges,,,51.5,,174.07,percent of total billed charges,,365,,,,fee schedule,,,85,,287.3,percent of total billed charges,,,85,,287.3,percent of total billed charges,,,49,,165.62,percent of total billed charges,,,90,,304.2,percent of total billed charges,,,65,,219.7,percent of total billed charges,,,80,,270.4,percent of total billed charges,,,55,,185.9,percent of total billed charges,,,55,,185.9,percent of total billed charges,,,65,,219.7,percent of total billed charges,,,78,,263.64,percent of total billed charges,,,70,,236.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,365,
XR Toes 4th Digit Left,73660,CPT,,,T3,both,,,338,202.8,,45.5,,153.79,percent of total billed charges,,,45.3,,153.11,percent of total billed charges,,,51,,172.38,percent of total billed charges,,,,,,,,,80,,270.4,percent of total billed charges,,,61.4,,207.53,percent of total billed charges,,,57.4,,194.01,percent of total billed charges,,,81,,273.78,percent of total billed charges,,,51.5,,174.07,percent of total billed charges,,365,,,,fee schedule,,,85,,287.3,percent of total billed charges,,,85,,287.3,percent of total billed charges,,,49,,165.62,percent of total billed charges,,,90,,304.2,percent of total billed charges,,,65,,219.7,percent of total billed charges,,,80,,270.4,percent of total billed charges,,,55,,185.9,percent of total billed charges,,,55,,185.9,percent of total billed charges,,,65,,219.7,percent of total billed charges,,,78,,263.64,percent of total billed charges,,,70,,236.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,365,
XR Toes 5th Digit Left,73660,CPT,,,T4,both,,,338,202.8,,45.5,,153.79,percent of total billed charges,,,45.3,,153.11,percent of total billed charges,,,51,,172.38,percent of total billed charges,,,,,,,,,80,,270.4,percent of total billed charges,,,61.4,,207.53,percent of total billed charges,,,57.4,,194.01,percent of total billed charges,,,81,,273.78,percent of total billed charges,,,51.5,,174.07,percent of total billed charges,,365,,,,fee schedule,,,85,,287.3,percent of total billed charges,,,85,,287.3,percent of total billed charges,,,49,,165.62,percent of total billed charges,,,90,,304.2,percent of total billed charges,,,65,,219.7,percent of total billed charges,,,80,,270.4,percent of total billed charges,,,55,,185.9,percent of total billed charges,,,55,,185.9,percent of total billed charges,,,65,,219.7,percent of total billed charges,,,78,,263.64,percent of total billed charges,,,70,,236.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,365,
XR Toes Great Right,73660,CPT,,,T5,both,,,338,202.8,,45.5,,153.79,percent of total billed charges,,,45.3,,153.11,percent of total billed charges,,,51,,172.38,percent of total billed charges,,,,,,,,,80,,270.4,percent of total billed charges,,,61.4,,207.53,percent of total billed charges,,,57.4,,194.01,percent of total billed charges,,,81,,273.78,percent of total billed charges,,,51.5,,174.07,percent of total billed charges,,365,,,,fee schedule,,,85,,287.3,percent of total billed charges,,,85,,287.3,percent of total billed charges,,,49,,165.62,percent of total billed charges,,,90,,304.2,percent of total billed charges,,,65,,219.7,percent of total billed charges,,,80,,270.4,percent of total billed charges,,,55,,185.9,percent of total billed charges,,,55,,185.9,percent of total billed charges,,,65,,219.7,percent of total billed charges,,,78,,263.64,percent of total billed charges,,,70,,236.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,365,
XR Toes 2nd Digit Right,73660,CPT,,,T6,both,,,338,202.8,,45.5,,153.79,percent of total billed charges,,,45.3,,153.11,percent of total billed charges,,,51,,172.38,percent of total billed charges,,,,,,,,,80,,270.4,percent of total billed charges,,,61.4,,207.53,percent of total billed charges,,,57.4,,194.01,percent of total billed charges,,,81,,273.78,percent of total billed charges,,,51.5,,174.07,percent of total billed charges,,365,,,,fee schedule,,,85,,287.3,percent of total billed charges,,,85,,287.3,percent of total billed charges,,,49,,165.62,percent of total billed charges,,,90,,304.2,percent of total billed charges,,,65,,219.7,percent of total billed charges,,,80,,270.4,percent of total billed charges,,,55,,185.9,percent of total billed charges,,,55,,185.9,percent of total billed charges,,,65,,219.7,percent of total billed charges,,,78,,263.64,percent of total billed charges,,,70,,236.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,365,
XR Toes 3rd Digit Right,73660,CPT,,,T7,both,,,338,202.8,,45.5,,153.79,percent of total billed charges,,,45.3,,153.11,percent of total billed charges,,,51,,172.38,percent of total billed charges,,,,,,,,,80,,270.4,percent of total billed charges,,,61.4,,207.53,percent of total billed charges,,,57.4,,194.01,percent of total billed charges,,,81,,273.78,percent of total billed charges,,,51.5,,174.07,percent of total billed charges,,365,,,,fee schedule,,,85,,287.3,percent of total billed charges,,,85,,287.3,percent of total billed charges,,,49,,165.62,percent of total billed charges,,,90,,304.2,percent of total billed charges,,,65,,219.7,percent of total billed charges,,,80,,270.4,percent of total billed charges,,,55,,185.9,percent of total billed charges,,,55,,185.9,percent of total billed charges,,,65,,219.7,percent of total billed charges,,,78,,263.64,percent of total billed charges,,,70,,236.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,365,
XR Toes 4th Digit Right,73660,CPT,,,T8,both,,,338,202.8,,45.5,,153.79,percent of total billed charges,,,45.3,,153.11,percent of total billed charges,,,51,,172.38,percent of total billed charges,,,,,,,,,80,,270.4,percent of total billed charges,,,61.4,,207.53,percent of total billed charges,,,57.4,,194.01,percent of total billed charges,,,81,,273.78,percent of total billed charges,,,51.5,,174.07,percent of total billed charges,,365,,,,fee schedule,,,85,,287.3,percent of total billed charges,,,85,,287.3,percent of total billed charges,,,49,,165.62,percent of total billed charges,,,90,,304.2,percent of total billed charges,,,65,,219.7,percent of total billed charges,,,80,,270.4,percent of total billed charges,,,55,,185.9,percent of total billed charges,,,55,,185.9,percent of total billed charges,,,65,,219.7,percent of total billed charges,,,78,,263.64,percent of total billed charges,,,70,,236.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,365,
XR Toes 5th Digit Right,73660,CPT,,,T9,both,,,338,202.8,,45.5,,153.79,percent of total billed charges,,,45.3,,153.11,percent of total billed charges,,,51,,172.38,percent of total billed charges,,,,,,,,,80,,270.4,percent of total billed charges,,,61.4,,207.53,percent of total billed charges,,,57.4,,194.01,percent of total billed charges,,,81,,273.78,percent of total billed charges,,,51.5,,174.07,percent of total billed charges,,365,,,,fee schedule,,,85,,287.3,percent of total billed charges,,,85,,287.3,percent of total billed charges,,,49,,165.62,percent of total billed charges,,,90,,304.2,percent of total billed charges,,,65,,219.7,percent of total billed charges,,,80,,270.4,percent of total billed charges,,,55,,185.9,percent of total billed charges,,,55,,185.9,percent of total billed charges,,,65,,219.7,percent of total billed charges,,,78,,263.64,percent of total billed charges,,,70,,236.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,365,
XR Toes Great Left,73660,CPT,,,TA,both,,,338,202.8,,45.5,,153.79,percent of total billed charges,,,45.3,,153.11,percent of total billed charges,,,51,,172.38,percent of total billed charges,,,,,,,,,80,,270.4,percent of total billed charges,,,61.4,,207.53,percent of total billed charges,,,57.4,,194.01,percent of total billed charges,,,81,,273.78,percent of total billed charges,,,51.5,,174.07,percent of total billed charges,,365,,,,fee schedule,,,85,,287.3,percent of total billed charges,,,85,,287.3,percent of total billed charges,,,49,,165.62,percent of total billed charges,,,90,,304.2,percent of total billed charges,,,65,,219.7,percent of total billed charges,,,80,,270.4,percent of total billed charges,,,55,,185.9,percent of total billed charges,,,55,,185.9,percent of total billed charges,,,65,,219.7,percent of total billed charges,,,78,,263.64,percent of total billed charges,,,70,,236.6,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,365,
CT Lower Extremity W/O Contrast Bil,73700,CPT,,,50,both,,,3732,2239.2,,45.5,,1698.06,percent of total billed charges,,,45.3,,1690.6,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,2985.6,percent of total billed charges,,,61.4,,2291.45,percent of total billed charges,,,57.4,,2142.17,percent of total billed charges,,,81,,3022.92,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2149.63,percent of total billed charges,,,85,,3172.2,percent of total billed charges,,,85,,3172.2,percent of total billed charges,,,49,,1828.68,percent of total billed charges,,,90,,3358.8,percent of total billed charges,,,65,,2425.8,percent of total billed charges,,,80,,2985.6,percent of total billed charges,,,55,,2052.6,percent of total billed charges,,,55,,2052.6,percent of total billed charges,,,65,,2425.8,percent of total billed charges,,,78,,2910.96,percent of total billed charges,,,70,,2612.4,percent of total billed charges,,,,,,,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,166.28,,,,150% of Medicare,,,166.28,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,166.28,3358.8,
CT Lower Extremity W/O Contrast Lt,73700,CPT,,,LT,both,,,3732,2239.2,,45.5,,1698.06,percent of total billed charges,,,45.3,,1690.6,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,2985.6,percent of total billed charges,,,61.4,,2291.45,percent of total billed charges,,,57.4,,2142.17,percent of total billed charges,,,81,,3022.92,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2149.63,percent of total billed charges,,,85,,3172.2,percent of total billed charges,,,85,,3172.2,percent of total billed charges,,,49,,1828.68,percent of total billed charges,,,90,,3358.8,percent of total billed charges,,,65,,2425.8,percent of total billed charges,,,80,,2985.6,percent of total billed charges,,,55,,2052.6,percent of total billed charges,,,55,,2052.6,percent of total billed charges,,,65,,2425.8,percent of total billed charges,,,78,,2910.96,percent of total billed charges,,,70,,2612.4,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,3358.8,
CT Lower Extremity W/O Contrast Rt,73700,CPT,,,RT,both,,,3732,2239.2,,45.5,,1698.06,percent of total billed charges,,,45.3,,1690.6,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,2985.6,percent of total billed charges,,,61.4,,2291.45,percent of total billed charges,,,57.4,,2142.17,percent of total billed charges,,,81,,3022.92,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2149.63,percent of total billed charges,,,85,,3172.2,percent of total billed charges,,,85,,3172.2,percent of total billed charges,,,49,,1828.68,percent of total billed charges,,,90,,3358.8,percent of total billed charges,,,65,,2425.8,percent of total billed charges,,,80,,2985.6,percent of total billed charges,,,55,,2052.6,percent of total billed charges,,,55,,2052.6,percent of total billed charges,,,65,,2425.8,percent of total billed charges,,,78,,2910.96,percent of total billed charges,,,70,,2612.4,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,3358.8,
CT Lower Extremity W/ Contrast Bil,73701,CPT,,,50,both,,,4391,2634.6,,45.5,,1997.91,percent of total billed charges,,,45.3,,1989.12,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3512.8,percent of total billed charges,,,61.4,,2696.07,percent of total billed charges,,,57.4,,2520.43,percent of total billed charges,,,81,,3556.71,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2529.22,percent of total billed charges,,,85,,3732.35,percent of total billed charges,,,85,,3732.35,percent of total billed charges,,,49,,2151.59,percent of total billed charges,,,90,,3951.9,percent of total billed charges,,,65,,2854.15,percent of total billed charges,,,80,,3512.8,percent of total billed charges,,,55,,2415.05,percent of total billed charges,,,55,,2415.05,percent of total billed charges,,,65,,2854.15,percent of total billed charges,,,78,,3424.98,percent of total billed charges,,,70,,3073.7,percent of total billed charges,,,,,,,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,,278.36,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,278.36,3951.9,
CT Lower Extremity W/ Contrast Lt,73701,CPT,,,LT,both,,,4391,2634.6,,45.5,,1997.91,percent of total billed charges,,,45.3,,1989.12,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3512.8,percent of total billed charges,,,61.4,,2696.07,percent of total billed charges,,,57.4,,2520.43,percent of total billed charges,,,81,,3556.71,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2529.22,percent of total billed charges,,,85,,3732.35,percent of total billed charges,,,85,,3732.35,percent of total billed charges,,,49,,2151.59,percent of total billed charges,,,90,,3951.9,percent of total billed charges,,,65,,2854.15,percent of total billed charges,,,80,,3512.8,percent of total billed charges,,,55,,2415.05,percent of total billed charges,,,55,,2415.05,percent of total billed charges,,,65,,2854.15,percent of total billed charges,,,78,,3424.98,percent of total billed charges,,,70,,3073.7,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,185.57,3951.9,
CT Lower Extremity W/ Contrast Rt,73701,CPT,,,RT,both,,,4391,2634.6,,45.5,,1997.91,percent of total billed charges,,,45.3,,1989.12,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3512.8,percent of total billed charges,,,61.4,,2696.07,percent of total billed charges,,,57.4,,2520.43,percent of total billed charges,,,81,,3556.71,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2529.22,percent of total billed charges,,,85,,3732.35,percent of total billed charges,,,85,,3732.35,percent of total billed charges,,,49,,2151.59,percent of total billed charges,,,90,,3951.9,percent of total billed charges,,,65,,2854.15,percent of total billed charges,,,80,,3512.8,percent of total billed charges,,,55,,2415.05,percent of total billed charges,,,55,,2415.05,percent of total billed charges,,,65,,2854.15,percent of total billed charges,,,78,,3424.98,percent of total billed charges,,,70,,3073.7,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,185.57,3951.9,
CT Lower Extremity W/&W/O Contrast Bil,73702,CPT,,,50,both,,,6329,3797.4,,45.5,,2879.7,percent of total billed charges,,,45.3,,2867.04,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,5063.2,percent of total billed charges,,,61.4,,3886.01,percent of total billed charges,,,57.4,,3632.85,percent of total billed charges,,,81,,5126.49,percent of total billed charges,,735,,,,fee schedule,,,57.6,,3645.5,percent of total billed charges,,,85,,5379.65,percent of total billed charges,,,85,,5379.65,percent of total billed charges,,,49,,3101.21,percent of total billed charges,,,90,,5696.1,percent of total billed charges,,,65,,4113.85,percent of total billed charges,,,80,,5063.2,percent of total billed charges,,,55,,3480.95,percent of total billed charges,,,55,,3480.95,percent of total billed charges,,,65,,4113.85,percent of total billed charges,,,78,,4936.62,percent of total billed charges,,,70,,4430.3,percent of total billed charges,,,,,,,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,278.36,,,,150% of Medicare,,,278.36,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,278.36,5696.1,
CT Lower Extremity W/&W/O Contrast Lt,73702,CPT,,,LT,both,,,6329,3797.4,,45.5,,2879.7,percent of total billed charges,,,45.3,,2867.04,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,5063.2,percent of total billed charges,,,61.4,,3886.01,percent of total billed charges,,,57.4,,3632.85,percent of total billed charges,,,81,,5126.49,percent of total billed charges,,735,,,,fee schedule,,,57.6,,3645.5,percent of total billed charges,,,85,,5379.65,percent of total billed charges,,,85,,5379.65,percent of total billed charges,,,49,,3101.21,percent of total billed charges,,,90,,5696.1,percent of total billed charges,,,65,,4113.85,percent of total billed charges,,,80,,5063.2,percent of total billed charges,,,55,,3480.95,percent of total billed charges,,,55,,3480.95,percent of total billed charges,,,65,,4113.85,percent of total billed charges,,,78,,4936.62,percent of total billed charges,,,70,,4430.3,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,185.57,5696.1,
CT Lower Extremity W/&W/O Contrast Rt,73702,CPT,,,RT,both,,,6329,3797.4,,45.5,,2879.7,percent of total billed charges,,,45.3,,2867.04,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,5063.2,percent of total billed charges,,,61.4,,3886.01,percent of total billed charges,,,57.4,,3632.85,percent of total billed charges,,,81,,5126.49,percent of total billed charges,,735,,,,fee schedule,,,57.6,,3645.5,percent of total billed charges,,,85,,5379.65,percent of total billed charges,,,85,,5379.65,percent of total billed charges,,,49,,3101.21,percent of total billed charges,,,90,,5696.1,percent of total billed charges,,,65,,4113.85,percent of total billed charges,,,80,,5063.2,percent of total billed charges,,,55,,3480.95,percent of total billed charges,,,55,,3480.95,percent of total billed charges,,,65,,4113.85,percent of total billed charges,,,78,,4936.62,percent of total billed charges,,,70,,4430.3,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,185.57,5696.1,
MRA Lower Ext W/O Contrast Lt-73725,73725,CPT,C8913,HCPCS,LT,both,,,5136,3081.6,,45.5,,2336.88,percent of total billed charges,,,45.3,,2326.61,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4108.8,percent of total billed charges,,,61.4,,3153.5,percent of total billed charges,,,57.4,,2948.06,percent of total billed charges,,,81,,4160.16,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2958.34,percent of total billed charges,,,85,,4365.6,percent of total billed charges,,,85,,4365.6,percent of total billed charges,,,49,,2516.64,percent of total billed charges,,,90,,4622.4,percent of total billed charges,,,65,,3338.4,percent of total billed charges,,,80,,4108.8,percent of total billed charges,,,55,,2824.8,percent of total billed charges,,,55,,2824.8,percent of total billed charges,,,65,,3338.4,percent of total billed charges,,,78,,4006.08,percent of total billed charges,,,70,,3595.2,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,251.97,4622.4,
MRA Lower Ext W/O Contrast Rt-73725,73725,CPT,C8913,HCPCS,RT,both,,,5136,3081.6,,45.5,,2336.88,percent of total billed charges,,,45.3,,2326.61,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4108.8,percent of total billed charges,,,61.4,,3153.5,percent of total billed charges,,,57.4,,2948.06,percent of total billed charges,,,81,,4160.16,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2958.34,percent of total billed charges,,,85,,4365.6,percent of total billed charges,,,85,,4365.6,percent of total billed charges,,,49,,2516.64,percent of total billed charges,,,90,,4622.4,percent of total billed charges,,,65,,3338.4,percent of total billed charges,,,80,,4108.8,percent of total billed charges,,,55,,2824.8,percent of total billed charges,,,55,,2824.8,percent of total billed charges,,,65,,3338.4,percent of total billed charges,,,78,,4006.08,percent of total billed charges,,,70,,3595.2,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,251.97,4622.4,
MRA Lower Ext W&W/O Contrast Lt-73725,73725,CPT,C8914,HCPCS,LT,both,,,7115,4269,,45.5,,3237.33,percent of total billed charges,,,45.3,,3223.1,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,5692,percent of total billed charges,,,61.4,,4368.61,percent of total billed charges,,,57.4,,4084.01,percent of total billed charges,,,81,,5763.15,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,4098.24,percent of total billed charges,,,85,,6047.75,percent of total billed charges,,,85,,6047.75,percent of total billed charges,,,49,,3486.35,percent of total billed charges,,,90,,6403.5,percent of total billed charges,,,65,,4624.75,percent of total billed charges,,,80,,5692,percent of total billed charges,,,55,,3913.25,percent of total billed charges,,,55,,3913.25,percent of total billed charges,,,65,,4624.75,percent of total billed charges,,,78,,5549.7,percent of total billed charges,,,70,,4980.5,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,372.28,6403.5,
MRA Lower Ext W&W/O Contrast Rt-73725,73725,CPT,C8914,HCPCS,RT,both,,,7115,4269,,45.5,,3237.33,percent of total billed charges,,,45.3,,3223.1,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,5692,percent of total billed charges,,,61.4,,4368.61,percent of total billed charges,,,57.4,,4084.01,percent of total billed charges,,,81,,5763.15,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,4098.24,percent of total billed charges,,,85,,6047.75,percent of total billed charges,,,85,,6047.75,percent of total billed charges,,,49,,3486.35,percent of total billed charges,,,90,,6403.5,percent of total billed charges,,,65,,4624.75,percent of total billed charges,,,80,,5692,percent of total billed charges,,,55,,3913.25,percent of total billed charges,,,55,,3913.25,percent of total billed charges,,,65,,4624.75,percent of total billed charges,,,78,,5549.7,percent of total billed charges,,,70,,4980.5,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,372.28,6403.5,
XR Abdomen 2 View,74019,CPT,,,,both,,,770,462,,45.5,,350.35,percent of total billed charges,,,45.3,,348.81,percent of total billed charges,,,51,,392.7,percent of total billed charges,,,,,,,,,80,,616,percent of total billed charges,,,61.4,,472.78,percent of total billed charges,,,57.4,,441.98,percent of total billed charges,,,81,,623.7,percent of total billed charges,,,51.5,,396.55,percent of total billed charges,,365,,,,fee schedule,,,85,,654.5,percent of total billed charges,,,85,,654.5,percent of total billed charges,,,49,,377.3,percent of total billed charges,,,90,,693,percent of total billed charges,,,65,,500.5,percent of total billed charges,,,80,,616,percent of total billed charges,,,55,,423.5,percent of total billed charges,,,55,,423.5,percent of total billed charges,,,65,,500.5,percent of total billed charges,,,78,,600.6,percent of total billed charges,,,70,,539,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,693,
CT Abdomen W/O Contrast,74150,CPT,,,,both,,,3430,2058,,45.5,,1560.65,percent of total billed charges,,,45.3,,1553.79,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,2744,percent of total billed charges,,,61.4,,2106.02,percent of total billed charges,,,57.4,,1968.82,percent of total billed charges,,,81,,2778.3,percent of total billed charges,,735,,,,fee schedule,,,57.6,,1975.68,percent of total billed charges,,,85,,2915.5,percent of total billed charges,,,85,,2915.5,percent of total billed charges,,,49,,1680.7,percent of total billed charges,,,90,,3087,percent of total billed charges,,,65,,2229.5,percent of total billed charges,,,80,,2744,percent of total billed charges,,,55,,1886.5,percent of total billed charges,,,55,,1886.5,percent of total billed charges,,,65,,2229.5,percent of total billed charges,,,78,,2675.4,percent of total billed charges,,,70,,2401,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,3087,
CT Abdomen W/ Contrast,74160,CPT,,,,both,,,4275,2565,,45.5,,1945.13,percent of total billed charges,,,45.3,,1936.58,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3420,percent of total billed charges,,,61.4,,2624.85,percent of total billed charges,,,57.4,,2453.85,percent of total billed charges,,,81,,3462.75,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2462.4,percent of total billed charges,,,85,,3633.75,percent of total billed charges,,,85,,3633.75,percent of total billed charges,,,49,,2094.75,percent of total billed charges,,,90,,3847.5,percent of total billed charges,,,65,,2778.75,percent of total billed charges,,,80,,3420,percent of total billed charges,,,55,,2351.25,percent of total billed charges,,,55,,2351.25,percent of total billed charges,,,65,,2778.75,percent of total billed charges,,,78,,3334.5,percent of total billed charges,,,70,,2992.5,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,185.57,3847.5,
CT Abdomen W/&W/O Contrast,74170,CPT,,,,both,,,4982,2989.2,,45.5,,2266.81,percent of total billed charges,,,45.3,,2256.85,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,3985.6,percent of total billed charges,,,61.4,,3058.95,percent of total billed charges,,,57.4,,2859.67,percent of total billed charges,,,81,,4035.42,percent of total billed charges,,735,,,,fee schedule,,,57.6,,2869.63,percent of total billed charges,,,85,,4234.7,percent of total billed charges,,,85,,4234.7,percent of total billed charges,,,49,,2441.18,percent of total billed charges,,,90,,4483.8,percent of total billed charges,,,65,,3238.3,percent of total billed charges,,,80,,3985.6,percent of total billed charges,,,55,,2740.1,percent of total billed charges,,,55,,2740.1,percent of total billed charges,,,65,,3238.3,percent of total billed charges,,,78,,3885.96,percent of total billed charges,,,70,,3487.4,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,185.57,4483.8,
CT Angiography Abd/Pel W/&W/O Contrast,74174,CPT,,,,both,,,7542,4525.2,,45.5,,3431.61,percent of total billed charges,,,45.3,,3416.53,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,6033.6,percent of total billed charges,,,61.4,,4630.79,percent of total billed charges,,,57.4,,4329.11,percent of total billed charges,,,81,,6109.02,percent of total billed charges,,735,,,,fee schedule,,,57.6,,4344.19,percent of total billed charges,,,85,,6410.7,percent of total billed charges,,,85,,6410.7,percent of total billed charges,,,49,,3695.58,percent of total billed charges,,,90,,6787.8,percent of total billed charges,,,65,,4902.3,percent of total billed charges,,,80,,6033.6,percent of total billed charges,,,55,,4148.1,percent of total billed charges,,,55,,4148.1,percent of total billed charges,,,65,,4902.3,percent of total billed charges,,,78,,5882.76,percent of total billed charges,,,70,,5279.4,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,372.28,6787.8,
CT Angiogram Abdomen W/&W/O Contrast,74175,CPT,,,,both,,,5631,3378.6,,45.5,,2562.11,percent of total billed charges,,,45.3,,2550.84,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,4504.8,percent of total billed charges,,,61.4,,3457.43,percent of total billed charges,,,57.4,,3232.19,percent of total billed charges,,,81,,4561.11,percent of total billed charges,,735,,,,fee schedule,,,57.6,,3243.46,percent of total billed charges,,,85,,4786.35,percent of total billed charges,,,85,,4786.35,percent of total billed charges,,,49,,2759.19,percent of total billed charges,,,90,,5067.9,percent of total billed charges,,,65,,3660.15,percent of total billed charges,,,80,,4504.8,percent of total billed charges,,,55,,3097.05,percent of total billed charges,,,55,,3097.05,percent of total billed charges,,,65,,3660.15,percent of total billed charges,,,78,,4392.18,percent of total billed charges,,,70,,3941.7,percent of total billed charges,,,,,,,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,185.57,,,,100% of Medicare,,,185.57,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,185.57,5067.9,
CT Abdomen/Pelvis W/O Contrast,74176,CPT,,,,both,,,7564,4538.4,,45.5,,3441.62,percent of total billed charges,,,45.3,,3426.49,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,6051.2,percent of total billed charges,,,61.4,,4644.3,percent of total billed charges,,,57.4,,4341.74,percent of total billed charges,,,81,,6126.84,percent of total billed charges,,735,,,,fee schedule,,,57.6,,4356.86,percent of total billed charges,,,85,,6429.4,percent of total billed charges,,,85,,6429.4,percent of total billed charges,,,49,,3706.36,percent of total billed charges,,,90,,6807.6,percent of total billed charges,,,65,,4916.6,percent of total billed charges,,,80,,6051.2,percent of total billed charges,,,55,,4160.2,percent of total billed charges,,,55,,4160.2,percent of total billed charges,,,65,,4916.6,percent of total billed charges,,,78,,5899.92,percent of total billed charges,,,70,,5294.8,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,251.97,6807.6,
CT Abdomen/Pelvis W/ Contrast,74177,CPT,,,,both,,,8759,5255.4,,45.5,,3985.35,percent of total billed charges,,,45.3,,3967.83,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,7007.2,percent of total billed charges,,,61.4,,5378.03,percent of total billed charges,,,57.4,,5027.67,percent of total billed charges,,,81,,7094.79,percent of total billed charges,,735,,,,fee schedule,,,57.6,,5045.18,percent of total billed charges,,,85,,7445.15,percent of total billed charges,,,85,,7445.15,percent of total billed charges,,,49,,4291.91,percent of total billed charges,,,90,,7883.1,percent of total billed charges,,,65,,5693.35,percent of total billed charges,,,80,,7007.2,percent of total billed charges,,,55,,4817.45,percent of total billed charges,,,55,,4817.45,percent of total billed charges,,,65,,5693.35,percent of total billed charges,,,78,,6832.02,percent of total billed charges,,,70,,6131.3,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,372.28,7883.1,
CT Abdomen/Pelvis W/&W/O Contrast,74178,CPT,,,,both,,,10439,6263.4,,45.5,,4749.75,percent of total billed charges,,,45.3,,4728.87,percent of total billed charges,,764,,,,fee schedule,,,,,,,,,80,,8351.2,percent of total billed charges,,,61.4,,6409.55,percent of total billed charges,,,57.4,,5991.99,percent of total billed charges,,,81,,8455.59,percent of total billed charges,,735,,,,fee schedule,,,57.6,,6012.86,percent of total billed charges,,,85,,8873.15,percent of total billed charges,,,85,,8873.15,percent of total billed charges,,,49,,5115.11,percent of total billed charges,,,90,,9395.1,percent of total billed charges,,,65,,6785.35,percent of total billed charges,,,80,,8351.2,percent of total billed charges,,,55,,5741.45,percent of total billed charges,,,55,,5741.45,percent of total billed charges,,,65,,6785.35,percent of total billed charges,,,78,,8142.42,percent of total billed charges,,,70,,7307.3,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,372.28,9395.1,
MRA Abdomen  W/O Contrast,74185,CPT,C8901,HCPCS,,both,,,4126,2475.6,,45.5,,1877.33,percent of total billed charges,,,45.3,,1869.08,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3300.8,percent of total billed charges,,,61.4,,2533.36,percent of total billed charges,,,57.4,,2368.32,percent of total billed charges,,,81,,3342.06,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2376.58,percent of total billed charges,,,85,,3507.1,percent of total billed charges,,,85,,3507.1,percent of total billed charges,,,49,,2021.74,percent of total billed charges,,,90,,3713.4,percent of total billed charges,,,65,,2681.9,percent of total billed charges,,,80,,3300.8,percent of total billed charges,,,55,,2269.3,percent of total billed charges,,,55,,2269.3,percent of total billed charges,,,65,,2681.9,percent of total billed charges,,,78,,3218.28,percent of total billed charges,,,70,,2888.2,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,251.97,3713.4,
MRA Abdomen W/ Contrast,74185,CPT,C8900,HCPCS,,both,,,4463,2677.8,,45.5,,2030.67,percent of total billed charges,,,45.3,,2021.74,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,3570.4,percent of total billed charges,,,61.4,,2740.28,percent of total billed charges,,,57.4,,2561.76,percent of total billed charges,,,81,,3615.03,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,2570.69,percent of total billed charges,,,85,,3793.55,percent of total billed charges,,,85,,3793.55,percent of total billed charges,,,49,,2186.87,percent of total billed charges,,,90,,4016.7,percent of total billed charges,,,65,,2900.95,percent of total billed charges,,,80,,3570.4,percent of total billed charges,,,55,,2454.65,percent of total billed charges,,,55,,2454.65,percent of total billed charges,,,65,,2900.95,percent of total billed charges,,,78,,3481.14,percent of total billed charges,,,70,,3124.1,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,372.28,4016.7,
MRA Abdomen W&W/O Contrast,74185,CPT,C8902,HCPCS,,both,,,5643,3385.8,,45.5,,2567.57,percent of total billed charges,,,45.3,,2556.28,percent of total billed charges,,1092,,,,fee schedule,,,,,,,,,80,,4514.4,percent of total billed charges,,,61.4,,3464.8,percent of total billed charges,,,57.4,,3239.08,percent of total billed charges,,,81,,4570.83,percent of total billed charges,,1050,,,,fee schedule,,,57.6,,3250.37,percent of total billed charges,,,85,,4796.55,percent of total billed charges,,,85,,4796.55,percent of total billed charges,,,49,,2765.07,percent of total billed charges,,,90,,5078.7,percent of total billed charges,,,65,,3667.95,percent of total billed charges,,,80,,4514.4,percent of total billed charges,,,55,,3103.65,percent of total billed charges,,,55,,3103.65,percent of total billed charges,,,65,,3667.95,percent of total billed charges,,,78,,4401.54,percent of total billed charges,,,70,,3950.1,percent of total billed charges,,,,,,,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,372.28,,,,100% of Medicare,,,372.28,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,372.28,5078.7,
XR Shuntogram Non-Vascular,75809,CPT,,,,both,,,1091,654.6,,45.5,,496.41,percent of total billed charges,,,45.3,,494.22,percent of total billed charges,,,51,,556.41,percent of total billed charges,,,,,,,,,80,,872.8,percent of total billed charges,,,61.4,,669.87,percent of total billed charges,,,57.4,,626.23,percent of total billed charges,,,81,,883.71,percent of total billed charges,,,51.5,,561.87,percent of total billed charges,,365,,,,fee schedule,,,85,,927.35,percent of total billed charges,,,85,,927.35,percent of total billed charges,,,49,,534.59,percent of total billed charges,,,90,,981.9,percent of total billed charges,,,65,,709.15,percent of total billed charges,,,80,,872.8,percent of total billed charges,,,55,,600.05,percent of total billed charges,,,55,,600.05,percent of total billed charges,,,65,,709.15,percent of total billed charges,,,78,,850.98,percent of total billed charges,,,70,,763.7,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,981.9,
XR Foreign Body Loc Nose/Rectum Child,76010,CPT,,,,both,,,391,234.6,,45.5,,177.91,percent of total billed charges,,,45.3,,177.12,percent of total billed charges,,,51,,199.41,percent of total billed charges,,,,,,,,,80,,312.8,percent of total billed charges,,,61.4,,240.07,percent of total billed charges,,,57.4,,224.43,percent of total billed charges,,,81,,316.71,percent of total billed charges,,,51.5,,201.37,percent of total billed charges,,365,,,,fee schedule,,,85,,332.35,percent of total billed charges,,,85,,332.35,percent of total billed charges,,,49,,191.59,percent of total billed charges,,,90,,351.9,percent of total billed charges,,,65,,254.15,percent of total billed charges,,,80,,312.8,percent of total billed charges,,,55,,215.05,percent of total billed charges,,,55,,215.05,percent of total billed charges,,,65,,254.15,percent of total billed charges,,,78,,304.98,percent of total billed charges,,,70,,273.7,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,365,
XR Abdomen AP + Lateral,76499,CPT,,,,both,,,516,309.6,,45.5,,234.78,percent of total billed charges,,,45.3,,233.75,percent of total billed charges,,,51,,263.16,percent of total billed charges,,,,,,,,,80,,412.8,percent of total billed charges,,,61.4,,316.82,percent of total billed charges,,,57.4,,296.18,percent of total billed charges,,,81,,417.96,percent of total billed charges,,,51.5,,265.74,percent of total billed charges,,365,,,,fee schedule,,,85,,438.6,percent of total billed charges,,,85,,438.6,percent of total billed charges,,,49,,252.84,percent of total billed charges,,,90,,464.4,percent of total billed charges,,,65,,335.4,percent of total billed charges,,,80,,412.8,percent of total billed charges,,,55,,283.8,percent of total billed charges,,,55,,283.8,percent of total billed charges,,,65,,335.4,percent of total billed charges,,,78,,402.48,percent of total billed charges,,,70,,361.2,percent of total billed charges,,,,,,,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,91.79,,,,100% of Medicare,,,91.79,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.79,464.4,
US XTR NON-VASC COMPLETE (76881),76881,CPT,,,TC,outpatient,,,640,384,,45.5,,291.2,percent of total billed charges,,,45.3,,289.92,percent of total billed charges,,,51,,326.4,percent of total billed charges,,,,,,,,,80,,512,percent of total billed charges,,,61.4,,392.96,percent of total billed charges,,,57.4,,367.36,percent of total billed charges,,,81,,518.4,percent of total billed charges,,,51.5,,329.6,percent of total billed charges,,,57.6,,368.64,percent of total billed charges,,,85,,544,percent of total billed charges,,,85,,544,percent of total billed charges,,,49,,313.6,percent of total billed charges,,,90,,576,percent of total billed charges,,,65,,416,percent of total billed charges,,,80,,512,percent of total billed charges,,,55,,352,percent of total billed charges,,,55,,352,percent of total billed charges,,,65,,416,percent of total billed charges,,,78,,499.2,percent of total billed charges,,,70,,448,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,576,
US XTR NON-VASC LMTD (76882),76882,CPT,,,,outpatient,,,437,262.2,,45.5,,198.84,percent of total billed charges,,,45.3,,197.96,percent of total billed charges,,,51,,222.87,percent of total billed charges,,,,,,,,,80,,349.6,percent of total billed charges,,,61.4,,268.32,percent of total billed charges,,,57.4,,250.84,percent of total billed charges,,,81,,353.97,percent of total billed charges,,,51.5,,225.06,percent of total billed charges,,,57.6,,251.71,percent of total billed charges,,,85,,371.45,percent of total billed charges,,,85,,371.45,percent of total billed charges,,,49,,214.13,percent of total billed charges,,,90,,393.3,percent of total billed charges,,,65,,284.05,percent of total billed charges,,,80,,349.6,percent of total billed charges,,,55,,240.35,percent of total billed charges,,,55,,240.35,percent of total billed charges,,,65,,284.05,percent of total billed charges,,,78,,340.86,percent of total billed charges,,,70,,305.9,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,393.3,
Ultrasonic Guidance for Injection Charge (76942),76942,CPT,,,TC,outpatient,,,1076,645.6,,45.5,,489.58,percent of total billed charges,,,45.3,,487.43,percent of total billed charges,,,51,,548.76,percent of total billed charges,,,,,,,,,80,,860.8,percent of total billed charges,,,61.4,,660.66,percent of total billed charges,,,57.4,,617.62,percent of total billed charges,,,81,,871.56,percent of total billed charges,,,51.5,,554.14,percent of total billed charges,,,57.6,,619.78,percent of total billed charges,,,85,,914.6,percent of total billed charges,,,85,,914.6,percent of total billed charges,,,49,,527.24,percent of total billed charges,,,90,,968.4,percent of total billed charges,,,65,,699.4,percent of total billed charges,,,80,,860.8,percent of total billed charges,,,55,,591.8,percent of total billed charges,,,55,,591.8,percent of total billed charges,,,65,,699.4,percent of total billed charges,,,78,,839.28,percent of total billed charges,,,70,,753.2,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,487.43,968.4,
CC ONLY - Ultrasonic Guidance for Injection Charge (76942),76942,CPT,,,,outpatient,,,1076,645.6,,45.5,,489.58,percent of total billed charges,,,45.3,,487.43,percent of total billed charges,,,51,,548.76,percent of total billed charges,,,,,,,,,80,,860.8,percent of total billed charges,,,61.4,,660.66,percent of total billed charges,,,57.4,,617.62,percent of total billed charges,,,81,,871.56,percent of total billed charges,,,51.5,,554.14,percent of total billed charges,,,57.6,,619.78,percent of total billed charges,,,85,,914.6,percent of total billed charges,,,85,,914.6,percent of total billed charges,,,49,,527.24,percent of total billed charges,,,90,,968.4,percent of total billed charges,,,65,,699.4,percent of total billed charges,,,80,,860.8,percent of total billed charges,,,55,,591.8,percent of total billed charges,,,55,,591.8,percent of total billed charges,,,65,,699.4,percent of total billed charges,,,78,,839.28,percent of total billed charges,,,70,,753.2,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,487.43,968.4,
Fluoroscopic Guidance- Needle Localization (77002),77002,CPT,,,TC,outpatient,,,1322,793.2,,45.5,,601.51,percent of total billed charges,,,45.3,,598.87,percent of total billed charges,,,51,,674.22,percent of total billed charges,,,,,,,,,80,,1057.6,percent of total billed charges,,,61.4,,811.71,percent of total billed charges,,,57.4,,758.83,percent of total billed charges,,,81,,1070.82,percent of total billed charges,,,51.5,,680.83,percent of total billed charges,,,57.6,,761.47,percent of total billed charges,,,85,,1123.7,percent of total billed charges,,,85,,1123.7,percent of total billed charges,,,49,,647.78,percent of total billed charges,,,90,,1189.8,percent of total billed charges,,,65,,859.3,percent of total billed charges,,,80,,1057.6,percent of total billed charges,,,55,,727.1,percent of total billed charges,,,55,,727.1,percent of total billed charges,,,65,,859.3,percent of total billed charges,,,78,,1031.16,percent of total billed charges,,,70,,925.4,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,598.87,1189.8,
Fluoroscopic Guidance- Spine (77003),77003,CPT,,,TC,outpatient,,,1245,747,,45.5,,566.48,percent of total billed charges,,,45.3,,563.99,percent of total billed charges,,,51,,634.95,percent of total billed charges,,,,,,,,,80,,996,percent of total billed charges,,,61.4,,764.43,percent of total billed charges,,,57.4,,714.63,percent of total billed charges,,,81,,1008.45,percent of total billed charges,,,51.5,,641.18,percent of total billed charges,,,57.6,,717.12,percent of total billed charges,,,85,,1058.25,percent of total billed charges,,,85,,1058.25,percent of total billed charges,,,49,,610.05,percent of total billed charges,,,90,,1120.5,percent of total billed charges,,,65,,809.25,percent of total billed charges,,,80,,996,percent of total billed charges,,,55,,684.75,percent of total billed charges,,,55,,684.75,percent of total billed charges,,,65,,809.25,percent of total billed charges,,,78,,971.1,percent of total billed charges,,,70,,871.5,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,563.99,1120.5,
XR Bone Age Studies,77072,CPT,,,,both,,,242,145.2,,45.5,,110.11,percent of total billed charges,,,45.3,,109.63,percent of total billed charges,,,51,,123.42,percent of total billed charges,,,,,,,,,80,,193.6,percent of total billed charges,,,61.4,,148.59,percent of total billed charges,,,57.4,,138.91,percent of total billed charges,,,81,,196.02,percent of total billed charges,,,51.5,,124.63,percent of total billed charges,,365,,,,fee schedule,,,85,,205.7,percent of total billed charges,,,85,,205.7,percent of total billed charges,,,49,,118.58,percent of total billed charges,,,90,,217.8,percent of total billed charges,,,65,,157.3,percent of total billed charges,,,80,,193.6,percent of total billed charges,,,55,,133.1,percent of total billed charges,,,55,,133.1,percent of total billed charges,,,65,,157.3,percent of total billed charges,,,78,,188.76,percent of total billed charges,,,70,,169.4,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,109.63,365,
XR Bone Length Studies,77073,CPT,,,,both,,,586,351.6,,45.5,,266.63,percent of total billed charges,,,45.3,,265.46,percent of total billed charges,,,51,,298.86,percent of total billed charges,,,,,,,,,80,,468.8,percent of total billed charges,,,61.4,,359.8,percent of total billed charges,,,57.4,,336.36,percent of total billed charges,,,81,,474.66,percent of total billed charges,,,51.5,,301.79,percent of total billed charges,,365,,,,fee schedule,,,85,,498.1,percent of total billed charges,,,85,,498.1,percent of total billed charges,,,49,,287.14,percent of total billed charges,,,90,,527.4,percent of total billed charges,,,65,,380.9,percent of total billed charges,,,80,,468.8,percent of total billed charges,,,55,,322.3,percent of total billed charges,,,55,,322.3,percent of total billed charges,,,65,,380.9,percent of total billed charges,,,78,,457.08,percent of total billed charges,,,70,,410.2,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,527.4,
XR Bone Survey Limited (Mets) H.O.,77074,CPT,,,,both,,,720,432,,45.5,,327.6,percent of total billed charges,,,45.3,,326.16,percent of total billed charges,,,51,,367.2,percent of total billed charges,,,,,,,,,80,,576,percent of total billed charges,,,61.4,,442.08,percent of total billed charges,,,57.4,,413.28,percent of total billed charges,,,81,,583.2,percent of total billed charges,,,51.5,,370.8,percent of total billed charges,,365,,,,fee schedule,,,85,,612,percent of total billed charges,,,85,,612,percent of total billed charges,,,49,,352.8,percent of total billed charges,,,90,,648,percent of total billed charges,,,65,,468,percent of total billed charges,,,80,,576,percent of total billed charges,,,55,,396,percent of total billed charges,,,55,,396,percent of total billed charges,,,65,,468,percent of total billed charges,,,78,,561.6,percent of total billed charges,,,70,,504,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,648,
XR Bone Survey Complete (Mets),77075,CPT,,,,both,,,1209,725.4,,45.5,,550.1,percent of total billed charges,,,45.3,,547.68,percent of total billed charges,,,51,,616.59,percent of total billed charges,,,,,,,,,80,,967.2,percent of total billed charges,,,61.4,,742.33,percent of total billed charges,,,57.4,,693.97,percent of total billed charges,,,81,,979.29,percent of total billed charges,,,51.5,,622.64,percent of total billed charges,,365,,,,fee schedule,,,85,,1027.65,percent of total billed charges,,,85,,1027.65,percent of total billed charges,,,49,,592.41,percent of total billed charges,,,90,,1088.1,percent of total billed charges,,,65,,785.85,percent of total billed charges,,,80,,967.2,percent of total billed charges,,,55,,664.95,percent of total billed charges,,,55,,664.95,percent of total billed charges,,,65,,785.85,percent of total billed charges,,,78,,943.02,percent of total billed charges,,,70,,846.3,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,1088.1,
XR Bone Survey Infant,77076,CPT,,,,both,,,390,234,,45.5,,177.45,percent of total billed charges,,,45.3,,176.67,percent of total billed charges,,,51,,198.9,percent of total billed charges,,,,,,,,,80,,312,percent of total billed charges,,,61.4,,239.46,percent of total billed charges,,,57.4,,223.86,percent of total billed charges,,,81,,315.9,percent of total billed charges,,,51.5,,200.85,percent of total billed charges,,365,,,,fee schedule,,,85,,331.5,percent of total billed charges,,,85,,331.5,percent of total billed charges,,,49,,191.1,percent of total billed charges,,,90,,351,percent of total billed charges,,,65,,253.5,percent of total billed charges,,,80,,312,percent of total billed charges,,,55,,214.5,percent of total billed charges,,,55,,214.5,percent of total billed charges,,,65,,253.5,percent of total billed charges,,,78,,304.2,percent of total billed charges,,,70,,273,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,365,
XR Joint Survey Single View,77077,CPT,,,,both,,,572,343.2,,45.5,,260.26,percent of total billed charges,,,45.3,,259.12,percent of total billed charges,,,51,,291.72,percent of total billed charges,,,,,,,,,80,,457.6,percent of total billed charges,,,61.4,,351.21,percent of total billed charges,,,57.4,,328.33,percent of total billed charges,,,81,,463.32,percent of total billed charges,,,51.5,,294.58,percent of total billed charges,,365,,,,fee schedule,,,85,,486.2,percent of total billed charges,,,85,,486.2,percent of total billed charges,,,49,,280.28,percent of total billed charges,,,90,,514.8,percent of total billed charges,,,65,,371.8,percent of total billed charges,,,80,,457.6,percent of total billed charges,,,55,,314.6,percent of total billed charges,,,55,,314.6,percent of total billed charges,,,65,,371.8,percent of total billed charges,,,78,,446.16,percent of total billed charges,,,70,,400.4,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,514.8,
XR Multiple Joints 1 View Bilateral Hands,77077,CPT,,,,both,,,572,343.2,,45.5,,260.26,percent of total billed charges,,,45.3,,259.12,percent of total billed charges,,,51,,291.72,percent of total billed charges,,,,,,,,,80,,457.6,percent of total billed charges,,,61.4,,351.21,percent of total billed charges,,,57.4,,328.33,percent of total billed charges,,,81,,463.32,percent of total billed charges,,,51.5,,294.58,percent of total billed charges,,365,,,,fee schedule,,,85,,486.2,percent of total billed charges,,,85,,486.2,percent of total billed charges,,,49,,280.28,percent of total billed charges,,,90,,514.8,percent of total billed charges,,,65,,371.8,percent of total billed charges,,,80,,457.6,percent of total billed charges,,,55,,314.6,percent of total billed charges,,,55,,314.6,percent of total billed charges,,,65,,371.8,percent of total billed charges,,,78,,446.16,percent of total billed charges,,,70,,400.4,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,514.8,
XR Multiple Joints 1 View Infant Lower Extremity,77077,CPT,,,,both,,,572,343.2,,45.5,,260.26,percent of total billed charges,,,45.3,,259.12,percent of total billed charges,,,51,,291.72,percent of total billed charges,,,,,,,,,80,,457.6,percent of total billed charges,,,61.4,,351.21,percent of total billed charges,,,57.4,,328.33,percent of total billed charges,,,81,,463.32,percent of total billed charges,,,51.5,,294.58,percent of total billed charges,,365,,,,fee schedule,,,85,,486.2,percent of total billed charges,,,85,,486.2,percent of total billed charges,,,49,,280.28,percent of total billed charges,,,90,,514.8,percent of total billed charges,,,65,,371.8,percent of total billed charges,,,80,,457.6,percent of total billed charges,,,55,,314.6,percent of total billed charges,,,55,,314.6,percent of total billed charges,,,65,,371.8,percent of total billed charges,,,78,,446.16,percent of total billed charges,,,70,,400.4,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,514.8,
BD Bone Density DEXA Axial Skeleton,77080,CPT,,,,both,,,797,478.2,,45.5,,362.64,percent of total billed charges,,,45.3,,361.04,percent of total billed charges,,,51,,406.47,percent of total billed charges,,,,,,,,,80,,637.6,percent of total billed charges,,,61.4,,489.36,percent of total billed charges,,,57.4,,457.48,percent of total billed charges,,,81,,645.57,percent of total billed charges,,,51.5,,410.46,percent of total billed charges,,,57.6,,459.07,percent of total billed charges,,,85,,677.45,percent of total billed charges,,,85,,677.45,percent of total billed charges,,,49,,390.53,percent of total billed charges,,,90,,717.3,percent of total billed charges,,,65,,518.05,percent of total billed charges,,,80,,637.6,percent of total billed charges,,,55,,438.35,percent of total billed charges,,,55,,438.35,percent of total billed charges,,,65,,518.05,percent of total billed charges,,,78,,621.66,percent of total billed charges,,,70,,557.9,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,36085.14769,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,36085.15,
"Basic Chemistry Panel, Calcium, total",80048,CPT,,,,both,,,374,224.4,,45.5,,170.17,percent of total billed charges,,,45.3,,169.42,percent of total billed charges,,11.38,,,,fee schedule,164% of fee schedule,,,,,,,,80,,299.2,percent of total billed charges,,,61.4,,229.64,percent of total billed charges,,,57.4,,214.68,percent of total billed charges,,,81,,302.94,percent of total billed charges,,10.97,,,,fee schedule,158% of fee schedule,,57.6,,215.42,percent of total billed charges,,,85,,317.9,percent of total billed charges,,,85,,317.9,percent of total billed charges,,,49,,183.26,percent of total billed charges,,,90,,336.6,percent of total billed charges,,,65,,243.1,percent of total billed charges,,,80,,299.2,percent of total billed charges,,,55,,205.7,percent of total billed charges,,,55,,205.7,percent of total billed charges,,,65,,243.1,percent of total billed charges,,,78,,291.72,percent of total billed charges,,,70,,261.8,percent of total billed charges,,,,,,,,8.46,,,,100% of Medicare,,8.46,,,,100% of Medicare,,8.46,,,,100% of Medicare,,8.46,,,,100% of Medicare,,8.46,,,,100% of Medicare,,8.46,,,45884.94,100% of Medicare,,8.46,,,,100% of Medicare,,8.46,,,,100% of Medicare,,8.46,,,,100% of Medicare,,8.46,,,,100% of Medicare,,8.46,,,,100% of Medicare,,8.46,,,,100% of Medicare,,,8.46,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,8.46,45884.94,
Electrolyte Panel,80051,CPT,,,,both,,,224,134.4,,45.5,,101.92,percent of total billed charges,,,45.3,,101.47,percent of total billed charges,,11.38,,,,fee schedule,164% of fee schedule,,,,,,,,80,,179.2,percent of total billed charges,,,61.4,,137.54,percent of total billed charges,,,57.4,,128.58,percent of total billed charges,,,81,,181.44,percent of total billed charges,,9.09,,,,fee schedule,158% of fee schedule,,57.6,,129.02,percent of total billed charges,,,85,,190.4,percent of total billed charges,,,85,,190.4,percent of total billed charges,,,49,,109.76,percent of total billed charges,,,90,,201.6,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,80,,179.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,78,,174.72,percent of total billed charges,,,70,,156.8,percent of total billed charges,,,,,,,,7.01,,,,100% of Medicare,,7.01,,,,100% of Medicare,,7.01,,,,100% of Medicare,,7.01,,,,100% of Medicare,,7.01,,,,100% of Medicare,,7.01,,,,100% of Medicare,,7.01,,,,100% of Medicare,,7.01,,,,100% of Medicare,,7.01,,,,100% of Medicare,,7.01,,,,100% of Medicare,,7.01,,,,100% of Medicare,,7.01,,,,100% of Medicare,,,7.01,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,7.01,201.6,
Fecal Lytes/pH/Osmo Timed Collection,80051,CPT,,,,both,,,224,134.4,,45.5,,101.92,percent of total billed charges,,,45.3,,101.47,percent of total billed charges,,9.43,,,,fee schedule,164% of fee schedule,,,,,,,,80,,179.2,percent of total billed charges,,,61.4,,137.54,percent of total billed charges,,,57.4,,128.58,percent of total billed charges,,,81,,181.44,percent of total billed charges,,9.09,,,,fee schedule,158% of fee schedule,,57.6,,129.02,percent of total billed charges,,,85,,190.4,percent of total billed charges,,,85,,190.4,percent of total billed charges,,,49,,109.76,percent of total billed charges,,,90,,201.6,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,80,,179.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,78,,174.72,percent of total billed charges,,,70,,156.8,percent of total billed charges,,,,,,,,7.01,,,,100% of Medicare,,7.01,,,,100% of Medicare,,7.01,,,,100% of Medicare,,7.01,,,,100% of Medicare,,7.01,,,,100% of Medicare,,7.01,,,,100% of Medicare,,7.01,,,,100% of Medicare,,7.01,,,,100% of Medicare,,7.01,,,,100% of Medicare,,7.01,,,,100% of Medicare,,7.01,,,,100% of Medicare,,7.01,,,,100% of Medicare,,,7.01,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,7.01,201.6,
Comprehensive Metabolic Panel,80053,CPT,,,,both,,,416,249.6,,45.5,,189.28,percent of total billed charges,,,45.3,,188.45,percent of total billed charges,,9.43,,,,fee schedule,164% of fee schedule,,,,,,,,80,,332.8,percent of total billed charges,,,61.4,,255.42,percent of total billed charges,,,57.4,,238.78,percent of total billed charges,,,81,,336.96,percent of total billed charges,,13.68,,,,fee schedule,158% of fee schedule,,57.6,,239.62,percent of total billed charges,,,85,,353.6,percent of total billed charges,,,85,,353.6,percent of total billed charges,,,49,,203.84,percent of total billed charges,,,90,,374.4,percent of total billed charges,,,65,,270.4,percent of total billed charges,,,80,,332.8,percent of total billed charges,,,55,,228.8,percent of total billed charges,,,55,,228.8,percent of total billed charges,,,65,,270.4,percent of total billed charges,,,78,,324.48,percent of total billed charges,,,70,,291.2,percent of total billed charges,,,,,,,,10.56,,,,100% of Medicare,,10.56,,,,100% of Medicare,,10.56,,,,100% of Medicare,,10.56,,,,100% of Medicare,,10.56,,,,100% of Medicare,,10.56,,,,100% of Medicare,,10.56,,,,100% of Medicare,,10.56,,,,100% of Medicare,,10.56,,,,100% of Medicare,,10.56,,,,100% of Medicare,,10.56,,,,100% of Medicare,,10.56,,,,100% of Medicare,,,10.56,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,9.43,374.4,
Coronary Risk/Lipid Panel,80061,CPT,,,,both,,,236,141.6,,45.5,,107.38,percent of total billed charges,,,45.3,,106.91,percent of total billed charges,,14.2,,,,fee schedule,164% of fee schedule,,,,,,,,80,,188.8,percent of total billed charges,,,61.4,,144.9,percent of total billed charges,,,57.4,,135.46,percent of total billed charges,,,81,,191.16,percent of total billed charges,,17.35,,,,fee schedule,158% of fee schedule,,57.6,,135.94,percent of total billed charges,,,85,,200.6,percent of total billed charges,,,85,,200.6,percent of total billed charges,,,49,,115.64,percent of total billed charges,,,90,,212.4,percent of total billed charges,,,65,,153.4,percent of total billed charges,,,80,,188.8,percent of total billed charges,,,55,,129.8,percent of total billed charges,,,55,,129.8,percent of total billed charges,,,65,,153.4,percent of total billed charges,,,78,,184.08,percent of total billed charges,,,70,,165.2,percent of total billed charges,,,,,,,,13.39,,,,100% of Medicare,,13.39,,,,100% of Medicare,,13.39,,,,100% of Medicare,,13.39,,,,100% of Medicare,,13.39,,,,100% of Medicare,,13.39,,,,100% of Medicare,,13.39,,,,100% of Medicare,,13.39,,,,100% of Medicare,,13.39,,,,100% of Medicare,,13.39,,,,100% of Medicare,,13.39,,,,100% of Medicare,,13.39,,,,100% of Medicare,,,13.39,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,13.39,212.4,
Kidney Chemistry Panel,80069,CPT,,,,both,,,337,202.2,,45.5,,153.34,percent of total billed charges,,,45.3,,152.66,percent of total billed charges,,18.01,,,,fee schedule,164% of fee schedule,,,,,,,,80,,269.6,percent of total billed charges,,,61.4,,206.92,percent of total billed charges,,,57.4,,193.44,percent of total billed charges,,,81,,272.97,percent of total billed charges,,11.25,,,,fee schedule,158% of fee schedule,,57.6,,194.11,percent of total billed charges,,,85,,286.45,percent of total billed charges,,,85,,286.45,percent of total billed charges,,,49,,165.13,percent of total billed charges,,,90,,303.3,percent of total billed charges,,,65,,219.05,percent of total billed charges,,,80,,269.6,percent of total billed charges,,,55,,185.35,percent of total billed charges,,,55,,185.35,percent of total billed charges,,,65,,219.05,percent of total billed charges,,,78,,262.86,percent of total billed charges,,,70,,235.9,percent of total billed charges,,,,,,,,8.68,,,,100% of Medicare,,8.68,,,,100% of Medicare,,8.68,,,,100% of Medicare,,8.68,,,,100% of Medicare,,8.68,,,,100% of Medicare,,8.68,,,,100% of Medicare,,8.68,,,,100% of Medicare,,8.68,,,,100% of Medicare,,8.68,,,,100% of Medicare,,8.68,,,,100% of Medicare,,8.68,,,,100% of Medicare,,8.68,,,,100% of Medicare,,,8.68,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,8.68,303.3,
Acute Hepatitis Panel,80074,CPT,,,,both,,,539,323.4,,45.5,,245.25,percent of total billed charges,,,45.3,,244.17,percent of total billed charges,,11.68,,,,fee schedule,164% of fee schedule,,,,,,,,80,,431.2,percent of total billed charges,,,61.4,,330.95,percent of total billed charges,,,57.4,,309.39,percent of total billed charges,,,81,,436.59,percent of total billed charges,,61.71,,,,fee schedule,158% of fee schedule,,57.6,,310.46,percent of total billed charges,,,85,,458.15,percent of total billed charges,,,85,,458.15,percent of total billed charges,,,49,,264.11,percent of total billed charges,,,90,,485.1,percent of total billed charges,,,65,,350.35,percent of total billed charges,,,80,,431.2,percent of total billed charges,,,55,,296.45,percent of total billed charges,,,55,,296.45,percent of total billed charges,,,65,,350.35,percent of total billed charges,,,78,,420.42,percent of total billed charges,,,70,,377.3,percent of total billed charges,,,,,,,,47.63,,,,100% of Medicare,,47.63,,,,100% of Medicare,,47.63,,,,100% of Medicare,,47.63,,,,100% of Medicare,,47.63,,,,100% of Medicare,,47.63,,,,100% of Medicare,,47.63,,,,100% of Medicare,,47.63,,,,100% of Medicare,,47.63,,,,100% of Medicare,,47.63,,,,100% of Medicare,,47.63,,,,100% of Medicare,,47.63,,,,100% of Medicare,,,47.63,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,11.68,485.1,
HBV Quantitative PCR 8800,87517,CPT,,,,both,,,930,558,,45.5,,423.15,percent of total billed charges,,,45.3,,421.29,percent of total billed charges,,,39,,362.7,percent of total billed charges,,,,,,,,,80,,744,percent of total billed charges,,,61.4,,571.02,percent of total billed charges,,,57.4,,533.82,percent of total billed charges,,,81,,753.3,percent of total billed charges,,,39,,362.7,percent of total billed charges,,,57.6,,535.68,percent of total billed charges,,,85,,790.5,percent of total billed charges,,,85,,790.5,percent of total billed charges,,,49,,455.7,percent of total billed charges,,,90,,837,percent of total billed charges,,,65,,604.5,percent of total billed charges,,,80,,744,percent of total billed charges,,,55,,511.5,percent of total billed charges,,,55,,511.5,percent of total billed charges,,,65,,604.5,percent of total billed charges,,,78,,725.4,percent of total billed charges,,,70,,651,percent of total billed charges,,,,,,,,42.84,,,,100% of Medicare,,42.84,,,,100% of Medicare,,42.84,,,,100% of Medicare,,42.84,,,,100% of Medicare,,42.84,,,,100% of Medicare,,42.84,,,,100% of Medicare,,42.84,,,,100% of Medicare,,42.84,,,,100% of Medicare,,42.84,,,,100% of Medicare,,42.84,,,,100% of Medicare,,42.84,,,,100% of Medicare,,42.84,,,,100% of Medicare,,,42.84,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,42.84,837,
HCV Quantitative PCR 8800,87522,CPT,,,,both,,,1007,604.2,,45.5,,458.19,percent of total billed charges,,,45.3,,456.17,percent of total billed charges,,,39,,392.73,percent of total billed charges,,,,,,,,,80,,805.6,percent of total billed charges,,,61.4,,618.3,percent of total billed charges,,,57.4,,578.02,percent of total billed charges,,,81,,815.67,percent of total billed charges,,,39,,392.73,percent of total billed charges,,,57.6,,580.03,percent of total billed charges,,,85,,855.95,percent of total billed charges,,,85,,855.95,percent of total billed charges,,,49,,493.43,percent of total billed charges,,,90,,906.3,percent of total billed charges,,,65,,654.55,percent of total billed charges,,,80,,805.6,percent of total billed charges,,,55,,553.85,percent of total billed charges,,,55,,553.85,percent of total billed charges,,,65,,654.55,percent of total billed charges,,,78,,785.46,percent of total billed charges,,,70,,704.9,percent of total billed charges,,,,,,,,42.84,,,,100% of Medicare,,42.84,,,,100% of Medicare,,42.84,,,,100% of Medicare,,42.84,,,,100% of Medicare,,42.84,,,,100% of Medicare,,42.84,,,,100% of Medicare,,42.84,,,,100% of Medicare,,42.84,,,,100% of Medicare,,42.84,,,,100% of Medicare,,42.84,,,,100% of Medicare,,42.84,,,,100% of Medicare,,42.84,,,,100% of Medicare,,,42.84,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,42.84,906.3,
HIV-1 Quantitative PCR,87536,CPT,,,,both,,,337,202.2,,45.5,,153.34,percent of total billed charges,,,45.3,,152.66,percent of total billed charges,,,39,,131.43,percent of total billed charges,,,,,,,,,80,,269.6,percent of total billed charges,,,61.4,,206.92,percent of total billed charges,,,57.4,,193.44,percent of total billed charges,,,81,,272.97,percent of total billed charges,,,39,,131.43,percent of total billed charges,,,57.6,,194.11,percent of total billed charges,,,85,,286.45,percent of total billed charges,,,85,,286.45,percent of total billed charges,,,49,,165.13,percent of total billed charges,,,90,,303.3,percent of total billed charges,,,65,,219.05,percent of total billed charges,,,80,,269.6,percent of total billed charges,,,55,,185.35,percent of total billed charges,,,55,,185.35,percent of total billed charges,,,65,,219.05,percent of total billed charges,,,78,,262.86,percent of total billed charges,,,70,,235.9,percent of total billed charges,,,,,,,,85.1,,,,100% of Medicare,,85.1,,,,100% of Medicare,,85.1,,,,100% of Medicare,,85.1,,,,100% of Medicare,,85.1,,,,100% of Medicare,,85.1,,,,100% of Medicare,,85.1,,,,100% of Medicare,,85.1,,,,100% of Medicare,,85.1,,,,100% of Medicare,,85.1,,,,100% of Medicare,,85.1,,,,100% of Medicare,,85.1,,,,100% of Medicare,,,85.1,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,85.1,303.3,
OT Biofeedback Units,90901,CPT,,,GO,both,,,176,105.6,,45.5,,80.08,percent of total billed charges,,,45.3,,79.73,percent of total billed charges,,,51,,89.76,percent of total billed charges,,,,,,,,,80,,140.8,percent of total billed charges,,,61.4,,108.06,percent of total billed charges,,,57.4,,101.02,percent of total billed charges,,,81,,142.56,percent of total billed charges,,,51.5,,90.64,percent of total billed charges,,,57.6,,101.38,percent of total billed charges,,,85,,149.6,percent of total billed charges,,,85,,149.6,percent of total billed charges,,,49,,86.24,percent of total billed charges,,,90,,158.4,percent of total billed charges,,,65,,114.4,percent of total billed charges,,,80,,140.8,percent of total billed charges,,,55,,96.8,percent of total billed charges,,,55,,96.8,percent of total billed charges,,,65,,114.4,percent of total billed charges,,,78,,137.28,percent of total billed charges,,,70,,123.2,percent of total billed charges,,,,,,,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,,19.29,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,19.29,158.4,
PT Biofeedback Units,90901,CPT,,,GP,both,,,176,105.6,,45.5,,80.08,percent of total billed charges,,,45.3,,79.73,percent of total billed charges,,,51,,89.76,percent of total billed charges,,,,,,,,,80,,140.8,percent of total billed charges,,,61.4,,108.06,percent of total billed charges,,,57.4,,101.02,percent of total billed charges,,,81,,142.56,percent of total billed charges,,,51.5,,90.64,percent of total billed charges,,,57.6,,101.38,percent of total billed charges,,,85,,149.6,percent of total billed charges,,,85,,149.6,percent of total billed charges,,,49,,86.24,percent of total billed charges,,,90,,158.4,percent of total billed charges,,,65,,114.4,percent of total billed charges,,,80,,140.8,percent of total billed charges,,,55,,96.8,percent of total billed charges,,,55,,96.8,percent of total billed charges,,,65,,114.4,percent of total billed charges,,,78,,137.28,percent of total billed charges,,,70,,123.2,percent of total billed charges,,,,,,,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,,19.29,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,19.29,158.4,
Biofeedback Training,90901,CPT,,,,both,,,224,134.4,,45.5,,101.92,percent of total billed charges,,,45.3,,101.47,percent of total billed charges,,,51,,114.24,percent of total billed charges,,,,,,,,,80,,179.2,percent of total billed charges,,,61.4,,137.54,percent of total billed charges,,,57.4,,128.58,percent of total billed charges,,,81,,181.44,percent of total billed charges,,,51.5,,115.36,percent of total billed charges,,,57.6,,129.02,percent of total billed charges,,,85,,190.4,percent of total billed charges,,,85,,190.4,percent of total billed charges,,,49,,109.76,percent of total billed charges,,,90,,201.6,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,80,,179.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,55,,123.2,percent of total billed charges,,,65,,145.6,percent of total billed charges,,,78,,174.72,percent of total billed charges,,,70,,156.8,percent of total billed charges,,,,,,,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,19.29,,,,100% of Medicare,,,19.29,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,19.29,201.6,
OT BioF/Peri/Urethral/Rectal Units,90912,CPT,,,GO,both,,,180,108,,45.5,,81.9,percent of total billed charges,,,45.3,,81.54,percent of total billed charges,,,51,,91.8,percent of total billed charges,,,,,,,,,80,,144,percent of total billed charges,,,61.4,,110.52,percent of total billed charges,,,57.4,,103.32,percent of total billed charges,,,81,,145.8,percent of total billed charges,,,51.5,,92.7,percent of total billed charges,,,57.6,,103.68,percent of total billed charges,,,85,,153,percent of total billed charges,,,85,,153,percent of total billed charges,,,49,,88.2,percent of total billed charges,,,90,,162,percent of total billed charges,,,65,,117,percent of total billed charges,,,80,,144,percent of total billed charges,,,55,,99,percent of total billed charges,,,55,,99,percent of total billed charges,,,65,,117,percent of total billed charges,,,78,,140.4,percent of total billed charges,,,70,,126,percent of total billed charges,,,,,,,,42.52,,,,100% of Medicare,,42.52,,,,100% of Medicare,,42.52,,,,100% of Medicare,,42.52,,,,100% of Medicare,,42.52,,,,100% of Medicare,,42.52,,,,100% of Medicare,,42.52,,,,100% of Medicare,,42.52,,,,100% of Medicare,,42.52,,,,100% of Medicare,,42.52,,,,100% of Medicare,,42.52,,,,100% of Medicare,,42.52,,,,100% of Medicare,,,42.52,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,42.52,162,
PT BioF/Peri/Urethral/Rectal Units,90912,CPT,,,GP,both,,,180,108,,45.5,,81.9,percent of total billed charges,,,45.3,,81.54,percent of total billed charges,,,51,,91.8,percent of total billed charges,,,,,,,,,80,,144,percent of total billed charges,,,61.4,,110.52,percent of total billed charges,,,57.4,,103.32,percent of total billed charges,,,81,,145.8,percent of total billed charges,,,51.5,,92.7,percent of total billed charges,,,57.6,,103.68,percent of total billed charges,,,85,,153,percent of total billed charges,,,85,,153,percent of total billed charges,,,49,,88.2,percent of total billed charges,,,90,,162,percent of total billed charges,,,65,,117,percent of total billed charges,,,80,,144,percent of total billed charges,,,55,,99,percent of total billed charges,,,55,,99,percent of total billed charges,,,65,,117,percent of total billed charges,,,78,,140.4,percent of total billed charges,,,70,,126,percent of total billed charges,,,,,,,,42.52,,,,100% of Medicare,,42.52,,,,100% of Medicare,,42.52,,,,100% of Medicare,,42.52,,,,100% of Medicare,,42.52,,,,100% of Medicare,,42.52,,,,100% of Medicare,,42.52,,,,100% of Medicare,,42.52,,,,100% of Medicare,,42.52,,,,100% of Medicare,,42.52,,,,100% of Medicare,,42.52,,,,100% of Medicare,,42.52,,,,100% of Medicare,,,42.52,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,42.52,162,
OT BioF/Peri/Ureth/Rect addl 15min Units,90913,CPT,,,GO,both,,,121,72.6,,45.5,,55.06,percent of total billed charges,,,45.3,,54.81,percent of total billed charges,,,51,,61.71,percent of total billed charges,,,,,,,,,80,,96.8,percent of total billed charges,,,61.4,,74.29,percent of total billed charges,,,57.4,,69.45,percent of total billed charges,,,81,,98.01,percent of total billed charges,,,51.5,,62.32,percent of total billed charges,,,57.6,,69.7,percent of total billed charges,,,85,,102.85,percent of total billed charges,,,85,,102.85,percent of total billed charges,,,49,,59.29,percent of total billed charges,,,90,,108.9,percent of total billed charges,,,65,,78.65,percent of total billed charges,,,80,,96.8,percent of total billed charges,,,55,,66.55,percent of total billed charges,,,55,,66.55,percent of total billed charges,,,65,,78.65,percent of total billed charges,,,78,,94.38,percent of total billed charges,,,70,,84.7,percent of total billed charges,,,,,,,,24.2,,,,100% of Medicare,,24.2,,,,100% of Medicare,,24.2,,,,100% of Medicare,,24.2,,,,100% of Medicare,,24.2,,,,100% of Medicare,,24.2,,,,100% of Medicare,,24.2,,,,100% of Medicare,,24.2,,,,100% of Medicare,,24.2,,,,100% of Medicare,,24.2,,,,100% of Medicare,,24.2,,,,100% of Medicare,,24.2,,,,100% of Medicare,,,24.2,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,24.2,108.9,
PT BioF/Peri/Ureth/Rect addl 15min Units,90913,CPT,,,GP,both,,,121,72.6,,45.5,,55.06,percent of total billed charges,,,45.3,,54.81,percent of total billed charges,,,51,,61.71,percent of total billed charges,,,,,,,,,80,,96.8,percent of total billed charges,,,61.4,,74.29,percent of total billed charges,,,57.4,,69.45,percent of total billed charges,,,81,,98.01,percent of total billed charges,,,51.5,,62.32,percent of total billed charges,,,57.6,,69.7,percent of total billed charges,,,85,,102.85,percent of total billed charges,,,85,,102.85,percent of total billed charges,,,49,,59.29,percent of total billed charges,,,90,,108.9,percent of total billed charges,,,65,,78.65,percent of total billed charges,,,80,,96.8,percent of total billed charges,,,55,,66.55,percent of total billed charges,,,55,,66.55,percent of total billed charges,,,65,,78.65,percent of total billed charges,,,78,,94.38,percent of total billed charges,,,70,,84.7,percent of total billed charges,,,,,,,,24.2,,,,100% of Medicare,,24.2,,,,100% of Medicare,,24.2,,,,100% of Medicare,,24.2,,,,100% of Medicare,,24.2,,,,100% of Medicare,,24.2,,,,100% of Medicare,,24.2,,,,100% of Medicare,,24.2,,,,100% of Medicare,,24.2,,,,100% of Medicare,,24.2,,,,100% of Medicare,,24.2,,,,100% of Medicare,,24.2,,,,100% of Medicare,,,24.2,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,24.2,108.9,
Rectal Sensation Test (91120),91120,CPT,,,,outpatient,,,894,536.4,,45.5,,406.77,percent of total billed charges,,,45.3,,404.98,percent of total billed charges,,,51,,455.94,percent of total billed charges,,,,,,,,,80,,715.2,percent of total billed charges,,,61.4,,548.92,percent of total billed charges,,,57.4,,513.16,percent of total billed charges,,,81,,724.14,percent of total billed charges,,,51.5,,460.41,percent of total billed charges,,,57.6,,514.94,percent of total billed charges,,,85,,759.9,percent of total billed charges,,,85,,759.9,percent of total billed charges,,,49,,438.06,percent of total billed charges,,,90,,804.6,percent of total billed charges,,,65,,581.1,percent of total billed charges,,,80,,715.2,percent of total billed charges,,,55,,491.7,percent of total billed charges,,,55,,491.7,percent of total billed charges,,,65,,581.1,percent of total billed charges,,,78,,697.32,percent of total billed charges,,,70,,625.8,percent of total billed charges,,,,,,,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,,324.61,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,324.61,804.6,
Anorectal manometry (91122),91122,CPT,,,TC,outpatient,,,1219,731.4,,45.5,,554.65,percent of total billed charges,,,45.3,,552.21,percent of total billed charges,,,51,,621.69,percent of total billed charges,,,,,,,,,80,,975.2,percent of total billed charges,,,61.4,,748.47,percent of total billed charges,,,57.4,,699.71,percent of total billed charges,,,81,,987.39,percent of total billed charges,,,51.5,,627.79,percent of total billed charges,,,57.6,,702.14,percent of total billed charges,,,85,,1036.15,percent of total billed charges,,,85,,1036.15,percent of total billed charges,,,49,,597.31,percent of total billed charges,,,90,,1097.1,percent of total billed charges,,,65,,792.35,percent of total billed charges,,,80,,975.2,percent of total billed charges,,,55,,670.45,percent of total billed charges,,,55,,670.45,percent of total billed charges,,,65,,792.35,percent of total billed charges,,,78,,950.82,percent of total billed charges,,,70,,853.3,percent of total billed charges,,,,,,,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,,324.61,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,324.61,1097.1,
CD Treatment Speech Language Voice Communication Auditory Processing,92507,CPT,,,GN,both,,,161,96.6,,45.5,,73.26,percent of total billed charges,,,45.3,,72.93,percent of total billed charges,,227.4,,,,fee schedule,353% of fee schedule,,,,,,,,80,,128.8,percent of total billed charges,,,61.4,,98.85,percent of total billed charges,,,57.4,,92.41,percent of total billed charges,,,81,,130.41,percent of total billed charges,,218.38,,,,fee schedule,339% of fee schedule,427.44,,,,fee schedule,,,85,,136.85,percent of total billed charges,,,85,,136.85,percent of total billed charges,,,49,,78.89,percent of total billed charges,,,90,,144.9,percent of total billed charges,,,65,,104.65,percent of total billed charges,,,80,,128.8,percent of total billed charges,,,55,,88.55,percent of total billed charges,,,55,,88.55,percent of total billed charges,,,65,,104.65,percent of total billed charges,,,78,,125.58,percent of total billed charges,,,70,,112.7,percent of total billed charges,,,,,,,,77.06,,,,100% of Medicare,,77.06,,,,100% of Medicare,,77.06,,,,100% of Medicare,,77.06,,,,100% of Medicare,,77.06,,,,100% of Medicare,,77.06,,,,100% of Medicare,,77.06,,,,100% of Medicare,,77.06,,,,100% of Medicare,,77.06,,,,100% of Medicare,,77.06,,,,100% of Medicare,,77.06,,,,100% of Medicare,,77.06,,,,100% of Medicare,,,77.06,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,72.93,427.44,
SLP Auditory Processing Treatment Units,92507,CPT,,,GN,both,,,161,96.6,,45.5,,73.26,percent of total billed charges,,,45.3,,72.93,percent of total billed charges,,227.4,,,,fee schedule,353% of fee schedule,,,,,,,,80,,128.8,percent of total billed charges,,,61.4,,98.85,percent of total billed charges,,,57.4,,92.41,percent of total billed charges,,,81,,130.41,percent of total billed charges,,218.38,,,,fee schedule,339% of fee schedule,427.44,,,,fee schedule,,,85,,136.85,percent of total billed charges,,,85,,136.85,percent of total billed charges,,,49,,78.89,percent of total billed charges,,,90,,144.9,percent of total billed charges,,,65,,104.65,percent of total billed charges,,,80,,128.8,percent of total billed charges,,,55,,88.55,percent of total billed charges,,,55,,88.55,percent of total billed charges,,,65,,104.65,percent of total billed charges,,,78,,125.58,percent of total billed charges,,,70,,112.7,percent of total billed charges,,,,,,,,77.06,,,,100% of Medicare,,77.06,,,,100% of Medicare,,77.06,,,,100% of Medicare,,77.06,,,,100% of Medicare,,77.06,,,,100% of Medicare,,77.06,,,,100% of Medicare,,77.06,,,,100% of Medicare,,77.06,,,,100% of Medicare,,77.06,,,,100% of Medicare,,77.06,,,,100% of Medicare,,77.06,,,,100% of Medicare,,77.06,,,,100% of Medicare,,,77.06,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,72.93,427.44,
SLP Class Units,92508,CPT,,,GN,both,,,102,61.2,,45.5,,46.41,percent of total billed charges,,,45.3,,46.21,percent of total billed charges,,69.82,,,,fee schedule,353% of fee schedule,,,,,,,,80,,81.6,percent of total billed charges,,,61.4,,62.63,percent of total billed charges,,,57.4,,58.55,percent of total billed charges,,,81,,82.62,percent of total billed charges,,67.05,,,,fee schedule,339% of fee schedule,427.44,,,,fee schedule,,,85,,86.7,percent of total billed charges,,,85,,86.7,percent of total billed charges,,,49,,49.98,percent of total billed charges,,,90,,91.8,percent of total billed charges,,,65,,66.3,percent of total billed charges,,,80,,81.6,percent of total billed charges,,,55,,56.1,percent of total billed charges,,,55,,56.1,percent of total billed charges,,,65,,66.3,percent of total billed charges,,,78,,79.56,percent of total billed charges,,,70,,71.4,percent of total billed charges,,,,,,,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,,24.31,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,24.31,427.44,
SLP Double Therapy Units,92508,CPT,,,GN,both,,,102,61.2,,45.5,,46.41,percent of total billed charges,,,45.3,,46.21,percent of total billed charges,,69.82,,,,fee schedule,353% of fee schedule,,,,,,,,80,,81.6,percent of total billed charges,,,61.4,,62.63,percent of total billed charges,,,57.4,,58.55,percent of total billed charges,,,81,,82.62,percent of total billed charges,,67.05,,,,fee schedule,339% of fee schedule,427.44,,,,fee schedule,,,85,,86.7,percent of total billed charges,,,85,,86.7,percent of total billed charges,,,49,,49.98,percent of total billed charges,,,90,,91.8,percent of total billed charges,,,65,,66.3,percent of total billed charges,,,80,,81.6,percent of total billed charges,,,55,,56.1,percent of total billed charges,,,55,,56.1,percent of total billed charges,,,65,,66.3,percent of total billed charges,,,78,,79.56,percent of total billed charges,,,70,,71.4,percent of total billed charges,,,,,,,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,,24.31,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,24.31,427.44,
SLP Group Therapy Units,92508,CPT,,,GN,both,,,102,61.2,,45.5,,46.41,percent of total billed charges,,,45.3,,46.21,percent of total billed charges,,69.82,,,,fee schedule,353% of fee schedule,,,,,,,,80,,81.6,percent of total billed charges,,,61.4,,62.63,percent of total billed charges,,,57.4,,58.55,percent of total billed charges,,,81,,82.62,percent of total billed charges,,67.05,,,,fee schedule,339% of fee schedule,427.44,,,,fee schedule,,,85,,86.7,percent of total billed charges,,,85,,86.7,percent of total billed charges,,,49,,49.98,percent of total billed charges,,,90,,91.8,percent of total billed charges,,,65,,66.3,percent of total billed charges,,,80,,81.6,percent of total billed charges,,,55,,56.1,percent of total billed charges,,,55,,56.1,percent of total billed charges,,,65,,66.3,percent of total billed charges,,,78,,79.56,percent of total billed charges,,,70,,71.4,percent of total billed charges,,,,,,,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,24.31,,,,100% of Medicare,,,24.31,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,24.31,427.44,
Evaluation of Speech Fluency Units,92521,CPT,,,GN,both,,,218,130.8,,45.5,,99.19,percent of total billed charges,,,45.3,,98.75,percent of total billed charges,,398.29,,,,fee schedule,353% of fee schedule,,,,,,,,80,,174.4,percent of total billed charges,,,61.4,,133.85,percent of total billed charges,,,57.4,,125.13,percent of total billed charges,,,81,,176.58,percent of total billed charges,,382.49,,,,fee schedule,339% of fee schedule,427.44,,,,fee schedule,,,85,,185.3,percent of total billed charges,,,85,,185.3,percent of total billed charges,,,49,,106.82,percent of total billed charges,,,90,,196.2,percent of total billed charges,,,65,,141.7,percent of total billed charges,,,80,,174.4,percent of total billed charges,,,55,,119.9,percent of total billed charges,,,55,,119.9,percent of total billed charges,,,65,,141.7,percent of total billed charges,,,78,,170.04,percent of total billed charges,,,70,,152.6,percent of total billed charges,,,,,,,,134.14,,,,100% of Medicare,,134.14,,,,100% of Medicare,,134.14,,,,100% of Medicare,,134.14,,,,100% of Medicare,,134.14,,,,100% of Medicare,,134.14,,,,100% of Medicare,,134.14,,,,100% of Medicare,,134.14,,,,100% of Medicare,,134.14,,,,100% of Medicare,,134.14,,,,100% of Medicare,,134.14,,,,100% of Medicare,,134.14,,,,100% of Medicare,,,134.14,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,98.75,427.44,
Evaluation of Speech Sound Production Units,92522,CPT,,,GN,both,,,272,163.2,,45.5,,123.76,percent of total billed charges,,,45.3,,123.22,percent of total billed charges,,335.1,,,,fee schedule,353% of fee schedule,,,,,,,,80,,217.6,percent of total billed charges,,,61.4,,167.01,percent of total billed charges,,,57.4,,156.13,percent of total billed charges,,,81,,220.32,percent of total billed charges,,321.81,,,,fee schedule,339% of fee schedule,427.44,,,,fee schedule,,,85,,231.2,percent of total billed charges,,,85,,231.2,percent of total billed charges,,,49,,133.28,percent of total billed charges,,,90,,244.8,percent of total billed charges,,,65,,176.8,percent of total billed charges,,,80,,217.6,percent of total billed charges,,,55,,149.6,percent of total billed charges,,,55,,149.6,percent of total billed charges,,,65,,176.8,percent of total billed charges,,,78,,212.16,percent of total billed charges,,,70,,190.4,percent of total billed charges,,,,,,,,112.12,,,,100% of Medicare,,112.12,,,,100% of Medicare,,112.12,,,,100% of Medicare,,112.12,,,,100% of Medicare,,112.12,,,,100% of Medicare,,112.12,,,,100% of Medicare,,112.12,,,,100% of Medicare,,112.12,,,,100% of Medicare,,112.12,,,,100% of Medicare,,112.12,,,,100% of Medicare,,112.12,,,,100% of Medicare,,112.12,,,,100% of Medicare,,,112.12,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,112.12,427.44,
Evaluation of Language Comprehension and Expression Units,92523,CPT,,,GN,both,,,253,151.8,,45.5,,115.12,percent of total billed charges,,,45.3,,114.61,percent of total billed charges,,684.43,,,,fee schedule,353% of fee schedule,,,,,,,,80,,202.4,percent of total billed charges,,,61.4,,155.34,percent of total billed charges,,,57.4,,145.22,percent of total billed charges,,,81,,204.93,percent of total billed charges,,657.29,,,,fee schedule,339% of fee schedule,427.44,,,,fee schedule,,,85,,215.05,percent of total billed charges,,,85,,215.05,percent of total billed charges,,,49,,123.97,percent of total billed charges,,,90,,227.7,percent of total billed charges,,,65,,164.45,percent of total billed charges,,,80,,202.4,percent of total billed charges,,,55,,139.15,percent of total billed charges,,,55,,139.15,percent of total billed charges,,,65,,164.45,percent of total billed charges,,,78,,197.34,percent of total billed charges,,,70,,177.1,percent of total billed charges,,,,,,,,229.89,,,,100% of Medicare,,229.89,,,,100% of Medicare,,229.89,,,,100% of Medicare,,229.89,,,,100% of Medicare,,229.89,,,,100% of Medicare,,229.89,,,,100% of Medicare,,229.89,,,,100% of Medicare,,229.89,,,,100% of Medicare,,229.89,,,,100% of Medicare,,229.89,,,,100% of Medicare,,229.89,,,,100% of Medicare,,229.89,,,,100% of Medicare,,,229.89,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,114.61,684.43,
Evaluation of Speech Sound Production w/ Evaluation of Language Comprehension and Expression Units,92523,CPT,,,GN,both,,,253,151.8,,45.5,,115.12,percent of total billed charges,,,45.3,,114.61,percent of total billed charges,,684.43,,,,fee schedule,353% of fee schedule,,,,,,,,80,,202.4,percent of total billed charges,,,61.4,,155.34,percent of total billed charges,,,57.4,,145.22,percent of total billed charges,,,81,,204.93,percent of total billed charges,,657.29,,,,fee schedule,339% of fee schedule,427.44,,,,fee schedule,,,85,,215.05,percent of total billed charges,,,85,,215.05,percent of total billed charges,,,49,,123.97,percent of total billed charges,,,90,,227.7,percent of total billed charges,,,65,,164.45,percent of total billed charges,,,80,,202.4,percent of total billed charges,,,55,,139.15,percent of total billed charges,,,55,,139.15,percent of total billed charges,,,65,,164.45,percent of total billed charges,,,78,,197.34,percent of total billed charges,,,70,,177.1,percent of total billed charges,,,,,,,,229.89,,,,100% of Medicare,,229.89,,,,100% of Medicare,,229.89,,,,100% of Medicare,,229.89,,,,100% of Medicare,,229.89,,,,100% of Medicare,,229.89,,,,100% of Medicare,,229.89,,,,100% of Medicare,,229.89,,,,100% of Medicare,,229.89,,,,100% of Medicare,,229.89,,,,100% of Medicare,,229.89,,,,100% of Medicare,,229.89,,,,100% of Medicare,,,229.89,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,114.61,684.43,
Behavioral and Qualitative Analysis of Voice and Resonance Units,92524,CPT,,,GN,both,,,213,127.8,,45.5,,96.92,percent of total billed charges,,,45.3,,96.49,percent of total billed charges,,327.16,,,,fee schedule,353% of fee schedule,,,,,,,,80,,170.4,percent of total billed charges,,,61.4,,130.78,percent of total billed charges,,,57.4,,122.26,percent of total billed charges,,,81,,172.53,percent of total billed charges,,314.19,,,,fee schedule,339% of fee schedule,427.44,,,,fee schedule,,,85,,181.05,percent of total billed charges,,,85,,181.05,percent of total billed charges,,,49,,104.37,percent of total billed charges,,,90,,191.7,percent of total billed charges,,,65,,138.45,percent of total billed charges,,,80,,170.4,percent of total billed charges,,,55,,117.15,percent of total billed charges,,,55,,117.15,percent of total billed charges,,,65,,138.45,percent of total billed charges,,,78,,166.14,percent of total billed charges,,,70,,149.1,percent of total billed charges,,,,,,,,109.81,,,,100% of Medicare,,109.81,,,,100% of Medicare,,109.81,,,,100% of Medicare,,109.81,,,,100% of Medicare,,109.81,,,,100% of Medicare,,109.81,,,33297.1,100% of Medicare,,109.81,,,,100% of Medicare,,109.81,,,,100% of Medicare,,109.81,,,,100% of Medicare,,109.81,,,,100% of Medicare,,109.81,,,,100% of Medicare,,109.81,,,,100% of Medicare,,,109.81,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,96.49,33297.1,
SLP Swallow Dysfnction Oral Feed Tx Unit,92526,CPT,,,GN,both,,,213,127.8,,45.5,,96.92,percent of total billed charges,,,45.3,,96.49,percent of total billed charges,,,51,,108.63,percent of total billed charges,,,,,,,,,80,,170.4,percent of total billed charges,,,61.4,,130.78,percent of total billed charges,,,57.4,,122.26,percent of total billed charges,,,81,,172.53,percent of total billed charges,,,51.5,,109.7,percent of total billed charges,,427.44,,,,fee schedule,,,85,,181.05,percent of total billed charges,,,85,,181.05,percent of total billed charges,,,49,,104.37,percent of total billed charges,,,90,,191.7,percent of total billed charges,,,65,,138.45,percent of total billed charges,,,80,,170.4,percent of total billed charges,,,55,,117.15,percent of total billed charges,,,55,,117.15,percent of total billed charges,,,65,,138.45,percent of total billed charges,,,78,,166.14,percent of total billed charges,,,70,,149.1,percent of total billed charges,,,,,,,,84.98,,,,100% of Medicare,,84.98,,,,100% of Medicare,,84.98,,,,100% of Medicare,,84.98,,,,100% of Medicare,,84.98,,,,100% of Medicare,,84.98,,,,100% of Medicare,,84.98,,,,100% of Medicare,,84.98,,,,100% of Medicare,,84.98,,,,100% of Medicare,,84.98,,,,100% of Medicare,,84.98,,,,100% of Medicare,,84.98,,,,100% of Medicare,,,84.98,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,84.98,427.44,
"SLP Screening Test, Pure Tone, Air Units",92551,CPT,,,GN,both,,,177,106.2,,45.5,,80.54,percent of total billed charges,,,45.3,,80.18,percent of total billed charges,,,51,,90.27,percent of total billed charges,,,,,,,,,80,,141.6,percent of total billed charges,,,61.4,,108.68,percent of total billed charges,,,57.4,,101.6,percent of total billed charges,,,81,,143.37,percent of total billed charges,,,51.5,,91.16,percent of total billed charges,,427.44,,,,fee schedule,,,85,,150.45,percent of total billed charges,,,85,,150.45,percent of total billed charges,,,49,,86.73,percent of total billed charges,,,90,,159.3,percent of total billed charges,,,65,,115.05,percent of total billed charges,,,80,,141.6,percent of total billed charges,,,55,,97.35,percent of total billed charges,,,55,,97.35,percent of total billed charges,,,65,,115.05,percent of total billed charges,,,78,,138.06,percent of total billed charges,,,70,,123.9,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,80.18,427.44,
SLP Use/Fit Speech Prosthetic Eval Units,92597,CPT,,,GN,both,,,129,77.4,,45.5,,58.7,percent of total billed charges,,,45.3,,58.44,percent of total billed charges,,,51,,65.79,percent of total billed charges,,,,,,,,,80,,103.2,percent of total billed charges,,,61.4,,79.21,percent of total billed charges,,,57.4,,74.05,percent of total billed charges,,,81,,104.49,percent of total billed charges,,,51.5,,66.44,percent of total billed charges,,427.44,,,,fee schedule,,,85,,109.65,percent of total billed charges,,,85,,109.65,percent of total billed charges,,,49,,63.21,percent of total billed charges,,,90,,116.1,percent of total billed charges,,,65,,83.85,percent of total billed charges,,,80,,103.2,percent of total billed charges,,,55,,70.95,percent of total billed charges,,,55,,70.95,percent of total billed charges,,,65,,83.85,percent of total billed charges,,,78,,100.62,percent of total billed charges,,,70,,90.3,percent of total billed charges,,,,,,,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,,73.43,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,58.44,427.44,
Eval Use/Fitting Voice Prosthetic Units,92597,CPT,,,,both,,,129,77.4,,45.5,,58.7,percent of total billed charges,,,45.3,,58.44,percent of total billed charges,,,51,,65.79,percent of total billed charges,,,,,,,,,80,,103.2,percent of total billed charges,,,61.4,,79.21,percent of total billed charges,,,57.4,,74.05,percent of total billed charges,,,81,,104.49,percent of total billed charges,,,51.5,,66.44,percent of total billed charges,,427.44,,,,fee schedule,,,85,,109.65,percent of total billed charges,,,85,,109.65,percent of total billed charges,,,49,,63.21,percent of total billed charges,,,90,,116.1,percent of total billed charges,,,65,,83.85,percent of total billed charges,,,80,,103.2,percent of total billed charges,,,55,,70.95,percent of total billed charges,,,55,,70.95,percent of total billed charges,,,65,,83.85,percent of total billed charges,,,78,,100.62,percent of total billed charges,,,70,,90.3,percent of total billed charges,,,,,,,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,,73.43,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,58.44,427.44,
Eval Use/Fitting Voice Prosthetic Units,92597,CPT,,,,both,,,129,77.4,,45.5,,58.7,percent of total billed charges,,,45.3,,58.44,percent of total billed charges,,,51,,65.79,percent of total billed charges,,,,,,,,,80,,103.2,percent of total billed charges,,,61.4,,79.21,percent of total billed charges,,,57.4,,74.05,percent of total billed charges,,,81,,104.49,percent of total billed charges,,,51.5,,66.44,percent of total billed charges,,427.44,,,,fee schedule,,,85,,109.65,percent of total billed charges,,,85,,109.65,percent of total billed charges,,,49,,63.21,percent of total billed charges,,,90,,116.1,percent of total billed charges,,,65,,83.85,percent of total billed charges,,,80,,103.2,percent of total billed charges,,,55,,70.95,percent of total billed charges,,,55,,70.95,percent of total billed charges,,,65,,83.85,percent of total billed charges,,,78,,100.62,percent of total billed charges,,,70,,90.3,percent of total billed charges,,,,,,,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,,73.43,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,58.44,427.44,
Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech,92597,CPT,,,,both,,,129,77.4,,45.5,,58.7,percent of total billed charges,,,45.3,,58.44,percent of total billed charges,,,51,,65.79,percent of total billed charges,,,,,,,,,80,,103.2,percent of total billed charges,,,61.4,,79.21,percent of total billed charges,,,57.4,,74.05,percent of total billed charges,,,81,,104.49,percent of total billed charges,,,51.5,,66.44,percent of total billed charges,,427.44,,,,fee schedule,,,85,,109.65,percent of total billed charges,,,85,,109.65,percent of total billed charges,,,49,,63.21,percent of total billed charges,,,90,,116.1,percent of total billed charges,,,65,,83.85,percent of total billed charges,,,80,,103.2,percent of total billed charges,,,55,,70.95,percent of total billed charges,,,55,,70.95,percent of total billed charges,,,65,,83.85,percent of total billed charges,,,78,,100.62,percent of total billed charges,,,70,,90.3,percent of total billed charges,,,,,,,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,73.43,,,,100% of Medicare,,,73.43,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,58.44,427.44,
SLP Non-Speech AAC Device Tx Units,92606,CPT,,,GN,both,,,151,90.6,,45.5,,68.71,percent of total billed charges,,,45.3,,68.4,percent of total billed charges,,,51,,77.01,percent of total billed charges,,,,,,,,,80,,120.8,percent of total billed charges,,,61.4,,92.71,percent of total billed charges,,,57.4,,86.67,percent of total billed charges,,,81,,122.31,percent of total billed charges,,,51.5,,77.77,percent of total billed charges,,427.44,,,,fee schedule,,,85,,128.35,percent of total billed charges,,,85,,128.35,percent of total billed charges,,,49,,73.99,percent of total billed charges,,,90,,135.9,percent of total billed charges,,,65,,98.15,percent of total billed charges,,,80,,120.8,percent of total billed charges,,,55,,83.05,percent of total billed charges,,,55,,83.05,percent of total billed charges,,,65,,98.15,percent of total billed charges,,,78,,117.78,percent of total billed charges,,,70,,105.7,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,68.4,427.44,
SLP Speech AAC Eval First Hour Units,92607,CPT,,,GN,both,,,589,353.4,,45.5,,268,percent of total billed charges,,,45.3,,266.82,percent of total billed charges,,,51,,300.39,percent of total billed charges,,,,,,,,,80,,471.2,percent of total billed charges,,,61.4,,361.65,percent of total billed charges,,,57.4,,338.09,percent of total billed charges,,,81,,477.09,percent of total billed charges,,,51.5,,303.34,percent of total billed charges,,427.44,,,,fee schedule,,,85,,500.65,percent of total billed charges,,,85,,500.65,percent of total billed charges,,,49,,288.61,percent of total billed charges,,,90,,530.1,percent of total billed charges,,,65,,382.85,percent of total billed charges,,,80,,471.2,percent of total billed charges,,,55,,323.95,percent of total billed charges,,,55,,323.95,percent of total billed charges,,,65,,382.85,percent of total billed charges,,,78,,459.42,percent of total billed charges,,,70,,412.3,percent of total billed charges,,,,,,,,124.09,,,,100% of Medicare,,124.09,,,,100% of Medicare,,124.09,,,,100% of Medicare,,124.09,,,,100% of Medicare,,124.09,,,,100% of Medicare,,124.09,,,,100% of Medicare,,124.09,,,,100% of Medicare,,124.09,,,,100% of Medicare,,124.09,,,,100% of Medicare,,124.09,,,,100% of Medicare,,124.09,,,,100% of Medicare,,124.09,,,,100% of Medicare,,,124.09,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,124.09,530.1,
SLP Speech AAC Eval addl ½ HR in units of 15 min,92608,CPT,,,,both,,,192,115.2,,45.5,,87.36,percent of total billed charges,,,45.3,,86.98,percent of total billed charges,,,51,,97.92,percent of total billed charges,,,,,,,,,80,,153.6,percent of total billed charges,,,61.4,,117.89,percent of total billed charges,,,57.4,,110.21,percent of total billed charges,,,81,,155.52,percent of total billed charges,,,51.5,,98.88,percent of total billed charges,,427.44,,,,fee schedule,,,85,,163.2,percent of total billed charges,,,85,,163.2,percent of total billed charges,,,49,,94.08,percent of total billed charges,,,90,,172.8,percent of total billed charges,,,65,,124.8,percent of total billed charges,,,80,,153.6,percent of total billed charges,,,55,,105.6,percent of total billed charges,,,55,,105.6,percent of total billed charges,,,65,,124.8,percent of total billed charges,,,78,,149.76,percent of total billed charges,,,70,,134.4,percent of total billed charges,,,,,,,,48.92,,,,100% of Medicare,,48.92,,,,100% of Medicare,,48.92,,,,100% of Medicare,,48.92,,,,100% of Medicare,,48.92,,,,100% of Medicare,,48.92,,,,100% of Medicare,,48.92,,,,100% of Medicare,,48.92,,,,100% of Medicare,,48.92,,,,100% of Medicare,,48.92,,,,100% of Medicare,,48.92,,,,100% of Medicare,,48.92,,,,100% of Medicare,,,48.92,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,48.92,427.44,
SLP Speech AAC Eval Addl 1/2 Hour Units,92608,CPT,,,GN,both,,,383,229.8,,45.5,,174.27,percent of total billed charges,,,45.3,,173.5,percent of total billed charges,,,51,,195.33,percent of total billed charges,,,,,,,,,80,,306.4,percent of total billed charges,,,61.4,,235.16,percent of total billed charges,,,57.4,,219.84,percent of total billed charges,,,81,,310.23,percent of total billed charges,,,51.5,,197.25,percent of total billed charges,,427.44,,,,fee schedule,,,85,,325.55,percent of total billed charges,,,85,,325.55,percent of total billed charges,,,49,,187.67,percent of total billed charges,,,90,,344.7,percent of total billed charges,,,65,,248.95,percent of total billed charges,,,80,,306.4,percent of total billed charges,,,55,,210.65,percent of total billed charges,,,55,,210.65,percent of total billed charges,,,65,,248.95,percent of total billed charges,,,78,,298.74,percent of total billed charges,,,70,,268.1,percent of total billed charges,,,,,,,,48.92,,,,100% of Medicare,,48.92,,,,100% of Medicare,,48.92,,,,100% of Medicare,,48.92,,,,100% of Medicare,,48.92,,,,100% of Medicare,,48.92,,,,100% of Medicare,,48.92,,,,100% of Medicare,,48.92,,,,100% of Medicare,,48.92,,,,100% of Medicare,,48.92,,,,100% of Medicare,,48.92,,,,100% of Medicare,,48.92,,,,100% of Medicare,,,48.92,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,48.92,427.44,
SLP Treatment-Speech Gen Device Units,92609,CPT,,,GN,both,,,134,80.4,,45.5,,60.97,percent of total billed charges,,,45.3,,60.7,percent of total billed charges,,,51,,68.34,percent of total billed charges,,,,,,,,,80,,107.2,percent of total billed charges,,,61.4,,82.28,percent of total billed charges,,,57.4,,76.92,percent of total billed charges,,,81,,108.54,percent of total billed charges,,,51.5,,69.01,percent of total billed charges,,427.44,,,,fee schedule,,,85,,113.9,percent of total billed charges,,,85,,113.9,percent of total billed charges,,,49,,65.66,percent of total billed charges,,,90,,120.6,percent of total billed charges,,,65,,87.1,percent of total billed charges,,,80,,107.2,percent of total billed charges,,,55,,73.7,percent of total billed charges,,,55,,73.7,percent of total billed charges,,,65,,87.1,percent of total billed charges,,,78,,104.52,percent of total billed charges,,,70,,93.8,percent of total billed charges,,,,,,,,103.75,,,,100% of Medicare,,103.75,,,,100% of Medicare,,103.75,,,,100% of Medicare,,103.75,,,,100% of Medicare,,103.75,,,,100% of Medicare,,103.75,,,,100% of Medicare,,103.75,,,,100% of Medicare,,103.75,,,,100% of Medicare,,103.75,,,,100% of Medicare,,103.75,,,,100% of Medicare,,103.75,,,,100% of Medicare,,103.75,,,,100% of Medicare,,,103.75,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,60.7,427.44,
SLP Pharyngeal Swallow Fnctn Eval Units,92610,CPT,,,GN,both,,,267,160.2,,45.5,,121.49,percent of total billed charges,,,45.3,,120.95,percent of total billed charges,,,51,,136.17,percent of total billed charges,,,,,,,,,80,,213.6,percent of total billed charges,,,61.4,,163.94,percent of total billed charges,,,57.4,,153.26,percent of total billed charges,,,81,,216.27,percent of total billed charges,,,51.5,,137.51,percent of total billed charges,,427.44,,,,fee schedule,,,85,,226.95,percent of total billed charges,,,85,,226.95,percent of total billed charges,,,49,,130.83,percent of total billed charges,,,90,,240.3,percent of total billed charges,,,65,,173.55,percent of total billed charges,,,80,,213.6,percent of total billed charges,,,55,,146.85,percent of total billed charges,,,55,,146.85,percent of total billed charges,,,65,,173.55,percent of total billed charges,,,78,,208.26,percent of total billed charges,,,70,,186.9,percent of total billed charges,,,,,,,,71.1,,,,100% of Medicare,,71.1,,,,100% of Medicare,,71.1,,,,100% of Medicare,,71.1,,,,100% of Medicare,,71.1,,,,100% of Medicare,,71.1,,,,100% of Medicare,,71.1,,,,100% of Medicare,,71.1,,,,100% of Medicare,,71.1,,,,100% of Medicare,,71.1,,,,100% of Medicare,,71.1,,,,100% of Medicare,,71.1,,,,100% of Medicare,,,71.1,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,71.1,427.44,
SLP Fiber Optic Endo Swallow Eval Units,92612,CPT,,,GN,both,,,894,536.4,,45.5,,406.77,percent of total billed charges,,,45.3,,404.98,percent of total billed charges,,,51,,455.94,percent of total billed charges,,,,,,,,,80,,715.2,percent of total billed charges,,,61.4,,548.92,percent of total billed charges,,,57.4,,513.16,percent of total billed charges,,,81,,724.14,percent of total billed charges,,,51.5,,460.41,percent of total billed charges,,427.44,,,,fee schedule,,,85,,759.9,percent of total billed charges,,,85,,759.9,percent of total billed charges,,,49,,438.06,percent of total billed charges,,,90,,804.6,percent of total billed charges,,,65,,581.1,percent of total billed charges,,,80,,715.2,percent of total billed charges,,,55,,491.7,percent of total billed charges,,,55,,491.7,percent of total billed charges,,,65,,581.1,percent of total billed charges,,,78,,697.32,percent of total billed charges,,,70,,625.8,percent of total billed charges,,,,,,,,66.47,,,,100% of Medicare,,66.47,,,,100% of Medicare,,66.47,,,,100% of Medicare,,66.47,,,,100% of Medicare,,66.47,,,,100% of Medicare,,66.47,,,,100% of Medicare,,66.47,,,,100% of Medicare,,66.47,,,,100% of Medicare,,66.47,,,,100% of Medicare,,66.47,,,,100% of Medicare,,66.47,,,,100% of Medicare,,66.47,,,,100% of Medicare,,,66.47,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,66.47,804.6,
US Art Extracranial Duplex Scan B/L,93880,CPT,,,,both,,,1393,835.8,,45.5,,633.82,percent of total billed charges,,,45.3,,631.03,percent of total billed charges,,,51,,710.43,percent of total billed charges,,,,,,,,,80,,1114.4,percent of total billed charges,,,61.4,,855.3,percent of total billed charges,,,57.4,,799.58,percent of total billed charges,,,81,,1128.33,percent of total billed charges,,,51.5,,717.4,percent of total billed charges,,,57.6,,802.37,percent of total billed charges,,,85,,1184.05,percent of total billed charges,,,85,,1184.05,percent of total billed charges,,,49,,682.57,percent of total billed charges,,,90,,1253.7,percent of total billed charges,,,65,,905.45,percent of total billed charges,,,80,,1114.4,percent of total billed charges,,,55,,766.15,percent of total billed charges,,,55,,766.15,percent of total billed charges,,,65,,905.45,percent of total billed charges,,,78,,1086.54,percent of total billed charges,,,70,,975.1,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,251.97,1253.7,
US Arterial B/L Lwr Extrem Duplex Scan,93925,CPT,,,,both,,,1676,1005.6,,45.5,,762.58,percent of total billed charges,,,45.3,,759.23,percent of total billed charges,,,51,,854.76,percent of total billed charges,,,,,,,,,80,,1340.8,percent of total billed charges,,,61.4,,1029.06,percent of total billed charges,,,57.4,,962.02,percent of total billed charges,,,81,,1357.56,percent of total billed charges,,,51.5,,863.14,percent of total billed charges,,,57.6,,965.38,percent of total billed charges,,,85,,1424.6,percent of total billed charges,,,85,,1424.6,percent of total billed charges,,,49,,821.24,percent of total billed charges,,,90,,1508.4,percent of total billed charges,,,65,,1089.4,percent of total billed charges,,,80,,1340.8,percent of total billed charges,,,55,,921.8,percent of total billed charges,,,55,,921.8,percent of total billed charges,,,65,,1089.4,percent of total billed charges,,,78,,1307.28,percent of total billed charges,,,70,,1173.2,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,251.97,1508.4,
US Arterial U/L Lwr Extrem Duplex Scan,93926,CPT,,,,both,,,1151,690.6,,45.5,,523.71,percent of total billed charges,,,45.3,,521.4,percent of total billed charges,,,51,,587.01,percent of total billed charges,,,,,,,,,80,,920.8,percent of total billed charges,,,61.4,,706.71,percent of total billed charges,,,57.4,,660.67,percent of total billed charges,,,81,,932.31,percent of total billed charges,,,51.5,,592.77,percent of total billed charges,,,57.6,,662.98,percent of total billed charges,,,85,,978.35,percent of total billed charges,,,85,,978.35,percent of total billed charges,,,49,,563.99,percent of total billed charges,,,90,,1035.9,percent of total billed charges,,,65,,748.15,percent of total billed charges,,,80,,920.8,percent of total billed charges,,,55,,633.05,percent of total billed charges,,,55,,633.05,percent of total billed charges,,,65,,748.15,percent of total billed charges,,,78,,897.78,percent of total billed charges,,,70,,805.7,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,1035.9,
US Venous B/L Lwr Extrem Duplex Scan,93970,CPT,,,,both,,,1951,1170.6,,45.5,,887.71,percent of total billed charges,,,45.3,,883.8,percent of total billed charges,,,51,,995.01,percent of total billed charges,,,,,,,,,80,,1560.8,percent of total billed charges,,,61.4,,1197.91,percent of total billed charges,,,57.4,,1119.87,percent of total billed charges,,,81,,1580.31,percent of total billed charges,,,51.5,,1004.77,percent of total billed charges,,,57.6,,1123.78,percent of total billed charges,,,85,,1658.35,percent of total billed charges,,,85,,1658.35,percent of total billed charges,,,49,,955.99,percent of total billed charges,,,90,,1755.9,percent of total billed charges,,,65,,1268.15,percent of total billed charges,,,80,,1560.8,percent of total billed charges,,,55,,1073.05,percent of total billed charges,,,55,,1073.05,percent of total billed charges,,,65,,1268.15,percent of total billed charges,,,78,,1521.78,percent of total billed charges,,,70,,1365.7,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,251.97,1755.9,
US Venous B/L Upper Extrem Duplex Scan,93970,CPT,,,,both,,,1951,1170.6,,45.5,,887.71,percent of total billed charges,,,45.3,,883.8,percent of total billed charges,,,51,,995.01,percent of total billed charges,,,,,,,,,80,,1560.8,percent of total billed charges,,,61.4,,1197.91,percent of total billed charges,,,57.4,,1119.87,percent of total billed charges,,,81,,1580.31,percent of total billed charges,,,51.5,,1004.77,percent of total billed charges,,,57.6,,1123.78,percent of total billed charges,,,85,,1658.35,percent of total billed charges,,,85,,1658.35,percent of total billed charges,,,49,,955.99,percent of total billed charges,,,90,,1755.9,percent of total billed charges,,,65,,1268.15,percent of total billed charges,,,80,,1560.8,percent of total billed charges,,,55,,1073.05,percent of total billed charges,,,55,,1073.05,percent of total billed charges,,,65,,1268.15,percent of total billed charges,,,78,,1521.78,percent of total billed charges,,,70,,1365.7,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,251.97,1755.9,
US Venous U/L Lower Extrem Duplex Scan,93971,CPT,,,,both,,,1304,782.4,,45.5,,593.32,percent of total billed charges,,,45.3,,590.71,percent of total billed charges,,,51,,665.04,percent of total billed charges,,,,,,,,,80,,1043.2,percent of total billed charges,,,61.4,,800.66,percent of total billed charges,,,57.4,,748.5,percent of total billed charges,,,81,,1056.24,percent of total billed charges,,,51.5,,671.56,percent of total billed charges,,,57.6,,751.1,percent of total billed charges,,,85,,1108.4,percent of total billed charges,,,85,,1108.4,percent of total billed charges,,,49,,638.96,percent of total billed charges,,,90,,1173.6,percent of total billed charges,,,65,,847.6,percent of total billed charges,,,80,,1043.2,percent of total billed charges,,,55,,717.2,percent of total billed charges,,,55,,717.2,percent of total billed charges,,,65,,847.6,percent of total billed charges,,,78,,1017.12,percent of total billed charges,,,70,,912.8,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,1173.6,
US Venous U/L Upper Extrem Duplex Scan,93971,CPT,,,,both,,,1304,782.4,,45.5,,593.32,percent of total billed charges,,,45.3,,590.71,percent of total billed charges,,,51,,665.04,percent of total billed charges,,,,,,,,,80,,1043.2,percent of total billed charges,,,61.4,,800.66,percent of total billed charges,,,57.4,,748.5,percent of total billed charges,,,81,,1056.24,percent of total billed charges,,,51.5,,671.56,percent of total billed charges,,,57.6,,751.1,percent of total billed charges,,,85,,1108.4,percent of total billed charges,,,85,,1108.4,percent of total billed charges,,,49,,638.96,percent of total billed charges,,,90,,1173.6,percent of total billed charges,,,65,,847.6,percent of total billed charges,,,80,,1043.2,percent of total billed charges,,,55,,717.2,percent of total billed charges,,,55,,717.2,percent of total billed charges,,,65,,847.6,percent of total billed charges,,,78,,1017.12,percent of total billed charges,,,70,,912.8,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,1173.6,
US Complete Abdominal Duplex Scan,93978,CPT,,,,both,,,1217,730.2,,45.5,,553.74,percent of total billed charges,,,45.3,,551.3,percent of total billed charges,,,51,,620.67,percent of total billed charges,,,,,,,,,80,,973.6,percent of total billed charges,,,61.4,,747.24,percent of total billed charges,,,57.4,,698.56,percent of total billed charges,,,81,,985.77,percent of total billed charges,,,51.5,,626.76,percent of total billed charges,,,57.6,,700.99,percent of total billed charges,,,85,,1034.45,percent of total billed charges,,,85,,1034.45,percent of total billed charges,,,49,,596.33,percent of total billed charges,,,90,,1095.3,percent of total billed charges,,,65,,791.05,percent of total billed charges,,,80,,973.6,percent of total billed charges,,,55,,669.35,percent of total billed charges,,,55,,669.35,percent of total billed charges,,,65,,791.05,percent of total billed charges,,,78,,949.26,percent of total billed charges,,,70,,851.9,percent of total billed charges,,,,,,,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,251.97,,,,100% of Medicare,,,251.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,251.97,1095.3,
US Limited Abdominal Duplex Scan,93979,CPT,,,,both,,,745,447,,45.5,,338.98,percent of total billed charges,,,45.3,,337.49,percent of total billed charges,,,51,,379.95,percent of total billed charges,,,,,,,,,80,,596,percent of total billed charges,,,61.4,,457.43,percent of total billed charges,,,57.4,,427.63,percent of total billed charges,,,81,,603.45,percent of total billed charges,,,51.5,,383.68,percent of total billed charges,,,57.6,,429.12,percent of total billed charges,,,85,,633.25,percent of total billed charges,,,85,,633.25,percent of total billed charges,,,49,,365.05,percent of total billed charges,,,90,,670.5,percent of total billed charges,,,65,,484.25,percent of total billed charges,,,80,,596,percent of total billed charges,,,55,,409.75,percent of total billed charges,,,55,,409.75,percent of total billed charges,,,65,,484.25,percent of total billed charges,,,78,,581.1,percent of total billed charges,,,70,,521.5,percent of total billed charges,,,,,,,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,110.85,,,,100% of Medicare,,,110.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,110.85,670.5,
Bronchospasm- Pre & Post BD (94060),94060,CPT,,,TC,outpatient,,,582,349.2,,45.5,,264.81,percent of total billed charges,,,45.3,,263.65,percent of total billed charges,,,51,,296.82,percent of total billed charges,,,,,,,,,80,,465.6,percent of total billed charges,,,61.4,,357.35,percent of total billed charges,,,57.4,,334.07,percent of total billed charges,,,81,,471.42,percent of total billed charges,,,51.5,,299.73,percent of total billed charges,,,57.6,,335.23,percent of total billed charges,,,85,,494.7,percent of total billed charges,,,85,,494.7,percent of total billed charges,,,49,,285.18,percent of total billed charges,,,90,,523.8,percent of total billed charges,,,65,,378.3,percent of total billed charges,,,80,,465.6,percent of total billed charges,,,55,,320.1,percent of total billed charges,,,55,,320.1,percent of total billed charges,,,65,,378.3,percent of total billed charges,,,78,,453.96,percent of total billed charges,,,70,,407.4,percent of total billed charges,,,,,,,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,,324.61,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,263.65,523.8,
Spriometry with Bronchodilators,94060,CPT,,,,outpatient,,,747,448.2,,45.5,,339.89,percent of total billed charges,,,45.3,,338.39,percent of total billed charges,,,51,,380.97,percent of total billed charges,,,,,,,,,80,,597.6,percent of total billed charges,,,61.4,,458.66,percent of total billed charges,,,57.4,,428.78,percent of total billed charges,,,81,,605.07,percent of total billed charges,,,51.5,,384.71,percent of total billed charges,,,57.6,,430.27,percent of total billed charges,,,85,,634.95,percent of total billed charges,,,85,,634.95,percent of total billed charges,,,49,,366.03,percent of total billed charges,,,90,,672.3,percent of total billed charges,,,65,,485.55,percent of total billed charges,,,80,,597.6,percent of total billed charges,,,55,,410.85,percent of total billed charges,,,55,,410.85,percent of total billed charges,,,65,,485.55,percent of total billed charges,,,78,,582.66,percent of total billed charges,,,70,,522.9,percent of total billed charges,,,,,,,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,,324.61,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,324.61,672.3,
Pulmonary NIF,94150,CPT,,,,outpatient,,,310,186,,45.5,,141.05,percent of total billed charges,,,45.3,,140.43,percent of total billed charges,,,51,,158.1,percent of total billed charges,,,,,,,,,80,,248,percent of total billed charges,,,61.4,,190.34,percent of total billed charges,,,57.4,,177.94,percent of total billed charges,,,81,,251.1,percent of total billed charges,,,51.5,,159.65,percent of total billed charges,,,57.6,,178.56,percent of total billed charges,,,85,,263.5,percent of total billed charges,,,85,,263.5,percent of total billed charges,,,49,,151.9,percent of total billed charges,,,90,,279,percent of total billed charges,,,65,,201.5,percent of total billed charges,,,80,,248,percent of total billed charges,,,55,,170.5,percent of total billed charges,,,55,,170.5,percent of total billed charges,,,65,,201.5,percent of total billed charges,,,78,,241.8,percent of total billed charges,,,70,,217,percent of total billed charges,,,,,,,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,,163.1,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,140.43,279,
Vital Capacity Test Charge-94150,94150,CPT,,,,outpatient,,,310,186,,45.5,,141.05,percent of total billed charges,,,45.3,,140.43,percent of total billed charges,,,51,,158.1,percent of total billed charges,,,,,,,,,80,,248,percent of total billed charges,,,61.4,,190.34,percent of total billed charges,,,57.4,,177.94,percent of total billed charges,,,81,,251.1,percent of total billed charges,,,51.5,,159.65,percent of total billed charges,,,57.6,,178.56,percent of total billed charges,,,85,,263.5,percent of total billed charges,,,85,,263.5,percent of total billed charges,,,49,,151.9,percent of total billed charges,,,90,,279,percent of total billed charges,,,65,,201.5,percent of total billed charges,,,80,,248,percent of total billed charges,,,55,,170.5,percent of total billed charges,,,55,,170.5,percent of total billed charges,,,65,,201.5,percent of total billed charges,,,78,,241.8,percent of total billed charges,,,70,,217,percent of total billed charges,,,,,,,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,,163.1,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,140.43,279,
PHYS/QHP SVCS OP PULM REHAB WO CONT OXIMTRY MNTR,94625,CPT,,,,both,,,221,132.6,,45.5,,100.56,percent of total billed charges,,,45.3,,100.11,percent of total billed charges,,,51,,112.71,percent of total billed charges,,,,,,,,,80,,176.8,percent of total billed charges,,,61.4,,135.69,percent of total billed charges,,,57.4,,126.85,percent of total billed charges,,,81,,179.01,percent of total billed charges,,,51.5,,113.82,percent of total billed charges,,,57.6,,127.3,percent of total billed charges,,,85,,187.85,percent of total billed charges,,,85,,187.85,percent of total billed charges,,,49,,108.29,percent of total billed charges,,,90,,198.9,percent of total billed charges,,,65,,143.65,percent of total billed charges,,,80,,176.8,percent of total billed charges,,,55,,121.55,percent of total billed charges,,,55,,121.55,percent of total billed charges,,,65,,143.65,percent of total billed charges,,,78,,172.38,percent of total billed charges,,,70,,154.7,percent of total billed charges,,,,,,,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,,61.92,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,61.92,198.9,
OP PULM REHAB W/CONT OXIMTRY MNTR,94626,CPT,,,,both,,,243,145.8,,45.5,,110.57,percent of total billed charges,,,45.3,,110.08,percent of total billed charges,,,51,,123.93,percent of total billed charges,,,,,,,,,80,,194.4,percent of total billed charges,,,61.4,,149.2,percent of total billed charges,,,57.4,,139.48,percent of total billed charges,,,81,,196.83,percent of total billed charges,,,51.5,,125.15,percent of total billed charges,,,57.6,,139.97,percent of total billed charges,,,85,,206.55,percent of total billed charges,,,85,,206.55,percent of total billed charges,,,49,,119.07,percent of total billed charges,,,90,,218.7,percent of total billed charges,,,65,,157.95,percent of total billed charges,,,80,,194.4,percent of total billed charges,,,55,,133.65,percent of total billed charges,,,55,,133.65,percent of total billed charges,,,65,,157.95,percent of total billed charges,,,78,,189.54,percent of total billed charges,,,70,,170.1,percent of total billed charges,,,,,,,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,,61.92,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,61.92,218.7,
Exhaled air analysisO2 Charge-94680,94680,CPT,,,TC,outpatient,,,374,224.4,,45.5,,170.17,percent of total billed charges,,,45.3,,169.42,percent of total billed charges,,,51,,190.74,percent of total billed charges,,,,,,,,,80,,299.2,percent of total billed charges,,,61.4,,229.64,percent of total billed charges,,,57.4,,214.68,percent of total billed charges,,,81,,302.94,percent of total billed charges,,,51.5,,192.61,percent of total billed charges,,,57.6,,215.42,percent of total billed charges,,,85,,317.9,percent of total billed charges,,,85,,317.9,percent of total billed charges,,,49,,183.26,percent of total billed charges,,,90,,336.6,percent of total billed charges,,,65,,243.1,percent of total billed charges,,,80,,299.2,percent of total billed charges,,,55,,205.7,percent of total billed charges,,,55,,205.7,percent of total billed charges,,,65,,243.1,percent of total billed charges,,,78,,291.72,percent of total billed charges,,,70,,261.8,percent of total billed charges,,,,,,,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,,163.1,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,163.1,336.6,
Exhaled air analysisO2/CO2 Charge-94681,94681,CPT,,,TC,outpatient,,,629,377.4,,45.5,,286.2,percent of total billed charges,,,45.3,,284.94,percent of total billed charges,,,51,,320.79,percent of total billed charges,,,,,,,,,80,,503.2,percent of total billed charges,,,61.4,,386.21,percent of total billed charges,,,57.4,,361.05,percent of total billed charges,,,81,,509.49,percent of total billed charges,,,51.5,,323.94,percent of total billed charges,,,57.6,,362.3,percent of total billed charges,,,85,,534.65,percent of total billed charges,,,85,,534.65,percent of total billed charges,,,49,,308.21,percent of total billed charges,,,90,,566.1,percent of total billed charges,,,65,,408.85,percent of total billed charges,,,80,,503.2,percent of total billed charges,,,55,,345.95,percent of total billed charges,,,55,,345.95,percent of total billed charges,,,65,,408.85,percent of total billed charges,,,78,,490.62,percent of total billed charges,,,70,,440.3,percent of total billed charges,,,,,,,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,,324.61,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,284.94,566.1,
Exhaled air analysis Charge-94690,94690,CPT,,,,outpatient,,,231,138.6,,45.5,,105.11,percent of total billed charges,,,45.3,,104.64,percent of total billed charges,,,51,,117.81,percent of total billed charges,,,,,,,,,80,,184.8,percent of total billed charges,,,61.4,,141.83,percent of total billed charges,,,57.4,,132.59,percent of total billed charges,,,81,,187.11,percent of total billed charges,,,51.5,,118.97,percent of total billed charges,,,57.6,,133.06,percent of total billed charges,,,85,,196.35,percent of total billed charges,,,85,,196.35,percent of total billed charges,,,49,,113.19,percent of total billed charges,,,90,,207.9,percent of total billed charges,,,65,,150.15,percent of total billed charges,,,80,,184.8,percent of total billed charges,,,55,,127.05,percent of total billed charges,,,55,,127.05,percent of total billed charges,,,65,,150.15,percent of total billed charges,,,78,,180.18,percent of total billed charges,,,70,,161.7,percent of total billed charges,,,,,,,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,,61.92,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,61.92,207.9,
Exercise Oximetry,94761,CPT,,,,outpatient,,,367,220.2,,45.5,,166.99,percent of total billed charges,,,45.3,,166.25,percent of total billed charges,,,51,,187.17,percent of total billed charges,,,,,,,,,80,,293.6,percent of total billed charges,,,61.4,,225.34,percent of total billed charges,,,57.4,,210.66,percent of total billed charges,,,81,,297.27,percent of total billed charges,,,51.5,,189.01,percent of total billed charges,,,57.6,,211.39,percent of total billed charges,,,85,,311.95,percent of total billed charges,,,85,,311.95,percent of total billed charges,,,49,,179.83,percent of total billed charges,,,90,,330.3,percent of total billed charges,,,65,,238.55,percent of total billed charges,,,80,,293.6,percent of total billed charges,,,55,,201.85,percent of total billed charges,,,55,,201.85,percent of total billed charges,,,65,,238.55,percent of total billed charges,,,78,,286.26,percent of total billed charges,,,70,,256.9,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,166.25,330.3,
O2 Uptk Exp Gas Alys Rest Indir Spx Charge-95805,95805,CPT,,,,outpatient,,,2959,1775.4,,45.5,,1346.35,percent of total billed charges,,,45.3,,1340.43,percent of total billed charges,,,51,,1509.09,percent of total billed charges,,,,,,,,,80,,2367.2,percent of total billed charges,,,61.4,,1816.83,percent of total billed charges,,,57.4,,1698.47,percent of total billed charges,,,81,,2396.79,percent of total billed charges,,,51.5,,1523.89,percent of total billed charges,,,57.6,,1704.38,percent of total billed charges,,,85,,2515.15,percent of total billed charges,,,85,,2515.15,percent of total billed charges,,,49,,1449.91,percent of total billed charges,,,90,,2663.1,percent of total billed charges,,,65,,1923.35,percent of total billed charges,,,80,,2367.2,percent of total billed charges,,,55,,1627.45,percent of total billed charges,,,55,,1627.45,percent of total billed charges,,,65,,1923.35,percent of total billed charges,,,78,,2308.02,percent of total billed charges,,,70,,2071.3,percent of total billed charges,,,,,,,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,,553.11,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,553.11,2663.1,
"POLYSOMNOGRAPHY, 1-3 Charge-95808",95808,CPT,,,TC,outpatient,,,4602,2761.2,,45.5,,2093.91,percent of total billed charges,,,45.3,,2084.71,percent of total billed charges,,,51,,2347.02,percent of total billed charges,,,,,,,,,80,,3681.6,percent of total billed charges,,,61.4,,2825.63,percent of total billed charges,,,57.4,,2641.55,percent of total billed charges,,,81,,3727.62,percent of total billed charges,,,51.5,,2370.03,percent of total billed charges,,,57.6,,2650.75,percent of total billed charges,,,85,,3911.7,percent of total billed charges,,,85,,3911.7,percent of total billed charges,,,49,,2254.98,percent of total billed charges,,,90,,4141.8,percent of total billed charges,,,65,,2991.3,percent of total billed charges,,,80,,3681.6,percent of total billed charges,,,55,,2531.1,percent of total billed charges,,,55,,2531.1,percent of total billed charges,,,65,,2991.3,percent of total billed charges,,,78,,3589.56,percent of total billed charges,,,70,,3221.4,percent of total billed charges,,,,,,,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,,1060.55,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1060.55,4141.8,
"POLYSOMNOGRAPHY, 4 OR MORE Charge-95810",95810,CPT,,,TC,outpatient,,,4659,2795.4,,45.5,,2119.85,percent of total billed charges,,,45.3,,2110.53,percent of total billed charges,,,51,,2376.09,percent of total billed charges,,,,,,,,,80,,3727.2,percent of total billed charges,,,61.4,,2860.63,percent of total billed charges,,,57.4,,2674.27,percent of total billed charges,,,81,,3773.79,percent of total billed charges,,,51.5,,2399.39,percent of total billed charges,,,57.6,,2683.58,percent of total billed charges,,,85,,3960.15,percent of total billed charges,,,85,,3960.15,percent of total billed charges,,,49,,2282.91,percent of total billed charges,,,90,,4193.1,percent of total billed charges,,,65,,3028.35,percent of total billed charges,,,80,,3727.2,percent of total billed charges,,,55,,2562.45,percent of total billed charges,,,55,,2562.45,percent of total billed charges,,,65,,3028.35,percent of total billed charges,,,78,,3634.02,percent of total billed charges,,,70,,3261.3,percent of total billed charges,,,,,,,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,,1060.55,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1060.55,4193.1,
"POLYSOMNOGRAPHY, W/CPAP Charge-95811",95811,CPT,,,TC,outpatient,,,4558,2734.8,,45.5,,2073.89,percent of total billed charges,,,45.3,,2064.77,percent of total billed charges,,,51,,2324.58,percent of total billed charges,,,,,,,,,80,,3646.4,percent of total billed charges,,,61.4,,2798.61,percent of total billed charges,,,57.4,,2616.29,percent of total billed charges,,,81,,3691.98,percent of total billed charges,,,51.5,,2347.37,percent of total billed charges,,,57.6,,2625.41,percent of total billed charges,,,85,,3874.3,percent of total billed charges,,,85,,3874.3,percent of total billed charges,,,49,,2233.42,percent of total billed charges,,,90,,4102.2,percent of total billed charges,,,65,,2962.7,percent of total billed charges,,,80,,3646.4,percent of total billed charges,,,55,,2506.9,percent of total billed charges,,,55,,2506.9,percent of total billed charges,,,65,,2962.7,percent of total billed charges,,,78,,3555.24,percent of total billed charges,,,70,,3190.6,percent of total billed charges,,,,,,,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,1060.55,,,,100% of Medicare,,,1060.55,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1060.55,4102.2,
OT ROM/Extremity Units,95851,CPT,,,GO,both,,,268,160.8,,45.5,,121.94,percent of total billed charges,,,45.3,,121.4,percent of total billed charges,,,51,,136.68,percent of total billed charges,,,,,,,,,80,,214.4,percent of total billed charges,,,61.4,,164.55,percent of total billed charges,,,57.4,,153.83,percent of total billed charges,,,81,,217.08,percent of total billed charges,,,51.5,,138.02,percent of total billed charges,,,57.6,,154.37,percent of total billed charges,,,85,,227.8,percent of total billed charges,,,85,,227.8,percent of total billed charges,,,49,,131.32,percent of total billed charges,,,90,,241.2,percent of total billed charges,,,65,,174.2,percent of total billed charges,,,80,,214.4,percent of total billed charges,,,55,,147.4,percent of total billed charges,,,55,,147.4,percent of total billed charges,,,65,,174.2,percent of total billed charges,,,78,,209.04,percent of total billed charges,,,70,,187.6,percent of total billed charges,,,,,,,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,,7.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,7.85,241.2,
ROM Extr/Trunk Exclude Hands PT,95851,CPT,,,GP,both,,,268,160.8,,45.5,,121.94,percent of total billed charges,,,45.3,,121.4,percent of total billed charges,,,51,,136.68,percent of total billed charges,,,,,,,,,80,,214.4,percent of total billed charges,,,61.4,,164.55,percent of total billed charges,,,57.4,,153.83,percent of total billed charges,,,81,,217.08,percent of total billed charges,,,51.5,,138.02,percent of total billed charges,,,57.6,,154.37,percent of total billed charges,,,85,,227.8,percent of total billed charges,,,85,,227.8,percent of total billed charges,,,49,,131.32,percent of total billed charges,,,90,,241.2,percent of total billed charges,,,65,,174.2,percent of total billed charges,,,80,,214.4,percent of total billed charges,,,55,,147.4,percent of total billed charges,,,55,,147.4,percent of total billed charges,,,65,,174.2,percent of total billed charges,,,78,,209.04,percent of total billed charges,,,70,,187.6,percent of total billed charges,,,,,,,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,7.85,,,,100% of Medicare,,,7.85,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,7.85,241.2,
OT ROM/Hand Units,95852,CPT,,,GO,both,,,103,61.8,,45.5,,46.87,percent of total billed charges,,,45.3,,46.66,percent of total billed charges,,,51,,52.53,percent of total billed charges,,,,,,,,,80,,82.4,percent of total billed charges,,,61.4,,63.24,percent of total billed charges,,,57.4,,59.12,percent of total billed charges,,,81,,83.43,percent of total billed charges,,,51.5,,53.05,percent of total billed charges,,,57.6,,59.33,percent of total billed charges,,,85,,87.55,percent of total billed charges,,,85,,87.55,percent of total billed charges,,,49,,50.47,percent of total billed charges,,,90,,92.7,percent of total billed charges,,,65,,66.95,percent of total billed charges,,,80,,82.4,percent of total billed charges,,,55,,56.65,percent of total billed charges,,,55,,56.65,percent of total billed charges,,,65,,66.95,percent of total billed charges,,,78,,80.34,percent of total billed charges,,,70,,72.1,percent of total billed charges,,,,,,,,5.89,,,,100% of Medicare,,5.89,,,,100% of Medicare,,5.89,,,,100% of Medicare,,5.89,,,,100% of Medicare,,5.89,,,,100% of Medicare,,5.89,,,,100% of Medicare,,5.89,,,,100% of Medicare,,5.89,,,,100% of Medicare,,5.89,,,,100% of Medicare,,5.89,,,,100% of Medicare,,5.89,,,,100% of Medicare,,5.89,,,,100% of Medicare,,,5.89,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,5.89,92.7,
ROM Measurement Hand Units PT,95852,CPT,,,GP,both,,,103,61.8,,45.5,,46.87,percent of total billed charges,,,45.3,,46.66,percent of total billed charges,,,51,,52.53,percent of total billed charges,,,,,,,,,80,,82.4,percent of total billed charges,,,61.4,,63.24,percent of total billed charges,,,57.4,,59.12,percent of total billed charges,,,81,,83.43,percent of total billed charges,,,51.5,,53.05,percent of total billed charges,,,57.6,,59.33,percent of total billed charges,,,85,,87.55,percent of total billed charges,,,85,,87.55,percent of total billed charges,,,49,,50.47,percent of total billed charges,,,90,,92.7,percent of total billed charges,,,65,,66.95,percent of total billed charges,,,80,,82.4,percent of total billed charges,,,55,,56.65,percent of total billed charges,,,55,,56.65,percent of total billed charges,,,65,,66.95,percent of total billed charges,,,78,,80.34,percent of total billed charges,,,70,,72.1,percent of total billed charges,,,,,,,,5.89,,,,100% of Medicare,,5.89,,,,100% of Medicare,,5.89,,,,100% of Medicare,,5.89,,,,100% of Medicare,,5.89,,,,100% of Medicare,,5.89,,,,100% of Medicare,,5.89,,,,100% of Medicare,,5.89,,,,100% of Medicare,,5.89,,,,100% of Medicare,,5.89,,,,100% of Medicare,,5.89,,,,100% of Medicare,,5.89,,,,100% of Medicare,,,5.89,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,5.89,92.7,
EMG 1 Limb Charge (95860),95860,CPT,,,,outpatient,,,825,495,,45.5,,375.38,percent of total billed charges,,,45.3,,373.73,percent of total billed charges,,,51,,420.75,percent of total billed charges,,,,,,,,,80,,660,percent of total billed charges,,,61.4,,506.55,percent of total billed charges,,,57.4,,473.55,percent of total billed charges,,,81,,668.25,percent of total billed charges,,,51.5,,424.88,percent of total billed charges,,,57.6,,475.2,percent of total billed charges,,,85,,701.25,percent of total billed charges,,,85,,701.25,percent of total billed charges,,,49,,404.25,percent of total billed charges,,,90,,742.5,percent of total billed charges,,,65,,536.25,percent of total billed charges,,,80,,660,percent of total billed charges,,,55,,453.75,percent of total billed charges,,,55,,453.75,percent of total billed charges,,,65,,536.25,percent of total billed charges,,,78,,643.5,percent of total billed charges,,,70,,577.5,percent of total billed charges,,,,,,,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,,134.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,134.37,742.5,
CC ONLY - EMG 2 Limbs Charge (95861),95861,CPT,,,,outpatient,,,1238,742.8,,45.5,,563.29,percent of total billed charges,,,45.3,,560.81,percent of total billed charges,,,51,,631.38,percent of total billed charges,,,,,,,,,80,,990.4,percent of total billed charges,,,61.4,,760.13,percent of total billed charges,,,57.4,,710.61,percent of total billed charges,,,81,,1002.78,percent of total billed charges,,,51.5,,637.57,percent of total billed charges,,,57.6,,713.09,percent of total billed charges,,,85,,1052.3,percent of total billed charges,,,85,,1052.3,percent of total billed charges,,,49,,606.62,percent of total billed charges,,,90,,1114.2,percent of total billed charges,,,65,,804.7,percent of total billed charges,,,80,,990.4,percent of total billed charges,,,55,,680.9,percent of total billed charges,,,55,,680.9,percent of total billed charges,,,65,,804.7,percent of total billed charges,,,78,,965.64,percent of total billed charges,,,70,,866.6,percent of total billed charges,,,,,,,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,30036.53,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,,134.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,134.37,30036.53,
EMG 2 Limbs Charge (95861),95861,CPT,,,,outpatient,,,1238,742.8,,45.5,,563.29,percent of total billed charges,,,45.3,,560.81,percent of total billed charges,,,51,,631.38,percent of total billed charges,,,,,,,,,80,,990.4,percent of total billed charges,,,61.4,,760.13,percent of total billed charges,,,57.4,,710.61,percent of total billed charges,,,81,,1002.78,percent of total billed charges,,,51.5,,637.57,percent of total billed charges,,,57.6,,713.09,percent of total billed charges,,,85,,1052.3,percent of total billed charges,,,85,,1052.3,percent of total billed charges,,,49,,606.62,percent of total billed charges,,,90,,1114.2,percent of total billed charges,,,65,,804.7,percent of total billed charges,,,80,,990.4,percent of total billed charges,,,55,,680.9,percent of total billed charges,,,55,,680.9,percent of total billed charges,,,65,,804.7,percent of total billed charges,,,78,,965.64,percent of total billed charges,,,70,,866.6,percent of total billed charges,,,,,,,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,,134.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,134.37,1114.2,
EMG 3 Limbs Charge (95863),95863,CPT,,,,outpatient,,,1420,852,,45.5,,646.1,percent of total billed charges,,,45.3,,643.26,percent of total billed charges,,,51,,724.2,percent of total billed charges,,,,,,,,,80,,1136,percent of total billed charges,,,61.4,,871.88,percent of total billed charges,,,57.4,,815.08,percent of total billed charges,,,81,,1150.2,percent of total billed charges,,,51.5,,731.3,percent of total billed charges,,,57.6,,817.92,percent of total billed charges,,,85,,1207,percent of total billed charges,,,85,,1207,percent of total billed charges,,,49,,695.8,percent of total billed charges,,,90,,1278,percent of total billed charges,,,65,,923,percent of total billed charges,,,80,,1136,percent of total billed charges,,,55,,781,percent of total billed charges,,,55,,781,percent of total billed charges,,,65,,923,percent of total billed charges,,,78,,1107.6,percent of total billed charges,,,70,,994,percent of total billed charges,,,,,,,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,,163.1,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,163.1,1278,
EMG 4 Limbs Charge (95864),95864,CPT,,,,outpatient,,,1553,931.8,,45.5,,706.62,percent of total billed charges,,,45.3,,703.51,percent of total billed charges,,,51,,792.03,percent of total billed charges,,,,,,,,,80,,1242.4,percent of total billed charges,,,61.4,,953.54,percent of total billed charges,,,57.4,,891.42,percent of total billed charges,,,81,,1257.93,percent of total billed charges,,,51.5,,799.8,percent of total billed charges,,,57.6,,894.53,percent of total billed charges,,,85,,1320.05,percent of total billed charges,,,85,,1320.05,percent of total billed charges,,,49,,760.97,percent of total billed charges,,,90,,1397.7,percent of total billed charges,,,65,,1009.45,percent of total billed charges,,,80,,1242.4,percent of total billed charges,,,55,,854.15,percent of total billed charges,,,55,,854.15,percent of total billed charges,,,65,,1009.45,percent of total billed charges,,,78,,1211.34,percent of total billed charges,,,70,,1087.1,percent of total billed charges,,,,,,,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,,163.1,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,163.1,1397.7,
"EMG Facial, Unilateral Charge (95867)",95867,CPT,,,,outpatient,,,637,382.2,,45.5,,289.84,percent of total billed charges,,,45.3,,288.56,percent of total billed charges,,,51,,324.87,percent of total billed charges,,,,,,,,,80,,509.6,percent of total billed charges,,,61.4,,391.12,percent of total billed charges,,,57.4,,365.64,percent of total billed charges,,,81,,515.97,percent of total billed charges,,,51.5,,328.06,percent of total billed charges,,,57.6,,366.91,percent of total billed charges,,,85,,541.45,percent of total billed charges,,,85,,541.45,percent of total billed charges,,,49,,312.13,percent of total billed charges,,,90,,573.3,percent of total billed charges,,,65,,414.05,percent of total billed charges,,,80,,509.6,percent of total billed charges,,,55,,350.35,percent of total billed charges,,,55,,350.35,percent of total billed charges,,,65,,414.05,percent of total billed charges,,,78,,496.86,percent of total billed charges,,,70,,445.9,percent of total billed charges,,,,,,,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,,324.61,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,288.56,573.3,
"EMG Facial, Bilateral Charge (95868)",95868,CPT,,,,outpatient,,,871,522.6,,45.5,,396.31,percent of total billed charges,,,45.3,,394.56,percent of total billed charges,,,51,,444.21,percent of total billed charges,,,,,,,,,80,,696.8,percent of total billed charges,,,61.4,,534.79,percent of total billed charges,,,57.4,,499.95,percent of total billed charges,,,81,,705.51,percent of total billed charges,,,51.5,,448.57,percent of total billed charges,,,57.6,,501.7,percent of total billed charges,,,85,,740.35,percent of total billed charges,,,85,,740.35,percent of total billed charges,,,49,,426.79,percent of total billed charges,,,90,,783.9,percent of total billed charges,,,65,,566.15,percent of total billed charges,,,80,,696.8,percent of total billed charges,,,55,,479.05,percent of total billed charges,,,55,,479.05,percent of total billed charges,,,65,,566.15,percent of total billed charges,,,78,,679.38,percent of total billed charges,,,70,,609.7,percent of total billed charges,,,,,,,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,,324.61,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,324.61,783.9,
Needle Electromyography; Thoracic Paraspinal Muscles (excluding T1 or T12) (95869),95869,CPT,,,,outpatient,,,588,352.8,,45.5,,267.54,percent of total billed charges,,,45.3,,266.36,percent of total billed charges,,,51,,299.88,percent of total billed charges,,,,,,,,,80,,470.4,percent of total billed charges,,,61.4,,361.03,percent of total billed charges,,,57.4,,337.51,percent of total billed charges,,,81,,476.28,percent of total billed charges,,,51.5,,302.82,percent of total billed charges,,,57.6,,338.69,percent of total billed charges,,,85,,499.8,percent of total billed charges,,,85,,499.8,percent of total billed charges,,,49,,288.12,percent of total billed charges,,,90,,529.2,percent of total billed charges,,,65,,382.2,percent of total billed charges,,,80,,470.4,percent of total billed charges,,,55,,323.4,percent of total billed charges,,,55,,323.4,percent of total billed charges,,,65,,382.2,percent of total billed charges,,,78,,458.64,percent of total billed charges,,,70,,411.6,percent of total billed charges,,,,,,,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,,324.61,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,266.36,529.2,
"EMG, Limited Charge (95870)",95870,CPT,,,,outpatient,,,317,190.2,,45.5,,144.24,percent of total billed charges,,,45.3,,143.6,percent of total billed charges,,,51,,161.67,percent of total billed charges,,,,,,,,,80,,253.6,percent of total billed charges,,,61.4,,194.64,percent of total billed charges,,,57.4,,181.96,percent of total billed charges,,,81,,256.77,percent of total billed charges,,,51.5,,163.26,percent of total billed charges,,,57.6,,182.59,percent of total billed charges,,,85,,269.45,percent of total billed charges,,,85,,269.45,percent of total billed charges,,,49,,155.33,percent of total billed charges,,,90,,285.3,percent of total billed charges,,,65,,206.05,percent of total billed charges,,,80,,253.6,percent of total billed charges,,,55,,174.35,percent of total billed charges,,,55,,174.35,percent of total billed charges,,,65,,206.05,percent of total billed charges,,,78,,247.26,percent of total billed charges,,,70,,221.9,percent of total billed charges,,,,,,,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,,134.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,134.37,285.3,
"Needle Electromyography, non-extremity (95887)",95887,CPT,,,,outpatient,,,385,231,,45.5,,175.18,percent of total billed charges,,,45.3,,174.41,percent of total billed charges,,,51,,196.35,percent of total billed charges,,,,,,,,,80,,308,percent of total billed charges,,,61.4,,236.39,percent of total billed charges,,,57.4,,220.99,percent of total billed charges,,,81,,311.85,percent of total billed charges,,,51.5,,198.28,percent of total billed charges,,,57.6,,221.76,percent of total billed charges,,,85,,327.25,percent of total billed charges,,,85,,327.25,percent of total billed charges,,,49,,188.65,percent of total billed charges,,,90,,346.5,percent of total billed charges,,,65,,250.25,percent of total billed charges,,,80,,308,percent of total billed charges,,,55,,211.75,percent of total billed charges,,,55,,211.75,percent of total billed charges,,,65,,250.25,percent of total billed charges,,,78,,300.3,percent of total billed charges,,,70,,269.5,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,174.41,346.5,
"Needle Electromyography, non-extremity Bilateral (95887-50)",95887,CPT,,,50,outpatient,,,404,242.4,,45.5,,183.82,percent of total billed charges,,,45.3,,183.01,percent of total billed charges,,,51,,206.04,percent of total billed charges,,,,,,,,,80,,323.2,percent of total billed charges,,,61.4,,248.06,percent of total billed charges,,,57.4,,231.9,percent of total billed charges,,,81,,327.24,percent of total billed charges,,,51.5,,208.06,percent of total billed charges,,,57.6,,232.7,percent of total billed charges,,,85,,343.4,percent of total billed charges,,,85,,343.4,percent of total billed charges,,,49,,197.96,percent of total billed charges,,,90,,363.6,percent of total billed charges,,,65,,262.6,percent of total billed charges,,,80,,323.2,percent of total billed charges,,,55,,222.2,percent of total billed charges,,,55,,222.2,percent of total billed charges,,,65,,262.6,percent of total billed charges,,,78,,315.12,percent of total billed charges,,,70,,282.8,percent of total billed charges,,,,,,,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,150% of Medicare,,,,,,,150% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,183.01,363.6,
Motor/Sensory Nerve Conduct Test,95905,CPT,,,TC,outpatient,,,468,280.8,,45.5,,212.94,percent of total billed charges,,,45.3,,212,percent of total billed charges,,,51,,238.68,percent of total billed charges,,,,,,,,,80,,374.4,percent of total billed charges,,,61.4,,287.35,percent of total billed charges,,,57.4,,268.63,percent of total billed charges,,,81,,379.08,percent of total billed charges,,,51.5,,241.02,percent of total billed charges,,,57.6,,269.57,percent of total billed charges,,,85,,397.8,percent of total billed charges,,,85,,397.8,percent of total billed charges,,,49,,229.32,percent of total billed charges,,,90,,421.2,percent of total billed charges,,,65,,304.2,percent of total billed charges,,,80,,374.4,percent of total billed charges,,,55,,257.4,percent of total billed charges,,,55,,257.4,percent of total billed charges,,,65,,304.2,percent of total billed charges,,,78,,365.04,percent of total billed charges,,,70,,327.6,percent of total billed charges,,,,,,,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,,415.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,212,421.2,
MOTOR&/SENS 1-2 NRV CNDJ TST (95907),95907,CPT,,,TC,outpatient,,,581,348.6,,45.5,,264.36,percent of total billed charges,,,45.3,,263.19,percent of total billed charges,,,51,,296.31,percent of total billed charges,,,,,,,,,80,,464.8,percent of total billed charges,,,61.4,,356.73,percent of total billed charges,,,57.4,,333.49,percent of total billed charges,,,81,,470.61,percent of total billed charges,,,51.5,,299.22,percent of total billed charges,,,57.6,,334.66,percent of total billed charges,,,85,,493.85,percent of total billed charges,,,85,,493.85,percent of total billed charges,,,49,,284.69,percent of total billed charges,,,90,,522.9,percent of total billed charges,,,65,,377.65,percent of total billed charges,,,80,,464.8,percent of total billed charges,,,55,,319.55,percent of total billed charges,,,55,,319.55,percent of total billed charges,,,65,,377.65,percent of total billed charges,,,78,,453.18,percent of total billed charges,,,70,,406.7,percent of total billed charges,,,,,,,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,,163.1,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,163.1,522.9,
MOTOR&SEN 11-12 NRV CND TEST (95912),95912,CPT,,,TC,outpatient,,,1754,1052.4,,45.5,,798.07,percent of total billed charges,,,45.3,,794.56,percent of total billed charges,,,51,,894.54,percent of total billed charges,,,,,,,,,80,,1403.2,percent of total billed charges,,,61.4,,1076.96,percent of total billed charges,,,57.4,,1006.8,percent of total billed charges,,,81,,1420.74,percent of total billed charges,,,51.5,,903.31,percent of total billed charges,,,57.6,,1010.3,percent of total billed charges,,,85,,1490.9,percent of total billed charges,,,85,,1490.9,percent of total billed charges,,,49,,859.46,percent of total billed charges,,,90,,1578.6,percent of total billed charges,,,65,,1140.1,percent of total billed charges,,,80,,1403.2,percent of total billed charges,,,55,,964.7,percent of total billed charges,,,55,,964.7,percent of total billed charges,,,65,,1140.1,percent of total billed charges,,,78,,1368.12,percent of total billed charges,,,70,,1227.8,percent of total billed charges,,,,,,,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,,553.11,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,553.11,1578.6,
MOTOR&SENS 13/> NRV CND TEST (95913),95913,CPT,,,TC,outpatient,,,1854,1112.4,,45.5,,843.57,percent of total billed charges,,,45.3,,839.86,percent of total billed charges,,,51,,945.54,percent of total billed charges,,,,,,,,,80,,1483.2,percent of total billed charges,,,61.4,,1138.36,percent of total billed charges,,,57.4,,1064.2,percent of total billed charges,,,81,,1501.74,percent of total billed charges,,,51.5,,954.81,percent of total billed charges,,,57.6,,1067.9,percent of total billed charges,,,85,,1575.9,percent of total billed charges,,,85,,1575.9,percent of total billed charges,,,49,,908.46,percent of total billed charges,,,90,,1668.6,percent of total billed charges,,,65,,1205.1,percent of total billed charges,,,80,,1483.2,percent of total billed charges,,,55,,1019.7,percent of total billed charges,,,55,,1019.7,percent of total billed charges,,,65,,1205.1,percent of total billed charges,,,78,,1446.12,percent of total billed charges,,,70,,1297.8,percent of total billed charges,,,,,,,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,,553.11,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,553.11,1668.6,
SSEP Single Upper Extremity Charge,95925,CPT,,,52,outpatient,,,1481,888.6,,45.5,,673.86,percent of total billed charges,,,45.3,,670.89,percent of total billed charges,,,51,,755.31,percent of total billed charges,,,,,,,,,80,,1184.8,percent of total billed charges,,,61.4,,909.33,percent of total billed charges,,,57.4,,850.09,percent of total billed charges,,,81,,1199.61,percent of total billed charges,,,51.5,,762.72,percent of total billed charges,,,57.6,,853.06,percent of total billed charges,,,85,,1258.85,percent of total billed charges,,,85,,1258.85,percent of total billed charges,,,49,,725.69,percent of total billed charges,,,90,,1332.9,percent of total billed charges,,,65,,962.65,percent of total billed charges,,,80,,1184.8,percent of total billed charges,,,55,,814.55,percent of total billed charges,,,55,,814.55,percent of total billed charges,,,65,,962.65,percent of total billed charges,,,78,,1155.18,percent of total billed charges,,,70,,1036.7,percent of total billed charges,,,,,,,,162.31,,,,50% of Medicare,,162.31,,,,50% of Medicare,,162.31,,,,50% of Medicare,,162.31,,,,50% of Medicare,,162.31,,,,50% of Medicare,,162.31,,,,50% of Medicare,,162.31,,,,50% of Medicare,,162.31,,,,50% of Medicare,,162.31,,,,50% of Medicare,,162.31,,,,50% of Medicare,,162.31,,,,50% of Medicare,,162.31,,,,50% of Medicare,,,162.31,,,,50% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,162.31,1332.9,
SSEP (B) Upper Extremities Charge,95925,CPT,,,,outpatient,,,1481,888.6,,45.5,,673.86,percent of total billed charges,,,45.3,,670.89,percent of total billed charges,,,51,,755.31,percent of total billed charges,,,,,,,,,80,,1184.8,percent of total billed charges,,,61.4,,909.33,percent of total billed charges,,,57.4,,850.09,percent of total billed charges,,,81,,1199.61,percent of total billed charges,,,51.5,,762.72,percent of total billed charges,,,57.6,,853.06,percent of total billed charges,,,85,,1258.85,percent of total billed charges,,,85,,1258.85,percent of total billed charges,,,49,,725.69,percent of total billed charges,,,90,,1332.9,percent of total billed charges,,,65,,962.65,percent of total billed charges,,,80,,1184.8,percent of total billed charges,,,55,,814.55,percent of total billed charges,,,55,,814.55,percent of total billed charges,,,65,,962.65,percent of total billed charges,,,78,,1155.18,percent of total billed charges,,,70,,1036.7,percent of total billed charges,,,,,,,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,,324.61,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,324.61,1332.9,
SSEP Single Lower Extremity Charge,95926,CPT,,,52,outpatient,,,1481,888.6,,45.5,,673.86,percent of total billed charges,,,45.3,,670.89,percent of total billed charges,,,51,,755.31,percent of total billed charges,,,,,,,,,80,,1184.8,percent of total billed charges,,,61.4,,909.33,percent of total billed charges,,,57.4,,850.09,percent of total billed charges,,,81,,1199.61,percent of total billed charges,,,51.5,,762.72,percent of total billed charges,,,57.6,,853.06,percent of total billed charges,,,85,,1258.85,percent of total billed charges,,,85,,1258.85,percent of total billed charges,,,49,,725.69,percent of total billed charges,,,90,,1332.9,percent of total billed charges,,,65,,962.65,percent of total billed charges,,,80,,1184.8,percent of total billed charges,,,55,,814.55,percent of total billed charges,,,55,,814.55,percent of total billed charges,,,65,,962.65,percent of total billed charges,,,78,,1155.18,percent of total billed charges,,,70,,1036.7,percent of total billed charges,,,,,,,,162.31,,,,50% of Medicare,,162.31,,,,50% of Medicare,,162.31,,,,50% of Medicare,,162.31,,,,50% of Medicare,,162.31,,,,50% of Medicare,,162.31,,,,50% of Medicare,,162.31,,,,50% of Medicare,,162.31,,,,50% of Medicare,,162.31,,,,50% of Medicare,,162.31,,,,50% of Medicare,,162.31,,,,50% of Medicare,,162.31,,,,50% of Medicare,,,162.31,,,,50% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,162.31,1332.9,
SSEP (B) Lower Extremities Charge,95926,CPT,,,,outpatient,,,1481,888.6,,45.5,,673.86,percent of total billed charges,,,45.3,,670.89,percent of total billed charges,,,51,,755.31,percent of total billed charges,,,,,,,,,80,,1184.8,percent of total billed charges,,,61.4,,909.33,percent of total billed charges,,,57.4,,850.09,percent of total billed charges,,,81,,1199.61,percent of total billed charges,,,51.5,,762.72,percent of total billed charges,,,57.6,,853.06,percent of total billed charges,,,85,,1258.85,percent of total billed charges,,,85,,1258.85,percent of total billed charges,,,49,,725.69,percent of total billed charges,,,90,,1332.9,percent of total billed charges,,,65,,962.65,percent of total billed charges,,,80,,1184.8,percent of total billed charges,,,55,,814.55,percent of total billed charges,,,55,,814.55,percent of total billed charges,,,65,,962.65,percent of total billed charges,,,78,,1155.18,percent of total billed charges,,,70,,1036.7,percent of total billed charges,,,,,,,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,,324.61,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,324.61,1332.9,
Visual Evoked Potentials,95930,CPT,,,,outpatient,,,1481,888.6,,45.5,,673.86,percent of total billed charges,,,45.3,,670.89,percent of total billed charges,,,51,,755.31,percent of total billed charges,,,,,,,,,80,,1184.8,percent of total billed charges,,,61.4,,909.33,percent of total billed charges,,,57.4,,850.09,percent of total billed charges,,,81,,1199.61,percent of total billed charges,,,51.5,,762.72,percent of total billed charges,,,57.6,,853.06,percent of total billed charges,,,85,,1258.85,percent of total billed charges,,,85,,1258.85,percent of total billed charges,,,49,,725.69,percent of total billed charges,,,90,,1332.9,percent of total billed charges,,,65,,962.65,percent of total billed charges,,,80,,1184.8,percent of total billed charges,,,55,,814.55,percent of total billed charges,,,55,,814.55,percent of total billed charges,,,65,,962.65,percent of total billed charges,,,78,,1155.18,percent of total billed charges,,,70,,1036.7,percent of total billed charges,,,,,,,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,,324.61,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,324.61,1332.9,
"Orbicularis Oculi (Blink) Reflex, by electrodiagnostic",95933,CPT,,,,outpatient,,,214,128.4,,45.5,,97.37,percent of total billed charges,,,45.3,,96.94,percent of total billed charges,,,51,,109.14,percent of total billed charges,,,,,,,,,80,,171.2,percent of total billed charges,,,61.4,,131.4,percent of total billed charges,,,57.4,,122.84,percent of total billed charges,,,81,,173.34,percent of total billed charges,,,51.5,,110.21,percent of total billed charges,,,57.6,,123.26,percent of total billed charges,,,85,,181.9,percent of total billed charges,,,85,,181.9,percent of total billed charges,,,49,,104.86,percent of total billed charges,,,90,,192.6,percent of total billed charges,,,65,,139.1,percent of total billed charges,,,80,,171.2,percent of total billed charges,,,55,,117.7,percent of total billed charges,,,55,,117.7,percent of total billed charges,,,65,,139.1,percent of total billed charges,,,78,,166.92,percent of total billed charges,,,70,,149.8,percent of total billed charges,,,,,,,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,61.92,,,,100% of Medicare,,,61.92,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,61.92,192.6,
Repetitive Stimulation Charge (95937),95937,CPT,,,,outpatient,,,467,280.2,,45.5,,212.49,percent of total billed charges,,,45.3,,211.55,percent of total billed charges,,,51,,238.17,percent of total billed charges,,,,,,,,,80,,373.6,percent of total billed charges,,,61.4,,286.74,percent of total billed charges,,,57.4,,268.06,percent of total billed charges,,,81,,378.27,percent of total billed charges,,,51.5,,240.51,percent of total billed charges,,,57.6,,268.99,percent of total billed charges,,,85,,396.95,percent of total billed charges,,,85,,396.95,percent of total billed charges,,,49,,228.83,percent of total billed charges,,,90,,420.3,percent of total billed charges,,,65,,303.55,percent of total billed charges,,,80,,373.6,percent of total billed charges,,,55,,256.85,percent of total billed charges,,,55,,256.85,percent of total billed charges,,,65,,303.55,percent of total billed charges,,,78,,364.26,percent of total billed charges,,,70,,326.9,percent of total billed charges,,,,,,,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,,163.1,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,163.1,420.3,
ANALYZE NEUROSTIM SIMPLE (95971),95971,CPT,,,,outpatient,,,532,319.2,,45.5,,242.06,percent of total billed charges,,,45.3,,241,percent of total billed charges,,,51,,271.32,percent of total billed charges,,,,,,,,,80,,425.6,percent of total billed charges,,,61.4,,326.65,percent of total billed charges,,,57.4,,305.37,percent of total billed charges,,,81,,430.92,percent of total billed charges,,,51.5,,273.98,percent of total billed charges,,,57.6,,306.43,percent of total billed charges,,,85,,452.2,percent of total billed charges,,,85,,452.2,percent of total billed charges,,,49,,260.68,percent of total billed charges,,,90,,478.8,percent of total billed charges,,,65,,345.8,percent of total billed charges,,,80,,425.6,percent of total billed charges,,,55,,292.6,percent of total billed charges,,,55,,292.6,percent of total billed charges,,,65,,345.8,percent of total billed charges,,,78,,414.96,percent of total billed charges,,,70,,372.4,percent of total billed charges,,,,,,,,95.68,,,,100% of Medicare,,95.68,,,,100% of Medicare,,95.68,,,,100% of Medicare,,95.68,,,,100% of Medicare,,95.68,,,,100% of Medicare,,95.68,,,,100% of Medicare,,95.68,,,,100% of Medicare,,95.68,,,,100% of Medicare,,95.68,,,,100% of Medicare,,95.68,,,,100% of Medicare,,95.68,,,,100% of Medicare,,95.68,,,,100% of Medicare,,,95.68,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,95.68,478.8,
"Analyze Neurostim, Complex, 1st hour",95972,CPT,,,,outpatient,,,620,372,,45.5,,282.1,percent of total billed charges,,,45.3,,280.86,percent of total billed charges,,,51,,316.2,percent of total billed charges,,,,,,,,,80,,496,percent of total billed charges,,,61.4,,380.68,percent of total billed charges,,,57.4,,355.88,percent of total billed charges,,,81,,502.2,percent of total billed charges,,,51.5,,319.3,percent of total billed charges,,,57.6,,357.12,percent of total billed charges,,,85,,527,percent of total billed charges,,,85,,527,percent of total billed charges,,,49,,303.8,percent of total billed charges,,,90,,558,percent of total billed charges,,,65,,403,percent of total billed charges,,,80,,496,percent of total billed charges,,,55,,341,percent of total billed charges,,,55,,341,percent of total billed charges,,,65,,403,percent of total billed charges,,,78,,483.6,percent of total billed charges,,,70,,434,percent of total billed charges,,,,,,,,95.68,,,,100% of Medicare,,95.68,,,,100% of Medicare,,95.68,,,,100% of Medicare,,95.68,,,,100% of Medicare,,95.68,,,,100% of Medicare,,95.68,,,,100% of Medicare,,95.68,,,,100% of Medicare,,95.68,,,,100% of Medicare,,95.68,,,,100% of Medicare,,95.68,,,,100% of Medicare,,95.68,,,,100% of Medicare,,95.68,,,,100% of Medicare,,,95.68,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,95.68,558,
Canalith Repositioning Units,95992,CPT,,,GP,both,,,164,98.4,,45.5,,74.62,percent of total billed charges,,,45.3,,74.29,percent of total billed charges,,,51,,83.64,percent of total billed charges,,,,,,,,,80,,131.2,percent of total billed charges,,,61.4,,100.7,percent of total billed charges,,,57.4,,94.14,percent of total billed charges,,,81,,132.84,percent of total billed charges,,,51.5,,84.46,percent of total billed charges,,,57.6,,94.46,percent of total billed charges,,,85,,139.4,percent of total billed charges,,,85,,139.4,percent of total billed charges,,,49,,80.36,percent of total billed charges,,,90,,147.6,percent of total billed charges,,,65,,106.6,percent of total billed charges,,,80,,131.2,percent of total billed charges,,,55,,90.2,percent of total billed charges,,,55,,90.2,percent of total billed charges,,,65,,106.6,percent of total billed charges,,,78,,127.92,percent of total billed charges,,,70,,114.8,percent of total billed charges,,,,,,,,35.65,,,,100% of Medicare,,35.65,,,,100% of Medicare,,35.65,,,,100% of Medicare,,35.65,,,,100% of Medicare,,35.65,,,,100% of Medicare,,35.65,,,46240.81,100% of Medicare,,35.65,,,,100% of Medicare,,35.65,,,,100% of Medicare,,35.65,,,,100% of Medicare,,35.65,,,,100% of Medicare,,35.65,,,,100% of Medicare,,35.65,,,,100% of Medicare,,,35.65,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,35.65,46240.81,
2D Gait Analysis Charge(95999),95999,CPT,,,,both,,,3362,2017.2,,45.5,,1529.71,percent of total billed charges,,,45.3,,1522.99,percent of total billed charges,,,51,,1714.62,percent of total billed charges,,,,,,,,,80,,2689.6,percent of total billed charges,,,61.4,,2064.27,percent of total billed charges,,,57.4,,1929.79,percent of total billed charges,,,81,,2723.22,percent of total billed charges,,,51.5,,1731.43,percent of total billed charges,,,57.6,,1936.51,percent of total billed charges,,,85,,2857.7,percent of total billed charges,,,85,,2857.7,percent of total billed charges,,,49,,1647.38,percent of total billed charges,,,90,,3025.8,percent of total billed charges,,,65,,2185.3,percent of total billed charges,,,80,,2689.6,percent of total billed charges,,,55,,1849.1,percent of total billed charges,,,55,,1849.1,percent of total billed charges,,,65,,2185.3,percent of total billed charges,,,78,,2622.36,percent of total billed charges,,,70,,2353.4,percent of total billed charges,,,,,,,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,163.1,,,,100% of Medicare,,,163.1,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,163.1,3025.8,
Comprehensive computer based motion analysis-1 Charge (96000),96000,CPT,,,,both,,,3031,1818.6,,45.5,,1379.11,percent of total billed charges,,,45.3,,1373.04,percent of total billed charges,,,51,,1545.81,percent of total billed charges,,,,,,,,,80,,2424.8,percent of total billed charges,,,61.4,,1861.03,percent of total billed charges,,,57.4,,1739.79,percent of total billed charges,,,81,,2455.11,percent of total billed charges,,,51.5,,1560.97,percent of total billed charges,,,57.6,,1745.86,percent of total billed charges,,,85,,2576.35,percent of total billed charges,,,85,,2576.35,percent of total billed charges,,,49,,1485.19,percent of total billed charges,,,90,,2727.9,percent of total billed charges,,,65,,1970.15,percent of total billed charges,,,80,,2424.8,percent of total billed charges,,,55,,1667.05,percent of total billed charges,,,55,,1667.05,percent of total billed charges,,,65,,1970.15,percent of total billed charges,,,78,,2364.18,percent of total billed charges,,,70,,2121.7,percent of total billed charges,,,,,,,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,,553.11,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,553.11,2727.9,
Comprehensive computer based motion analysis-2 Charge (96000),96000,CPT,,,,both,,,6814,4088.4,,45.5,,3100.37,percent of total billed charges,,,45.3,,3086.74,percent of total billed charges,,,51,,3475.14,percent of total billed charges,,,,,,,,,80,,5451.2,percent of total billed charges,,,61.4,,4183.8,percent of total billed charges,,,57.4,,3911.24,percent of total billed charges,,,81,,5519.34,percent of total billed charges,,,51.5,,3509.21,percent of total billed charges,,,57.6,,3924.86,percent of total billed charges,,,85,,5791.9,percent of total billed charges,,,85,,5791.9,percent of total billed charges,,,49,,3338.86,percent of total billed charges,,,90,,6132.6,percent of total billed charges,,,65,,4429.1,percent of total billed charges,,,80,,5451.2,percent of total billed charges,,,55,,3747.7,percent of total billed charges,,,55,,3747.7,percent of total billed charges,,,65,,4429.1,percent of total billed charges,,,78,,5314.92,percent of total billed charges,,,70,,4769.8,percent of total billed charges,,,,,,,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,,553.11,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,553.11,6132.6,
Comprehensive computer based motion analysis-3 Charge (96000),96000,CPT,,,,both,,,7551,4530.6,,45.5,,3435.71,percent of total billed charges,,,45.3,,3420.6,percent of total billed charges,,,51,,3851.01,percent of total billed charges,,,,,,,,,80,,6040.8,percent of total billed charges,,,61.4,,4636.31,percent of total billed charges,,,57.4,,4334.27,percent of total billed charges,,,81,,6116.31,percent of total billed charges,,,51.5,,3888.77,percent of total billed charges,,,57.6,,4349.38,percent of total billed charges,,,85,,6418.35,percent of total billed charges,,,85,,6418.35,percent of total billed charges,,,49,,3699.99,percent of total billed charges,,,90,,6795.9,percent of total billed charges,,,65,,4908.15,percent of total billed charges,,,80,,6040.8,percent of total billed charges,,,55,,4153.05,percent of total billed charges,,,55,,4153.05,percent of total billed charges,,,65,,4908.15,percent of total billed charges,,,78,,5889.78,percent of total billed charges,,,70,,5285.7,percent of total billed charges,,,,,,,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,,553.11,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,553.11,6795.9,
Comprehensive computer based motion analysis-4 Charge (96000),96000,CPT,,,,both,,,8089,4853.4,,45.5,,3680.5,percent of total billed charges,,,45.3,,3664.32,percent of total billed charges,,,51,,4125.39,percent of total billed charges,,,,,,,,,80,,6471.2,percent of total billed charges,,,61.4,,4966.65,percent of total billed charges,,,57.4,,4643.09,percent of total billed charges,,,81,,6552.09,percent of total billed charges,,,51.5,,4165.84,percent of total billed charges,,,57.6,,4659.26,percent of total billed charges,,,85,,6875.65,percent of total billed charges,,,85,,6875.65,percent of total billed charges,,,49,,3963.61,percent of total billed charges,,,90,,7280.1,percent of total billed charges,,,65,,5257.85,percent of total billed charges,,,80,,6471.2,percent of total billed charges,,,55,,4448.95,percent of total billed charges,,,55,,4448.95,percent of total billed charges,,,65,,5257.85,percent of total billed charges,,,78,,6309.42,percent of total billed charges,,,70,,5662.3,percent of total billed charges,,,,,,,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,,553.11,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,553.11,7280.1,
Comprehensive computer based motion analysis-5 Charge (96000),96000,CPT,,,,both,,,8361,5016.6,,45.5,,3804.26,percent of total billed charges,,,45.3,,3787.53,percent of total billed charges,,,51,,4264.11,percent of total billed charges,,,,,,,,,80,,6688.8,percent of total billed charges,,,61.4,,5133.65,percent of total billed charges,,,57.4,,4799.21,percent of total billed charges,,,81,,6772.41,percent of total billed charges,,,51.5,,4305.92,percent of total billed charges,,,57.6,,4815.94,percent of total billed charges,,,85,,7106.85,percent of total billed charges,,,85,,7106.85,percent of total billed charges,,,49,,4096.89,percent of total billed charges,,,90,,7524.9,percent of total billed charges,,,65,,5434.65,percent of total billed charges,,,80,,6688.8,percent of total billed charges,,,55,,4598.55,percent of total billed charges,,,55,,4598.55,percent of total billed charges,,,65,,5434.65,percent of total billed charges,,,78,,6521.58,percent of total billed charges,,,70,,5852.7,percent of total billed charges,,,,,,,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,,553.11,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,553.11,7524.9,
"Dynamic surface electromyography, during walking or other functional activities, 1-12 muscles Charge",96002,CPT,,,,both,,,1482,889.2,,45.5,,674.31,percent of total billed charges,,,45.3,,671.35,percent of total billed charges,,,51,,755.82,percent of total billed charges,,,,,,,,,80,,1185.6,percent of total billed charges,,,61.4,,909.95,percent of total billed charges,,,57.4,,850.67,percent of total billed charges,,,81,,1200.42,percent of total billed charges,,,51.5,,763.23,percent of total billed charges,,,57.6,,853.63,percent of total billed charges,,,85,,1259.7,percent of total billed charges,,,85,,1259.7,percent of total billed charges,,,49,,726.18,percent of total billed charges,,,90,,1333.8,percent of total billed charges,,,65,,963.3,percent of total billed charges,,,80,,1185.6,percent of total billed charges,,,55,,815.1,percent of total billed charges,,,55,,815.1,percent of total billed charges,,,65,,963.3,percent of total billed charges,,,78,,1155.96,percent of total billed charges,,,70,,1037.4,percent of total billed charges,,,,,,,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,,324.61,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,324.61,1333.8,
SLP Assessment of Aphasia Units,96105,CPT,,,GN,both,,,432,259.2,,45.5,,196.56,percent of total billed charges,,,45.3,,195.7,percent of total billed charges,,,51,,220.32,percent of total billed charges,,,,,,,,,80,,345.6,percent of total billed charges,,,61.4,,265.25,percent of total billed charges,,,57.4,,247.97,percent of total billed charges,,,81,,349.92,percent of total billed charges,,,51.5,,222.48,percent of total billed charges,,,57.6,,248.83,percent of total billed charges,,,85,,367.2,percent of total billed charges,,,85,,367.2,percent of total billed charges,,,49,,211.68,percent of total billed charges,,,90,,388.8,percent of total billed charges,,,65,,280.8,percent of total billed charges,,,80,,345.6,percent of total billed charges,,,55,,237.6,percent of total billed charges,,,55,,237.6,percent of total billed charges,,,65,,280.8,percent of total billed charges,,,78,,336.96,percent of total billed charges,,,70,,302.4,percent of total billed charges,,,,,,,,96.99,,,,100% of Medicare,,96.99,,,,100% of Medicare,,96.99,,,,100% of Medicare,,96.99,,,,100% of Medicare,,96.99,,,,100% of Medicare,,96.99,,,,100% of Medicare,,96.99,,,,100% of Medicare,,96.99,,,,100% of Medicare,,96.99,,,,100% of Medicare,,96.99,,,,100% of Medicare,,96.99,,,,100% of Medicare,,96.99,,,,100% of Medicare,,,96.99,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,96.99,388.8,
Assessment of aphasia,96105,CPT,,,,both,,,432,259.2,,45.5,,196.56,percent of total billed charges,,,45.3,,195.7,percent of total billed charges,,,51,,220.32,percent of total billed charges,,,,,,,,,80,,345.6,percent of total billed charges,,,61.4,,265.25,percent of total billed charges,,,57.4,,247.97,percent of total billed charges,,,81,,349.92,percent of total billed charges,,,51.5,,222.48,percent of total billed charges,,,57.6,,248.83,percent of total billed charges,,,85,,367.2,percent of total billed charges,,,85,,367.2,percent of total billed charges,,,49,,211.68,percent of total billed charges,,,90,,388.8,percent of total billed charges,,,65,,280.8,percent of total billed charges,,,80,,345.6,percent of total billed charges,,,55,,237.6,percent of total billed charges,,,55,,237.6,percent of total billed charges,,,65,,280.8,percent of total billed charges,,,78,,336.96,percent of total billed charges,,,70,,302.4,percent of total billed charges,,,,,,,,96.99,,,,100% of Medicare,,96.99,,,,100% of Medicare,,96.99,,,,100% of Medicare,,96.99,,,,100% of Medicare,,96.99,,,,100% of Medicare,,96.99,,,25027.7725,100% of Medicare,,96.99,,,,100% of Medicare,,96.99,,,,100% of Medicare,,96.99,,,,100% of Medicare,,96.99,,,,100% of Medicare,,96.99,,,,100% of Medicare,,96.99,,,,100% of Medicare,,,96.99,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,96.99,25027.77,
"Neurobehavioral Status Exam, per hour",96116,CPT,,,,both,,,619,371.4,,45.5,,281.65,percent of total billed charges,,,45.3,,280.41,percent of total billed charges,,,51,,315.69,percent of total billed charges,,,,,,,,,80,,495.2,percent of total billed charges,,,61.4,,380.07,percent of total billed charges,,,57.4,,355.31,percent of total billed charges,,,81,,501.39,percent of total billed charges,,,51.5,,318.79,percent of total billed charges,,,57.6,,356.54,percent of total billed charges,,,85,,526.15,percent of total billed charges,,,85,,526.15,percent of total billed charges,,,49,,303.31,percent of total billed charges,,,90,,557.1,percent of total billed charges,,,65,,402.35,percent of total billed charges,,,80,,495.2,percent of total billed charges,,,55,,340.45,percent of total billed charges,,,55,,340.45,percent of total billed charges,,,65,,402.35,percent of total billed charges,,,78,,482.82,percent of total billed charges,,,70,,433.3,percent of total billed charges,,,,,,,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,,324.61,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,280.41,557.1,
"Telehealth Neurobehavioral Status Exam, per hour (96116)",96116,CPT,,,,both,,,619,371.4,,45.5,,281.65,percent of total billed charges,,,45.3,,280.41,percent of total billed charges,,,51,,315.69,percent of total billed charges,,,,,,,,,80,,495.2,percent of total billed charges,,,61.4,,380.07,percent of total billed charges,,,57.4,,355.31,percent of total billed charges,,,81,,501.39,percent of total billed charges,,,51.5,,318.79,percent of total billed charges,,,57.6,,356.54,percent of total billed charges,,,85,,526.15,percent of total billed charges,,,85,,526.15,percent of total billed charges,,,49,,303.31,percent of total billed charges,,,90,,557.1,percent of total billed charges,,,65,,402.35,percent of total billed charges,,,80,,495.2,percent of total billed charges,,,55,,340.45,percent of total billed charges,,,55,,340.45,percent of total billed charges,,,65,,402.35,percent of total billed charges,,,78,,482.82,percent of total billed charges,,,70,,433.3,percent of total billed charges,,,,,,,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,,324.61,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,280.41,557.1,
Neurobehavioral Status Exam Add On (96121),96121,CPT,,,,both,,,316,189.6,,45.5,,143.78,percent of total billed charges,,,45.3,,143.15,percent of total billed charges,,,51,,161.16,percent of total billed charges,,,,,,,,,80,,252.8,percent of total billed charges,,,61.4,,194.02,percent of total billed charges,,,57.4,,181.38,percent of total billed charges,,,81,,255.96,percent of total billed charges,,,51.5,,162.74,percent of total billed charges,,,57.6,,182.02,percent of total billed charges,,,85,,268.6,percent of total billed charges,,,85,,268.6,percent of total billed charges,,,49,,154.84,percent of total billed charges,,,90,,284.4,percent of total billed charges,,,65,,205.4,percent of total billed charges,,,80,,252.8,percent of total billed charges,,,55,,173.8,percent of total billed charges,,,55,,173.8,percent of total billed charges,,,65,,205.4,percent of total billed charges,,,78,,246.48,percent of total billed charges,,,70,,221.2,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,143.15,284.4,
Telehealth Neurobehavioral Status Exam Add On (96121),96121,CPT,,,,both,,,316,189.6,,45.5,,143.78,percent of total billed charges,,,45.3,,143.15,percent of total billed charges,,,51,,161.16,percent of total billed charges,,,,,,,,,80,,252.8,percent of total billed charges,,,61.4,,194.02,percent of total billed charges,,,57.4,,181.38,percent of total billed charges,,,81,,255.96,percent of total billed charges,,,51.5,,162.74,percent of total billed charges,,,57.6,,182.02,percent of total billed charges,,,85,,268.6,percent of total billed charges,,,85,,268.6,percent of total billed charges,,,49,,154.84,percent of total billed charges,,,90,,284.4,percent of total billed charges,,,65,,205.4,percent of total billed charges,,,80,,252.8,percent of total billed charges,,,55,,173.8,percent of total billed charges,,,55,,173.8,percent of total billed charges,,,65,,205.4,percent of total billed charges,,,78,,246.48,percent of total billed charges,,,70,,221.2,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,143.15,284.4,
Brief emotional/behavioral assessment (96127),96127,CPT,,,,both,,,70,42,,45.5,,31.85,percent of total billed charges,,,45.3,,31.71,percent of total billed charges,,,51,,35.7,percent of total billed charges,,,,,,,,,80,,56,percent of total billed charges,,,61.4,,42.98,percent of total billed charges,,,57.4,,40.18,percent of total billed charges,,,81,,56.7,percent of total billed charges,,,51.5,,36.05,percent of total billed charges,,,57.6,,40.32,percent of total billed charges,,,85,,59.5,percent of total billed charges,,,85,,59.5,percent of total billed charges,,,49,,34.3,percent of total billed charges,,,90,,63,percent of total billed charges,,,65,,45.5,percent of total billed charges,,,80,,56,percent of total billed charges,,,55,,38.5,percent of total billed charges,,,55,,38.5,percent of total billed charges,,,65,,45.5,percent of total billed charges,,,78,,54.6,percent of total billed charges,,,70,,49,percent of total billed charges,,,,,,,,40.91,,,,100% of Medicare,,40.91,,,,100% of Medicare,,40.91,,,,100% of Medicare,,40.91,,,,100% of Medicare,,40.91,,,,100% of Medicare,,40.91,,,37630.6725,100% of Medicare,,40.91,,,,100% of Medicare,,40.91,,,,100% of Medicare,,40.91,,,,100% of Medicare,,40.91,,,,100% of Medicare,,40.91,,,,100% of Medicare,,40.91,,,,100% of Medicare,,,40.91,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,31.71,37630.67,
"Psych testing by physician or other qualified health professional, first hour (96130)",96130,CPT,,,,both,,,529,317.4,,45.5,,240.7,percent of total billed charges,,,45.3,,239.64,percent of total billed charges,,,51,,269.79,percent of total billed charges,,,,,,,,,80,,423.2,percent of total billed charges,,,61.4,,324.81,percent of total billed charges,,,57.4,,303.65,percent of total billed charges,,,81,,428.49,percent of total billed charges,,,51.5,,272.44,percent of total billed charges,,,57.6,,304.7,percent of total billed charges,,,85,,449.65,percent of total billed charges,,,85,,449.65,percent of total billed charges,,,49,,259.21,percent of total billed charges,,,90,,476.1,percent of total billed charges,,,65,,343.85,percent of total billed charges,,,80,,423.2,percent of total billed charges,,,55,,290.95,percent of total billed charges,,,55,,290.95,percent of total billed charges,,,65,,343.85,percent of total billed charges,,,78,,412.62,percent of total billed charges,,,70,,370.3,percent of total billed charges,,,,,,,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,,324.61,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,239.64,476.1,
"Telehealth Psych testing by physician/qualified, 1st hour (96130)",96130,CPT,,,,both,,,529,317.4,,45.5,,240.7,percent of total billed charges,,,45.3,,239.64,percent of total billed charges,,,51,,269.79,percent of total billed charges,,,,,,,,,80,,423.2,percent of total billed charges,,,61.4,,324.81,percent of total billed charges,,,57.4,,303.65,percent of total billed charges,,,81,,428.49,percent of total billed charges,,,51.5,,272.44,percent of total billed charges,,,57.6,,304.7,percent of total billed charges,,,85,,449.65,percent of total billed charges,,,85,,449.65,percent of total billed charges,,,49,,259.21,percent of total billed charges,,,90,,476.1,percent of total billed charges,,,65,,343.85,percent of total billed charges,,,80,,423.2,percent of total billed charges,,,55,,290.95,percent of total billed charges,,,55,,290.95,percent of total billed charges,,,65,,343.85,percent of total billed charges,,,78,,412.62,percent of total billed charges,,,70,,370.3,percent of total billed charges,,,,,,,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,324.61,,,,100% of Medicare,,,324.61,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,239.64,476.1,
"Psych testing by physician or other health professional, each additional hour (96131)",96131,CPT,,,,both,,,510,306,,45.5,,232.05,percent of total billed charges,,,45.3,,231.03,percent of total billed charges,,,51,,260.1,percent of total billed charges,,,,,,,,,80,,408,percent of total billed charges,,,61.4,,313.14,percent of total billed charges,,,57.4,,292.74,percent of total billed charges,,,81,,413.1,percent of total billed charges,,,51.5,,262.65,percent of total billed charges,,,57.6,,293.76,percent of total billed charges,,,85,,433.5,percent of total billed charges,,,85,,433.5,percent of total billed charges,,,49,,249.9,percent of total billed charges,,,90,,459,percent of total billed charges,,,65,,331.5,percent of total billed charges,,,80,,408,percent of total billed charges,,,55,,280.5,percent of total billed charges,,,55,,280.5,percent of total billed charges,,,65,,331.5,percent of total billed charges,,,78,,397.8,percent of total billed charges,,,70,,357,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,231.03,459,
"Telehealth Psych testing by physician/qualified, EA Addtl hour (96131)",96131,CPT,,,,both,,,510,306,,45.5,,232.05,percent of total billed charges,,,45.3,,231.03,percent of total billed charges,,,51,,260.1,percent of total billed charges,,,,,,,,,80,,408,percent of total billed charges,,,61.4,,313.14,percent of total billed charges,,,57.4,,292.74,percent of total billed charges,,,81,,413.1,percent of total billed charges,,,51.5,,262.65,percent of total billed charges,,,57.6,,293.76,percent of total billed charges,,,85,,433.5,percent of total billed charges,,,85,,433.5,percent of total billed charges,,,49,,249.9,percent of total billed charges,,,90,,459,percent of total billed charges,,,65,,331.5,percent of total billed charges,,,80,,408,percent of total billed charges,,,55,,280.5,percent of total billed charges,,,55,,280.5,percent of total billed charges,,,65,,331.5,percent of total billed charges,,,78,,397.8,percent of total billed charges,,,70,,357,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,231.03,459,
Neuropsych testing by physician or other qualified healthcare professional. First Hour (96132),96132,CPT,,,,both,,,903,541.8,,45.5,,410.87,percent of total billed charges,,,45.3,,409.06,percent of total billed charges,,,51,,460.53,percent of total billed charges,,,,,,,,,80,,722.4,percent of total billed charges,,,61.4,,554.44,percent of total billed charges,,,57.4,,518.32,percent of total billed charges,,,81,,731.43,percent of total billed charges,,,51.5,,465.05,percent of total billed charges,,,57.6,,520.13,percent of total billed charges,,,85,,767.55,percent of total billed charges,,,85,,767.55,percent of total billed charges,,,49,,442.47,percent of total billed charges,,,90,,812.7,percent of total billed charges,,,65,,586.95,percent of total billed charges,,,80,,722.4,percent of total billed charges,,,55,,496.65,percent of total billed charges,,,55,,496.65,percent of total billed charges,,,65,,586.95,percent of total billed charges,,,78,,704.34,percent of total billed charges,,,70,,632.1,percent of total billed charges,,,,,,,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,,553.11,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,409.06,812.7,
"Telehealth Neuropsych testing by physician/qualified, 1st hour (96132)",96132,CPT,,,,both,,,903,541.8,,45.5,,410.87,percent of total billed charges,,,45.3,,409.06,percent of total billed charges,,,51,,460.53,percent of total billed charges,,,,,,,,,80,,722.4,percent of total billed charges,,,61.4,,554.44,percent of total billed charges,,,57.4,,518.32,percent of total billed charges,,,81,,731.43,percent of total billed charges,,,51.5,,465.05,percent of total billed charges,,,57.6,,520.13,percent of total billed charges,,,85,,767.55,percent of total billed charges,,,85,,767.55,percent of total billed charges,,,49,,442.47,percent of total billed charges,,,90,,812.7,percent of total billed charges,,,65,,586.95,percent of total billed charges,,,80,,722.4,percent of total billed charges,,,55,,496.65,percent of total billed charges,,,55,,496.65,percent of total billed charges,,,65,,586.95,percent of total billed charges,,,78,,704.34,percent of total billed charges,,,70,,632.1,percent of total billed charges,,,,,,,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,553.11,,,,100% of Medicare,,,553.11,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,409.06,812.7,
"Neuropsych testing by physician or other qualified healthcare professional, each additional hour (96",96133,CPT,,,,both,,,827,496.2,,45.5,,376.29,percent of total billed charges,,,45.3,,374.63,percent of total billed charges,,,51,,421.77,percent of total billed charges,,,,,,,,,80,,661.6,percent of total billed charges,,,61.4,,507.78,percent of total billed charges,,,57.4,,474.7,percent of total billed charges,,,81,,669.87,percent of total billed charges,,,51.5,,425.91,percent of total billed charges,,,57.6,,476.35,percent of total billed charges,,,85,,702.95,percent of total billed charges,,,85,,702.95,percent of total billed charges,,,49,,405.23,percent of total billed charges,,,90,,744.3,percent of total billed charges,,,65,,537.55,percent of total billed charges,,,80,,661.6,percent of total billed charges,,,55,,454.85,percent of total billed charges,,,55,,454.85,percent of total billed charges,,,65,,537.55,percent of total billed charges,,,78,,645.06,percent of total billed charges,,,70,,578.9,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,374.63,744.3,
"Telehealth Neuropsych testing by physician/qualified, EA Addtl (96133)",96133,CPT,,,,both,,,827,496.2,,45.5,,376.29,percent of total billed charges,,,45.3,,374.63,percent of total billed charges,,,51,,421.77,percent of total billed charges,,,,,,,,,80,,661.6,percent of total billed charges,,,61.4,,507.78,percent of total billed charges,,,57.4,,474.7,percent of total billed charges,,,81,,669.87,percent of total billed charges,,,51.5,,425.91,percent of total billed charges,,,57.6,,476.35,percent of total billed charges,,,85,,702.95,percent of total billed charges,,,85,,702.95,percent of total billed charges,,,49,,405.23,percent of total billed charges,,,90,,744.3,percent of total billed charges,,,65,,537.55,percent of total billed charges,,,80,,661.6,percent of total billed charges,,,55,,454.85,percent of total billed charges,,,55,,454.85,percent of total billed charges,,,65,,537.55,percent of total billed charges,,,78,,645.06,percent of total billed charges,,,70,,578.9,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,374.63,744.3,
"Psych or Neuropsych test admin or scoring by physician or other qualified healthcare professional, f",96136,CPT,,,,both,,,384,230.4,,45.5,,174.72,percent of total billed charges,,,45.3,,173.95,percent of total billed charges,,,51,,195.84,percent of total billed charges,,,,,,,,,80,,307.2,percent of total billed charges,,,61.4,,235.78,percent of total billed charges,,,57.4,,220.42,percent of total billed charges,,,81,,311.04,percent of total billed charges,,,51.5,,197.76,percent of total billed charges,,,57.6,,221.18,percent of total billed charges,,,85,,326.4,percent of total billed charges,,,85,,326.4,percent of total billed charges,,,49,,188.16,percent of total billed charges,,,90,,345.6,percent of total billed charges,,,65,,249.6,percent of total billed charges,,,80,,307.2,percent of total billed charges,,,55,,211.2,percent of total billed charges,,,55,,211.2,percent of total billed charges,,,65,,249.6,percent of total billed charges,,,78,,299.52,percent of total billed charges,,,70,,268.8,percent of total billed charges,,,,,,,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,,134.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,134.37,345.6,
"Telehealth Psych or Neuropsych test admin & scoring by phys, Itl 30 min (96136)",96136,CPT,,,,both,,,384,230.4,,45.5,,174.72,percent of total billed charges,,,45.3,,173.95,percent of total billed charges,,,51,,195.84,percent of total billed charges,,,,,,,,,80,,307.2,percent of total billed charges,,,61.4,,235.78,percent of total billed charges,,,57.4,,220.42,percent of total billed charges,,,81,,311.04,percent of total billed charges,,,51.5,,197.76,percent of total billed charges,,,57.6,,221.18,percent of total billed charges,,,85,,326.4,percent of total billed charges,,,85,,326.4,percent of total billed charges,,,49,,188.16,percent of total billed charges,,,90,,345.6,percent of total billed charges,,,65,,249.6,percent of total billed charges,,,80,,307.2,percent of total billed charges,,,55,,211.2,percent of total billed charges,,,55,,211.2,percent of total billed charges,,,65,,249.6,percent of total billed charges,,,78,,299.52,percent of total billed charges,,,70,,268.8,percent of total billed charges,,,,,,,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,,134.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,134.37,345.6,
"Psych or neuropsych test admin and scoring, each additional 30 mins (96137)",96137,CPT,,,,both,,,346,207.6,,45.5,,157.43,percent of total billed charges,,,45.3,,156.74,percent of total billed charges,,,51,,176.46,percent of total billed charges,,,,,,,,,80,,276.8,percent of total billed charges,,,61.4,,212.44,percent of total billed charges,,,57.4,,198.6,percent of total billed charges,,,81,,280.26,percent of total billed charges,,,51.5,,178.19,percent of total billed charges,,,57.6,,199.3,percent of total billed charges,,,85,,294.1,percent of total billed charges,,,85,,294.1,percent of total billed charges,,,49,,169.54,percent of total billed charges,,,90,,311.4,percent of total billed charges,,,65,,224.9,percent of total billed charges,,,80,,276.8,percent of total billed charges,,,55,,190.3,percent of total billed charges,,,55,,190.3,percent of total billed charges,,,65,,224.9,percent of total billed charges,,,78,,269.88,percent of total billed charges,,,70,,242.2,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,156.74,311.4,
"Telehealth Psych or Neuropsych test admin & scoring, EA Addtl 30 min (96137)",96137,CPT,,,,both,,,346,207.6,,45.5,,157.43,percent of total billed charges,,,45.3,,156.74,percent of total billed charges,,,51,,176.46,percent of total billed charges,,,,,,,,,80,,276.8,percent of total billed charges,,,61.4,,212.44,percent of total billed charges,,,57.4,,198.6,percent of total billed charges,,,81,,280.26,percent of total billed charges,,,51.5,,178.19,percent of total billed charges,,,57.6,,199.3,percent of total billed charges,,,85,,294.1,percent of total billed charges,,,85,,294.1,percent of total billed charges,,,49,,169.54,percent of total billed charges,,,90,,311.4,percent of total billed charges,,,65,,224.9,percent of total billed charges,,,80,,276.8,percent of total billed charges,,,55,,190.3,percent of total billed charges,,,55,,190.3,percent of total billed charges,,,65,,224.9,percent of total billed charges,,,78,,269.88,percent of total billed charges,,,70,,242.2,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,156.74,311.4,
"Psych or neuropsych test admin and scoring by technician, first 30 minutes (96138)",96138,CPT,,,,both,,,468,280.8,,45.5,,212.94,percent of total billed charges,,,45.3,,212,percent of total billed charges,,,51,,238.68,percent of total billed charges,,,,,,,,,80,,374.4,percent of total billed charges,,,61.4,,287.35,percent of total billed charges,,,57.4,,268.63,percent of total billed charges,,,81,,379.08,percent of total billed charges,,,51.5,,241.02,percent of total billed charges,,,57.6,,269.57,percent of total billed charges,,,85,,397.8,percent of total billed charges,,,85,,397.8,percent of total billed charges,,,49,,229.32,percent of total billed charges,,,90,,421.2,percent of total billed charges,,,65,,304.2,percent of total billed charges,,,80,,374.4,percent of total billed charges,,,55,,257.4,percent of total billed charges,,,55,,257.4,percent of total billed charges,,,65,,304.2,percent of total billed charges,,,78,,365.04,percent of total billed charges,,,70,,327.6,percent of total billed charges,,,,,,,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,,415.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,212,421.2,
"Telehealth Psych or Neuropsych test admin & scoring by tech, Itl 30 min (96138)",96138,CPT,,,,both,,,468,280.8,,45.5,,212.94,percent of total billed charges,,,45.3,,212,percent of total billed charges,,,51,,238.68,percent of total billed charges,,,,,,,,,80,,374.4,percent of total billed charges,,,61.4,,287.35,percent of total billed charges,,,57.4,,268.63,percent of total billed charges,,,81,,379.08,percent of total billed charges,,,51.5,,241.02,percent of total billed charges,,,57.6,,269.57,percent of total billed charges,,,85,,397.8,percent of total billed charges,,,85,,397.8,percent of total billed charges,,,49,,229.32,percent of total billed charges,,,90,,421.2,percent of total billed charges,,,65,,304.2,percent of total billed charges,,,80,,374.4,percent of total billed charges,,,55,,257.4,percent of total billed charges,,,55,,257.4,percent of total billed charges,,,65,,304.2,percent of total billed charges,,,78,,365.04,percent of total billed charges,,,70,,327.6,percent of total billed charges,,,,,,,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,,415.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,212,421.2,
"Psych or neuropsych test admin by technician, each additional 30 minutes (96139)",96139,CPT,,,,both,,,330,198,,45.5,,150.15,percent of total billed charges,,,45.3,,149.49,percent of total billed charges,,,51,,168.3,percent of total billed charges,,,,,,,,,80,,264,percent of total billed charges,,,61.4,,202.62,percent of total billed charges,,,57.4,,189.42,percent of total billed charges,,,81,,267.3,percent of total billed charges,,,51.5,,169.95,percent of total billed charges,,,57.6,,190.08,percent of total billed charges,,,85,,280.5,percent of total billed charges,,,85,,280.5,percent of total billed charges,,,49,,161.7,percent of total billed charges,,,90,,297,percent of total billed charges,,,65,,214.5,percent of total billed charges,,,80,,264,percent of total billed charges,,,55,,181.5,percent of total billed charges,,,55,,181.5,percent of total billed charges,,,65,,214.5,percent of total billed charges,,,78,,257.4,percent of total billed charges,,,70,,231,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,149.49,297,
"Telehealth Psych or Neuropsych test admin by technician, EA Addtl 30 min (96139)",96139,CPT,,,,both,,,330,198,,45.5,,150.15,percent of total billed charges,,,45.3,,149.49,percent of total billed charges,,,51,,168.3,percent of total billed charges,,,,,,,,,80,,264,percent of total billed charges,,,61.4,,202.62,percent of total billed charges,,,57.4,,189.42,percent of total billed charges,,,81,,267.3,percent of total billed charges,,,51.5,,169.95,percent of total billed charges,,,57.6,,190.08,percent of total billed charges,,,85,,280.5,percent of total billed charges,,,85,,280.5,percent of total billed charges,,,49,,161.7,percent of total billed charges,,,90,,297,percent of total billed charges,,,65,,214.5,percent of total billed charges,,,80,,264,percent of total billed charges,,,55,,181.5,percent of total billed charges,,,55,,181.5,percent of total billed charges,,,65,,214.5,percent of total billed charges,,,78,,257.4,percent of total billed charges,,,70,,231,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,149.49,297,
Psych or neuropsych test admin with single automated instrument (96146),96146,CPT,,,,both,,,142,85.2,,45.5,,64.61,percent of total billed charges,,,45.3,,64.33,percent of total billed charges,,,51,,72.42,percent of total billed charges,,,,,,,,,80,,113.6,percent of total billed charges,,,61.4,,87.19,percent of total billed charges,,,57.4,,81.51,percent of total billed charges,,,81,,115.02,percent of total billed charges,,,51.5,,73.13,percent of total billed charges,,,57.6,,81.79,percent of total billed charges,,,85,,120.7,percent of total billed charges,,,85,,120.7,percent of total billed charges,,,49,,69.58,percent of total billed charges,,,90,,127.8,percent of total billed charges,,,65,,92.3,percent of total billed charges,,,80,,113.6,percent of total billed charges,,,55,,78.1,percent of total billed charges,,,55,,78.1,percent of total billed charges,,,65,,92.3,percent of total billed charges,,,78,,110.76,percent of total billed charges,,,70,,99.4,percent of total billed charges,,,,,,,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,25.53,,,,100% of Medicare,,,25.53,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,25.53,127.8,
Health and Behavior Assessment/Re-Assessment (96156),96156,CPT,,,,both,,,320,192,,45.5,,145.6,percent of total billed charges,,,45.3,,144.96,percent of total billed charges,,,51,,163.2,percent of total billed charges,,,,,,,,,80,,256,percent of total billed charges,,,61.4,,196.48,percent of total billed charges,,,57.4,,183.68,percent of total billed charges,,,81,,259.2,percent of total billed charges,,,51.5,,164.8,percent of total billed charges,,,57.6,,184.32,percent of total billed charges,,,85,,272,percent of total billed charges,,,85,,272,percent of total billed charges,,,49,,156.8,percent of total billed charges,,,90,,288,percent of total billed charges,,,65,,208,percent of total billed charges,,,80,,256,percent of total billed charges,,,55,,176,percent of total billed charges,,,55,,176,percent of total billed charges,,,65,,208,percent of total billed charges,,,78,,249.6,percent of total billed charges,,,70,,224,percent of total billed charges,,,,,,,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,,96.42,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,96.42,288,
Soc Health and Behavior Assessment/Re-Assessment (96156),96156,CPT,,,,both,,,320,192,,45.5,,145.6,percent of total billed charges,,,45.3,,144.96,percent of total billed charges,,,51,,163.2,percent of total billed charges,,,,,,,,,80,,256,percent of total billed charges,,,61.4,,196.48,percent of total billed charges,,,57.4,,183.68,percent of total billed charges,,,81,,259.2,percent of total billed charges,,,51.5,,164.8,percent of total billed charges,,,57.6,,184.32,percent of total billed charges,,,85,,272,percent of total billed charges,,,85,,272,percent of total billed charges,,,49,,156.8,percent of total billed charges,,,90,,288,percent of total billed charges,,,65,,208,percent of total billed charges,,,80,,256,percent of total billed charges,,,55,,176,percent of total billed charges,,,55,,176,percent of total billed charges,,,65,,208,percent of total billed charges,,,78,,249.6,percent of total billed charges,,,70,,224,percent of total billed charges,,,,,,,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,,96.42,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,96.42,288,
Telehealth Health and Behavior Assessment/Re-Assessment (96156),96156,CPT,,,,both,,,320,192,,45.5,,145.6,percent of total billed charges,,,45.3,,144.96,percent of total billed charges,,,51,,163.2,percent of total billed charges,,,,,,,,,80,,256,percent of total billed charges,,,61.4,,196.48,percent of total billed charges,,,57.4,,183.68,percent of total billed charges,,,81,,259.2,percent of total billed charges,,,51.5,,164.8,percent of total billed charges,,,57.6,,184.32,percent of total billed charges,,,85,,272,percent of total billed charges,,,85,,272,percent of total billed charges,,,49,,156.8,percent of total billed charges,,,90,,288,percent of total billed charges,,,65,,208,percent of total billed charges,,,80,,256,percent of total billed charges,,,55,,176,percent of total billed charges,,,55,,176,percent of total billed charges,,,65,,208,percent of total billed charges,,,78,,249.6,percent of total billed charges,,,70,,224,percent of total billed charges,,,,,,,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,,96.42,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,96.42,288,
"Health and Behavior Intervention, Indiv, initial 30 min (96158)",96158,CPT,,,,both,,,320,192,,45.5,,145.6,percent of total billed charges,,,45.3,,144.96,percent of total billed charges,,,51,,163.2,percent of total billed charges,,,,,,,,,80,,256,percent of total billed charges,,,61.4,,196.48,percent of total billed charges,,,57.4,,183.68,percent of total billed charges,,,81,,259.2,percent of total billed charges,,,51.5,,164.8,percent of total billed charges,,,57.6,,184.32,percent of total billed charges,,,85,,272,percent of total billed charges,,,85,,272,percent of total billed charges,,,49,,156.8,percent of total billed charges,,,90,,288,percent of total billed charges,,,65,,208,percent of total billed charges,,,80,,256,percent of total billed charges,,,55,,176,percent of total billed charges,,,55,,176,percent of total billed charges,,,65,,208,percent of total billed charges,,,78,,249.6,percent of total billed charges,,,70,,224,percent of total billed charges,,,,,,,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,,167.49,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,144.96,288,
"Soc Health and Behavior Intervention, Indiv, initial 30 min (96158)",96158,CPT,,,,both,,,320,192,,45.5,,145.6,percent of total billed charges,,,45.3,,144.96,percent of total billed charges,,,51,,163.2,percent of total billed charges,,,,,,,,,80,,256,percent of total billed charges,,,61.4,,196.48,percent of total billed charges,,,57.4,,183.68,percent of total billed charges,,,81,,259.2,percent of total billed charges,,,51.5,,164.8,percent of total billed charges,,,57.6,,184.32,percent of total billed charges,,,85,,272,percent of total billed charges,,,85,,272,percent of total billed charges,,,49,,156.8,percent of total billed charges,,,90,,288,percent of total billed charges,,,65,,208,percent of total billed charges,,,80,,256,percent of total billed charges,,,55,,176,percent of total billed charges,,,55,,176,percent of total billed charges,,,65,,208,percent of total billed charges,,,78,,249.6,percent of total billed charges,,,70,,224,percent of total billed charges,,,,,,,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,,167.49,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,144.96,288,
"Telehealth Health and Behavior Intervention, Indiv, Itl 30 min (96158)",96158,CPT,,,,both,,,320,192,,45.5,,145.6,percent of total billed charges,,,45.3,,144.96,percent of total billed charges,,,51,,163.2,percent of total billed charges,,,,,,,,,80,,256,percent of total billed charges,,,61.4,,196.48,percent of total billed charges,,,57.4,,183.68,percent of total billed charges,,,81,,259.2,percent of total billed charges,,,51.5,,164.8,percent of total billed charges,,,57.6,,184.32,percent of total billed charges,,,85,,272,percent of total billed charges,,,85,,272,percent of total billed charges,,,49,,156.8,percent of total billed charges,,,90,,288,percent of total billed charges,,,65,,208,percent of total billed charges,,,80,,256,percent of total billed charges,,,55,,176,percent of total billed charges,,,55,,176,percent of total billed charges,,,65,,208,percent of total billed charges,,,78,,249.6,percent of total billed charges,,,70,,224,percent of total billed charges,,,,,,,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,167.49,,,,100% of Medicare,,,167.49,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,144.96,288,
"Health and Behavior Intervention, Indiv, Ea Addtl 15 min (96159)",96159,CPT,,,,both,,,161,96.6,,45.5,,73.26,percent of total billed charges,,,45.3,,72.93,percent of total billed charges,,,51,,82.11,percent of total billed charges,,,,,,,,,80,,128.8,percent of total billed charges,,,61.4,,98.85,percent of total billed charges,,,57.4,,92.41,percent of total billed charges,,,81,,130.41,percent of total billed charges,,,51.5,,82.92,percent of total billed charges,,,57.6,,92.74,percent of total billed charges,,,85,,136.85,percent of total billed charges,,,85,,136.85,percent of total billed charges,,,49,,78.89,percent of total billed charges,,,90,,144.9,percent of total billed charges,,,65,,104.65,percent of total billed charges,,,80,,128.8,percent of total billed charges,,,55,,88.55,percent of total billed charges,,,55,,88.55,percent of total billed charges,,,65,,104.65,percent of total billed charges,,,78,,125.58,percent of total billed charges,,,70,,112.7,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,72.93,144.9,
"Soc Health and Behavior Intervention, Indiv, Ea Addtl 15 min (96159)",96159,CPT,,,,both,,,161,96.6,,45.5,,73.26,percent of total billed charges,,,45.3,,72.93,percent of total billed charges,,,51,,82.11,percent of total billed charges,,,,,,,,,80,,128.8,percent of total billed charges,,,61.4,,98.85,percent of total billed charges,,,57.4,,92.41,percent of total billed charges,,,81,,130.41,percent of total billed charges,,,51.5,,82.92,percent of total billed charges,,,57.6,,92.74,percent of total billed charges,,,85,,136.85,percent of total billed charges,,,85,,136.85,percent of total billed charges,,,49,,78.89,percent of total billed charges,,,90,,144.9,percent of total billed charges,,,65,,104.65,percent of total billed charges,,,80,,128.8,percent of total billed charges,,,55,,88.55,percent of total billed charges,,,55,,88.55,percent of total billed charges,,,65,,104.65,percent of total billed charges,,,78,,125.58,percent of total billed charges,,,70,,112.7,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,72.93,144.9,
"Telehealth Health and Behavior Intervention, Indiv, EA Addtl (96159)",96159,CPT,,,,both,,,161,96.6,,45.5,,73.26,percent of total billed charges,,,45.3,,72.93,percent of total billed charges,,,51,,82.11,percent of total billed charges,,,,,,,,,80,,128.8,percent of total billed charges,,,61.4,,98.85,percent of total billed charges,,,57.4,,92.41,percent of total billed charges,,,81,,130.41,percent of total billed charges,,,51.5,,82.92,percent of total billed charges,,,57.6,,92.74,percent of total billed charges,,,85,,136.85,percent of total billed charges,,,85,,136.85,percent of total billed charges,,,49,,78.89,percent of total billed charges,,,90,,144.9,percent of total billed charges,,,65,,104.65,percent of total billed charges,,,80,,128.8,percent of total billed charges,,,55,,88.55,percent of total billed charges,,,55,,88.55,percent of total billed charges,,,65,,104.65,percent of total billed charges,,,78,,125.58,percent of total billed charges,,,70,,112.7,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,72.93,144.9,
"Health and Behavior Intervention Group, Initial 30 min (96164)",96164,CPT,,,,both,,,206,123.6,,45.5,,93.73,percent of total billed charges,,,45.3,,93.32,percent of total billed charges,,,51,,105.06,percent of total billed charges,,,,,,,,,80,,164.8,percent of total billed charges,,,61.4,,126.48,percent of total billed charges,,,57.4,,118.24,percent of total billed charges,,,81,,166.86,percent of total billed charges,,,51.5,,106.09,percent of total billed charges,,,57.6,,118.66,percent of total billed charges,,,85,,175.1,percent of total billed charges,,,85,,175.1,percent of total billed charges,,,49,,100.94,percent of total billed charges,,,90,,185.4,percent of total billed charges,,,65,,133.9,percent of total billed charges,,,80,,164.8,percent of total billed charges,,,55,,113.3,percent of total billed charges,,,55,,113.3,percent of total billed charges,,,65,,133.9,percent of total billed charges,,,78,,160.68,percent of total billed charges,,,70,,144.2,percent of total billed charges,,,,,,,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,,31.05,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,31.05,185.4,
"Soc Health and Behavior Intervention Group, Initial 30 min (96164)",96164,CPT,,,,both,,,206,123.6,,45.5,,93.73,percent of total billed charges,,,45.3,,93.32,percent of total billed charges,,,51,,105.06,percent of total billed charges,,,,,,,,,80,,164.8,percent of total billed charges,,,61.4,,126.48,percent of total billed charges,,,57.4,,118.24,percent of total billed charges,,,81,,166.86,percent of total billed charges,,,51.5,,106.09,percent of total billed charges,,,57.6,,118.66,percent of total billed charges,,,85,,175.1,percent of total billed charges,,,85,,175.1,percent of total billed charges,,,49,,100.94,percent of total billed charges,,,90,,185.4,percent of total billed charges,,,65,,133.9,percent of total billed charges,,,80,,164.8,percent of total billed charges,,,55,,113.3,percent of total billed charges,,,55,,113.3,percent of total billed charges,,,65,,133.9,percent of total billed charges,,,78,,160.68,percent of total billed charges,,,70,,144.2,percent of total billed charges,,,,,,,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,,31.05,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,31.05,185.4,
"Telehealth Health and Behavior Intervention Grp, Itl 30 min (96164)",96164,CPT,,,,both,,,206,123.6,,45.5,,93.73,percent of total billed charges,,,45.3,,93.32,percent of total billed charges,,,51,,105.06,percent of total billed charges,,,,,,,,,80,,164.8,percent of total billed charges,,,61.4,,126.48,percent of total billed charges,,,57.4,,118.24,percent of total billed charges,,,81,,166.86,percent of total billed charges,,,51.5,,106.09,percent of total billed charges,,,57.6,,118.66,percent of total billed charges,,,85,,175.1,percent of total billed charges,,,85,,175.1,percent of total billed charges,,,49,,100.94,percent of total billed charges,,,90,,185.4,percent of total billed charges,,,65,,133.9,percent of total billed charges,,,80,,164.8,percent of total billed charges,,,55,,113.3,percent of total billed charges,,,55,,113.3,percent of total billed charges,,,65,,133.9,percent of total billed charges,,,78,,160.68,percent of total billed charges,,,70,,144.2,percent of total billed charges,,,,,,,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,,31.05,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,31.05,185.4,
"Health and Behavior Intervention Group, Ea Addtl 15 min (96165)",96165,CPT,,,,both,,,109,65.4,,45.5,,49.6,percent of total billed charges,,,45.3,,49.38,percent of total billed charges,,,51,,55.59,percent of total billed charges,,,,,,,,,80,,87.2,percent of total billed charges,,,61.4,,66.93,percent of total billed charges,,,57.4,,62.57,percent of total billed charges,,,81,,88.29,percent of total billed charges,,,51.5,,56.14,percent of total billed charges,,,57.6,,62.78,percent of total billed charges,,,85,,92.65,percent of total billed charges,,,85,,92.65,percent of total billed charges,,,49,,53.41,percent of total billed charges,,,90,,98.1,percent of total billed charges,,,65,,70.85,percent of total billed charges,,,80,,87.2,percent of total billed charges,,,55,,59.95,percent of total billed charges,,,55,,59.95,percent of total billed charges,,,65,,70.85,percent of total billed charges,,,78,,85.02,percent of total billed charges,,,70,,76.3,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,49.38,98.1,
"Soc Health and Behavior Intervention Group, Ea Addtl 15 min (96165)",96165,CPT,,,,both,,,109,65.4,,45.5,,49.6,percent of total billed charges,,,45.3,,49.38,percent of total billed charges,,,51,,55.59,percent of total billed charges,,,,,,,,,80,,87.2,percent of total billed charges,,,61.4,,66.93,percent of total billed charges,,,57.4,,62.57,percent of total billed charges,,,81,,88.29,percent of total billed charges,,,51.5,,56.14,percent of total billed charges,,,57.6,,62.78,percent of total billed charges,,,85,,92.65,percent of total billed charges,,,85,,92.65,percent of total billed charges,,,49,,53.41,percent of total billed charges,,,90,,98.1,percent of total billed charges,,,65,,70.85,percent of total billed charges,,,80,,87.2,percent of total billed charges,,,55,,59.95,percent of total billed charges,,,55,,59.95,percent of total billed charges,,,65,,70.85,percent of total billed charges,,,78,,85.02,percent of total billed charges,,,70,,76.3,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,49.38,98.1,
"Telehealth Health and Behavior Intervention Grp, EA Addtl 15 min (96165)",96165,CPT,,,,both,,,109,65.4,,45.5,,49.6,percent of total billed charges,,,45.3,,49.38,percent of total billed charges,,,51,,55.59,percent of total billed charges,,,,,,,,,80,,87.2,percent of total billed charges,,,61.4,,66.93,percent of total billed charges,,,57.4,,62.57,percent of total billed charges,,,81,,88.29,percent of total billed charges,,,51.5,,56.14,percent of total billed charges,,,57.6,,62.78,percent of total billed charges,,,85,,92.65,percent of total billed charges,,,85,,92.65,percent of total billed charges,,,49,,53.41,percent of total billed charges,,,90,,98.1,percent of total billed charges,,,65,,70.85,percent of total billed charges,,,80,,87.2,percent of total billed charges,,,55,,59.95,percent of total billed charges,,,55,,59.95,percent of total billed charges,,,65,,70.85,percent of total billed charges,,,78,,85.02,percent of total billed charges,,,70,,76.3,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,49.38,98.1,
"Health and Behavior Intervention Family, Initial 30 min (96167)",96167,CPT,,,,both,,,322,193.2,,45.5,,146.51,percent of total billed charges,,,45.3,,145.87,percent of total billed charges,,,51,,164.22,percent of total billed charges,,,,,,,,,80,,257.6,percent of total billed charges,,,61.4,,197.71,percent of total billed charges,,,57.4,,184.83,percent of total billed charges,,,81,,260.82,percent of total billed charges,,,51.5,,165.83,percent of total billed charges,,,57.6,,185.47,percent of total billed charges,,,85,,273.7,percent of total billed charges,,,85,,273.7,percent of total billed charges,,,49,,157.78,percent of total billed charges,,,90,,289.8,percent of total billed charges,,,65,,209.3,percent of total billed charges,,,80,,257.6,percent of total billed charges,,,55,,177.1,percent of total billed charges,,,55,,177.1,percent of total billed charges,,,65,,209.3,percent of total billed charges,,,78,,251.16,percent of total billed charges,,,70,,225.4,percent of total billed charges,,,,,,,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,,31.05,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,31.05,289.8,
"Soc Health and Behavior Intervention Family, Initial 30 min (96167)",96167,CPT,,,,both,,,322,193.2,,45.5,,146.51,percent of total billed charges,,,45.3,,145.87,percent of total billed charges,,,51,,164.22,percent of total billed charges,,,,,,,,,80,,257.6,percent of total billed charges,,,61.4,,197.71,percent of total billed charges,,,57.4,,184.83,percent of total billed charges,,,81,,260.82,percent of total billed charges,,,51.5,,165.83,percent of total billed charges,,,57.6,,185.47,percent of total billed charges,,,85,,273.7,percent of total billed charges,,,85,,273.7,percent of total billed charges,,,49,,157.78,percent of total billed charges,,,90,,289.8,percent of total billed charges,,,65,,209.3,percent of total billed charges,,,80,,257.6,percent of total billed charges,,,55,,177.1,percent of total billed charges,,,55,,177.1,percent of total billed charges,,,65,,209.3,percent of total billed charges,,,78,,251.16,percent of total billed charges,,,70,,225.4,percent of total billed charges,,,,,,,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,,31.05,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,31.05,289.8,
"Telehealth Health and Behavior Intervention Family, Itl 30 min (96167)",96167,CPT,,,,both,,,322,193.2,,45.5,,146.51,percent of total billed charges,,,45.3,,145.87,percent of total billed charges,,,51,,164.22,percent of total billed charges,,,,,,,,,80,,257.6,percent of total billed charges,,,61.4,,197.71,percent of total billed charges,,,57.4,,184.83,percent of total billed charges,,,81,,260.82,percent of total billed charges,,,51.5,,165.83,percent of total billed charges,,,57.6,,185.47,percent of total billed charges,,,85,,273.7,percent of total billed charges,,,85,,273.7,percent of total billed charges,,,49,,157.78,percent of total billed charges,,,90,,289.8,percent of total billed charges,,,65,,209.3,percent of total billed charges,,,80,,257.6,percent of total billed charges,,,55,,177.1,percent of total billed charges,,,55,,177.1,percent of total billed charges,,,65,,209.3,percent of total billed charges,,,78,,251.16,percent of total billed charges,,,70,,225.4,percent of total billed charges,,,,,,,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,31.05,,,,100% of Medicare,,,31.05,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,31.05,289.8,
"Health and Behavior Intervention Family, Ea Addtl 15 min (96168)",96168,CPT,,,,both,,,161,96.6,,45.5,,73.26,percent of total billed charges,,,45.3,,72.93,percent of total billed charges,,,51,,82.11,percent of total billed charges,,,,,,,,,80,,128.8,percent of total billed charges,,,61.4,,98.85,percent of total billed charges,,,57.4,,92.41,percent of total billed charges,,,81,,130.41,percent of total billed charges,,,51.5,,82.92,percent of total billed charges,,,57.6,,92.74,percent of total billed charges,,,85,,136.85,percent of total billed charges,,,85,,136.85,percent of total billed charges,,,49,,78.89,percent of total billed charges,,,90,,144.9,percent of total billed charges,,,65,,104.65,percent of total billed charges,,,80,,128.8,percent of total billed charges,,,55,,88.55,percent of total billed charges,,,55,,88.55,percent of total billed charges,,,65,,104.65,percent of total billed charges,,,78,,125.58,percent of total billed charges,,,70,,112.7,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,72.93,144.9,
"Soc Health and Behavior Intervention Family, Ea Addtl 15 min (96168)",96168,CPT,,,,both,,,161,96.6,,45.5,,73.26,percent of total billed charges,,,45.3,,72.93,percent of total billed charges,,,51,,82.11,percent of total billed charges,,,,,,,,,80,,128.8,percent of total billed charges,,,61.4,,98.85,percent of total billed charges,,,57.4,,92.41,percent of total billed charges,,,81,,130.41,percent of total billed charges,,,51.5,,82.92,percent of total billed charges,,,57.6,,92.74,percent of total billed charges,,,85,,136.85,percent of total billed charges,,,85,,136.85,percent of total billed charges,,,49,,78.89,percent of total billed charges,,,90,,144.9,percent of total billed charges,,,65,,104.65,percent of total billed charges,,,80,,128.8,percent of total billed charges,,,55,,88.55,percent of total billed charges,,,55,,88.55,percent of total billed charges,,,65,,104.65,percent of total billed charges,,,78,,125.58,percent of total billed charges,,,70,,112.7,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,72.93,144.9,
"Telehealth Health and Behavior Intervention Family, Ea Addtl 15 min (96168)",96168,CPT,,,,both,,,161,96.6,,45.5,,73.26,percent of total billed charges,,,45.3,,72.93,percent of total billed charges,,,51,,82.11,percent of total billed charges,,,,,,,,,80,,128.8,percent of total billed charges,,,61.4,,98.85,percent of total billed charges,,,57.4,,92.41,percent of total billed charges,,,81,,130.41,percent of total billed charges,,,51.5,,82.92,percent of total billed charges,,,57.6,,92.74,percent of total billed charges,,,85,,136.85,percent of total billed charges,,,85,,136.85,percent of total billed charges,,,49,,78.89,percent of total billed charges,,,90,,144.9,percent of total billed charges,,,65,,104.65,percent of total billed charges,,,80,,128.8,percent of total billed charges,,,55,,88.55,percent of total billed charges,,,55,,88.55,percent of total billed charges,,,65,,104.65,percent of total billed charges,,,78,,125.58,percent of total billed charges,,,70,,112.7,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,72.93,144.9,
"Health and Behavior Interv Fmly w/o Patient, Initial 30 min (96170)",96170,CPT,,,,both,,,313,187.8,,45.5,,142.42,percent of total billed charges,,,45.3,,141.79,percent of total billed charges,,,51,,159.63,percent of total billed charges,,,,,,,,,80,,250.4,percent of total billed charges,,,61.4,,192.18,percent of total billed charges,,,57.4,,179.66,percent of total billed charges,,,81,,253.53,percent of total billed charges,,,51.5,,161.2,percent of total billed charges,,,57.6,,180.29,percent of total billed charges,,,85,,266.05,percent of total billed charges,,,85,,266.05,percent of total billed charges,,,49,,153.37,percent of total billed charges,,,90,,281.7,percent of total billed charges,,,65,,203.45,percent of total billed charges,,,80,,250.4,percent of total billed charges,,,55,,172.15,percent of total billed charges,,,55,,172.15,percent of total billed charges,,,65,,203.45,percent of total billed charges,,,78,,244.14,percent of total billed charges,,,70,,219.1,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,141.79,281.7,
"Soc  Health and Behavior Interv Fmly w/o Patient, Initial 30 min (96170)",96170,CPT,,,,both,,,313,187.8,,45.5,,142.42,percent of total billed charges,,,45.3,,141.79,percent of total billed charges,,,51,,159.63,percent of total billed charges,,,,,,,,,80,,250.4,percent of total billed charges,,,61.4,,192.18,percent of total billed charges,,,57.4,,179.66,percent of total billed charges,,,81,,253.53,percent of total billed charges,,,51.5,,161.2,percent of total billed charges,,,57.6,,180.29,percent of total billed charges,,,85,,266.05,percent of total billed charges,,,85,,266.05,percent of total billed charges,,,49,,153.37,percent of total billed charges,,,90,,281.7,percent of total billed charges,,,65,,203.45,percent of total billed charges,,,80,,250.4,percent of total billed charges,,,55,,172.15,percent of total billed charges,,,55,,172.15,percent of total billed charges,,,65,,203.45,percent of total billed charges,,,78,,244.14,percent of total billed charges,,,70,,219.1,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,141.79,281.7,
"Telehealth Health and Behavior Interv Fmly w/o Patient, Init (96170)",96170,CPT,,,,both,,,313,187.8,,45.5,,142.42,percent of total billed charges,,,45.3,,141.79,percent of total billed charges,,,51,,159.63,percent of total billed charges,,,,,,,,,80,,250.4,percent of total billed charges,,,61.4,,192.18,percent of total billed charges,,,57.4,,179.66,percent of total billed charges,,,81,,253.53,percent of total billed charges,,,51.5,,161.2,percent of total billed charges,,,57.6,,180.29,percent of total billed charges,,,85,,266.05,percent of total billed charges,,,85,,266.05,percent of total billed charges,,,49,,153.37,percent of total billed charges,,,90,,281.7,percent of total billed charges,,,65,,203.45,percent of total billed charges,,,80,,250.4,percent of total billed charges,,,55,,172.15,percent of total billed charges,,,55,,172.15,percent of total billed charges,,,65,,203.45,percent of total billed charges,,,78,,244.14,percent of total billed charges,,,70,,219.1,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,141.79,281.7,
"Health and Behavior Interv Fmly w/o Patient, Ea Addtl 15 min (96171)",96171,CPT,,,,both,,,197,118.2,,45.5,,89.64,percent of total billed charges,,,45.3,,89.24,percent of total billed charges,,,51,,100.47,percent of total billed charges,,,,,,,,,80,,157.6,percent of total billed charges,,,61.4,,120.96,percent of total billed charges,,,57.4,,113.08,percent of total billed charges,,,81,,159.57,percent of total billed charges,,,51.5,,101.46,percent of total billed charges,,,57.6,,113.47,percent of total billed charges,,,85,,167.45,percent of total billed charges,,,85,,167.45,percent of total billed charges,,,49,,96.53,percent of total billed charges,,,90,,177.3,percent of total billed charges,,,65,,128.05,percent of total billed charges,,,80,,157.6,percent of total billed charges,,,55,,108.35,percent of total billed charges,,,55,,108.35,percent of total billed charges,,,65,,128.05,percent of total billed charges,,,78,,153.66,percent of total billed charges,,,70,,137.9,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,89.24,177.3,
"Soc Health and Behavior Interv Fmly w/o Patient, Ea Addtl 15 min (96171)",96171,CPT,,,,both,,,197,118.2,,45.5,,89.64,percent of total billed charges,,,45.3,,89.24,percent of total billed charges,,,51,,100.47,percent of total billed charges,,,,,,,,,80,,157.6,percent of total billed charges,,,61.4,,120.96,percent of total billed charges,,,57.4,,113.08,percent of total billed charges,,,81,,159.57,percent of total billed charges,,,51.5,,101.46,percent of total billed charges,,,57.6,,113.47,percent of total billed charges,,,85,,167.45,percent of total billed charges,,,85,,167.45,percent of total billed charges,,,49,,96.53,percent of total billed charges,,,90,,177.3,percent of total billed charges,,,65,,128.05,percent of total billed charges,,,80,,157.6,percent of total billed charges,,,55,,108.35,percent of total billed charges,,,55,,108.35,percent of total billed charges,,,65,,128.05,percent of total billed charges,,,78,,153.66,percent of total billed charges,,,70,,137.9,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,89.24,177.3,
"Telehealth Health and Behavior Interv Fmly w/o Patient, EA Addtl (96171)",96171,CPT,,,,both,,,197,118.2,,45.5,,89.64,percent of total billed charges,,,45.3,,89.24,percent of total billed charges,,,51,,100.47,percent of total billed charges,,,,,,,,,80,,157.6,percent of total billed charges,,,61.4,,120.96,percent of total billed charges,,,57.4,,113.08,percent of total billed charges,,,81,,159.57,percent of total billed charges,,,51.5,,101.46,percent of total billed charges,,,57.6,,113.47,percent of total billed charges,,,85,,167.45,percent of total billed charges,,,85,,167.45,percent of total billed charges,,,49,,96.53,percent of total billed charges,,,90,,177.3,percent of total billed charges,,,65,,128.05,percent of total billed charges,,,80,,157.6,percent of total billed charges,,,55,,108.35,percent of total billed charges,,,55,,108.35,percent of total billed charges,,,65,,128.05,percent of total billed charges,,,78,,153.66,percent of total billed charges,,,70,,137.9,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,89.24,177.3,
"Therapeutic,prophylactic or diagnostic injection",96372,CPT,,,,outpatient,,,144,86.4,,45.5,,65.52,percent of total billed charges,,,45.3,,65.23,percent of total billed charges,,,51,,73.44,percent of total billed charges,,,,,,,,,80,,115.2,percent of total billed charges,,,61.4,,88.42,percent of total billed charges,,,57.4,,82.66,percent of total billed charges,,,81,,116.64,percent of total billed charges,,,51.5,,74.16,percent of total billed charges,,,57.6,,82.94,percent of total billed charges,,,85,,122.4,percent of total billed charges,,,85,,122.4,percent of total billed charges,,,49,,70.56,percent of total billed charges,,,90,,129.6,percent of total billed charges,,,65,,93.6,percent of total billed charges,,,80,,115.2,percent of total billed charges,,,55,,79.2,percent of total billed charges,,,55,,79.2,percent of total billed charges,,,65,,93.6,percent of total billed charges,,,78,,112.32,percent of total billed charges,,,70,,100.8,percent of total billed charges,,,,,,,,74.19,,,,100% of Medicare,,74.19,,,,100% of Medicare,,74.19,,,,100% of Medicare,,74.19,,,,100% of Medicare,,74.19,,,,100% of Medicare,,74.19,,,,100% of Medicare,,74.19,,,,100% of Medicare,,74.19,,,,100% of Medicare,,74.19,,,,100% of Medicare,,74.19,,,,100% of Medicare,,74.19,,,,100% of Medicare,,74.19,,,,100% of Medicare,,,74.19,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,65.23,129.6,
"Therapeutic, Prophylactic, Diagnostic Injections/Infusions  single or initial substance/drug 96374",96374,CPT,,,,outpatient,,,592,355.2,,45.5,,269.36,percent of total billed charges,,,45.3,,268.18,percent of total billed charges,,,51,,301.92,percent of total billed charges,,,,,,,,,80,,473.6,percent of total billed charges,,,61.4,,363.49,percent of total billed charges,,,57.4,,339.81,percent of total billed charges,,,81,,479.52,percent of total billed charges,,,51.5,,304.88,percent of total billed charges,,,57.6,,340.99,percent of total billed charges,,,85,,503.2,percent of total billed charges,,,85,,503.2,percent of total billed charges,,,49,,290.08,percent of total billed charges,,,90,,532.8,percent of total billed charges,,,65,,384.8,percent of total billed charges,,,80,,473.6,percent of total billed charges,,,55,,325.6,percent of total billed charges,,,55,,325.6,percent of total billed charges,,,65,,384.8,percent of total billed charges,,,78,,461.76,percent of total billed charges,,,70,,414.4,percent of total billed charges,,,,,,,,219.63,,,,100% of Medicare,,219.63,,,,100% of Medicare,,219.63,,,,100% of Medicare,,219.63,,,,100% of Medicare,,219.63,,,,100% of Medicare,,219.63,,,,100% of Medicare,,219.63,,,,100% of Medicare,,219.63,,,,100% of Medicare,,219.63,,,,100% of Medicare,,219.63,,,,100% of Medicare,,219.63,,,,100% of Medicare,,219.63,,,,100% of Medicare,,,219.63,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,219.63,532.8,
"Chemotherapy, into CNS Charge-96450",96450,CPT,,,,outpatient,,,1137,682.2,,45.5,,517.34,percent of total billed charges,,,45.3,,515.06,percent of total billed charges,,,51,,579.87,percent of total billed charges,,,,,,,,,80,,909.6,percent of total billed charges,,,61.4,,698.12,percent of total billed charges,,,57.4,,652.64,percent of total billed charges,,,81,,920.97,percent of total billed charges,,,51.5,,585.56,percent of total billed charges,,,57.6,,654.91,percent of total billed charges,,,85,,966.45,percent of total billed charges,,,85,,966.45,percent of total billed charges,,,49,,557.13,percent of total billed charges,,,90,,1023.3,percent of total billed charges,,,65,,739.05,percent of total billed charges,,,80,,909.6,percent of total billed charges,,,55,,625.35,percent of total billed charges,,,55,,625.35,percent of total billed charges,,,65,,739.05,percent of total billed charges,,,78,,886.86,percent of total billed charges,,,70,,795.9,percent of total billed charges,,,,,,,,345.76,,,,100% of Medicare,,345.76,,,,100% of Medicare,,345.76,,,,100% of Medicare,,345.76,,,,100% of Medicare,,345.76,,,,100% of Medicare,,345.76,,,,100% of Medicare,,345.76,,,,100% of Medicare,,345.76,,,,100% of Medicare,,345.76,,,,100% of Medicare,,345.76,,,,100% of Medicare,,345.76,,,,100% of Medicare,,345.76,,,,100% of Medicare,,,345.76,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,345.76,1023.3,
Behavior ID Assessment by Phys/QHP Health Ea 15 min (97151),97151,CPT,,,,both,,,324,194.4,,45.5,,147.42,percent of total billed charges,,,45.3,,146.77,percent of total billed charges,,,51,,165.24,percent of total billed charges,,,,,,,,,80,,259.2,percent of total billed charges,,,61.4,,198.94,percent of total billed charges,,,57.4,,185.98,percent of total billed charges,,,81,,262.44,percent of total billed charges,,,51.5,,166.86,percent of total billed charges,,,57.6,,186.62,percent of total billed charges,,,85,,275.4,percent of total billed charges,,,85,,275.4,percent of total billed charges,,,49,,158.76,percent of total billed charges,,,90,,291.6,percent of total billed charges,,,65,,210.6,percent of total billed charges,,,80,,259.2,percent of total billed charges,,,55,,178.2,percent of total billed charges,,,55,,178.2,percent of total billed charges,,,65,,210.6,percent of total billed charges,,,78,,252.72,percent of total billed charges,,,70,,226.8,percent of total billed charges,,,,,,,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,24285.426,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,,96.42,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,96.42,24285.43,
Soc Health and Behavior ID Assessment by Phys/QHP Health Ea 15 min (97151),97151,CPT,,,,both,,,324,194.4,,45.5,,147.42,percent of total billed charges,,,45.3,,146.77,percent of total billed charges,,,51,,165.24,percent of total billed charges,,,,,,,,,80,,259.2,percent of total billed charges,,,61.4,,198.94,percent of total billed charges,,,57.4,,185.98,percent of total billed charges,,,81,,262.44,percent of total billed charges,,,51.5,,166.86,percent of total billed charges,,,57.6,,186.62,percent of total billed charges,,,85,,275.4,percent of total billed charges,,,85,,275.4,percent of total billed charges,,,49,,158.76,percent of total billed charges,,,90,,291.6,percent of total billed charges,,,65,,210.6,percent of total billed charges,,,80,,259.2,percent of total billed charges,,,55,,178.2,percent of total billed charges,,,55,,178.2,percent of total billed charges,,,65,,210.6,percent of total billed charges,,,78,,252.72,percent of total billed charges,,,70,,226.8,percent of total billed charges,,,,,,,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,,96.42,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,96.42,291.6,
Active Wound Care > 20 cm Units,97598,CPT,,,GP,both,,,239,143.4,,45.5,,108.75,percent of total billed charges,,,45.3,,108.27,percent of total billed charges,,,51,,121.89,percent of total billed charges,,,,,,,,,80,,191.2,percent of total billed charges,,,61.4,,146.75,percent of total billed charges,,,57.4,,137.19,percent of total billed charges,,,81,,193.59,percent of total billed charges,,,51.5,,123.09,percent of total billed charges,,,57.6,,137.66,percent of total billed charges,,,85,,203.15,percent of total billed charges,,,85,,203.15,percent of total billed charges,,,49,,117.11,percent of total billed charges,,,90,,215.1,percent of total billed charges,,,65,,155.35,percent of total billed charges,,,80,,191.2,percent of total billed charges,,,55,,131.45,percent of total billed charges,,,55,,131.45,percent of total billed charges,,,65,,155.35,percent of total billed charges,,,78,,186.42,percent of total billed charges,,,70,,167.3,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,108.27,215.1,
"Selective Debridement, Each Additional sq. 20 CM (add-on code) 97598",97598,CPT,,,,outpatient,,,670,402,,45.5,,304.85,percent of total billed charges,,,45.3,,303.51,percent of total billed charges,,,51,,341.7,percent of total billed charges,,,,,,,,,80,,536,percent of total billed charges,,,61.4,,411.38,percent of total billed charges,,,57.4,,384.58,percent of total billed charges,,,81,,542.7,percent of total billed charges,,,51.5,,345.05,percent of total billed charges,,,57.6,,385.92,percent of total billed charges,,,85,,569.5,percent of total billed charges,,,85,,569.5,percent of total billed charges,,,49,,328.3,percent of total billed charges,,,90,,603,percent of total billed charges,,,65,,435.5,percent of total billed charges,,,80,,536,percent of total billed charges,,,55,,368.5,percent of total billed charges,,,55,,368.5,percent of total billed charges,,,65,,435.5,percent of total billed charges,,,78,,522.6,percent of total billed charges,,,70,,469,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,303.51,603,
Wound(s) Care Non-Selective Units,97602,CPT,,,GP,both,,,239,143.4,,45.5,,108.75,percent of total billed charges,,,45.3,,108.27,percent of total billed charges,,,51,,121.89,percent of total billed charges,,,,,,,,,80,,191.2,percent of total billed charges,,,61.4,,146.75,percent of total billed charges,,,57.4,,137.19,percent of total billed charges,,,81,,193.59,percent of total billed charges,,,51.5,,123.09,percent of total billed charges,,,57.6,,137.66,percent of total billed charges,,,85,,203.15,percent of total billed charges,,,85,,203.15,percent of total billed charges,,,49,,117.11,percent of total billed charges,,,90,,215.1,percent of total billed charges,,,65,,155.35,percent of total billed charges,,,80,,191.2,percent of total billed charges,,,55,,131.45,percent of total billed charges,,,55,,131.45,percent of total billed charges,,,65,,155.35,percent of total billed charges,,,78,,186.42,percent of total billed charges,,,70,,167.3,percent of total billed charges,,,,,,,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,,207.13,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,108.27,215.1,
Non-Selective Debridement Including Topical Application Charge (97602),97602,CPT,,,,outpatient,,,552,331.2,,45.5,,251.16,percent of total billed charges,,,45.3,,250.06,percent of total billed charges,,,51,,281.52,percent of total billed charges,,,,,,,,,80,,441.6,percent of total billed charges,,,61.4,,338.93,percent of total billed charges,,,57.4,,316.85,percent of total billed charges,,,81,,447.12,percent of total billed charges,,,51.5,,284.28,percent of total billed charges,,,57.6,,317.95,percent of total billed charges,,,85,,469.2,percent of total billed charges,,,85,,469.2,percent of total billed charges,,,49,,270.48,percent of total billed charges,,,90,,496.8,percent of total billed charges,,,65,,358.8,percent of total billed charges,,,80,,441.6,percent of total billed charges,,,55,,303.6,percent of total billed charges,,,55,,303.6,percent of total billed charges,,,65,,358.8,percent of total billed charges,,,78,,430.56,percent of total billed charges,,,70,,386.4,percent of total billed charges,,,,,,,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,,207.13,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,207.13,496.8,
Neg Pressure Wound Tx  < 50 sq cm (97605),97605,CPT,,,,outpatient,,,328,196.8,,45.5,,149.24,percent of total billed charges,,,45.3,,148.58,percent of total billed charges,,,51,,167.28,percent of total billed charges,,,,,,,,,80,,262.4,percent of total billed charges,,,61.4,,201.39,percent of total billed charges,,,57.4,,188.27,percent of total billed charges,,,81,,265.68,percent of total billed charges,,,51.5,,168.92,percent of total billed charges,,,57.6,,188.93,percent of total billed charges,,,85,,278.8,percent of total billed charges,,,85,,278.8,percent of total billed charges,,,49,,160.72,percent of total billed charges,,,90,,295.2,percent of total billed charges,,,65,,213.2,percent of total billed charges,,,80,,262.4,percent of total billed charges,,,55,,180.4,percent of total billed charges,,,55,,180.4,percent of total billed charges,,,65,,213.2,percent of total billed charges,,,78,,255.84,percent of total billed charges,,,70,,229.6,percent of total billed charges,,,,,,,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,207.13,,,,100% of Medicare,,,207.13,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,148.58,295.2,
Neg Pressure Wound Tx  > 50 sq cm (97606),97606,CPT,,,,outpatient,,,630,378,,45.5,,286.65,percent of total billed charges,,,45.3,,285.39,percent of total billed charges,,,51,,321.3,percent of total billed charges,,,,,,,,,80,,504,percent of total billed charges,,,61.4,,386.82,percent of total billed charges,,,57.4,,361.62,percent of total billed charges,,,81,,510.3,percent of total billed charges,,,51.5,,324.45,percent of total billed charges,,,57.6,,362.88,percent of total billed charges,,,85,,535.5,percent of total billed charges,,,85,,535.5,percent of total billed charges,,,49,,308.7,percent of total billed charges,,,90,,567,percent of total billed charges,,,65,,409.5,percent of total billed charges,,,80,,504,percent of total billed charges,,,55,,346.5,percent of total billed charges,,,55,,346.5,percent of total billed charges,,,65,,409.5,percent of total billed charges,,,78,,491.4,percent of total billed charges,,,70,,441,percent of total billed charges,,,,,,,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,416.48,,,,100% of Medicare,,,416.48,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,285.39,567,
OT Physical Performance Test,97750,CPT,,,GO,both,,,289,173.4,,45.5,,131.5,percent of total billed charges,,,45.3,,130.92,percent of total billed charges,,,51,,147.39,percent of total billed charges,,,,,,,,,80,,231.2,percent of total billed charges,,,61.4,,177.45,percent of total billed charges,,,57.4,,165.89,percent of total billed charges,,,81,,234.09,percent of total billed charges,,,51.5,,148.84,percent of total billed charges,,,57.6,,166.46,percent of total billed charges,,,85,,245.65,percent of total billed charges,,,85,,245.65,percent of total billed charges,,,49,,141.61,percent of total billed charges,,,90,,260.1,percent of total billed charges,,,65,,187.85,percent of total billed charges,,,80,,231.2,percent of total billed charges,,,55,,158.95,percent of total billed charges,,,55,,158.95,percent of total billed charges,,,65,,187.85,percent of total billed charges,,,78,,225.42,percent of total billed charges,,,70,,202.3,percent of total billed charges,,,,,,,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,,34.17,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,34.17,260.1,
PT Evaluation Physical Performance Functional Capacity,97750,CPT,,,GP,both,,,289,173.4,,45.5,,131.5,percent of total billed charges,,,45.3,,130.92,percent of total billed charges,,,51,,147.39,percent of total billed charges,,,,,,,,,80,,231.2,percent of total billed charges,,,61.4,,177.45,percent of total billed charges,,,57.4,,165.89,percent of total billed charges,,,81,,234.09,percent of total billed charges,,,51.5,,148.84,percent of total billed charges,,,57.6,,166.46,percent of total billed charges,,,85,,245.65,percent of total billed charges,,,85,,245.65,percent of total billed charges,,,49,,141.61,percent of total billed charges,,,90,,260.1,percent of total billed charges,,,65,,187.85,percent of total billed charges,,,80,,231.2,percent of total billed charges,,,55,,158.95,percent of total billed charges,,,55,,158.95,percent of total billed charges,,,65,,187.85,percent of total billed charges,,,78,,225.42,percent of total billed charges,,,70,,202.3,percent of total billed charges,,,,,,,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,,34.17,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,34.17,260.1,
PT Physical Performance Test,97750,CPT,,,GP,both,,,289,173.4,,45.5,,131.5,percent of total billed charges,,,45.3,,130.92,percent of total billed charges,,,51,,147.39,percent of total billed charges,,,,,,,,,80,,231.2,percent of total billed charges,,,61.4,,177.45,percent of total billed charges,,,57.4,,165.89,percent of total billed charges,,,81,,234.09,percent of total billed charges,,,51.5,,148.84,percent of total billed charges,,,57.6,,166.46,percent of total billed charges,,,85,,245.65,percent of total billed charges,,,85,,245.65,percent of total billed charges,,,49,,141.61,percent of total billed charges,,,90,,260.1,percent of total billed charges,,,65,,187.85,percent of total billed charges,,,80,,231.2,percent of total billed charges,,,55,,158.95,percent of total billed charges,,,55,,158.95,percent of total billed charges,,,65,,187.85,percent of total billed charges,,,78,,225.42,percent of total billed charges,,,70,,202.3,percent of total billed charges,,,,,,,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,34.17,,,,100% of Medicare,,,34.17,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,34.17,260.1,
OT Assistive Technology Eval Units,97755,CPT,,,GO,both,,,256,153.6,,45.5,,116.48,percent of total billed charges,,,45.3,,115.97,percent of total billed charges,,,51,,130.56,percent of total billed charges,,,,,,,,,80,,204.8,percent of total billed charges,,,61.4,,157.18,percent of total billed charges,,,57.4,,146.94,percent of total billed charges,,,81,,207.36,percent of total billed charges,,,51.5,,131.84,percent of total billed charges,,,57.6,,147.46,percent of total billed charges,,,85,,217.6,percent of total billed charges,,,85,,217.6,percent of total billed charges,,,49,,125.44,percent of total billed charges,,,90,,230.4,percent of total billed charges,,,65,,166.4,percent of total billed charges,,,80,,204.8,percent of total billed charges,,,55,,140.8,percent of total billed charges,,,55,,140.8,percent of total billed charges,,,65,,166.4,percent of total billed charges,,,78,,199.68,percent of total billed charges,,,70,,179.2,percent of total billed charges,,,,,,,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,,38.71,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,38.71,230.4,
PT Assistive Technology Eval Units,97755,CPT,,,GP,both,,,256,153.6,,45.5,,116.48,percent of total billed charges,,,45.3,,115.97,percent of total billed charges,,,51,,130.56,percent of total billed charges,,,,,,,,,80,,204.8,percent of total billed charges,,,61.4,,157.18,percent of total billed charges,,,57.4,,146.94,percent of total billed charges,,,81,,207.36,percent of total billed charges,,,51.5,,131.84,percent of total billed charges,,,57.6,,147.46,percent of total billed charges,,,85,,217.6,percent of total billed charges,,,85,,217.6,percent of total billed charges,,,49,,125.44,percent of total billed charges,,,90,,230.4,percent of total billed charges,,,65,,166.4,percent of total billed charges,,,80,,204.8,percent of total billed charges,,,55,,140.8,percent of total billed charges,,,55,,140.8,percent of total billed charges,,,65,,166.4,percent of total billed charges,,,78,,199.68,percent of total billed charges,,,70,,179.2,percent of total billed charges,,,,,,,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,,38.71,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,38.71,230.4,
PT Evaluation Assistive Technology,97755,CPT,,,GP,both,,,256,153.6,,45.5,,116.48,percent of total billed charges,,,45.3,,115.97,percent of total billed charges,,,51,,130.56,percent of total billed charges,,,,,,,,,80,,204.8,percent of total billed charges,,,61.4,,157.18,percent of total billed charges,,,57.4,,146.94,percent of total billed charges,,,81,,207.36,percent of total billed charges,,,51.5,,131.84,percent of total billed charges,,,57.6,,147.46,percent of total billed charges,,,85,,217.6,percent of total billed charges,,,85,,217.6,percent of total billed charges,,,49,,125.44,percent of total billed charges,,,90,,230.4,percent of total billed charges,,,65,,166.4,percent of total billed charges,,,80,,204.8,percent of total billed charges,,,55,,140.8,percent of total billed charges,,,55,,140.8,percent of total billed charges,,,65,,166.4,percent of total billed charges,,,78,,199.68,percent of total billed charges,,,70,,179.2,percent of total billed charges,,,,,,,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,38.71,,,,100% of Medicare,,,38.71,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,38.71,230.4,
OT Orthotic Management/Train Units,97760,CPT,,,GO,both,,,227,136.2,,45.5,,103.29,percent of total billed charges,,,45.3,,102.83,percent of total billed charges,,,51,,115.77,percent of total billed charges,,,,,,,,,80,,181.6,percent of total billed charges,,,61.4,,139.38,percent of total billed charges,,,57.4,,130.3,percent of total billed charges,,,81,,183.87,percent of total billed charges,,,51.5,,116.91,percent of total billed charges,,,57.6,,130.75,percent of total billed charges,,,85,,192.95,percent of total billed charges,,,85,,192.95,percent of total billed charges,,,49,,111.23,percent of total billed charges,,,90,,204.3,percent of total billed charges,,,65,,147.55,percent of total billed charges,,,80,,181.6,percent of total billed charges,,,55,,124.85,percent of total billed charges,,,55,,124.85,percent of total billed charges,,,65,,147.55,percent of total billed charges,,,78,,177.06,percent of total billed charges,,,70,,158.9,percent of total billed charges,,,,,,,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,,47.05,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,47.05,204.3,
PT Orthotic Management and Training,97760,CPT,,,GP,both,,,227,136.2,,45.5,,103.29,percent of total billed charges,,,45.3,,102.83,percent of total billed charges,,,51,,115.77,percent of total billed charges,,,,,,,,,80,,181.6,percent of total billed charges,,,61.4,,139.38,percent of total billed charges,,,57.4,,130.3,percent of total billed charges,,,81,,183.87,percent of total billed charges,,,51.5,,116.91,percent of total billed charges,,,57.6,,130.75,percent of total billed charges,,,85,,192.95,percent of total billed charges,,,85,,192.95,percent of total billed charges,,,49,,111.23,percent of total billed charges,,,90,,204.3,percent of total billed charges,,,65,,147.55,percent of total billed charges,,,80,,181.6,percent of total billed charges,,,55,,124.85,percent of total billed charges,,,55,,124.85,percent of total billed charges,,,65,,147.55,percent of total billed charges,,,78,,177.06,percent of total billed charges,,,70,,158.9,percent of total billed charges,,,,,,,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,,47.05,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,47.05,204.3,
PT Orthotic Management/Train Units,97760,CPT,,,GP,both,,,227,136.2,,45.5,,103.29,percent of total billed charges,,,45.3,,102.83,percent of total billed charges,,,51,,115.77,percent of total billed charges,,,,,,,,,80,,181.6,percent of total billed charges,,,61.4,,139.38,percent of total billed charges,,,57.4,,130.3,percent of total billed charges,,,81,,183.87,percent of total billed charges,,,51.5,,116.91,percent of total billed charges,,,57.6,,130.75,percent of total billed charges,,,85,,192.95,percent of total billed charges,,,85,,192.95,percent of total billed charges,,,49,,111.23,percent of total billed charges,,,90,,204.3,percent of total billed charges,,,65,,147.55,percent of total billed charges,,,80,,181.6,percent of total billed charges,,,55,,124.85,percent of total billed charges,,,55,,124.85,percent of total billed charges,,,65,,147.55,percent of total billed charges,,,78,,177.06,percent of total billed charges,,,70,,158.9,percent of total billed charges,,,,,,,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,47.05,,,,100% of Medicare,,,47.05,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,47.05,204.3,
OT Prosthetic Management/Train Units,97761,CPT,,,GO,both,,,247,148.2,,45.5,,112.39,percent of total billed charges,,,45.3,,111.89,percent of total billed charges,,,51,,125.97,percent of total billed charges,,,,,,,,,80,,197.6,percent of total billed charges,,,61.4,,151.66,percent of total billed charges,,,57.4,,141.78,percent of total billed charges,,,81,,200.07,percent of total billed charges,,,51.5,,127.21,percent of total billed charges,,,57.6,,142.27,percent of total billed charges,,,85,,209.95,percent of total billed charges,,,85,,209.95,percent of total billed charges,,,49,,121.03,percent of total billed charges,,,90,,222.3,percent of total billed charges,,,65,,160.55,percent of total billed charges,,,80,,197.6,percent of total billed charges,,,55,,135.85,percent of total billed charges,,,55,,135.85,percent of total billed charges,,,65,,160.55,percent of total billed charges,,,78,,192.66,percent of total billed charges,,,70,,172.9,percent of total billed charges,,,,,,,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,,41.43,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,41.43,222.3,
PT Prosthetic Management and Training,97761,CPT,,,GP,both,,,247,148.2,,45.5,,112.39,percent of total billed charges,,,45.3,,111.89,percent of total billed charges,,,51,,125.97,percent of total billed charges,,,,,,,,,80,,197.6,percent of total billed charges,,,61.4,,151.66,percent of total billed charges,,,57.4,,141.78,percent of total billed charges,,,81,,200.07,percent of total billed charges,,,51.5,,127.21,percent of total billed charges,,,57.6,,142.27,percent of total billed charges,,,85,,209.95,percent of total billed charges,,,85,,209.95,percent of total billed charges,,,49,,121.03,percent of total billed charges,,,90,,222.3,percent of total billed charges,,,65,,160.55,percent of total billed charges,,,80,,197.6,percent of total billed charges,,,55,,135.85,percent of total billed charges,,,55,,135.85,percent of total billed charges,,,65,,160.55,percent of total billed charges,,,78,,192.66,percent of total billed charges,,,70,,172.9,percent of total billed charges,,,,,,,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,,41.43,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,41.43,222.3,
PT Prosthetic Management/Train Units,97761,CPT,,,GP,both,,,247,148.2,,45.5,,112.39,percent of total billed charges,,,45.3,,111.89,percent of total billed charges,,,51,,125.97,percent of total billed charges,,,,,,,,,80,,197.6,percent of total billed charges,,,61.4,,151.66,percent of total billed charges,,,57.4,,141.78,percent of total billed charges,,,81,,200.07,percent of total billed charges,,,51.5,,127.21,percent of total billed charges,,,57.6,,142.27,percent of total billed charges,,,85,,209.95,percent of total billed charges,,,85,,209.95,percent of total billed charges,,,49,,121.03,percent of total billed charges,,,90,,222.3,percent of total billed charges,,,65,,160.55,percent of total billed charges,,,80,,197.6,percent of total billed charges,,,55,,135.85,percent of total billed charges,,,55,,135.85,percent of total billed charges,,,65,,160.55,percent of total billed charges,,,78,,192.66,percent of total billed charges,,,70,,172.9,percent of total billed charges,,,,,,,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,41.43,,,,100% of Medicare,,,41.43,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,41.43,222.3,
OT Orthotic/Prosthetic Use Subsequent Unit(s),97763,CPT,,,GO,both,,,158,94.8,,45.5,,71.89,percent of total billed charges,,,45.3,,71.57,percent of total billed charges,,,51,,80.58,percent of total billed charges,,,,,,,,,80,,126.4,percent of total billed charges,,,61.4,,97.01,percent of total billed charges,,,57.4,,90.69,percent of total billed charges,,,81,,127.98,percent of total billed charges,,,51.5,,81.37,percent of total billed charges,,,57.6,,91.01,percent of total billed charges,,,85,,134.3,percent of total billed charges,,,85,,134.3,percent of total billed charges,,,49,,77.42,percent of total billed charges,,,90,,142.2,percent of total billed charges,,,65,,102.7,percent of total billed charges,,,80,,126.4,percent of total billed charges,,,55,,86.9,percent of total billed charges,,,55,,86.9,percent of total billed charges,,,65,,102.7,percent of total billed charges,,,78,,123.24,percent of total billed charges,,,70,,110.6,percent of total billed charges,,,,,,,,51.36,,,,100% of Medicare,,51.36,,,,100% of Medicare,,51.36,,,,100% of Medicare,,51.36,,,,100% of Medicare,,51.36,,,,100% of Medicare,,51.36,,,,100% of Medicare,,51.36,,,,100% of Medicare,,51.36,,,,100% of Medicare,,51.36,,,,100% of Medicare,,51.36,,,,100% of Medicare,,51.36,,,,100% of Medicare,,51.36,,,,100% of Medicare,,,51.36,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,51.36,142.2,
PT Orthotic/Prosthetic Use Subsequent Unit(s),97763,CPT,,,GP,both,,,158,94.8,,45.5,,71.89,percent of total billed charges,,,45.3,,71.57,percent of total billed charges,,,51,,80.58,percent of total billed charges,,,,,,,,,80,,126.4,percent of total billed charges,,,61.4,,97.01,percent of total billed charges,,,57.4,,90.69,percent of total billed charges,,,81,,127.98,percent of total billed charges,,,51.5,,81.37,percent of total billed charges,,,57.6,,91.01,percent of total billed charges,,,85,,134.3,percent of total billed charges,,,85,,134.3,percent of total billed charges,,,49,,77.42,percent of total billed charges,,,90,,142.2,percent of total billed charges,,,65,,102.7,percent of total billed charges,,,80,,126.4,percent of total billed charges,,,55,,86.9,percent of total billed charges,,,55,,86.9,percent of total billed charges,,,65,,102.7,percent of total billed charges,,,78,,123.24,percent of total billed charges,,,70,,110.6,percent of total billed charges,,,,,,,,51.36,,,,100% of Medicare,,51.36,,,,100% of Medicare,,51.36,,,,100% of Medicare,,51.36,,,,100% of Medicare,,51.36,,,,100% of Medicare,,51.36,,,,100% of Medicare,,51.36,,,,100% of Medicare,,51.36,,,,100% of Medicare,,51.36,,,,100% of Medicare,,51.36,,,,100% of Medicare,,51.36,,,,100% of Medicare,,51.36,,,,100% of Medicare,,,51.36,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,51.36,142.2,
OSTEOPATHIC MANIPULATION 1-2 BODY REGIONS (98925),98925,CPT,,,,outpatient,,,131,78.6,,45.5,,59.61,percent of total billed charges,,,45.3,,59.34,percent of total billed charges,,,51,,66.81,percent of total billed charges,,,,,,,,,80,,104.8,percent of total billed charges,,,61.4,,80.43,percent of total billed charges,,,57.4,,75.19,percent of total billed charges,,,81,,106.11,percent of total billed charges,,,51.5,,67.47,percent of total billed charges,,,57.6,,75.46,percent of total billed charges,,,85,,111.35,percent of total billed charges,,,85,,111.35,percent of total billed charges,,,49,,64.19,percent of total billed charges,,,90,,117.9,percent of total billed charges,,,65,,85.15,percent of total billed charges,,,80,,104.8,percent of total billed charges,,,55,,72.05,percent of total billed charges,,,55,,72.05,percent of total billed charges,,,65,,85.15,percent of total billed charges,,,78,,102.18,percent of total billed charges,,,70,,91.7,percent of total billed charges,,,,,,,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,,26.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,26.37,117.9,
OSTEOPATHIC MANIPULATION 3-4 BODY REGIONS (98926),98926,CPT,,,,outpatient,,,134,80.4,,45.5,,60.97,percent of total billed charges,,,45.3,,60.7,percent of total billed charges,,,51,,68.34,percent of total billed charges,,,,,,,,,80,,107.2,percent of total billed charges,,,61.4,,82.28,percent of total billed charges,,,57.4,,76.92,percent of total billed charges,,,81,,108.54,percent of total billed charges,,,51.5,,69.01,percent of total billed charges,,,57.6,,77.18,percent of total billed charges,,,85,,113.9,percent of total billed charges,,,85,,113.9,percent of total billed charges,,,49,,65.66,percent of total billed charges,,,90,,120.6,percent of total billed charges,,,65,,87.1,percent of total billed charges,,,80,,107.2,percent of total billed charges,,,55,,73.7,percent of total billed charges,,,55,,73.7,percent of total billed charges,,,65,,87.1,percent of total billed charges,,,78,,104.52,percent of total billed charges,,,70,,93.8,percent of total billed charges,,,,,,,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,,26.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,26.37,120.6,
OSTEOPATHIC MANIPULATION 5-6 BODY REGIONS (98927),98927,CPT,,,,outpatient,,,137,82.2,,45.5,,62.34,percent of total billed charges,,,45.3,,62.06,percent of total billed charges,,,51,,69.87,percent of total billed charges,,,,,,,,,80,,109.6,percent of total billed charges,,,61.4,,84.12,percent of total billed charges,,,57.4,,78.64,percent of total billed charges,,,81,,110.97,percent of total billed charges,,,51.5,,70.56,percent of total billed charges,,,57.6,,78.91,percent of total billed charges,,,85,,116.45,percent of total billed charges,,,85,,116.45,percent of total billed charges,,,49,,67.13,percent of total billed charges,,,90,,123.3,percent of total billed charges,,,65,,89.05,percent of total billed charges,,,80,,109.6,percent of total billed charges,,,55,,75.35,percent of total billed charges,,,55,,75.35,percent of total billed charges,,,65,,89.05,percent of total billed charges,,,78,,106.86,percent of total billed charges,,,70,,95.9,percent of total billed charges,,,,,,,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,,26.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,26.37,123.3,
OSTEOPATHIC MANIPULATION 7-8 BODY REGIONS (98928),98928,CPT,,,,outpatient,,,144,86.4,,45.5,,65.52,percent of total billed charges,,,45.3,,65.23,percent of total billed charges,,,51,,73.44,percent of total billed charges,,,,,,,,,80,,115.2,percent of total billed charges,,,61.4,,88.42,percent of total billed charges,,,57.4,,82.66,percent of total billed charges,,,81,,116.64,percent of total billed charges,,,51.5,,74.16,percent of total billed charges,,,57.6,,82.94,percent of total billed charges,,,85,,122.4,percent of total billed charges,,,85,,122.4,percent of total billed charges,,,49,,70.56,percent of total billed charges,,,90,,129.6,percent of total billed charges,,,65,,93.6,percent of total billed charges,,,80,,115.2,percent of total billed charges,,,55,,79.2,percent of total billed charges,,,55,,79.2,percent of total billed charges,,,65,,93.6,percent of total billed charges,,,78,,112.32,percent of total billed charges,,,70,,100.8,percent of total billed charges,,,,,,,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,,26.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,26.37,129.6,
OSTEOPATHIC MANIPULATION 9-10 BODY REGIONS (98929),98929,CPT,,,,outpatient,,,153,91.8,,45.5,,69.62,percent of total billed charges,,,45.3,,69.31,percent of total billed charges,,,51,,78.03,percent of total billed charges,,,,,,,,,80,,122.4,percent of total billed charges,,,61.4,,93.94,percent of total billed charges,,,57.4,,87.82,percent of total billed charges,,,81,,123.93,percent of total billed charges,,,51.5,,78.8,percent of total billed charges,,,57.6,,88.13,percent of total billed charges,,,85,,130.05,percent of total billed charges,,,85,,130.05,percent of total billed charges,,,49,,74.97,percent of total billed charges,,,90,,137.7,percent of total billed charges,,,65,,99.45,percent of total billed charges,,,80,,122.4,percent of total billed charges,,,55,,84.15,percent of total billed charges,,,55,,84.15,percent of total billed charges,,,65,,99.45,percent of total billed charges,,,78,,119.34,percent of total billed charges,,,70,,107.1,percent of total billed charges,,,,,,,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,,26.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,26.37,137.7,
Chiro Manual Treatment Spinal 1-2 regions Charge,98940,CPT,,,,outpatient,,,115,69,,45.5,,52.33,percent of total billed charges,,,45.3,,52.1,percent of total billed charges,,,51,,58.65,percent of total billed charges,,,,,,,,,80,,92,percent of total billed charges,,,61.4,,70.61,percent of total billed charges,,,57.4,,66.01,percent of total billed charges,,,81,,93.15,percent of total billed charges,,,51.5,,59.23,percent of total billed charges,,,57.6,,66.24,percent of total billed charges,,,85,,97.75,percent of total billed charges,,,85,,97.75,percent of total billed charges,,,49,,56.35,percent of total billed charges,,,90,,103.5,percent of total billed charges,,,65,,74.75,percent of total billed charges,,,80,,92,percent of total billed charges,,,55,,63.25,percent of total billed charges,,,55,,63.25,percent of total billed charges,,,65,,74.75,percent of total billed charges,,,78,,89.7,percent of total billed charges,,,70,,80.5,percent of total billed charges,,,,,,,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,,26.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,26.37,103.5,
Chiro Manual Treatment Spinal 3-4 regions Charge,98941,CPT,,,,outpatient,,,149,89.4,,45.5,,67.8,percent of total billed charges,,,45.3,,67.5,percent of total billed charges,,,51,,75.99,percent of total billed charges,,,,,,,,,80,,119.2,percent of total billed charges,,,61.4,,91.49,percent of total billed charges,,,57.4,,85.53,percent of total billed charges,,,81,,120.69,percent of total billed charges,,,51.5,,76.74,percent of total billed charges,,,57.6,,85.82,percent of total billed charges,,,85,,126.65,percent of total billed charges,,,85,,126.65,percent of total billed charges,,,49,,73.01,percent of total billed charges,,,90,,134.1,percent of total billed charges,,,65,,96.85,percent of total billed charges,,,80,,119.2,percent of total billed charges,,,55,,81.95,percent of total billed charges,,,55,,81.95,percent of total billed charges,,,65,,96.85,percent of total billed charges,,,78,,116.22,percent of total billed charges,,,70,,104.3,percent of total billed charges,,,,,,,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,,26.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,26.37,134.1,
Chiro Manual Treatment Spinal 5 regions Charge,98942,CPT,,,,outpatient,,,163,97.8,,45.5,,74.17,percent of total billed charges,,,45.3,,73.84,percent of total billed charges,,,51,,83.13,percent of total billed charges,,,,,,,,,80,,130.4,percent of total billed charges,,,61.4,,100.08,percent of total billed charges,,,57.4,,93.56,percent of total billed charges,,,81,,132.03,percent of total billed charges,,,51.5,,83.95,percent of total billed charges,,,57.6,,93.89,percent of total billed charges,,,85,,138.55,percent of total billed charges,,,85,,138.55,percent of total billed charges,,,49,,79.87,percent of total billed charges,,,90,,146.7,percent of total billed charges,,,65,,105.95,percent of total billed charges,,,80,,130.4,percent of total billed charges,,,55,,89.65,percent of total billed charges,,,55,,89.65,percent of total billed charges,,,65,,105.95,percent of total billed charges,,,78,,127.14,percent of total billed charges,,,70,,114.1,percent of total billed charges,,,,,,,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,26.37,,,,100% of Medicare,,,26.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,26.37,146.7,
Chiro Manual Treatment Extra Spinal 1 or more Regions Charge,98943,CPT,,,,outpatient,,,140,84,,45.5,,63.7,percent of total billed charges,,,45.3,,63.42,percent of total billed charges,,,51,,71.4,percent of total billed charges,,,,,,,,,80,,112,percent of total billed charges,,,61.4,,85.96,percent of total billed charges,,,57.4,,80.36,percent of total billed charges,,,81,,113.4,percent of total billed charges,,,51.5,,72.1,percent of total billed charges,,,57.6,,80.64,percent of total billed charges,,,85,,119,percent of total billed charges,,,85,,119,percent of total billed charges,,,49,,68.6,percent of total billed charges,,,90,,126,percent of total billed charges,,,65,,91,percent of total billed charges,,,80,,112,percent of total billed charges,,,55,,77,percent of total billed charges,,,55,,77,percent of total billed charges,,,65,,91,percent of total billed charges,,,78,,109.2,percent of total billed charges,,,70,,98,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,63.42,126,
NO SHOW / CANCELLATION PAIN PROGRAM CHARGE $1500,99199,CPT,,,,outpatient,,,1500,900,,45.5,,682.5,percent of total billed charges,,,45.3,,679.5,percent of total billed charges,,,51,,765,percent of total billed charges,,,,,,,,,80,,1200,percent of total billed charges,,,61.4,,921,percent of total billed charges,,,57.4,,861,percent of total billed charges,,,81,,1215,percent of total billed charges,,,51.5,,772.5,percent of total billed charges,,,57.6,,864,percent of total billed charges,,,85,,1275,percent of total billed charges,,,85,,1275,percent of total billed charges,,,49,,735,percent of total billed charges,,,90,,1350,percent of total billed charges,,,65,,975,percent of total billed charges,,,80,,1200,percent of total billed charges,,,55,,825,percent of total billed charges,,,55,,825,percent of total billed charges,,,65,,975,percent of total billed charges,,,78,,1170,percent of total billed charges,,,70,,1050,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,679.5,1350,
Office Visit Level 2 New Charge- 99202,99202,CPT,G0463,HCPCS,,outpatient,,,338,202.8,,45.5,,153.79,percent of total billed charges,,,45.3,,153.11,percent of total billed charges,,170,,,,case rate,once per unique code,,,,,,,,80,,270.4,percent of total billed charges,,65,,,,case rate,,65,,,,case rate,,,81,,273.78,percent of total billed charges,,163,,,,fee schedule,,,57.6,,194.69,percent of total billed charges,,,85,,287.3,percent of total billed charges,,,85,,287.3,percent of total billed charges,,,49,,165.62,percent of total billed charges,,,90,,304.2,percent of total billed charges,,,65,,219.7,percent of total billed charges,,,80,,270.4,percent of total billed charges,,,55,,185.9,percent of total billed charges,,,55,,185.9,percent of total billed charges,,,65,,219.7,percent of total billed charges,,,78,,263.64,percent of total billed charges,,,70,,236.6,percent of total billed charges,,,,,,,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,,134.34,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,65,304.2,
Office Visit Level 3 New Charge- 99203,99203,CPT,G0463,HCPCS,,outpatient,,,446,267.6,,45.5,,202.93,percent of total billed charges,,,45.3,,202.04,percent of total billed charges,,170,,,,case rate,once per unique code,,,,,,,,80,,356.8,percent of total billed charges,,65,,,,case rate,,65,,,,case rate,,,81,,361.26,percent of total billed charges,,163,,,,fee schedule,,,57.6,,256.9,percent of total billed charges,,,85,,379.1,percent of total billed charges,,,85,,379.1,percent of total billed charges,,,49,,218.54,percent of total billed charges,,,90,,401.4,percent of total billed charges,,,65,,289.9,percent of total billed charges,,,80,,356.8,percent of total billed charges,,,55,,245.3,percent of total billed charges,,,55,,245.3,percent of total billed charges,,,65,,289.9,percent of total billed charges,,,78,,347.88,percent of total billed charges,,,70,,312.2,percent of total billed charges,,,,,,,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,,134.34,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,65,401.4,
Office Visit Level 4 New Charge- 99204,99204,CPT,G0463,HCPCS,,outpatient,,,569,341.4,,45.5,,258.9,percent of total billed charges,,,45.3,,257.76,percent of total billed charges,,170,,,,case rate,once per unique code,,,,,,,,80,,455.2,percent of total billed charges,,65,,,,case rate,,65,,,,case rate,,,81,,460.89,percent of total billed charges,,163,,,,fee schedule,,,57.6,,327.74,percent of total billed charges,,,85,,483.65,percent of total billed charges,,,85,,483.65,percent of total billed charges,,,49,,278.81,percent of total billed charges,,,90,,512.1,percent of total billed charges,,,65,,369.85,percent of total billed charges,,,80,,455.2,percent of total billed charges,,,55,,312.95,percent of total billed charges,,,55,,312.95,percent of total billed charges,,,65,,369.85,percent of total billed charges,,,78,,443.82,percent of total billed charges,,,70,,398.3,percent of total billed charges,,,,,,,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,,134.34,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,65,512.1,
Office Visit Level 5 New Charge- 99205,99205,CPT,G0463,HCPCS,,outpatient,,,739,443.4,,45.5,,336.25,percent of total billed charges,,,45.3,,334.77,percent of total billed charges,,170,,,,case rate,once per unique code,,,,,,,,80,,591.2,percent of total billed charges,,65,,,,case rate,,65,,,,case rate,,,81,,598.59,percent of total billed charges,,163,,,,fee schedule,,,57.6,,425.66,percent of total billed charges,,,85,,628.15,percent of total billed charges,,,85,,628.15,percent of total billed charges,,,49,,362.11,percent of total billed charges,,,90,,665.1,percent of total billed charges,,,65,,480.35,percent of total billed charges,,,80,,591.2,percent of total billed charges,,,55,,406.45,percent of total billed charges,,,55,,406.45,percent of total billed charges,,,65,,480.35,percent of total billed charges,,,78,,576.42,percent of total billed charges,,,70,,517.3,percent of total billed charges,,,,,,,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,,134.34,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,65,665.1,
Office Visit Level 1 Est Charge- 99211,99211,CPT,G0463,HCPCS,,outpatient,,,200,120,,45.5,,91,percent of total billed charges,,,45.3,,90.6,percent of total billed charges,,170,,,,case rate,once per unique code,,,,,,,,80,,160,percent of total billed charges,,65,,,,case rate,,65,,,,case rate,,,81,,162,percent of total billed charges,,163,,,,fee schedule,,,57.6,,115.2,percent of total billed charges,,,85,,170,percent of total billed charges,,,85,,170,percent of total billed charges,,,49,,98,percent of total billed charges,,,90,,180,percent of total billed charges,,,65,,130,percent of total billed charges,,,80,,160,percent of total billed charges,,,55,,110,percent of total billed charges,,,55,,110,percent of total billed charges,,,65,,130,percent of total billed charges,,,78,,156,percent of total billed charges,,,70,,140,percent of total billed charges,,,,,,,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,,134.34,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,65,180,
Office Visit Level 2 Est Charge- 99212,99212,CPT,G0463,HCPCS,,outpatient,,,226,135.6,,45.5,,102.83,percent of total billed charges,,,45.3,,102.38,percent of total billed charges,,170,,,,case rate,once per unique code,,,,,,,,80,,180.8,percent of total billed charges,,65,,,,case rate,,65,,,,case rate,,,81,,183.06,percent of total billed charges,,163,,,,fee schedule,,,57.6,,130.18,percent of total billed charges,,,85,,192.1,percent of total billed charges,,,85,,192.1,percent of total billed charges,,,49,,110.74,percent of total billed charges,,,90,,203.4,percent of total billed charges,,,65,,146.9,percent of total billed charges,,,80,,180.8,percent of total billed charges,,,55,,124.3,percent of total billed charges,,,55,,124.3,percent of total billed charges,,,65,,146.9,percent of total billed charges,,,78,,176.28,percent of total billed charges,,,70,,158.2,percent of total billed charges,,,,,,,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,,134.34,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,65,203.4,
Affiliates On Site Technical Charge,99213,CPT,,,,outpatient,,,237,142.2,,45.5,,107.84,percent of total billed charges,,,45.3,,107.36,percent of total billed charges,,170,,,,case rate,once per unique code,,,,,,,,80,,189.6,percent of total billed charges,,65,,,,case rate,,65,,,,case rate,,,81,,191.97,percent of total billed charges,,163,,,,fee schedule,,,57.6,,136.51,percent of total billed charges,,,85,,201.45,percent of total billed charges,,,85,,201.45,percent of total billed charges,,,49,,116.13,percent of total billed charges,,,90,,213.3,percent of total billed charges,,,65,,154.05,percent of total billed charges,,,80,,189.6,percent of total billed charges,,,55,,130.35,percent of total billed charges,,,55,,130.35,percent of total billed charges,,,65,,154.05,percent of total billed charges,,,78,,184.86,percent of total billed charges,,,70,,165.9,percent of total billed charges,,,,,,,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,,134.34,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,65,213.3,
Office Visit Level 3 Est Charge- 99213,99213,CPT,G0463,HCPCS,,outpatient,,,237,142.2,,45.5,,107.84,percent of total billed charges,,,45.3,,107.36,percent of total billed charges,,170,,,,case rate,once per unique code,,,,,,,,80,,189.6,percent of total billed charges,,65,,,,case rate,,65,,,,case rate,,,81,,191.97,percent of total billed charges,,163,,,,fee schedule,,,57.6,,136.51,percent of total billed charges,,,85,,201.45,percent of total billed charges,,,85,,201.45,percent of total billed charges,,,49,,116.13,percent of total billed charges,,,90,,213.3,percent of total billed charges,,,65,,154.05,percent of total billed charges,,,80,,189.6,percent of total billed charges,,,55,,130.35,percent of total billed charges,,,55,,130.35,percent of total billed charges,,,65,,154.05,percent of total billed charges,,,78,,184.86,percent of total billed charges,,,70,,165.9,percent of total billed charges,,,,,,,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,,134.34,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,65,213.3,
Office Visit Level 4 Est Charge- 99214,99214,CPT,G0463,HCPCS,,outpatient,,,298,178.8,,45.5,,135.59,percent of total billed charges,,,45.3,,134.99,percent of total billed charges,,170,,,,case rate,once per unique code,,,,,,,,80,,238.4,percent of total billed charges,,65,,,,case rate,,65,,,,case rate,,,81,,241.38,percent of total billed charges,,163,,,,fee schedule,,,57.6,,171.65,percent of total billed charges,,,85,,253.3,percent of total billed charges,,,85,,253.3,percent of total billed charges,,,49,,146.02,percent of total billed charges,,,90,,268.2,percent of total billed charges,,,65,,193.7,percent of total billed charges,,,80,,238.4,percent of total billed charges,,,55,,163.9,percent of total billed charges,,,55,,163.9,percent of total billed charges,,,65,,193.7,percent of total billed charges,,,78,,232.44,percent of total billed charges,,,70,,208.6,percent of total billed charges,,,,,,,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,,134.34,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,65,268.2,
Office Visit Level 5 Est Charge- 99215,99215,CPT,G0463,HCPCS,,outpatient,,,379,227.4,,45.5,,172.45,percent of total billed charges,,,45.3,,171.69,percent of total billed charges,,170,,,,case rate,once per unique code,,,,,,,,80,,303.2,percent of total billed charges,,65,,,,case rate,,65,,,,case rate,,,81,,306.99,percent of total billed charges,,163,,,,fee schedule,,,57.6,,218.3,percent of total billed charges,,,85,,322.15,percent of total billed charges,,,85,,322.15,percent of total billed charges,,,49,,185.71,percent of total billed charges,,,90,,341.1,percent of total billed charges,,,65,,246.35,percent of total billed charges,,,80,,303.2,percent of total billed charges,,,55,,208.45,percent of total billed charges,,,55,,208.45,percent of total billed charges,,,65,,246.35,percent of total billed charges,,,78,,295.62,percent of total billed charges,,,70,,265.3,percent of total billed charges,,,,,,,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,,134.34,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,65,341.1,
Office Consult Level 2 Charge- 99242,99242,CPT,G0463,HCPCS,,outpatient,,,130,78,,45.5,,59.15,percent of total billed charges,,,45.3,,58.89,percent of total billed charges,,170,,,,case rate,once per unique code,,,,,,,,80,,104,percent of total billed charges,,65,,,,case rate,,65,,,,case rate,,,81,,105.3,percent of total billed charges,,163,,,,fee schedule,,,57.6,,74.88,percent of total billed charges,,,85,,110.5,percent of total billed charges,,,85,,110.5,percent of total billed charges,,,49,,63.7,percent of total billed charges,,,90,,117,percent of total billed charges,,,65,,84.5,percent of total billed charges,,,80,,104,percent of total billed charges,,,55,,71.5,percent of total billed charges,,,55,,71.5,percent of total billed charges,,,65,,84.5,percent of total billed charges,,,78,,101.4,percent of total billed charges,,,70,,91,percent of total billed charges,,,,,,,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,,134.34,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,58.89,170,
Office Consult Level 3 Charge- 99243,99243,CPT,G0463,HCPCS,,outpatient,,,130,78,,45.5,,59.15,percent of total billed charges,,,45.3,,58.89,percent of total billed charges,,170,,,,case rate,once per unique code,,,,,,,,80,,104,percent of total billed charges,,65,,,,case rate,,65,,,,case rate,,,81,,105.3,percent of total billed charges,,163,,,,fee schedule,,,57.6,,74.88,percent of total billed charges,,,85,,110.5,percent of total billed charges,,,85,,110.5,percent of total billed charges,,,49,,63.7,percent of total billed charges,,,90,,117,percent of total billed charges,,,65,,84.5,percent of total billed charges,,,80,,104,percent of total billed charges,,,55,,71.5,percent of total billed charges,,,55,,71.5,percent of total billed charges,,,65,,84.5,percent of total billed charges,,,78,,101.4,percent of total billed charges,,,70,,91,percent of total billed charges,,,,,,,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,,134.34,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,58.89,170,
Office Consult Level 4 Charge- 99244,99244,CPT,G0463,HCPCS,,outpatient,,,222,133.2,,45.5,,101.01,percent of total billed charges,,,45.3,,100.57,percent of total billed charges,,170,,,,case rate,once per unique code,,,,,,,,80,,177.6,percent of total billed charges,,65,,,,case rate,,65,,,,case rate,,,81,,179.82,percent of total billed charges,,163,,,,fee schedule,,,57.6,,127.87,percent of total billed charges,,,85,,188.7,percent of total billed charges,,,85,,188.7,percent of total billed charges,,,49,,108.78,percent of total billed charges,,,90,,199.8,percent of total billed charges,,,65,,144.3,percent of total billed charges,,,80,,177.6,percent of total billed charges,,,55,,122.1,percent of total billed charges,,,55,,122.1,percent of total billed charges,,,65,,144.3,percent of total billed charges,,,78,,173.16,percent of total billed charges,,,70,,155.4,percent of total billed charges,,,,,,,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,,134.34,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,65,199.8,
Office Consult Level 5 Charge- 99245,99245,CPT,G0463,HCPCS,,outpatient,,,265,159,,45.5,,120.58,percent of total billed charges,,,45.3,,120.05,percent of total billed charges,,170,,,,case rate,once per unique code,,,,,,,,80,,212,percent of total billed charges,,65,,,,case rate,,65,,,,case rate,,,81,,214.65,percent of total billed charges,,163,,,,fee schedule,,,57.6,,152.64,percent of total billed charges,,,85,,225.25,percent of total billed charges,,,85,,225.25,percent of total billed charges,,,49,,129.85,percent of total billed charges,,,90,,238.5,percent of total billed charges,,,65,,172.25,percent of total billed charges,,,80,,212,percent of total billed charges,,,55,,145.75,percent of total billed charges,,,55,,145.75,percent of total billed charges,,,65,,172.25,percent of total billed charges,,,78,,206.7,percent of total billed charges,,,70,,185.5,percent of total billed charges,,,,,,,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,134.34,,,,100% of Medicare,,,134.34,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,65,238.5,
Prolonged E/M (Non  face to face); first hour-99358,99358,CPT,,,,outpatient,,,268,160.8,,45.5,,121.94,percent of total billed charges,,,45.3,,121.4,percent of total billed charges,,,51,,136.68,percent of total billed charges,,,,,,,,,80,,214.4,percent of total billed charges,,,61.4,,164.55,percent of total billed charges,,,57.4,,153.83,percent of total billed charges,,,81,,217.08,percent of total billed charges,,,51.5,,138.02,percent of total billed charges,,,57.6,,154.37,percent of total billed charges,,,85,,227.8,percent of total billed charges,,,85,,227.8,percent of total billed charges,,,49,,131.32,percent of total billed charges,,,90,,241.2,percent of total billed charges,,,65,,174.2,percent of total billed charges,,,80,,214.4,percent of total billed charges,,,55,,147.4,percent of total billed charges,,,55,,147.4,percent of total billed charges,,,65,,174.2,percent of total billed charges,,,78,,209.04,percent of total billed charges,,,70,,187.6,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,121.4,241.2,
Prolonged E/M (non-face to face); each additional 30 minutes- 99359,99359,CPT,,,,outpatient,,,143,85.8,,45.5,,65.07,percent of total billed charges,,,45.3,,64.78,percent of total billed charges,,,51,,72.93,percent of total billed charges,,,,,,,,,80,,114.4,percent of total billed charges,,,61.4,,87.8,percent of total billed charges,,,57.4,,82.08,percent of total billed charges,,,81,,115.83,percent of total billed charges,,,51.5,,73.65,percent of total billed charges,,,57.6,,82.37,percent of total billed charges,,,85,,121.55,percent of total billed charges,,,85,,121.55,percent of total billed charges,,,49,,70.07,percent of total billed charges,,,90,,128.7,percent of total billed charges,,,65,,92.95,percent of total billed charges,,,80,,114.4,percent of total billed charges,,,55,,78.65,percent of total billed charges,,,55,,78.65,percent of total billed charges,,,65,,92.95,percent of total billed charges,,,78,,111.54,percent of total billed charges,,,70,,100.1,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,64.78,128.7,
Advanced Care Planning 30 min (99497),99497,CPT,,,,outpatient,,,183,109.8,,45.5,,83.27,percent of total billed charges,,,45.3,,82.9,percent of total billed charges,,,51,,93.33,percent of total billed charges,,,,,,,,,80,,146.4,percent of total billed charges,,,61.4,,112.36,percent of total billed charges,,,57.4,,105.04,percent of total billed charges,,,81,,148.23,percent of total billed charges,,,51.5,,94.25,percent of total billed charges,,,57.6,,105.41,percent of total billed charges,,,85,,155.55,percent of total billed charges,,,85,,155.55,percent of total billed charges,,,49,,89.67,percent of total billed charges,,,90,,164.7,percent of total billed charges,,,65,,118.95,percent of total billed charges,,,80,,146.4,percent of total billed charges,,,55,,100.65,percent of total billed charges,,,55,,100.65,percent of total billed charges,,,65,,118.95,percent of total billed charges,,,78,,142.74,percent of total billed charges,,,70,,128.1,percent of total billed charges,,,,,,,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,96.42,,,,100% of Medicare,,,96.42,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,82.9,164.7,
"Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation w",0232T,CPT,,,,outpatient,,,852,511.2,,45.5,,387.66,percent of total billed charges,,,45.3,,385.96,percent of total billed charges,,,51,,434.52,percent of total billed charges,,,,,,,,,80,,681.6,percent of total billed charges,,,61.4,,523.13,percent of total billed charges,,,57.4,,489.05,percent of total billed charges,,,81,,690.12,percent of total billed charges,,,51.5,,438.78,percent of total billed charges,,,57.6,,490.75,percent of total billed charges,,,85,,724.2,percent of total billed charges,,,85,,724.2,percent of total billed charges,,,49,,417.48,percent of total billed charges,,,90,,766.8,percent of total billed charges,,,65,,553.8,percent of total billed charges,,,80,,681.6,percent of total billed charges,,,55,,468.6,percent of total billed charges,,,55,,468.6,percent of total billed charges,,,65,,553.8,percent of total billed charges,,,78,,664.56,percent of total billed charges,,,70,,596.4,percent of total billed charges,,,,,,,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,415.97,,,,100% of Medicare,,,415.97,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,385.96,766.8,
Withdrawl of Arterial Blood,36600,CPT,,,,outpatient,,,194,116.4,,45.5,,88.27,percent of total billed charges,,,45.3,,87.88,percent of total billed charges,,,51,,98.94,percent of total billed charges,,,,,,,,,80,,155.2,percent of total billed charges,,,61.4,,119.12,percent of total billed charges,,,57.4,,111.36,percent of total billed charges,,,81,,157.14,percent of total billed charges,,,51.5,,99.91,percent of total billed charges,,,57.6,,111.74,percent of total billed charges,,,85,,164.9,percent of total billed charges,,,85,,164.9,percent of total billed charges,,,49,,95.06,percent of total billed charges,,,90,,174.6,percent of total billed charges,,,65,,126.1,percent of total billed charges,,,80,,155.2,percent of total billed charges,,,55,,106.7,percent of total billed charges,,,55,,106.7,percent of total billed charges,,,65,,126.1,percent of total billed charges,,,78,,151.32,percent of total billed charges,,,70,,135.8,percent of total billed charges,,,,,,,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,134.37,,,,100% of Medicare,,,134.37,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,87.88,174.6,
CHEMODENERV EACH ADD'L EXTRM 1-4 MUSCLES (64643),64643,CPT,,,,outpatient,,,1025,615,,45.5,,466.38,percent of total billed charges,,,45.3,,464.33,percent of total billed charges,,,51,,522.75,percent of total billed charges,,,,,,,,,80,,820,percent of total billed charges,,,61.4,,629.35,percent of total billed charges,,,57.4,,588.35,percent of total billed charges,,,81,,830.25,percent of total billed charges,,,51.5,,527.88,percent of total billed charges,,,57.6,,590.4,percent of total billed charges,,,85,,871.25,percent of total billed charges,,,85,,871.25,percent of total billed charges,,,49,,502.25,percent of total billed charges,,,90,,922.5,percent of total billed charges,,,65,,666.25,percent of total billed charges,,,80,,820,percent of total billed charges,,,55,,563.75,percent of total billed charges,,,55,,563.75,percent of total billed charges,,,65,,666.25,percent of total billed charges,,,78,,799.5,percent of total billed charges,,,70,,717.5,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,464.33,922.5,
CC ONLY - CHEMODENERV EACH ADD'L EXTRM 1-4 MUSCLES (64643),64643,CPT,,,,outpatient,,,1046,627.6,,45.5,,475.93,percent of total billed charges,,,45.3,,473.84,percent of total billed charges,,,51,,533.46,percent of total billed charges,,,,,,,,,80,,836.8,percent of total billed charges,,,61.4,,642.24,percent of total billed charges,,,57.4,,600.4,percent of total billed charges,,,81,,847.26,percent of total billed charges,,,51.5,,538.69,percent of total billed charges,,,57.6,,602.5,percent of total billed charges,,,85,,889.1,percent of total billed charges,,,85,,889.1,percent of total billed charges,,,49,,512.54,percent of total billed charges,,,90,,941.4,percent of total billed charges,,,65,,679.9,percent of total billed charges,,,80,,836.8,percent of total billed charges,,,55,,575.3,percent of total billed charges,,,55,,575.3,percent of total billed charges,,,65,,679.9,percent of total billed charges,,,78,,815.88,percent of total billed charges,,,70,,732.2,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,22891.98,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,473.84,22891.98,
CC ONLY - CHEMODENERV EACH ADD'L EXTREM 5/> MUSCLES (64645),64645,CPT,,,,outpatient,,,902,541.2,,45.5,,410.41,percent of total billed charges,,,45.3,,408.61,percent of total billed charges,,,51,,460.02,percent of total billed charges,,,,,,,,,80,,721.6,percent of total billed charges,,,61.4,,553.83,percent of total billed charges,,,57.4,,517.75,percent of total billed charges,,,81,,730.62,percent of total billed charges,,,51.5,,464.53,percent of total billed charges,,,57.6,,519.55,percent of total billed charges,,,85,,766.7,percent of total billed charges,,,85,,766.7,percent of total billed charges,,,49,,441.98,percent of total billed charges,,,90,,811.8,percent of total billed charges,,,65,,586.3,percent of total billed charges,,,80,,721.6,percent of total billed charges,,,55,,496.1,percent of total billed charges,,,55,,496.1,percent of total billed charges,,,65,,586.3,percent of total billed charges,,,78,,703.56,percent of total billed charges,,,70,,631.4,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,74153.55571,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,408.61,74153.56,
CHEMODENERV EACH ADD'L EXTREM 5/> MUSCLES (64645),64645,CPT,,,,outpatient,,,1050,630,,45.5,,477.75,percent of total billed charges,,,45.3,,475.65,percent of total billed charges,,,51,,535.5,percent of total billed charges,,,,,,,,,80,,840,percent of total billed charges,,,61.4,,644.7,percent of total billed charges,,,57.4,,602.7,percent of total billed charges,,,81,,850.5,percent of total billed charges,,,51.5,,540.75,percent of total billed charges,,,57.6,,604.8,percent of total billed charges,,,85,,892.5,percent of total billed charges,,,85,,892.5,percent of total billed charges,,,49,,514.5,percent of total billed charges,,,90,,945,percent of total billed charges,,,65,,682.5,percent of total billed charges,,,80,,840,percent of total billed charges,,,55,,577.5,percent of total billed charges,,,55,,577.5,percent of total billed charges,,,65,,682.5,percent of total billed charges,,,78,,819,percent of total billed charges,,,70,,735,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,475.65,945,
Electrical Stimulation Guidance for Chemodenervation Charge (95873),95873,CPT,,,TC,outpatient,,,228,136.8,,45.5,,103.74,percent of total billed charges,,,45.3,,103.28,percent of total billed charges,,,51,,116.28,percent of total billed charges,,,,,,,,,80,,182.4,percent of total billed charges,,,61.4,,139.99,percent of total billed charges,,,57.4,,130.87,percent of total billed charges,,,81,,184.68,percent of total billed charges,,,51.5,,117.42,percent of total billed charges,,,57.6,,131.33,percent of total billed charges,,,85,,193.8,percent of total billed charges,,,85,,193.8,percent of total billed charges,,,49,,111.72,percent of total billed charges,,,90,,205.2,percent of total billed charges,,,65,,148.2,percent of total billed charges,,,80,,182.4,percent of total billed charges,,,55,,125.4,percent of total billed charges,,,55,,125.4,percent of total billed charges,,,65,,148.2,percent of total billed charges,,,78,,177.84,percent of total billed charges,,,70,,159.6,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,103.28,205.2,
CC ONLY - Electrical Stimulation Guidance for Chemodenervation Charge (95873),95873,CPT,,,,outpatient,,,228,136.8,,45.5,,103.74,percent of total billed charges,,,45.3,,103.28,percent of total billed charges,,,51,,116.28,percent of total billed charges,,,,,,,,,80,,182.4,percent of total billed charges,,,61.4,,139.99,percent of total billed charges,,,57.4,,130.87,percent of total billed charges,,,81,,184.68,percent of total billed charges,,,51.5,,117.42,percent of total billed charges,,,57.6,,131.33,percent of total billed charges,,,85,,193.8,percent of total billed charges,,,85,,193.8,percent of total billed charges,,,49,,111.72,percent of total billed charges,,,90,,205.2,percent of total billed charges,,,65,,148.2,percent of total billed charges,,,80,,182.4,percent of total billed charges,,,55,,125.4,percent of total billed charges,,,55,,125.4,percent of total billed charges,,,65,,148.2,percent of total billed charges,,,78,,177.84,percent of total billed charges,,,70,,159.6,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,39845.25,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,103.28,39845.25,
EMG Guidance with Chemodenervation Charge (95874),95874,CPT,,,TC,outpatient,,,202,121.2,,45.5,,91.91,percent of total billed charges,,,45.3,,91.51,percent of total billed charges,,,51,,103.02,percent of total billed charges,,,,,,,,,80,,161.6,percent of total billed charges,,,61.4,,124.03,percent of total billed charges,,,57.4,,115.95,percent of total billed charges,,,81,,163.62,percent of total billed charges,,,51.5,,104.03,percent of total billed charges,,,57.6,,116.35,percent of total billed charges,,,85,,171.7,percent of total billed charges,,,85,,171.7,percent of total billed charges,,,49,,98.98,percent of total billed charges,,,90,,181.8,percent of total billed charges,,,65,,131.3,percent of total billed charges,,,80,,161.6,percent of total billed charges,,,55,,111.1,percent of total billed charges,,,55,,111.1,percent of total billed charges,,,65,,131.3,percent of total billed charges,,,78,,157.56,percent of total billed charges,,,70,,141.4,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.51,181.8,
CC ONLY - EMG Guidance with Chemodenervation Charge (95874),95874,CPT,,,,outpatient,,,202,121.2,,45.5,,91.91,percent of total billed charges,,,45.3,,91.51,percent of total billed charges,,,51,,103.02,percent of total billed charges,,,,,,,,,80,,161.6,percent of total billed charges,,,61.4,,124.03,percent of total billed charges,,,57.4,,115.95,percent of total billed charges,,,81,,163.62,percent of total billed charges,,,51.5,,104.03,percent of total billed charges,,,57.6,,116.35,percent of total billed charges,,,85,,171.7,percent of total billed charges,,,85,,171.7,percent of total billed charges,,,49,,98.98,percent of total billed charges,,,90,,181.8,percent of total billed charges,,,65,,131.3,percent of total billed charges,,,80,,161.6,percent of total billed charges,,,55,,111.1,percent of total billed charges,,,55,,111.1,percent of total billed charges,,,65,,131.3,percent of total billed charges,,,78,,157.56,percent of total billed charges,,,70,,141.4,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,91.51,181.8,
"Diabetics only, the off-the-shelf depth inlay to accomodate multi-density inserts, per shoe K0628 or",A5500,HCPCS,,,,outpatient,,,399,239.4,,45.5,,181.55,percent of total billed charges,,,45.3,,180.75,percent of total billed charges,,,51,,203.49,percent of total billed charges,,,,,,,,,80,,319.2,percent of total billed charges,,,61.4,,244.99,percent of total billed charges,,,57.4,,229.03,percent of total billed charges,,,81,,323.19,percent of total billed charges,,,51.5,,205.49,percent of total billed charges,,,57.6,,229.82,percent of total billed charges,,,85,,339.15,percent of total billed charges,,,85,,339.15,percent of total billed charges,,,49,,195.51,percent of total billed charges,,,90,,359.1,percent of total billed charges,,,65,,259.35,percent of total billed charges,,,80,,319.2,percent of total billed charges,,,55,,219.45,percent of total billed charges,,,55,,219.45,percent of total billed charges,,,65,,259.35,percent of total billed charges,,,78,,311.22,percent of total billed charges,,,70,,279.3,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,180.75,359.1,
"Diabetic Only, Custom Molded Shoe",A5501,HCPCS,,,,outpatient,,,1190,714,,45.5,,541.45,percent of total billed charges,,,45.3,,539.07,percent of total billed charges,,,51,,606.9,percent of total billed charges,,,,,,,,,80,,952,percent of total billed charges,,,61.4,,730.66,percent of total billed charges,,,57.4,,683.06,percent of total billed charges,,,81,,963.9,percent of total billed charges,,,51.5,,612.85,percent of total billed charges,,,57.6,,685.44,percent of total billed charges,,,85,,1011.5,percent of total billed charges,,,85,,1011.5,percent of total billed charges,,,49,,583.1,percent of total billed charges,,,90,,1071,percent of total billed charges,,,65,,773.5,percent of total billed charges,,,80,,952,percent of total billed charges,,,55,,654.5,percent of total billed charges,,,55,,654.5,percent of total billed charges,,,65,,773.5,percent of total billed charges,,,78,,928.2,percent of total billed charges,,,70,,833,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,539.07,1071,
Rock Bottom,A5503,HCPCS,,,,outpatient,,,176,105.6,,45.5,,80.08,percent of total billed charges,,,45.3,,79.73,percent of total billed charges,,,51,,89.76,percent of total billed charges,,,,,,,,,80,,140.8,percent of total billed charges,,,61.4,,108.06,percent of total billed charges,,,57.4,,101.02,percent of total billed charges,,,81,,142.56,percent of total billed charges,,,51.5,,90.64,percent of total billed charges,,,57.6,,101.38,percent of total billed charges,,,85,,149.6,percent of total billed charges,,,85,,149.6,percent of total billed charges,,,49,,86.24,percent of total billed charges,,,90,,158.4,percent of total billed charges,,,65,,114.4,percent of total billed charges,,,80,,140.8,percent of total billed charges,,,55,,96.8,percent of total billed charges,,,55,,96.8,percent of total billed charges,,,65,,114.4,percent of total billed charges,,,78,,137.28,percent of total billed charges,,,70,,123.2,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,79.73,158.4,
"Wedge, Shoe",A5504,HCPCS,,,,outpatient,,,107,64.2,,45.5,,48.69,percent of total billed charges,,,45.3,,48.47,percent of total billed charges,,,51,,54.57,percent of total billed charges,,,,,,,,,80,,85.6,percent of total billed charges,,,61.4,,65.7,percent of total billed charges,,,57.4,,61.42,percent of total billed charges,,,81,,86.67,percent of total billed charges,,,51.5,,55.11,percent of total billed charges,,,57.6,,61.63,percent of total billed charges,,,85,,90.95,percent of total billed charges,,,85,,90.95,percent of total billed charges,,,49,,52.43,percent of total billed charges,,,90,,96.3,percent of total billed charges,,,65,,69.55,percent of total billed charges,,,80,,85.6,percent of total billed charges,,,55,,58.85,percent of total billed charges,,,55,,58.85,percent of total billed charges,,,65,,69.55,percent of total billed charges,,,78,,83.46,percent of total billed charges,,,70,,74.9,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,48.47,96.3,
"Metatarsal Bar, Rocker",A5505,HCPCS,,,,outpatient,,,176,105.6,,45.5,,80.08,percent of total billed charges,,,45.3,,79.73,percent of total billed charges,,,51,,89.76,percent of total billed charges,,,,,,,,,80,,140.8,percent of total billed charges,,,61.4,,108.06,percent of total billed charges,,,57.4,,101.02,percent of total billed charges,,,81,,142.56,percent of total billed charges,,,51.5,,90.64,percent of total billed charges,,,57.6,,101.38,percent of total billed charges,,,85,,149.6,percent of total billed charges,,,85,,149.6,percent of total billed charges,,,49,,86.24,percent of total billed charges,,,90,,158.4,percent of total billed charges,,,65,,114.4,percent of total billed charges,,,80,,140.8,percent of total billed charges,,,55,,96.8,percent of total billed charges,,,55,,96.8,percent of total billed charges,,,65,,114.4,percent of total billed charges,,,78,,137.28,percent of total billed charges,,,70,,123.2,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,79.73,158.4,
Off-set Heel,A5506,HCPCS,,,,outpatient,,,176,105.6,,45.5,,80.08,percent of total billed charges,,,45.3,,79.73,percent of total billed charges,,,51,,89.76,percent of total billed charges,,,,,,,,,80,,140.8,percent of total billed charges,,,61.4,,108.06,percent of total billed charges,,,57.4,,101.02,percent of total billed charges,,,81,,142.56,percent of total billed charges,,,51.5,,90.64,percent of total billed charges,,,57.6,,101.38,percent of total billed charges,,,85,,149.6,percent of total billed charges,,,85,,149.6,percent of total billed charges,,,49,,86.24,percent of total billed charges,,,90,,158.4,percent of total billed charges,,,65,,114.4,percent of total billed charges,,,80,,140.8,percent of total billed charges,,,55,,96.8,percent of total billed charges,,,55,,96.8,percent of total billed charges,,,65,,114.4,percent of total billed charges,,,78,,137.28,percent of total billed charges,,,70,,123.2,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,79.73,158.4,
"Diabetic Only, Not Otherwise Specified Shoe Modification",A5507,HCPCS,,,,outpatient,,,176,105.6,,45.5,,80.08,percent of total billed charges,,,45.3,,79.73,percent of total billed charges,,,51,,89.76,percent of total billed charges,,,,,,,,,80,,140.8,percent of total billed charges,,,61.4,,108.06,percent of total billed charges,,,57.4,,101.02,percent of total billed charges,,,81,,142.56,percent of total billed charges,,,51.5,,90.64,percent of total billed charges,,,57.6,,101.38,percent of total billed charges,,,85,,149.6,percent of total billed charges,,,85,,149.6,percent of total billed charges,,,49,,86.24,percent of total billed charges,,,90,,158.4,percent of total billed charges,,,65,,114.4,percent of total billed charges,,,80,,140.8,percent of total billed charges,,,55,,96.8,percent of total billed charges,,,55,,96.8,percent of total billed charges,,,65,,114.4,percent of total billed charges,,,78,,137.28,percent of total billed charges,,,70,,123.2,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,79.73,158.4,
"Multiple Density Insert, Prefabricated, Molded to Patient",A5512,HCPCS,,,,outpatient,,,162,97.2,,45.5,,73.71,percent of total billed charges,,,45.3,,73.39,percent of total billed charges,,,51,,82.62,percent of total billed charges,,,,,,,,,80,,129.6,percent of total billed charges,,,61.4,,99.47,percent of total billed charges,,,57.4,,92.99,percent of total billed charges,,,81,,131.22,percent of total billed charges,,,51.5,,83.43,percent of total billed charges,,,57.6,,93.31,percent of total billed charges,,,85,,137.7,percent of total billed charges,,,85,,137.7,percent of total billed charges,,,49,,79.38,percent of total billed charges,,,90,,145.8,percent of total billed charges,,,65,,105.3,percent of total billed charges,,,80,,129.6,percent of total billed charges,,,55,,89.1,percent of total billed charges,,,55,,89.1,percent of total billed charges,,,65,,105.3,percent of total billed charges,,,78,,126.36,percent of total billed charges,,,70,,113.4,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,73.39,145.8,
"Multiple Density Insert, Custom Fabricated,  Molded to Patient",A5513,HCPCS,,,,outpatient,,,242,145.2,,45.5,,110.11,percent of total billed charges,,,45.3,,109.63,percent of total billed charges,,,51,,123.42,percent of total billed charges,,,,,,,,,80,,193.6,percent of total billed charges,,,61.4,,148.59,percent of total billed charges,,,57.4,,138.91,percent of total billed charges,,,81,,196.02,percent of total billed charges,,,51.5,,124.63,percent of total billed charges,,,57.6,,139.39,percent of total billed charges,,,85,,205.7,percent of total billed charges,,,85,,205.7,percent of total billed charges,,,49,,118.58,percent of total billed charges,,,90,,217.8,percent of total billed charges,,,65,,157.3,percent of total billed charges,,,80,,193.6,percent of total billed charges,,,55,,133.1,percent of total billed charges,,,55,,133.1,percent of total billed charges,,,65,,157.3,percent of total billed charges,,,78,,188.76,percent of total billed charges,,,70,,169.4,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,109.63,217.8,
"Helmet, Non-Molded",A8000,HCPCS,,,,outpatient,,,777,466.2,,45.5,,353.54,percent of total billed charges,,,45.3,,351.98,percent of total billed charges,,,51,,396.27,percent of total billed charges,,,,,,,,,80,,621.6,percent of total billed charges,,,61.4,,477.08,percent of total billed charges,,,57.4,,446,percent of total billed charges,,,81,,629.37,percent of total billed charges,,,51.5,,400.16,percent of total billed charges,,,57.6,,447.55,percent of total billed charges,,,85,,660.45,percent of total billed charges,,,85,,660.45,percent of total billed charges,,,49,,380.73,percent of total billed charges,,,90,,699.3,percent of total billed charges,,,65,,505.05,percent of total billed charges,,,80,,621.6,percent of total billed charges,,,55,,427.35,percent of total billed charges,,,55,,427.35,percent of total billed charges,,,65,,505.05,percent of total billed charges,,,78,,606.06,percent of total billed charges,,,70,,543.9,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,351.98,699.3,
Hard Protet Helmet Prefabricated,A8001,HCPCS,,,,outpatient,,,928,556.8,,45.5,,422.24,percent of total billed charges,,,45.3,,420.38,percent of total billed charges,,,51,,473.28,percent of total billed charges,,,,,,,,,80,,742.4,percent of total billed charges,,,61.4,,569.79,percent of total billed charges,,,57.4,,532.67,percent of total billed charges,,,81,,751.68,percent of total billed charges,,,51.5,,477.92,percent of total billed charges,,,57.6,,534.53,percent of total billed charges,,,85,,788.8,percent of total billed charges,,,85,,788.8,percent of total billed charges,,,49,,454.72,percent of total billed charges,,,90,,835.2,percent of total billed charges,,,65,,603.2,percent of total billed charges,,,80,,742.4,percent of total billed charges,,,55,,510.4,percent of total billed charges,,,55,,510.4,percent of total billed charges,,,65,,603.2,percent of total billed charges,,,78,,723.84,percent of total billed charges,,,70,,649.6,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,420.38,835.2,
"Helmet, Molded to Model",A8003,HCPCS,,,,outpatient,,,2924,1754.4,,45.5,,1330.42,percent of total billed charges,,,45.3,,1324.57,percent of total billed charges,,,51,,1491.24,percent of total billed charges,,,,,,,,,80,,2339.2,percent of total billed charges,,,61.4,,1795.34,percent of total billed charges,,,57.4,,1678.38,percent of total billed charges,,,81,,2368.44,percent of total billed charges,,,51.5,,1505.86,percent of total billed charges,,,57.6,,1684.22,percent of total billed charges,,,85,,2485.4,percent of total billed charges,,,85,,2485.4,percent of total billed charges,,,49,,1432.76,percent of total billed charges,,,90,,2631.6,percent of total billed charges,,,65,,1900.6,percent of total billed charges,,,80,,2339.2,percent of total billed charges,,,55,,1608.2,percent of total billed charges,,,55,,1608.2,percent of total billed charges,,,65,,1900.6,percent of total billed charges,,,78,,2280.72,percent of total billed charges,,,70,,2046.8,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,1324.57,2631.6,
Wheeled Walker Frame with Trunk Support,E0140,HCPCS,,,,outpatient,,,1510,906,,45.5,,687.05,percent of total billed charges,,,45.3,,684.03,percent of total billed charges,,,51,,770.1,percent of total billed charges,,,,,,,,,80,,1208,percent of total billed charges,,,61.4,,927.14,percent of total billed charges,,,57.4,,866.74,percent of total billed charges,,,81,,1223.1,percent of total billed charges,,,51.5,,777.65,percent of total billed charges,,,57.6,,869.76,percent of total billed charges,,,85,,1283.5,percent of total billed charges,,,85,,1283.5,percent of total billed charges,,,49,,739.9,percent of total billed charges,,,90,,1359,percent of total billed charges,,,65,,981.5,percent of total billed charges,,,80,,1208,percent of total billed charges,,,55,,830.5,percent of total billed charges,,,55,,830.5,percent of total billed charges,,,65,,981.5,percent of total billed charges,,,78,,1177.8,percent of total billed charges,,,70,,1057,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,684.03,1359,
"Pad, Sheepskin, Synthetic",E0188,HCPCS,,,,outpatient,,,13,7.8,,45.5,,5.92,percent of total billed charges,,,45.3,,5.89,percent of total billed charges,,,51,,6.63,percent of total billed charges,,,,,,,,,80,,10.4,percent of total billed charges,,,61.4,,7.98,percent of total billed charges,,,57.4,,7.46,percent of total billed charges,,,81,,10.53,percent of total billed charges,,,51.5,,6.7,percent of total billed charges,,,57.6,,7.49,percent of total billed charges,,,85,,11.05,percent of total billed charges,,,85,,11.05,percent of total billed charges,,,49,,6.37,percent of total billed charges,,,90,,11.7,percent of total billed charges,,,65,,8.45,percent of total billed charges,,,80,,10.4,percent of total billed charges,,,55,,7.15,percent of total billed charges,,,55,,7.15,percent of total billed charges,,,65,,8.45,percent of total billed charges,,,78,,10.14,percent of total billed charges,,,70,,9.1,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,,,,,,,,,,,,,,,,,,,,,5.89,11.7,
"Pad, Sheepskin, Lambs Wool, Any Size",E0189,HCPCS,,,,outpatient,,,36,21.6,,45.5,,16.38,percent of total billed charges,,,45.3,,16.31,percent of total billed charges,,,51,,18.36,percent of total billed charges,,,,,,,,,80,,28.8,percent of total billed charges,,,61.4,,22.1,percent of total billed charges,,,57.4,,20.66,percent of total billed charges,,,81,,29.16,percent of total billed charges,,,51.5,,18.54,percent of total billed charges,,,57.6,,20.74,percent of total billed charges,,,85,,30.6,percent of total billed charges,,,85,,30.6,percent of total billed charges,,,49,,17.64,percent of total billed charges,,,90,,32.4,percent of total billed charges,,,65,,23.4,percent of total billed charges,,,80,,28.8,percent of total billed charges,,,55,,19.8,percent of total billed charges,,,55,,19.8,percent of total billed charges,,,65,,23.4,percent of total billed charges,,,78,,28.08,percent of total billed charges,,,70,,25.2,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,16.31,32.4,
"Protector, Heel or Elbow, Each",E0191,HCPCS,,,,outpatient,,,32,19.2,,45.5,,14.56,percent of total billed charges,,,45.3,,14.5,percent of total billed charges,,,51,,16.32,percent of total billed charges,,,,,,,,,80,,25.6,percent of total billed charges,,,61.4,,19.65,percent of total billed charges,,,57.4,,18.37,percent of total billed charges,,,81,,25.92,percent of total billed charges,,,51.5,,16.48,percent of total billed charges,,,57.6,,18.43,percent of total billed charges,,,85,,27.2,percent of total billed charges,,,85,,27.2,percent of total billed charges,,,49,,15.68,percent of total billed charges,,,90,,28.8,percent of total billed charges,,,65,,20.8,percent of total billed charges,,,80,,25.6,percent of total billed charges,,,55,,17.6,percent of total billed charges,,,55,,17.6,percent of total billed charges,,,65,,20.8,percent of total billed charges,,,78,,24.96,percent of total billed charges,,,70,,22.4,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,14.5,28.8,
"E0770 FES, Complete System, NOS",E0770,HCPCS,,,,outpatient,,,7923,4753.8,,45.5,,3604.97,percent of total billed charges,,,45.3,,3589.12,percent of total billed charges,,,51,,4040.73,percent of total billed charges,,,,,,,,,80,,6338.4,percent of total billed charges,,,61.4,,4864.72,percent of total billed charges,,,57.4,,4547.8,percent of total billed charges,,,81,,6417.63,percent of total billed charges,,,51.5,,4080.35,percent of total billed charges,,,57.6,,4563.65,percent of total billed charges,,,85,,6734.55,percent of total billed charges,,,85,,6734.55,percent of total billed charges,,,49,,3882.27,percent of total billed charges,,,90,,7130.7,percent of total billed charges,,,65,,5149.95,percent of total billed charges,,,80,,6338.4,percent of total billed charges,,,55,,4357.65,percent of total billed charges,,,55,,4357.65,percent of total billed charges,,,65,,5149.95,percent of total billed charges,,,78,,6179.94,percent of total billed charges,,,70,,5546.1,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,3589.12,7130.7,
"OB Flat Headrest, Small",E0955,HCPCS,,,,outpatient,,,186,111.6,,45.5,,84.63,percent of total billed charges,,,45.3,,84.26,percent of total billed charges,,,51,,94.86,percent of total billed charges,,,,,,,,,80,,148.8,percent of total billed charges,,,61.4,,114.2,percent of total billed charges,,,57.4,,106.76,percent of total billed charges,,,81,,150.66,percent of total billed charges,,,51.5,,95.79,percent of total billed charges,,,57.6,,107.14,percent of total billed charges,,,85,,158.1,percent of total billed charges,,,85,,158.1,percent of total billed charges,,,49,,91.14,percent of total billed charges,,,90,,167.4,percent of total billed charges,,,65,,120.9,percent of total billed charges,,,80,,148.8,percent of total billed charges,,,55,,102.3,percent of total billed charges,,,55,,102.3,percent of total billed charges,,,65,,120.9,percent of total billed charges,,,78,,145.08,percent of total billed charges,,,70,,130.2,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,84.26,167.4,
Biangular Back Option,K0108,HCPCS,,,,outpatient,,,168,100.8,,45.5,,76.44,percent of total billed charges,,,45.3,,76.1,percent of total billed charges,,,51,,85.68,percent of total billed charges,,,,,,,,,80,,134.4,percent of total billed charges,,,61.4,,103.15,percent of total billed charges,,,57.4,,96.43,percent of total billed charges,,,81,,136.08,percent of total billed charges,,,51.5,,86.52,percent of total billed charges,,,57.6,,96.77,percent of total billed charges,,,85,,142.8,percent of total billed charges,,,85,,142.8,percent of total billed charges,,,49,,82.32,percent of total billed charges,,,90,,151.2,percent of total billed charges,,,65,,109.2,percent of total billed charges,,,80,,134.4,percent of total billed charges,,,55,,92.4,percent of total billed charges,,,55,,92.4,percent of total billed charges,,,65,,109.2,percent of total billed charges,,,78,,131.04,percent of total billed charges,,,70,,117.6,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,76.1,151.2,
Seat Hardware - Adjustable Growth,K0108,HCPCS,,,,outpatient,,,840,504,,45.5,,382.2,percent of total billed charges,,,45.3,,380.52,percent of total billed charges,,,51,,428.4,percent of total billed charges,,,,,,,,,80,,672,percent of total billed charges,,,61.4,,515.76,percent of total billed charges,,,57.4,,482.16,percent of total billed charges,,,81,,680.4,percent of total billed charges,,,51.5,,432.6,percent of total billed charges,,,57.6,,483.84,percent of total billed charges,,,85,,714,percent of total billed charges,,,85,,714,percent of total billed charges,,,49,,411.6,percent of total billed charges,,,90,,756,percent of total billed charges,,,65,,546,percent of total billed charges,,,80,,672,percent of total billed charges,,,55,,462,percent of total billed charges,,,55,,462,percent of total billed charges,,,65,,546,percent of total billed charges,,,78,,655.2,percent of total billed charges,,,70,,588,percent of total billed charges,,,,,,,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,100% of Medicare,,,,,,,100% of Medicare,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,,,,,EAPG Rate,100% of IL Medicaid,380.52,756,
Half day rehab,0931,RC,,,,outpatient,,,0.01,0.01,,,,,,not paid as case rate,,,,,,not paid as case rate,1101,,,,case rate,,,42,,,percent of total billed charges,,,,,,,not paid as case rate,932,,,,case rate,,932,,,,case rate,,,,,,,not paid as case rate,1059,,,,case rate,,,,,,,not billed as case rate,,,,,,,not billed as case rate,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,483,,,,case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,not billed as case rate,,,,,,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,932,1101,
Full day rehab,0932,RC,,,,outpatient,,,0.01,0.01,,,,,,not paid as case rate,,,,,,not paid as case rate,1931,,,,case rate,,,42,,,percent of total billed charges,,,,,,,not paid as case rate,1477,,,,case rate,61.4% up to max 1477,1477,,,,case rate,57.4% up to 1477,,,,,,not paid as case rate,1857,,,,case rate,,,,,,,not billed as case rate,,,,,,,not billed as case rate,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,791,,,,case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,not billed as case rate,,,,,,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,,,,,,not billed as case rate,1477,1931,